WI0700101_GEO THERMAL_20061121

Permit Number WI0700101
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Permitted Flow
Facilit
Facility Name
Hal Holloman
Location Address
1049 Scarlet Oak Dr
Greenville
Owner
Owner Name
Hal
Dates/Events
NC 27858
Holloman
Orig Issue
11/09/06
App Received Draft Initiated
10/09/06
Scheduled
Issuance
Central Files: APS_ SINP_
11/21/06
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Michael Hadley
102 Middle St
Jacksonville
Major/Minor
Minor
NC
Region
Washington
County
Pitt
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Hal Holloman
300 Crestline Blvd
Greenville
Public Notice Issue
11/09/06
NC
Effective
11/09/06
28546
27834
Expiration
Re gulated Activities Re quested/Received Events -~----------------------
Heat Pump Injection RO staff report requested
RO staff report received
Outfall NULL
Waterbody Name Stream Index Number Current Class
10/10/06
10/25/06
Subbasin
VYA
r14QG
Michael F. Easley, Gavemar
q [xia ' William G. Ross Jr., Secretary
c North Carolina Depar menl of Environment and Natural Resources
Alan W. Klimek, P.E. Directot
IN Division of Water Quality
November 9, 2006
Hall Holioman
300 Crestline Blvd.
Greenville, NC 27834
Re: Notice of Intent to Construct Type 5QW Injection Wells
Dear Mr. Holloman:
In accordance with the notification you submitted to the Underground Injection Control (UIC)
Program received on October 9, 2006, the Aquifer Protection Section (APS) acknowledges your
intent to construct [7] closed -loop geothermal water-onlN injection wells for the operation of a
ground -source heat pump. The facility address is 1049 Scarlet Oak Drive, Greenville, North
Carolina 27858.
The system as described in your notification is deemed permitted by rile North Carolina
Administrative Code Title 15A: 2C,021 I (u)(2)) and will not require an injection well permit
from the State, but you should check with your county health department prior to constructing
the system because they may have additional construction or permitting requirements for this
type of system. If you modify your system at any time, including the addition of antifreeze,
corrosion inhibitors, or any other substances to the circulating fluid, you must contact the
Aquifer Protection Section to verify compliance with applicable rules.
Thank you for submitting this notification. Please contact me at 919-715-6166 or
Michael-Rocers,W�ncmail.net if you have any questions about geothermal heating or injection
well rules and regulations.
Best Regards,
Michael Rogers
Hydrogeological Technician 11
UIC Program
cc: David May, Washington Regional Office
Coastal Geothermal
Central Office-UIC Files
,IVatm 1;
Aquifer Proteciion Section 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone- [phone]
Internet: htta;llwww.ucwaterauaiity or$ 2728 Capital Boulevard Raleigh. NC 27644 Fox I: [phone]
Fax 2. [phone]
An Equal OpporturiglAlfimrative Adon Employer— 50% Re0ydedV10% Post Consumer Raper Customer Service; [phone]

