WI0600098_Sherman Drive_20120619

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
6/19/2012
Mr. Carl W. Bolz
599 East Street
Middletown, CT 06457
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
�PeP mmitNo_W_I060I?098;
66 Sherman Pines Drive, Fuquary-Varina NC 27526
Dear Mr. Bolz:
Dee Freeman
Secretary
On 11 June 2012 the Aquifer Protection Section (APS) in the Fayetteville Regional Office
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:
The injection well system contains only potable water per 15A NCAC 2C .0222;
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;
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
.0211(u)(2). Additionally, you should contact the H ett 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 Jim Barber at 910-433-3340 or email at [e-mail] if you have any
questions.
Sincerely
A. VArnhardt, L.G.
Re
APS Central Files - Permit No. WI00600098
Harnett County Health Dept.
Andy Smart — Bowman Mechanical Services, Inc.
1145��,,,Technical Court
AQUIFER PROTECTION'SECT&rner, NC 27529
225 Green St., Ste. 714
Fayetteville, North Carolina 28361
Phone: [phone] FAX : [phone] Customer Service: 1-877-623-6748,
Internet: www.h20.enr.state.nc.us
An Equal Opportunity 1 Affirmative Action Employer
NonrthCarolina
Naturally

,F I 'A
06/08/2012 04:
PAGE 0.,
NORTH. C, ROLA'NA DEPARTM E NT 0FENV MEN.T AN D,',NA'11JRAL,R.ES0URCES`
M)TIVICATiON OF,JNUNT TO CONSTRUCTOR OPERATE INJEC T ION WELLS.
Wi(h.
These wells-are-perwir�od bj., rule" and di) not
oilOtt.
jawry �mvre.
:r:i!��d-jw- 1kN(-W,-#tK
nail t_i�
GEOTHERMAL DMCT' EXPAM, biN CLOSED-LOOF1 WEUS
gas wpart-of ageqtlierq6the d
Print Clearly or. A .,pe Informadom Illegible Subminah Will Be RetmrnedAv Incomplete.
DATE: 'Z( 20. PERM I0 (o 0 0 C(to be conipleted by DWQ)
A. TYPE Or GEC?') HERMAL-CLOSED-LOOF WELLTO BE CONSTAWTEP ;Z 15
X R., e
'on (as per .AC 02C.0223) N
P� i15ANCf:0 Lt.,
STATUS or, YMLLOWNER (.choasc.one)
,(I) Single FathilyResidence �mWth is form two (1) bdiskn6s days prio-f to conj;,("cflou-. 1A
M. Business/Orianization. Submit this form ',30,oays prior to constriictfop.,.
-(3) Qqvernrnenf:: State.,` Municipal._ County,— Federal $Ulbmif,this fbrlin 30 days.
06,9r to Construction,
WELL OWj�tER—Tor single family residences.list thIeIpt6oerty -6Wner(s). Forjall.others, Iigf, 000e of the
business,-Orgwjzdti6p,or govMtnent 0geyiey. jad person ,delegated" signature authority,*
(J State: .Zip code Cow S
nty
Day Tole No;:
EMAIL Address:
ress:
kjjiV-,jjCA1,,L0CATl[0r4 OF *JkLLSft
0 to
(�I) Parcel WnOr of well Acation Number (PIN) .,
County: ,
bWQttj Lod'beothermui.N j6c4w(Rcvis 48612612j
Page,
P

100RI-IERSTONE RES: -BLPR.L
in' 'd&ess)i.
City:
E. MAPS, ]PLANS, AND SPUCMCATION'
0) M#P.s TWA, be 51PWed or -otherwise accurately jfi.dic4'4W distances and ofieptaiions ref -featufft:located
within 2S0ileet. of the , injection *ell(i). .Lzbegl all #eatures=cic tidy and iRgN& a- ti&th v2-
,s owing-ffie'locatiolls'U the following.,
• PIP, o -e4' injection weir 4. t4r'. W -- P — - m
rop: '; Pp Y'WC
locations •' i,c, systems and iissd'ci §OfAY, *jd&ion
• BbuildihgS`sites, drain fieldsi or repair aie�is'
'Ppro-pert boundaries
0, 'S.5urface water bodies or 'pme* nttat 's6pr*: oV4joundvh&r,.
(2) Plans and specification,. of the surface and- subsurface construction details aftfid welt system;
F. istmy additives
TYPES AMP CONCENTRATIONS OF ADI) -IVES U - IT thai will be uW �end their
e4ncentrations. Gnlyudditivestliat,the DepaMnetit,6f, aldl'and,k-i;rnan'Serv'icts' DiV`
ist6b of'.P(jb ic,W4h4,
deteppines do not adversely affect human: health shall ire �e used. A list of Approved additives .can:) e found
onlind. At A 11,otlier- additives require approval Pfi.
WEL".L"pRt.LLE,K',1$.FORWTiON I %(if known').
Name:, Glen A'Darch Wellbriltin� PLC
Cornpany,Narne', jaign A Darch Well —Nllij1g'LLe,` ;h Contact Person -Gig Dar8i
C. ity: Wa ToMA Statd', NC Zip Qoft--1-7587, Q-94*,,Wake
Day T
C. 010)
EMAIL.Address' gj%WtdjjIjjiigQ LcQ'
L919
DWQ/U1CiCl.,ed4Lw Pno 2.

