WI0800277_GEO THERMAL_20120131

Permit Number
Program Category
Ground Water
Permit Type
WI0800277 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Game Warden Complex
Location Address
Saw Mill Rd
Camp Lejeune
Owner
Owner Name
Carl
Dates/Events
NC 28547
H Baker
Scheduled
Orig Issue
01/31/12
App Received Draft Initiated Issuance
12/16/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Central F.iles: APS_ SWP_
01/31/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Carl H. Baker Jr.
Deputy Officer Public Works
Bldg 1005 Michael Rd
Camp Lejeune
Major/Minor
Minor
NC
Region
Wilmington
County
Onslow
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Carl H. Baker Jr.
Deputy Officer Public Works
Bldg 1005 Michael Rd
Camp Lejeune
Public Notice Issue
01/31/12
NC
Effective
01/31/12
285472521
285472521
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
AWA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Carl Baker.....: Deputy Public Works Officer
Building 1005 Michael Rd.
Camp Lejeune, NC 28547
Charles Wakild, P.E.
Director
01/31/2012
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0800277
Game Warden Complex
Camp Lejeune, NC 28547
Dear Mr. Baker:
Dee Freeman
Secretary
On 12/16/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl y
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 .021 l(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 [e-mail] ifyou have any questions.
cc: Wilmington Regional Office -APS
APS Central Files -Pennit No. WI0800277
Onslow County.Health Dept.
s n@re~y, I nI'
~~Lll~
for Debr~ W~tts
Supervisoc../
Mike Hadley (Coastal Geothermal, 102 Middle St., Jacksonville, NC 28546)
AQUIFER PROTECTION SECTION
1636 Mail Serv.ice Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St, Raleigh, North Carolina ·27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterguali1y.org
An Equal Opportunity I Affirmative Action Employer
.NifrthCaroliria l.vatutnl~ · • ·············· rfl
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 peroait when they are constructed in
accordance with the rules of 15A NCAC 02C _0200 and this Notice is submitted prior to construction.
DATE: December 07
A.
In
C.
0
Print or Type Information and Mail to the address on the Last Page.
20_11 PERMIT NO.
STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence
Government: X State Municipal
(to be filled in by DWQ)
Business/Organization
County Federal
WELL OWNER - For individual residences, list each owner on property deed. For all others, state name of
entity and name of persons delegated authority to sign on behalf of the business or agency:
Carl Baker. Deputy Public Works Officer
Mailing Address: Building 1005 Michael Rd.
City: Camp Leieune State: NC Zip Code: 28547 County: Onslow
Day Tele No.: _910-451-2213 Cell No.: NIA
EMAIL Address: -,rl r, ,k : ! Fax No.:
LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well si
(2) Physical Address (if different than mailing address):
Game Warden Complex
City: Canes Leieune State: NC Zip Code: 28547
WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Sanford Sweeting
NC Well Drilling Contractor Certification No.: 2082
Company Name: Coastal Geothermal
Contact Person. Mike Hadley EMAIL Address: mhadlevf&.}birec.rr.com
Address: 102 Middle St.
County: OnSiOW
City: Jacksonville Zip Code: 28546 State: NC County: Onslow_ ---
Office Tele No_: 910-353-0926 Cell No.: 910-376-1100 Fax No. 910-353-1060
GPUIUiC 5QW Notification (Revised Vt8/2011)
RE-M VEL r atN k , LiM
Aqd;fw PmtAdil p SeMen
1 DEC A 20

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyName: ___ -=-N=/A=-------------------------------
Contact Person~: ---------------~E=MA~=IL~A=d=d=r=es=s~: ___________ _
Address: ___________________________________ _
City: _________ Zip Code: ___ _ State: __ County: _________ _
Office Tele No.: Cell No.: _________ F=--ax:=N~o=-·=-------
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: 1 Depth of each boring (feet): 305
* If existing water supply wells will be used then provide the ieformation in item (4) below .
(2) Type of tubing to be used (steel, PVC, etc): _HDPE _____ _
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter,~
and extent of casing appearing above ground: _ NIA __________ _
( 4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** _X_ Other(specify) _______ _
** By selecting bentonite grout, a variance is hereby requested to ISA NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from __ O_ to 305_ (feet)
If well 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 clearl y 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/UIC 5QW Notification (Revised 3/18/2011) Page2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021 l(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 prope rty deed).
H 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 docwnent 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 ae ~ordance with th~ro;d specifications and conditions of
iliePenllit" ( kJ ~.~
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Print or Type Full Name
Signature of Property Owner/Applicant
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]
GPU/UIC 5QW Notification (Revised 3/18/2011)
RE~EIVEO / DENR I DWQ
Aqu,fer Protection Section
DEC 16 2011
Page 3
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