WI0700167_GEO THERMAL_20100319

Program Category
Ground Water
Permit Type
WI0700167
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Joan C. Strausbaugh SFR
Location Address
41661 Ocean View Dr
Avon
Owner
Owner Name
Joan
Dates/Events
NC
C
27915
Strausbaugh
Orig Issue
03/19/10
App Received Draft Initiated
03/16/10
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall l-
Scheduled
Issuance
Central Files: APS_ SWP_
03/19/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Joan C. Strausbaugh
Owner
PO Box 609
Clifton Forge VA
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Joan C. Strausbaugh
Owner
PO Box 609
Clifton Forge VA
Public Notice Issue
03/19/10
Effective
03/19/10
24422
24422
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
3/2212010
Joan Strausbaugh
P.Q. Box 609
Clifton Forge, VA 24422
Subject: Acknowledgement of Intent to Construct Type _5QW Injection Well System
Permit No- WI0700167
41661 Ocean View Dr.
Avon, NC 27915
Dear.Ms. Strausbaugh:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
03/16/2010. the Aquifer Protection Section (APS) acknowledges your intent to construct a closed -loop geothermal water-
only injection well system for the operation of a ground -source heat pump located at 41661 Ocean View Dr., Avon, Dare
County, NC 27915. 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 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].
SM' eIy,
for Mic 1 Rogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Washington Regional Office - APS
APS Central Files - Permit No. WI0700167
Dare County Health Dept.
Jeff Stagg (J.A. Stagg Energy Enterprises, Inc., 636 Benefit Rd., Chesapeake, VA 23322)
Wes Schaaff (2301 Patterson Ave. SW, Roanoke, VA 24016 )
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleig h. North Carolina 27699-1636
Location: 2728 Capital Boulevard, Ralagh. North Carolina 27604 One
Phone, 919-733 3221 I FAX 1; 919-715-4588; FAX [phone]-EQ481Customer Serum,1-877-623-6748 North Carolina
Imemet www.nayateraualfiV.ora
an Equal Dpporwolty l A�irMalrve Amrr Emplover Naturally

FAX COVER SHEET
GEOTHERMAL LOOPS
J A STAGG ENERGY ENTERPRISES, INC.
Service Disabled Veteran Owned Company
International Ground Source Heat Pump Association Accredited Installer and Trainer since 1992
VIRGINIA CLASS A HVA, WWP CONTRACTOR #2705113253A
NORTH CAROLINA WELL CONTRACTOR #3538 Howard Cutter
NORTH CAROLINA H-3 CONTRACTOR LICENSE #29277 _
Jeffrey Stagg 636 Benefit. Rd, Chesapeake, Va. 23322--Ph/Fax [phone] Cell 757-438-9392 [e-mail] -- —�
7s-q�'--� , '�
RECEIVED 1 QENR 1 QWQ
Aquifer Protection Section
MAR 18 2010

NORTH CAROLINA
DEPARTNIENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPES W WELL(S)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and marl to address on the back page.
DATE: _ _ Z 2' �- 211 60
A.
a
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the envirotxment (i.e.
closed -loop-)?
Yes Continue completing this form.
Na Do Not complete this farm. Complete other UIC application forms for installing
either a SA7 well (open -loop well 'fin epotable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other anffTeeze or corrosion inhibitors).
PROPERTY OWNER(S)IAPPLICANT(S)
List gacb Property Owner lis d. on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signalum): 1 ? Sroja 7 C--kq
Mailing Address: 2 Q . Z ox 60Y
City,�_ Y4 State: Zip Code: ��2-ZCounty: Gl.906
Home/Office Tele No.: Celt No.:a-' �Z
Email Address: 1 lV'cV wo'o"4-VO&'-,-d)Website:
(2) Physical Address of Well Site (if different than above); L1 - G iyC45AN 'Vl C W D
City: �V" 0 State: 1J C Zip Code: ci )S County: ►2 A 9c,
Home/Office Tele No.: 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 UIC well)
p, Company Name:
Contact Persoa: EMAIL Address:
Address:
City:
Office Tele No.:
State: Zip Code: Cotmty: RIEG&V69 i ;_1-.1.4:a D1AJf3
Cell No.: ftkiff't Prom -�AOn
Website Address of Company, if any: M AM 18 1-0 l l)
OPUAAC 5QW Nodfieation of kdent Form (REA.uti 81201t) pop 1

·'
C. WILL DRU,I,D INPOBMATION
CompanyName: ::r .. A. S,~·G"C €rJEQ.GY t:NrefLPRi,t J€,[, 1,JC,..
