WI0700128_GEO THERMAL_20081202

Permit Number
Program Category
Ground Water
Permit Type
WI0700128 / Central Files: APS_ SWP_
12/02/08
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michae1.rogers
Permitted Flow
Facilit
Facility Name
Barbara Lies SFR
Location Address
132 W Pettie Shore
Cofield
Owner
Owner Name
Barbara
Dates/Even ts
NC 27922
Lies
Orig Issue
12/02/08
App Received Draft Initiated
12/01/08
Regulated Activities
Heat Pump Injection
Outfall i-f.J .i . ·
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Hertford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Barbara Lies
132 W Petttie Shore
Cofield NC
Public Notice Issue
12/02/08
Effective
12/02/08
27922
Expiration
Stream Index Number Current Class Subbasin
Michael F. Easley, Governor
William G, Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins Director
Division of Wsur Quality
12/2/2098
Barbara Lies
132 West Petrie Shore
Cofield, NC 27922
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10700129
132 West Petrie Shore
Cofield, NC: 27922
Dear Ms. Lies:
In accordance with the application submitted to the Underground Injection Control (UIC) Program that
was received on 12111[}8, the Aquifer Protection Section (APS) acknowledges your intent to construct a
closed -loop geothermal water-on1% injection well system for the operation of a ground -source heat pump
located at 132 West Petrie Shore, Cofield, Hertford County, NC 27922. This system is deemed permitted
by rule (North Carolina Administrative Code Title 15A, Subchapter 2C, Section .021 l(u)(2)).
However, it is recommended that you contact the Hertford 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].
Sincerely,
0WA,A
41n&&A-L-
Michael Rogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Washington Regional Office - APS
APS Central Files - Permit No. W10700128
Hertford County Health Dept.
Gary Hughes (Gary Hughes Electric and HVAC: - PO Box 312- Colerain, NC 27924)
a Carolina
NNawrldil
Aqui&r Protection Section 1636 Mail Service Center Raleigh, NC 27699.1636
Internet www_ncwatergdaiity.ore Location: 2729 Capital Boulevard Raleigh, NC 2704
An Equal OpportunitylAffirmaWe Action Employer— W/o Ragcledlt 0% Post Consumer Paper
Telephone: [phone]I
Fax 1. [phone]
Fax 2: [phone]
Customer Service: [phone]

Dec 01 OS 07:23P Jeffrey A Stagg 757-421-2148
Nov 12 ud 1 1: ma Dui li wy „ W &Osv RECEIVED 1 DENR 1 ❑VVP
Aquifer Protection Sediorl
DEC 412006
NORTH CMOLINA
DEPARTSfENT Of EN VV,0NMENT AND NATURAL RESOURCES (NCDENR)
NOTBaCATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTBXILMAL
WATER -ONLY WJFCTION WELL SY MEM:
TYPI& _ )W WELLS
ht Accordance with the provisions of NCAC Title 15A: 02C.0200, please
conmplew this notipicatiau and m;el to address on the lack page (please Print or TMe inform$ricn).
VATS: �1,_ 0 � 72, 20 0
P-2
Well Type Confumaiorr Dues the proposed system circulate potable wateuc lv (n❑ additives) in
oonlinuous piping that cortrlrletely isolaitm the fluid from the environment (i.e.
-&lased-tau ?
Yea Corrtinue coomgletiog this form -
iv Do Not comple7e this form Complete other UX application fbm= for iinsiaUing
either-&5A i well ❑ en -loop w-ell iniecti!3 potable watcr into the aquifer) or a 5QM well (closed -
loop welt eonWining additives such as R Z?, ethavoi, or other antifreeze or corrosion mLibito n).
A- OPERTY OWNER('S)�A.PPLXCANT(S)
�--J List each Propel y Owner listed on property deed (if owned by a business or gove~rnmart agency, State frame of
entity and a represerdattve vtr)&Ahority for signature): Lie S
(1) Mailing Address: 13 ?— i► , RGd- -�l� 5��7'( e_ _
City: sta*eL Zip Code:?79?-Z- -_-County, eftl�'rdL.
Florne-Cdfi a Tale No.: Cell No.: 6 f� _
Etnnil Address: Nebsite•
(2) PbLysical Address of Wrll Site CEdifF'erentthan above):
City: Sure: Zip CDde. CQt+zrty:
Home.Aotfice Tele No.: _ --- _ Cell No_:
B. AUTHORMED ALGENT OF OWNER, IF ANY {if The Permit Applicant clues n own the subject property,
attach a letter from tine property owner authorWmg Agent to install and operate UIC well)
Company Namen
Contact Petsnn• EIkdA1L►ddt
Address:
City: _ — State: Zip Codec County: _
Office Tele No.: Cel ltila:
Website Address of Compwy, if any:
GpUtritC SQW :%WRcation of Intem Foam (Revised $P2 k08)
11 /12/08 12:15 PM
PINICST4N PUMP &
rwl
Page 4

