296 Transmittal Forms for Permit & Application & Payment 2009 Enter your transmittal number -y X228142
Transmittal Number
Your unique Transmittal Number can be accessed online:htto://mass.qov/dep/service/online/trasmfrm.shtml or call
MassDEP's InfoLine at 617-338-2255 or 800-462-0444(from 508,781,and 978 area codes).
Massachusetts Department of Environmental Protection
Transmittal Form for Permit Application and Payment
e type or A. Permit Information
eparate
tal Form
completed
permit
)n.
BRP W S06 a, b &c Registration of Discharges to Underground
1.Permit Code:7 or 8 character code for permit instructions Injection Wells
Installation and Operation of closed loop qeo-thermal heating system water loop and DX wells.
3.Type of Project or Activity
your
iyable to alth pp B. Applicant Information - Firm or Individual
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idiusetts
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it form to.
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Permits,
LSP.
Only
Nonotuck Mill, L.L.C.
1.Name of Firm-Or,if party needing this approval is an individual enter name below:
2.LastName of Individual -- --
296 Nonotuck Street
5.Street Address
Nonhmapton (Florence)
6.Citytrown
Matthew McDonough (Properly Manager)
11.Contact Person
3.First Name of Individual
4.MI
MA 01062 413-537-9109
7.State 8 Zip Code 9.Telephone#
mcdonoughrealty @yahoo.com
12.e-mail address(optional)
10.Ext.#
C. Facility, Site or Individual Requiring Approval
Nonotuck Mill L.L.C.
L Name of Facility,Site Or Individual
296 Nonotuck Street
2.Street Address
Northampton (Florence) MA
3.City/Town 4.State
8.DEP Facility Number(if Known)
01062 413-537-9109
5 Zip Code 6.Telephone# 7.Ext.#
1-17208
9.Federal I.D. Number(if Known) 10.BWSC Tracking#(if Known)
D. Application Prepared by (if different from Section Bp
ECS, Inc
1.Name of Finn Or Individual
588 Silver Street
2.Address
Agawam MA
3.City/Town 4.State
Richard Starodoj
8.Contact Person
01001 413-789-3530 325
5.Zip Code 6.Telephone# 7.Ext.#
9. LSP Number(BWSC Permits only)
E. Permit - Project Coordination
1. Is this project subject to MEPA review? 0 yes 0 no
If yes,enter the project's EOEA file number-assigned when an
Environmental Notification Form is submitted to the MEPA unit:
EOEA File Number
F. Amount Due
Special Provisions:
1. 0 Fee Exempt(city,town or municipal housing authorityystate agency if fee is$100 or less).
There am no fee exemptions for BWSC permits,regardless of applicant status.
0 Hardship Request-payment extensions according to 310 CMR 4.04(3Xc).
0 Alternative Schedule Project(according to 310 CMR 4.05 and 4.10).
0 Homeowner(according to 310 CMR 4.02).
13291 $240.00 5/5/09
Check Number Dollar Amount Date
mventional.doc•rev. 1/07 Page 1 of 1
1
ons
out
SO
key
rot
rn
ions
ions
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells El
BRP WS 06 Modification to an Existing UIC Registration
■
X228142
Transmittal Number
UIC Registration Fee (check the appropriate well type category)
a. High includes the following well types-5A5,5D4,5W20&5X25 Registration Fee=$480.00
b. Moderate includes the following well types-5A6,5A19, 5F1, 5S23&
5X27
Low includes the following well types-5A7,5A8,5B22,5D2,5G30,
5R21&5X29
Pre-closure/WS-06d form-for UIC wells not previously registered with MassDEP. Registration of
these wells is not done using this form.They must be submitted on a Pre-Closure/WS-06d form.
Residential Exemption [for four units or fewer]—the following well types(typical residential activities)
are exempt from a UIC registration fee and have a separate registration form WS-06e—5A7, 5D2,
5G30&5X18.
c.
d.
e.
Registration Fee=$240.00
Registration Fee=$ 90.00
See the Class V Injection Well Type Table at the end of the Instructions for well type.
Transaction Type
Registration: ® Initial- new registration ❑ Initial-existing registration ❑ Conversion
❑ Partial Closure/Registration
Modification: ❑ Change of owner/operator ❑ Change in or additional well/code(s)
❑ Change in location well(s)
For modifications (required)
❑ Change in 4 of discharge wells (+/-)
UIC Registration D#issued by MassDEP in the original UIC
A. Facility Information
For modifications, enter new or revised information
Nonotuck Mill
Facility/Property Name
Nonotuck Mill, L.L.0 541330
Company Name SIC Code#
Northampton Hampshire
(Florence) County
NA
Facility PWS ID#(if appropriate)
413-537-9109
Facility Telephone Number
NA
EPA Hazardous Waste Generator ID#
iventonal doe rev.0&06
296 Nonotuck Street
Facility Street Address
(MassDEP Use Only)Facility#
MA 01062
State Zip Code
mcdonoughrealty@yahoo.com
Facility Email(optional)
NA
EPA Hazardous Waste Generator ID#
BRP WS 06 a,b,c-Regis ti of pscharges to Underground Injection Wells.Page 1 019
1
ans
ons-
ions-
:ions
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells
BRP WS 06 Modification to an Existing UIC Registration ❑
X228142
Transmittal Number
B. Owner/OperatorInformation
For modifications, enter new or revised information
Nonotuck Mill, L.L.C.