o0F wA rE�1G
Michael E Easley, Govemor
William G. Ross Ir., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. VJimekc P.E. Director
Division of Water Quality
November 9, 2006
Hall Holloman
300 Crestline Blvd.
Greenville, NC 27834
Re: Notice of Intent to Construct Type 5QW Injection Wells
In accordance with the notification you submitted to the Underground Injection Control (UIC)
Program received on October 9, 2006, the Aquifer Protection Section (APS) acknowledges your
intent to construct [71 closed -loop geothermal water -only injection wells for the operation of a
ground -source heat pump. The facility address is 1049 Scarlet Oak Drive, Greenville, North
Carolina 27858.
The system as described in your notification is deemed permitted by rule (North Carolina
Administrative Code Title 15A: 2C.0211(u)(2)) and will not require an injection well permit
from the State, but you should check with your county health department prior to constructing
the system because they may have additional construction or permitting requirements for this
type of system. If you modify your system at any time, including the addition of antifreeze,
corrosion inhibitors, or any other substances to the circulating fluid, you must contact the
Aquifer Protection Section to verify compliance with applicable rules.
Thank you for submitting this notification. Please contact me at 919-715-6166 or
Michael.Rogers«dncmail.net if you have any questions about geothermal heating or injection
well rules and regulations.
Best Regards,
Michael Rogers
Hydrogeological Technician II
UIC Program
cc: David May, Washington Regional Office
Coastal Geothermal
Central Office-L'IC Files
Aquifer Protection S=aon 1636 Maii Service Cenrer Raleigh, NC 27699-1636
interne[: htto://www,ncwaterquaiity.org 2728 Capital Boulevard Raleigh, NC 27604
An Equal OpportuniolAffirmaiive Action Employer— 50% Recycled 10% Post Consumer Paper
NVN" Carolina
tllt1I#1
Telephone: [phone]
Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 10/23/06
To: A quifer Protection Section Central Office
Central Office Reviewer: Dennis Ro gers
Regional Login No: __ _
County: Pitt
Permittee: Hal Holloman
Project Name: Holloman Residence
Application No.: WI0700101
L GENERAL INFORMATION
1. This application is (check all that apply): [8] New D Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals D Attachment B included D 503 regulated D 503 exempt
D Distribution of Residuals D Surface Disposal
D Closed-loop Groundwater Remediation [8] Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? [8] Yes or D No.
a. Date of site visit: 10/20/06
b. Person contacted and contact information: Hal Holloman (252 )916-7375
c. Site visit conducted by: Randy Sipe
RECEIVED/ DENR / DWQ A . .,__ ,.,.,_~,~ . "~"TION
d. Inspection Report Attached: [8] Yes or D No. OCT 2 6 2006
2. Is the following information entered into the BIMS record for this application correct?
[8] Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions:
c . USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Dis posal and Injection Sites:
(If multi ple sites either indicate which sites the information a pp lies to , co py and p aste a new section into the
document for each site , or attach additional pa Qes for each site)
a. Location(s): __
b. Driving Directions:
c. USGS Quadrangle Map name and number: __ (f ~
d. Latitude:~~JJ . ...l. "/ Longitude: ~/1. OCo
II. NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section )
Description Of Waste (S) And Facilities
1. Please attach completed rating sheet. Facility Classification: N/ A
2. Are the new treatment facilities adequate for the type of waste and disposal system?
FORM: Holloman Closed Loop UIC Staff Report 10-06
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Q Yes D No IZI NI A. If no, please explain: __
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No IZI NIA. Ifno, please explain: __
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes IZI No D N/ A. If no, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No~
NI A. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No IZ! N/ A. If no, please explain: __
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No IZ! NIA. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or IZ! No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No IZ! NIA. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No IZI NIA If yes, attach list of sites
with restrictions (Certification B?)
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
D Heating/cooling water return flow ( 5A 7)
~ Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5L/"Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes ~ No
3. Are there any potential pollution sources that may affect injection? D Yes IZI No
FORM: Holloman Closed Loop UIC Staff Report 10-06 2
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
What is/are the pollution source( s )? -----'-'-W-'-'--=h=a'-'---t =isc....;t=h-=-e -=d=is=ta=n=-=c=e--=o=f....::;th=e"-=in""'je=c=-=ti=-=· o=na...w'-'-e=l=l (=s.,_) =fr=o=m=---t=h=--=e__,p=-=o=ll=u=ti=o=n
source(s )? ft.
4 . What is the minimum distance of proposed injection wells from the property boundary? 25 ft.
5 . Quality of drainage at site: D Good [2J Adequate D Poor
6. Flooding potential of site: D Low [2J Moderate D High
7 . For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: NI A
8 . Does the map presented represent the actual site (property lines, wells, surface drainage)? [2J Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.: The site conditions appear
consistent with the information provided with the application. No potential contaminant sources were observed
on the site on in the surrounding area. There does not appear to be a significant potential for the proposed site
for the system to flood.
2. Attach Well Construction Data Sheet-if needed information is available
3 . Do you foresee any problems with issuance/renewal of this permit? D Yes [2J No. If yes, please explain
briefly. __ .
4 . List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5 . List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
FORM: Holloman Closed Loop UIC Staff Report 10-06 3
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Condition
Reason
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office, ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
S. Signature of report preparers):
Signature of APS regional super
Date. 10 { 1
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FOR.MW Ilolloman Closed Loop UIC Staff Report I0-06 4

