WI0700118_GEO THERMAL_20120517

Beverly Eaves Perdue
Governor
AVA NCDENR-
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 17, 2012
James and Deborah Millis
Post Office Box 2139
Kill Devil Hills, NC 27948
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0700118
Dear Mr. and Mrs. Millis:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted· to the Di vision of Water Quality. You
may view the revised rules on our website at http ://portal.ncdenr.org/web/wq/ap s.
If you have any questions regarding your current permit or the rule revisions, please feel free to -
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service. Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity\ Affinnative Aclion Employer
One North Carolina
:Vnturn//!f
Permit Number Wl0700118
Program Category
Ground Water
Permit Type
..
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Permitted Flow
Facilit
Facility Name
James and Deborah Millis SFR
Location Address
164 Ocean Blvd
Southern Shores
Owner
Owner Name
James
Dates/Events
NC
H
27949
Millis
Orig Issue
10/06/08
App Received Draft Initiated
09/11/08
Scheduled
Issuance
Central Files: APS_ SWP_
10/13/08
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
James Millis, Jr
PO Box 2139
Kill Devil Hills
Public Notice Issue
10/06/08
NC
Effective
10/06/0~
27948
Expiration
09/30/13
.;..;Rc;ce.,.,g'-u--'la:....;t....;.e.;;.;d....;.A...c..cc...t __ iv_i_ti_e_s ________________ Re q uested/Received Events
Heat Pump Injection Region comments on draft requested
Region comments on draft received
Outfall r i i !;_L
Waterbody Name Stream Index Number Current Class
09/16/08
09/23/08
Subbasin
Permit Nui'n • r W10700118
Central Files: APS SWP
10/01/08
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Permitted Flow
dCility
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
L
Facility Name
James and Deborah Millis SFR
Location Address
164 Ocean Blvd
Southern Shores NC 27949
a r•
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Name
James H
IE
Owner Type
individual
Millis Owner Affiliation
Jaynes Millis, Jr
PO Box 2139
Kill Devil Dills
NC 27948
Scheduled
❑rig issue App Received Draft Initiated Issuance
09/11/08
Regulated Activities
Heat Pump Injection
utfall NULL
Public Notice kssue Effective Expiration
/*I fiat 113 I3
Region comments on draft requested 09/16/08
Region comments on draft received 09/23/08
Waterbody Name Stream Index Number Current Class Subbasin

Michael F. Easley, Governor
William G. Ross Jr.. Secretary
North Carolina Department of Environment and Natural Resources
Coleus FL Sullins, Director
Division of Water Quality
October 6, 2008
James and Deborah Millis Jr.
P.O. Box 2139
Kill Devil Hills, NC 27948
Re: Issuance of Injection Well Permit
Permit No. WI0700118
Issued to James and Deborah Millis, Jr.
Dear Mr. and Mrs. Millis:
In accordance with your application received September 11, 2008, I am forwarding Permit No.
WI0700118 for the operation of a vertical closed -loop geothermal mixed -fluid heat pump
injection well system to be located 164 Ocean Blvd., Southern Shores, Dare County, NC 27949
This permit shall be effective from the date of issuance until September 30. 2013, and shall be
subject to the conditions and limitations stated therein.
Please pay special attention to the bolded language in the permit. In addition, please
submit copies of the Well Construction Completion form (GW-1) and site map after
construction as required in Part I paragraphs 8 and 9.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit
an application to renew the permit three months prior to its expiration date. As indicated in the
permit, this permit is not transferable to any person without prior notice to, and approval by, the
Director of the Division of Water Quality. If you have any questions regarding your permit or
the Underground Injection Control Program please call Mr. Qu Qi at [phone] or me at
[phone].
Michael Rogers, Environmental Specialist
cc: David May — Washington Regional Office
Central Office File — W10700118
Brian McDonald — Outer Banks Heating & Cooling (via fax and USPS)
Alexander M. Engart, AIA
Dare County Environmental Health Dept.
Attachment(s)
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1 636
Internet: lino://www.ncwateroualitv.oru 2728 Capital Boulevard Raleigh, NC 27604
An Equal Oppottuoity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper
N°'" Carolina
'aturall{i
Telephone: [phone]
Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
James and Deborah Millis
FOR THE CONSTRUCTION AND OPERATION OF 9 TYPE 5QM INJECTION WELLS,
defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of
operating a vertical closed -loop geothermal -mixed -fluid heat pump system. This system is
located at 164 Ocean Blvd., Southern Shores, Dare County, North Carolina 27949, and will be
constructed and operated in accordance with the application dated September 11, 2008, and in
conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the
Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an
injection well shall be in compliance with Title 15A North Carolina Administrative Code 2C
.0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well construction and
use.
This permit shall be effective, unless revoked, from the date of its issuance until September 30,
2013, and shall be subject to the specified conditions and limitations set forth in Parts I through
X hereof.
Permit issued this the °i, day of , 2008.
K\Coleen H. Sullins, Director
- Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0700118 Page 2

