WI0700114_GEO THERMAL_20080725

Pei"mit Number WI0700114
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Permitted Flow
Facil it
Facility Name
Artisan Marble and Tile Inc
Location Address
2230 W Lake Ave
Nags Head
')wn er
Owner Name
Francis
r t es /Events
NC 27959
Elbers
Scheduled
Orig Issu e
07/25108
App Received Draft Initiated Issuance
07/14/08
Reoulated Activities
Heat Pump Injection
Outfall NULL
Central Files : APS_ SWP_
07/25/08
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Francis Elbers
206 W Villa Dunes Dr
Nags Head NC
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Francis Elbers
206 W Villa Dunes Dr
Nags Head NC
Public Notice Issue
07/25/08
Effective
07/25/08
27959
27959
Expirati on
Waterbody Name Stream Index Numbe r Current Class Subbasin
87/16/2006 12:20 2524411989 ARTISAN PAGE 62162
NORTH CAROLINA,
Dl, PARTNT.W OF ENWRONMIENT AND NATURAL MO 1RCE5
NOTMCATION OF PFMNT TO CONSTRUCT A CLOSED -IMP
GEOTHERMAL WATER -ONLY INJE C nON WELL SYSTEM
(GROUND COUPLED BEAT PUMP)
Type 5QW Wells
kn Accorch m vi l) tW provisivr's fNCAC Trrtle ISA: 02C.0200
Cowplete application and audl to address on the back page
This is g2jt#e proper faro to be used for injection welk ia an �eR�� eoofteraW system.
&� not r tt" form for S"CK rs tfat circulate tb r4 YMbe .
TO- DMCTOR, NORTH CAROLINA DIVISION OFWATER QUALI'I`Y
DATE: �� . _ 20crz-
A. SYSTEtvI CLASS€l✓ICA'T ON D ms the proPased system circulate potable waUr in confin ous
piping that completely isoiatas the htdd from the envinmuient?
YES If yes, tam wntinue completing this fotm.
NO if•no, do not compkie tWs form. Form G rW-57 HP, Applicadon For
Pemdt To Cortstrw1 Ar&&0r Use A Welf(s) For Inja.Von Wrh A Rwl
Pzmp S Xwem, should to compktedi
H. SYSTEM FLUID Will ar�y a"fives be inhodwc d to the sy n's citrWaft beat uat&frr
fluid? This inr-lades, but is not iinxi d to carmsloa Inldbitm and/or atyfiffeerm,
YES Ifyes, do not oomplete this funn_ Form GW-57 i-tF, Applicatirarr For
Petmi! To CQrtftrucr And/Or Use,,# Well(s) For h#eeMm Wfth A Heat
Pump •System s1m1d be completed.
NO if'w, thm cov inue completing dais farm.
C. PROPERTY O%NER
Name E ZA J G t
Addmss:
City: L' 1 Stow zip Cade;
Count►: z i T,-lephone:
D. STATUS OF PROPERT'IT dVJNR
private: Federal: Comruex"sal,
5 : IVlurr zipal: Native ,Amevicara. Lwuk:
Rai I" Gw"c--3-7 CI. Page 3. of 4

0711612068 12:23 7524411989
AF2TISAF� PAGE 01162
E
F:
FACILITY (5M) DATA
(Fill out ONLY if'the Status of Owner is fed , StMe, .MuMolpal or Com memial).
-NMne of Businem or Fa0i eA rt Stt n— f V-1AUW 4",-a__ i 1-c A(
City: Stagy: County:
Telape. _ __ Conf�tct lea s�rr�: to G���� -'
St nd vd IndustriA Codo(s} SIC, which describes commercial faciiity:
MAT PafJW CC]NT ACTOR DATA
Address:Y ST_
City= E tt4._W _ Stagy: A# C, Zip C. )de: j a�a Caty.
T'elephom; �Z 4 ., - _ Contaa Pena C-C.,3 R___ P� -- -
CONSTRUCTION DATA (dam one)
(I)
(2)
(3)
NOTE:
EMUNG WELLS) being proposed for ust< as a ground-ompled bw ptwy
well(s) FmvWe ttw informalim in (1) throuA (3) below to the best of your
kncwle e, Ausch a copy of Emir GW- l (Well Cart RccvH) if
available -
XI __ PROPOSED WELL(S) to be constructed for as a ,end -coupled heat pinup
well(s), Fmvide the information in (1) tWIMO (3) below a3 PRO KM
caomatruction specificmiom. Submit Fom GRi_1 aftet cuasbiwim
well Drilling Conn -a ce s Name- Po P-L . U
NC Contractor Cefficatiun nub:
Daw to be oovAructc&- 7,h _q — % r--8--- Number a
AppvNiwaba depth ofeaucb baring (fe ,Y —
woo carsiv. Ls the wa(s) Caged' -
(a) YES — If'yesr then pmvide; thv using inf nmation. below.
Type: Galvanised iwl Black steel; Piasiic_. Cher (specifr).. _ _—.—
Casing depth: from #v * (refemge to 3stxi surface)
Casing extends above ground iuches
() NO . --
Groto (grout -tire vcrtical lend of the borehole to a mWmum dVffi of20 feet b l.s.)
(a) Groul type: Cement ____w ]Bentonite ,_ der (agecify) _
(b) Grt uwd surface and grmu dipth (rrfmvdm to land surface)
Xaround Cows' loop poring., from Q to � (&,ea.
around well cminz fmm to � (feef).
11M WEU i7B.It.i.M CVATMACTOR CAN 9 WLY -OM DATA FOR MTEBR EMTING OR
PROP06ED WELLS IF -11-H S. IM)MI&A V 0 K lS UNAVAI 4KE BY QTtMK MEANS,
H.ewxsed 7/06 OW"C-57,t. €'age 2 of4