WASHINGTON REGIONAL OFFICE - APS SECTION - PHOTOGRAPHIC RECORD
Site Name: Holloman Closed Loop UIC Incident/Permit Number: W10700101
Site Location:
1049 Scarlett Oak Drive Site TownlCi
Greenville, NC
Photographer:
Photographer.
R. Sipe
R. Sipe
Date:
Date:
10/2012006
"
10/20=06
"r
Photo Location:
Photo Location:
Side yard of
- � jl •.- � i ; +� �-
Front yard of
T
residence
_
residence
Photo Direction:
Photo Direction:
West
1_ 'fir -
Southwest
Comments'
Comments:
Area of proposed
closed loop
House under
system in
construction at sit
Photographer:
Photographer:
R. Sipe
-
R. Sipe
pate:
Date:
10/20/2006
1 D12012008
�i
Photo Location;
Photo Location:
backyard of
backyard of
--
residence
._
_ .
residence
_
Photo Direction;
Photo Direction.
West
South
!a +
CommenW
Comments:
Area of proposed
t w.closed � � -
Area of proposed
- • ''� -
losed loop
closed loop syster,
_
_ � + - --
system

I i.
n
Holleman Residence
1049 Scarlett Oak Drive
Greenville, NC
wal
j tea.
Ra
�4
Location of proposed closed loop system .' j
• -
r
r
P- if
1

Permit: Wl0700101
SOC:
County: Pitt
Region: Washington
Effective:
Effective:
Contact Person: Michael Hadley
Directions to Facility:
Compliance Inspection Report
Expiration:
Expiration:
Owner: Hal Holloman
Facility: Hal Holloman
1049 Scarlet Oak Dr
Greenville NC 27858
Phone: [phone]
Take 264 to Greenville and stay on 264 bypass, which becomes Greenville Blvd. Turn east onto 10 St (NC Hwy 33 East). Go east
until Portertown Road. Turn right (south) and continue until turn right onto Scarlett Oak.
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 10/20/2006
Primary Inspector: Dwight R Sipe
Secondary lnspector(s):
Entry Time: 10:00 AM
Certification: Phone:
Exit Time: 11 :00 AM
Phone:
Reason for Inspection: Routine Inspection Type: Reconnaissance
Permit Inspection Type: Injection Water Only GSHP Well System (5QW)
Facility Status: ■ Compliant O Not Compliant
Question Areas:
■Wells
(See attachment summary)
Page: 1
Permit: WI0700101
Inspection Date: 10/20/2006
Inspection Summary:
Owner -Facility: Hal Holloman
Inspection Type: Reconnaissance Reason for Visit: Routine
The site conditions appear consistent with the information provided in the application. No potential sources of
contamination were observed on the site or in the surrounding area. There does not appear to be a significant potential for
the proposed location of the closed loop system to flood.
Page: 2
AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: October 10-2006
To: ❑
Landon Davidson, ARO-APS
❑
Art Barnhardt, FRO-APS
❑
Andrew Pitner, MRO-APS
❑
Jay Zimmerman, RRO-APS
RECEIVED
I)WO- s ■AR0
® David May, WaRO-APS
❑ Charlie Stehman, WiRO-APS
❑ Sherri Knight, W SRO-APS
From: D. Michael Rovers , Groundwater Protection Unit
Telephone. [phone] Fax: [phone]
E Maid: Dennis.Rogers{rrmemail.net
RECEIVED I CENR I DWQ
A. Permit Number: WI0700101 !;FUTON
B. Owner: Hal Holleman
OCT 132006
C. Facility/Operation: Holleman Residence
® Proposed ❑ Existing ❑ Facility ❑ Operation
D. Application:
1. Permit Type: ❑ Animal ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Rernediation (ND)
® UIC — (5QW) Closed loop water
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
1 Project Type: ® New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: ® I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within calendar days, please take the following actions:
® Return a Completed APSARR Form.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment H for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: 90m,jil. -< Date: 1,9—t�
FORM: APSARR 07/06 Page 1 of l

