WI0800263_GEO THERMAL_20111025

Permit Number
Program Category
Ground Water
Permit Type
WI0800263 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Andrew May SFR
Location Address
75 Balsam Rd
Jacksonville
Owner
Owner Name
Andrew
DateslEvents
NC 28546
May
Scheduled
Orig Issue
10/25/11
App Received Draft Initiated Issuance
10/19/11
Regulated Activities
Heat Pump Injection
P ri vate residence, single famil y
Outfall NU~L
Central Files : APS_ SWP_
10/25/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Andrew May
Owner
743 Lynchburg Dr
Jacksonville
Major/Minor
Minor
NC
Region
Wilmington
County
Onslow
Facility Contact Afflllatlon
Owner Type
Individual
Owner Affiliation
Andrew May
Owner
7 43 Lynchburg Dr
Jacksonville
Public Notice Issue
10/25/11
NC
Effective
10/25/11
28546
28546
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Andrew May
743 Lynchburgh Dr.
Jacksonville, NC 28546
AVA NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
10/25/2011
Subject: Acknowledgement ofintent to Construct Type 5QW Injection Well System
Permit No. WI0800263
7 5 Balsam Rd.
Jacksonville, NC 28546
Dear Mr. May:
Dee Freeman
Secretary
On 10/19/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onlv
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 systein 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 [phone] or Michael.Roe ers@ncdenr.e ov if you have any questions.
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI0800263
Onslow County Health Dept.
S~cerely, , \J , ·
"1J/.¼ ~wrD
forD~atts
Supervisor
Mike Smith (Climate Control Heating & Cooling Co., Inc., 102 Middle St., Jacksonville, NC
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwaterauality.oro ·
An Equal Opportunity I Affirmative Action Employe r
28546)
NirthCarolina
;vaturatlu
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-Q WELLN
In Accordance with. the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or lypee information).
DATE: October 17. 2011
A.
B.
Weu Type Confrrnmdon: Does 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 iTIC application forms for installing
either a 5A7 well (open -loop well iniectine 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(S)
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 signature): Andrew May_
(1) Mailing Address: 743 Lynchburgh Drive
City: Jacksonville State: NC Zip Code: 28546 County: Onslow
Borne/Office Tele No.: 910-358-0883 Cell No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above) 75 Balsam Road
City: Jacksonville State:NC Zip Code: 28546
Home/Office Tele No.: 910-358-0883 Cell No_:
County:Onslow_
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 [}IC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
State: Zip Code:
_County:
Office Tele No.: Cell No.:
GPUfU1C 5QW Notification of intent Form (Revised 1/2008) Page 1

C. WELL DRILLER MORMATION
Company Name: Coastal Geothermal
Well Driller Contractor's Name: Sanford Sweetinr
NC Contractor Certification No.: NC 2082
Contact Person: Mike Smith EMAIL Address: msmithru!bizec.rr_corn
Address: 102 Middle St.
City: Jacksonville Zip Code: 28546 County: Onslow
Office Tele No.: 910-353-9040 Cell No.: 910-376-1101
D. HEAT PUMP CONTRACTOR INFORMATION (H different than driller)
Company Name: Climate Control Heating and Cooling Company Inc.
Contact Person: Mike Smith EMAIL Address: msmith@,bizecm.com
Address: 102 Middle St
City: Jacksonville Zip Code: 28546 County: Onslow
Office Teie 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. Loop Geothermal
O. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: October 2011 _ Number of borings: 6
Approximate depth of each boring (feet): 200_
(2) Type of tubing to be used (copper, PVC, etc): High Density Polyethylene
(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: �galvanired steel black steel__pIastic 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: PumpingX_ Pressure Other
(c) Grout depth of tubing (reference to land surface): from _0 to 200 (feet)
If well has casing, indicate gout depth: from to _ (feet)
GPUIUIC 5Qw Notification of Intent Form (Revised 812008) Page 3

H. INJECTION -RELATED EQUIPMENT
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 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 signet/ 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 re3ated appurtenances in accordance with the Afp�oved spycifications and conditions of the Permit."
Signature of Propfity Owner/Upticant
Print or Type Full Name andAle
Signature of Property Owner/Applicant
Print or Type Aull Name and title -
Signature of Authorized Agent, if any
Print or Type Full Name and title
Piease return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-iTIC Program C F E006fNR19Mr
1636 Mail Service Center ''Cfi1f�N
Raleigh, NC 27699-1636 OCT 10 2p}}
Telephone [phone]
GPIJ/rilC 5QW Notification of Intent Form (Revised 8/2008)

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