WI0700159_GEO THERMAL_20091216

Permit Number,
Program Category
Ground Water
Permit Type
WI07001 59 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit ,
Facility Name
Jon P. Graham SFR
Location Address
104 S Granville St
Edenton
Owner
Owner Name
Jon
Dates/Events
NC 27932
p Graham
Orig Issue
12/16/09
App Received Draft Initiated
12/14/09
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall ,UL
Scheduled
Issuance
Central Files: APS_ SWP_
12/16/09
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Jeff Stagg
636 Benefit Rd
Chesapeake
Major/Minor
Minor
VA
Region
Washington
County
Chowan
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Jon P. Graham
Owner
104 S Granville St
Edenton
Public Notice Issue
12/16/09
NC
Effective
12/16/09
23322
27932
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
��
NCDEN�
North Carolina Department of Environment and Natural Resources
Division of Water QuOty
Beverly Eaves Perdu: Coleen H. Sullins
Governor Director
12/ 1612009
Jon P. Graham
104 S. Granville 5t.
Edenton, NC 27932
Subject; Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10700159
104 S. Granville St.
Edenton, NC 27932
Dear Mr. Graham:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
1211412009, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed -loop geothermal water-
Wy injection well system for the operation of a ground -source heat pump located at 104 S. Granville St., Edenton,
Chowan County, NC 27932. 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 Chowan 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].
Sin rely,
for MichaeiRogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Washington Reglonat Office - APS
APS Central Files - Permit No. W10700159
Chowan County Health Dept.
Jeff Stagg (J.A. Stagg Energy Enterprises, Inc., 636 Benefit Ad„ Chesapeake, VA 23322)
Gary G_ Hughes (Gary's Electrical Service, Inc., P.Q. Sox 312, Colerain, NC 27924)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699.1636
Location 2728 Capital Eoulevard. Raleigh. North Carolina 27604 One
Phone, 919-733-3221 l FAX 1: 919-71541588; FAX [phone] CwtomerService: 1-8T7-623-5748 NorthCarol.ina
Interner,, WwrigEteraLa tr .orc
An. Equal Uppwrunty % Alilr TKM! Amon Employer �)Vaturjqll,#

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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCI)ENR)
NOTIFICATION OF IN:T'EN7 W CONMUCr Ac E -L (V GEOTHER_X&L
wATEk DNLV INJECTrON WELL SYSTEM:
TYPE 5-OW WIELL S)
in Acvwdancc wililt the pravisions of NCAC Title 15A: 42C_0200, please
wroptcte tl)is notification and rnail to address on the back page (please PP' tar information).
r
PATE._ IS ► ° p a�
Well 75pe Co)rjh' - malinn: hoes the pmposed system circulato potable wg _only (no additives) in
continuous piping that completely isolates the fluid from the eriviroru=t (i.e.
closed -loop)?
Yes Continue completing this form.
So Do Not complete this form. Complete other WC application forms for installing
eithaa SKI well (Q=400p welt jWgitins potable water into the aquiver) or a SQM well (elosed-
loop well containingadditiv such ss R 22, ethanol, or other antifre= or corrosion inhibitors),
A. PROPERTY OWNER(SYAPI MICANT(S)
List each Property Owner fisted on property deed (if Owned by a bminess or government agency, state name of
ty and a rep=cntative w?autherity far signature): `i 61M
{ t) Mailing Address: L ,�C
City: ' State: NG Zip Cedt: eZ%2 _ County: O -�
Ham&0ff ca Tale No.:-
Ermaii Address: 6 Ah&�-) cj4hm W .bsi
• r�>n
(2) Physical Address of Well Site (if diiYerent' than above):
City: - State: Zip Code; County:
Home Office Teie No,:
Cell No.:
NAK A THOR17,ED AGED' OF OWNER, IF ANY (if the Permit Applieanl dark nit Own the sub*t property,
.�jv,w,h a Ietter from the property owner authorizing Agent to install and. operate UlC well)
Company Nam: --
Contact person;,
Address:
City: -
State: Zip Code: County:
OfficeTe1e No.:
Website Address of Company, if any:w_ - _ RECEIVED I DENR I DVQ
ytn rr Proled l)n Serilon
GnUIUTC 3QW Notification of bicmt Fozm (Devised 8 OOP, _ ",_ f .I Pic 1

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Dec 14 09 11:11 a
C. WELL DRT11 LER MFORMATION
Company Name:--^ T A. '5- A 6-s eWi e-G"r C--�JT-tF' ,
Well Driller Contractor's Name: 1 a w A g...4 �C. S:W -ram
NC Contractor Certifzcatioa No.:
contact perm - 3� f? - -- - lti;,a Fi Address; (►�,.. C �++
a
Addrusss: � �}. y
City. , i + �+1� �!6► .{ _ Zip Code. C.�3 'I�'� County:
Offirx Tole No_: Cell NO.: �
0. HEAT PUMP CONTRACTOR WORMATION (if diff'ercot than driller),
Comp, my Name; IA 12J,� - � i:�' lcia Lset ut C t .i 1,L -
Contvct YU-4,L_i EVAIL Address: �AarL?,ylt,t
Address: �� _ �x U� - rj — `' �• ( c
City: I' Zip Code: -,2�-Y County. T6 e
-Z
E, STATUS OF �PPLrCANr
Private: ; Federal,. _ _ Goranimial:
stale: Municipal: Native American Lands
F. iNUCTION PRGCEMW (briefly describe how the injection wells) will be used.)
G. WELL CONSTRUCTION DATA
(t) Proposed date to be constructed: �A;umber of borings:
Approxhnau� depth of each boring
(2) 7ype of ttt * to be used (capper, PVC, etc):
(3) Well casing. Is the well(s) cmed? (check either (a.) Yea or (b.) No below)
(a) Yes _ if yes, then provide caging information below
Type: -galvanized steel black steel, plastic_ _ether (Specify)
Casing depth: From `ta feet (reference to Sand surface)
Casing extends to above ground inches
(b) No _—
(4) Grout Info (material surrounding well casing and)or piping) -
(a) Grout type: Neat Cement $entcnitA Other (specify)
(b) Grout placement: Purnpim_ Pressure Other
(c) Grout depth of tubing (rcf'er=ce to land surface): fmm '`, to U ❑ (fcct)
it well has rasing, indicate grout depth; from feet)
GPUAJIC SQW Notification of lnt" Form (RcYisad WC08) Nop ?