07/15/2008 12:2 3 2524411989 ARTISAN PAGE 02/02
H. INIBCTION-RELATEDBQillPMENT
Attach a diag,:am showing the engineering layout of the iqjection equiptmint in>:d exterior pipiugftubing
associated with the roj~oo operation. The mWlu:faetutu,s brochun: mtlY provide supplementary
:infonn~on. .
L LOCATION OF WELL(S) Attach two maps.
{1) Include a .site map (C811 be dtawn) sho-wiag: buildinp, p:oparty lines surface water bodies,
poteniial sources of groundwater contamination and 1he oriemBtion qf $kl distances ~een
tb.e propoaed well(s) and any exuding well{s) or waste disp(,sal facilities such as septic bmks
vr drmn &Ids kk::ated wilhin 200 fi!et oftbe ground,-ooupled heat pump well system. Label all
features clearly and include a north ~w.
(2) location map referencing the site to two nearl,ypenniment refer~ poin1s (such B.'l .roadst
streams and high\ffy intersections).
J. PERMIT UST: At,tach a list of all pemws or e01JfflUCtion approvals that are related to the site.
Example, include:
(1) H~us Wsste Management program PfflI1itB umlct RCRA
(2) NC Division ofWater Quality Non-Dischqe pennits
(3) Sewage TNBtrnent and Disposal Pet:mits
CER1WICATION
"'I he.t\'!by certify, under penalty of law~ that I have pmonalJy examined and am familiar wi1h the
infonnation submitted in this docnm.eot and all attaclunenm thereto $ld that,, based on my inquiry of
those individuals immediately responsible for obtaining said infonnation. t believe that the infonnation
is true, accurate and cotnplete. 1 am afflU'e that there are siguificant penahieBy including the possilillit;y
ofnn.es and 1~ :ful" subnliUing false inibrmatiQn. I agRe to constr®f, opnte, mmtein,
rc,pa.ir, Md if applicablt; ~ 1he ground..source heat pump system and all relmed~ces i:o
~ w.nh the approved specifications and conditions ·of the Perrott."
ltevised7/06
-----ct.~~
.If auth<mzed agent is acting on behalf of the well OW1N!.1'.
please supply a letter signed by the owner
autlwmlng tM abwe agent.
rR.f\rJC f <; c(JY5R s
P"~ . ARTJSJ\)l ti\ Ja ~~ ~
OWIUI~57CL Page3of4
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:VISION PER TOWN AND SITE REVISE
"VISIONS PER FIRE MARSHAL
EVASIONS PER NAGS HEAD COMMISSIONERS
OWNER I
'EVISE WATERLINE LOCATION I
:EVISE WATERLINE NOTES - - I
ADD TANKAGE DETAILS
REVISIONS PER DCHO
ADD POWER CONDUITS
ADD GEOTHERMAL WELLS
REVISIONS
COPYRW7 0 Z007
CAABLE & ASSOCIATES, P.C.
THIS DOCUMW IS THE PROPERTY OF
QU ELE & ASSOCIATES, P.C., ALL
RIGHTS ARE RESERVED. ANY RE--
PRODUCWN OF THIS OR POSSESSION
WrIHOlff PRIOR PERMISSIN OF
QUISLE & ASSOCIATES, P.C. WILL
C4NSTWE MIOLATION OF COPNICHT
IAWS. MOIAMON WILL BE SUBJECT
TO LEGAL ACTION
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ENGINEERING * CONSULTING * PLANNING
ENVIRONMENTAL SCIENCES *
SURVEYING
Phane: [phone] Fax. [phone]
E-vall. qulhfebeorLhllnk.ftd

Michael F. Easley, Governor
William G. Rau Jr., Secretary
North Carolina Department of Env i ronment and Natural Resources
Coleen H. Sullins Director
Division of Water Quality
July 17, 2008
Francis Elbers
206 West Villa Dunes Drive
Nags Head, NC 27959
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well Systetn
Permit No. WI0700114
2230 West Lake Drive
Nags Head, NC 27959
Dear Mr. Elbers:
In accordance with the application submitted to the Underground Injection Control (UIC) Program that
was received an July 14, 2008, the Aquifer Protection Section (APS) acknowledges your intent to
construct a closed -loop geothermal water -only injection well system for the operation of a ground -source
Pleat pump located at 2230 West Lake Drive, Nags Head, Dare County, NC 27959. This system is
deemed permitted by rule (North Carolina Administrative Code Title 15A, Subchapter 2C, Section
-0211(u)(2)}.
However, it is recommended that you contact the Dare County Health Department, as 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 APS to verify compliance with applicable rules.
Thank you for submitting this notification. If you have any questions please call me at [phone].
Sincerely,
{���� uwkA,u
1
4C Michael Rogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Washington Regional Office - APS
APS Central Fifes - Permit No. W10700114
Dare County Health Dept.
Chris Sterner 1 Chris's Mechanical, 2039 New Bern St., Kill Devil Hills, NC 27948
Aquifer Protection Section 1636 Mail Service Center
Internet: www,ncwatcquality.org Location: 2728 Capital Boulevard
An Equal OpporlunilylAffErmaWa Action Employer— 50% Recycled110% Post Consumer Paper
OR hCarul ina Na
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2; (919) 715-6D48
Customer Service: [phone]