Fill - Free fillable GEOTHERMAL APPLICATION (Town of Smithtown) PDF form

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

GEOTHERMAL APPLICATION

Property Owner’s name ____________________________ Phone No.________________

Address

____________________________________________________________________________

• Two (2) original signed and notarized applications–If new owner, proof of ownership

(example deed, contract of sale, etc.)

• Three (3) Engineer’s Stamped Plans – see page 6 for additional instructions

• Letter of Intent (commercial)

• Letter of Authorization from Owner (commercial)

• Contractors’ and Electrician’s Suffolk County license and insurance if not current and on file

(Workers’ Compensation, Disability and Liability) with valid expiration dates

• Fee – cash or check to the Town of Smithtown – check current fee schedule

Submit this page with application

(To be filled in by Building Department)

Application/Permit # __________________ Date _____________

S.C.T.M ___________________ Zoning District _______

Receipt # ____________

Plan Approved by ___________________ Date ____________

Permit Issued ________________ Permit Expires _______

To receive a Certificate of Compliance you must also submit the following:

1. Notarized Letter of Certification

On “Company Letterhead” reference building permit number and property owner’s

name and address. Must state that the installation is to manufacturer’s specifications

and all applicable New York State Building Codes

2. Electric Certificate from an approved Agency

3. Final construction approval

4. As-Built Drawings

(see page 3)

Current Fees

Payment due with application

Check or cash only

Commercial – $250 Residential $150

(Certificate of Compliance included)

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

COMMERCIAL* RESIDENTIAL

Approval may be required from Planning and Engineering

Address/location of System______________________________________________

Engineer

_________________________Address_________________________________

Village/City___________________State______Zip________Tel.___________

Fax ________________ E-Mail________________

Contractor________________________Address_______________________________________

Village/City___________________State______Zip________Tel.___________

Fax _______________ E-Mail____________________________

Electrician________________________Address_______________________________________

Village/City___________________State______Zip________Tel.___________

Fax _______________ E-Mail____________________________

Electrical Inspection Agency_______________________________________

Geothermal Systems

(indicate type of system)

A Closed Loop System uses buried high-density polyethylene (HDPE)

plastic piping installed in drilled and grouted boreholes that conductively

exchanges thermal (heat) energy with the ground via circulating water or

a water/antifreeze mixture through the piping system.

An Open Loop System is a series of standard water wells that extract

and use groundwater durectkt as a geat-exchange source then return

the heated or colled groundwater back to the aquifer

A Direct Exchange System uses buried copper tubing that conductively

exhanges heat energy with the ground via circulating a refrigerant through

the tubing

I, _____________________________ as the ____________________________

print name Agent, Contractor, Engineer, Owner,

Signature

___________________________

Sworn before me:

Notary stamp

This _____day of __________, 20____

_______________________________

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

APPLICATION FOR PERMIT

Permit applications shall include, but not be limited to, the following items which may be

satisfied by documentation supplied by the design engineer, installer or equipment

manufacturer as applicable:

(1) Demonstrate compliance with applicable site plan requirements.

(2) A plot plan on an approved property survey no greater than 1" = 40' scale depicting the limits

of the setback zone distance from structures, property lines and public

roads.

(3) Certification by the design engineer and/or installer that the Geothermal System complies

with all applicable regulations and all applicable state and/or local building

codes.

(4) Certification by the design engineer and/or installer that the Geothermal System was

installed as designed and that the design and installation complies with the

relevant industry standards and guidelines outlined below in section C(2), including

but not limited to AirConditioning Contractors of America (ACCA) Manual J heat

pump unit sizing for residential systems, ACCA Manual N or comparable load

calculation techniques for commercial systems, and manufacturer-specified

closed loop and DX field design guidelines

(5) For Open Loop systems only, a one-line diagram of the electrical components on the plot

plan (submersible pump power supply)in sufficient detail to allow for a determination that the

manner of installation conforms to the National Electric Code, Electrical Code of theTown of

Smithtown and the New York State Uniform Fire Prevention and Building Code.

(6) Certification of (1) through (5) above must be performed by a licensed Professional Engineer.

