WI0700343_Application_20130820

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND,NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION' WELLS
In Accordance With the Provisions of 15AENCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN, WELLS
These wells inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
(check one) _X_New Application
Renewal* Modification
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 8/20 20_13_
PERMIT NO. /A l5/Z0,3y S _(leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence _X_ Business/Organization
Government: State Municipal County Federal
B. WELL OWNER/PERMIT APPLICANT — For individual residences, list owner(s) on property deed. For all
others, list name of entity and name of person delegated authority to sign on behalf of the business or agency:
George and Kathleen Giffin
Mailing Address: 821 Pelican Drive
City: New Bern
Day Tele No • 252-638-8131
State: _NC Zip Code: 28560 County: Craven
Cell No.:
EMAIL Address: Fax No.:
C. WELL OPERATOR (if different from well owner) — For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the
business or agency:
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
D. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 2-056-022 County: Craven
(2) Physical Address (if different than mailing address): 821 Pelican Drive
City: New Bern State: NC Zip Code: 28560
GPU/UIC 5A7 Permit Application (Revised 8/8/2013) Page I

E. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Christopher Blackmon
NC Well Drilling Contractor Certification No.: 4145-A
Company Name: Applied Resource Management, P.C.
Contact Person: Jim Cornette EMAIL Address: jim [e-mail]
bellsouth.net
Address: PO Box 882
City: Hampstead
Zip Code: 28443 State: NC County: Fender
Office Tele No.: _910-270-2919 CeII No.: Fax No.: 910-270-2988
F. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: Airtech Mechanical
NC HVAC Contractor License No.:
Company Name: Airtech Mechanical
Contact Person: Patrick McKee EMAIL Address: [e-mail]
airtechnc.com
Address: 153 Two Lakes Trail
City: New Bern
Zip Code: 28560 State: NC County: Craven
Office Tele No.: 252-636-5841 Cell No.: Fax No.:
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation?
(2) Personal consumption?
YES NO X
YES NO X
H. WELL CONSTRUCTION REQUIREMENTS — As specified inri 5A NCAC 02C .0224(d):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
I5A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
(a) For screen and gravel -packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
GPU/1.1IC 5A7 I'cnnit Application (Revised 8/8/2013) Page 2

L. 1:
WELL CONSTRUCTION SPECIFICATIONS I Ii
1
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTING WELLS t. I ,; PROPOSED WELLS
*For existing wells, please attach a copy of the TOP ,Con'st`rtiction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be; used foc wells having the same construction
specifications as long as the diagram'clearly identifies or rdistinguishes each well from one another.
I;
Each diagram shall demonstrate compliance with'the;Well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
„
(a) Depth of each boring below land surface
•
(b) Well casing and screen type, thickness, and diameter
(c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water -bearing zones with 1500
mng/L chloride or greater per 15A NCAC 02C.0107(0(8)
(f)
(g)
J. OPERATING DATA
Length of well screen or open borehole and depth below land surface
Length of sand or gravel packing around well screen and depth below land surface
(1) Injection Rate: Average (daily) _12_gallons per minute (gpm).
(2) Injection Volume: Average (daily) _8,500 gallons per day (gpd).
(3) Injection Pressure: Average (daily) _<30_ pounds/square inch (psi).
(4) Injection Temperature: Average (January) _58° F, Average (July) _70_ ° F.
K. SITE MAP — As specified in 15A NCAC 02C .0224(b)(4), attach a site -specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in I5A NCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable co my 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 5A7 Permit Application (Revised 8/8/2013) Page 3

L. CERTIFICATION (to be signed as required below or by tliatiperson's authorized agent)
15A NCAC 02C .0211(el requires that all permit applications `shall be signed as follows:
1. for a corporation: by a responsible corporate officer; 1 `
2. for a partnership or sole proprietorship:: by,a genera} partner or the proprietor, respectively;
3. for a municipality or a state, federal,.'or other;piibl 9'agency: by either a principal executive
officer or ranking publicly elected official; ' '' • it
4. for all others: by the well owner (person(s> listedon the,property deed).
If an authorized agent is signing on behalf of the !ap'pticant, 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 andj 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 accord}ce.with he:approve pecii»ations an ,conditions of
the Permit "
Signature of Property Owner/Applicant
Print or Type 11 Name i rtn vi
Q�,J�zn pit a
Signature of Property Owner/App scar t
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWR - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5A7 Permit Application (Revised 8/8/2013) Page 4

