WI0800203_GEO THERMAL_20100716

\,
Perm it Number WI0800203
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
2040 Blue Creek Road
Location Address
2040 Blue Creek Rd
Jacksonville
Owner
Owner Name
Tom
Dates/Events
NC 28540
Costa
Central Files : APS_ SWP_
07/16/10
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
Onslow
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Tom Costa
2040 Blue Creek Rd
Jacksonville NC
28546
28540
Orig Issue
07/16/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
07/16/10
Expiration
07/09/10 07/16/10
Re g ulated Activities
He at Pump Inj ection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Tom Costa
Judi Costa
2040 Blue Creek Rd
Jacksonville. NC 28540
·~ ;;-;;-., __ _
MCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Suliins
Director
7/16/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0800203
2040 Blue Creek Rd, Jacksonville, NC 27540
Dear Mr. & Mrs. Costa:
Dee Freeman
Secretary
On 7/9/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onh
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 .02ll(u)(2). Additionally, you should contact the Onslow 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.Ro2ers(dmcdenr.rrnv if you have any questions.
Sincerely,
O~A-~
for Debra Watts
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI0800203
Onslow County Health Dept.
Supervisor
Costal Geothermal-Mike Smith -102 Middle Street. Jacksonville. NC 28546
AQUIFER PROTECTION SECTION
1636 Mail Sen1ice Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Caroiina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Sen1ice: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opporrnn ,ty \ Affirmaiive Action Employer
One
North Carolina
.. ?Vatilrallg
NORTH CAROLINA
Ri:(;EIVED / DENR / owa
AQUIFFRPROTEr.TION SECTtON
JUL (J:'8_2018
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:~Ju'""'-l _7 _____ , 2010 ~ 01) a)~
Well Type Confirmation: Does the proposed system circulate potable water onl y (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 5A 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): --~T~o=m~an=d~J~u=d1~· C~o=s~ta~----------
(1) Mailing Address: ---=2-=--04--'--'0=----B=lu=e'--'C=r=e=ek,.:..=..aR=d __________________ _
City : Jacksonville State: NC Zip Code: 28540 County:'--'O=n=s=lo~w~---
Home/Office Tele No.: 910-347-2442 Cell No.:
Email Address: _________ ~W~e~b~s=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=MA~~I=L~A~d=d=r~es=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) Page I
C. WELL DRil..LER INFORMATION
Company Name: ___ C~o=as=tac:...l -=G-=-eo=th=erm=a=--1 ____________________ _
Well Driller Contractor's Name: -=S=anfi=o=rd~S=--w~ee=ti=n=g __________________ _
NC Contractor Certification No.: NC 2082 ----------------------
Contact Person_: _M_ik~e ~S~m_ith _______ ~E~MA-~IL~A=d=dr=e=ss~=--~m=s=m=ith=--®-b=iz=e=c=.rr=.c=o=m ___ _
Address: 102 Middle St. ___________________________ _
City: Jacksonville Zip Code: 28546 _____ County: ----=O=ns=l=o..:.:.w __ _
Office Tele No.: 910-353-9040 Cell No.: 910-376-1101 ----------------
D~ HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Climate Control Heating and Cooling Company Inc.
Contact Person: Mike Smith EMAIL Address: msmit bizec.rr.com
Address: 102 Middle St _________________________ _
City: Jacksonville Zip Code: 28546 County: __ ....:::Oe..:ns=lo'-'-w,__ ____ _
Office Tele No.: 910-353-9040 Cell No.: 910-376-1101 ----------------
E. STATUS OF APPLICANT
Private: X
State:
Federal:
Munfoipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loop Geothermal
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _July 2010 ______ Number of borings: __ 4 __
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 fil: (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_ X_ Pressure Other __
(c) Grout depth of tubing (reference to land surface): :from _0 __ to __ 200 __ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Pagel
H. I NUCTION-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 beat 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 agrcc to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with xthed specifi 'ons d conditions of the Permit."
Signature of Property Owner/Applicant
IDAN (M&ram
Print or Type Full Name and title
I
ty Owner/Applicant
co-rrw
Print or Type Fuli 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 RECEIVED IDENR /DWQ
1636 Mail Service Center A0UlFFR'PR0TF(;T1r)N SECTION
Raleigh, NC 27699-1636 JUL 49 2610
Telephone [phone]
GPUAUIC 5QW Notification of Intent Form (Revised 8/2008) Page 3

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NORTH CAROIsINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTEFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-UW 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: Jul i 7 , 2010
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i_e.
closed -loom)?
Yes X Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well a en -loop well inectin potable water into the aquifer) or a SQM well (closed -
loop well containing additives such as R-22, ethanol, or other antifrccze or corrosion inhibitors),
A. PROPERTY OWNER(5)/A.PPLXCANT(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): Tom and Judi Costa
(1)
(2)
Mailing Address: 2040 Blue Creek Rd
City: Jacksonville
Home/Office Tele No.: 910-347-2442
Email Address:
State: NC Zip Code: 28540 County: Onslow
Cell No.:
Physical Address of Well Site (if different than above):
City:
Home/Office Tele No.:
State: Zip Code:
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:
Address.
City:
Office Tele No.:
State:
Website Address of Company, if any:
Zip Code:
EMAIL Address:
County-
GPUIUIC 5QW Notification of bitent Form (Revised 8/2009) Page 1

C. WELL DRILLER INFORMATION
CompanyName: ___ C~o=as=ta=l~G~e~o=th=e=nn=al'------------------------
Well Driller Contractor's Name: ~S~an_fi~o_rd_S~w~ee~t=in=g~-------------------
NC Contractor Certification No.: NC 2082 ______________________ _
Contact Person . .a..: --=-M=1=·k=e-=S=m=i=th=-----------=E=MA-'=-'=IL=-=-A=d=d=re=s=s:'---_-'m=s011=·th@=-=b=iz=e=c=.rr=.c=o=m=-----
Address: 102 Middle St. __________________________ _
City: Jacksonville Zip Code: 28546 _____ County: ___ Ons~=lo~w~---
Office Tele No.: 910-353-9040 _______ Cell No.: 910-376-1101 ________ _
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Climate Control Heating and Cooling Company Inc.
Contact Person: Mike Smith EMAIL Address: [e-mail]
Address: 102 Middle St ___________________________ _
City: Jacksonville Zip Code: 28546 County: ___ O~ns=lo~w~------
Office Tele No.: 910-353-9040 ______ Cell No.: 910-376-1101 ________ _
E. STATUS OF APPLICANT
Private: X
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loop Geothermal
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _July 2010 ______ Number of borings: __ 4 __
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 m: (b.) No below)
(a) Yes ___ ifyes, 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_ X_ Pressure__ Other
(c) Grout depth of tubing (reference to land surface): from _0 __ to __ 200 __ (feet)
If well has casing, indicate grout depth: from ____ to ____ (feet)
GPU/UIC 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,
1. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(I) 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 1 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, 1 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 appr -oved specific ' ns an conditions of the Permit"
Signature of Property Owner/Applicant
Print or Type Full N e an 'tic
A �
r�
Sioature of Propirty O ner/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-TJIC Progra FCcV�!
1636 Mail Service Center R'pn���yy�
Raleigh, NC 27699-1635 Al+�CTICjy
Telephone [phone] t S ��J�
GPU/LTIC 5QW Notification of Intent Porn (Revised 812008) Page 3

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