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcem~nt action as provided
for in N.C.G.S. 87-94. .
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that
are generally subject to flooding include those with concave slope, alluvial or colluvial
soils, gullies, depressions, and drainage ways.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each geothermal injection well shall have permanently ~ffixed an identification plate
according to 2C .0213(g).
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection
well to:
Aquifer Protection Section ..,... UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
GW-1s must be submitted within 30 days of completion of well construction. Copies of
the GW-1 form(s) shall be retained on-site and available for inspection.
9. Well construction records must also be submitted for the existing water supply wells on-
site as well as a site map showing any water supply wells on adjacent properties as
specified in NCAC .021 l(d)(l)(D).
Permit No. WI0700118 Page 3
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight ( 48) hours prior to constructing each injection well, the Permittee shall
notify the Aquifer Protection Section-Underground Injection Control (UIC), Central Office
staff, telephone number [phone] and the Washington Regional Office, telephone
number [phone].
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances, which may be
imposed by other local, state, and federal agencies, which have jurisdiction. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
PARTIV-PERFORMANCESTANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater, which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
PermitNo. WI0700118 Page4
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section-
Underground Injection Control (UIC), Central Office staff, telephone number (919) 715-
6166 and the Washington Regional Office, telephone number [phone].
Notification is required so that Division staff can inspect or otherwise review the injection
facility and determine if it is in compliance with permit conditions.
PART VI -INSP~CTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place
on or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed
necessary by the Division of Water Quality to insure surface and ground water protection,
will be established and an acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Washington Regional Office, telephone number (252)
946-6481, any of the following:
(A) Any occurrence at the injection facility, which results in any unusual
operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said · application or in any report to
Permit No. WI0700118 Page 5
. the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Pennittee shall
take such immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 90 days prior to the expiration of this permit, request an
extension.
PART IX -CHANGE OF WELL STATUS
•
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Pennittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well _shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe, which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
Permit No. WI07001 l 8 Page 6
•
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specifiedin 15A NCAC 2C .0213(h)(l) within 30 days of completion
of abandonment. •
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-DIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X -OPERATION AND USE SPECIAL CONDITIONS
Permit No. WI0700118 Page 7
Re: WI0700118 Draft permit and App
1 of 1
Subject: Re: WI07001 l8 Draft permit and App
From: David May <[e-mail]>
Date: Tue, 23 Sep 2008 15:35:54 -0500
To: Michael Rogers <[e-mail]>
OK with us.
David
Michael Rogers wrote:
Per our new 5QM permitting process, attached is the draft permit and scanned application for a new
5QM well for your review. Ifwe don't hear anything thing back by 9/23/08, that you want to conduct
a pre-permitting approval field inspection, we will go ahead and issue permit.
Thanks
David May, Regional Supervisor
Division of Water Quality
Aquifer Protection Section
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
10/1/2008 10:14 AM
ALEXANDER M ENGART AIR
May 29, 2007
REGEier Protection R�
Muller ct a
SEP 0 2 ZCO8
To Whom It May Concern:
RE: Remodeling and Additions at 164 Ocean Boulevard (Dare County Parcel if 0218870.00)
Please be advised that Alexander M. Eugart, architect, is authorized to act as our agent for filings
and permit applications appropriate to this project.
BOX 8154, DUCK STATION KITTY HAWK. NC 27(.149
252 • 261 • 4473

