WI0700496_Permit (Issuance)_20191120

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule" and do not require an individual permit when constructed in accordance with
the rules of This notice must be submitted Prior to construction.
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
As described in 2<' these wells circulate potable water only or a mixture of potable water and
performance -enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As described in _ these wells circulate a refrigerant gas as partof a geothermal heating and
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: 10/21 2019 PERMITNO. 1 %(� (� G (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(asper x Number of wells:
(2) Direct Expansion (as per , - _ j) Number of wells:
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence _x_ Submit this form two (2) business days prior to construction.
(2) Business/Organization _ Submit this form 30 days prior to construction.
(3) Government: State Municipal _ County _ Federal _ Submit this form 30 days
prior to construction.
C. WELL OWNER — For single family residences list the property owner(s). For all others, list name of the
business, organization, or government agency and person delegated signature authority:
Belle & David Jones
Mailing Address: 4904 Lunar Drive
City: Kitty Hawk State: NC Zip Code: 27949 County: Daze
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 987605175911
County: Dare
(2) Physical Address (if different than mailing address):
Same
City:
State: _ Zip Code:
UIC Closed -Loop Geothermal Notification (Revised 8/5/2013) Page I

E. MAPS, PLANS, AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site -specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites, drain fields, or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at 1;q . , , _ All other additives require approval prior to use.
Geosafe antifreeze @ 15%
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Arthur J. Tatem
NC Well Drilling Contractor Certification No.: 4200A
Company Name: Virginia Energy Services Contact Person: Art Tatem
City: Knotts Island State: NC_ Zip Code:27950_ County: Currituck
Day Tele No.:
EMAIL Address:
252-455-7710
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Norris Mechanical
Cell No.: 252-202-9490
Fax No.:
Contact Person: Hersey Norris EMAIL Address: norrisoffice(a)rmrrismechanical.com
Address: P. O. Box 217
City: Harbinger Zip Code: 27941 State: NC County: Dare
Office Tele No.: 252-491-2673 Cell No.: Fax No.:
UIC/Closed-Loop Geothermal Notification (Revised 8/5/2013) Pa$e 2

1. PROTECTION — Provide a brief description of how (1) water supply wells; (2) surface water bodies; and (3)
septic systems and associated spray irrigation sites, drain fields, or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
1'mtection will be Prnwided during the drilling Process by containing fluids in a pit or pan and providing sill
tcrrce if run of1'is a danger. Dore holes will be fully grputcil to protect from aquifer cross contamination
J. VARIANCE —Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Resources may grant
a variance from applicable well construction or operation standards provided that:
(1) use of the well(s) will not endanger human health and welfare or the groundwater; and
(2) that construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request should accompany submittal of this nofification to expedite evaluation of the request.
The variance request form can be accessed online at htip://porlal.ncdcnr orghvchfwo/-,im/gwnro(permit-
arplications
K, SIGNATURES —The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .0211(c) requires signatures as follows:
(a) for a corporation: by a responsible corporate otiicer,
(b) for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
(e) for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
(d) for all others: by the well owner,
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, grants them signature
authority, and is signed and dated by the applicant.
"I hereby cert6, under penalty of law, that I have personally examined and ran 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 beUeve that the information is true, accurate and
complete. I am aware that there are significant penalties, including the passibility offtnes and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all relaled per enances in accordance with the 1 SA NCAC 02C 0200 Rules."
Pr
• ggaturt of PropOwncrlA ,
rkant
David N. Jor12s l3�lur s. �,,s�
Print or Type Full Name
Signature of Authorized Agent, If any
Print or Type Full Name
UIC/Closedd.00p Ueothe l Notification (Revised 8/5/2a13) Page 3
Scanned with CamScanner