Dec 41 08 07:23P Jeffrey A Stag
Nov 12 08 11:158 Jettrey H o«y g RECE1VED / DENR I [)VV
Aquifer ProtMj.'Secti,3
DEC o
C. WELL DRUAXR INFORMATION
Company Name: DQ I I, I I 6r ICOCvS 1-1
Well Driller ConMetoes Name: . _ _ -pop, I<- ( -- -
757-421-21 08 p.3
NC Contractor Ceti ic2tion No.:
Contact Person: ._ I _ i'i� �" l" Lam_ EMAIL Address: ot• C,fS
Address: -i w- 01—t-l3 4s7r
City: )15 Qcsry� A a8eil zrip Code: tZ,4�Z_ Cota*:._—
Office Tete No.7�r'-4 —!Z,O3 Cell No.: 1% ~Z-04n,
A HEAT PCIVe CONTRACTOR INFORMATION (if dfffwettt tha* drWer)
Company Name- AR-Y H L) LFF_ r e p y R C
Contact Person s >� — EMAIL Address: -- —
`�6�
Zip Cade: ry County:-
Ul�ice
E. STATUS OF APPLICANT
NA
Privaw:Fedemsl: Commercial.
State: Municipal: Dative American lands:
F. INJECTION PRUG'iv" URE (bricily desmbe how the in wflon weli.(s) ►+grill be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 4 aV - _Number of borings: _ q —
Appminute depth of mcb baring (Beet): Z-tDQ _
(2) Type ofwbing to be usW (capper, PVC, ex):
(3) Well casing. is the waelE(sj cased.? (check either (a.) Yes or (b.) No below)
(a) Yes ifyes, then pmvide casing iffDrmation below
Type: l gWvaruzed steel black steel_ _-_ _plas^tic _a9w (Specify)
Casing depth: FYmw to Feet (reference to land sur&ca)
Casing ex �ft above &noand iFICh s
(b) No
(4) Gsvut Info (material sumunding well casusg and/or piping).
(a) Grout type: Neat C=W= BentcoiteAL other (simify)
(b) Groan placement Puraping", Nessure Other
(c) Grout depth of tubing (reference to land surface) : from _ � __ to (feet)
If well has casft;g, indicate grout delxt L From to `_ (feet)
GI,'t lC SQiW Natifiauinn of InTmt.Fonn (RCri6ed Sl2DM) Paga 2
11/12/88 12:16 QM PINKSTQN PUMP 8 Page 8

