HomeMy WebLinkAboutWI0800229_GEO THERMAL_20110121Permit Number WI0800229
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Terry & Melissa Leifheit SFR
Location Address
149 Hawkins Landing
Jacksonville
Owner
Owner Name
Terry
Dates/Events
NC 28540
Leifheit
Central Files : APS_ SWP_
01/21/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Michael Hadley
102 Middle St
Jacksonville NC
Major/Minor
Minor
Region
Wilmington
County
Onslow
Facility Contact Affiliation
Owner Type
Individual
Own~r Affiliation
Terry Leifheit
149 Hawkins Landing
Jacksonville NC
28546
28540
Orig Issue
01/18/11
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
01/18/11
Expiration
01/07/11 01/18/11
Re g ulated Activities
Heatfump Inj ection
Outfall rtJU.
Waterbody Name Stream Index Number Current Class Subbasin
Permit Number
Program Category
Ground Water
Permit Type
WI0800229 I
Injection Water Only GSHP Well System (SOW}
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Terry & Melissa Leifeit SFR
Location Address
149 Hawkins Landing
Jacksonville
Owner
Owner Name
Terry
Dates/Events
NC 28540
Leifeit
Orig Issue
01/18/11
App Received Draft Initiated
01/07/11
Re gulated Activities
Heat Pu mp Injectio n
Outfall h'lJl. ..
Scheduled
Issuance
Central Files : APS_ SWP_· _
01/18/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Michael Hadley
102 Middle St
Jacksonville NC
Major/Minor
Minor
Region
Wilmington
County
Onslow
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Terry Leifeit
149 Hawkins Landing
Jacksonville NC
Public Notice Issue
01/18/11
Effective
01/18/11
28546
28540
Expiration
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 S-QW 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 -TM& information).
DATE: Jan. 05. 2011 WT t Jq 00 �--
A.
B.
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.
dosed -loop)?
Yes x Continue completing this form.
No Do Not complete this form_ Complete other [TIC application farms for installing
either a 5A7 well (open -loop well in'iecting 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)IAPPLICANT(5)
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; Ted & Melissa Leifheit
(1) Mailing Address: 149 Hawkins Landing
City: Jacksonville State: NC_ Zip Code: 28540 County: Onslow
Home/Office Tele No.: 910-353-3797 Cell No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County:
Home/Office Tele No.: Cell No.:
AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter fi-om 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:
GPU/UTC 5QW Notification of Intent Fo m (Revised 7/2008) Page i
RCDENR
North uaroiina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue CQleerl H. SLINns
Governor Director
1111 &t2 M I.
TerrE Leitheil
Melissa Lvifheit
140 Hawking Land inc
kicksolivih,_ N(' 2854:P
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10800-229
149 Hail -king Land ina. lacksonvilit. NC 2,F;;4 1
Dear Terry & Melissa:
Dee Freeman
cuecretwi. y
On 1/7/2011. the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
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:
The injection well system contains only potable 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 Onslov, County Health
Department as they may have additional requirements for this We 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 if you have any questions,
Sincerely,
U wa�'
for Dcbru �A, anx
Suliervi liar
cc; Wilminmon Regional Office- APS
APS Central Files - Permit No. Wv it),M02"tr
Onshv,v County Health Dept.
Coastal Gcods,ennai Clinitiee Ct�nrrs?l Flestin� Corifin I.�ttn; Mike } larllr� l
1+?36 Marl Service Curler. kale' 4i North Cara' na 27699-1636
Lecario t 2726 va. waI Sourevard. Raleigh, North Carolina 27604
Prom. 919-733.3221 +. FAX t 919 ; ' 5,)9BE.. rAX 2: 915-715.6046 ? C,vstrimr Serme 1 •g � ,, -oZIU4$
Fntarrw: W*W.ncwatefaW1ity.ora
North Carolina
her "aii.rw aotnt- i k m0c-.:r-•= Lr.rr. 7=rnom, ti
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: mhadley@bizec.rr.com
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
Address: 102 Middle St.
EMAIL Address: mhadley@ bizec.rr.com
City: Jacksonville State: NC Zip Code: _28546_~ County: Onslow
Office Tele No.: 910-353-9040 Cell No.:910-376-1100 ---
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 Loop Geothermal Heat Transfer Systems
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: Jan/Feb 201 l __ Number of borings: 5 __
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 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)
(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 _255_ (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 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.
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 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 approved ~~nditioni of the Pennit."
~[D ' .L--4:
Signature of PropertyOwner/Apcant
Me, )1.5ses: A-. L·e.)~he ,~f-
Print or Tn,e Full Name and title
Signature of Property Owner/Al)plicant
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-VIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (919) 715-6935
GPU/UIC SQW Notification of Intent Form (Revised 7/2008) Page 3
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MSL - M{N1I1dUM BUILDNC LINE
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D&UE o DRAINAGE & UTILITY OF RARTM LAZE
EASEMENT as L7
HAWIONS LANDING - 71Y R/W J
SPRYA70
NOTE. THIS DOCUMENT ORIGINALLY tSSVEII AND SEALED B� J
JOHN L PIERCE,PLS, L-2548, ON MAY 26. 2DO.9.
THIS MEDIA SHALL NOT EIE CONSIDERED A CERTIFIED
DOCUMENT.
REF: M.B. 43. P. 81. 9- K-1508 BOUNDARY SURVEY 149 HAMIHS LANDING
LOT NO. 22 BLOCK
THIS IS TO CERTIFY THAT THIS MAP IS A TRa
REPRESENTArON OF THE PROPERTY HEREON AS
SUBSIIVISM 9NLUAMS FARM, SECTION III-8
COMPILED BY ACTUAL SURVEY OF THE PREMISES
AND THAT THERE ARE NO ENCROACHMENTS ACCORD-
JACKSONVILLE ONSLOW
100NSHIP COUNTY, N.C.
