WI0700120_GEO THERMAL_20081007

Pe rmit Number WI0700120
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
m ichael.rogers
Permitted Flow
Fa irt
Facility Name
Martin J. & Kathryn W. Felps SFR
Location Address
3205a S Virginia Dare Tri
Nags Head NC 27959
Owner Name
Martin J Felps
D ·JF,,~ ls
Scheduled
Central Files : APS_ SWP_
10/07/08
Permit Tracking Sllp
Status
Active
Project Type
New Project
Version
1.00
Perm it Classification
Individual
Permit Contact Affiliation
Porky Cutter
800 Dryden St
Virginia Bch VA
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Martin Felps
15021 Crown Point Rd
Moseley VA
23462
23120
Orig Issue
10/07/08
App Received Draft Initiated Issuance Public Notice Issue Effective
10/07/08
Expiration
09/29/08 10/07/08
Hea t Pum p Inj ection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
RECEIVED I DENR I DWQ
NORTH CAROLINA A0UIFFR-PR0Tr-r,'n0N SFGIdN
f �3��►.� 1�1 �►i<ti����lt���ilatu�i<!r.•��i�i►� rr��;a �s:i�.Ysl�lti�l�
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLS)
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the hack page (please Print or Tyne information).
�7
DATE: L 20-
A.
B.
Well Type Canfirrmoion: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes X— Continue completing this form.
No Do Not complete this form. Complete other UIC applications forms for installing
either a 5A7 well oens-loop well in'ectin 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):
(1) Mai l ing Address: I S i- 1 L 2, C L . , ,f 0) V i J 7
City: OA D I� 6� ---- State: Zip Coder � 2�� County:��
Home _ ce Tele No k 0 4- 7_ T 4 f-+ T Cell No.: fie s4-_
Email Address: Website:
(2) Physical Address of Well Site (if different than above): S ' r A � Utz! C
City: &Wd 6,6AA State: LJL Zip Code: 2 y7 ` , County:
Home/Office Tele No.: c 3F' s cif 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 UlC well)
Company Name:
Contact Person. EMAIL Address:
Address:
City:
State: Zip Code:
County:
Office Tele No.: Cell No.:
Website Address of Company, if any:
GPU/UIC: 5QW Noti5catim of Intent Form (Revised 8/2008) Page 1

C. WELL DRILLER INFORMATION
Company Name: til.H ... L-1,J& CorJ Su L,,TA-.J 1 .5
RECEIVED/ DENR / DWQ
AQUIFi:RPR{)TJ=CTION SECTION
SEP 292008
~no~L
Well Driller Contractor's Name: _-A_o_R.---=--~___,y __ G-=-......cu'----'-1_1~E=-f._=-----------
NC Contractor Cetjtification No.: ---'3~5_3~~~-----------------
Contact Person: ,Po(Ll::,"( Cv TT"E(2_ EMAIL Address:f?r k'-1 yo.,@Cc)l. .. "<ii"'"
Address: <lO?:> D fL'{ ~ 2{"
City: 'V ,fUs-t"1"' ~~c+l Zip Code: Z..'3Y lo "'L County: __________ _
Office Tele No.:76?-'i ~-<o~ Cell No.:J·n-"i J 1-~3G,
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: r. A S:rAC~t-CcJiS-/lJ,-v' Gr02efl:.0R-rf6S I rJ c.--r J
Contact Person: r_f FF 5-r-A 6:? EMAIL Address:
Address: I () '-f, I Nb IM crec(.Z.. ['L£
City: &~fzAk£/ v'A---Zip Code:,.2] ]1) County: __________ _
Office Tele No.: -----~--Cell No.: ________ _
E. STATUS OF APPLICANT
Private: ~ Federal; Commercial:
State: Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Gec.>1~l..-~Se..b Loof' ~~ PvrnP
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: oc,...-Zoo~ Number of borings: Z
Approximate depth of each boring (feet): 2.-oo
(2) Type of tubing to be used (copper, PVC, etc): Pt>t-Y E"TH'fLLW'I!:
(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 )<1
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite _}{_ Other (specify) ______ _
(b) Grout pl~cement: Pumping )d Pressure~-Other __
(c) Grout depth of tubing (reference to land surface): from 0 to 2.-ec (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Fonn (Revised 8/2008) Page2
RECEIVED I OENR I DWG]
R0l1lFFa-PRnlxrT10N SFCTION
H. INJECTION -RELATED EQUIPMENT SEP 2 8 2008
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.
LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) 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 200 feet of
the geothermal heat pump well system. Label all Features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two Fixed
reference points such as roads, streams, and/or highway intersections.
J, CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I Hereby certify, under penalty of law, that l have personally examined and am familiar with the inforniation
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 passibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
a]! related appurtenances in accordance with the approved specifications and conditions of the Permit."
:.sci•4
Signature of op_erty wner/Applicant
Print or Type Full Name and title
Srgs afore Jf Property Owner/ pplicant
W. rT—,-,-PS
Print or Type full Name and title
Signature of Authorized Agent, if any
Print or Type Full Nance and tithe
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, IBC 27699-1636
Telephone [phone]
Gt'li/WC 5QW Notification of latent Form (Revised 8/20UH) Page 3

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4ap of 3205a S Virginia Dare TrI Nags Head, NC by Mapiuest
Page 1 of 2
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http://www.mapquest.com/maps?cityNags+Head&state=NC&address=3205a+S+Virgini... 9/22/2008

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
101212008
Martin J. Felps
Kathryn. W. Felps
15021 Crown Point Rd.
Moseley. VA 23120
Subjeev Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10700120
3205-A S. Virginia Dare Trl.
Nags Head. NC 27959
Dear Mr. and M.rs• Felps:
In accordance with the application submitted to the Underground Injection Control (UIQ Program that
was received on 09/29/2008, the Aquifer Protection Section (APS) acknowledges your intent to construct
a closed -loop geothermal water-onlN injection well system for the operation of a ground -source heat
pump located at 3205-A S. Virginia Dare TrI,, 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 hihibitors, 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 meat [phone],
sin 'rely,
bDx— Michael o ers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Washington Regional Office - APS
,APS Central Files - Permit No. WI0700120
Dare County Health Dept,
J.A. Stagg Energy Enterprises, Inc. (3eff Stagg, 1041 Indian Creek Rd. Chesapeake. VA 23322)
Aquifer Protection Section 1636 Mail Service Center
Internet: www.nowaternualitv.org Location: 2728 Capital Boulevard
An Equal OpportunitylAffinna6ve Acfw Employer 50% Recycted110% Post Consumer Paper
'_�"` taro i
Iatur�r�y"
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax L [phone]
Fax 2; [phone]
Customer Service: [phone]

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