WI0800273_GEO THERMAL_20120124

Permit Number
Program Category
Ground Water
Permit Type
WI0800273 ✓
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Christopher & Margaret Johnson
Location Address
3217 Red Berry
Wilmington
Owner
Owner Name
Christopher
Dates/Events
NC
N
28409
Johnson
Scheduled
Orig Issue
01/24/12
App Received Draft Initiated Issuance
12/02/11
Regulated Activities
Heat Pump Injection
Outfall MULL
Central Files: APS_ SWP_. _
01/24/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Chris Deal
Driller Well
9124 Old River Rd
Burgaw
Major/Minor
Minor
NC
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Christopher N. Johnson
3217 Red Berry
Wilmington
Public Notice Issue
01/24/12
NC
Effective
01/24/12
28425
~8409
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
A011
NCE)GWR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
1/24/2011
Christopher N. Johnson
Margaret J. Johnson
3217 Red Berry
Wilmington, NC 28409
Subject:: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10800273
3217 Red Berry, Wilmington, NC 28409
Dear Mr. do Mrs. Joimson:
Dee Freeman
Secretary
On December 2, 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 systern 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
Adm inistrative Code Title 1 SA 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.Ra rs cdenr. ov if you have any questions.
Sincerely,
0 � `�
a► (V4
atts
Supervisor
cc: WilminatonRegionalOffice -APS
APS Central files - Permit No. W IOSO0273
New Hanover County Health Dept.
Cape Fear Drilling Services, Inc (Christopher Deal)
O'Brien Service Co. (Timmy Williams)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Rzk1glh, North Carolina 27899-1636
Location: 512 N. Sabsbary SL, Raleigh, North Carolina 27604
Phone: 91 MD7.64641 FAX: 9194W-6496
Internet; w�rw�ya it '0
An Equal OpporWIty l Affirrnalivs AcHon Employer
One
N6fthCarolina
AWA(M �Y.

NORTH CAROLINA DEPARTMENT OF ENVIRONMLM AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CON9M1UCT OR OPERA'Tll INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0204
CLOSEDADOP WATER -ONLY GECUIEEP24AL WJEGUON WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "peamitted by rule" and do notregnire an individual permit when they are constructed in
accordance with the Hiles of 15A NCAC NC .0200 and this Notice is submitted prior to ronstruction_
Print or yype Information and 4&d tow 1heAddress an the .Last Page -
DATE: Nov.23 . 20_1 I� PERMIT NO� .0 ED%00La (to be filled in by D'WQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Indivitfua] Residence X, Businc&Organization
Goverment: State Municipal County Federal.
H. WELL OWNIKR— For individual residences, list each owner on property deed. For all others, slate name of
entity —and name of person delegatedauthorityto sign on behalf of the business or agency:
�r'� er� r� �❑1�r15o� _
- M cLcagr-r_f HMSO01 - --
Mailing Address:
City: i ltA State: _NC Zip Cocleaq09 County: WW qfWtWeR
Day Tele No.: 10 - ly d 7 Cell No.:
ENTAIL Address: Pax No.:
C. LOCATION OF WEi.L STI'E--Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site:_.- County:
(2) Physical Address (if different than mailing address): Same as above _
City: -- -- State: NC Tip Code:
A WELL DRILLER WORMA.TION
Well Drilling Contractor's Name: Q*istopher E Deal
NC Well Drilling ContractorCertiflcatron No.: 254$A
Company Nerne:Cape Fear Wiling Services Inc.
Contact Person: Chris Deal. EMAIL kddress: chrivL c "llin m
Address: 9124 Old River Roam_
City: Burgaw Zip Code. 29425 State: NG County- Pander Aquir Y � _N� 1 DVJ
Office Tele No.: 930-259-8252_ Cell No.- 9I0-604-0624 Fax No. 910-259-5LOB im SW'�p�
40MA 1C 5QW Noli irarim (Revised 3/18/2011) Page I
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E.
F.
HEAT PIMP COWMCTOREUORMATTON Cifdifferert than driller)
Company Nawe:0'13rien Service Co.
Contact Person_ JisumLWilliaxr►s EMAIL Address. Iimmv(brienswvice.cam
Address. 3309 Enterprise Drive _
City: Wilmington Zip Code: 28405 State: NC County: New Hatmver
Office Tele No.: 9 t 0-799-6611 Cell No.: 910-443-5999 Fax No.: 910-749 5584
VIFJ.L CONSMUC.Ii ON DATA
CI) Nwnber of horings to be wnstructed*: 4 Depth of each boring (feet): 250
* If edsting wcder supply "lls wil! he used then provide the information in item raj below.
(2) Type of tubing to be used (steel, PVC, ctc): it inch NUPE
(3) Well casing. If the wells) will use casing tbm provide the tie (steel. PVC, etc..), diameter. deppth.
and extent of casing appearing above ground: None
(4) Grout (mawrhd surrounding well casing and/or piping):
(a) Grout type. Cement Scnionite** _X_ Other (specify)
"By ==Cling beoraRft grunt,a variVKC is kleby mquesud to 15A NCAC 2C ,n213(d)(IXA), K'birh requirvsa cmarearTym gaswl,
(b) Grout depth of tubing (reference to land surfaee): from O to _250 (feet)
tf well has easing, indicate grout depth: from to (feet)
Q WELL LOCATIONS —Maps must be scaled or of wr+vise accurately indicate distances and orientations of
features located within 1000 feet of the injection weil(s). Label all features clearly and include a north arrow.
(1) Attach a site -specific map showing the locations of the following:
r Proposed injection wells Buildings * Property boundaries
* Surface water bodies x Water supply welts
* Septic tanks and associated spray irrigation sues, drain fields, or repair areas
Existing or potential sources ❑f'groundwater contamination
(2) Aa=h a topographic map of the area exaendiug IA mile frorn the injection well site that indicates the
facility's location and the map name.
Nom. in mow caser, on aerla PAVtngruph of tlteprope7# pomel showing prop" thug and s&uca et car he
obtained and downkaded fmw the applicable mmey GlS websife- T)+ptcaffy. [ire propeny cme he searched by
owner name or addrm The ipearkm of Ike wells to relation to prnperiy ho&wdarics, houses. septfe tavrU other
welh, etc. can fhtw be drawn in by hwwL Also, a `Iwyer' can be selerlad shawlrzg topographic wxtours ar
elevation dada.
GPi31UIC 5QW Nonficati(m IRevised 311VZOI t)
Rage 2
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H. CERTIFICATION (to be signed as required below or 6y that person's authorized agent)
15A NCAC O2C .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 o►vner (which means all persons listed on the Propegy_de dI_
If an authorised agent is signing on behaif of tie applicant, tlien supply a lefter signed by the
applicant that names and authurim tacir agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that 1 have personally exainined and am fasniIiar with the information
submitted in this docUrnent and aft attachments thereto and chat, based on my inquiry of tbose individuals
immediately responsible for obtaining said information, 1 believe that the infonnation is true, accurate and
complete, i am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information, 1 agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit"
Signature o roperty Ow pljjcant
jll'k r-' g2 e 'r 1J '9'1 rt So
Print or Type All Name
Print or pe Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Seetion
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECOVER 1 DENR l DM
Aquifer Pral"ary Sec!!an
DEC 0 2, 2011
GPrJ/i.;1C 5QW Notifcatim (Rev i5cd 3/18120$1)
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