WI0700248_GEO THERMAL_20111021

Permit Number
Program Category
Ground Water
Permit Type
WI0700248 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Terence Facey SFR
Location Address
108 Santee Cir
Hertford
Owner
Owner Name
Terence
Dates/Events
NC 27944
Facey
Scheduled
Orig Issue
10/21/11
App Received Draft Initiated Issuance
10/03/11
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
10/21/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Charles C. Menefee
2257 Santa Fe Arch
Virginia Beach VA
Major/Minor
Minor
Region
Washington
County
Perquimans
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Terence Facey
Owner
108 Santee Cir
Hertford
Public Notice Issue
10/21/11
NC
Effective
10/21/11
23456
27944
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
~A ~," ......... MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Terence Facey
108 Santee Circle
Hertford, NC 27944
Coleen H. Sullins
Director
10/21/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0700248
108 Santee Circle
Hertford, NC 27944
Dear Mr. Facey:
Dee Freeman
Secretary
On 10/03/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
geothermal 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:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .021 l{u)(2). Additionally, you should contact the Perquimans 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.RoE?ers@.ncdenr.gov if you have any questions.
cc: Washington Regional Office -APS
APS Central Files -Permit No. WI0700-48
Perquimans County Health Dept.
!I Y.' J;/tf Dxllj 0
for Deb~a ~atts
Supervi~
Charles Menefee (C & G Well Drilling, Inc., 2257 Santa Fe Arch, Virginia Beach, VA 23456)
Rob Whitley (R.E. Whitley, Inc., 910 Badham Rd., Edenton, NC 27932)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
internet: www.ncwaterguality.org
An Equal Opporiuniiy \ Affirmative Action Employer
NOnehC .. ort 'arollna
vVatutalf!f
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NORTH C'AROLINA
D EPARI'MIftNT CIF ENVTP,0NMENT AND NATI:iRAL RESOURCES (NC DEN R)
NOTI FlCAVON OF INTENT TO CONSTRUCT A �I.{�E�3T11,40� CEOTHERMA L
W T -ONLY iNJii;C'TION WELL 51'STEm.
TYPE 5-OW, WELL{S)
In Ace ndanec with the provisions O' NICAC -Atle 15A: 02C,02W. pluaw
complete thiti notification and trail to address on the back pegr. (please fto or ryjX intonrlx�i(n).
DATE: �-� , 20,,E �
We,i rj,,pe ConfirmalwR: Does tho proposed system circulate potable _vALc pj2jx (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
Yes ---V—/Conl in Ue completing this Form.
No Do Not complete this form. Complete: outer VAC oppiication €a ms ror installing
dither a 5A7 well tie -loop well i 's� potable water into the aquifer) ma SQM wci l (ck*cd-
loop well containing �dit'v s such as R42, ethanol, oe othet a►ttiiieeze or corrosion inhibitorsy.
A. PROPERTY OWNER(S)IAPPLICANT(.S)
List P40 Property Owner listed on pr❑pesty deed iit'owned by a business or government agency, state name of
entity and aroprnlativr wlaurFhariiy Cut s'sgnatum):
t 1 ] Mailing A4dms: _I Q S 5 TL' . C i rc r It
City. � .v4 --w_ Sure: ±,Zip Code:__County:_ ��,►:w► .sS
HnmeOffe¢ Tole Na- . L �.
�� lot"• .
iwrr►ai1 Address: "_ _ _ _ _MF+lE� --
(2) Physical Address V, Well Site (if different than mauve): T
City; _ _ _ . _ ... _._ .. State: _.__ Zip COt1C: _ - County: �^
Horne/Ofllee Tcle No. � _ Ce112_ ,. .._
tf. AUTH011IZEU AGEN"1 OF OWNER, IF ANY (ifthe Vcrmil Applivant dac.� nit awn the subjet:t property,
attwh a letter Own tine property owner authorizing Agent to install and opmte UIC well)
Company Nanw.
['clntuct I'cr- V ^
Addy -s_
t'ity: . . , . ';rate: %Jip (%W .w._ -. _.. ..._...... counry
!)1l�ca i'ele N:ti.- � Lr�li No
W01�i` It!• ditty t% Ul C..oir parry, i ['any:

