WI0800250_GEO THERMAL_20110809

Permit Number WI0800250 /
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Skeet Range Addition
Location Address
Skeet Range Addition
Camp Lejeune
Owner
Owner Name
McB Camp Lejeune
Dates/Events
NC 28547
Central Files: APS_ SWP_
08/09/11
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
Government -Federal
Owner Affiliation
Carl H. Baker
Deputy Officer Public Works
Building 1005
Camp Lejeune NC
28546
28547
Orig Issue
08/09/11
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
08/09/11
Expiration
08/02/11 08/09/11
Re g ulated Activities
Heat Pump Injection
Outfall 'U
Waterbody Name Stream Index Number Current Class Subbasin
NA
NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
MCB Camp Lejeune
Attn: Carl H. Baker, Deputy Public Works Officer
Building 1005 Michael Road
MCB Camp Lejeune, NC 28547
Coleen H. Sullins
Director
8/9/201 1
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0800250
Skeet Range. Addition, MCB Camp Lejeune. NC 2854 7
Dear Mr. Baker:
Dee Freeman
Secretary
On 8/2/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
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 ISA Section 2C Subchapter .02ll(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 [phone] or Michael.Ro2:ers 1amcdenr.Qov if you have any questions.
cc: Wiimington Regional Office -APS
APS Central Files -Permit No. WI0800250
Onslow County Health Dept.
Coastal Geothennal (Mike Hadley)
Ramsey Air Conditionin g (Kurney Ramsey)
AQUIFER PROTECTION SECTION
1636 Mail Service Cenier . Raleigh. North Caro lina 27699-1636
Locaiion: 2728 Capital Bouievard, Raleigh . North Carolina 27604
O~A-~
fiir Debra Watts
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588 ; FAX 2: 919-715-6048 I Cusiomer Service: 1-877-623-5748
Internet www.ncwaterauali 1v .ora
h.1 E~ual OpportunitJ' \ Affirmative Acton Employer
• Tone, C 1· N..2rtn aro 111. a
/Vatutal~lf
t � ., �t3 ry .
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIRCATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5—QW WELLS)
1n Accordance with the provisions of NCAC Title 15AA 02C.0200, please
complete this notification and mail to address on the back page (please Print or Type information).
DATE: duly 21. 2011 0100a60
Well Type Confirnwion: hoes 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 (off -loop well mn iecring 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 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 w]authority for signatures; MCB Camp Lejeune ATTN: Carl 1-1. Baker, Deputy
Public Works Officer
(1} Mailing Address: Building 1005 Michael Road
City: MCB Camp Lcjeune State: NC_ Zip Code: 28547 County: Onslow
HomelOffice Tele No.: 910-451-2213 CeU No.:
Email Address: carl.hbakerriusmc.mii Website:
(2) Physical Address of Well Site (if different than above): _Skeet Range Addition
City: MCB Camp Leieune 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 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:
CPU/LTIC 5QW Notification of lm-nt Form (Revised 7/2008)
RECEIVED t DENR I OW)
AQIIIFFR'pRt1iFMON SFCWN Page 1
AUG 0 2 2011

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: Ramsey Air Conditioning~----------
Contact Person: Kurne y Ramse y EMAIL Address:
Address: 2731 Commerce Rd.
City: Jacksonville State: NC Zip Code: _28546_ County: Onslow
Office Tele No.: 910-455-0414 _____ 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 Sy stems
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _Aug-Sept-201 l __ Number of borings: _5 __
Approximate depth of each boring (feet):_305' _____ _
(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) Grouttype: NeatCement__ Bentonite_x_ Other(specify) ______ _
(b) Grout placement: Pumping_ X_ Pressure Other
(c) Grout depth of tubing (reference to land surface): from_0 ___ to _305_ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 7/2008) Page 2
FL INJECTION -RELATED EQ[]IPMEN
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 he drawn) showing: buildings, property Ines, 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
Mote: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that 1 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, aintain, rep , and if applicable, abandon the injection well and
all related appurtenances in accordance with thproveti sp*iC catigns and conditions of the Permit."
Signature of PropertyY)wner/Applicant
_Carl Balser, 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-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (919) 7I5-6935
AQUI rt=l pp() wo
s
AUG p� 2011r`cr�ory
GPUIU 1C 5QW Notification of Inteiit Fom (Revised V2008) Page 3

D
C
8
C-112 — Diol
C-122 1
SKEET RANGE RELOCATION (P115fi6}
C-132 C
(SKEET HOUSES #1 THROUGH #4) t , ; , q, T 1 , ;, ; 11J 31' 1 .
MILITARY WORDING BOGS
PROJECT BOUNDAR�
(SKEET}
SKEET R
�t�X1STIN�
WETLANDS
WETLANDS
�� 0
floodMWDSVIT
f,' RgPa
4�Q

a n 2 A C
R L a! ^► 4
l C
r �
ti
ti
ap
2
p % �sawo mrwx:am V p &9EF.-D EEii 4 p 4¢aiws sErH [/ e B l"
'-ARC3iERY m
- E si�1
0 El
RETAIL suif.ofnic _ � _ , -
Fie 38.5D m i MEET NOTES; - - - cif H0TE8 -- MW KEY ND7E5;
r7•`-••- 1. SEE SOW. C- al POR ERNA LECEw, ER -x YNnI 0 a• F � rF�
MOO=_ GENERAL NOTES no AlBwkwTK s-Fm
_� "'` 'T — '�"— 0 SEPTC aRA04AGE FlU TOTAL LEWM OF © A' x j/P RED
,� "- 3 �, R SEE SRH£R C40O FOR SIA VEY COwm TIYNp! - .'}.a FEPE•
• • +vim '-"I _r NAL, SURREY NOM W RFFE MCE � 1ERRf%a OEOTHERWI #]a. SiE YELTLIINOR
-.-SO =' A 9-4 HAY WER NS. QS A' YXTM' SEV's SUMCE TO REWL 9 8$E1 C R ADmxkY. 1R V�7lAN.
� MAN. YM.33.KL SE- `.DYER P-IOIA iYR ---������ rz
SHELTER A SGS> SW 1RWWO H ♦>-RQF FOR SOIL CGRfEPA w. 1a G41E WLVE ,
HE = 36.00
:e e RWRTER tag SERWE TO RETAIL ]t WATER YRVff- cOPfMTR0R STOP
Loa
�� SEE SL4ER E-101 FOR EIELTA[A MR Purl. Mum sa 5}FIR P-101A FOR
��---- --- s arrRRWDR. gffi yWCi m
mm
�50 _'� ® Y1N0 WMRaRWR
L� IN I
SITE ll fILTY PLAN ao w GRAPFgC SCALE ` 12shm
n ,� _�
- C-141
7 A G �r•�••`�
i

SKE-ETHOUSEJ5
I
CD
c�
CD
C'4
+ EEI
<9
SKEETHOUSE#7
A3 ARCHERY
C-503 SHOP
EIFFE = 36.01