WI0800215_GEO THERMAL_20101109

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NCDENR I t•J
Beve rly Eaves Perdu e
Governor
D on William so n
4 01 P oin t D1ive
Swansboro. NC 285 84
North Carolina Depa rtment of Environment and ,~
Divis ion of Wate r Qual ity
Coleen H. Sullins
Director
l li9/20l0
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Pennit No . WI0'.;,0;J2l:;
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Dear Mr. Williamson:
On 10/22/2010, 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 weJI construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .Q213, 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 shoutd contact the Onsl o w 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(cimcdenr.l!ov if you have any questions.
Sincerely,
.. U,~?-~~'\___(
tor Deb ra Watts
Supervis or
cc : W ilmi ngton Regi on al Offi c e -APS
APS Central File s -P ermit No . W l0 800 '.! 15
O n siow County Health Dept.
Coasra l Gcothcnnal (M ike H ad ley) 10'.! Mid dl e St. fa ckso nvi llc . NC '.!8546
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1635
Locaiion: 2728 Capita l Boulevard, Ra!eigh. North Carolina 27604
Phone [phone] \ FAX 1: 919-715-0588: FAX 2: 919-715-6048 \ Cusmmer Service: 1-877-623-6748
Internet: www.ncwate ra ua li ty .oro
An Equai Opport.:n '.'.y \ Affirma•:ve Ac:.011 Employer
None, C 1. ortn ~aro ma
r/\7aturaltu
Permit Number WI0800215 /
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
401 Point Drive
Location Address
401 Point Dr
Swansboro
Owner
Owner Name
Don
Dates/Events
NC 28584
Willamson
Central Flies: APS_ SWP_
11/09/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Mike Hadley
Contractor
102 Middle St
Jacksonville NC
Major/Minor
Minor
Region
Wilmington
County
Onslow
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Don Willamson
401 Point Dr
Swansboro NC
28546
28584
Orig Issue
11/09/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
11/09/10
Expiration
10/22/10 11/09/10
Re g ulated Activities
Hea t Pump Inj ection
Outf all ;,:~ l' :
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Don Williamson
40 I Point Drive
Swansboro , NC 28584
AWA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
I 1/9/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
PermitNo . WI0800215
401 Point Drive, Swansboro, NC 28584
Dear Mr. Williamson:
Dee Freeman
Secretary
On 10/22/2010, 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 pennit 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 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.Rogers<alncdenr.eov if you have any questions.
Sincerely,
~·A~
for Debra Watts
cc: Wilmington Regional Office -APS
APS Central Files -Pennit No . Wl08002 l5
Onslow County Health Dept.
Supervisor
Coastal Geothennal (M ikc Hadley) 102 Middle St. Jackson vii le, NC '.?.8546
AQU!FER PROTECTION SECTION
1636 Mai l Service Center, Raleigh. North Carolina 27699-1636
Location: 2728 Capital f,loulevard, Raleigh, North Carolina 27604
Phone : [phone] \ FAX 1: 919-715-D588 ; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwaterauali tv .o rg
An Equal Oppo~uniiy \ Affirmative Actjon Employer
NOnehC ,. ort aroillla
Natura/lg
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: 10-20-10
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-loo p)?
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 injecting 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)/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 signatures; Don Williamson
(1) Mailing Address: 401 Point Dr
City: _Swansboro State: _NC_ Zip Code:...;2=8=5~84~---County: Onslow .. ;
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Home/Office Tele No.: 910-325-0173 Cell No.: C) ri, n
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Email Address : Website: f'.,) ·u :,-,.,,-
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t;,;> r-,~ ... (2) Physical Address of Well Site (if different than above):
County: -·-w er. City: _______ State: __ Zip Code:
en l'l
Home/Office Tele No.: ___ C=el=l =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'-=-==IL=-A=-==d=dr=e=ss..,_: __________ _
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 7/2008) Page I
C. WELL DRILLER INFORMATION
Company Name: Coastal Geothermal
Well Driller Contractor's Name: Sanford Sweeting
NC Contractor Certification No.: NC 2082
Contact Person: Mike Hadley EMAIL Address: [e-mail]
Address: 102 Middle St.
City: Jacksonville Zip Code: 28546 County: Onslow
Office Tele No.: __ 910-353-0926 Cell No.: 910-376-1100 _____ _
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company:_ Climate Control Heating & Cooling Co ____________ _
Contact Person: Mike Hadley EMAIL Address: [e-mail]
Address: 102 Middle St
City: Jacksonville State: NC Zip Code: _ 28546 __ County:_On~s=lo~w-'-----
Office Tele No.: 910-353-9040 ______ Cell No.:910-376-1100 _____ _
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: _Oct/Nov 2010 ________ Number of borings: _10 __
Approximate depth of each boring (feet):_255 __
(2) Type of tubing to be used (copper, PVC, etc): _High Density Polyethylene_X
(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) 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 _ O ___ to 255 _ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 7/2008) Page2
H. 1`NJECTION-RELATED EQUIPMEN
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 WEL4S)
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 mast 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, rilaintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the apj roved specifications and conditions of the Permit."
Signatu'rrlf Property OwnWAppitcant
C A�i �,� P I J �,j � 1 1 VI, +'MSo&:1
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]
GPUMC SQW Notification of Intent Form (Revised 7/2008) Page 3

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