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Mach a d=m showi& the ec &Gering layout or pmpmd mod floe on of tho JhJedmoqWpmeM and eximoor
ptpftV*bis8 &moc tho it ongXrWaa. The manor's 5 ura may pxovicie szzplrIeancxttary
infbtte fon.
LOCATION° DF 1R5j
Atm& two OqAft aPmaps ahowi9 the #bitapring idiom
(1) hrlude it Ske IVW (cm be davft AowbW buRdhw. prvaW lhm% 2wAce waver boffiwo paeendal
wu= of gumdwoer am==Wdon and tits m=tdim of ad &ftnom bdwmn the pmgosed wa(s) and
Say axing weil(s) or waste disposal fsci3eti m such as septic moks or dtin Reid, low Within 200 feet of
dw seothamW heat Pmr well Vatmm Labol OR fares cIetriy► and include A ngo ME.
(2) The Siuo Nfap swat show the subject property In reUgm to the sanomding area by using at chest two find�I
refmco POWS stack as mils, isms. aadAm hwnvw b*rse Umm
J. UWATION
Now. This Pit Apptieatiao mast be aimed byllA pataoa appearkg Qn the
horded kVI prvpe+rty deed.
"1 hereby certify. under pamW of Irv, thm i have pwsomaliy =mnincd earl am famTw whh time hifo madon
aabmftd in 26 dDmW= &d AU MWJ=� fb=W sett} that, bused on ►gy ia*q of throe individuals
immeffiateiy respwm-We for Dbulifog said i 6m mean, I bolim the the ration is tm, acameft and oomplctc,
I am aware Iliac them am 5�9WACW pet WtM h3cludiV the sty of Ems and imp6som=4 for submining
false k hrunWon. 1 agree to cacasanu k opwAle, muinblLi, repair, and if appiexhIe, aba kdon the i4jaxion well Bud
all raiair�i appurtenances ► a�� ` ;�;., �Wkadum and condilim ofthe Permit"
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Rogers, Michael
From: Jeff Stagg ([e-mail]]
Sent: Wednesday, December 16, 2009 10:23 AM
To: Rogers, Michael
Subject: RE: Graham 5QW well
Michael.
In this case, there isn't any more room. This is a VERY tight area to work with in the downtown area. If you would prefer,
I could start with a 25ft set back on all other jabs? I would like to design no further than that if possible, as to keep the
friction loss down for circulation KW. These people now have no heat.
We do make an as -built drawing for every job.
We will be sure to grout each bore hole FULLY with bentonite. Hope this helps.
Thanks,
Jeff
"Geo"-Jeff
Jeffrey A. Stagg
IGSHPA Accredited Since 1992
(International Ground Source Heat Pump Association)
Pinkston Geothermal
1 A Stagg Energy Enterprises
636 Benefit Rd -
Chesapeake, Va. 23322
757-438-9392
www.fox43tv.com/Eeneric news]peneric_ special_ green Pin_ kstonGeothermal 20090320
www_fox43tv.com'subindex/ news at 7igoinF green
From: Rogers, Michael[mailto:[e-mail]]
Sent: Tuesday, December 15, 2009 10:18 AM
To: Jeff Stagg
Subject: RE: Graham 5QW well
Jeff
In reviewing the site map, the borings are going to be 10 feet from the house. Is there room on the Iot to have the
nearest well 25' from the house?
Michael Rogers, P.G. {NC & FLf
Environmental Specialist
NC ©iv of Water Quality- Aquifer Prot fan Section {APS}
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Jeff Stagg [mailtc:[e-mail]]
Sent: Monday, December 14, 2009 10.30 AM
To, Rogers, Michael
Cc: 'Amber Vegas'
Subject: RE: Graham 5QW well

Thanks Michael,
We are waiting for signature page right now. Will send all as soon as possible.
Jeff.
"Geo"-Jeff
Jeffrey A. Stagg
IGSHPA Accredited Since 1992
(International Ground Source Heat Pump Association)
Pinkston Geothermal
J A Stagg Energy Enterprises
636 Benefit Rd .
Chesapeake, Va .23322
757-438-9392
www.fox43tv.com/generic/news/generic special g reen PinkstonGeothermal 20090320
www.fox43tv.com /subindex/news at 7 /going green
From: Rogers, Michael [mailto:[e-mail]]
Sent: Monday, December 14, 2009 10:10 AM
To: [e-mail]
Subject: Graham SQW well
Jeff-
We rec'd the NOi for the above. However, the signature page was unreadable. Also, the proposed date, number of
borings, depth, and type and depth of grout was blank on page 2. Therefore, please complete page 2 and re-fax page 2
and signature page.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
2
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