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HomeMy WebLinkAboutWI0800217_GEO THERMAL_20101124Permit Number Program Category Ground Water Permit Type WI0800217 / Injection Water Only GSHP Well System (5QW) Primary Reviewer michael.rogers Coastal SW Rule Permitted Flow Facilitv Facility Name John & Vivian Westbrook SFR Location Address 126 Leslie Dr Hubert Owner Owner Name John Dates/Events NC 28539 Westbrook Orig Issue 11/24/10 App Received Draft Initiated 11/15/10 Re !:l ulated Activities Heat Pump Inject ion Outfall Scheduled Issuance Central Files: APS_ SWP_ 11/24/10 Permit Tracking Slip Status Active Project Type New Project Version 1.00 Permit Classification Individual Permit Contact Affiliation Bruce Brazill 102 Middle St Jacksonville NC Major/Minor Minor Region Wilmington County Onslow Facility Contact Affiliation Owner Type Individual Owner Affiliation John Westbrook 289 Creedmoor Rd Jacksonville NC Public Notice Issue 11/24/10 Effective 11/24/10 28546 28546 Expiration Waterbody Name Stream Index Number Current Class Subbasin A;7A NCQENR North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Coleen H. Sullins Governor Director 1112-4/20 3 0 John Westbrooic Vivian Westbrook 289 Creedmoor Road Jacksonville. NC 28546 Subject: Acknowledgement of Intent to Construct Type 5QW injection Well System Permit -No. WIOSD0117 126 Leslie Drive; Huber, NC 25539 Dear Dr. & Mrs, Westbrook: Dee Freeman Secretary On 11/15/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-lonl• 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 injectiob well system contains only,potabie water, 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 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 (919) 715-6166 or Michael.Rosersimnedenr.vvv if you have any questions. Sincerely, Uukk- 1hr Debra Watts sultery isur cc: Wilmington Regional Office - APS APS Cant ral Files - Permit No. W10800217 Onslow County Health Dept. Climate Conrnvl Beating & Cooling Co., inc. r Coastal Geothennal 1144iku Smith) AQUIFER PROTECTION SECTION 1636 Mail SeMce Center. Raleigh, booth Carolina 27599-1636 Lacafi= 2728 Capital Boulevard, Raleigh. North Carolina 27604 Phone: 919-75?3221 l FAX 1: 919.715-058$; FAX 2: 919-715-66481 Custarner ^aervime 1.877-623.6748 Internet wwwxmteg1uaI4y.p Hn Equal Opawunq 1ATfirmative ACN6n Empin±asr One N ortb Carolina �,�aturally 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 WELLISS} In Accordance with the provisions of NCAC Title 15A: 02C.0200, please complete this notification and mail to address on the hack page (please Print or Tme information). DATE: November 11 2010 010 f 0 <� L_j r1 i G� 8, Well Type Confarnwion: Does the proposed system circulate potable water only (no additives) in continuous piping that completely isolates the fluid from the environment (i.e. closed -lop)? 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 in'el cting potable water into the aquifer) or a 5QM well (closed - loop weli containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors). PROPERTY OWNERS)/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 wlauthority for signature); Dr. John_& Vivian Westbrook (1) Mailing Address: 289 Creedmoor Road City: Jacksonville State: NC Zip Code: 28546 County: Onslow Home/Office Teie No.: 9� 1 o) 353-7848 _ Cell No.: 9f l 01--389-1 I32 Email Address: Website; (2) Physical Address of Well Site (if different than above): 125 Leslie Drive City: Hubert State: NC Zip Code: 28539 County: Onslow Home/Office TeleNo.: (910) 353-7848 _ Cell No.: (9I0)-389-1132 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.; CelI No.: Website Address of Company, if any: GPUIUIC 5QW Notification of Intent Form (Revised 812008) NOV 16 7010 Pap I C. WELL DRILLER INFORMATION CompanyName: ___ ~C-=-oas=ta=l~G""'e=-=o=th=e=rrn=al~--------------------- Well Driller Contractor's Name: ~S=an=fo=r=d ~S~w~e~et=in-g _____________________ _ NC Contractor Certification No.: ;..;N=C,....,2=0"-"8=2'------------------------ Contact Person-=-: =M=i=k=e -=S=m=it=h,__ ______ ---=E=MA=-==IL=---.,..,.:A=d=dr=-=e=ss=: __ ______=cms=m=i=th=®=b =iz=ec=·=rr=.c=-=o=m"'----- Address: 102 Middle St. ___________________________ _ City: Jacksonville Zip Code: 28546 _____ County: --~Ons~=lo~w~--- Office Tele No.: ~9=10~-=35""'3~-~90~4~0'--------Cell No.: ______________ _ D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) Company Name: Climate Control Heating and Cooling Company Inc. Contact Person: Mike Smith EMAIL Address: msmith@ bizec.rr.com Address: 102 Middle St. ___________________________ _ City: Jacksonville Zip Code: 28546 County: __ ...;::O=-ns=l=o'-'-'w'-------- Office Tele No.: (=9-=-10=--)c..::3=5-=-3-...:;.9-=--0---'--'40=--------Cell No.: _____________ _ 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 Geothermal G. WELL CONSTRUCTION DATA (1) Proposed date to be constructed: November 2010 Number of borings: ill Approximate depth of each boring (feet): 200 feet (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 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 ..... X~_ Other (specify) ______ _ Grout placement: Pumping X Pressure Other Grout depth of tubing (reference to land surface): from O to _____ 2=00.;a.___ (feet) If well has casing, indicate grout depth: from ___ to ____ (feet) GPU/UIC 5QW 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. 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 waxer 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. "1 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 far 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 approved specifications and conditions of the Permit" a1w of Property Owner/Applicant r - �, �1L�, Print or'ry Full Name and title Signature of Propert Qwner/Applicant lV 1l esflbmold. 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 (919) 715-6935 GPUf[]IC 5QW Notification of Intent Form (Revised 8/2008) Page 3 Google Maps Page 1 of 1 Notes Dr. John Westbrook c maps 126 Leslie Skive Hubert, NC I 'V - 7 •­� http:llmaps.google.comlmaps?hl en&ie=UTF8&U=34.66124; 77.15857&spn=0.018179,... 11/10/2010 Google Maps Page 1 of 1 C-10 sic, maps ate' Creel Nee" s� "poi a r1 A pystes L>5 Cempgrouna �a pond��i��r �ni„s4ta G� R-� Red Fi�rn Grill �� Notes Dr. John Westbrook 126 Leslie Drive Hubert, NC 02010 C ovule - Map data C2010 Gcogie - http:llmaps.google.coml?ie=UTF8&11=34.660499; 77.162089&spn=0.018179,0.032916... 11/10/2010 - . K z IrCsu - i V e, Z I 1� iF.- 4,6 C;a r"- f rd.10