WI0800279_GEO THERMAL_20120201

Permit Number
Program Category
Ground Water
Permit Type
,. it
WI0800279 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Gail Lybrook SFR
Location Address
1400 Regatta Dr
Wilmington
Owner
Owner Name
Gail
Dates/Events
NC 28401
Lybrook
·Scheduled
Orig Issue
02/01/12
App Received Draft Initiated Issuance
11/20/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
02/01/12
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
Gail Lybrook
2810 Bartram Rd
Winston Salem
Public Notice Issue
02/01/12
NC
Effective
02/01/12
28425
27106
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NCDENR
North Carolina Department of Environment and Natural Reseilrces
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Govemor Director
February 1, 2012
Gail Lybrook
28 10 Bartram Road
Winston-Salem, NC 27106
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10800279
1400 Regatta Drive, Wilmington, NC
Dear Ms. Lybrook:
Dee Freeman
Secretary
On 12/2012011, 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 wellsystem 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 Subebapter .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 chrp penalties.
Please contact Mike Rogers at [phone] or Michael.Rggers &ncdenr.gov if you have any questions.
Sincerely,
0 ,�
for Debra
Supervisor
cc: WilmingtonRegionslOffice-APS
APS Central Files - Permit No. W 10800279
New Flanover County Health Dept
Cape Fear Drilling Services, Inc (Christopher Deal)
O'Brien Service, Co (Jimmy Williams)
AQUIFER PROTECTfON SECTION
1836 Mail Service Center, Raleigh, NoM Carolina 27699-16M
Location; 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: 9 1 U07-6164 1 FAX 919-W7-6496
Internet WM11Cwat8rQ0aGtV.ore
An Equal appod6rnily i A[timrailva Action Employer
One
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NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE U JECTION VVEL S
In Accordance With dtc I'mVisisans of ] SA NCAC 02C .0209
These wells circulate potable water only as part of age•otherr al heating and cooling system.
These wells arc'permined by rule" and do nct require an individual permit when they are comtruct-ed in accoreanc,�
with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
DATE; D,c. 12 , 1011
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PERMIT NO. L) � (to be filled in bar DWQy A0 UjrM-p'R1�W.,' 0W REMON
A. STATUS OF WELL OWNER (chow oche)
-Non-Government: Individual Residettae X
Government: State Municipal
B usin esslOrgw iraii oni
County Federal
DEC 20NO
D. WELL OR'NER — For individual residences, list arc • owner on property deed. For all others. state name of
entity gL)_d dame of person delegated authority la sign on bc6alf of the business or agency:
Mail ing Ad4ress:8 �d �Y7�i'Yi?rc G
City: 1i y LSrZI��' State: _NC Zip Coce:.o?g/a1. .3,4M P �r
Day Tele No_: Cc I : e
EMAIL Address: - —�.� �:�lY�a�' ca 7�:`IAt� Yr: m
C. LOCATION OF WELL SITIE — Where t ie injection wells are physically located:
(3) Parcel Identification Number (PIT1; ofwel; site:_ County:
(2) Physical Address (if different than mailing addr�ssj; S"e- -i6 -
City: ►'►�i ► ti �, State: M, Zip Code:
D. WELL DROLLER INFORMATION
WeL• Driflin6 Caatractor's Nacre: —CMstopherEDcal
NC %ell Drilling Contactor CertSficatiort ?io.: 2548A
Company lwame:Cfye F a it inc.
Contact Contact Person,_ Chr's Dg41 EM.Ajl, Mdm= _chr:sr@a �.=d=dri I I t�g.cam
Address: 9124 Old River Read
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Llt" . _ LAVL " LAP __4d t&J >LAVZ. _a! _ l..UuHkky. rcllll L{w
Office Tole No.: ,910-25942.52_ Cel[No.: 9 l4-bit-062d� F'ax Nc. _9 ] D- 5ii:—.581$
F- HEAT PUMI P CONTRACTOR INFORMATION (ifdiderez thw driltcr)
Company Name_Q'driorl 5erviceCe,.
Contact Person_fimmy Williams _ FMAILArldress: MEWED I DENRI OVVQ
irrt v.n o~rt AQNIFr-R'PRnTFCTl0N �;- iION
Address: 3308 Enterprise DEC 2 0 Z41'
R
below,
Cite: WiLraington Zip Coda: 29405 State: NC County: New
Hanover.
