WI0800196_GEO THERMAL_20100602

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~CDE NR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
J
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
Dee Freeman
Secretary
Kathy Becker
272 Roberts Road
Newport, NC 28570
6i2!2010
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
PerrnitNo. WI0800196 ·
272 Roberts Road, Newport, NC 28570
Dear Ms. Becker:
On 5/12/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
geothermal injection well system for the operation of a ground-source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
, 2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted. .
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the Carteret County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Ro !!ers (w,ncdenr. !!OV if you have any questions.
cc: Wilmington Regional Office a APS
APS Central Files -Permit No. WI0800196
Carteret County Health Dept.
Sincerely,
forQ~A,~
Supervisor
Coastal Geothermal (Mike Smith -102 Middle Street, Jacksonville, NC 28546)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh , North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh . North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Custome r Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity I Affirmative Action Employer
Permit Number WI0800196
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Kathy Becker SFR
Location Address
272 Roberts Rd
Newport
Owner
Owner Name
Kathy
Dates/Events
NC 28570
Becker
Central Files: APS_ SWP_
06/02/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Mike Smith
Contractor Heat Pump
102 Middle St
Jacksonville NC
Major/Minor
Minor
Region
Wilmington
County
Carteret
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Kathy Becker
272 Roberts Rd
Newport NC
28546
28570
Orig Issue
06/02/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
06/02/10
Effective
06/02/10
Expiration
05/12/10
Re g ulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
\\\) \ ffi C() I uf (£)
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL(S)
In Accordance with the provisions ofNCACTitle 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or~ information).
DATE:~M=a-y~4~ ____ _,, 2010_
Well Type Confirmation: Does the proposed system circulate potable water onlv (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loop)?
Yes _X_ Continue completing this form.
No ___ Do Not complete this form. Complete other UIC application forms for installing
either a SA 7 well ( open-loop well injecting potable water into the aquifer) or a SQM well ( closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): +;r;)ia gm.I Kathy Becker _________ _
(1) Mailing Address: 272 Roberts Road _______________ _
City: New port State: NC_ Zip Code:28S70 County:-'C=art=er=et=----
Home/Office Tele No.: 252-223-5957 Cell No.:
Email Address: _________ W-'-'--"-eb=s=it=e~: _____________ _
Physical Address of Well Site (if different than above): ______________ _
City: _________ State: __ Zip Code: ______ CoWlty: _____ _
Home/Office Tele No.: -----------~C~e~ll _N_o~.: __________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: _____________________________ _
Contact Person"-: --------------=E=MA=I=L:..::A=d=dr=e=s=s,_: __________ _
Address: ________________________________ _
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: _______________ _
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008)
RECEIVED / DENR / DWQ
AQUIFJ:R ·PROTFr.TIClN SECTIO ~age 1
MAY 12 2010
C. WELL DRILLER INFORMATION
Company Name : Coastal -Geothermal
Well Driller Contractor's Name : ..ecS~an:!±f:i~o~rd~Sw=ee"-!:tin=g __________________ _
NC Contractor Certification No.: NC 2082, _____________________ _
Contact Person,.,,.:Mik=· .,,e__,,S""m~ith,,.._ __________ =E:e.,cMA=I=-<=Lc..:.A=d=dr=-e=s=s:,__m=sm=it=h®=b=iz=e=c.=rr=.c=o=m~--
Address: 102 Middle Street, __________________________ _
City: Jacksonville _____ Zip Code: 28546 __ County: Onslow __________ _
Office Tele No.: 910-353-9026 Cell No.: 910-376-1101
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyName :Climate Control Heating & Cooling Co .• Inc.
Contact Person,.,_: ...::M~ik=e~S~m~ith:!a!:..... __________ E!,=MA~~l~L...::A~d""d,..,re,,,,s~s:~ms,,,rm""""'·th@"=,.,,b=iz""'e""c.=rr=·c=o=m'°---__ _
Address: 102 Middle Street. __________________________ _
City: Jacksonville ________ Zip Code: 28546 __ County: Onslow ____ _
Office Tele No .: 910-353-9040 Cell No.: 910-376-1101 _______ _
E. STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p Geothermal Heat Transfer Systems
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _June 2010 _____ Number of borings: __ 3 __ _
Approximate depth of each boring (feet):_200 ______ _
(2) Type of tubing to be used (copper, PVC, etc): _High Density Polyethylene ______ _
(3}Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: __galvanized steel __ black steel__plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No _X_
( 4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite _X __ Other (specify) ______ _
(b) Grout placement: Pumping_)(_ Pressure Other __
( c) Grout depth of tubing (reference to land surface): from __ O __ to_ 250 ___ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 2
H. INJEC'rION-RELATED EQUIPMENT
Attach a diagram showing .the. engineering layout or proposed modification .of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information. ·
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1)
(2)
Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
·sources of groundwater.contamination and the orientation of and distances between the proposed weH(s) and
any existing well(s) or waste disposal facilities such as septic tiillks or drain :fields located within 200 feet of
the geothe~al heat pump well system .. Label all features clearly and-include a north arrow.