Name of Owner
Northampton (Florence)
City/Town
ECS, Inc.
296 Nonotuck Street
Address of owner Of different from facility)
MA 01062
State Zip Code
568 Silver Street
Name of Operator(if different from owner)
Agawam
City/Town
Matt McDonough (Mill Property Manager)
Legal Contact
Ownership Type:
Private: ❑ Industrial
Address of operator(if different from facility)
MA 01001
State City/Town
413-537-9109 (413)584-8266
Legal Contact Phone# Legal Contact Fax#
Z Commercial ❑ Non-profit
Public: ❑ Local ❑ Regional ❑ State
❑ Residential
❑ Federal
C. Injection Well Information
For modifications, enter only new or revised information:
Registration: ❑ Individual or ® Area
Direct Heat Reinjection 5A6 7 Total (2 Water Loop, 5 DX)
(Closed Loop) Well Code Number of wells
Well Construction (check all that apply)
❑ Drywell ❑ Septic Tank
❑ Drainfield/ Leachfield
Z Other(describe):
❑ Cesspool ❑ Dug Well ❑ Improved Sinkhole
❑ Dustwater onto the ground
Drilled Well
Heat from closed loop geo thermal heating system
Type of discharge
No water discharge(closed loop geo thermal heating system)
Source of water discharged to the well
14,400
Average flow(gallons per day) Month/Year of well construction Month/Year ceased using well(s)for previous use(s)
2 2
#of entry points to existing system #of entry paints for proposed system Total#of entry points to system
List any treatment devices in place or proposed prior to the injection point:
None-closed loop geothermal
iventional doc•rev.08)06
BRP WS 06 a,b,c-Registration of ascharges to Underground Injection Wells•Page 2 of 9
IS
18
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells
BRP WS 06 Modification to an Existing UIC Registration ❑
X228142
Transmittal Number
C. Injection Well Information (cont.)
15 approx
Depth to water table(feet)
Sand, Till
Soil type(s)at side-e.g.,fill,sandy till,gravel,sand
1,800 feet west
Distance to nearest Public Water Supply(within 2500)
20 approx
Depth to bedrock(feet)
None(non-contact cooling water 850' east)
Distance to nearest private drinking water well(within 1250')
Well 1214000-02G (City of Northampton)
Name of nearest Public Water Supply
D. Operational Status
® Designed, not yet constructed
❑ Temp. abandoned
❑ Under Construction
❑Active
❑ Conversion to another well type
❑ Partial Closure/conversion to another well type (well code) ❑ Active/Partial Closure
❑ Permanently abandoned/not reported previously
Closed Water Loop Geo Thermal Heat Loop Closed ose ofDinjection p Geo Thermal Heat Loop
Source of injection fluid(#1)
15 gpm
Source of injection fluid(#3) Rate of injection(gpm or other unit value)
Ethanol (Dilute)for water loops Refrigerant for DX system
Potential contaminant#1 Potential contaminant#2
Compressor Oil for DX system - -Potential contaminant#3 Potential contaminant#4
E. Site Information
Are there any other discharges on site?
If yes, are they permitted with MassDEP?
If no, are they registered with MassDEP as Class V
wells?
Please list the type or types of discharges:
❑ Yes
❑ Yes
❑ Yes
Z No
❑ No
❑ No
Check any of the following that apply to this site:
Superfund site
Bureau of Waste Site Cleanup Priority Site
Bureau of Waste Site Cleanup Waiver Site
Please provide a copy of the letter of authorization if applicable.
ivenlmnal doe•rev.08106
NA
NA
If yes,Federal ID#
1-17208
If yes,file number
If yes,file number
BRP WS 06 a,b.c-Registration 01 Discharges 10 Underground Injection Weis'Page 3 of
ns
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells
BRP WS 06 Modification to an Existing UIC Registration ❑
X228142
Transmittal Number
E Site Information (cons.)
If the site is currently being regulated by the Bureau of Waste Site Cleanup, check any of the
following that apply:
❑ Incident Response
❑ Short Term Measure
Activity and use limitations:
Confirm that the applicant has checked that the site does not have any activity restrictions with
respect to limiting discharges on the site. - - -
❑ No restrictions El Restrictions (please explain;attach additional sheets if necessary):
Oil release under eastern portion of building downgradient of area covered by this permit. See
previously attached information.
Location of Facility:
Is the facility located on Native American lands? ❑ Yes ® No
19'48.33" 72 40'37.35"
Latitude: 42 Longitude: degrees min(')sec(")
degrees min(')sec(")
Latitude& Longitude are no longer optional data.
Identify the method used for locating the latitude/longitude coordinates for the UIC Class V well(s):
Type:
❑ Approximate location of point of UIC Class V well(s)
❑ Approximate center of drainfield(s)
❑ Approximate location of area wellfield(s)
❑ Approximate center of facility(ies)
❑Approximate center of area where discharges are located
Accuracy:
• Estimated horizontal accuracy is less than +/-100 feet
❑ Estimated horizontal accuracy is less than +/-500 feet
❑ Estimated horizontal accuracy is less than +/- 1000 feet
BRP ws nfi a.b c Registration M Discharges to Underground Injection weus•Page 4 of
venunnai Boo-rev.08/06
-Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells E
BRP WS 06 Modification to an Existing UIC Registration ❑
X228142
Transmittal Number
E.-Site Information (cont.)
