WI0800242_GEO THERMAL_20110511

Permit Number
Program Category
Ground Water
Permit Type
WI0800242 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g .smith
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
David Flint SFR
Location Address
282 Riggs Rd
Hubert
Owner Name
David
Oates/E ve nts
NC 28539
Flint
Scheduled
Central Files: APS_ SWP_
05/11/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David Flint
Owner
282 Riggs Rd
Hubert NC
Major/Minor
Minor
Region
Wilmington
County
Onslow
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David Flint
Owner
282 Riggs Rd
Hubert NC
28539
28539
Orig Issue
05/11/11
App Received Draft Initiated Issuance Public Notice Issue Effective
05/11/11
Expiration
05/09/11 05/11/11
Reaulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
X -I rYWA
it- Ar
�CDEN�
North. Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
05/11/2011
David Flint
282 Riggs Rd.
Hubert, NC 28539
Subject: Acknowledgement of Intent to Construct Type: 5QW Injection Well System
Permit No. W10800242
282 Rings Rd.
Hubert, NC 28539
Dear Mr. Flint:
Dee Freeman
Secretary
On 05/09/2011, 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:
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 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.RoQers(&ncdenr.Uoy if you have any questions.
5i •erely, LID
for Deb a Vl tts
Supervi-o
cc: Wiirnington Regional Office - APS
APS Central File= - Permit No. NVI)fi1,1:24'
Onslow County Health Dept.
Mike Hadley (Climate Control Hearing & Cooling Co., 102 Middle St.. Jacksonville, NC 28546)
AQUIFER PROTECTION "SECTION
1536 MBii 5ewe Censer, Raielgh, North'Cardirta 27699-1636
Location- 2726 Caprtal SaWavard, Raleiph, North Card na 27604
Snore 919-733-2221 FAX 1 FAX 2:RIP -715-�046 � Cusiomer5aMm 1-377-623-6748
Internet: amw.ncwateraualrcv.om `• •``
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}A)ID~@q~
--RECf:IV!:U I Ut:Nh I i.bWQ
NORTH CAROLINA Aquifer Protection Section
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)MAY O 9 2.0ft.
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: May 5, 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 me 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@/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state naine of
entity and a representative w/authority for signatures; David Flint
(1) Mailing Address: 282 Riggs Rd.
City: Hubert State: NC _ Zip Code: 28539 County: Onslow
Home/Office Tele No.: 910-577-7312 Cell No.: 910-389-7483
Email Address:. ______ ~W~e=b=s=ite==--------------
(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: __ N/A'--------------------
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 1
C. WELL DRILLER INFORMATION
Company Name: Coastal Geothermal
RE~EIVEu I Ch.s,·lltV DIAi(;\
Aqwfer Pro~ Srrcti';.;.IJI
Well Driller Contractor's Name: Sanford Sweeting
NC Contractor Certification No.: NC 2082
,MAY O 9 2011
Contact Person: Mike Hadley EMAIL Address: mhadle y@ 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 Hadle y EMAIL Address: mhadle y@ bizec.rr.com
Address: 102 Middle St
City: Jacksonville State: NC Zip Code: _ 28546 __ County:'""'O"""ns=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 Svstems
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _May 201 l ____ Number of borings: __ 2 __
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!!! (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 placement: Pumping__ X_ Pressure__ Other __
( c) Grout depth of tubing (reference to land surface): from _ O __ to _ 250 _ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 7/2008) Page2
H. 1NJECTION-RELATED EQUIPNTN
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 (cab be drawn) showing: buildings, property lines, stuface 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 personalty 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 speci - .ations and conditions of the Permit."
RECEN _ Signature of�operty Owner/Applicant
Aquder 1aiorse. f ;7r�/)
MAY a 8 2011 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-U-IC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/LT[C SQW Notification of Intent. Form (Revised 7/2008) ?age 3

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91a-376-1100
910-353-0926
102 Middle Street Fax: 91Q-353-1064
Jacksonville, NC 28546 [e-mail]