Aug.28. 2008 3:50PM _. No.6862—'P• 1/4-
-T
( iN eec:r
gg I. inch = 30 ft.
�• �23N 1 '
23 I
524% 100
I l4QtyOS'O0"E (PLAT)
100.97'
WOOD FENCE N04-02:27wE « d
1_ ut 4pcove
iV
'reposed Closed M
pop geothermal a"+ +a arm 1- o 00 %
Dopfield, 7 bores tir n
i 200' OR 1400'
,fvertical bore,
ULLY 't.
1
4P• ^ + J CHAIN LINK
d
iROUTED 1 o FENCE
• Water Meter • T � s� ••.5.: ; Ib ' E'1]I1� ��°
;1( fire Hydrant
O Ex. CM
�+
QOV Mrs. OF
PAMM M.
z zt
oo
Area . 12236.3 Sa4 3` . / G 9
Lot Coverage x 3,0e3 Sq. Ft +232•L1
posed Coverage - 3.677 Sq. Ft. (30% \ \ '•�
yi / ttl\It11111enI
>d Lanes are subject to change IA A4e
backs shown are per Zanin9l they
rmt reflect any Restrictive revenants
t nay exlst. The Setbacks
posed OeflUng equal to or 1'. then
Io Sq. Ft, these Setbacks need to be \)I
Ined prior• to consb•uctlon.
survey Is based or+ the existing evhlence
on A+ CMJu Ucn with the recorded
1, M. DOUGIAS SMNS, JR', P&S.. certify that this pbl wos drawn from on actual 0e+d Ip+d surveythat
rn M by latitudt, and deport. h of least 1:10,000; - �A1114111gs\\
JAW day of yA0. 200 CURVE DATA,
C-1 R-on.00' L-10624' C-SOS-42'f0'E 106.19'
C-2 R=970.00' L-10e.17' C-MWQV40'V 102d1'
ITE LOT 521, SECTION 1
am�� "Mon SEA SCAPE
SURVEYED FOR
DUNN & ASSOCIATES, INC.
ATLANTIC TOWNSHIP K1TrY HAWK
u VICINITY MAP (N.T.S.17V . DARE COUNTY NORTH CARQLINA
ATE: 1-12-05 F.I.R.M.: 370439 0001 D q
EV.DATE: 6-23-0 F.I.R.M. DATE: 4-2-93 ,8 . xhW1 yAFL 'iSvUx.c
VLE
LAN/COV. FLOOD ZONE: X 2700 N. Crootan Hwy. Kill Devil Hills, NC. 27948
1'=30'REC. REF. Phone: [phone] Fax:[phone]
O.:04-0g4 M.0.3 PG. 58
dbarmsnt so pa
O.: 04064SP PIN Nd.: A Kama �ie be " far s,y p a
!\ROH]ny1e:1]dR]]

525 1 524 523
MD PIN TOLD PIN
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p: 110?5
"-MD PIN
Ra BTO
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DR1VE
160+1
LUNAR
NORTH
f�' ��) L 11•'�` y1'` �tni
MI OCEAN Tv DAY COLCSTRUC TICN 2 ^.am OlFr :T rOMPANv INC. 1 .a+"•'e n"`rru...
OF:.LOT 620,`SECTION I a ta..•"._�•;r!ryq
SEA SCAPE
KITTY HAWK DARE COUNTY NORTH CAROLINA
800rod W. Mdpiffe, Jr.,R L.9., t»nlfd that thN OW "a drown from ac actual field pad wary; �t<','
hot the error of oloacro a I:OIgllalad by6tRldto and dope I, M I:p ; that Is oqo
n oeacrdanho With G.S. 47-30 as anointed. +'; � �� '..... • :":1 ++{.,
Mlmw Iaghandodd MMIMoloth. dodof JULY +AD.■84. u!i
cenmmtbh L•Z7B1
GEORGE W MDOETTE, JR., LAND SURVEYOR
NORTH CAROLINA AND VIRIMNIA '
P.O. BOX 406/KRTY HAWK, N.C. Zr949
TELEPHOME [phone]
1EfERENCE1 (M. B. 3, PO. 56.57) FlELD DA1Et JI�LY 9, 1964
:tLE NUMBER: 486-84-28-10 9CAlEr 1' :3d

