WI0700156_GEO THERMAL_20091124

.SA
MCD EMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Bever ly Eaves Perdue
Governor
Doug Evins
Karen Evins
159 Brumley Road
Knots Island, NC 27950
SUBJECT:
Dear Mr. & Mrs. Evins :
Coleen H. Sullins
Director
Aquifer Protection Section
November 24, 2009
Acknowledgement of Construction of
Type 5QW Injection Well System
Doug & Karen Evins property
236 Knotts Island Road
Knotts IslandJ Currituck County, North Carolina
P e rm it N o . Wl0 700156
Dee Freeman
Secretary
In accordance with the information submitted, the Aquifer Protection Section (APS) acknowledges that a closed-
loop geothermal water only injection system has been constructed at 236 Knotts Island Road, Knotts Island, Currituck
County, North Carolina. This system is deemed permitted by rule (North Carolina Administrative Code Title 1 SA,
Subchapter 2C, Section .021 l(u)(2).
If you modify your system at any time, includin g the addition of antifreeze, corrosion inhibitors, or any other
substances to the circulating fluid, you must contact the Aquifer Protection Section to verify compliance with applicable
rules.
If additional information or clarification is required , please contact me at [phone].
Sincerely,
I . c J '
, aW/fJ)u
David Mav 7
Aqu ifer P;otect16ri Regional Supervisor
Washington Regional Office
cc : Aquife r Protect io n Sec t io n Cen tral Files Pennit N o. W10 7001 56
WaRO-APS
N orth Ca ro lin a Divisio n of W ater Quality
943 Washi ngton Squ are M all
Washi ngton, NC 27889
Internet: www.nc.watergualitv .org
Phone: [phone]
FAX [phone]
An Equ al Oppo rt unity /Affirm ati ve Act ion Employe r -50% Recyc led/10% Post Consume r Paper
Nirth Carolina /Va tu rally
1,#ELtt CONTRACTOR:.
Well Contractor Individual
:" ell Contractor CompanyName!jJ
Street Address J
i lF' I17JG� Jr�!Ir GI S V/-
I a}Civ�r Town State Zip Code
Area code Phone number
2. WELL INFORMATION: l'- t, �C_ f - N50
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(it applicable)
3. WELL USE (Check Applicable Box)- Residenttal Water Supply
CATS DRILLED�� `I
TIME COMPLETED Atit ® PM
d. WELL LOCATION -
CITY, _ CM, -I n _ COLJNTI� ' r k
(Slreet Name, Numbers, Community, Subdivision, Lot No., Parca Zip Code)
TOPOGRAPHIC 1 LAND SETTING' (check appropriate box)
❑Slope DValley ®Flat ❑Ridge []Other
LATITUDE 36 `, 3,� S 3 " DMS OR 3XY.)O i:XXXX DO
LONGITUDE 75 -55 ' -`l & " DMS OR 7XxXXXXXXXX OD
Latitudehongitude source: jDGPS ❑Topographic map
{location of well must be shown on a USGS top map andaftacheV to
this form if not using GPS)
s. WELL OWNER
A l-uG Q+ r6a Ei/,A,, j _
Owner Name
15 p /?r ,-) /Z V
Street Address
City or Town { n State Zip Code
Area code Phone number
6. WELL DETAILS: _
a. TOTAL DEPTH: 7 d
b. DOES WELL REPLACE EXISTING WELL.? YES C NOJS-
1
c. WATER LEVEL Below Top of Casing: pT
(Use " i" if Above Top of Casing)
d. TOP OF CASING ISM/ FT. Above Land Surface'
'Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .011 &
e. YIELD (gpm): —r3- — _ METHOD Of TEST &,&e i
L DISINFECTION: Type Ch Amount • 5 a,
RESIDENTIAL WELL corrsTRycTroty RFcaRn
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRA,CT4R CERTIFICATION # Howart! Cutter # 3538-rt
g. WATER ZONES [depihy:
Top Bottom L� C:5, Tap
y Name Top Bottom Top
-/:•7r:_ � Top _ Bottom Tap
1174 3�
F:
Bottom
Bottom
Bottom
Thickness)
T. CASING: Depth
Diameter Weight Material
-fop �� Bottom
Ft. 51
Top Bottom
Ft.
Tap Bottom
Ft.-
6 GROUT: Depth
Material Method
Top CS Bottom
Ft. t,L'� r
Top Bottom C5
Ft. 1LSn,-r-''
Top Bottom
Ft,
9. SCREEN: Depth
Diameter Slot Size Material
Taps, Bottom � r
Ft. r in. IQ in- C
Top Bottom
Ft. in, in.
ToR Bottom
Ft. in. in.
