WI0800208_GEO THERMAL_20101011

Permit Number
Program Category
Ground Water
Permit Type
WI0800208
Injection Water Only GSHP Well System (SQW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
1920 South Churchill Drive
Location Address
1920 S Churchill Dr
Wilmington
Owner
Owner Name
Michael
Dates/Events
NC 28403
Yarnoz
Orig Issue
10/11/10
App Received Draft Initiated
10/01/10
Re g ulated Activities
Heat Pump Inj ection
Outfall i''l 11 '.
Scheduled
Issuance
Central Files: APS_ SWP_
10/11/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
H Michael Sage
Driller Well
PO Box 882
Hampstead
Major/Minor
Minor
NC
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Michael Yamoz
1920 S Churchill Dr
Wilmington
Public Notice Issue
10/11/10
NC
Effective
10/11/10
28443
28403
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
' A---TA
NCDENR
Nort h Carolina Departmen t of Env ironmen t and Natural Resources
Div ision of Water Quality
Beve rly Eaves Perdue
Governor
M ich ael Y arn oz
Charmai ne Le wis
1920 So uth Ch urch ill Drive
Wilmingto n, N C 2 840 3
Coleen H. Sullins
Directo r
10/12 /20 10
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI080020 8
192 0 Sou t h Churchill Drive, Wilmi ngton, NC 28403
Dear Michael & Charmaine:
Dee Freema n
Secretary
On 10/1 /2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl y
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:
l . 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 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.Ro gers @ ncdenr.1mv if you have any questions.
_(jWQA .~
Jor Debra Watts
Super visor
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI0 800208
Ne w Hanover County Health Dept.
Applied Resource Mgmt, P.C (.lim Cornette) PO Box 882, Hampstead, NC 28443
Tay1or ·s Heating & Air (Chris .lames) 801 N. Dow Road. Carolina Bead1, NC 28428
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Bo uieva rd, Raleigh, North Carolina 27604
Phone: [phone] i FAX 1: 919-715-0588; FAX 2: 919 -715-6048 I Customer Service: 1-877 -623 -6748
Internet: www:n cwate rg ual ity.orq
An Equal Opportunity\ Afiirmaii ve Aciion Employe r
No~1 C 1· 01u1 aro 1na
1.?vaturalfy
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSEWLOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-OW WELL(S)
In Accordance with the provisions ofNCAC Title 15A: 02C.4200, please
complete this notification and mail to address on the back page (please Print or Type information).
DATE: September 22. 2010 Viol 00acy
A.
B.
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 -loop)?
Yes X Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well o en -loop well injects 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).
PROPERTY OWNER(S)IAPPLICANr(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): Michael Yarnoz & Charmaine Lewis
(1)
(2)
Mailing Address: 1920 S. Churchill Drive
City! _ Wilmington State:. NC Zip Code: 28403 County: New Hanover
Home/Office Tele No.: 910-399-2970 Cell No.: 910-274-1222
Email Address: Website:
Physical Address of Well Site (if different than above):
City;
State: Zip Code: County:
Horne/Office Tele No.: Cell No ---
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 U1C well)
Company Name:
Contact Person:
Address:
City:
Office Tele No.:
State: Zip Code:
Website Address of Company, if any:
EMAIL Address:
County:
ConI>�
GPLJ/UfC 5QW Notification of Intent Form (Revised 812008) 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=o=e ________________ _
NC Contractor Certification No.: 2531-A
Contact Person: Jim Cornette EMAIL Address: Jim ARM(@ bellsouth.net
Address: ----=-P..:.;.O=·=-=B=o=x.::....=88=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: Taylor's Heating and Air
Contact Person.-=-: ---=C=hr=is'---"J=am=e"'-s __________ =E=MA=.:=IL=-=A=d=d::.are=s=s: __________ _
Address: 801 N. Dow Road
City: Carolina Beach Zip Code: 28428 County: New Hanover
Office Tele No.: 910~458-4859 Cell No.: ----"-9-=-10"---'-44-'-'3~-~54~7-'-7 _____ _
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 loo p g eothermal s ystem. Water onl y, grouted along the loo p's entirety .
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _l~0~/4~/~1-=--0 ______ Number of borings: _8 ___ _
Approximate depth of each boring (feet): __ 2~0~0_' _____ _
(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 2! (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
Other (specify) _ _,.;Tc..=h=e=rm=e=x-"----
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 of Intent Form (Revised 8/2008) Page 2
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipingftubing 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:
(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 l have personally examined and am familiar with the information
submitted in this domment 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 passibility of tines 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.."
sw
%Idcl�
ope"# OwnedApplicant
U
1? ' Full Name and title
Si re of Property Owner/App rcant
ChQ r rna inc-_A. LeyyL
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 l3ENR-DWQ
Aquifer Protection Section-U11C Program
1636 Mail Service Center
Raleigh, NC 27699-1536
Telephone [phone]
GPUIVIC 5Qw Natirkatim of tnrem Form (Revlsu4 WON) PW 3

N
Approximate Property Lines
Approximate Building Perimeter 1
Approximate Closed Loop Locations
Notes:
1, Subject property and surrounding area are serviced by public sewer and wafer services,
2. Well locations are approximate and will be a minimum of 20' apart and 25' from the building.
3. Adapted from Google Earth and New Hanover County GIS Map, September, 2010.
TITLE: SITE MAP FIGURE:
iPed t�e5aurce Mana.:ement f C 1920 CHURCHILL ❑DIVE
P.O.Box 882, Hamps ead, N 44 JOB; SCALE: DATE: DRAWN BY:
[91Qj 27Q 2939 FAX [phone] Yarnoz As Shown 9/22/1 p aNH

Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
2. Well locations are approximate and will be a minimum of 20' ❑part ❑nd 25' from the building.
3. Adapted from Google Earth and New Hanover County GIS Map, September, 2010.
TITLE: SITE MAP FIGURE:
lied Resource Mana ement f C 1920 CHURCHILL DRIVE
88 , Hampstead, NC 28443 JOB: SCALE: DATE: DRAWN BY:
(91 Q) 270-2919 FAX [phone] Ya rnoz As Shown 9/22/ 10 DNH 1

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