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Home My WebLink AboutWI0800200_GEO THERMAL_20100623Permit Number WI0800200 Program Category Ground Water Permit Type Central Files : APS_ SWP_ 06/23/10 Permit Tracking Slip Status Active Project Type New Project Injection Water Only GSHP Well System (5QW) Version 1.00 Permit Classification Individual Primary Reviewer michael.rogers Coastal SW Rule Permitted Flow Facilit Facility Name Ernest Connon & Catherine Connon Location Address 355 W 1st St Ocean Isle Beach Owner Owner Name Ernest Dates/Events NC 28469 Connon Orig Issue 06/23/10 App Received Draft In i tiated 06/21/10 Re g ulated Activities Heat Pump Inject ion Outfall t-~· JLL Waterbody Name Scheduled Issuance Permit Contact Affiliation Justin Fulford 3461 Holden Beach Rd Sw Supply NC Major/Minor Minor Region Wilmington County Brunswick Facility Contact Affiliation Owner Type Individual Owner Affiliation Ernest Connon PO Box 7367 Fairfax Station Public Notice Issue 06/23/10 VA Effective 06/23/10 28462 22039 Expiration Stream Index Number Current Class Subbasin NA MCDEN R North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Governor Ernest Connon Catherine Connon PO Box 7367 Fairfax Station, VA 22039 Coleen H. Sullins Director 6/23/2010 Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System Permit No. WI0800200 355 West 1st Street, Ocean Isle Beach, NC 28469 Dear Mr. & Mrs. Connon: Dee Freeman Secretary On 6/21/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water- only geothermal injection well system for the operation of a ground-source heat pump located at the address referenced above. An individual permit is ~ot 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 Brunswick 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 (919) 715-6166 or Michael.Rogers@ncdem.Qov if you have any questions. Sincerely, for£~~ cc: Wilmington Regional Office -APS APS Central Files -Permit No. WI0800200 Bruswick County Health Dept. Supervisor Al Fulford Heating & Air (Justin Fulford -3461 Holden Beach Rd SW, Supply, NC 28462) AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Carolina 27699-1636 Location : 2728 Capital Boulevard, Raleigh, North Carolina 27604 Phone: 919-733-3221 \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748 Internet: www.ncwaterquality.org An Equal Opportunity \ Affirmative Action Employer NirthCarolina )Vatural/11 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-OW WELL(S) In Accordance with the provisions of NCAC Title 15A: 02C.0200, please complete this notification and mail to address on the back page (please Print or Type information). DATE: June 14.2010 Wa O'sCO2)0C7 Well Type Confirmation: Does the proposed system circulate potable water onh (no additives) in continuous piping that completely isolates the fluid from the environment (i.e. closed -loot})? Yes X Continue completing this form_ No Do Not complete this form. Complete other UIC application forms for installing either a SA7 well (open -loop well iniectinpotable water into the aquifer) or a 5QM well (closed - loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors). A. PROPERTY OWNER(S)IAPPLICA YT(S) List each Property Owner listed on property deed (if owned by a business or government agency, state name of entity and a representative wlauthority for signature): Ernest James Connon and Catherine Connon (1) Mailing Address: P.O_ Box 7367 City: Fairfax Station State: VA Lip Code: 22039 County: Fairfax Home/Office Tele No.: 703-503-6614 Cell No.: Email Address: Connoncathvia-hotmail.com Website: (2) Physical Address of Well Site (if different than above): 355 West V' Street City: Ocean Isle Beach State: NC Zip Code: 28469 County: Brunswick Home/Office Tele No.. Cell No.: 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 UfC well) Company Name: Contact Person: EMAIL