WI0800241_GEO THERMAL_20110509

Permit Number
Program Category
Ground Water
Permit Type
WI0800241 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
F.acility Name
Tom Costa SFR
Location Address
221 Petteway Dr
Jacksonville
Owner
Owner Name
Tom
Dates/Events
NC 28540
Costa
Scheduled
Orig Issue
05/09/11
App Received Draft Initiated Issuance
05/05/11
Reaulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
05/09/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Tom Costa
2040 Blue Creek Rd
Jacksonville NC
Major/Minor
Minor
Region
Wilmington
County
Onslow
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Tom Costa
2040 Blue Creek Rd
Jacksonville NC
Public Notice Issue
05/09/11
Effective
05/09/11
28540
28540
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
407A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
05/09/2011
Tom Costa
Judi Costa
2040 Blue Creek Rd.
Jacksonville, NC 28540
Subject: Acknowledgement of intent to Construct Type 5QW Injection Well System
Permit No. W10800241
221 Petteway Dr.
Jacksonville, NC 28540
Dear Mr. and Mrs. Costa:
Dee Freeman
Secretary
On 0510512011, 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 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 ,02I3, 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 .021l(u)(2). Additionally, you should contact the Orsslow County Health
Department m 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.RoLerstrz ncdenr.Lov if you have any questions.
Si ereiy,
for Debr tts
5uperviso
cc: Wilmington Regional Office - APS
APS Central Files - Permit No. W10800241
Onslow County Health Dept.
Mike Smith (Climate Control Heating & Cooling Co., 102 Middle St., Jacksonville, NC 28546)
Aouir5R PROTECTION SECTION
1636 Mail Sevim Center, Raleicth, North Carolina 2759n-t836
Location; 2728 Capisai Boulevard, Raleigh, North Carolina 27544. 011e
Phone: [phone] � FAX 1: 915-715-0588: FAX [phone] t Custamr Service. 1-877-s23.6748 N orthCBTDlina
Internet: www.netKatergualft� .ors ������'�l��
An Eq jm oppor[nrry %Afrma+iv5Iu_on Employe

DATE:
~l
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
RECEIVED/ DENR / DWQ
Aquifer Protection ection
MAY 06 2 11
complete this notification and mail to address on the back page (please Print or~ information).
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 5A 7 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; Judi and Tom Costa;...... __________ _
(1) Mailing Address: 2040 Blue Creek Road
City: Jacksonville State: _NC_ Zip Code: ..... 2=8=5'--"4-=-0 ___ County: Onslow
Home/Office Tele No.: 910-347-2442 Cell No.:
Email Address:. ______ ~W~e=b=s=ite==--------------
(2) Physical Address of Well Site (if different than above): _ 221 Petteway
Drive ___________ _
City: Jacksonville
Onslow
State:_ NC_ Zip Code: _2~8=5~4..c...0 ___ County:
Home/Office Tele No.: ______ ...,aC=e=ll=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: __________________ _
ContactPerson~=-----------~E=MA~=lL~A=d=dr~e=ss==-----------
Address: __________________ _
City: _________ State: ___ Zip Code: _____ County: _______ _
Office Tele No.: Cell No.:
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_~: ~M=i=k~e =S=m=it=h ______ E=MA==I=L~A=d~d~re=s=s:~m=s=m=i=th-@ ......... bi=z~ec=.rr=·=c=om=--------
Address: 102 Middle St
City: Jacksonville State: NC Zip Code: _28546 __ County:""""Ons"-"==lo'"'"w _____ _
Office Tele No.: 910-353-9040 Cell No.:910-376-1101 -------------
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: __ April 2011 _______ Number of borings: _4 __ _
Approximate depth of each boring (feet):_ 250 ______ _
(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) 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 _ (feet)
If well has casing, indicate grout depth: from __ O_ to _250 ___ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 7/2008) Page3
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 specific~and conditions of the Permit."
~ Lh-~
Signature of Property Owner/Applicant
r I "i,14-1 6s171
Print or Type Full Name and title
-~J.--L!__
;~~pertyl;:;r/Applicant
Wld' l/, COvlr;
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 RE~E/VEO / DENR I DWQ
Aquifer Protection Section-me Program Aquifer Protection Section
1636 Mail Service Center MAY O 5 2011 Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification of Intent Form (Revised 7/2008) Page4
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RECEIVED I DENR 14WD
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MAY 0 5 2011
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