WI0700158_GEO THERMAL_20091216 (2)

Permit Number
Program Category
Ground Water
Permit Type
✓/
WI07001 58 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Richard Rosenberg SFR
Location Address
34 Meekins Rd
Bayboro
Owner
Owner Name
Richard
Dates/Events
NC 28515
Rosenberg
Orig Issue
12/16/09
App Received Draft Initiated
12/09/09
Reg ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Scheduled
Issuance
Central Files: APS_ SWP_
12/16/09
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Richard Rosenberg
Owner
34 Meekins Rd
Bayboro NC
Major/Minor
Minor
Region
Washington
County
Pamlico
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Richard Rosenberg
Owner
34 Meekins Rd
Bayboro NC
Public Notice Issue
12/16/09
Effective
12/16/09
28515
28515
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
A;�
.:r1L-A
.
NC©ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
12/16/2009
Richard Rosenberg
34 Meekins Road
Bayboro, NC 28515
Subject; Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No, WI0700158
34 Meekins Road
Bayboro, NC 29515
Dear Mr. Rosenberg:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
12/09/2009. the Aquifer Protection Section (APS) acknowledges your intent to construct a closed -loop geothermal water-
gnly injection well system for the operation of a ground -source heat pump located at 34 Meekins Road, Bayboro, Pamlico
County, NC 28515. This system is deemed permitted by rule {North Carolina Administrative Code Title 15A, Subchapter
2C, Section .0211(u)(7)).
However, it is recommended that you contact the Pamlico 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].
S erely,
formic Rogers
Environmental Specialist
PU-Aquifer Protection Section
cc: Washington Regional Office - APS
APS Central Files - Permit No. W10700158
Pamlico County Health Dept.
H. Michael Sage (Applied Resource Management, P.C., P-0, Box 882, Hampstead, NC 28443)
Patrick McKee (Airtech Mechanical Services, 153 Two Lakes Trail, New Bern, NC- 28560)
ACUIFER PROTECTION SECTION
1636!Nail Sarvioe Center, Ralegh. North Carolina 27699-1636
Lontion: 2728 Capital Boulevard, Raleigh, North Carolina 27684 One
Phone: [phone] FAX 1: 919-715-05M: FAX 2: 919.715-60481 Gustornerserme 1.877-sr-6748 NaithCarolina
Internet: %v".ruwateroualitv.or.. ;Vjau` i'allff
art Eptrat ©ppartmty r AtnrmaSive Aekan Empiaysr �L

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER pNLY INJECTION WELL SYSTEM:
TYPE 5-OW WELL S
In Accordance with the provisions of NCAC Title I5A: 02C.0200, please
complete this notification and [nail to address on the back page (please Print or T information).
DATE: December 7. 2009
A.
B.
Well Type Confirmation: in: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -look)?
Yes X Continue completing this form,
No Do Not complete this form. Complete other UIC application forms for installing
eithcr a 5A7 well (open -loop well infecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R 22, ethanol, or other antifreeze or corrosion inhibitors).
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 wlauthority for signature): Richard RosenberL,
(1) Mailing Address: 34 Meekins Road
City: BaN boro State: NC Zip Code: 28515 County: Pamlico
Home/Office Tele No.: 585-297-4378 Cell No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County:
Home/Office Tele No_: Cell No.:
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: Aqui* Pmtection Section
DEC, Q g 2009
GPU/UIC 5QW Notification of intent Fonn (Revised 8/2008) Pzgc l