-04,15 919 3 636 6 89, �,BLDR
If. HFAT )PI MP -CO
Cqmpa- ny'.Nat��,' -Bo%ynm.WcNcal SeMi Ihc.,
A ldresst 14S`Teghr icAl Court.
chy": Mffi6t cme.. 27S24. 'S C' c W*,
- Office Tide No.' �r(9 19-�772-6460: Cell -No::
lYNoi:, Fax No:: :(919) 77-59Z94
........... ----------

TONE F4�GE 05
qT,.ORIqERSNE'�ES BL RD_
I.
PROTECTION — Provide A brief description: -of how_(F)' wAt r-supply
,weM;(2)surface water ­esbCdj' ;,ma(3)
'S�eptic,systems and'associated spray irrigation sites, drain fieldsi or, tep.�ir areas -within, 1 21% feet of proposed
ipje,c d ''.1 " - , , 11, - I . I ­­ - i . . I ,
tjon w Ils will b.c�.prbtecte during construction 6f,the Nye -
Use Cemvpima gwLng andsilt&3&ing whi le &ilfinft,
J. VARJANCk — Pursuant to 15A NCAC 02C'.024 1. the bire'c'tor'of th'Division-of Water Quality may grant a
variance frpm applicable well construction or opeTation,staiiLWds provided that;
,(l) we of the well(s) will. not endanger hurnari health -and welfare or the groundwatev- aTI&
that construction or.opeTation in accordAnce- with'the! staWards is not technically feasible or the
-proposed constructionl*oyi des- equal . or betterprotection of the groundwa ' ter;
Any variance request should accompany submittal of this notification to expedite evaluation QI-the request.
The Variance requestfbrtn can be accessed onliae,'at _http)jr.2aji t
K. StGNATURES, — Tile foilOwIng'sectiO)"Is to -N-WipPleie&as'required below'_or'by that pers6iWs, authorized
agent. 15ANCAC.02C.0211(e)requires signatkaes as,,.f6ilows:
for 4 corporation: by a responsjb'je torporate_'Aicer;
for'a partnership or sole proprietorship:, by ageneral partner -or the propiiet6r.-resp6aively;
for a.inunicipalityorasuite; fede ,or"otheV'Pub lio .agency: ',by either a,pr'indjal executive.
officer or ranking publicly elected offIcial:r
(d) for alle. well by tbell owner;
,(e) for. any , ,other person'authorizedto acuon behalf' of the applicia'nf;', d6c(anefitafibii..ihall bc;
submitted -witli thg,notifleation that, clearly 4identifies the per"Wril grants tbOm signatuit
authority,, and is signed anij,4atcd'ny-the applicant;
I herebv cerd penalty of . laii, that. have, and am familiar wifivilie lnfdr�natian
' - fy, uil�r. penalty I _� I . -
,yj mjttjd in thiv 4,�e*ment and all, attachments thereto and that, .based on my ioquir}, .&fthds'6 individuals
immediately rgspoglfbid'for obtaining- said- information; I-beltive that the information is -true, a&uOvie and
'A� es' , i�s
Complete. I altj mvate that there are -signifi-zqnt penalties, iixWin�� the possibilitypossibilityaJ,, , and.hnp oninent,
for's6bmillingpise information, J agree to constnxt; operate, *ajj#qjn; ropair; anid -if appficable;.abandbn
VW injecHo?, well and all relatedappurtcqqnces in -accordance ivith.4he IIANCAC QIC 060 ptaes.,
7 ------
ftasture oYW6perty Owner/App*x4j,
V V ti
,Print or'TvFull Nattio
Signature of Autho!O#d Agidt; ir any
'Print or Tppe:Buil..Natrig.
DWQt
god 4130120 2)
Odosed-L&p 6ebtIJeffTW04Od9Cidi (.R'60