Michael F, Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins Director
Division of Water Quality
September 15, 2008
James Millis
Deborah Millis
PO Box 2139
Hill Devil Hills., NC 27948
Subject Acknowledgement of Application No. W10700118
James and Deborah Millis - SFR
Injection Mixed Fluid GSHP Well System (5QM)
Dare
Dear Mr & Mrs Millis:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on September 11, 2008. This application package has been assigned the number
listed above and will be reviewed by Michael 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 additional information requests.
Please be aware that the Division's Regional Office, copied below. must 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 Michael Rogers at 919-715-6 1 66, or via e-mail 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
hurpl/h2o enr.state.nc.usldocumentsidwy orggchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS
PROJECT.
Sincerely,
Cwk.
16j3COP
for Debra J. Watts
Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Brian McDonald - Outer Banks Heating & Cooling, PO Box 14] 5 , Nags Head, NC 27959
Permit Application File W107001 I8
leemtliCarolitia
Naturally
Aquifer Protection Section 1636 Mail Service Center Raleigh. NC 27699-1636 Telephone: [phone]
Internet: www.ncwaterquaiity.org Location: 2728 Capital Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal Opportunity/Affirmative Action Employer- 50% Recycledll0% Post Consumer Paper Customer Service: [phone]

6
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
RECEIVED 1 DENR 1 DWO
Aquifer P►ote,ctinn Section
SEP 112008
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 50M WELL(S)
New Permit Application OR Renewal (check one)
DATE:
PERMIT NO.
/&'
, 20D/5
(leave blank if NEW permit application)
A. PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature):
gi41n1 e 5 g• r1 rL G US/ ved50r 4H Aevc.Lii
(I) Mailing Address: ! • it. SQyc
City: Ala- P1✓ 1.. M'LJ4 Stater C. Zip Code: tcj f '$ County: D 4 JE.
Home/Office Tele No.: 4 5'L ' I ' ! 7 Cell No.:
EMAIL Address:
(2) Physical Address of Site (if different than above):
lip " cc.&w Bd c { Gekit-' D
City: %aC1THei ) bate: NC Zip Code: 1-' ,g'7 County: .401'&-.
Horne/Office Tele No.: Cell No.:
EMAIL Address:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.. Cell No.:
Website Address of Company, if any.
C. STATUS OF APPLICANT
Private: _X Federal. Commercial:
State: Municipal: Native American Lands:
GPUNIC 5QM Weil Permit Application (Revised 7/2008) Page t

D. WELL DRILLER INFORMATION
Company Name: q)R / 4-L1iV 9 c-otki $ 4 t7 75 /tV7 4.7W * t.,
Well Drilling Contractor's Name: relAK 6arreek-
NC Contractor Certification No.: 35 3 810
Contact Person: AtIKAT 6 CIT E# — EMAIL Address: f ° & ..4 (7GDj( Mr
Address: goo 9 D A 3T1 I
City: VA. ,P-,,,cd-i-/ 01 Zip Code: (--- County:
Office Tele No.: 757 f / 'Lb% Cell No.:
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: 0(4 e& '`t A[K3 Yai ri49 GooLtAlr
Contact Person: 13Am \rrMciptiAlitLD EMAIL Address:
Address: pa. a. 1Zd)
City: ,40 5 HMO / AfC Zip Code: .1-7/9 i County:
Office Te1e No.: 1St, . -r4(' /7f Cell No.:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
6--1-.45sat) [mob 5 rfriaemL 6 7" pimp
srs Tel f & ,P410,1.7� s/ CE—
G. WELL CONSTRUCTION DATA (Skin to Section Hifthis is a Permit RENEWAL)
(1) Proposed date to be constructed: Number of borings: 7
Approximate depth of each boring (feet): _ 00
(2) Chemical additives to be used in closed -loop system (only those chemicals indicated have been approved):
R-22 propylene glycol ethanol as) r11ROg.. geOther (other additives will
need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): PYe..•
(4) Well casing. Is the well(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES _ if yes, then provide casing information such as type (steel, PVC, plastic, etc.), diameter,
depth, and extent of casing appearing above ground:
(b) NO
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite X Other (specify)
(b) Grout depth of tubing (reference to land surface): from 0 to 1.60 (feet)
If well has casing, indicate grout depth: from to (feet)
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
GPU/UIC 5QM Well Permit Application (Revised 7/2008) Page 2