Address: Address: City: State; Zip Code: County: Office Tele No.: Cell No.: Website Address of Company, if any: GPUIUIC 5QW Notification of Intent Form (Revised 9/2008) JFa$p"l +.IN � � � � ra C. WELL DRILLER INFORMATION Company Name: A pp lied Resource Management, P.C. Well Driller Contractor's Name: --'H~. M_ic_h_a_el_S_a-g_e ________________ _ NC Contractor Certification No.: -----=2=5-=--3-=-1-_,_A"---------------------- Contact Person"--: -=-J=im=---=C=o=m=e=tt=e __________ =E=MA=-"'I=L"-'A==dd=r=e=ss'"'": """J""'im~A'-='-RM===--=b--=-e=ll=so"""u=th=·=ne=t'---_ Address: __ ------"---P--'--'.O=.'---=B=o=x=---8=8=2'----------------------------- City: Hampstead Zip Code: 28443 County: ---=-P~en=d~e-=-r ________ _ Office Tele No.: 910-270-2919 Cell No.: 910-512-4890 D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) Company Name: Al Fulford Heating and Air Contact Person: Justin Fulford Address: 3461 Holden Beach Road SW City: Supply Zip Code: 28462 Office Tele No.: 910-8426589 E. STATUS OF APPLICANT Private: ____x__ Federal: State: Municipal: __ EMAIL Address: Justin@alfulfordheatingandair.com County: --~B=r=un=s=w=i=ck=-------- Cell No.: ----------- Commercial: Native American Lands: F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used) Closed Loo p geothermal s ystem. Water onl y. Grouted along the loo p 's entirety. G. WELL CONSTRUCTION DATA (1) Proposed date to be constructed: __ 6_/2_8_/l_0 _____ Number of borings: __ 6 __ Approximate depth of each boring (feet): __ -==2-=-3-=-0' ______ _ (2) Type of tubing to be used (copper, PVC, etc): _ _,c.HD~P~Ec....._ ___________ _ (3) Well casing. Is the well(s) cased? (check either (a.) Yes m: (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) (b) (c) Grout type: Neat Cement __ Bentonite Grout placement: Pumping__ Pressure X Grout depth of tubing (reference to land surface): from Other (specify) Thermex Other 0 to 230' (feet) If well has casing, indicate grout depth: from ___ to ____ (feet) GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page2 N. INJECTION -RELATED EQUIPMENT Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior piping/tubing associated with the infection operation. The manufacturer's brochure may provide supplementary information. I. LOCATION OF WELL(S) Attach two copies of maps showing the fallowing 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 foet of the geothernaal heat pump well system. Label all features Omly and include_a north arrow. (2) The Site Map roust show the subject property in relation to the surrounding area by using at least two fixed reference points such as roads. streams, andim highway intersections. .I. CFRTWICATION 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 irdormation 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. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment, for subrnilting false information. I agree to construct_ operate, maintain, repair, and if applicable, abandon the injection well and all related appurtenances in accordance with the appp�Lred specifications and conditions of the Permit" Signature of PnipartX Oyrner/Applicant Print or Type Pull Name and title -C a-z- Signature of Property Owner/Applicant _�/ rt Print or Type Full Name and title Signature of Authorized Agent, if any Print or Type F W1 Nam and title Please return two copies of the completed Application package to. North Carolina DENR-DWQ Aquifer Protection Smoot-LIC Program 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (W) 715-6935 GPU1WC 5QW Not:ticafiun afintent Form (Reviscd W21)09) PW3 Approximate Property Lines - - - Approximate New Residence Perimeter Approximate 230" deep Closed Loop Locations Notes: 1. Subject property serviced by public water and sewer. 2. Well locations are approximate and will be a minimum of 20' apart and 25' from the building. 