Central Files: APS SWP
1 Olt 0106
WI0700109 Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
dennis.rogers
Permitted now
cil V
Facility Name
Hal Holloman
Location Address
1049 Scarlet Oak Dr
Greenville
Owner Name
Hal
NC 27858
Status
Project Type
In review
New Project
Version
Permit Classification
Individual
Permft Contact Affiliatian
Michael
Hadley
102 Middle St
Jacksonville
NC 28546
MajorfMincr Region
Minor Washington
County
Pitt
Facility Contact Affiliation
Owner Type
Individual
Holleman Owner Affiliation
Hal Hollorrnan
300 Crestline Blvd
Greenville NC 27834
Scheduled
❑rig issue App Received Draft Initiated Issuance Publ[c Notice Issue Effective Expiration
i Q109l06
'
Waterbody Name
Stream index Number Current Class
Subbasin

apF W ATERQG Michael F. Easley, Governor
P William G. Ross Jr., Secretary
A r North Carolina Department of Environment and Natural Resources
7 �
0 ►C Alan VW. Klimek, P.E. Director
Division of Water Quality
October 10, 2006
Hal Holloman
300 Crestline Blvd.
Greenville, NC 27834
Subject: Acknowledgement of Application. No. W10700101
Injection Water Only GSHP Well System (SQW)
Pitt County
Dear Mr. Holloman:
The Aquifer Protection Section of the Division of Water Quality (the Division) acknowledges receipt of
your permit application and supporting materials on October 9, 2006. This application package has been
assigned the number listed above and will be reviewed by Dennis Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if
necessary. To ensure the maximum efficiency in processing permit applications, the Division requests
your assistance in providing a timely and complete response to any additionai information requests.
Please be aware that the Division's Regional Office, copied below, trust provide recommendations prior
to final action by the Division. Please also note at this time, processing permit applications can take as
long as 60 - 90 days after receipt of a complete application.
If you have any questions, please contact Dennis Rogers by phone at [phone] or by email at
[e-mail]. If the reviewer is unavailable, you may leave a message, and they will
respond promptly. Also note that the Division has reorganized. To review our new organizational chart,
go to httsa:llli2o.car.state,nc.us/documents/dwci Q chart.l df.
PLEASE REFER TO TFIE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRMS
ON THIS PROJECT.
Sincerely,
for Debra . Watts
Supervisor
cc: Washington Regional office. Aquifer Protection Section
Fermis Application File W10700101
M. iehael Hadley — 102 Middle Street, Jacksonville, NC 28546
Aquifer Protection Section 1636 Mal Service Center
Internet: www.ncwaterouaiitv.ora Location: 2728 Capital Boulevard
An Equa4 Opp ortun tylAFrirmative Action Employer— 50%RecyeledM0% Post Consumer ;caper
No" C Carolina
Naura!!y
Raleigh, NC 27699-1636 Telephone. [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2• [phone]
Customer Service: [phone]