AS-BUILT DRAWINGS

Upon completion of construction, a scaled as-built drawing must be provided showing the

locations of buried wells, closed loops, DX boreholes and horizontal connector piping,

triangulated from two points on the property such as a building corner or other permanent

structure. Offsets must also be shown from the nearest property line,and on-site septic systems

and private water wells. As-built drawings must be certified by a licensed Professional Engineer.

DECOMMISSIONING

A. If the Geothermal System remains nonfunctional or inoperative for a continuous period

of one year, the Building Director may require that the buried ground heat exchanger

be taken out of service by the property owner

B. Closed Loop piping systems shall be decommissioned by flushing and filling the piping

with potable water and capping off the ends. If the heat transfer fluid contains

regulated materials (e.g., antifreeze, biocides, or corrosion inhibitors), the heat

transfer fluid shall be contained and disposed of in accordance with applicable

regulations.

C. Open Loop wells shall be decommissioned per NYSDEC requirements.

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

SETBACKS AND SEPARATION

Distances for Geothermal Systems (in feet)

Provide Separation Setbacks

Required

ACTUAL

<45

Required

>45 gpm

Required

ACTUAL

<45 gpm

Required

>45 gpm

Required

ACTUAL

Public water Supply Well

100¹ 100¹ 100¹ 200¹ 200¹

P riva te Water Supply Well

25 25 50¹٫²50100¹٫²

Sewage Disposal Structure, e.g.

septic tank, cesspool

25¹ 50 75¹٫²2550¹

Storm water Recharge

Structure, e.g., leach

field, unlined catch basin

25 25 50¹ 25 50¹

Potential Source of

contamination, e.g. Underground

Petroleum Storage Tank,

Chemical Use and Waste

Storage Area, etc.

25 25² 50² 25 25

On-Site Utility, Sewage and

Water Line, Lined Catch Basin

10 10 10 10 10

Building Foundation

10 10 10 10 10²

Property Line

10 10 10 10 10

Closed Loop

and DX

Systems

Supply Well Return Well

OPEN LOOP SYSTEMS³

NOTES

1. Consistent with SCDHS General Guidance Memorandum #25, Guidelines Regarding

the Use of Geothermal Well Systems for Closed Loop and Open Loop systems (applies

to geothermal systems proposed in conjunction with applications for the approval of

sewage disposal and water supply facilities).

2. Setbacks and separation distances should be verified by a qualified water supply

engineer or hydrogeologist for protection of building structures during re-injection

through return well (under shallow water table conditions), protection of geothermal

supply well water quality from sewage or chemical contamination, and protection of

private drinking water supply well from thermal

3. Separation distance between the supply and return wells at a project site should at a

minimum be based on recommendation from the drilling contractor, geothermal system

designer, and heat pump manufacturer to minimize thermal interference. For high

capacity systems (rated >45 gpm), separation distances should be verified by a qualified

water supply engineer or hydrogeologist.

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

§ 112-1.4. Geothermal permitting code.

A. Geothermal Systems

1. Definitions

a. A Closed Loop system uses buried high-density polyethylene (HDPE) plastic

piping installed in drilled and grouted boreholes that conductively exchanges

thermal (heat) energy with the ground via circulating water or a water/antifreeze

mixture through the piping system.

b. An Open Loop system is a series of standard water wells that extract and use

groundwater directly as a heat-exchange source then return the heated or

cooled groundwater back to the aquifer.

c. A Direct Exchange system uses buried copper tubing that conductively

exchanges heat energy with the ground via circulating a refrigerant through the

tubing.

2. There are several types of Geothermal Systems, also known as Ground Source Heat

Pumps, typically used on Long Island for space heating and cooling. They include:

Closed Loop, Open Loop, and Direct Exchange systems and are distinguished by the

type of Ground Heat Exchanger (GHX) installed in the earth for heat transfer.

3. The Closed Loop and Direct Exchange (DX) GHXs may be installed vertically in

drilled boreholes or horizontally in excavated trenches then backfilled. The Open

Loop systems are installed only in vertical drilled boreholes.

4. When Geothermal Systems are proposed in conjunction with applications for the

approval of sewage disposal and water supply facilities at a particular project site, the

installation is also subject to guidelines issued by Suffolk County Department of

Health Services (SCDHS) in General Guidance Memorandum #25-Guidelines

Regarding the Use of Geothermal Well Systems (Memo 25).