10, SANDIGRAVEL PACK:
Depth
Size Material
Top_-r2 Bottom
Ft.
Top Bollom
Ft.
Top Bollom
Ft.
11. DRILLING LOG
Top Bottom
Formation Description
fLi
1 CG2 r
1
1
r
1
1
1
1
f'T-J
ff—
12. REMARK&
`� A 2009
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY O IS RECORD HAS BEEN
PROVIDED TO THELL NE�
SIGNATUi= E OF CERTIFIED b
PRINT NAME OF PERSON
Submit within 30 days of completion to: Division of Water Quality -
1617 Mall Service Center, Raleigh, NC 27699-161, Phone: [phone]DO
DATE .
Information Processing, -
RECEIVED
i DENR � DWa
AGIIJIFFR pRs1TF-rTIr1t,1 fi>~0414
AUG 0 2 20M
Farm GW-1a
Rev-.2f09

Mappinij Search
_◄__,_ ____________ ___) 2.J
Site Information
Map Tool Options
The current cursor mode is set to 'Pan / Recenter'. Clicking on the map directly will adjust the center of the
map will shift the extent of the entire map.
Aowaed if. ea&ew
Mr. Allen Clark
% Washington County Environmental Health Dept.
943 Washington Square Mall
Washington, NC 27889
Dear Mr. Clark,
November 18. 2009
W -�-- 010 C3) 5 (r�
1 have included the GW-Ia completion reports for the 3 geothermal loops and another for the
5 geothermal loops on the Douglas Evins property at 236 Ki�Island Road, Knotts Island,
NC 27950. - -
I was not the contractor or the driller however I did observe the installation of these loops
and can confirm they were installed and grouted properly,
Since 1 wasn't the contractor or the driller I cannot sign these completion reports. They
should probably be signed by the contractor Mr. Hellstrom. I have been unable to reach Mr.
Hel lstrom.
Sincerely,
,A-w 4"96I " ` &% §wL?
............................
800 Dryden Street
Virginia Beau, VA 23462
Ph: 757/418-2036
Email_ , orkvva cccox .ziet

lIEESLDENT,LIL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION i#
1. WELL CONTRACTOR:
Anders Heilstrom
Well Contractor (Individual) Name
Geysgr C;e Ahermal _ Well Contractor Company Name
101SeachView Or. -
Street Address
it ' la Beaqh. VA 23464
City or Town State Zip Code
t 757 ) 487-0323
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #wappllcable)
3. WELL USE (Check Applicable Box). Residential Water Supply [3
DATE DRILLED June 25.2008
TIME COMPLETED AM p PM
4. WELL LOCATION:
CITY: Knotts island
COUNTY
236 Knotts Island Road.
27950
(Sheet Name. Numikem, CornmuMy. Subdivision, Lot No-, PartW. Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
(checkappg3nate box)
0Slope ❑Valley ❑Flat DRidge
❑Other
LATITUDE 36 ,'
" DMS OR 3x,xxxxxxxxx Do
LONGITUDE 75
" DMS OR 7x.xxxxxxxxx DO
Latitudellongitude source. 03PS []Topographic map
(Iocabon of well must be shown on a USGS topo map andattached to
this form ifnot using GPS)
5. WELL OWNER
Dowlas Bvins
Owner dame
t59 Brumley Road
Street Address
Knotts Island- NC 279540 _
City or Town State Zip Code
7{ 57 ) 429-3204
Area Trade Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 200 ft. _
b. DOES WELL REPLACE EXISTING WELL? YES ,-1 NO V
c. WATER LEVEL Below Top of Casing: NA --FF.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS NA FT. Above Land Surface'
'Tap of casing terminated allDr below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD tgpml- NA METHOD OF TEST NA
f. DISINFECTION. Type NA Amount NA
g. WATER ZONES (depth):
Tap ?
Bottom _-
_ __.
Top
Bottom _
Top
Bottom
Top
Bottom _
Top
Bottom
Tap
Bottom
Thickness/
7. CASING:
Depth
Diameter
weight Material
Top
Bottom
Ft.
NONE
Top
Bottom
Ft.
- Tap
Bottom
Ft.
-- -�
8. GROUTS
Depth
Material
Method
Top 0
Bottom 200
Ft. BENTONITE TREMIE
Top
Bottom
Ft.
Top
Bottom
Ft.
_..
9. SCREEN:
Depth
Diameter Slat Size Material
Top 0
Bottom 0
Ft.
in,
in.
Top
Bottom
Ft
in.
in.
Top
Bottom
Ft.
in.
in.
10. SANDIGRAVEL PACK:
Depth
Size
Material
Tap 0
Bottom 0
Ft,
Top
Bottom
Ft
Top
Bottom
Ft.