Application Reviewer. /G1 >F ( S
Pre -Review: Conducted? Yes ❑ No (within 2 weeks of receipt)
O.K. to Process? Yes ❑ No
If No, ❑ Pre -Review Return (return form to supervisor)
Owner: P(r❑ .xisting Unknown Owner TF_ tie_ ❑ Non -Gov't { IElnd. or Org.)
FacilitylOperatinn: Proposed ❑ Existing
Regulated Activities:
ApplieationlPermit:
Fee Category: ❑ ND Major ❑ ND Minor
�- ❑ Express Review project
❑ Gov. -County ❑ Gov. -State
❑ Facility ❑ Operatio"ther
❑ SFRApplication ❑ Recycle
❑ Gov. -Municipal
❑ Gov. -Federal
❑ Other:
❑ Other_
Permit Type: ❑ Surface Irrigation ❑ Surface Irrigation — SFR ❑ Reuse ❑ Nigh -Rate Infil.-
!1 t ❑ Recycle ❑ InfilAvap. Lagoon ❑ Pump & Haul [i 6W Remed. (ND)
�L For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal ❑ Animal
❑ 503 ❑ 503 Exempt
Projed Type_ ❑ Major Mod.. ElMinor Mod. ❑ i(enewal ElRenewal with Major Mod.
SSpecial Entry Issues:�111ew
❑ Name Change ❑ Ownership Change ❑ Other:
Notes-

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
F_NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED IIEAT PUMP)
Type SQW Wells
In Accordance with the provisions of NCAC'rdlc 13A: 02C.02W
Complete application and mail to address on the Traci; paage.
This is not the proper form to be used for injection wells in an open-Ino_g geothermal system.
Do not use this form for systems that circulate anv substances other than water.
TO: DIRECTOR, NORTH CAROLDiA DIVISION OF WATER QUALITY
DATE: _Sept. 25 _ , 20 06
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES X If yes, then continue completing this form.
NO If no, do not complete this form. 1Fanrn GW-57 HP, Application For
Perma To Construct AndlOr Use: A Well(v) For Injection With A Hear
Pimp �vslem, should be completed.
B. SYSTEM FLUID Will any additives be introduced to the system's circulating beat transfer
fluid? Tl�s includes. but is not limited to corrosion inhibitors and/or antifreezes.
YES If yes, do not complete this form. Form GW-57 HP, Application For
Permit To Construct AndlOr Use A Well fsj Fbr Injection With A Hear
Pump System, should be completed.
NO X If no then continue completing this form.
C. PROPERTY OWNER
Name: Hal Holloman
Address:300 Crestline Blvd
City: Greenville _ State: _NC, Zip. Code: 27834
county- Pitt Telephone. [phone]_ -
D. STATUS OF PROPERTY` OWNER
Private: x Federal: Commercial:
State. Municipal: Native American Lands:
GW-57 CL (]an, 2000) Page I of 4
_C3
rJ
:n

E. JOB (SITE) DATA
Name : Hnl..H'4lloman _________ _
Address: · '~Scarlet Oak Drive ~~
City: Greenville _S_ta_t_e_: -N-C--Z-ip_C_o-de-:--~--d.""'1-'!TH,~,..,.f""oo-1run_t_y_: -Pitt
Telephone: [phone] Contact Person: Hal Holloman'-------
F. HEAT PUMP CONTRACTOR DATA
G.
Name: Coastal Geothermal.
Address: 102 Middle St -------------------City: Jacksonville State: NC Zip Code: 28546_ County: Onslow
Telephone: (910) ,S-0926 Contact Person: Mike Radle\
3~3
CONSTRUCTION DATA (check one)
____ EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (4) below to the best of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if available.
X PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (4) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(1) Well Drilling Contractor's Name: S=an=fo=r=d'-"L=·--=S""'w"'"'e=et=i=ng_.__ ________ _
NC Contractor Certification number: NC -2082
Date to be constructed: _ November , 2006_ Number of borings: _ 7 __
Approximate depth of each boring (feet): _____ =2-=-00"'-'-------
(2) Well casing: Is the well(s) cased?
(a) YES __ If yes, then provide the casing information below.
Type: Galvanized steel __ Black steel __ Plastic __ Other (specify) ____ _
Casing depth: From ___ to ___ ft. (reference to land surface)
Casing extends above ground ____ inches
(b) NO ___ X ______ _
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.1.s.):
(a) Grouttype: Cement __ Bentonite _x_ Other (specify) _______ _
(b) Grouted surface and grout depth (reference to land surface):
_x_ around closed loop piping; from .JL_ to ..1fil)__ (feet).
__ around well casing; from __ to __ (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW-57 CL (Jan, 2000) Page 2 of 4
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
1. "LOCATION OF WELL(S) Attach twin maps.
(1) Include a site map (can be drawn) showing: buildings, property lines surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between the
proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks or drain
fields located within 200 feet of the ground -coupled heat pump well system. Label all features
clearly and include a north arrow.
(2) location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections).
PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
" 1 hereby certify, under penalty of law, that I have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of those
individuals immediately responsible for obtaining said information, I believe that the information is true,
accurate and complete. I am aware that there are significant penalties, including the possibility of fines
and imprisonment, for submitting false information. I agree to construct, operate. maintain, repair, and if
applicable, abandon the ground -source heat pump system and all related appurtenances in accordance
with the approved specifications and conditions of Ifni Permit.'- J.
i-
(5igiia(ure of *ell Owner or Authorized Agent)
If authorized agent is acting on behalf of the well owner.
please srrppdy a letter signed by the owner
authorizing the above agent.
GW-57 CL (Ian, 2000) �- !J0 90 Page 3 of 4
- I,

