WI0700142_GEO THERMAL_20090728

Permit Number
Program Category
Ground Water
Permit Type
Wl0700142
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
ECSU Education Building
Location Address
Education Building Site
Elizabeth Cty
Owner
Owner Name
NC
Elizabeth City State University
Dates/Events
27909
Orig Issue
07/28/09
App Received Draft Initiated
07/22/09
Re g ulated Activities
Heat Pump Injection
Outfall NULi
Scheduled
Issuance
Central Files: APS_ SWP_
07/28/09
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Mike Hadley
Driller Well
102 Middle St
Jacksonville NC
Major/Minor
Minor
Region
Washington
County
Pasquotank
Facility Contact Affiliation
Owner Type
Government -State
Owner Afflllatlon
Charles Hall
1704 Weeksville Rd
Elizabeth Cty
Public Notice Issue
07/28/09
NC
Effective
07/28/09
28546
27909
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-0 W WELL (S}
In Accordance with the provisions ofNCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or~ information).
DATE: July 2, 2009
Well Type Confirmation: Does the proposed system circulate potable water onl y (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 application forms for installing
either a 5A7 well (open-loop well injecting 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).
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signatures; Actus Lend Lease Charles Hall
(1) Mailing Address: Elizabeth City State University 1704 Weeksville Rd., Campus Box 749
City: Elizabeth City State: _NC_Zip Code: 27909 County: Pa squ otank
Home/Office Tele No.: 252-335-3961 Fax No.: 252-335-3960
Email Address: _____ ____.W"""'e=b=si=te""'": ____________ _
(2) Physical Address of Well Site (if different than above): Education Building Site __
City: Elizabeth Citv State: _NC_Zip Code: 27909 County: Pasguogmk
Home/Office Tele No.: _____ __,Ce=ll-=--N=o=.: _________ _
B. AUTIIORIZED 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: Elizabeth City State University _____ _
Contact Person: Charles Hall EMA.IL Address:
Address: 1704 Weeksville Rd., Campus Box 749 _______________ _
City: Elizabeth Ci ty State: _NC_Zip Code: =-27'""9'""'09.:;.._ __ County: Pas quotank
Office Tele No.; 252-335-3961 Cell No.:
Website Address of Company, if any: _____________ _ RECEIVED / DENR / owa
AQUIFFR·PRnTFr.Tl/"lN ~l:CTION
JUL 2 2 2009
C. WELL DRILLER INFORMATION
Company Name: Coastal Geotherm al
Well Driller Contractor's Name: Sanford Sweeting
NC Contractor Certification No.: NC 2082
Contact Person: Mike Hadley EMAIL Address: mhadley@ bizec.rr.com
Address: 102 Middle St.
City: Jacksonville Zip Code: 28546 County: Onslow
Office Tele No.: 910-353-0926 Cell No.: 910-376-1100
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company: _NIA (for testing only) ______________ _
Contact Person"--: ________________ _
Address: __________________ _
City: State: Zip Code: ____ County: _______ _
Office Tele No.: ___ Cell No.:
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State:_X_ Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p Geothermal Heat Trans fer Svs tems FOR TESTING ONLY (at this time)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _July/August -2009 ___ Number of borings: _2 __ _
Approximate depth of each boring (feet): __ 300 _____ _
(2) Type of tubing to be used (copper, PVC; etc): _High Density Polyethylene_X
(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) Grout type: Neat Cement__ Bentonite _x_ Other (specify) _____ _
(b) Grout placement: Pumping_X_ Pressure__ Other __
( c) Grout depth of tubing (reference to land surface): from _ O __ to _300 _ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
H, INJECTION -RELATED EQUIPMENT
Attach a ding= showing the engineering layout or proposed modification of the Wwtion equipment and mtmior
piping/tubing assmated with the infection operaiiom. The manui er's brochure may provide supplementary
imforruatietx.
1. LOCATION OF WELUSj
Attach two copies of maps showing the following info meatnan:
(I) Include a Site Map (can be drawn) showing: buildings, property limaes, surface water bodies, potential
sources of groundwater conuminstion and the orientation of and d 9unc;es bemma the proposed wOU(s) and
any existing wcll(s) or waste disposal facilities such as septic taroks or drain fields located within 200 feet of
the geoflu mat heat pmap well system. Label all features clearly and isiclaede a northaxmw.
(2) Tho Site Map must show the masbjeect property in relation to the surrounding area by using at least two fixed
ref�maace points such as roads, streams, aaaadilor highway intearseLuons.
d, CERTIFICATION
Note: Thin Permit Application roast be sib by fj& person appearing on the
recorded legal property defied,
"I hereby ocatify, under penalty of law, that I have personally examined and am familiar with the information
aaeebmitted in this document and all attachments thereto and that, based on my inquiry acf those individuals
immaedi�ately responsible Tier obtaining said infmwtion, I believe that the mftT mWon is true, accwift and complete.
I am awam that there are significant penalties, i wiudi g the p maiWity of fines and imprisonment; for submitting
feriae information. I agree to construct, operate, maintain, repair, and if applicable, abandon the uveectiou well and
all related aappurtenaw)es in accordance with the approvod Vacfficatim and conditions of the Permit.,,
Side lkpptm�aera.
Print at Typo id Name and title
Signature ofPr'operty 0wnerlApplicard
Print at Type Full Nam and title
i
Pr9t ir Type Full Waim� and title
Please return two caapies of the completed Application paackAge to:
North Carolina DENR DWQ
Aquifer Protection Section -TIC Program' ��a
1636 Mast Service Center
Raleigh, NC 276"-1636
Telephone [phone] RECEIVED f rTff1 IRFC
RQif€FF'�:dRtlifii ,Tf� 1tu SFCTiN

