WI0800205_GEO THERMAL_20100825

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NCD" C
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
GovernOi
William Andrew Rivenbark
361.5 Angus Drive
Castle Hayne, NC 28429
Coleen H. Sullins
Director
8/25/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No . WI0800205
3625 Angus Drive, Castle Hayne , NC 28429
Dear Mr. Rivenbark:
Dee Freeman
Secretary
On 8/16/2010, 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 .0211 (u)(2). Additionally, you should contact the New Hanover 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.Rooers(aincdenr.g:ov if you have any questions.
Sincerely,
10,Qbra~ A.~
cc: Wilmington Regional Office -APS ~
APS Central File~ -Permit No. WIU ll lJti:.!O:,
New Hanover County Health Dept.
Supervisor
Applied Resource Mgmt (Jim Cornette -PO Box 882. Hamps te ad, NC 28443)
O"Brien Heating & Air (Jimmy Williams -3308 Enterprise Drive, Wilmington, NC 28405)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capiial Boulevard , Raleigh. North Carolina 27604
Phone : [phone] I FAX 1: 919-715 -0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterauali tv .o rg
An Equal Opporturity \ Affirmaiive Action Employer
NonehC .. art . . aro11na
/\Jatutnlly
Permit Number WI0800205
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
3625 Angus Drive
Location Address
3625 Angus Dr
Castle Hayne
Owner
Owner Name
William
Dates/Events
NC 28429
Andre Rivenbark
w
Central Files: APS_ SWP_
08/25/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Jimmy Williams
Contractor Heat Pump
3308 Enterprise Dr
Wilmington NC
Major/Minor
Minor
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
William Andrew Rivenbark
3615 Angus Dr
Castle Hayne NC
28405
28429
Orig Issue
08/25/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
08/25/10
Effective
08/25/10
Expiration
08/16/10
Re Qulated Activities
Heat Pump Injection
Outfall l'-d' I_
Waterbody Name Stream Index Number Current Class Subbasin
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 WELLS)
In Accordance with the provisions of NCAC Title I5A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Type information).
DATE: Aucust 12.2010
Well Type Confirmation: Does the proposed system circulate potable water onl4 (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loan)?
Yes X Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well iniecting potable 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)IAPPLICANT(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): William Andrew Rivenbark
(1) Mailing Address: ^ 3615 Anaus Drive
City: Castle HaVne State: NC Zip Code: 28429 County: New Hanover-
Home/Office Tele No.: 910- 264-2360 Cell No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above): 3625 Angus Drive
City: Castle HaN,ne State: NC Zip Code: 28429 County: New Hanover
Rome/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 UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
city: State: zip Code: County:
Office Tele No.: Cell No..
Website Address of Company, if any:
9
in
30
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GPUIUIC 5gW Notification of Intent Form (Revised W2008) Page 1