* Proposed Geothermal Well Location
* Existing Irrigation Well Location
(Buried approximately 10' east of house)
Note: Adapted from Craven County GIS.
Iv
-1'4.4\
Applied Resource
Management, P. C.
Hampstcad, NC 28443
TITLE: FIGURE:
SITE MAP WITH PROPOSED WELLS
JOB: SCALE: DATE: DRAWN BY:
Giffin 1 "=100' 9/9/2013 KLC/JLC
1

GEOTHERMAL HEATING/COOLING WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxes. Fill in depths and details of well construction on
the blank lines provided. Use additional sheets as needed.
Open -Hole Well Design
11 Proposed 0 Existing
11] Injection; 0 Supply;
0 Dual Purpose
Land Surface
Record Depths Below
Land Surface on Lines
Provided
(Ft.)
}
(Ft.)
Screened Well Design
Proposed ❑ Existing
❑ Injection; ❑ Supply;
❑ Dual Purpose
Return or Supply Line
Casing
b
Grout
WELL DETAILS
Casing Material: PVC
Casing Diameter (in.): 4"
Casing Thickness (in.): SCH40
Grout Type: Bentonite
(cement, bentonite, or mix)
Screen Material: PVC
Screen Slot Size (in.): .020
Sand/Gravel Pack
Material: #2 Sand
Bedrock
Open Hole
Bentonite Seal
(f present)
Sand/Gravel Pack
Screen
1 (Ft.)
Record Depths Below
Land Surface on Lines
Provided
20
L5
58
ZS
(Ft.)
(Ft.)
(Ft.)
(Ft.)
NC Certified Well Driller Name Christopher Blackmon
Certification # 4145-A

Proposed Geothermal Well Location
Note: Adapted from Craven County GIS.
Applied Reeource
Management, P. C.
Hsmpet ..4 NC28443
TITLE:
SITE MAP WITH PROPOSED WELLS
JOB: SCALE: DATE: DRAWN BY:
Giffin 1 "=100' 8/20/2013 KLC
FIGURE:

�i;it..t ,
GEOTHERMAL e.ti ATING/COOLING' WELIi9'CL-. TRUCTION, DETAIL
Choose applicable Injection Well design and check the appropriate boxes.' 4ill in depths and'details of well construction on
the blank lines provided. Use additional sheets as needed.
en -Hole Well Design
Proposed ❑ Existing
'eetion; ❑ Supply;
1 Purpose
Land Surface
Record Depths Below
Land Surface on Lines
Provided
(Ft.)
041
;,r
i
,it
,'o•n,
11• ;
fait 4
rat
t�r
041
i;P
is
II:
n
(Ft.)
(Ft.)
Return or Supply Line
Casing
Grout
WELL DETAILS
Casing Materi.: PVC
Casing Diameter ( ): 4"
Casing Thickness (in.): SCH40
Grout Type: Bentonite
(cement, bento
Screen Material: PVC
Screen Slot Size (' .020
Sand/GravelP: k
Material:
Bedrock
Open Hole
or mix)
#2 Sand
Bentonite Seal
(if present)
Sand/Gravel Pack
Screen
it Screened WelliDesign
Z Proposed '❑ Exist ng
Ei Injection; ❑ Supply;
I ❑ Dual Purpose
(Ft.)
Record Depths Below
Land Surface on Lines
Provided
145
5
150
(Ft.)
(Ft.)
(Ft.)
200 (Ft.)
NC Certified Well Driller Name_ Christopher Blackmon Certification # 4145-A

August 23, 2013
NCDENR
DWQ - Aquifer Protection Section
Attn.: Mr. David May
943 Washington Square Mall
Washington, North Carolina 27889
Re.:
Geothermal, Envirohmental,
&Well Drilling
Application for a permit to construction Injection Well
George and Kathleen Giffen Property
821 Pelican Drive
New Bern, North Carolina 28560
Dear Mr. May,
Please find enclosed the application to construction an open loop injection well for the
above reference property. As we discussed, we have indicated two option areas for the
well to be installed. We prefer to install the well in Option 1 location. If you need further
information, please contact us.
Sincerely, ai
Karen Corbett
Office Manager
encs.
C€;. 11-,J; v/ r
AUG 272013
WASI-BNQ I ON REGIONAL OFFICE
L_
Applied Resource Management, PC
P.O. Box 882, 257 transfer Station Rd., Hampstead, NC 28443 910.270.2919 Fax [phone]