Well Driller Contractor's Name: .Sp;l\l.DA L l Cu Tf1P'2.-: ►
. NC.Contractor Certification No.: ~---·· ....... a=-·=g.,,.;._l~B~--!A:.....3...-----------
Contact Person: -::5€'~ St"'!\ 6& · -' ~ f'r ~L~. ---EMAIL Address; ,) ~~~4.loi~•CoJt\
Address: (cz3 (p &°tJE"f:t r f 1\
City: (+\O_pJ>Q\llc--pA Zip Code: 2,j37.,'l,_ Collllty: ________ _
0:fficeTeleNo.: _______ CellNo.: 7S"?-'i.3J;-q3q"L
D. BEAT PUMP CONTRACTOR INFORMATION (if different than driller),
CompanyName: H VA C SoLUT1 a ,✓5
E.
F.
G.
Contact Person: ~c .s· SL\J A A f:F EMAJL Address:
Address: 'Z..3D l PA TrFt.lSn N AVE"'. S\i..J
City: R oAvJ DK-£: Zip Cod~: ___ Comity: _________ _
Office Tele No.: 51-\ o -"3>4?...-I 1..r2,_ 1._ Cell No.: _______ _
STATUS OJ APPLICANT
Private: ~ Federal:_ Commercial:
State: Municipal:_ Native American Lands:_
INJECTION PROCEDURE (briefly describe how the injection well{s) will be used)
. NO: A w~(k \JveL--L .
Ge-b.,-t.\~k CLDS.G"b Goo.P
WELL CONSTRUCTION DAT.A ·s-(J) Proposed date to be constructed: _____ Number ofboringa: ___ _
Approximate depth of each boring (feet): 2 o n
(2) Type ottubfng to be used {copper, PVC, etc): __ . .L.H~;J~P__.;:E"";;,__.. ____ _
, (3) Well casing. Is the well(s) cased? (check either (a.) Yea IE (b.) No below)
{a} Yes __ ifyes.thenprovidecasinginformationbelow
Type: ___galvanized steel _black steel_Jlastic_other (specify)
Casing depth: From _____ to _ __,;feet (reference to land sudico)
Casmg extends m above ground ____ inehes
(b) No ~
(4) Orout Info (material surrounding well casing and/or piping):
(a) Orouttype: Neat Cement_ Bentonite ~ Other (specify) ____ _
(b) OroutpJacement: Pumpin&)4_. Pressure_ Other_
(c) Groutdepthoftubing(referencetolandsurface): n-om Q to 20Q {feet)
If well bas casln& Indicate grout depth: fi'om ___ to ___ (feet)
,,-.S9'1'trff,. .,.....,,..,._ ...... _ _._. __ -·~----41 ff--l'Wl--..f--~ ,..,_.-ii.,......,
B. INJECl'ION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
~ipinWfubing associated with the irtjection operation. The manufacturer's brochure may provide supplementary
infonnation.
L 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 weJl(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geotbennal 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. CERTMCATION
Note: This Permtt Application must be 1lped by !ISi! person appearing on tbe
recorded legal property deed. · ·
''I hereby certify, under penalty of law, that I have personally examined and am familiar with ~ information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said infonnation, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibilizy of fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all rolated appor1en8DCeS ln~witb "e:%:5~ oftbePennll"
_ v \ 1gnatute of Property Owner/Applicant /.
::r;,~ c. s+ra. <.tSki~s V/
Print or Type Full 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 tho completed Application package to:
North Carolina DENR-DWQ
Aqujfer Protection Seedon-mC Program
1636 Mall Service Center
Ralejgh 9 NC 27699-1636
Telephoae [phone]
OPU/UIC 5QW Nodffcation oflntollt Fonn (bvJscd 812008)
RECEIVED I DENR / OWQ
Aquifer Protection Section
MAR 18 2010
\ \
=F 41661 ocean view dr avon,nc. - Googie Maps
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W WELUSl
In Accordance With the Provisions ofNCAC Title 15A 42C.0204
Print or type the required information and marl to address on the back page.
