WI0700220_GEO THERMAL_20110414

Permit Number
Program Category
Ground Water
Permit Type
WI0700220 / Central Files: APS_ SWP_
04/14/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facili_ty Name
Frances D Inglis SFR
Location Address
101 E Water St
Edenton
Owner
Owner Name
Frances
Dates/Events
NC 27932
D Inglis
Orig Issue
04/12/11
App Received Draft Initiated
04/12/11
Re g ulated Activities
Heat Pum p Inj ection
Outfall i .Jl 11 :
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Jeff Stagg
Driller Well
PO Box 15482
Chesapeake
Major/Minor
Minor
VA
Region
Washington
County
Chowan
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Frances D. Inglis
101 E Water St
Edenton
Public Notice Issue
04/12/11
NC
Effective
04/12/11
233285482
27932
Expiration
Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Frances D. Ingli
tOl F. Water Street
Edenton. NC 279321
.....��f..■..4
CC
NCDGNR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coieen H. Sullins
Director
4 14!2i11 ]
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WIVU020
till L. Water Street. Edenton. NC 279"
Dear Frances:
Dee Freeman
Secretary
On 4112/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-ioop water-onl•
geothemtal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
The injection well system contains only potable water,
The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .i1213, and
The required notification form and associated maps have been completely and accurately submitted
Failure to comply with all of these condition~ constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Chowan County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.RotrersFci4ncdenrrtro4' if you have any questions.
Sincerely.,^^^cerely
F
ibr• D7 irra Watts
SuPeTWSW
cc: Washington Regional Office - APS
APS Central Files - Permit No. 140 700221)
C lrnwan County Health Dept.
Pinkston Pump and 11'e11. Inc 0efi'Stagg l
l?.£. Whitiev, ln� Glob Whiticv)
AQUIFER PRpI rCTION SECTI01'
1636 Marl Service Center. Ral4h. Nom Carolina 2769q-153t
Location- 2728 Capital bouLwait. Rama. Nort'l Care irta 2760 4
Pnons:9tF-733a22" FA'. t:91-715JHL FA!',-1 e1�­ "5-604C. s �ustaMcl Sarvo -3-b23r674r
interres: WWW.ncwatereuslit.J.orq
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Apr 12 1102:1 !3p p.1
RECEIVED 1 DENR 1 DWa Pinkstoa Pump & Well, Inc.
` Agtaifer protemion Section p 0 Box 15482
APR 12 ZO11 Chesapcakc, VA 23328-5482
�r �ss (757) 421-21081(866) 749-1980
-+
f �7in0e C, rffiftal
To: Tanya Fax [phone]
From: Debbie Sanders Date: 04112111
(d a bhi e� sta age nergr.wrrr)
Re: Inglis, 101 E VMter Skrest. Edenton Pages: 7 (in6uding caM sheet)
0 Urgpnt © For Avub w 13 PIMM C.orrmterrt G lalaaw Rear CI Please RecycW
Now:
'For the above referenced, following is the Type 5-QW Wells) apptication, property site plan
with the Proposed Geothermal Closed Loop area and two (2) pages of map directiort.4_
Two (2) hard copies are being forwarded today.
Thank you'

Apr 12 1102 46p
RECENLIJ � DENR I DWQ A2
A,quiler Pmfadion Sec i'on
APR 12 7011
NORTH CAROLTNA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTJNNT TO CONSTRUCT A C'I,QSF:D-L['1(lP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-OW_WELLS)
In A"ordancc with the provisions oi'NCAC 'Title I5A; 02C:.0200, please
complete this rotification and mail to addrims oo the back. page (please Print or 3 e inlbrmetion),
]DATE: � � 3 , 20 i 1 00 ca ak
A.
a
! lift 7,Ype Confb7nadon: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loan)?
Yea TX� Continue completing this form.
No Do Not complete this form. Complete outer U I C application Forms for installitng
either a 5A7 well o ert-loop well injectin potable water into the aquifer} or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antif mze or corrosion inhibitors},
PROPERTY OWN F•,R(S)/APPLICANT(S)
List a, l Pmpct•ty Owner listed on praperty deed (if owned by & business or government agency, state name of
entity and a re -presentative w/authority for sigriatwv):
(1) Mailing Address:��
city: V02 staw- & zip soft:-leL.r� zzza�v-County:
Home/Office T'ele No.: 2 ?1,-- u C oil N
EtnM Address ���'r -Ze t. y 'chs'tc:
-/fy - , rr, 6/,0 240 0
(2) Physical Address of Well Site (if different than above): /,'`'/ A r _
Code: op
State: tc Q�r Cattmy: / r�Ed � _
HontefOfHice Tele No.:
Cei' Nu._
AUTIHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant do_ Ls not own the subject property,
Attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company NwTiu: --
Contact Person: EMML Address.
Addrra5:
city: state: Zip code.
County:
01rice TeleNo,: Cell ;~fo.:
Website Address ofCcxnn:,ny, if any:
C+Pt1M� 5Qw Norifcs[:oa �,r [�tc,�t 3'ar�n tx�Wi� 812048) Fage 1