L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests ownership in
the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be the
responsibility of the applicant to ensure that the ground-source heat pump system's well(s) conforms to
the Well Construction Standards (Title 15A NCAC 2C .0200)
GW-57 CL
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UICProgram
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
(Jan, 2000) Page 4 of 4
9 C rI't-OR-k i�r'
re �J►�� �� I�� PC, 2- 7 FSe
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Map Output
Page 1 of 1
n2en
Ritt County Government
4Greenville, North Carolina
11;1;P www.pittcountync.gov
85352
57778
L
58789
ParcelNumber
072420
F 57758
58773
Accounthiumber
.0.
65370 RO
57780
rrr 58781
LocationNumber
0
Location direction
58772
o��rF�
58782
LucationStreet
SCARLET OAK
65``369 65371�
0 58783
LocationType
❑R
65368�$7850 49598
65367'
9Oty 58771
528p5 Pb
67832
far.
r58785
C
\
58704
Municipality
OwnerName
OwnerAddressl
HOLLOMAN HAROLD L JF
HOLLOMAN BLAIR M
p
f
OwnerAddmss2
300 CRESTLINE DRIVE
65365 67844 67831 67833 -
OwnerAddress3
.0
� ,9(,tT R�
CityStateZip
GREENVILLE NC 27834
-
67848 21527 !
�q pKOr
67835 7
� 72409 40860
Legalaescription
DeedBaok
OAK HILL EAST
002111
67847 O 72423
65364 /
DeedPage
00233
67848 �+ti' ,67836 72410
MapBlockLot
5606.00-01-0729.000
72422 46862
Township
CHICOD
+�V�6783T 72411
67845 46863
CensusTract
10
67838
FireTaxdistrict
EASTERN PINES
72421 72412
C. 468t34
UseCode
RR RESIDENTIAL(Rural Homesite)
67$44 839 - 72413 46885
D.
YearBuilt
14919
HeatedSquareFoot
j 72420 a 46866
SalesMonthYear
0512D06
c 72414 �.
s�
Indicated5alesPrice
$51,000
67843
67840 46867 Q
Acres
0.00
/
TotalTaxVatue
545,000
67842 { ,72415
BuildingValue
67841 72419
LandValue
$45,000
72416 49808
ExtraFeatureValue
$0
'OLCINN
23109 p241g .�
ElementarySchool
WINTERGREEN
PRIMARYIINTERMEDIATE
4t3870 0-
MiddleSchool
HOPE MIDDLE
72417 4$873
IaighSchoal
D.H. CDNLEY
46871 �
46872`
NumberBuildings
0
Ff�
MapBook
MB65-117
Neighborhood
02103
02123 56627
NCPinNumber
5606010729
56628
I
Lothiumbef
38
BlockNumber
BuildingNumber
14886 56626
UnitN um be r
56628
SectlonNumber
2
—
TractNumber
PhaseNumber
52528 52527 52526
SubdivisionName
OAK HILL EAST
qq rr��
0 9 �4 2rf t
1
Disclaimer: This lax record is prepared for the inventory of real property within Pitt
County and is compiled from recorded deeds, plats, tax maps, surveys, and other
public records. Users of this data are hereby notified that the aforementioned
public primary information sources should be consulted for verification. Pitt County
Data Current As Of:
assumes no legal responsibility for the information contained herein.
Friday, September
15, 2006 @ 3:2 1 PM
Copyright @ 2006. Pitt Couniv, North Carolina.
http:llgis.pittcountyne. govlsery l eticom.esri.esrimap.Esrimap?SeiviceN ame=opi s_ov&Cli e... 101912006