DATE: 2- — 2,4 20 {0
Well Type Conj3rmation: Does the proposed system circulate potable water o (no additives) in
continuous piping that oompletely isolates the fluid from the environment (i.e.
closed -loot))?
Ye$ Continue completing this form.
Na Do Not complete this form. Complete other MC application forms for installing
either a 5A7 well Co= -loop well inogeft 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)IAPPLICANT(S)
List eProperty Ovvnea Iisted on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority far signature): __ 12_ AAJ _ . -_L' AS_C-�L L7-6
(I) Mailing Address: O • �_ w
city l�I �IrtI C� P � State: ([� Zip Code: , ��County: G�� -
Home/Office Tele No.: 6YO db _-- 7 !a �f Cell Ne.:.Va- ?21�-'3
Email Address: V►V"W'ad-VaC/C bsite:
(2) Physical Address of Well Site (if different than above): Lf t 4 (c OCEAfQ V) tg tin,' .0-4,
City: P�"' D 1\1 State: N C Zip Cade: ZJ j I.S County: - _ aAA .E
Horne/Office Tele No.. Cell No.:
H. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does no own the subject property,
attach a letter from the property owner authorizing Agent to install and operate 1AC well)
[, Company Name:
Contact Person: EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.. _ . CSINIo E) ft
Website Address of Company, if any. ggnifer Prntection Section
MAR IS 2010
OPUtlItC 5QW NOB;adon of Intent Form (Revised SM08) Pa$a 1

C. WELL DRUIM WORMATTON
D.
L
F.
a
Company Name: T A. _5ZA E 19 6NZF"'QC'� I-t" R:ls ��� 2 ►+-�
WeU Driller Cootmetor's Name:
'NC Contractor Certification No.: - 2-8 ) B— A
C.antact Person:' d
Address: _ P L
City: 1 _5. ��� A Zip Code: _ � 3 `Z�'Z Comfy:
Office Tele No.: Ceti No.: ?677 --4
HEAT PUMP CONTRACTOR WORMATION (if didermt than driller),
Company Name: A C_ `SI._ U l o
Contact Person: - F-NWL Address: - - - -
Address: • - 50
City: 4c- Zip Code: County:
Office Tele No.: S Ij 0 3q Z J Ll Z L Cell No.:
STATUS OFAPPLICANT
Private: Federal: CommercW:
State: Municipal: Native Amerlsw La ads:
INJECTION PROCEDURE (briefly describe how the injection well(s) wit/ be used)
C. Lk:); is _i� L Q 0 _P
WELL CONSTRUCTION DATA
(t) Proposed dm to be constructed:
Number of bores:�
Approximate depth ofeaeb boring (fact): 7
(2) Type oftdbing to be used (copper, PVC, etc): 7 G C
(3) Well casing. Ts the well(s) cased? (check either (a.) Yes Lr (b.) No below)
(a) Yes if yes, then provide casing information below
Type: __&Wvanind steel black suW__piasdc other (specW)
Casing depth: From to feet (reference to lend surface)
Casing wrwe s to above gmund Inches
(b) No.
(4) Grout info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite �4_ Other (specify)
(b) [bout placement: Pumping Pressure Dthcr
(c) Grout depth of tubing (reference to land surface): 'Promo to L7 CL (feet)
If well has casing, indicate grout depth: from to _(feet)
.,.......,.- .W,_.­ +.._..__AM"A ft,

B. INJECTION-RELATED EQUIPMENT
~~h a d}agram s~owing !fte eng~~~g layout or proposed modification of the iajection equipment and exterior
p1ping/tubmg associated with the mJection operation. The manufacturer's brochure may provide supplementary
information.
L LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(I) 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 prrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at ]east two fixed
reference points such as roads, streams, and/or ~ghway intersections. -------------------------...... ,.,·----~.,..--------=------J. CERTMCATION
Note; This Permit AppUcation must be 1lped by !Im person appearing on tbe
recorded legal property deed. -
''I hereby certify, under penalty of law, that I have personally examined and am familiar with ~e information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said infonnation, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties. including the possibilit;y of fines and imprisonment. for submitting
false infonnation. I agree to construct, operate, main• repair, and if applicable, abandon the injection well and
allrolatedapplll'lellallCesln~ •e:,;:-~oflhePonnil"
v \ 1gnatute of Property Owner/Applicant .