Apr 12 11 02:20p
RECEIVED/ DENR / D~
Aquifer Protection Section
p.3
APR 12 201'
C. WELL DRILLER INFORMATION
Company N<1111e: PINKSTON PUMP AND WEU ., INC
Well Driller Contractor's Na.me: --~H...!:O=W..!.A!!.R!:!:D~E-:....::C~UTT~il../E~·R~--~-~-----
NC Contractor Certification No.: ORILI..ING #3 538-.e,_ H~3 #29277 JEFFREY A. STA GO
Contact Pers.on: JEFF STAGG ---~EMAIL AddTes!i: jcff@staggencrg_y.Qom
Address: PO Box 1548,~2-----------------~-~~-~-
City: CHESAPEAKF . VA ZipCode: 23382 County:----~~~----
Office Tdi: No.: -757-421-2108 ______ ~~ Cell No.: 757•438~9392. ________ _
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Q_ · '= . w t±,, r t...E;;:.J...Y_, ...-..LN~.,.,C-•-· -------------;;
ContactPerson: Q.QQ:. W!-IIQEY BMAILAddrc ss:
Address: I) o:Z & t::-1 '--~\J.l y H 1...
City: C.oL,t;{l,/i;\JN Zip Code: 1,'")°11....'--l County: __________ _
Office Tele No.: "l...s""l_->>"(a-¼l..l Cell No.: .25,1..-":,1.S -'2.S O <;;>
It. STATUS OF APPLICANT
F.
G.
Private: _x_ __
State:
J<'cdcr,il:
Municipal: __
CornmerciaJ:
Native American lands:
INJECTION PROCEDURE (briefly describe how the injection woll(s) will be used)
NOT A WATER WELL -Q80THERMAL CLOSED L.O OP
WELL CONSTRUCTION DATA
O\" f (rJ
(1) Proposed date to be constructed: ___,_A...,S=A....,P'-_____ Number of borings: ---'---1 __
Approximate depth of each boring (fcct): _ __,2=00=-----~-
(2) Type of tubing to be used (copper. PVC, etc): -~"~D~PE-=--------------
(3) Well ca,;in~. ls the well(s) Qased? (check either (a.) Yes 2I (b.) No below)
(a) Yes ___ if yes. then providi: casing information below
Type: __galvanized steel __ black stccl__plastic __ olhci:t (specify)
Casing depth: From ___ to~--feet (reference to land surface)
Casing extends to above ground -~-inches
(b) No X
(4) Grout Info (material SUlTOunding well Clll>ing and/or piping):
(a) Grout type: ~eat Cement__ Bentonite _x ____ Olher (specify) ______ _
(b) Gmut placement: Pumping X Pressun: Oth=r_
(c;) Grout llcptl1 ufiul.Jing (ref~n:mc<:! m laM surface): from o to ___ 20=0 _____ {foet)
If well has casing. indicate grout depth: from ___ to _~ ___ (feet)
GPU/UlC ,Qw Notificatio11 of In~ti~ l·'unn (H.c'liscd 11/2008) P11gc2
Apr 1211 Q2:20p RZCE1VF—DJ[)ENF31 CM p.d
A tsilrer Prntarti0n S t rt
APR 12
H. 1N4ECi'ION-RELATED EQUIPMENT
Attach a diagram showing; the era,Wneering layout or propo9cd modification of the injection equipment and exterior
pipinglt&ng associraW with the injection opera[ion. The manufacturer's brochun: may provide supplernerttary
information,
1. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) sl owing: buildings, property lines, stwface water bodies, potential
sources of gmundwaer contamination and the 4rient$tion of and distances between tbt 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 geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Ttte Site Map r: im show the subject property in relation to the surrounding area by using at setts[ two fixod
reference point,, such as roads, streams, andlor highway 'intersections.
J. CERTIIFI'CATION
Notes 'T'h& Permit Application must be signed by gg h person appearing on the
recorded tegg5d property deed.
"i hereby certify, under penalty of law, that I have pevonally examined and tort familiar with the information
submitted in this document and all sttachmente tlheruto and that, based an my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete,
1 am aware that there um significant penalties, including the possibility of fines and ltnprisonmepr for submitting
false information, l agree to construct, operate, maintain , repair, and if apr+y able, abandon the injection well and
all Mated appurtcn=cs in accordance with theppproved speci ficatigm and coeO tlons o F the Pfrrnit."
Signature o(Proparty ©wmer/Applicant
Print or Type Full Name and title
5ignaturc of Property Owner/Applicam
Print or Type Full Name and title
Signature ofAuthoriaed Agent, if any
Print or Type Full Namcr and title
Please return two copiGc at the completed Application packag c to:
North Carolina AENR-DWO
Aquifer Protection Smtion-UPC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
CP(Y f IC 59W Nutitimfloh s of lnttl»[ I',mn (Revised RROOR) pogo 3

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