' oq
l^
PLOT PLAN LQT 99 SHERMAN; PINCS.) OR
CQRNER-STONE RESIDENTIAL BU1l DE'RS Ii C :
i, GEORGE, C GE" TY L "=32G AS 'A "PRL�Fe$StuP1�F�LAhtD Sl(R!7EYLR-
'IN THE HqE
�
STATE OF.,[vORTi.CAROLIMA- Dp -aY C RVY' THAT THIS
PRELPMMARY PLAr'WAS DRAWN QIIHR tt' SUkRVISipN J;
. :- �� S✓�tJ�/I�ii
�� � a C4udFr}
THAT THEE-LO7",LINES ARE: DRAWN AS DASHED LINES FROM 'SAID
F CFERENCES S ' OW^I Ht_ REOhj t t 3AT THIS PRCLIMINAP,Y P "A ;r
.
kaj f [!R' RECORVATIGN �CUNVEStt(C 5 OR SALES
' 1 T ;}
� F-*+•
. Z
:4t.ITIv�SS hIY QRIGji�AI SIG�JArl1Rc. ttih)➢ S_•AL. THIS THE
✓ �.. a D6Y ;Ow
=1�a6
�, Y. r �..
P. ORES$ GNAL A\D C!R
r.rtrGi►...
VICINITY MAP
I ;UnVE _ .;
i CEcI5� NLN Est . _.
=NOT TO ;SCALE...

3 57, 514 (p 25 3
--78, 817 3 01
lap Tool Options
The current cursor mode is set to 'Select/ldentify'.Click on a
map feature to select it. Clicking on a map feature that has
already been selected will unselect. Dragging on the map will
create a window that selects multiple features. Use the drag
select for better accuracy when selecting points. The
calartnhla thama ran ha cat fin tha rinht
_Active Tool: Select Feature
Map Layer P Pin
I ar F]
Mode: Point/Box
Y
Mapping ; Search
Show All Selections —
Selection Options_— _— T Clear
JZoom to selected map feature
I Selected_ Parcel Feature _
—
[PIN
10655-43-2970.000
080655 0118 55 _ —_
1[REID]
10064640
OWNER INFORMATION
[AccountNumber]
1500000387
[Name1]
_
BOLZ CARL & WIFE_
[1 ame2]
BOLZ ANITA
[Address1]
599 EAST STREET
[Address2
[Address3I
[City]
MIDDLETOWN j
[State] _
CT
[ZipCode]
06457-
ASSESSMENT
INFORMATION
[ParcelBuildingValue]
[ParcelObxfValue]
[ParcelLandValue] 45000
[TotalAssessedValue] 45000
PARGLL INFORMATION
1000066
[Legal Description] LT#19 SHERMAN
PINES 1.944MAP#2008
348
[LegalLandUnits] 1.94 II
Site Information

.. 06/ 11 / 2012 10: 41 9197799294 PAGE 01 / 0
06108/2012 04:15 9193080689 COPNERSTONE RES B1-DR PAGE 02
NIOW H CAIt,f1>:,IN4 DEPAX'l MENT OF ENV1R0NlvMNT ANP NATURAL RESOURCPS JUN � � 2012
l+ o 'I ITICA'l ION OF X TT'ENT ` o CONsTRU T OR OpER1,TE INJECTION VYELil.P /0
ese wells are "Po -Milted by rule" and do not require an bh*Yidual perPna when coral Vied M aCeordatwe a-iih
the rrrle<c QJ'I S.� .?Vt QC tl2C . h1Q�+, 7hls nonce mtxvt be suhm ltivd t�ricir toto c�orrsir
OR
As dowfibcd in M NC C t32C ,0223 those wells circulate a mfr%geiant � � c� F� f � g at t�e�t[ng end
cooling system,
Arirrt C/r/airy or 7Vp lnjornarn'on, tUegi�le,StitlmtrteLs Will Be l�alitme,s Ineor�tplel
.DATE: t I , 2E1 �—. P��MX'1' �iU .._ _ —(V be completed by )DwQ)
A. TYPE 01 GUO'I(`HERMAL
(1) p ueo�as (riper 1t1; NCA
(2.) direct Eximsion (m per 15A
)p WELL TO HE MID
r2
-- � Nwnbet of wells:.. .
02C -0223) Mumber of wells:
B. STATUS OF WFLL OWNVIR (chonsc o e)
(1�) �af�l. Ie amt y n3 — abmit is io two (2) bush +d yq prior to cc�net�ttctfan,
(Z) Busit2es';/Drgalion Siibmih is forma treys prior W eatrstrtte�lr►n.
(3) �Govemtwnt: State ,_,,,,-,,,, Mini al Cb , tV Federal — Submit thlo form 30 days
prwr to construction.
WELL OWNER — For single fast' y rosldeom-s list the pro � owner(s). For ail others, list nnmo Uf the
i business. orpnjutin.N or govemjdet)t nemy person delegat signature aulhoa itY
Wiling Address:
City:
State: CA4 Zlp Code:. -- ------ County:
Day Tole N1,4
r�all No.:
EMA Address:f3o[:s+aL:, fS Fax No
PHYSICAL T-.clCATION OF WELL SUE
4�� (1) Fareel l&,noftcailon Number (PIN) of well
.6
t� 76
K �q Q\0 o o
MQMIC/Ctosed-Loop t7eatherM91 Natiliaatim (Revi6ed'V3012012) Pare l