-:Jo~ C. ~..J-ra,t.tSba,u_fJ /4
Print or Type Full 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 copie5 of tho completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Seedon-IDC Program
1636 Mail Serviee Center
Rale.igh. NC 27699 .. 1636
Telephone [phone]
GPU/UIC SQW Notification of Intent Ponn (bvJscd 8/2008)
REC_EIVED I DENR / DWQ
Aqurfer Protection Section
MAR 18 2010
'..r.�.�... ..::ram: �•1: —G� "r'--.... •cr r.:
..._ 5k17�VFY F1;tl;:
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41661 ocean view dx avon,nc. - Google Maps
Page I of I
Address 41661 Ocean View Dr
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Mar 'IB10%00a
p.1
FAX COVER SHEET
GEOTHERMAL LOOPS
J A STAGG ENERGY ENTERPRISES, INC.
Service Disabled Veteran Owned Company
Intematonal Ground Source Heat Pump Association Accredited instaHer and Trainer since 1992
VIRGINIA CLASS A HVA, VVWP CONTRACTOR #2705113263A
NORTH CAROLINA WELL CONTRACTOR #3538 Howard Cutter
NORTH CAROLINA H-3 CONTRACTOR LICENSE 429277
Jeffrey Stag 634 Benefit Rd. Chmpeake, Va. 23322 Ph1Fax [phone] Ccif 757-438-9392 icIT*,sftg eacrgy.cam
Li1 (061 O C-L A'-z V IL' L-j 0(ti.
A�VQP�, NC
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Mar 18 10 1 Q: ©Qa , �n p.i
RECEIVED I DENR ! DM
- - - — AquAr Pral&zlioll SecOn
MAR 16 2010
NORTH CAROUNA
DEPARTME� ,tr OF ENVIROMaNT AND NATURAL RESOURCES
NOTIFICATION OF WMNT TO CONSTRUCT A CLOS10-LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE Sl?W WELL
In Accordance With the Provisions ofNCAC Tltlt ISA 02C.0204
Prime or type the required driformaimn and mail to adat~esr on the back page.
DATE: Z — 2- (o . 20 l a
F`eQ ?ype ConfawsaWoa: Does the proposed systom circulate pourable W to cr on(no additives) in
continuous piping that completely isolate, the fluid from the enrriramment (i.e.
�k100 7
Yc�X Continue completing this form.
No Igo Not complete this form. Complete vidier UlC application fonts for installing
either a 5A7 well ( e i-loop well g potable wat= into the aquifer) or a 5QM ► ell (closod-
loop well containing 'r3 r' such as R-22, ethanol, or other autificrze or corrosion inhibitors).
A. PROPERTY OWNER(S)1_►► TUCANT(S)
List Wh Property Ow= listed on property deed (if owned by a businm or govermnent agency, stm name of
entity and a representstivc wlauthority for si p): (• . S: as7-
(1) Mai lir<7gAddress: p o- • ulc 603, -- -
Cily. Ya►� Swc Zip Code:
Home�Oftice Tele Na.:�- �-.v •II NO.:�_�>_ _-
Emall Address: +rt GYW� T p fir, �hsitc -- --
(2) Physical Address of Well Site (if differeru than above)-- vC�AfQ yi e ,_1 -o
city: _ �' J,-J scare: PJ C zip Code: Z) J_5� - --- - c outttr -A .0 E
Horne/Office Tele No.:
Ct 1I NND.:
$ AUTHORIZED AGENT OF OWNER, IF A-W (if the Permit Applicant 4og not own the subject property,
a ach a letter from the property owner authorizing Agent to install and operate UIC well)
1, Company 'Name:
contact pa soro• EMAIL Address:—_
Addrm!
City. _ �_ Stage Zip Cods: County:_ --
Office Tele No.. ;ell No.:
Website Address of Compaey, if any:
()P'U"C 3QW NoGffc Kioo of intcct T^drra (R—i-d a2M) ftc i

Mar 16 1010.00a
P-3
G WELL DRMLER INFDIitMTION
compwy Name: A.
Welt Driller CMhOoeg Name: FDA LL ';W
Nr- Cmractur CenificadmNo.: Z9 1
CQW= PCrsor
Add=:
City: Q.% . T.ap Code:
O cc'I'aio No.:
D.
