WI0800216_GEO THERMAL_20101109

Permit Number
Program Category
Ground Water
Permit Type
WI0800216
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Pre-Trial Detention Center
Location Address
Lyman Rd
Camp Lejeune
Owner
Owner Name
McB Camp Lejeune
Dates/Events
NC 28547
Central Files : 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
Driller Well
102 Middle St
Jacksonville NC
Major/Minor
Minor
Region
Wilmington
County
Onslow
Facility Contact Affiliation
Owner Type
Government -Federal
Owner Affiliation
Carl H . Baker
Building 1005
Camp Lejeune NC
28546
28547
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 a ulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
RCDENR
North Carolina Department of Environment and Nawra
Division of Water Qua#ity
Beverly Eaves Perdue Coleen H. Sullins
Governor director
11/09/201.0
Carl H. Baker — Deputy Public Works Officer
MCB Camp Lejeune
Building 1005
Michael Rd.
Camp Lejeune, NC 28547
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Permit No. WI0800216
Pre -Trial Detention Center
Lyman Rd,
Camp Lejeune, NC 28547
Dear Mr, Baker:
Resources
Des Freeman
Secretary
On 10/22/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -on]
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 Nortb
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. Onsiow 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.Roger&a nederin Uov if you have any questions.
Sin' ely, r-,
for Debra a
Supervisor
cc: Wilmington Regional Office - APS
.kPS Central Files - Permit No. LV70500216
Onslow County Health Dept.
Mike Hadley (Coastal Geothermal, 102 Middle St, Jacksonville, NC 28546)
AQUIFER PROTECTION SECTION
1636 Mail Seance Centel, Raleigh, North Carolina 27698.1 E36
Location. 2728 Capital Boulevard, Raleigh, Narth Carolina 27604 One
Phone: 919•733-=1 1 FAX [phone]; FAX [phone] Customer 5srvice: 1-877-623-6748 Nortli (Carolina
lntemet: www.nCwateraualitv•Qm �'��f �'"'
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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 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Pr� or Twe information).
DATE_ Oct.05.2010
Well Type ConflrmWion: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loofa)?
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 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}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 signatures; MCB Camp Lejeune ATTN: Carl H. Baker, Deputy
Public Works Officer
(1) Mailing Address: Building 1005 Michael Road
-City: MCB Camp Lejeune State: NC_Zip Code: 28547 County: Onsiow
Home10ffice Tele No.: 910-451-2213 Cell No.:
Email Address: carl.h.bakeyibusmc_mil Website:
(2) Physical Address of Well Site (if different than above): Pre -Trial Detention Center, Lyman Rd
City: MCB Camp Lejeune State: NC_ Zip Code: 28547_,County:
Onslow
Home/Office Tele No.: 910-451-2213
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 iUIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Cell No_:
Website Address of Company, if any:
GPU/UIC 5QW Notifica6en oflutait Form (Revised 7/2008) Page 1

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: mhadle [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: _NIA _____________________ _
Contact Person: EMAIL Address: "'-----------======----------
Address: -----------------
City: ---------=S"""ta=te""'": __ Zip Code: _____ County: ______ _
Office Tele No.: Cell No.:
E. STATUS OF APPLICANT
Private:
State:
Federal: X
Municipal: __
------------
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p Geothermal Heat Transfer Systems
For testing purposes
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: __ Oct/2010 ____ Number of borings: _1 __ _
Approximate depth of each boring (feet):_300' _____ _
(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!!!'. (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: __galvaniud 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 _300_ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC SQW Notification of Intent Form (Revised 7/2008) Page2
H. INJECTION -RELATED EQUIPKEN'T
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:
(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.
t2) The Site Map trust 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_
.I. CERTIFICATION
Note: This Permit Application must he 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, l 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 th approved s[ e� ifications and conditions of the Permit,"
" j - r---�
SiO66m oT Property Owner/Applicant - -
Carl Baker, Deputy Public Works Officer
Print or Type Ful I 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]
GPU UIC SCOW Notification of intent Form (Revised 7/2008) Page 3

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NORTII 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: Oct. 05 , 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-loop)?
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 SQM well (closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
B.
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; MCB Camp Lejeune ATIN: Carl H. Baker, Deputy
Public Works Officer
(1) Mailing Address: Building 1005 Michael Road. __
City: MCB Camp Lejeune_ State: NC_ Zip Code: .... 2=8=54~7 ___ County: Onslow
Home/Office Tele No.: 910-451-2213 Cell No.:
Email Address: [e-mail] Website:
(2) Physical Address of Well Site (if different than above): Pre-Trial Detention Center~yman Rd
City: MCB Cam p Le jeune State:_ NC_ Zip Code: 28547 ~ounty:
Onslow
0
Home/Office Tele No.: 910-451-2213 C) n
AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subj ~c property,
N attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: __________________ _ " r .,
("".). ~ __.... --l '
Contact Person . .,_: ------------=E=MA~=IL=-A=-=-=d=dr=e=ss==------------,-,-r-
N ~~t --:
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Address: __________________ _ ~ r :, r
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 1
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:_N/A _____________________ _
ContactPerson~: ________ _____,,E=MA--=-.,=IL~A=d=dr=e=ss=: _________ _
Address: ________________ _
City: ---------=S=ta=te=: __ Zip Code: _____ County: ______ _
Office Tele No.: Cell No.: ___________ _
E. STATUS OF APPLICANT
Private:
State:
Federal: X
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p Geothermal Heat Transfer Systems
"for testing purposes
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: __ Oct/2010 ____ Number of borings: _l __ _
Approximate depth of each boring (feet):_300' _____ _
(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 or (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) Grouttype: NeatCement__ Bentonite_x_ Other(specify) ______ _
(b) Grout p lacement: Pumping_ X_ Pressure Other __
(c) Grout depth of tubing (reference to land surface): from _O ___ to _300_ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 7 /2008) Page2
H. INJECTION -RELATED EQUIPPVIENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufactwer's brochure may provide supplementary
information.
L LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(l) 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 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, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the apI roved speoificatii ns and conditions of the Permit."
SignIfure of hoperty Owner/Applicant
_Carl baker, Deputy Public Works Officer
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-U1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUflXC 5QW Notification of intent Form (Revised 7/2008) Page 3

, Print - Maps
Page 1 of 1
Bing Maps
My Notes
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