C. WELL DRILLER INFORMATION
Company Name: A pp lied Resource Manae.ement. P.C.
Well Driller Contractor's Name: _H_. M_ic_h_a_el_S_a~g~e ________________ _
NC Contractor Certification No.: -----=2=53"'--1=--=A=-------------------------
Contact Person: Jim Cornette EMAIL Address: Jim ARM@ bellsouth.net
Address: -----=-P""".O""'.'""B"""o=x=-8=8=2=-------------------------------
City: Ham pstead Zip Code: 28443 County: --~P~e=n=de=r ________ _
Office Tele No.: 910-270-2919 Cell No.: 910-512-4890
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: __ ----'A"-"=irt"""e'""c=h-=-M=e=c=h=an=i=c=al'""S"""'e=rv~i=ce=s=-----------------------
Contact Person: Patrick McKee
Address: 153 Two Lakes Trail
City: New Bern Zip Code:
Office Tele No.: 252-636-5841
E. STATUS OF APPLICANT
Private: X
State:
Federal:
Municipal: __
EMAIL Address:
28560 County: --~C=r-=av"'""'e=n=-------------
Cell No.: --------
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed loo p geothermal s vstem. Water onl v. grouted alornz. the loo p's entire!
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 12/16/09 Number of borings: __ 3 __
Approximate depth of each boring (feet):_200' ______ _
(2) Type of tubing to be used (copper, PVC, etc): _HDPE ____________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes m: (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: _galvanized steel __ black steel_plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No X
(4) Grout Info (material surrounding well casing and/or piping):
(a)
(b)
(c)
Grout type: Neat Cement __ Bentonite Other (specify) _Thermex __ _
Grout placement: Pumping__ Pressure_X _ Other
Grout depth of tubing (reference to land surface): from O to 200 (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification oflntent Form (Revised 8/2008) Page 2
Dec 03 2009 S: 17PM HP LBSERJET FnX W• 2
R. INJECTION-ELELATED EQUIPMENT
Attraeh a diagram showing the engineering layout or proposed tnodificution of the injection Nuipmerrt and exterior
plpingltubing assaciat-d with the injection operation. The rrattufactursr's bMr-hurC may provide SuppteMCMIry
i� vftirrtzstiv3�.
1. LOCATION OF W ELL(S)
attach two copies of maps showing tho t6 lowing information:
(t ) Include a Site Map (can be drawn) shoeing: buildirrtp, property liner, surfac,2 water bodies, potential
sourees of groundwater contamination and the orientation of and dlslances between the proposed wu[1(s) &Ad
my existing well(s) or wasic disposal facilities such as septic tanks or drain. Fields iocived within 104 Feet ai`
the geothernt$t heat pump well system. Label all features clearly and include a north mow.
(2 'I"he Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference paints such as roads, streams, and/or highway interactions.
J. CERTIIFTCATION
Nutt: 'this Permit Applicativa must be aigeted by gc4sh person appearing on the
r+ecurdtd kgal property deal.
.1 herdby certify, under penalty of law, thus L have personally examined and am fi;anlllar with the infosmatiarl
subrrAttd in th4 document and all attachments thereto and that, pissed on my inquiry of those individuals
irnfnodiately responsible for obtaining .said information, 1 believe that the information is true, accurate and complete.
I run aware that there are significurtt penalti4t, including the possibility of fines and imprisomnent, for subrsitting
false irtt'onmation. 1 agree to constntot, operate, mainuin, repair, and if applicable, abandon the irdecdon well and
all rc[trlcd appurtenances in accordartcu with the oved spec led Zs�nlions oftlz Yertttit."
SigttApfd ❑t erOpCny UwnBr1Appri%C1tnt t1
Print Or Type Full lvame ar,d title
Signature of Proporty Owner/Applicarn
Print ur Type FuiI Nwne and titit:
Signature of Authorized Agent, if any
Print or Type Full Narne And title
Please murn two"pies of she cotnpiered A ppiicatiort parkrage w:
North Carolina DENR-DWO
Aquifer FroWtion Sectfonl-UIC Program
1.636 Xail Service Center RECEIVED i GEW i CWC
Raleigh, NC 27699-1636 ftiifer Ptrllwl"' Arbon
Telephone [phone] DEC 4 � 2009
GruIU]C iQw Nw icujw� a!'In[rut I�arrr (Reyisml Vzuot) IAN"3
t)0 39ad Sx'dC :i1.VM t]Ntt KSV a96Z0LZ075 Wet Suez/161Zi

Approximate Property Lines
- - - Approximate Building Perimeter
Existing Well
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are currently serviced by public sewer and water.
2. Geothermal well locations are approximate and will be a minimum of 20' apart, and 25' from the
existing structure.
JAdapted from Pamlico County GIS Map, December 2009.
7 t-� lied Reoource Management f C
8 oapstead, NC 2844-7-
910) 270.2919 FAX [phone]
TITLE:
G15 MAP
JOB: SCALE: DATE: DRAWN BY:
Rosenberg 1 " = —150' 12/3/09 DNH
FIGURE:

Approximate Property Lines
-- -- - Approximate Building Perimeter
` Approximate Closed Loop Locations
Notes:
1, Subject property and surrounding area are currently serviced by public sewer and water.
2. Geothermal well locations are approximate and will be a minimum of 20' ❑port, and 25' from the
existing structure.
(Adapted from Pamlico County GIS Map, December 2009.
7 rrlied Krocurce, Mana,-•emerlt FC
1z -Box 8n. li mpsteod NC 2 443
[910) 270-2919 FAX [phone]
TITLE:
JOB: SCALE:
Rosenberg 11" _ ---1
G15 MAP
dA�J DRAWN BY-
5012i/3la9 I DN H f
1IMPINN

.Ro gers, Michael
From:
Sent:
To:
Jim Cornette [e-mail]]
Thursday, December 10, 2009 4:54 PM
Rogers, Michael
Subject: Re: Rosenberg saw
Hi Michael.
There is no known well on the Rosenberg property. Diana will email you a map without the well on
the legend. If we find otherwise when drilling, we will update your file.
Thanks for paying attention to the details.
Jim
~----Original Message -----
:F,:rgqi:_Ro gers, Micnael_
To: Jim ARM @bellsouth.net
Sent: Wednesday, December 09, 2009 5:07 PM
Subject: Rosenberg saw
Jim-
We rec'd the NOi for the above. On the site map in the legend there was a symbol for an existing well, but there was
no well indicated. If there is an existing well please send via email a revised site map w/well shown.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection S~ction (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
1
,Ro ge·rs, Michael
From:
Sent:
To:
Subject:
Attachments;
Mike,
Diana Helias [[e-mail]]
Friday, December 11, 2009 9:43 AM
Rogers, Michael
Meekins Road NOi
Meekins Road fig1 .pdf
I have corrected the map for the Rosenberg residence NOi on Meekins Road in Pamlico County.
Thank you,
Diana Helias
Project Coordinator
Applied Resource Management, P.C.
www.ARM-PC.com
ARM 's Waterworks
www .WaterWorksWells.com
· 910.270.2919
910.270.2988 Fax
P.O. Box 882
Hampstead, North Carolina 28443
1