B. Permitted Geothermal Systems and Locations

1. Geothermal Systems may be permitted, installed, and erected pursuant to a building

permit and subject to the project meeting all other requirements including compliance

with applicable plumbing, electrical and mechanical codes.

2. Permitted Geothermal Systems eligible to receive a building permit are those that are

of a system listed in Section A(1); comply with the applicable General Requirements

in Section C; and satisfy the following basic criteria:

a. An Open Loop system using standard water well(s) to both extract and return

groundwater from/to the same aquifer and with well screens set within 50

vertical feet of one another.

b. An Open Loop system that is not connected to a potable water system.

c. An Open Loop system where the depth to groundwater is at least 20 feet

below the surface.

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

d. A vertical Closed Loop system using standard HDPE“U-bends” installed into

drilled boreholes and grouted fully from bottom to top per industry standards.

e. A Horizontal Closed Loop System, using standard HDPE pipe installed into

horizontal trenches and backfilled per industry standards.

f. A DX-to-earth contact system including either horizontal, diagonal or vertical

loops and DX-to-water systems including vertical loops.

g. Is not proposed to be located within the following Areas of Potential

Sensitivity:

(i) 100 year Flood hazard zones considered V or AE zone on the FEMA

Flood Maps.

(ii) Tidal or fresh water wetland.

(iii) Regulated tidal or fresh water surface water body.

(iv) Coastal erosion hazard area.

3. Other Geothermal Systems that are not eligible for a building permit under the

requirements of Section B(2) - including those located within Areas of Potential

Sensitivity- may be allowed at the discretion of the Building Director after appropriate

additional review and evaluation and contingent on obtaining other required permits

or approvals from other regulatory agencies, such as the New York State Department

of Environmental Conservation (NYSDEC) and the U.S. Environmental Protection

Agency (USEPA).

C. General Requirements

1. Permit applications shall be submitted to the Building Department on forms it provides

and shall comply with the requirements therein, including but not limited to the

following:

a. Application for Permit.

(i) Permit applications shall include, but not be limited to, the following

items which may be satisfied by documentation supplied by the design

engineer, installer or equipment manufacturer as applicable:

(1) Demonstrate compliance with applicable site plan

requirements.

(2) A plot plan on an approved property survey no greater than 1"

= 40' scale depicting the limits of the setback zone distance

from structures, property lines and public roads.

(3) Certification by the design engineer and/or installer that the

Geothermal System complies with all applicable regulations

and all applicable state and/or local building codes.

(4) Certification by the design engineer and/or installer that the

Geothermal System was installed as designed and that the

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

design and installation complies with the relevant industry

standards and guidelines outlined below in section C(1)(b)

including but not limited to Air Conditioning Contractors of

America (ACCA) Manual J heat pump unit sizing for residential

systems, ACCA Manual N or comparable load calculation

techniques for commercial systems, and manufacturer-

specified closed loop and DX field design guidelines.

(5) For Open Loop systems only, a one-line diagram of the

electrical components on the plot plan (submersible pump

power supply) in sufficient detail to allow for a determination

that the manner of installation conforms to the National Electric

Code, Electrical Code of the Town of Smithtown and the New

York State Uniform Fire Prevention and Building Code.

(6) Certification of (1) through (5) above must be performed by a

licensed Professional Engineer.

b. Design Standards and Guidelines

(i) The design and installation standards of Geothermal Systems

including related wells and boreholes for the GHX shall conform to

applicable industry standards, including, but not limited to, those listed

below by type of system, and shall comply with the Building Code as

well as all other applicable requirements:

(1) All Systems: The American National Standards Institute (ANSI),

the American Society for Testing and Materials (ASTM), the

American Society of Heating, Refrigeration, and Air

Conditioning Engineers (ASHRAE), the Air-Conditioning and

Refrigeration Institute (ARI), ACCA, Refrigeration Section of the

International Building Code, and other similar certifying

organizations. The manufacturer specifications shall be

submitted as part of the application. The individual piping

loops, circuits, and fully constructed piping network for all

Geothermal Systems shall be pressure tested for integrity of

original material and joints prior to backfill in accordance with

the manufacturer’s instructions and the governing standards or

guidelines. Materials used to backfill horizontal GHXs and the

buried, horizontal piping for vertical GHXs shall be suitable

granular soil and shall be free from frozen lumps, ashes,

refuse, vegetable or organic matter, rocks or boulders over 150

mm (6 in) in any dimension, or other materials that may

damage the piping. The backfilled excavations shall be

compacted in accordance with industry standard practice and

governing guidelines and regulations.