Map Output
Page 1 of 1
. c ar,► Rift County Government
Greenville, North Carolina P T� WTI
TY
[t
°fir:r.w www.pittcountync.gov
ParcelNumber 072420
AccountNumber
i .' - LocatlonNumber 0
Location Direction
Location5treet SCARLET OAK
LocationType DR
a r{� `� 1 Municipality
OwnerName HOLLOMAN HAROLD L JR
OwnerAddressl HOLLOMAN BLAIR M
OwnerAddress2 300 CRESTLiNE DRIVE
QwnerAddress3
R0 CityStateYip GREENVILLE NC 27834
0 04Ar �� Legal Description OAK HILL EAST
} OeedBook 002111
DeedPage 00233
. ' • to : - MapBlockLot 5606.00-01.0729-000
$ _ y`r - �+ _' Township CHICO❑
CensusTract 10
Cr- FireTaxDistrict EASTERN PINES
;• +,r�s 4. 4 +r�• UseCode RR RESIDENTIAL(Rural Homesite)
�: ► :°' Year6uiit
HeatedSquareFoot
qQM
SalesManthYear 0512006
'k
A ti y` y w IndicatedSalesPrice 55f ,000
Acres 0.00
r •}
;Wf elk •{s 'irr� " Y TotaiTaxValue $45,000
«S rrr r ,.y �[ ❑ , 8uiidingValue
O LandValue $45,000
a
l`•h'r �` i% �J.
mot+ �� Rio ExtraFeatureValue $0
:""tir t .. +� f' • WINTERGREEN
Elernentary5chool
a PRIMARYIINTERMEDiATE
0 ri ~- � MiddleSchaai HOPE MIDDLE
+.
! p�el�;. fit' HighSchool ❑-H-CONLEY
E•f NumberBuildings 0
MapBook MB65-117
.
`;F ��� i Neighborhood 02103
NCPinNumber 5605010729
tr y �`! LotNumber 38
R'' # SlockNumber
' y
'_ ,, ►' BuildingNumber
f
t. r UnitNumber
a r� 3� + • { ` jz,r r SectlonNumber 2
++■■ fQL�r� -� ..�, TractNumber
PhaseNumlaer
re
SubdivisionName OAK HILL EAST
Disclaimer: This tax record Is prepared for the inventory of real property within Pitt
County and is compiled from recorded deeds, plats, tax maps, surveys, and other
public records- Users of this data are hereby notified that the aforementioned
public primary information sources should be consulted for Verification. Pitt County data Current As Of:
assumes no legal responsibility for the information contained herein- Friday, September 15, 2006 @ 3:21 PM
® 2006, Pitt County, North Carolina.
http:llg i s. p i ttcou ntyiie. goals ery i etico m . e sri . c srimap , E srimap? S erg i c eNam e=op i s_o V & C l is ... 10J912 0 06

CLIMATE OONTROL HEATING & COOLING, INC.
102 MIDDLE STREET
JACKSONVILLE. NC28546
81N5H040