1521\
D.B. 1782,
PG. 137
F i
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O
Ex. CM
,0,
Ex. PK Nail
0
Water Meter
00(
Fence
00 (
A
CATV
Ex. S:S:S. Nail
N 1
& Washer
15231
\ /
D.B. L484.
PG. 435 lal L
O
O c
CV P
tr)
E
/ 1 Inch = 30 fE
15201 D.B. 1345,
\ _ / PG. 456 (PL
108 05 FlI
L—
I519'1
I D.B. 394,
PG. 219
O
O
125Met- P
.00
r
?. 5 d?
SUBDIVISION
00 r
25 MSL
CONTROL
MONUMENT
TYPICAL i
PARKING
SPACE
SPACE
100.00'
— — — — -' —
C
107.56' e
S2189'O9•yy
PNAIL
—
— —
fP C/L INTRS. OF
— —
— — —
NORTH LUNAR DR..
& PALMER DRIVE
EDG OF A HA
i CPA woo"
_.A=d 51C�llnd
J
I� 1525�
�f D.B. 1318.
PG. 448
I�
15.' 1-11""
d
n 1n SUBDIVISION
N N CONTROL
®L MONUMENT
—N11'08'00"E
FE000
NC
Y12.I7'
— —. _ DE LINE ONLYZ — /^�
NOTES, Rddress� 49131 Palmer Drive . PALMER Dl%M'',:....(60... R/W)
Optic
8e yV®u
Lot Are. = 13,793 Sq. Ft. t S47�(p6" b�° f
s�aa
Lot Coverage= 2,905 Sq. Ft. (21.1Z) ®O Dare County
Flood Zones are subject -to change Heal Department
Setbacks show n ih S fl �1
n re as per a ubd.
Plat and as per Zoningl they do not
reflect any Restrictive Covenants
nay exist. The side Setbacks
®�
in
shown are as per existing house
square Footage. The side setbacks
will change If the heated square footage
Is Increased to more than 3,000 Sq. Ft.
as Siw:cP
Bib/
This survey was based on the existing
lfa0 d�
property corners found In conjunction
the
with recorded reference given.
1�
I, M. DOUDIAS SIYONS, JR., P.LS., cer0ry that MIS plat was drown Imm On ochol field land survey
that the .mar or d.wr. a. cakulatm by kiihxl.. and defarWrw Is at Most 1:10.Mo:
Wtnen my hand and Seal Nis asth day of 11mt &D. 20g9PRE® p
NARy
SITE LOT 524, SEA SCAPE, SECTION 1
an �n SURVEYED FOR
^_ATLANRC MILLS STAYLOR and
O
amano°r CEAN wife VIRGINIA STAYLOR
ATLANTIC TOWNSHIP DARE COUNTY
VICINITY MAP .(N.T.S.) - KITTY HAWK NORTH CAROLINA
)ATE: 5-27-09 F.I.R.M.: 3720 9876 00 1
2EV.: - F.I.R.M. DATE: 9-20-06 mtc' . ,Sunl" ,Sv/ux:ca/„ 60. A.
FLOOD ZONE: ZONE "X" 2700 N. Croaton Hwy. Kill Devil Hills, NC. 27948
KALE: 1" = 30' REC. REF. M.B. 3, PG. 56 Phone: [phone] Fax: [phone]
ILE NO.: 09-054 D.B08987605173719 . 1570, PG. 384 My �aau,od:m a.. ar ml.anoa of mb aaa.neat m p,.Ns'Aee
>WG NO.: 09054SP PIN Arm sea nw.L h. Mw.nt for W. t. b. an .dyad dwmnenl

I
521 I
N 7g o SZ �
0p W \ 523
0
8
p.,
R
p /
LOT \7/
O` ARE - 8,890 S
15 J
2 0
h � "
/ v
(7 o N" h Q- x
P
\ J ry0
A
O EXISTING PIN
0 EXISTING CONC. MONUMENT A. SO.76,
I R ' 40.00'
],WILLIAM T. ROBBINS hereby certify
Ithat this map is correct and that the buildings
shown lie entirely on this lot. That there are no
encroachments of other bVtj s,gs on the said lot
wcept as noted. ,ass 4a,
T.
LOT SURVEY FOR
WARREN W. a PATRICIA A. WATTS
OF
LOT 522, SEA SCAPE
KITTY HAWK, ATLANTIC TAR, DARE COUNTY
NORTH CAROLINA
AS RECORDED IN M.BB, PG. 56, DARECO. REGISTRY
" SOUTHERN SURVEYING
,rd.Eley. pnd Land Plammng
Zone. 00 W',A'R' hn.tciwnlxB. Q16
' AOtrinrl. Nl :Tro (nIa13M IliS-.

�a
-7 Lc T
(IK' 521
4 �
I tl
1
5�9 S.F. a
J no'
I
/SLO T
P 522
-- L
_.. _ .,. ._. I- nl ._
+ N //
J
10
LOT
520
` 65
i
J
-LOT
5 Z4
BENNETT STi-rEET 6o'Tr/w
Or
25,61.06. I -FT Ef X
FLOOD ZONE °C
GD. EL. = 24.4'
I, WILLIAM T ROBBINS hereby certify
! URVEY FOR
that this mop is correct and that the buildings
shown lie entirely on this lot. Thal there an no
6EN R. C WIFE UOFtOTHY W. KIRBY
\encroachments of other buildings on the said lot
`acept as noted.
c SEA SCAPE'
LOT J! _T . SECTION 1, S
SEA•,�n,,,r
PL/,T BUUK 5. PAGE 56
-VCAH01�,,�.,
••TFi)F0:9
ATLANTIC TUWN,iHIP
�':
LoPE CUUNTY, WXTH CARULINA
-.677
oats:
/c-I- =
SOUTHERN SURVEYING
Scaly.
AND LAND PLANNING
WILLIAM T. ROBBINS, R.L.S.
Omrn:
P. 0. Box 769
KITTY HAWK, N.L. 27949