Provide a narrative description of the site and the feature to be permitted. As an example:"The site is
on the west side of Main Street,the third building north of High Street. The disposal field lies 100 feet
off the southwest corner of the building"
Site is on south side of Nonotuck Street. Water loop wells are located adjacent to west side of
western most building. DX wells are located adjacent to south east portion of western most building.
Site plans depicting well locations have been previously submitted.
All additional information that is relevant to the installation or operation of this injection well and to the
determination of its potential to endanger underground sources of drinking water (USDWs)—
including a site map showing the facility and UIC well(s), on-site drinking water wells, all other on-site
discharges and the drains leading to the well and/or drainage area served by the well. MSDS sheets
for chemicals likely to be discharged into well must be submitted. Analytical data available on the
discharge or raw water as applicable.
® Map attached ® Detail sheets attached ® MSDS sheets attached ® Other information attached
Attach a map of the facility based on a USGS topographical map or MassGIS Color Ortho
Photography that clearly indicates both your facility and the location of the discharge.
The USGS topographical map is available at:
http://maps.massdis.state.ma.us/MassGISToposiviewer.htm
or the Color Orthophotography At: http://maps.massgiss to te.ma.us/MassGlSColorOrthos/viewer.htm.
Attach sbuildings, b abutting tpp all
UIC wells, location of on-site drinking wells, location of monitoring wellsand a locus .
Attach a narrative description of the shallow injection well system and its major components.The
description should contain a diagram including the plan view and cross sectional view of the shallow
injection well system, indicating piping,junction boxes, tanks, and leachfields. Dimensions of all major
components and design calculations must be included.
Attach the Material Safety Data Sheets for all chemical products stored or used at the facility which
may intentionally(additive)discharge or unintentionally (spill/leak)discharged to the shallow injection
well(s).
Attach existing analytical testing data from the existing waste stream or raw water for expected
contaminants in proposed waste stream, based on specified testing parameters.
For stormwater submittals (if applicable):
Attach a letter from the local municipality or other responsible party committing to long term
maintenance of the UIC system, as described in the maintenance stipulations of the UIC Program
Registration Approval if this applies (responsibility for maintenance is to be transferred).
Attach a letter from the local municipality or other responsible party if there is a discharge from the
UIC system (actual or proposed)to another offsite system (town storm sewer or wetlands).
BRP WS 06 a.b,c—RepstraUm of Discharges to Underground Injection Wells Page 5 of 9
rveneonar dcc•rev.06106
Massachusetts Department of Environmental Protection -_=-
Bureau of Resource Protection - Drinking Water Program
-BRP WS O6 a,b1C
Registration of Discharges to Underground Injection Wells El
BRP WS 06 Modification to an Existing UIC Registration ❑
X228142 - -
Transmittal Number
E7 Site Information (cunt.)
Who must register:-.- -. -
Any party who discharges to a Class V Well as defined in 310 CMR 27.00 must apply except those
listed as exempt from the registration requirement as per 310 CMR 27.07:
(2) Groundwater Remediation Projects.Any injection into a Class IV or Class V injection well during
a response action conducted or performed in accordance with the provisions of M.G.L.c. 21 E
and the Massachusetts Contingency Plan, 310 CMR 40.0000, dr for the purpose of remediation
at a release site, pursuant to the provisions under the Comprehensive Environmental Response_,
Compensation, and Liability Act of 1980 (CERCLA),42 U.S.C.9601-9675, or pursuant to
requirements and provisions under the Resource Conservation and Recovery Act(RCRA), 42
U.S.C. 6901-6992k shall be exempt from:
(b)the registration requirements set forth in 310 CMR 27.08;
3) Registration.The following Class V injection wells are also exempt from the registration
requirements of 310 CMR 27.08:
(a)on-site subsurface sewage disposal systems used solely for the disposal of sanitary sewage
and regulated under 310 CMR 15.000.
(b)Class V injection wells permitted under 314 CMR 5.00.
Any party closing a UIC Class V well that has not previously registered with the MassDEP UIC
Program must register using the BRP WS-06d Pre-Closure Form.
If you have not previously registered and you are closing the use of the well(s)for one (or more)uses
but want to continue using the well(s)for one (or more)uses you must mark the top of this form by
checking the box for"Transaction Type"-Partial Closure/Registration and attach the Pre-Closure
Notification Form to this submittal.The Pre-Closure Notification Form must be submitted to the
Boston Office.The Boston Office will forward the Pre-Closure form to the appropriate
MassDEP Regional Office for those uses that you intend to discontinue to discharge to the
Class V Well. All further communication on closure of the well(s)including filing of the Post-
Closure document should be with the appropriate MassDEP Regional Office.
If you have not previously Registered and you are converting the well from a"prohibited"use to a use
that is"authorized by rule"you must mark the top of this form by checking the box for"Transaction
Type"- Conversion and attach the Pre-Closure Notification Form for those uses that you intend to
discontinue to discharge to the Class V Well.The Pre-Closure Notification Form must be
submitted to the Boston Office.The Boston Office will forward the Pre-Closure form to
appropriate MassDEP Regional Office for those uses that you intend to discontinue
discharging to the Class V Well. All further communication an closure
of the Regional well(s)including
e.
filing of the Post-Closure document should be with the appropriate
If you are registering a well(s)at a residential structure (four units or fewer),the MassDEP UIC
registration form WS-06e should be used instead of this one.