RECEIVED / OENR / D'['JQ
Aquifer Protection Section
SEP 112008
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(I) 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 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
J. POT ABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties? __ YES __J(No
If Yes, than indicate location on attached map(s).
K. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the recorded legal property deed.
"l hereby certify, under penalty of law, that I have personally examined and am familiar with the infonnation
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 infonnation. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Pennit."
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Property Owner/Applicant
~i~ Signature of Authoriz~
,A..(£1(; l'tlOl)eA 11 . 8</ ylf"?l . 4/l.Gff 17&:,r
Print or Type Full Name l
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UlC SQM Well Pennit Application (Revised 7/2008) Page3
•Parcel Card Page 1 of 2
Parcel Number: 1021887000
County of Bare, North Carolina
Owner Information:
MILLIS, .LAMES H JR
POBOX 2139
KILL DEVIL HILLS NC 27948
Submit
Parcel information:
Parcel: 021887000 PIN: 986819701060
District: 20 - SOUTHERN SHORES
Subdivision: SO/SH AMENDED PLAT B SEC 3
LotBlkSect: Lot: 9 10 Blk: 26 Sec: 3
Multiple Lots: -
PlatCabSlide: PL: 1 SL: 36 Units: 1
Deed Date: 3/19/2007 BkPg: 1722/335
Property Use: Single Family Residential
CLICK HERE FOR, TAX CERTIFICATIOH-
BUILD1NG USE and FEATURES
BUSE: Single Fain Dwg
Exterior Walls Vinyl Lap Siding - N/A
Interior Walls Drywall - N/A
Floors
Roof Cover
Roof Structure
Heat -Fuel
Heat -Type
Air Conditioning
Carpeting - Ceramic or Quarry Tile
Asphalt Cornposition Shingle
Gable or Hip
Electric
Forced Air / Duct
Central Air
MISCELLANEOUS USE
Muse I : 1 St Prefab Fplace
Muse2: Pool(In Ground)
Muse3: Conc Dck Around Pool
Muse4: Dtachd Free Stdg Dck
Muse5:
LAND USE
LUSE: 20-Oceanfront
Luse2:
Luse3:
Luse4:
Luse5:
Luse6:
LAND AREA: 35000 Square Feet *please see notes below
Print Date: 8/28/2008
•
021887-000 20-936819-RT-035
164 OCEAN BLVD
Building — Cogent Vatue: 0 S!M
Actual Year Built: 1998
Baths: 4
Bedrooms: 6
FINISHED SQ FT: *pleases see notes below*
drawing! = 3120
Misc -C r-rent YiIue 534,500
Land - Current Value: $1.755400
m , - m. .. •• Total Current Value: $2,070,600
*The Finished Square Footage of the building(s) and the Land Area information is based on data in the Tax Appraisal
program as ofJanuary 2008, and will be updated at least twice a year_
*Finished Square Footage indicates the area of a building that is heated or unheated and has interior finish_ The
finished square footage is shown for up to 3 drawings per parcel from the Tax Appraisal program. Usually each
drawing denotes one building. Larger, or more involved buildings sometimes require two or more drawings in the
Tax Appraisal program, and in these cases the finished square footage of these drawings will need to be added
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State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
William G. Ross Jr., Secretary
Coleen H. Sullins, Director
Division of Water Quality
Aquifer Protection Section
Location: 2728 Capital Blvd.
Raleigh, NC 27604
Mailing Address: 1636 Mail Service Center
Raleigh, N.C. 27699-1636
FAX: [phone]
[phone]
1 FAX TO: o.rTh ►(Y1(tQ4rruJ)
REF: 1� �r 1 i �
s - rY
Date:
e.
FAX NUMBER: N 5 0-
FROM:
PHONE' .Th 2 — 32Z1
[okIcl
NO. OF PAGES INCLUDING THIS SHEET:

DATE,TIME
FAX NO./NAME
DURATION
PAGE(S)
RESULT
MODE
TRANSMISSION VERIFICATION REPORT
10/13 15: 00
912524410539
00:02:28
09
OK
STANDARD
ECM
TIME 10/13/2008 16:03
NAME NCDE&NR/WATER QUAL
FAX [phone]
TEL [phone]
�t r 6 • ' CN
ITDW�
r
H
Q �
Ivlichaei F. Easley, Governor
William G. Ross Jr.. Secretary
North Carolina Department of Environment and Natural Resources
Caleen H. Sullins. Director
Division of Water Quality
James and Deborah Millis Jr.
P.O. Box 2139
Kill Devil Hills, NC 27948
October 6, 2008
46
Re: Issuance of Injection Well Permit
Permit No. W10700118
Issued to James and Deborah Millis, Jr.
Dear Mr. and Mrs. Millis:
In accordance with your application received September 11, 2008, I am forwarding Permit No.
WI0700118 for the operation of a vertical closed -loop geothermal mixed -fluid heat pump
injection well system to be located 164 Ocean Blvd.. Southern Shores, Dare County, NC 27949
This permit shall be effective from the date of issuance until September 30, 2013, and shall be
subject to the conditions and limitations stated therein.
Please pay special attention to the bolded Language in the permit. In addition, please
submit copies of the Well Construction Completion form (GW-1) and site map after
construction as required in Part I paragraphs 8 and 9.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit
an application to renew the permit three months prior to its expiration date. As indicated in the
permit, this permit is not transferable to any person without prior notice to. and approval by, the
Director of the Division of Water Quality. If you have any questions regarding your permit or
the Underground Injection Control Program please cal] Mr. Qu Qi at [phone] or me at
[phone].
Michael Rogers, Environmental Specialist
cc: David May — Washington Regional Office
Central Office File— W10700118
Brian McDonald — Outer Banks Heating. 8: Cooling (via, fax and USPS)
Alexander M. Engart. A1A
Dare County Environmental Health Dept.
Attachment(s)
Aquifer Protection Section 1636 Mai! Service Center
Raleigh, NC 27699-1636
Internet: htxp:liweww.ncwateroualitv.tsr; 2728 Capital Boulevard Raleigh. NC 27604
An Equal opportunitylAffirmative Action Employer- 50% Recycled110% Post Consumer Paper
tong
lti'��rrtCarolina
, aturalfj
Telephone. [phone]
Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

Michael F. Easley, Governor
H
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins Director
Division of Water Duatity
September 15, 2008
James Millis
Deborah Millis
PO Box 2139
Kill Devil Hills, NC 27948
Subject: Acknowledgement of Application No. WI0700118
.lames and Deborah Millis - SFR
Injection Mixed Fluid GSHP Well System (SQM)
Dare
Dear Mr & Mrs Millis:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on September 11, 2008. This application package has been assigned the number
listed above and wilt be reviewed by Michael 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 additional information requests.
Please be aware that the Division's Regional Office, copied below, must 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 Michael Rogers at 919-715-6166, or via e-mail 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
hrtn:/lh2o.enr.state.nc.usldocurnents/dwu oruchart.pdf,
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS
PROJECT.
Sincerely.
CNA_
�'j, �j•
for Debra J. Watts
Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Brian McDonald - Outer Banks Heating & Cooling, PO Box 1415 , Nags Head, NC 27959
Permit Application File WI070011 S
Aquifer Protection Section 1636 Mali Service Center
Internet www.ncwaterquaii4Y.org Location: 2728 Capital Boulevard
An Equal Opportunity/Affirmative Action Employer- 50% Recyded/10% Post Consumer Paper
Aaaiun
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]