3. Adapted from Google Earth and Brunswick County GIS Map, June 2010. TITLE: SITE MAP FIGURE: 7 v�lied Resource Manacement �e 355 W 1 st STREET Box 8 . Hampstead, JOB: SCALE: DATE: DRAWN BY: [1 910) 270.2919 FAX 270-2988 Connon 1 " = 60' 1 6/15/1 ❑ ❑NH Priat Plw iew Page 1 of 1 Parcel Number 1257JC004 - Plat Bate Land Valera $1.440,000 Building Value $0 Other Value $0 Deferred VaAm $0 Total Taxable Value 1$1,440.000 Heated Sq Ft Account Number 61640580 PIN 11064063128b2 Owner Owner Address 1 CONNON ERNEST JAMES ET CATHERINE Owner Address 2 PO BOAC 7367 Crty FAIRFAX STATION State IVA Year Built Zip 22039 Bedrooms Legal Descnpdon L-4 PH-1 THE I ELAN DER @ 01B PLAT 21 A34 FUN Ba Os Parcel Street Number Stories Parcel Street Ext Wall1 Street Type Ext Wal! 2 Neighborhood C619 strew Dir Suiadivk§on munk!ipatml OCEAN ISLE BEACH Deed Lbok Deed Page Deed Date 1399 Fire Tax Dist ict OCEAN ISLE Township SHALLOTTE Acreage Sale Price $550 ,D00 0198 18f2ar2000 fiat Book Prat Page 1]iscJar7w: Map and parcel data are believed to be accurate, but accuracy is not Map Scale guaranteed. This is not a legal dacum ent and should not be substituted far a title search, 1 inch = 112 feet appraisal, survey, or far zoning verification. Approximate Property Lines - Approximate New Residence Perimeter Approximate 230' deep Closed Loop Locations Notes: 1. Subject property serviced by public water and sewer. 2. Well locations are approximate and will be a minimum of 20' apart and 25' from the building. 3. Adapted from Google Earth and Brunswick County GIS Map, June 2010. TITLE: SITE MAP FIGURE: Hed KeSaurce Mana:;ement PC 355 W 1st STREET At- o, Box 882, Hampstead, Nc 2844JOB: SCALE: DATE; DRAWN BY: 4i01 27D-2914 FAX 27a 2488 Connon 1 " - 60' 6/15/10 DNH Print Preview . Pa ge ] of 1 Brrinswlck County, .N C: f-, p', I I _ 1 Parcel Number 257J C004 61640580 106406372852 CONNON ERN EST JAM ES ET CATHERINE Plat D ate $1,440,000 Account Number Land ifakre PIN Building Vah►e $0 Owner Other Value $0 OwnerAddress l Deferred Value $0 OwnerAd*ess 2 PO 13OX 7367 Total Taxable Value $1,440,000 Heated Sq Ft Year Built Bedrooms Fu#Baths stories Fxt: mall 1 j CkI FAIRFAX STATION WA 122G39 L-A PH-1 THE ISLANDER DIH PLAT 21 j64 i State Zip Legal Descn)tion Parcelstrest mumr Parcel street St►ed Type Ext WaY 2 Street Dir Neighborhood C619 Subd.ividor? Deed Book OCEAN ISLE BEAC H 1399 Fire Tax District OCEAN ISLE Deed Page 019E i.Township SHALLOTTE Acreage Dead Date 8128f200D Flat Boole Sale Price $550,000 Plat Page Disclainer; Map and parcel data are believed to be accurate, but accuracy is not Map Scale guaranteed - This is not a legal document and shauId not be substituted for a title search, 1 inch =112 feet appraisal, survey, or for zoning verification. Application Reviewer: --~~ ___ '4_-;r __ ·~J_----_-______ _ Pre-Review: ~Yes D No (within2 weeks ofreceipt) [J"Yes D No If No, D Pre-Review Return (return form to supervisor) Conducted? O .K. to Process? Owner: sJ(Existing 0 Unknown Owner Type: ffl Non-Gov't (0 Ind. or]Jf Org.) 0 Gov.-Municipal 0 Gov.-County D Gov.-State O Gov .-Federal Facilitv/Operation: 0 Proposed _(2i Existing ~ Facility O Operation-Other O Other: Regulated Activities : ---------------------------------- Application/Permit: Fee Category: Permit Type: Project Type: 0 ND Major O ND Minor D Express Review project 0 SFR O Application 0 Recycle D Other D Surface Irrigation O Surface Irrigation -SFR D High-Rate Infil. j;j Infil./Evap . Lagoon 0 Reuse 0 Recycle D Reuse Distribution Line 0 Pump & Haul L] GW Remed. (ND) For Residuals: D Land App. 0 D&M D Surface Disposal 0 Animal 0 503 0 503 Exempt D New Special Entrv Issues: 0 Name Change 0 Majo, Mod . 0 Mino, Mod. @ en,wal ftenewal with Majo, Mod. D Ownership Change D Other : ------------------- Notes: --------------------------------------------- FORM: BIMS Entry 060512