Who must submit a notification form: •
If the Owner or Operator information(name address or other contact information)changes you must notify the UIC
program at least 30 days prior to the change(s).
If you are adding wells(Area Registration);relocating the well(s),changing the discharge(Well Code)to the well(s)or
adding additional discharges(Well Code)you must notify MassDEP at least 60 days prior to the change.
If you are closing the well(s)and relocating the well(s)and are planning to have the same discharge(Well Code),you
must mark the top of this form by checking the box for Relocation of Well(s)and attach to this submittal a Pre-Closure
Form for the well(s)being closed.
BRP WS 06 a,b,c.Registration of Dsdarge$to underground Injecllon wells.Page 6 of 9
vent Dnaldoc•rev-0&06
Macsaehusefs-Department of Environmental Protection
13hreau of Resource P-rOTection --Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells Er
BRP WS 06 Modification to an Existing UIC Registration ❑
X228142 -
Transmittal Number
—E Site Information (cont.) - -
_______ Fees:- -- . .
_. An application fee(effective 10/08/04)is due when the Registration application is submitted. There is
----
no application fee associated with submitting a Modification application to an existing Registration.
Category Registration Fee
Registration Form -- -
_. . BRP WS06a _.. _ ... . - . High . .. -_. $480.00
BRP WS 06 b
Moderate $240.00
BRP WS 06 c Low $ 90.00
BRP WS 06 d Pre-Closure/Registration $ 90.00
BRP WS 06 e Residential Registration No fee-exempt
No MassDEP Transmittal Form or number is needed when submitting a Modification to an existing
UIC Registration or when submitting a Residential Registration Form (WS-06e).
There is no annual compliance fee associated with this Registration.
BRP W$06 a.0 c-Registration of Discharges to Underground Injection Wells-Page 7 of 9
wenllonal doe'rev.08/06
-Massachusetts-Deparimeni oE-Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of rischargestoUndergroundInjection Wells
BRP WS 06 Modification to an Existing UIC Registration
0
X228142
Transmittal Number
-f:Affidavit
The injection well(s)described above is used for placement or injection of fluids into the ground. I/we
understand that this well is subject to inventory requirements and compliance with the regulations
under the Underground.injection Control Program established pursuant to the Safe Drinking Water
Act, P.L.93-523, and amendments, and I/we hereby serve notice that the well is proposed or in
service. -
I/weagree:
That the well( c) scrbed herein will ofior Bts-charges other than those described
above;
2. That I/we will notify the Massachusetts Drinking Water Program/UIC Program (on forms provided
by the UIC program) if any of the information (including Ownership, Location or Type of
discharge)for the above well(s)changes, but before the change (30 days minimum notice on
ownership/operator and 60 day notice on all other changes);
3. That 1/we will notify the Massachusetts Drinking Water Program/UIC Program (on forms provided
by the UIC program—Pre-Closure Notification Form)when the above well(s) is no longer in use,
but before abandonment and file a Post Closure Notification Form within seven days of
completing the closure with the UIC program.
4. That I/we will maintain financial responsibility for the well described above;and
5. That Uwe will provide a sampling tap (approved by MassDEP) and allow sampling at the point of
injection.
I/We certify under penalty of law that I/we have personally examined and am/are familiar with the
information submitted in this document and all attachments and based on my personal knowledge or
inquiry of those individuals immediately responsible for obtaining the information. I/We believe the
information is true, ;ccurate, and complete. I/we am/are aware that there are significant penalties for
s _rysng;.IS; in :r,ation, including possible fines and imprisonment.
-- 5/6/2009
awre of Preparer Date
Richard Starodoj Project Manager(ECS, Inc.)
PositioNritle
Printed Name of Preparer
aentionald -rev.06106
BRP WS 06 a.b c-Registration 01 DLYlurges to Underground Injection Wells•Page 0 of 9
-Massachusetts-Department of Environmental Protection
Bureau of Resource Protection- Drinking Water Program
BRP WS 06 a,b,c
-Registration of Discharges to Underground Injection Wells
BRP-WS 06 Modification to an Existing UIC Registration ❑
X228142
Transmittal Number
—.-Questions
-Any questions may be directed to the UIC Program at(617)348-4014 or to the UIC Contact at your
Regional MassDEP Office.
Find your region:http:/Imass.gov/dep/about/reoionTndvourhtm
Submit Application to:
MassDEP
- Drinking Water Program
1 Winter Street-6t" Floor,
Boston, MA 02108
Attn: UIC Program
MAILING ADDRESSES
UIC Program, MassDEP Northeast Regional Office(NERO),
205b Lowell Street,Wilmington, MA 01887
UIC Program, MassDEP Southeast Regional Office (SERO),
20 Riverside Dr., Lakeville, MA 02347
UIC Program, MassDEP Central Regional Office(CERO),
627 Main Street,Worcester, MA 01608
UIC Program, MassDEP Western Regional Office (WERO),
State House West,4th Floor, 436 Dwight Street, Springfield, MA 01103
UIC Program, MassDEP Boston Office,
One Winter Street–6th Floor, Boston, MA 02108
SERVICE CENTER PHONE NUMBERS:
Northeast Regional Office
Southeast Regional Office
Central Regional Office
Western Regional Office
Send duplicate copies of all forms to:
Local Board of Health
Local Plumbing Inspector
vem,onal doc•rev.06106
978-694-3200
508-946-2714
508-792-7683
413-784-1100 ext. 214
BRP W S 06 e,0,c-Registration of Discharges to Underground Inlecew Wells•Page 9 of c
Enter your transmittal number X228143
Transmittal Number
Your unique Transmittal Number can be accessed online:http://mass.qov/dep/service/onlinehrasmfnn.shtml or call
MassDEP's InfoLine at 617-338-2255 or 800-462-0444(from 508,781,and 978 area codes).
