WI0500156_Application_20220329

RECEIVED
2. Current Ownership Status
Has there been a change of ownership since permit last issued? YES
If yes, indicate New Owner's c ::tact information:
Name(s)
Mailing Address:
City: _ _ _ State. Zip Code:
Day Tele No.: � Email Address.:
MAR 2 9 2022
North Carolina Department of Environmental Quality — Division of Water Resources
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APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WEIR ce
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application Renewal* X Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Sections A thru E. and M (signature page) only
Print or Type Information and Mail to the Address on the Last Page illegible Applications Will Be Returned As Incomplete.
DATE: 3/3
, 20 22 PERMIT NO. _ W10500156 (leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS . Leave Blank if New WeWPermit Application)
1. Current Use of Weil
a. I wish to continue to use the well as Geothermal Well Drinking Water Supply Well
Other Water Supply Use- Indicate use (i.e., irrigation, etc.)
b. Terminate Use: If the well is no longer being used as a geothermal injection well and yo wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandment
Record (GW-30). V•-•
Yes, I wish to rescind the permit
ti'
a
County:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence X Business/Organization
Government State Municipal County Federal
C. WELL OWNER(SyPERM T APPLICANT — For single family residences, list all persons listed on the
property • For all others, list name usiness/agency and name of person and title with delegated authority
to sign:
Mailing Address: 411 Gilmore Rd.
City: Chapel Hill State: NC Zip Code: 27516 County: Chatham
Day Tele No.: 919-795-1305 _
Cell No.: 919-795-1305
EMAIL Address: [e-mail] Fax No.: NA
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 1

D. WELL OPERATOR (if different from well owner) — For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
to sign: Same as above
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: _ Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: County: _.
(2) Physical Address (if different than mailing address): Same
City:
County Zip Code:
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
G. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name:
NC HVAC Contractor License No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.:
Fax No.:
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES
(2) Personal consumption? YES
NO
NO
I. WELL CONSTRUCTION REQUIREMENTS — As specified in 15A NCAC 02C .0224(d ):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A 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:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 2

(3)
(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.
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.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTING WELLS PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction 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 for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
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
mg/L chloride or greater per 15A NCAC 02C . 0107(Y)18z
(f)
(g)
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
K. OPERATING DATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) ° F.
L. SITE MAP — As specified in 15A NCAC 02C ,0224i b j(J, 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 15A 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)
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 3

NOTE: In most cases an aerial photograph of the property pared showing property lines and structures can be
obtained and downloaded from the applicable county GIS websit& 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
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211tel 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 all the person( saisted on the proper' deed.
If 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 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 related appurtenances in accordance with the approved specifications and conditions of the
Permit."
•
Signature ofOwner licant-
Property pP� 1
Print or Type Full Name and Title
Signatiircof Property Owner/Applicant
Print or Type Fulllame and Title
� 47,
"
Signature of Authorized Ag if any trj
fC Cy
Print or Type Full Name and Title ry-,.
p
Submit two copies of the completed application package to: to
rc
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 4