06I.11/2012 10:31 9197799294 P"GE 92/07
06/08/2012 04.15 919;-1Q30689 UUMtK, IUNt. Kt-s ut-IJx r;Aat Yjzj
Y
(2.) Physical Address (if different than mailing address): `
City: State: Zip Code:
E. MAPS, PLANS, AND SPRCMCAnONS
(1) Maps trust W scaled or otherwise accurately Indicate distances and Otlefttions of features located
within 250 feet of the injection weii(s). Label i1 feaUM a , - Attach a
site -specific Map rbowing the locations of the following:
• Pproposed injection well • Wwater supply wells
loeatim • sseptic systems and associated spray irrigation
• Bbuilding3 sites, drain fields, or repair areas
• Ppmpetty boundaries
• Ssurfitce water bodies + JEMistitrg of pcy Wtial sources of giwttndwatcr•
sontwnrlatian
(2) Plat and specifications of the surface and subsurface oonslruction details ofthe well system.
)Er TYPES AND CONCENTIttAUONS OF ADMIVES — List arty additives that will be used and their
coaaeritrations. Only aM ves that the Department of Health and Hum= Services' Division of Tlublic He4jth
detertiTi s do not adversely affect ltttum. health shall be used. A• list of approved additives can he found
online at I p �,ncdenr.or h/w /. c t /a�vtira, All other additives require approval prior to use.
Water only w4 _
G. WELL »aMLER 1NiF0RMTXON (if known)
Well Driiling Contractor's Namv-. Glen Aro eja D (In LLC
NC Well Drilling Contractor C;ertificatlon No.: 'tom -A
Company Name! — Ow A D41 h Well 11d1lin Ll, - Catttwt.Person: .Cleo ,d .0muh
City, State: _NC_,_, Zip Code: 2 County: Wake ...„�--
Day Tcla Nvn' f91y1 i 6- $;gyp _ -- - - Coll No. f121422n9. 1 - -
FMAiL Address;i{ax Np.:
17WQ(tjlC/Clo9t&Loop Geadwmai Nutiti+n Alm (Rovised 43U012) pap 2

.06/11/2012 10:31 9197799294 1
@6/08/2012 04:15 9193030689 00 NEPSTONE PES LLDR
i
PAGE 03/07
PAGE 04
[- HEAT PUMP CONTRACTOR INfrORMA►TION
lY
CQJJ17 1datE19:.Inc.`
�o�nta,c;t pet's0A' 1 S art A w '
Clty: Qsrner ZIP COdC. _ 27529 StAte: 'NC Crxrr�ty:
Office Tele No..-._,[phone] CoU No.:
PWQ/t3 OCIMa 1-Lamp Gm0le al N0015WWA (Poo isxd. 4/3012042) ��

0r51111/2012 10:31 9197799294 - PAGE 04107
,%/08,'2012 04:15 9193030889 CTIR lE PSTONE RES RLPR PAGE fly
L PROTECTION — Pmvide a br#ef description of how (1) wotear supply; weils; (2) guru watet bcx o, anal (3)
se}ttic systoms and associated spray irrigation sits, drain fields, or repair areas wi0fin 250 feet of The proposed
injection wells will be prnte4IUO during.comu4 lon of tha wells:
- — sae oemtit�otarv„3ilIl"�,Illil�., _. _ -
J. VARIANCE — PwMuant to ! SA NCAC 02C .0241 the Director of the Division of Water Quality may grant a
w daxice from applicable waft const otion of operetlon swulwds provided that:
(1) use of tie Well(S) will not endanger human health and walfar+e or tie groundwater. and
(2) th9t 00O..Shwtion or operation ip accordepce wM the stattclards is not technically feasible or the
propo$w 0onstrU9000 pmVidea equ4l car better protection of the grow4water,
Any variance request should acae►mMV submittal oftivs notification to expedi#e evalu tioh oft{xe xa quost.
The varitutce request form can be accessed online at hlt�ttai nr enr.br�Cvrml�/rrglar,_y�}t vn/�a:at"
splicationg
SIGNATURV,$ — The hallowing section is to be corhploW as required below or by that person's authorized
agent: 15A NCAC 02C .0211(e) requites sip. tares as follows; =
(4) for a wrporation, by a respousible corporate officer;
(b) for a palter M111p Qr sole pmprilemrship: by a general partner or the pmpxietojr respecfiively;
(c) for a municipality or a state, fedeMl, or ether public agency: by either a principal executive
off'im or rankiol publicly eieci ofcsial;
9