Massachusetts Department of Environmental Protection
Transmittal Form for Permit Application and Payment
'°r A. Permit Information
BRP WS06 a, b&c - Registration of Discharges to Underground
1.Perna Code.7 or 8thamder code from permit nstrucions Injection Wells
Installation and Operation of closed loop geo-thermal heating system (Kelix Water Loop)
3.Type of Project or Activity
cot
leted
:lo B. Applicant Information- Firm or Individual
realth
ens Nonotuck Mill L.L.C.
ha
mi to
x
MA
ies of
De
1.Name of Firm-Or,if party needing this approval is an individual enter name below:
2.Last Name of lndMdual
296 Nonotuck Street
5.Street Address
Northampton(Florence)
6.City/Town
Matthew McDonough (Property
11.Contact Person
- _- -- 3.First Name of individual
4.MI
Manager)
MA
7.State
01062 413-537-9109
8.Zip Code 9.Telephone#
mcdonoughrealty@Yahoo.com
12.e-mail address(optional)
10.Ext#
3 ion. C. Facility, Site or Individual
Nonotuck Mill L.L.C.
1.Name of Facility,Site Or Individual
296 Nonotuck Street
2.Street Address
Northampton(Florence) MA
4.State
'our
Id be
our
Requiring Approval
Saying 3.City/Town
01062
5 Zip Code
413-537-9109
6.Telephone# 7.Ext.#
1-17208
10.BWSC Tracking#(d Known)
ust 8.DEP Facility Number(if Known)
Dt this
win to. D. Application Prepared by (if different from Section B)a
9.Federal I.D.Number(11 Known)
4062 ECS, Inc
MA 1.Name of Firm Or Individual
588 Silver Street
2.Address
Agawam
3.City/Town
;ennits'
.P. Richard Starodoj
8.Contact Person
)nly
MA 01001
4.State 5.Zip Code
413-789-3530
6.Telephone#
9.LSP Number(BWSC Permits only)
325
7.Ext.#
E. Permit- Project Coordination
1. Is this project subject to MEPA review? ❑yes ®no
If yes,enter the project's EOEA file number-assigned when an
Environmental Notification Fonn is submitted to Ole MEPA unit:
EOEA File Number
F. Amount Due
Special Provisions:
1. ❑Fee Exempt(dty,town or municipal housing authority)(state agency if fee is$100 or less).
There are no fee exemptions for BWSC permits,regardless of applicant status.
Hardship❑ (according according
chedule Project(anrding to 310 ).( 3)(c)to 310 CMR
CMR 4.05 and 4 10).
Alfemative
❑Homeowner(according to 310 CMR 4.02).
13292 $240.00
Check Number Dollar Amount
elix.doc•rev. 1/07
5/5/09
Date
Page 1 of 1
ins
Massachusetts Department of Environmental Protection
Bureau of Resource Protection- Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells 0
BRP WS 06 Modification to an Existing UIC Registration
X228143
Transmittal Number.
UIC Registration Fee (check the appropriate well type category)
❑ a. High includes the following well types-5A5, 5D4,5W20&5X25
Z b. Moderate includes the following well types-5A6, 5A19,5F1, 5S23&
5X27
❑ c. Low includes the following well types-5A7, 5A8,5622,5D2,5G30,
5R21&5X29
d. Pre-closure/WS-06d form-for UIC wells not previously registered with MassDEP. Registration of
these wells is not done using this form.They must be submitted on a Pre-Closure/WS-06d form.
e. Residential Exemption [for four units or fewer]-the following well types(typical residential activities)
are exempt from a UIC registration fee and have a separate registration form WS-06e-5A7,5D2,
5G30&5X18.
Registration Fee=$480.00
Registration Fee=$240.00
Registration Fee= $ 90.00
See the Class V Injection Well Type Table at the end of the Instructions for well type.