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C> WELL DRILLER INFORMATION
Cornwy Name:
Well Mier Contractor's Name: _d)� d&,M eAleel
NC Co<Imtctor Certification No.: , 3 L.�
_ n
Contact Person;
1:;
(Q 7L'A
A ddruz:
City. _ - .�. �aU Code: _ County;
0MceTele No.: 2L Cell No_ %
p. HEAT PUMP CONTRACTOR UgFDRIHATION (if [lfill'creat than driller)
Company Name; l
h + ' E
Contact Person: pg� ; � &,, s: "41 0-1r-r
Address . LO
City: rl Zip Code: 7 , - — County: ❑ s+►a� r1
Office Tcle No.: -3a sa Ceell1'`No.:
G. STATUS � PLICA,N`Y'
F t'iva[e: - Fedtral' Corn"w4cia3:
State: — Municipal:, Native American Lartd9:
F, INJECTION ION PROCEDURE (briefly describe how the in1mion wall(s) will be used)
G. WELL CONSTRUCy" ON DATA
(t) Proposed date to be comb uctoi.. �4' fr,� � Number of bonne.
Appnwlmate depth of each boring (feet): �,1 ---�-
(2) Type of tubing to by M&I (copper, PVC., etc):
(3) Wei l caslitg, is the well(s) cased? (check either (o.) Yes Er_ ( _ No Wow
(a) Yes _, if'yes, then prvvi& casing infGrMrMY stiun below
Type: _pIvanized steel _black steel---plastic—other (specify)
Casing death: From to, —feet (reference to land surface)
Cming extend, to Bove ground _.._niches
(h) No 7r
(4) Grout Info (materiel surrounding well casing andlor piping):
(a) Grout type; Neal Cement_ Sentortitc __X_,__ Othcr (gmify)
(b) Groin placement; Pumping ft34rut ^ -- - mer T ---,-
(c) Grout d" of tubing(rvferaneE to land surface): from trJ _ to m_ '--_ (feet)
If welt has casing, indicate grout depth: from to (feet)

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H. INJECTION-RELAUD EQiJIIPM NT
Attach a diagram showing the engincering� Iayow nr propmcA m6dificalton rf' the injccii�tn equillttleitt And exterior
prptng/lubing mssaciated with the iRiecilon rrperxtion. The mart oracturer't brochurc miry pmvitlr. su{rfrl��n+:nlrir►
information.
1. LOCATION OF WELLS)
Attacli two copies of maps showing the fallowing, infonoatiw,
(t) l nciWc a Site Map (ean be drawn) cho wing. hu i ld i ngs. pt operty l i ni, mi rfacc water Wic& puTent ial
sources of'grouodwatcr containhiat'son and the orientation orand dimances hetwocn the pmpmLed wvflts?. and
any existing welds) or waste disp&W faeiliti" such as septic tanks or drain fields 10,imled within 200 feet of
zhegcuthermal beat pump wall systern. Tahel All (eatures clearly and SjrVtfc A_n rttLarr w.
(2) The Site Map must show the xilhjacl property in relation to the gurrnundim area by using at kasi two fixed
reference points such as roads, sirmrns, and/or highway intersaclions.
J. CERTIFICATION
Note: This Permit Applies t-iait must be sklr ed by SIch person app"ring on the
reeorded legal properq deed.
-I hereby certify. under penalty of law, that I have gersomlly examined artd am rhrniliar with the inforrnatinn
submitted in this dmument and all attachrnents thereto and that, based on my inquiry of those individuals
immediately rersponsibie for obraining said information. I believe that tiic informal iort is true. accurate and complete.
I ern aware that there arc significant frerzalties, including the possib fity of fines and imprisonniam. for suhmining
false infomnadvn. I agree to construct, operate. maintain. repair, and if applicable. abandon i1he injection well and
all relmedappurtenances in a-cardance with the approved speciticutions and conditions of the Peimk."
Sik nQI re of t'roperty OwnertApplican,
i?riRt or'T'yN Full Nam and title
Signature of property Owner/Applicant
Print Typti {'ul1 Nome and title
�SjVa-Toljre rixed Anent. if any - r'
Ar F Gs �Itimc arxi (ills
Plew ntrturn two entries arthe cgmpleted Application preclrage iri:
North Carolina DENR-DWQ
Aquifer Protection Scetlon,UlC Program
1106 Mail Servicc Ccntcr
' lateigh, NC 27699-1636
Telephone [phone]

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Perquimans County, North Carolina -Property Values
Perquimans County, North Carolina
Property Values and Property Cards
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Name & Address Parcel Desc
FACEY, TERENCE A. & BERYL Map: 2-D082-I012-AP
108 SANTEE CIRCLE Pin:
HERTFORD, NC 27944 Account: 257170
12-1 ALBE.PLANTATION
108 SANTEE CIRCLE
Acres: 0
Sale Year: 2000
Sale Price: $59375
Land:
Land Use:
lmprv:
Bldg:
Total Taxable Value:
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Values
$80,000.00
$3,500.00
$275,300.00
Page 1 of 1
Every Reasonable Effort bas been made to assure the Accuracy of these maps and associated data. Perquimans County, North Carolina and Pearson Appraisal Assume no liability arising from use
of these Values or Data contained on this website. The values and property data is provided without warranty of any kind either expressed or implied, including, but not limited to, the implied
warrantees of merchantability and fitness for a particular purpose.
http://www.co.perquimans.nc.us/taxcards/index.php?mode=search&term=7866-80-9120 10/3/2011