11. DRILLING LOG
Top Bottom
0 1200
1
1
1
1
. 1
1
r
Formation Description
NO SAMPLES TAKEN
12. REMARKS--
151 NON. PROD IJCI.NG-GEOTHERMAL. CLOSED LOOPS -
LOOPS WERE INSTALLED TO 200 FEET AND GROUTED
FRAM Toll TQ BOTTOM. NQ SAIVIPLES TAKEN.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE ---
Anders Hellstrorn
PRINTED NAME OF PERSON CONSTRUCTWG_THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, , -; Fq�jrr�GW.to
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone]tr` IgS

- SrAT£
, ; RESIDEIIT�",tAL WELL CONSTRUCTION RECOxn
North Carolina Deportment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Anders Hellstrorr
Well Contractor (Individual) Name
Gevser Geothermal
WO Contractor Company Name
1501 Beachview ❑r,
Street Address
i 'a ach. YA 23464
City or Town State Zip Code
757 5 487-0323- --
Area code Phone number
F1[51-4WWI :IYa7.t;T_ 1ir413
WELL CONSTRUCTION PERM$T#
OTHER ASSOCIATED PERMIT#(If aWicahle)
SITE WELL ID *(if applicable)
3. WELL USE (Check Applicable Box): Residentlai Water Supply ❑
DATE DRILLED June 25. 2008_
TIME COMPLETED AM ❑ PM 0(
4. WELL LOCATION:
CITY: Knotts Island COUNTY
236 Knotts Island Road. 27950
(Street Name, Numbers, Community, Subdivision, Lot No., Paroel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING: (cmteck appropriate box)
❑ Slope o Valley O Flat L1 Ridge j3Other
LATITUDE 36 DMs OR 3x.XXXXXXXXX DID
LONGITUOE 75 DMS OR 7x.)=XX)(XXX DD
Latitudellongitude source: ❑3PS ❑Topographic map
{location of weh must be shown on a USGS tops map andattached to
this form if not using GPS)
S. WELL OWNER
Doualas Evin
Owner Name
159 B
Street Address
l d
City or Town State Zip Code
7t _ 57 ) 429-3204
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 200 1•t.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Pf
C. WATER LEVEL Below Top of Casing- NA _ FT
(Use '+' if Above Top of Casing)
d. TOP OF CASING is NA I T. Above Land Surface'
'Top of casing terminated atlor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e, YIELD igpml: NA METHOD OF TEST-NAf. DISINFECTION: Type NA Amount: _[SEA
g. WATER ZONES (depth):
Top ? _
Bottom
Top
— Bottom
Tap
Bottom
Tap
Bottom
Tap
_. Bottom
Top
Bottom
Thicknessl
7. CASING:
depth
Diameter
Welght Material
Top
Bottom
Ft,
NONE
Top
Bottom
Ft
Top
Bottom
Ft,
8. GROUT:
Depth
Material
Method
Top D
Bottom 200
Ft,
BENTONITE TREMIE
Top
Bottom
Ft.
W
_
Top
Bottom
Ft.
8. SCREEN:
Depth
Diameter
Slat
Size Material
Top O
Bottom 0
Ft.
in.
in.
Tap
Bottom
Ft.
in.
in.
Top
Bottom
FL
in.
in-
10. SANMRAVEL PACK!
Depth
size
Material
Top U
Bottom 0
Ft.
Top
Bottom
Ft -
Tap
Bottom
Ft.
11. DRILLING LOG
Top Bottom
n iann
1
1
1
1
1
1
l
1
I
Formation Description
NO SAMPLES TAKEN
12. REMARKS-
t3 NON PRODUCING -GEOTHERMAL CLOSED LOOPS -
LOOPS WERE INSTALLED TO 200 FEET AND GROUTED
FROM TDP TO BOTTOM, NO SAMPLES TAKEN.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER. ---w- -
SIGNATURE OF CERTIFIED WELL CONTRACTOR' DATE
Anders Hellstrom _
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit►4thin 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] Rev. dlp5

woad & e&&ff
November 16. 2001)
Mr_ Allen Clark � � ^ �
% Washington County Environmental Health Dept. ��
943 Washington Square Mall
Washington, NC 27889
Dear Mr. Clark,
I have included 2 copies of the Type 5-QW Wells form for Mr. Doug Evins Geothermal
Closed Loops installed on June 258', 2008 by Geyser Geothermal.
Please understand that I had no involvement in the contracting, permitting or installation of
these wells other than I was there when these loops were drilled and grouted. I can however
confirm that they were drilled and grouted to NC state regulations.
I have attempted to make you a field sketch of the loop locations to the best of my
remembrance.