Transaction Type
Registration: ® Initial-new registration ❑ Initial-existing registration ❑ Conversion
❑ Partial Closure/Registration
Modification: ❑ Change of owner/operator ❑ Change in or additional well/code(s)
❑ Change in location well(s) ❑ Change in#of discharge wells (+/-)
For modifications (required)
UIC Registration ID#issued by MassDEP in the original UIC
A. Facility Information
For modifications, enter new or revised Information:
Nonotuck Mill
Facility/Property Name
Nonotuck Mill, L.L.0 541330
Company Name SIC Code
Northampton Hampshire
(Florence) County
NA
Facility PWS ID#(if appropriate)
413-537-9109
Facility Telephone Number
NA
EPA Hazardous Waste Generator ID#
cdoc•rev.aeros
296 Nonotuck Street
Facility Street Address
(MassDEP Use Only)Facility#
MA 01062
State Zip Code
mcdonoughrealty @yahoo.com
Facility Email(optional)
NA
EPA Hazardous Waste Generator ID#
BRP ws as a¢c-RegLstraboo oI Discharges to Underground Injection w ells•Page 1 or 9
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells
BRP WS 06 Modification to an Existing UIC Registration ❑
X228143
Transmittal Number
xis-
ons
B. Owner/Operator Information
For modifications, enter new or revised information:
Nonotuck Mill, L.L.C. 296 Nonotuck Street
Name of Owner Address of owner(if different from facility)
Northampton (Florence) MA 01062
State_ - — Zip Code
ECS. Inc.NCB, n _- 588 Silver 01 a Street
Address of operator(if different from facility)
Name of Operator(if different from owner) – - 01001
Agawam �_ ._. MA--
City/Town
Matt McDonough 413 584-8266
Matt McDonough (Mill Manager) 413-537-9109 gal Contact Phone 1- )
Legal Contact Legal Contact Phone# Legal Contact Fax#
Ownership Type:
Private: ❑ Industrial E Commercial ❑ Non-profit ❑ Residential
Public: ❑ Local ❑ Regional ❑ State
❑ Federal
C. Injection Well Information
For modifications, enter only new or revised information:
Registration: E Individual or ❑ Area
Direct Heat Reinjection 5X25 1
(Closed Loop-Keliz Type)
Well Code Number of wells
Well Construction (check all that apply)
❑ Drywell ❑ Septic Tank ❑ Cesspool ❑ Dug Well ❑ Improved Sinkhole
❑ Drainfield /Leachfield ❑ Dustwater onto the ground
Drilled Well
E Other (describe):
Heat from closed loop geo thermal heating system — — -
Type of discharge
No water discharge(closed loop geo thermal heating system) — —
Source of water discharged to the well
14,400 --- — -
Average flow(gallons per day) Month/Year of well construction Month/Year ceased using well(s)for previous use(s)
1 1
#of entry points to existing system #of entry points for proposed system Total#of entry points to system
List any treatment devices in place or proposed prior to the injection point:
None -closed loop geothermal
doc-rev 08/06
BRP WS 06 aA.c-Regislrabon of DISCI,arges to Underground InleGlon Wells.Page 2 of
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells
BRP WS 06 Modification to an Existing UIC Registration ❑
X228143
Transmittal Number
C. Injection Well Information (cont.)
15 approx
Depth to water table(feet)
Sand
Soil type(s)at side-e.g.,fill,sandy till,gravel,sand
1,800 feet west
Distance to nearest Public Water Supply(within 2500')
20 approx
Depth to bedrock(feet)
None( non-contact cooling water 850' east)
Distance to nearest private drinking water well(within 1250')
Well 1214000-02G (City of Northampton)
Name of nearest Public Water Supply
D. Operational Status
® Designed, not yet constructed ❑ Under Construction ❑Active
❑ Temp. abandoned ❑ Conversion to another well type
❑ Partial Closure/conversion to another well type (well code) ❑ Active/Partial Closure
❑ Permanently abandoned/not reported previously
Closed Water Loop Geo Thermal Heat Loop
(Kelix Type)
Source of injection fluid(#3)
Ethanol (Dilute)
Potential contaminant#1
Source of injection fluid(#2)
15 gpm
Rate of Injection(gpm or other unit value)
Potential contaminant#2
Potential contaminant#3
Potential contaminant#4
E. Site Information
Are there any other discharges on site?
If yes, are they permitted with MassDEP?
If no,are they registered with MassDEP as Class V
wells?
Please list the type or types of discharges:
❑ Yes ® No
❑ Yes ❑ No
❑ Yes ❑ No
Check any of the following that apply to this site:
a. ❑ Superfund site
b. Z Bureau of Waste Sae Cleanup Priority Site
c. ❑ Bureau of Waste Site Cleanup Waiver Site
Please provide a copy of the letter of authorization if applicable
doc•rev.08)06
NA
NA
If yes,Federal ID#
1-17208
If yes,file number
If yes,file number
ORP WS 06 ae c.Re Italian or Discharges IA)underground Injection Wells.Page3 of s
IS
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells El
BRP WS 06 Modification to an Existing UIC Registration ❑
X228143
Transmittal Number
E. Site Information (cont.)
If the site is currently being regulated by the Bureau of Waste Site Cleanup, check any of the
following that apply:
❑ Incident Response ❑ Short Term Measure
Activity and use limitations: -
Confirm that the applicant has checked that the site does not have any activity restrictions with
respect to limiting discharges on the site.
❑ No restrictions ® Restrictions(please explain; attach additional sheets if necessary):
Oil release under eastern portion of building downgradient of area covered by this permit. See
previously attached information.
Location of Facility:
Is the facility located on Native American lands? ❑ Yes ® No
42 19'48.33 72 40' 37.35"
Latitude: degrees min(')sec(") Longitude: degrees min(')sec(y
Latitude 8 Longitude are no longer optional data.