WG TO THE BEST OF MY KNOWLEDGE, EXCEPT AS
SHOWN. THE RATIO OF PRECISION IS 1:10.GOD+_
TERRENCE J. LEFTOT
PREPARED FUR_
JOHN L. PIERCE & ASSOCIATES, P.A. (C-1888)
405 JOHNSON BLVD., JACKSONAU-F- NC 28541
PHONE (914j346-9800 FAIL• (910)346-121D
JOHN L PIERCE. P-LS.. L-2596
MAY 26. 2009 1C0'
GATE: — -- SCALE' }"� _ -
F.B_— P J8B 2911186
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stiLfA
CDENR
North Carolina Department of Environment af►d M
Division of \ka!er Qtialliv
Beverly Eaves Pefiue Caleer, H. 'Sullins
Governor ❑irecior
1!18,2011
Merry Leifhcit
h3 � llssu 1.wt13tei:
140 liawkin?. f .mdin-
.iacksonvitk_'.-iC 2ti540
Subject: Acknowledgement of Intent to Construct Type 5QW injection Well System
Permit Nil. W 1,.-,,, i,,
149 Vial+'klo 'NC2U,40
Dear Terry d'c Melissa:
Dn 117I2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
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 weli system contains only potable 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
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 (919) 715-6166 or if you have any questions.
Sincerely,
U
161- C]Qat"a warts
Supci visor
cc: Wilmington Regional Office - APS
APS Cenual Files - Pcrtnit No, W 110800271:
Onsiov, County Health Dept.
Cc,ausl Gk:oiherma! Chniate Control 13.catinn & Conlnig i Atm.- Mike Hadley)
ic36 F., ! Service Center. Ra+sim_ North GaV.na 27699-1636
Locauon: 2726 -a0ol Bou: varc, Raleigh. North Carolina 27604
Fnane� gi 7.7;3 322 i � -tir i � 3t�-'?:,-0583 �R;{ ?_ 91?•J75-5�c8'uus:omer 5enn�� 4.877•fiL3 8ifi.°
rntsrna,: www.ncwaterou_a!r' -pgre
4:- LO'' - ' l'V13r111_';' . r.YL,7 '.-=-.:1V�ETOM E,
One,
No _hCaroiina
C"l-tarz,74
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 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: Jan. 05 , 2011
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 SQM 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; Te rrv & Melissa Leifheit
(1) Mailing Address: 149 Hawkins Landing
City: Jacksonville State:_ NC_ Zip Code:_2_8~5_40 ___ County: Onslow
Home/Office Tele No.: 910-353-3797 Cell No.:
Email Address: ______ --'W"-e=b=s1=·te=: _____________ _
(2) Physical Address of Well Site (if different than above): ____________ _
City: _________ State: __ Zip Code: ___ County: _____ _
Home/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: __________________ _
ContactPerson~=-----------~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 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: mhadley@ bizec.rr.com
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"'-: -=Mik=·=e"-"-'H=ad=l=ey.,__ ___ -=E=MA=-==IL"""A==ddr=e=ss"'-: =mh=ad=l=ey.,_.@ ... =P1=·z=ec=.rr=.c=o=m'-
Address: I 02 Middle St.
City: Jacksonville State: NC Zip Code: _ 28546 __ County: Onslow
Office Tele No.: 910-353-9040 ___ Cell No.:910-376-1100
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 Heat Transfer Systems
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: Jan/Feb 201 l __ Number of borings: 5 __
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)
(b)
(c)
Grout type: Neat Cement__ Bentonite _}(_ Other (specify) ______ _
Grout placement: Pumping_ X_ Pressure Other
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. INJECTION -RELATED EQUIP EN
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipingitubing 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 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 imprisonnnent, 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 specificatio.;is and conditions of the Permit."
Signature of ProperlylOwneRApplicant - —
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-LUC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (919) 715-6935
GPUIUIC 5QW Notification of Intent Fonn (Revised 7/2008) Page 3
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NOTE.; THIS DOCUMENT ORIGINALLY ISSUED AND SEALED 9�
J
JOHN L. PIERCF-PLS, L-2596, ON MAY 26, 2009.
THIS MEDIA SHALL NOT BE CONSIDERED A CERTIFIED
DOCUMENT.
REF: M.B. 43. P. 87, SL. K-1508 BOUNDARY
SURVEY 149 FfAWKINS LANDING
LOT NO. 22 BLOCK
THIS IS TO CERTIFY THAT THIS MAP 1S A TRUE
REPRESENTATION OF THE PROPERTY HEREON AS
SUBDIVISION WILLIAMS FARM, SECTION pI-B
COMPILED BY ACTUAL SURVEY OF THE PREMISES
JACKSONVifiE ONSLOY¢
AND THAT THERE ARE NO ENCROACHMETITS ACCORD-
TOWNSHIP COUNTY, N.C.
ING TO THE BEST OF MY KNOWLEDGE, EXCEPT AS
TERRENCE J. LEiFFiL7T
SHOWN. THE RATIO OF PREQSION IS 1:10,000+.
PREPARED FOR:
JOFIN L PIERCE, P.LS.. L-2598
JOHN L. PIERCE & ASSOCIATES, P.A. (0-1888)
4D5 JOHNSON BLVD_, JACKSONVILLE, NC 28541
PHONE (910)348-9800 FAX: (910),146-1210
DATE: MAY 26, 20M SCALE. `'— 100
F.B. _ P. JOB 1 2911166
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