NONRESIDENP'IAL WELL CONSTRVC-110N RFCORD
North Carolina Departgrcnt of Environment and Natural Rosourms- Division of Water Quality
WELL CONTRACTOR CERTMCATION it 2082
1. WELL CONTRACTOR:
Sanford Sweetinq
Well Contractor (Individual) Nome
Coastal Geothermal
Well Contractor Company flame
102 Middle St
Street Address
_ Jacksonville NC 28546
City or Town State Zip Code
9c 1 d > 353-0926
Area code Phone number
Z. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# Wl0700142
OTHER ASSOCIATED PERMITS(dapplicable)
SI'TIE WELL ID#(dapplicable)
3. WELL USE (Check One Box) Monitoring ❑ Muniaipal1publia ❑
IndustriallCorrmiarcial ❑ Agricultural ❑ Recovery p Injection ❑
Irrigation❑ Other N(pist use) Closed Low Geothern
DA-M DRILLED 08- 3&4-2009
4. VVELL LOCATION:
Education Building Site
(Street Name, Numbers, Community. Subdivision. Lot No- Parcel. Zip Code)
CITY: Elizabeth City _ COUNTY Pasouotank
TOPOGRAPHIC 1 LAND SETTING: (check appropriate box)
❑ Slope E3 Valley dF7at o Ridge ❑Other
LATITUDE 36 a 16 ' Wfi-O oo • DMS OR 3X.XXXKKX)(lXx DD
LONGITUDE 7E - 12 ' 6 OMO " DMs Ott 7x.xxxxxxxxx DD
Latitudellong'riude source: E]GPS QTopographic map
(location otwell must be shown on a USGS topo map andeftached to
this form rFrrot using GPS)
5 FACILITY (Name of the business where the well is located.)
EJizaheth City State S1@C115.
Fac#tty Name Facility ID# (if applicable)
AM4 Weeksville Rd - -- --
street Address
Elizabeth City NC 27209
City orTown StaI8 Zip Cade
Charles Hati
Contact Name
1704 Week-,VH1RRd C,amnits RinX 749�
Mailing Address
Elirahath City NC: 979(]<I
CityorTown State Zip Code
(2523313%1
Area code Phone number
G. WELL DETAILS:
a. TOTAL aEPT'H:, 300'
b. DOES WELL REPLACE EXISTING, WELL? YES ❑ NOD/
c. WATER LEVEL Below Top of Casing: 101 FT_
(ties *+' if Above Top of Casing)
d, TOP OF CASING IS nLa FT. Above Land Surface'
'Top of casing terminated atlor below land surface may require
a variance in accordanoo with 15A NCAC 2C .Qt 18.
e. YIELD (gpm): _01a METHOD OF TEST
f. DISiNFEC PION: Type 01a Amount
g. WATER ZONES (depth):
Top nja- Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thicknessl
T. CASING: Depth Diameter Weight Material
Topwnla Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
:Top 0 Bothm 3oa, Ft. Sefltonite DUM12
Top Bottom R.
Top Bottom FT,
9. SCREEN. Depth Diameter Slot Size Material
Top nla Bottom Ff. in_ in.
= Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SANDIGRAVEL PACK:
Depth Size Material
Top_0ja_Bottom Ft,
Top Bottom Ft.
Top Bottom Ft,
11. DRILLING LOG
Top Bottom
0 130
30 180
80 195
95 - 1 300
1
1
1
= 12. REMARKS:
Formation Description
s
Set 2-300'geoffienral loops Fortestimg
100 HERENYC@2TIFYTMTTHIS WELL WAS CONSTRUCTED IN ACODRDANCE wrTH
15A NCAC 2C, WELL CONSrRiIC ION STANMRM AHD THAT A COPY OF THIS
RECORD FLIS E7i1 pR/tVID v T OWNER
{�►��f 08-05-09
SIGNA E OF CERTIFIED WELL CONTRACT DATE
Seaford sweet)a
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Di►riSion of Water Quality - information Processing, Farm Rev. ?_J09109
1617 Mail service Center, Raleigh, NC 27699-161, Phane : [phone]