Please understand when these geothermal loops were installed this was a relatively bare
acreage. There were no buildings, septic tank, laterals or wells. There was only an open field
with a small shallow freshwater pond.
Please forward copies to the Aquifer Protection Section in Raleigh, NC.
If I can be of further assistance please contact me.
Sincerely,
.9719urcard ".9od y " &ftA �U
Howard "Porky" Cutter, MGWC
f
faov 1 s 2"1 1
............................
800 Dryden Street
Virginia Beach, VA 23462
Ph: 757/415-2036
Email: , ork •ova «cm.not

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-QW 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 IYru,. information).
DATE: June, 25 th 2008
Well Type Confirmation: Does the proposed system circulate potable water onl (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loo p)?
Yes _X _ Continue completing this form.
No ___ Do Not complete this form. Complete other UIC application forms for installing
either a 5A 7 well ( open-loop well injecting potable water into the aquifer) or a SQM 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 signature): Doug Evins
(I) Mailing Address: 159 Brumley Road
City: Knotts Island State: NC Zip Code: 27950 County: ____ _
Home/Office Tele No.: 757-429-3204 . Cell No.: 757-377-3239
Email Address: I ho !!natr ci,cox.net Website:
(2) Physical Address of Well Site (if different than above): 236 Knotts Island Road
City: Knotts Island State: NC Zip Code: 27950 County: _____ _
Home/Office Tele No.: Cell No.:
B. 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 UIC well)
Company Name: --------------------------------
Contact Person: EMAIL Address: "----------------=~=-:c..==.oc= __________ _
Address:-------------------------~--------. ''.:_;
City: _________ State: __ Zip Code: ______ County:
Office Tele No.: Cell No.:
Website Address of Company, if any:. _______________ _
I .,;
C. WELL DRILLER JNFORMA TION
Company Name:Ge yser Geothermal
Well Driller Contractor's Name: ______________________ _
NC Contractor Certification No.: _________________________ _
Contact Person: Anders Hellstrom EMAIL Address:
Address: 1501 Beachview Dr. _______________________ _
City: Virginia Beach Zip Code: 23464 County: __________ _
Office Tele No.: 757-487-0323 Cell No.: 757-635-4689
D. HEAT PUMP CONTRACTOR JNFORMA TION (if different than driller)
Company Name: _______________________________ _
Contact Person . .,_: -----------------=E=MA=-:,cI=L'----'A'--==dd=r=e=ss=: __________ _
Address:----------------------------------
City: _________ Zip Code: ____ County: _____________ _
Office Tele No.: Cell No.: __________ _
E. STATUS OF APPLICANT
F.
G.
Private: X Federal: Commercial:
State: Municipal: __ Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
NON INJECTION! GEOTHERMAL CLOSED LOOP WATER ONLY!
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _______ Number of borings: 3 and 5 loops_
Approximate depth of each boring (feet): 200 ft.
(2) Type of tubing to be used (copper, PVC, etc): Polyethylene
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (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 __ 0 __ to _20 __ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
H. INJECTION-RELATED EQUIPMENT
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.
I. 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, arid/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 I have personally examined and am familiar with the information
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 possibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
Signature of Property Owner/Applicant
Print or Type Fu1l Name and title
Signature of Property Owner/Applicant
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 Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-DIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Doug Evins
Karen Evins
159 Brumley Road
Knots Island, NC 27950
Coleen H. Sullins
Director
Aquifer Protection Section
November 24, 2009
SUBJECT- Acknowledgement of Construction of
Type 5QW Injection Well System
Doug & Karen Evins property
236 Knotts Island Road
Knotts Island, Currituck County, North Carolina
Permit No. W10700156
Dear Mr. & Mrs, Evins:
Dee Freeman
Secretary
In accordance with the information submitted, the Aquifer Protection Section (APS) acknowledges that a closed -
loop geothermal water only injection system has been constructed at 236 Knotts Island Road, Knotts island, Currituck
County, North Carolina. This system is deemed permitted by rule (North Carolina Administrative Code `l'itle 15A,
Subchapter 2C, Section .0211(u)(2).
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 Aquifer Protection Section to verify compliance with applicable
ru les.
If additional information or clarification is required, please contact me at [phone].
Sincerely,
David May
Aquifer Protee6n Regional Supervisor
Washington Regional Office
cc: Aquifer Protection Section Central Files - Permit No. WI0700156
WaRa-APS
North Carolina Division of Water Quality Internet wwmLngwaterquality r
943 Washington Square Mail Phone [phone]
Washington, NC 27889 FAX [phone]
An Equal OpportunitylAffirmative Action Employer— 50% Recycledl10% Past Consumer Paper
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