L
IMA.T PUMP CONTRACTOR Jib MMATION (ff dill'e"At thin dr9a ),
Company Name �t'�!( .'_C
Contact
City: - A Zip Code, y Caonty: L� 1
affcc Tele No.: ❑ - -L 19 Z� Call No.:
STATUS OF AMICANT
Private: Federal: CoMmercial.
SM*-- M1micipal: Native Anmrfcan Lands:
F. INJECTION PROMURR Wofy describe how the injection well(s) will be used)
f� " 1A,
6%--, C �C�_ L-015-P
Q ALL CONSTMriC'1TON DATA
(1) Prop°--,-,d data to Abe coasnucwd:
Number of boring:
Apptpxmuft depth of cads boring ('fat): 2 v 13
(2) Tp° oftubfng to be used (mPper, PVC, =).' F E
(3) Wall CW* Is do wall(s) cased? (Che& aithcr W Yea gr 04 NO btlaw)
(a) Yes if yea, then pm4& raging information below
TWW _pjvftnLzCd steel hla& stcai____- 1a.sdc oter (Verify)
Ce, depth: Froth to feet (refi ftwe to land surfaeo)
Casing extwxIs to abova ground �inches
(b) No
(4) ama Info (materisl surrvcuzding wdl casing andlor piping).
(a,) &out type: Neat Cemwnt Benlonite Other (speci6r)
(b) dmut placemcnt: PumPh,94 Pressure Other
(C) Grour depth of tubing (re&vwcc to land awface): horn D. to (feet)
If well has casing, frOo ft grm depth: from to , (f=)

Mar 161010:00a
p-4
AL IlQECMN-RFJATED EQDlKmzn
Ausch a diugram sltowbW the englr Wing layot4 or pruposedmodificffdon of the in ectfan equipnaa I an cxtcrior
pipft tubing associated whit the injection Operation. The manufscttuer's bractturc may provide strppiemmlary
idbcmatlan.
L LOCATION OF VVEWS)
AUKh Iwo copies of maps showing the following f h maflou:
(I) include a Site W {can be drawn} showing. buildings, property Iines, surface war bodies, potmiffd
sommes of groundwaW cmitamimitim and the orientatiao of mA di s aces between the proposed well(s) and
any Laxistiug weWs) or waste disposal hies such as septic tanks or drain fields locowd within 200 Ad of
the geotlner nW heat pump well system La6cl all fbatttr q clearly artd i { w
[2) 'e Sits Mep must sbow the subjecr property in relation to the surrot nft area by using at low two fixed
refzruace pai= such as roads, shank;, andfor highway is erseedorts.
J. CIMi'II<+'XCA77ON
Noce: This Permit Applieation must be signed by,t� permn appearing oa the
recorded lept property deed.
*7 hereby certify, under pen&hy of law, that I have pemnally wmminod and am f�mWiar with the information
sttbm tml in ltszs document artd aU attachments thwto and that, based en my kgnity of these individuals
immediately msponsiible for obudaing said Wonnadan, I believe that the infi m lion is t vr, ammm and cornpkm
I am aware that that$ are significant penahles, Inchtding the possibility offlnes and imprisomment; for submift
ffl%o information. I agree to oonstrut4 opt maintain, repair, and if Applicable, aboxI t the injection well and
all related apptaGcnatZCes in actor a th approveds bong d conditions nFtlte l?etmit."
I
r-rra`urm i n1-7N r O of Prop" OwnWAppf cant h!
A4U1W Pfn S'"
MAR if 2810
Print or —Type Full Name cud
siguat= ofPro"Ownw/Applicant
Pritti: or Type FuU Na mo =d tide
siPaMMOfAufhrsrrmdAgeat, Ifauy
Prim or TYpc M Name and title
Please rewm two copies offt aatnpletod Application peckagc to.
North Car ollm DENH DWQ
Aquifer Protection Sectloo MC Freamm
'106 AUR ScrYUe Center
Raleigh, NC 276",.1636
Telepbone (97 9) 71"935
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Rogers, Michael
From: [e-mail]
Sent:
To:
Sunday, April 04, 2010 10:06 PM
Rogers, Michael
Subject: Permit# WI0?00167 Well Completion Reports
Attachments: Strausbaugh Boring Locations.pdf; Strausbaugh Well Completion Reports.pdf
Michael,
Attached are the well completion reports for the Strausbaugh residence in Avon, NC. Permit# WI0700167.
Copies have been sent to J.A. Stagg Enterprises, Inc.