Identify the method used for locating the latitude/longitude coordinates for the UIC Class V well(s):
Type:
❑ Approximate location of point of UIC Class V well(s)
❑ Approximate center of drainfield(s)
❑ Approximate location of area wellfield(s)
® Approximate center of facilityfes)
❑ Approximate center of area where discharges are located
Accuracy:
Z Estimated horizontal accuracy is less than +1-100 feet
❑ Estimated horizontal accuracy is less than +/-500 feet
❑ Estimated horizontal accuracy is less than +1- 1000 feet
BRP WS Ofi a,b.c-Registratim of scharges to Underground Injection Wells•Page 4 of 9
�.floc•rev.O8■Da
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells El
BRP WS 06 Modification to an Existing UIC Registration ❑
X228143
Number
E. Site Information (cont.)
Provide a narrative description of the site and the feature to be permitted. As an example:"The site is
on the west side of Main Street,the third building north of High Street.The disposal field lies 100 feet
off the southwest corner of the building"
Site is on south side of Nonotuck Street. Kelix water loop is located southwest and adjacent to south
west side of western most building. Site plan depicting well location has been previously submitted_
All additional information that is relevant to the installation or operation of this injection well and to the
determination of its potential to endanger underground sources of drinking water (USDWs)-
including a site map showing the facility and UIC well(s), on-site drinking water wells, all other on-site
discharges
or chemicals liiikely to be discharged into well must be submitted.Analytical data available a on the sheets
discharge or raw water as applicable.
® Map attached El Detail sheets attached ® MSDS sheets attached ® Other information attached
Attach a Photography pthathdearly facility both your facility and the location of the dl scharge.
y
The USGS topographical map is available at:
httffilmaps.massdis.state.ma.us/MassGIST000s/viewer.htm
or the Color Orthophotography At: http://maps.massgiss fate.ma.us/MassGISColorOrthos/viewer.htm.
Attach a site plan showing buildings, boundaries, abutting streets, location of test pits, location of all
UIC wells, location of on-site drinking water wells, location of monitoring wells and a locus map.
Attach a narrative description of the shallow injection well system and its major components.The
description should contain a diagram including the plan view and cross sectional view of the shallow
injection well system, indicating piping,junction boxes,tanks, and leachfields. Dimensions of all major
components and design calculations must be included.
Attach the Material Safety Data Sheets for all chemical products stored or used at the facility which
may intentionally(additive)discharge or unintentionally(spill/leak)discharged to the shallow injection
well(s).
Attach existing analytical testing data from the existing waste stream or raw water for expected
contaminants in proposed waste stream, based on specified testing parameters.
For stormwater submittals (if applicable):
Attach a letter from the local municipality or other responsible party committing to long term
maintenance of the UIC system, as described in the maintenance stipulations of the UIC Program
Registration Approval if this applies(responsibility for maintenance is to be transferred).
Attach a letter from the local municipality or other responsible party UIC system (actual or proposed)to another l
o her offsite system (town storm sewer or wetlands)from the
BRP WS 06 a b.c-Registration of Discharges to Undeegraund InJectLon Weis'Page 5 of 9
x.doc•rev.08106
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells
BRP WS 06 Modification to an Existing UIC Registration ❑
X228143
Transmittal Number
E. Site Information (cunt.)
Who must register:
Any party who discharges to a Class V Well as defined in 310 CMR 27.00 must apply except those
listed as exempt from the registration requirement as per 310 CMR 27.07:
(2) Groundwater Remediation Projects.Any injection into a Class IV or Class V injection well during
- a response action conducted or performed in accordance with the provisions of M.G.L.c. 21 E
and the Massachusetts Contingency Plan, 310 CMR 40.0000, or for the purpose of remediation
at a release site, pursuant to the provisions under the Comprehensive Environmental Response,
Compensation,and Liability Act of 1980(CERCLA),42 U.S:C 9601-9675, or pursuant to
requirements and provisions under the Resource Conservation and Recovery Act(RCRA), 42
U.S.C. 6901-6992k shall be exempt from:
(b)the registration requirements set forth in 310 CMR 27.08;
3) Registration.The following Class V injection wells are also exempt from the registration
requirements of 310 CMR 27.08:
(a)on-site subsurface sewage disposal systems used solely for the disposal of sanitary sewage
and regulated under 310 CMR 15.000.
(b) Class V injection wells permitted under 314 CMR 5.00.
Any party closing a UIC Class V well that has not previously registered with the MassDEP UIC
Program must register using the BRP WS-06d Pre-Closure Form.
If you have not previously registered and you are closing the use of the well(s)for one (or more)uses
but want to continue using the well(s)for one (or more) uses you must mark the top of this form by
checking the box for"Transaction Type"- Partial Closure/Registration and attach the Pre-Closure
Notification Form to this submittal.The Pre-Closure Notification Form must be submitted to the
Boston Office.The Boston Office will forward the Pre-Closure form to the appropriate
MassDEP Regional Office for those uses that you intend to discontinue to discharge to the
Class V Well.All further communication on closure of the well(s)including filing of the Post-
Closure document should be with the appropriate MassDEP Regional Office.
If you have not previously Registered and you are converting the well from a"prohibited"use to a use
that is"authorized by rule"you must mark the top of this form by checking the box for"Transaction
Type"- Conversion and attach the Pre-Closure Notification Form for those uses that you intend to
discontinue to discharge to the Class V Well.The Pre-Closure Notification Form must be
submitted to the Boston Office.The Boston Office will forward the Pre-Closure form to
appropriate MassDEP Regional Office for those uses that you intend to discontinue
discharging to the Class V Well. All further communication on closure of the well(s)including
filing of the Post-Closure document should be with the appropriate MassDEP Regional Office.