(2) Open Loop Systems: The National Ground Water Association

(NGWA) and the American Water Works Association (AWWA).

(3) Closed Loop Systems: the International Ground Source Heat

Pump Association (IGSHPA) and the NGWA.

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

(4) Direct Exchange (DX) Systems: the Canadian Standards

Association (CSA), the National Association of Corrosion

Engineers (NACE), the American Society of Mechanical

Engineers (ASME) and in accordance with manufacturer’s

guidelines, methods and standards.

(ii) For Closed Loop systems, the following specifically

applies:

(1) Closed Loop borefield installers must be trained and accredited

by IGSHPA and certified by the piping manufacturer in

polyethylene pipe heat-fusion or electro-fuse welding

techniques, whichever is used.

(2) Closed Loop borefields that will supply greater than 50 tons of

heating/cooling capacity must be designed by an IGSHPA

Certified Geothermal Designer in good standing with IGSHPA.

(3) If antifreeze solutions are used as a circulating fluid in the

buried ground heat exchanger, only antifreeze recommended

by IGSHPA such as methanol, ethanol, and food grade

propylene glycol shall be permitted.

(4) The borehole annulus (space between the borehole wall and

piping) shall be filled and sealed through its entire depth with a

high-solids bentonite clay grout (at least 20 percent solids by

weight), from the bottom of the borehole to the top using the

tremie method of grouting.

(5) Where grouting material extends through zones of salt water, a

salt water resistant grout material shall be used.

(iii) For Open Loop systems, the following specifically applies:

(1) Open Loop system contractors must be registered by NYSDEC

for drilling and installing wells and installing and start-up of

submersible pumps and a copy of a NYSDEC Well Completion

Report must be submitted after the installation of the wells.

(2) Well drilling contractors must notify the Suffolk County Water

Authority (SCWA) of the location of wells installed as part of an

Open Loop geothermal system.

(3) Open Loop systems with rated pumping capacity of greater

than 45 gallons per minute (gpm), or systems of lesser capacity

proposed on a site with existing water supply wells and for

which the combined pumping capacity of proposed and existing

wells exceeds 45 gpm, must obtain a Long Island Well Permit

from the NYSDEC Division of Water.

(4) Open Loop systems with rated pumping capacity of greater

than 45 gpm shall employ use of a plate-frame or shell-in-tube

heat exchanger (HX) installed between the well piping and

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

building hydronic loop to prevent cross-contamination of the

return water by refrigerant, biocides, or corrosion inhibitors.

(5) Heat pump coils and HX material of construction for Open Loop

systems must be compatible with the groundwater chemistry

per manufacturer’s limits.

(6) Water Extraction

(i) Open Loop systems may utilize a waterway to the

extent permissible under Federal, State, or local

municipal laws or regulations.

(ii) Installation requirements for Open Loop wells shall be

the same as those for potable water wells, with respect

to the means to prevent aquifer contamination (grouting,

etc.), or in conformance with standards, regulations, or

guidelines established by the Town Engineer, NYSDEC,

NGWA, and AWWA.

(iii) Any water table drawdown caused by an extraction well

or wells shall not cause harm to the environment or

otherwise impact the use of existing water supply wells

on neighboring properties.

(7) Discharge of Water

(i) Discharge of water from Open Loop systems into storm

or sanitary sewer systems shall be prohibited, except

upon written approval by the SCDHS, NYSDEC, or

other authority having jurisdiction.

(ii) Discharge of water from Open Loop systems into a

waterway or tidal or fresh water wetland is not allowed

unless approved by applicable Federal, State, and local

authorities.

(iii) Underground injection of water discharge from an open

loop system shall be subject to the following conditions:

(1) Returned water shall contain no treatment

additives or other introduced chemicals.

(2) The return well shall recharge the same aquifer

from which the supply water is extracted and

recharge shall occur within 50 vertical feet of the

supply well screen.

(3) The return well shall discharge the water below

the water table depth to prevent aeration of the

return water which can lead to precipitation of

iron or other minerals and premature plugging of

the well screens.

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

(8) Return water practices shall not cause erosion, harm to the

environment or flooding at the surface or other nuisance

conditions on neighboring properties.