Dec 01 08 07:24p Jeffrey A Stagg CFIVED / DENR / ON 757421-2108 pA
gi+i* PmteCliart 5eCtion
DEC 4 7888
H. DUEMON-RELAITEDRQUt#'MENT
Attach a diagram showing the engimering layout ar proposed tnvdifacation of the injection equipment and exteriar
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
iafarmarion.
I. LOCATION OF WELL(S)
Attach two copies of reaps showing the Following information. '-
(1) Include a Site Map Cc= be drawn) sheaving- buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances hetween the proposed well(s) and
any existing well(s) or wane disposal facilities such as septic tames or drain fields located. within 200 feet of
1
-lie geothermal heat pump welt system label all fames clearly and ihctude a north Lirt'D�v.
(2) The Site Map trust show the subject property- in relation to the surround-ing area by sir at least nvo fixed
reference points such as roans, stt-parm, aredfor highway intet3estiom
3. C
Notr. Thi% Permit App'#ication most be signed by each person appearing on the
raeorde3 lega) pm perty deed.
") herebv certify, under penalty of law, that 1 have personal€y examined and am familiar with the inforrna6an
submitted in this document and all attaclrnrents thereto mmd the based oa my inquiry of those indiv7dusls
irrmediately Tesponsible for obtaining said information, l believe that the information is true., accurate and oontnlete.
I am aware that there are significart penalties, including the possibility of fines and imprisonment, for sula"ting
fElse information. I agree io coustruet, operate, maintain, repair, and if applicable, abandon the info--tion well and
all ref" appurtenances in aucordanae with the approved sped fications nd conditions of the Permit"
Signature of Property 0%%*m AppUcant
_-_ my b a ram L e S -
Print or T;Te Full Name aced title
Sig nature of Property OwnorlApplicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Applicaeion paekage rm:
North CaroHaa DEN-R-I1WQ
Aquifer Proteetion Section- UYC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
(77PLUUIC st7w Narfcakm oflnt%vu 3orm Cft-ised &2W
1111210S 12:15 PM
FINKSTON PUMP &
Vag* 3
Page B

Dec 01 08 07;24p
Jeffrey A Stagg
RECEIVED 1 DENR i DWQ
Aquifer Protection Section
757-421-2108 p•5
jwsTC{DPY t3FFICE 5BGarro CDFY BL.ECnUCAL OR BUiLDTNG RNW. THIRD COPY HOMt7MNR
HERTFORD-GATES DISTRICT HEALTH DEPT.Rt. 1, sox 112 A
P. a. Box 246 .-- Operational Permit -- Gates, N.C. 27937
Winton, N. C. 27986 GATES COUIM 357-1380
BMTFORD COUNTY 358-7833 -
Name �z � /S � 3d wr��+r .+B � 0SAZ
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Subd vWon Nurse _ Lot Nor. � Pia Number
No B4U1MrW No. Pcople washing Machine }� Antama�c Dis6wAsi►et -S'
Liggid Capadty o[Taa1_Ia d Q _ 6A1� Na of US1es
r ?'. am
5otuce d water supply ,o(�,�frt► n}stanoe From wa1� //a0 _ _ Lot sire . — -
nefe If&6 f .Z�d fnspedor 4 .f7 eCi/A �5
aj
flo ue --Mobile Homo _ Type of Hua wsr
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s*ic sy t lwtaller_ ►��Y tIT �' 9.s_�s_rr - I
Taalt Serial Narnber j /' sS+ d� �Tsnk Manamomm Diu � %✓� �'�+ �r
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IMPROVEMENT PERMIT SUBJECT TO REVOCATION IF SITE PLAN OR INTENDED USE IS CIUNCED.
N° x7918

Deo 87 08 07:24p Jeffrey A Stagg
757-421 -2 1 fl8
Petty Shore Rd, Cofeld, Hertford_ North Carolina 27922 - uooglc .LvI"
Address petty Share Rd , C,etc,"ie Maps on your phme
} �. l'' Cofleld, NC 27922 W-heword -GMAPYW466453
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Dec 01 08 07:23p Jaffrey A Stagg 757-421-2108 P.1
RECEIVED / DENR /'DVVQ
Aquifer protection Sectorl
DEC o i 2w8
facs"fl
To: Fax:
k-� 'L
Fmcn." Date.
Pages:
CC:
0 Urgent 13 For Raview El Ple&se Comment ID Please RePIV 0 Please RaGyolo
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