If you are registering a well(s)at a residential structure (four units or fewer),the MassDEP UIC
registration form WS-06e should be used instead of this one.
Who must submit a notification form:
If the Owner or Operator information(name address or other contact information)changes you must notify the UIC
program at least 30 days prior to the change(s).
If you are adding wells(Area Registration):relocating the well(s),changing the discharge(Well Code)to the well(s)or
adding additional discharges(Well Code)you must notify MassDEP at least 60 days prior to the change.
If you are closing the well(s)and relocating the well(s)and are planning to have the same discharge(Well Code),you
must mark the top of this form by checking the box for Relocation of Well(s)and attach to this submittal a Pre-Closure
Form for the well(s)being closed.
BRP W5 06 a o,c-Registration of Dlstliarge6 to Underground Injection Wells•Page fi of 9
doc'rev.06/66
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells
BRP WS 06 Modification to an Existing UIC Registration ❑
X228143
Transmittal Number
E. Site Information (cone.)
Fees:
An application fee (effective 10/08/04) is due when the Registration application is submitted. There is
no application fee associated with submitting a Modification application to an existing Registration.
Registration Form Category Registration Fee
BRP WS 06 a High $480.00
BRP WS 06 b Moderate $240.00
BRP WS 06 c Low $ 90.00
BRP WS 06 d Pre-Closure/Registration $ 90.00
BRP WS 06 e Residential Registration No fee -exempt
No MassDEP Transmittal Form or number is needed when submitting a Modification to an existing
UIC Registration or when submitting a Residential Registration Form (WS-06e).
There is no annual compliance fee associated with this Registration.
BRP WS 06 a,b C-Registration of Discharges to Underground Injection Wells-Page 7 of 9
doc•rev.08/06
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells
BRP WS 06 Modification to an Existing UIC Registration
X228143
Transmittal Number
F. Affidavit
The injection well(s)described above is used for placement or injection of fluids into the ground. I/we
understand that this well is subject to inventory requirements and compliance with the regulations
under
P.L. 93-523, and amendment,Control
nd Uwe hereby established
erve notice that the wells proposed or in
service.
Uwe agree:
I-. T-hatthe well(s)described herein will.not be used for-discharges-other than those described
above;
2. That Uwe will notify the Massachusetts Drinking Water Program/UIC Program (on forms provided
by the UIC program)if any of the information (including Ownership, Location or Type of
discharge)for the above well(s)changes, but before the change (30 days minimum notice on
ownership/operator and 60 day notice on all other changes);
3. That Uwe will notify the Massachusetts Drinking Water Program/UIC Program (on forms provided
by the UIC program—but before abandonment and filer l Form)
a Post Notification Form within se longer in use,
seven days of
completing the closure with the UIC program.
4. That Uwe will maintain financial responsibility for the well described above; and
5. That Uwe will provide a sampling tap(approved by MassDEP)and allow sampling at the point of
injection.
INVe certify under penalty of law that I/we have personally examined and am/are familiar with the
information submitted in this document and all attachments and based on my personal knowledge or
inquiry of those individuals immediately responsible for obtaining the information. I/We believe the
info mtion is true, a u -te, and complete. Uwe
w fines and am/are awartoomenere are significant penalties for
_ 5/6/2009
t'"� Date
t re of Preparer I�
Richard Starodoj Project Manager (ECS, Inc.)
Position/Title
Printe Name of Preparer
doc•rev.60/06
BRP WS 06 a,b,c-R gistraUon of Discharges to Underground Injection Wells•Page 0 of 9
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS 06 a,b,c
Registration of Discharges to Underground Injection Wells ®❑
BRP WS 06 Modification to an Existing UIC Registration
X228143
Transmittal Number
Questions
Any questions may be directed to the UIC Program at(617) 348-4014 or to the UIC Contact at your
Regional MassDEP Office. -
Find your region: http://mass.gov/deplaboutfregion/findvouchtm
Submit Application to:
MassDEP
Drinking Water Program
1 Winter Street-6th Floor,
Boston, MA 02108
Attn: UIC Program
MAILING ADDRESSES
UIC Program, MassDEP Northeast Regional Office(NERO),
205b Lowell Street,Wilmington, MA 01887
UIC Program, MassDEP Southeast Regional Office(SERO),
20 Riverside Dr., Lakeville, MA 02347
UIC Program, MassDEP Central Regional Office(CERO),
627 Main Street,Worcester, MA 01608
UIC Program, MassDEP Western Regional Office (WERO),
State House West,4th Floor, 436 Dwight Street, Springfield, MA 01103
UIC Program, MassDEP Boston Office,
One Winter Street—6th Floor, Boston, MA 02108
SERVICE CENTER PHONE NUMBERS:
Northeast Regional Office
Southeast Regional Office
Central Regional Office
Western Regional Office
978-694-3200
508-946-2714
508-792-7683
413-784-1100 ext. 214
Send duplicate copies of all forms to:
Local Board of Health
Local Plumbing Inspector
BRP W$06 a,b c-Registration of Discharges to underground Inlectron Wells•Page 9 of 9
doc rev.OWQS