(iv) For DX systems, the following applies:

(1) DX system contractors shall demonstrate they have

successfully completed a DX system installers training course

and are certified by an applicable equipment and material

manufacturer to install DX systems.

(2) Piping and tubing shall be of a material equivalent to or better

than Type Air Conditioning Refrigeration (ACR) piping, tubing

and associated fittings in accordance with the appropriate

ASTM Standard and ASME Standard.

(3) Below-grade joints shall be purged with inert gas and brazed in

accordance with American Welding Society (AWS) Standards.

Piping tubing and fittings shall be installed in accordance with

CSA standards.

(4) DX system contractors shall perform joining of all refrigerant

connections per CSA standards.

(5) All underground Type ACR piping and tubing shall have a

cathodic protection system which shall be designed and

installed in accordance with the appropriate CSA standards

and local site-specific conditions.

(6) For vertical DX boreholes that are drilled into saturated aquifer

materials (below the water table), the borehole annulus shall be

filled and sealed through its entire depth with a geothermal

grout from the bottom of the borehole to the top using the

tremie method of grouting per CSA standards.

(7) Horizontal DX GHXs and vertical DX boreholes lying above the

water table shall be backfilled and compacted as specified in

section B(1)(b)(i)(1). Due consideration shall be given to

settling of the excavated area.

2. As-Built Drawings

a. Upon completion of construction, a scaled as-built drawing must be provided

showing the locations of buried wells, closed loops, DX boreholes and

horizontal connector piping, triangulated from two points on the property such

as a building corner or other permanent structure. Offsets must also be

shown from the nearest property line, ond on-site speptic systems and private

water wells. As-built drawings must be certified by a licenset Professional

Engineer

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

3. Decommissioning

a. If the Geothermal System remains nonfunctional or inoperative for a

continuous period of one year, the Building Director may require that the

buried ground heat exchanger be taken out of service by the property

owner.

b. Closed Loop piping systems shall be decommissioned by flushing and

filling the piping with potable water and capping off the ends. If the heat

transfer fluid contains regulated materials (e.g., antifreeze, biocides, or

corrosion inhibitors), the heat transfer fluid shall be contained and disposed of

in accordance with applicable regulations.

c. Open Loop wells shall be decommissioned per NYSDEC requirements.

4. Setbacks and Separation Distances

Setbacks and Separation

Distances for Geothermal Systems (in feet)

Closed

Loop and

Systems

Open Loop Systems

Supply Well

Return Well

<45 gpm

>45 gpm <45 gpm >45 gpm

Public Water Supply Well 100

100

200

Private Water Supply Well 25 25 50

1,2

50 100

1,2

Sewage Disposal

Structure, e.g., septic tank,

cesspool

50 75

1,2

25 50

Storm water Recharge

Structure, e.g., leach field,

unlined catch basin

25 25 50

25 50

Potential Source of

Contamination, e.g.

Underground Petroleum

Storage Tank, Chemical

Use and Waste Storage

Area, etc.

25 25

On-Site Utility, Sewage

and Water Line, Lined

Catch Basin

10 10 10 10 10

Building Foundation 10 10 10 10 10

Property Line 10 10 10 10 10

For Design Standards see §112-1.4.Geothermal permitting code

W:\work\Web Forms-App_Geothermal_Perm_inst 4-6-15

Notes:

1. Consistent with SCDHS General Guidance Memorandum #25, Guidelines Regarding the Use

of Geothermal Well Systems for Closed Loop and Open Loop systems (applies to geothermal

systems proposed in conjunction with applications for the approval of sewage disposal and

water supply facilities).

2. Setbacks and separation distances should be verified by a qualified water supply engineer or

hydrogeologist for protection of building structures during re-injection through return well

(under shallow water table conditions), protection of geothermal supply well water quality from

sewage or chemical contamination, and protection of private drinking water supply well from

thermal effects or water level drawdown caused by geothermal wells.

3. Separation distance between the supply and return wells at a project site should at a minimum

be based on recommendation from the drilling contractor, geothermal system designer, and

heat pump manufacturer to minimize thermal interference. For high capacity systems (rated

>45 gpm), separation distances should be verified by a qualified water supply engineer or

hydrogeologist.

Dated: March 19, 2015

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