The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference ·points such as io~ds, streams~ and/or highway intersections.
J. CERTIFICATION
Note: This PermitApplication must be signed by each person appearing on the
recorded l~gal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the' information
submitted in this document and all attachments · thereto · and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the .information is true, accurate · and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
allrelated appurtenances in accm:dance with the approved specifications and co11ditions of the Permit."
. ~ L,5~&,'x.sJ
Signature of Property Owner/Applicant
V...o...~""\e.e."f' ~~S.o-n ~,
Print or Type Full Name and title
Signature of Property Owner/ Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-VIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page3
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-0 W WELL(S)
In Accordance with the provisions ofNCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or~ information).
DATE: ~M=a_.._y_4 _____ ~, 2010_
Well Type Confirmation: Does the proposed system circulate potable water onl (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loo p)?
Yes _X_ Continue completing this form.
No ___ Do Not complete this form. Complete other UIC application forms for installing
either a SA 7 well (Qnm-loop wen injecting potable water into the aquifer) or a SQM wen (closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): D ffl1 d Kathy Becker _________ _
(1) Mailing Address: 272 Roberts Road _______________ _
City: Newp ort State: NC_ Zip Code:=2==85::....:7....::;0 ____ County: Carteret
Home/Office Tele No.: 252-223-5957 Cell No.:
Email Address: _________ W~e=bs=it=e~: _____________ _
(2) Physical Address of Well Site (if different than above): ______________ _
City: _________ State: __ Zip Code: ______ County: _____ _
Home/Office Tele No.: -----------~C~e=ll~N~o~·~= __________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: _____________________________ _
Contact Person.~: _______________ E_MAIL __ A_d~d_r_es_s_: __________ _
Address: ________________________________ _
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Cell No.: RECEIVED/ OENR I DWQ
Website Address of Company, if any: AQI IIF J:R·PROTFr.TION SECTION
MAY 12 2010
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page I
C. WELL DRILLER INFORMATION
Company Name: Coastal Geothermal
Well Driller Contractor's Name: ~S=an=ft=o=rd~S~w~ee-=t=in=g>---------------------
NC Contractor Certification No.: NC 2082 ______________________ _
Contact Person_:M_ik_e_S_m_i_th ____________ E_MA_I_L_A_d_dr_e_ss_:_m_s_m_i_th_@_,_b_iz_e~c._rr_.c~o_m __ _
Address: 102 Middle Street, __________________________ _
City: Jacksonville _____ Zip Code: 28546 __ County: Onslow __________ _
Office Tele No.: 910-353-9026 Cell No.: 910-376-1101
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:Climate Control Heating & Cooling Co .. Inc.
Contact Person~: ~M~i_k~e ~S~m_it~h ___________ E_MA_I_L_A_dd_r_e _ss_: _m_s_m_i_th_@_t _b_iz_e_c._rr_.c_o_m ___ _
Address: 102 Middle Street, __________________________ _
City: Jacksonville ________ Zip Code: 28546 __ County: Onslow ____ _
Office Tele No.: 910-353-9040 Cell No.: 910-376-1101 ---------
E. STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loop Geothermal Heat Transfer Systems
G. WELL CONSTRUCTION DATA
(I) Proposed date to be constructed: _June 2010 _____ Number of borings: __ 3 __ _
Approximate depth of each boring (feet):_200 ______ _
(2) Type of tubing to be used (copper, PVC, etc): _High Density Polyethylene ______ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: _galvanized steel __ black steel__plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grouttype: Neat Cement__ Bentonite_X __ Other(specify) ______ _
(b) Grout placement: Pumping_ X_ Pressure Other
(c) Grout depth of tubing (reference to land surface): from __ O __ to _250 ___ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/illC SQW Notification of Intent Form (Revised 8/2008) Page2
H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
~~o•O \?w~ i2u:Y o:{
Signature of Property ~er/A pplicant
¼\r\ \ee.1' ~-~~~~'(_e;(
Print or Type Full Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page3
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