ivairEi. In more Lail!: Of lig pherrOgnyfin Cif ibe prodpoly pared .y.x.215 ero ftnim gewitu caa be
obtabred and doynkitii4lifone the appSe414- tydaqii GIS websin :(tillarkl.,1e ProPeter "11 tir isivrehoof by
twner ,rvange ar taiftw,v, The location of Uri- 15'CURi rina to likopti-j, 3oradades, bons, 1ii ather
/PeirSj. etc. can ti4a Lt4:'"F(elfg,r by band 'illrfor' ma be setae:It:11 rlwvio4- topographic vontoilitis or elevation
Crift.TITICArrItlf(' sigi:ied asr uirtibaksiw or by the NrForE;.-'e.i. rlithorized agx1:)
t -.c41! "eqCAC 02c 02'!!4c,J rwipires the all ponnit Elipplications baU tio s.igned as fizillovs
1. for a cpol-nliolut by a responl »prfiteoftleA3r,
2.. for a pita& iltip CJY. SOle proplietirailiii): try a. general r.lait :iell Or the proprietor„ rotrpe:ztiveLy.,
3. for a nallniCipflity c a state, feller or other public. 3.ancy. by cither a principal executive officer
or ranking publicly elected offic-il;
4. for all othas: by all the.. AlersoEn sllisted tile_Trq1141,...
if an autheriami Jitizatt i.signing 1311 hiEfIX tr applica0.1, then supply a tottiir Eitpu.:411 r the
applionnit that ita7r-,tri and anthorkes1F.4ragent to mign this application GM their Pr:el:tall
"1 liel'eby certify, airidkI peril:Ili:3T f law„ tivai1 have r.,ersonally an _familiar wth t. idorrnation
subrnitted in thiA dritlinent and all attaoltmer:ft thereto and tjhai bt-hod ed.1 iny inquiry of those individuals
Ernmed.lately respornibict for obtaining sal4 ioaraadon, I believe lint flie. information is trite, acuutate and
complete. I ant aware thar Vlore are siigiilicrint perAties„ including litv pallibility of fines .F.,nd itopyisonraent,
for submitting false ialbrroalion. I agree to coirstruct, operate, rrialuttiti.., repair, aixi if applicali..1t, .abarid.on the
in301.760E, well and ail ;.•(..tlattid 3ppuritenaric„.11: aec(ndinize with the axittiled s.pecifications and onridirlons of the
1)ertnit.."
,::..1griattu'3 of lAraperty Ovral.z;ippiteatit
•
Tyriz PuiliNarre Igat Titk;
twfbf Property g..E.,:nerl.A.19hic3nt
z(403.19-14. 3u.-.F.-frn_
l-rifu or ri)pef,...111 Name gig Tiff,:
E-111'cl Of AllthOlind b timy
or Full Name aid
two copies of • aiipplioft k WI.d.age to:
DivisiouofWalva llesontrees
iiinar Quality RcOetlial Operath'ens Sett ;MI CRVQ2E0S)
1636 GI ail Service Centn
. RAVA, TITC 2769944216
Telepflm 01.19) 807-6461
Cr.
'll'ati1n. Return ffl.??Ttr. ,A411:iliva.tion R.ev, 4
?age 4

GEOTHERMAL HEATING/COOLING WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxes. Fill in depths below land surface (BLS) and
details of well construction on the blank lines provided Use additional sheets as needed
Olen -Hole Well Design
Proposed Existing
Injection; Supply;
Dual Purpose
1 and 'urtats
Record Depths Below
Land Surface (BLS)
on Lines Provided
1
Bottom of casing
(Ft. BLS)
Total Depth
(Ft. BLS)
}
(Ft)
Return or Supply Line
Casing
Grout
Screened Well Design
Proposed Existing
Injection; Supply;
Dual Purpose
1.
WELL DETAILS
Casing Material:
Casing Diameter (in.):
Grout Type: _ _ Grout Depth (BLS):
Top of Bentonite Seal (if present):
Bottom of Bentonite Seal
Screen Material:
Screen Slot Size (in.):
Sand/Gravel Pack
Material Type:
Bedrock
•pen Hole
Bentonite Seal
(fpresent)
Sand/Gravel Pack
Screen
it
(Ft.)
Record Depths Below
Land Surface (BLS) on
Lines Provided
•
1
(Ft. BLS)
(Ft. BLS)
Bottom of casing
(Ft. BLS)
(Total Depth
Ft. BLS)
NC Certified Well Driller Name:
Certification No.:

Rogers, Michael
From: Shrestha, Shristi R
Sent: Tuesday, March 22, 2022 4:19 PM
To: [e-mail]
Cc: Rogers, Michael; Rice, Eric
Subject: Geothermal well application W10500156
Attachments: Scanned from a Xerox MFP 2nd Floor (2).pdf; Permit-or-Name-Change-of-Ownership-
Rev.-2-18-2020 (3).docx
Kevin,
We have received the application for a Geothermal well with permit number WI0500156 located at 411
Gilmore , Chapel Hill, NC 27516. The application isn't complete without both owner names and signatures. The
older permit has Kevin O'Dell and Angela Burton as owners listed. If there has been a change in ownership the
please fill the attached form.
Thank you,
Shristi
Shristi R. Shrestha
Hydrogeologist, Ground Water Resources Section
NCDEQ Division of Water Resources
919-707-3662 office
[[e-mail]][e-mail]
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Rice, Eric <[e-mail]>
Sent: Monday, March 21, 2022 5:48 PM
To: Shrestha, Shristi R <[e-mail]>
Cc: Rogers, Michael <[e-mail]>
Subject: WI0500156
Hi Shristi:
RRO received the attached Geothermal Water Return renewal application. Also, they sent another unsigned original
which we will recycle unless there was some reason for that submittal that you all are aware of. We will send over the
original by interoffice mail.
Thanks.
ER
Email correspondence to and from this address is subject to the
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North Carolina Public Records Law and may be disclosed to third parties.
t
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