H. ` 0JECTION-RELATED EQUIPMENT /
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and e.�Wrior
piVing/tubing associated with the injection operation. The manufacturer's brochure may provide supple entary
lf1fQKL11126011.
I. LOCATI OF WELL(S)
Attach tw opies of maps showing the following information:
(1) Includ6 a Site Map (can be drawn) showing: buildings, property lines, surface wa `r bodies, potential
sources LXground%vater contamination and the orientation of and distances between th proposed well(s) and
any existan_ wells) or waste disposal facilities such as septic tanks or drain fields l -ated within 200 feet of
the geotherrlilheat pump well system. Label all features clearly and include a no arrow.
1
(2) The Site Map m�*t show the subject property in relation to the surrounding ca by using at least two fixed
reference points su�4 as roads, stye ms, and/or highway intersections.
J. CERTIFICATION �f
Note: This Permit Application � at be signed by each person appex0tig on the
recorded legal property d
"I hereby certify, under penalty of law, `tbat I have /pibility
.-amined and am familiar with the information
submitted in this document and all aitach,enis thel�at, based on my inquiry of those individuals
immediately responsible for obtaining said i116m nation,at the information is true, accurate and complete -
I am aware that there are significant penalties, Z)cludiibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, M ntand if applicable, abandon the injection well and
all related appurtenances in accordance with the appr�vtions and conditions of the Permit."
Signet of Prob rt}- Owner/Applicant
or Type Full
Signature of Property
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
rn two copies of the completed Application package to:
North Carolina DENR-DWQ
luifer Protection Section -[TIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636 RECEIVED; DENR I DWO
Telephone [phone] AptNF" aan-m"nN RFPWN

II !'
J E� 1 � r l� I
E
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NOT FOR
CONSTRUCTION
EUZABETH CrrY STATE
UHIYERSRI' SCNOOL OF
EPUCATIONAHR
l RSYC•HDLO(Y
OESIGM
pE4ELOPAlEN7
MECHANICAL
S17E
WORK
PLAN
Wgmslo7

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coieen H. Sullins
bovernor director
7/28l2009
Charles Hall
Elizabeth City State University
1704 Weeksville Road
Campus Box 749
Elizabeth City, NC 27909
Subj ect: Acknowledgement of intent to Construct Type 5Q W Injection W ell System
Permit No, WI0700142
Education Building Site
Elizabeth City, NC 27909
Dcar Mr. Hall:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground injection Control (LAC) Program that was received on
7122149, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed -loop geothermal water-onl•,
injection well system for the operation of a ground -source heat pump located at Education Building Site, Elizabeth City,
Pasquotanl: County, NC 27909, 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 Pasquotank County Health Department, as they may have additional
construction or peffiitting 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,
__0 UJCfk Aq.bcu�'V
Michael Rogers
Environmental Specialist
GVU -Aquifer Protection Section
cc- Washington Regional Office - APS
APS Central Files - Permit No. W10700142
Pasquotanl; County Health. Dept.
Mike Hadley (Coastal Geothermal - 102 Middle Street, 3acksonviile, NC 29546)
AQUIFER PROTECTION SECTION
1606 Mail Service Canter. Raleigh, North Carolina 27699-1636
Location; 2728CaprW Boulevard, Raleigh, North Carolina 27604 One
Phone:[phone]FAk 1:919-715-0508: FAX 2: 919-715-66481 Gusiornerseraloe:.-877-623 6748 NorffiCarol ina
Internet: 2m-nmataroualb.0ro Naturally
An Eeudl ilpDDrtunity L AffiRnalive Aaiun ErnobyP-