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=Q.=e ________________ _
NC Contractor Certification No.: 2531-A
Contact Person"-: -=-J=im"'"""'C--=o=m=e=tt=e __________ =E~MA~I=L"-'A~dd-=-r~e-=-ss~:~J=im ____ A_RM~(u); ... u.~.b~e_lls~o ... u~th_._ne_t __
Address: __ _____,e_P..co.O=.'--"B=o=x"---'8=8=2,_____ _________________________ _
City: Ham pstead Zip Code: 28443 County: __ _,,P--=e=n=de=r ________ _
Office Tele No.: 910-270-2919 Cell No.: 910-512-4890
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: O'Brien Heating and Air
Contact Person: Jimm v Williams EMAIL Address: Jimm v@ obrienservice.com
Address: 3308 Ente rp rise Drive
City: Wilmin gt on Zip Code: 28405 County: __ _,,N~e~w~H=an=o~v~e=r ______ _
Office Tele No.: 910-799-6611
E. STATUS OF APPLICANT
Private: _x_
State:
Federal:
Municipal: __
Cell No.: __________ _
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p geothermal sy stem. Water onl v. Grouted alon g the loo p 's entire!Y .
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 8/25/2010 Number of borings: __ 6~--
Approximate depth of each boring (feet): __ ,...2-=-00"-'-------
(2) Type of tubing to be used (copper, PVC, etc): __ HD __ P_E ___________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes Q! (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 Other (specify) _G==-aro"""u"""t _._(T=h=e=rm=ex=).____
Grout placement: Pumping____X__ Pressure Other
Grout depth of tubing (reference to land surface): from O to 200 (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification oflntent Form (Revised 8/2008) Page2
AUG-iO-2O1O[T!!i) 21.2i 0 QRRIEN SERVICE CO
r'yk �l — i lyL 1]• IJ L : Vni L11 J411V. LL '-4
(FAX)9f0 i99 5884 R.0021002
1:i 1N]ECM0N-Rli.ATW 1:C UIPMZNT
ArMs,:lt s ds"%Mn showiag the enshratring layaur at prorQ5ecl modification of [lie ;jeetiaa o2ul�lma:]i }ad'Warz r
p!pinglrubing aesociaaod with -N! injection aperatim, ho mane acturcr's brochure snnyprovide supp!ementa, y.
inrorreMtien.
I. LOCATION OF WEIJ4!J)
Amch two capics of ataps showlnS the following info oration:
(I) fnrllydr: a 5i10 Map (cAa b,. t4cswn) shawiag: bulldingis, property lia;s, surface waier bodies, potcnEA.'
xcurces of groundwater carltanlinatian aiid thv orientation if and distance~ be wmi tho proposed well(,,) and
:uay cai:zing r#elI(s) at wufae ds3po=I iaci3ities such as;i.-1l;ii LaalCs or drain L`dds 1Dealcd withs'.n 2a1) f,;t at
t110 grot6cru>-Ll !zu'd pVinp well system. Libel all feriUics vlearly wrid Include a nonh z+row,
(2) Th.: Site M.p must show the aubjccl property in rcl: twm to the xurrourdinF ttrea by sxcing of I Av. 1wt5 iixrd
referea= paints such as made, stmams, oalur bsgswny in; crsccdans.
1 CERT17:'IC.ATION
Notct; 'Tula PenzisAPPUratIon must: be Signed try Srgpersoa appearing on the
recorded lopl property deed.
"T lrurtby certif�G undor penalty of law, that T have pe -.gginally exurinad and va ffimitiar with the information
liuhmitted in this document and ttll attiachm-,tts Ihoncio anti 'hK based an my Incluiry or tho6a lndiWirhzrl5
h rnedigwly respaasible for vl7WWn1; said informatloit, I bclicvt chat tlto inform ytio is in v,accur x and euirrpletc.
1 am aware that th= arc sib-piFant pa:rialtirz, inelo.din0 the passibility of fires and imprison rncnt, for 3chrm-1Lting
ftlisc iAfacrnut ", I agree to oas:S"0, OpMte, masatain. rcpalr, arad if app!icaolc, abandon the injcwiou well :sacs
n4l-:clutvd appuncctutcrs ia:tccoiducr wlth the appmved And :ondhlona at the Pamir''
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err
' Sigrr�turt uFPrhlrert}� �#wnzr'lAp�liC9rit
RECEIVEMENRIDWO
4U1FF R,PQf rr-M10N'AE'CTjN Print or Type Full tiasva and 0aa
ftmture ofFropeny Owaer/Appiimni
Prinz or Type Fuit Tlnr.,e and Grtc
Surf ofAutbolUnl AV -At, if any
Print or Typa PatIt Nam = :mod title
Aunt romra two copies of dhc compIrtod ApPUmtlion paclnr to
North Carolina DENB-11 WQ
AquiferPrctrerion Section -MC Program
1636 Zti+1 d Service Cecs:er
Ralcigh, NC 27699-1636
Talaphone (919) 71-N-6939
CiP nj'lC SQW WnlifiW' 11n 0riMLVI Ki7mi (KcvliW !<r_tlusl
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N
Approximate Property Lines
Approximate New Building Perimeter
Approximate Closed Loop Locations
Notes:
1. Subject property to be serviced by private well and septic.
2, Well locations are approximate and will be a minimum of 20' apart and 25' from the building,
3. Adapted from New Hanover County GIS Map, August, 2010.
TITLE; SITE MAP FIGURE;
7 lied Resource Mana ement PC 3625 ANGUS DRIVE
PO. Box 682, Hampstead,3 JOB; SCALE: DATE: DRAWN BY:
[phone] FAX [phone] Rlvenbark 1 = 185' , 8/1 1/10 DNH

N
Approximate Property Lines
Approximate New Building Perimeter
Approximate Closed Loop Locations
Notes:
1. Subject property to be serviced by private well and septic.
2, Well locations are approximate and will be a minimum of 20' apart and 25' from the building.
3. Adapted from New Hanover County GIS Map, August, 2010.
TITLE, SITE MAP FIGURE:
7 lied F�coouroe Mana. ement f C 3625 ANGUS DRIVE
A Box 8 Hampstead, N28443J06: SCALE; DATE. DRAWN BY.
(930) 27029Z9 FAX [phone] RIvenbark I"
_ --- 1 85' 8/1 1 /1 0 DNH

AUG-11-2010 WED 02:00 PM NHC ENVIRONMENTAL HEALTH FAX NO. 9107987269 P. 03/03
.. ;;//)
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RIVENBARK WILLIAM
ANDREW
RIVENBARK ETTA KERR
WILLIAM
12-MAR-10
451213
RIVENBARK WILLIAM ANDREW
RIVENBARK ETTA KERR WILLIAM
5473
232
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IMPROVED
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5473 232 451213
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