Of'f ce Tele No.: 910-799-6611 Cell No.: 910-443-5999
WELL CONSTRUCTION DATA
Fax No.: 914-799:264
(1) Number of bor,ngs to be constructed*: 1 _Depth of each baring (feet)_-M
If existing water st-apply welts will be used then provide the infornwtran in Wm (4)
(2)Type of tubing to be used (steel, PVC, etc): —inch _PVC
(3) Well casing. If the well(s) will use casing tben provide the = (steel. PVC, etc_), dim r det,tF•,
And e t of casing appearing above ground: —4 inch PVC_190 feet_leaving l fooi above
�raund
(4) Grout (material surrounding well zasingandfiar piping).
(a) Gmt type: Cement Bentarite** X Other (specify) _
• • Fly secct:ng befttom r grouk a viir m=cc iu hrreby requestedur 15A NCAC 2.0 -02 Wd)(i )-A , wHch requires s erme,�u type Smut.
(b) Gmut depthof tubing Crefervticc to 1 acid surfaeei: from _0 to _190 (feet)
If well has casing, indicate grout depth: from — to (feet}
G. WELL LOCATIONS -Maps must be scalcd or otherwise accurately indicate —distances and orientations of
features located within 1000 feet vfrhe injection well(s). La�iLf Sressiearly alr�inel�d�� ns�r�h�Erszw-
(1) Attach a site -specific rnap shGw..r g the _ocations of the followir,g:
"Proposed injection webs * Buildings * Property boundaries
" Surface water bodies K Water supply tive115
* Septic tanks and asseciat:d spray irrigation sizes, dram field& ar repair areas
a Existing or potential soul ces of groundwater contaminamn
(2)Attach a torsoeruphie n1ap of the are;. exianding ti4 mile from the injection well site brat indicates the
facilitv's lucation and rl,,e map nan le -
NO VE. In rasa caries, an aerie! photograph of the property,parcel showmg,pruperty lines and yrracwras can be
obtaitsed and dowr+lnaded from the appUeabfe cotrwy G1S welrrire 47ica[y, the prwpernf can be searched by
awn¢r nrrxru� or address The teem on of abe wells ire relation [c properly boundaries, hatrses, septic tan&l , other
wefts, etc can (lien be drown in by Hanel[. Also, a `layer' can be selected shewing topographic ronfours or
elevation da(a.
GPU(VIC 5QW No 1-3cedw (7tss'Lxx` 311&2011)
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1 SA NCAC 02C .021 i (b) requires that ali gcrrnit applications shall be signed as follows:
I. for a corporation. by a responsible corporate officer;
2. for a psrrtaership or sole proprietarship_ by a general partner or the ptoprictor, ccspectircIy;
3. far a municipality or a state, federal, or outer public agency: by either a principal ". ccutive
officer or ranking publicly elected official:
4. for all others: by the well awrier (_wA& rn cars all l2ersons Ii n the pmpQEtLkc-d)
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that namies and authorizes their agent to sign this application on their behalf.
"il hereby ccrff3, ruder penalty of law. -,hat I liave personally examined and am fandiar with the iafotmat:an
submitted in this doawrnerrt and all attachments thereto and that. based an rry inquir'v of those individuals
immedlatLely responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are sigWficant penalties, including the posszoility of fines and imprisoluaCUL,
for sUbnlitdng false: #rdonttadDn. I agree to construct_ opcmle, maintain, repair, nrxi if applicable, abandon. the
injection well and all! related appurienanaes in accordance with the app oved specifications and conditions of
the Permit."
Signs of ,Party-- - piiyartt
Printor'Type Full Name
Signature of Property tu-ncr/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Prim or Type Full Name
Subrnit tale complete application package to.
-
"a
- Aquifer Protection Section
1636 Mail Service Center
Ralf igh, NC 276"-1636
Teel ,hone [phone]
GPL;TULCSQW Nos'rlCat1U7 (Revised 3/1W20 E 1)
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~CAPE FEAR ORllllNG SERVICES, INC
9124 Old River load• ·1urgaw, IIC 28415 • 19111 251-8252