WI0800256_GEO THERMAL_20110906

Permit Number WI0800256 /
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Francis Casieri SFR
Location Address
7335 Cotesworth Dr
Wilmington
Owner
Owner Name
Francis
Pates/Event s
NC 28405
Casieri
Central Files: APS_ SWP_
09/06/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Francis Casieri
Owner
7335 Cotesworth Dr
Wilmington NC
Major/Minor
Minor
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Francis Casieri
Owner
7335 Cotesworth Dr
Wilmington NC
28405
28405
Orig Issue App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
09/06/11
Expiration
09/06/11 09/06/11 09/06/11
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
NCDENR
North Carolina Department of Environment and Natural Resources
Division at Water Quality
Beverly saves Perdue Coleen H. Sullins
Govemor Director
09/06/2011
Francis Casieri
Dorothy Casieri
7335 Cotesworth Dr.
Wilmington, NC 28405
Subject: Acknowledgement of Intent to Construct Type 5QW injection Well System
Permit No. W10800256
7335 Cotesworth Dr.
Wilmington, NC 28405
Dear Mr. Casieri:
Dee Freeman
Secretary
On 09/06/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl-
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,
1 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 New Hanover 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.Ro«ersia ncdenr.eov if you have any questions.
S cerely,
t.2-7
for D Watts
Sup r
cc: Wilmington Regional Office - APS
APS Central Files - Permit No. W10800256
New Hanover County Health Dept.
Diana Helias (ARM's WaterWorks. P.O. Box 882, Hampstead, NC 28443)
Jimmy Williams (O'Brien Service Company, 3308 Enterprise Dr., Wilmington, NC 28405)
AQUIFEP PP.Gi s-710N SECTION
106 Mail Servim Cente,, Raietgn, North Carolina 27694-1636
Lo:alm: 2726 Cvirai Bwimrd, Raleigh, North Gaeofina 27604 lie
Phone: 919-73u•37—?1 l FAX t:349•?t5 d58R: FA.Y 2- 919-71M04,,"P. Customer Service: 677-M-674 i aro a
in!e7let www.ncWatemuai[tV.0ro WC
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)tJID 'dix)J5(o
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED-LOOP WATER-ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on the Last Page.
DATE: August 22 . 20 ___!_!__ PERMIT NO. ________ (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non-Government: Individual Residence X Business/Organization __
Government: State Municipal __ County__ Federal
B. WELL OWNER -For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency :
Francis and Dorothy Casieri
Mailing Address: 7335 Cotesworth Drive
City: Wilmington State: NC Zip Code:._2_84_0_5 ____ County: New Hanover
D~y Tele No.:·· 910-395-4168 Cell No.:
EMAIL Address: [e-mail] Fax No.:
C. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) ofwell site: R04418-005-029-000 County: New Hanover
(2) Physical Address (if different than mailing address): ________________ _
City: ________________ State: NC Zip Code: ________ _
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: _H_._M_i_ch_a_e_l_S_a_g_e ___________________ _
NC Well Drilling Contractor Certification No.: _2_5_3 _1A __________________ _
Company Name: ARM's Waterworks
Contact Person: Diana Helias
Address: PO Box 882
EMAIL Address: [e-mail]
City: Hampstead Zip Code: 28443 State: NC County: _P_e_n_d_e_r ______ _
Office Tele No.: 910-270-2919 Cell No.: Fax No.: 910-270-2988
GPU/UIC SQW Notification (Revised 3/18/2011)
--------
RECEIVED/ DENR 'ovva
Aquifer Protection Section
SEP O 6 2011
Page I
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: O'Brien Service Company
Contact Person: Jimmy Williams
Address: 3308 Enterprise Drive
EMAIL Address:
City: Wilmington Zip Code: _28_4_0_5 __ State: NC County: New Hanover
Office Tele No.: 910-799-6611 Cell No.: Fax No.: -----------
F. WELL CONSTRUCTION DATA
(1) Number ofborings to be constructed*: 4 Depth of each boring (feet):_2 _50 ______ _
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): _H_D_P_E _____________ _
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: _N_/_A _________________ _
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** __ Other (specify) _T_h_e_r_m_-_e_x ___ _
** By selecting bentonite grout, a variance is hereby requested to I SA NCAC 2C .0213(d)( I )(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from _O ___ to 250 (feet)
Ifwell has casing, indicate grout depth: from ____ to ____ (feet)
G. WELL LOCATIONS-Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow .
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/VIC 5QW Notification (Revised 3/18/2011) Page2
H. CERTMCATION (to be signed as required below or by that person's authorized agent)
1 SA NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons -listed on the gropern deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"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, opezate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
L
t atore o Owner/Applicant
Print or Type Fill Name
rt,Al ,
Sipature of Property Owner/Applicant
OVDtt k 1q, dl�.5i��+
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone] RECEIVED
DEMR 1 DV�U
Aquifer ProfWitan Section
GPU/UIC 5QW Notification (Revised 3/1812011) Page 3

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LSD. SI[:IIII.}I.^t'!f � .. F 'i, _ •`•..-__
Adapted from USGS Topographic Map
"Scotts Hill, N.C.," 1971
Contour Interval = 5 Feet
TITLE:
lied l�e5ol�rce Mans ement f C
P.O.ox bbZ HOMPSTeaCLJOB:
� [910] 270-2919 FAX [phone] Vw
N
I
FIGURE:
SITE VICINITY MAP
SCALE: DATE: DRAWN BY: 1
I "=2,000' 8/31 /201 1 KLC

Approximate Well Locations, Spaced 201 apart
Approximate Property Line
Notes: 1. RroperFies are in this area are on sewer and water service provided by Cape Fear Sewer and Water Authority.
2. Map adapted from New Hanover GIS
TITLE: SITE MAP FIGURE:
7335 Cotesworth Drive
)r.€ied Resource Management FC - P.0 BOX 882, Hampstead,NU28443 JOB: SCALE: !DATE: DRAWN BY:
[phone] FAX [phone]
Casied As Shown ! 8/22/11 ! ❑NH
j

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PARK]: R04418-005-029-000
CASIERI FRANCIS ] DOROTHIY A
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New Hanover County
PARID: R04418-005-029-000
CASIERI FRANCIS J DOROTHY A
Parcel
Alt ID
Address
Unit
City
Zip Code
Neighborhood
Class
Land Use Code
Living Units
Acres
Zoning
Legal
Legal Description
Tax District
Owners
Owner
City
State
Country
Zip
315812.77.8219.000
7335 COTESWORTH DR
WILMINGTON
3490
RES-Residential
10-1 Fam Res
1
0
LOT 17R SECTION 1 WESSEX
FD
CASIERI FRANCIS J DOROTHY A
WILMINGTON
NC
28405
THE DATA IS FROM 2011
Page 1 of 1
7335 COTESWORTH DR
http://etax.nhcgov.com/Forms/PrintDatalet.aspx?pin=R04418-005-029-000&gsp=PROFIL... 8/30/2011