Thanks,
Randall E. Cutter CWD/PI
IGSHPA Accredited Installer
Geothermal GSHP Loops
Innovative Environmental Drilling
6105 Rest Home Rd.
Claremont, NC 28610
828-228-1695
ra ndy@ied ril Ii ng.com
www .iedrilling.com
1
RESMENTIAL WELL CONSTRUCTION RECORD
North Carolina Depof Environn=d and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTMCATION # 2818—A
1. WELL CONTRACTOR:
Randall E. Cutter_
Well Contractor (individual) Name
Innovative Environmental Drilling
Well Contractor Company Name
6105 Rest Home Rd.
Street Address
Claremont NC 28610
City or Town State Zip Code
828 a 228-1695
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10700167
OTHER ASSOCIATED PERMM#('rf appiicabfe)
SITE WELL iD *,,itappiicable] GL-1
3. WELL USE (Check Applicable Box)Residential Water Supply ❑
DATE DRILLED 3/22/2010
TIME COMPLETED 1:30 AM ❑ PM
4. WELL LOCATION:
CITY: Avon COUNTY Dare
41661 Ocean View Dr. 27915
(Street {raft, Numixas, Community, Subdivision, Lot No., Parcel, Zip Code}
TOPOGRAPHIC 1 LAND SETTING: (check appropriate box)
❑Slope ❑Valley wfFlat ❑Ridge ❑Other
LAT$TUDE 35 ° 2 202•000n " DUS OR 3x.xxxxxxxxx DO
LONGITUDE 75 ° 30 283•om " DMS OR 7x.xxx*0fxxx DD
LebtudeAongitude source: L. PS ❑Topographic map
(location of well mast be shown an a USGS lopo map andattached to
this farm if not using GPS)
5. WELL OWNER
Joan C. Strausbeuoh
Owner Name
x
Street Address
Clifton Forge VA 24422
City or Town State Zip Code
55 4> 0 8fi2-7269
Area code Phone number
s. WELL DETAILS:
a, TOTAL DEPTH:-2 10'
b. DOES WELL REPLACE EXISTING WELL? YES 0 Na Pf
e. WATER LEVEL Below Top of casing: NIA FT -
(Use '+" d Above Top of Casing)
d. TAP OF CASINO IS NIA FT. Above Land Surface"
'Top of casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .01IS.
e. YIELD (gpm): NIA METHOD OF TEST NIA
f. DISINFECTION: Type NIA Amount -NIA
g. WATER ZONES (depth):
Top NIA
9abom
Top
Bottom _
Top
Bottom
Top
Bottom
Tap
Bottom
Top
Bottom
Thlckrness!
7. CASING;
depth
Diameter
Weight Material
Top NIA
Bottom
Ft.
Top
Bottom
Ft
Top
Bottom
Ft-
= 8. GROUT.-
Depth
Materiat
Method
Top 0
Bottom 210
Ft. Bentonite
PumL]ed
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN:
Depth
Diameter
Slot
Stae Material
Top NIA
Bottom
Ft.
in.
in.
Top
Bottom
Ft
in.
in.
Top
Bottom
Ft,
in-
in.
1D. SANDIGRAVEL PACK:
Depth
Size
Mate"
Tap NIA
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft
11. DRILLING LOG
Top Bottom
NIA 1
1
1
1
1
1
1
I
I
1
I
I
Formation Descrtption
No Sarnr)les Taken
12. REMARKS:
This -is a Geotherrratt-closed la p well. No precise eMncis I -
samples were taken.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WTTH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS SEEN
PROViD TQ THE ELL tJ ER.
_ 4121Zt71p
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Randall E- Cutler
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 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- 2109

RE IDENTIAL WELL CONSTRUCTION RECORD
Womb Carolina Department of Environment and Natural Reso► mes- Division of Water Quality
WELL CONTRACTOR CERTMCATION # 2819 A
11. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (individual) Name
IInoyative Environmental ❑hilina
Well Contractor Company Name
61Q5 _Rent Home Rd.
Street Address
Claremont NC 28610
City or Town State Zip Code
6C 28 22871695 Area coda Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W 10700167
OTHER ASSOCIATED PERMIT#(it appllrable)
SITE WELL ID Wit applirame) GL-2
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 3A22 010
TIME COMPLETED 4:00 AM II PM
4. WELL LOCATION:
cITY: Avon COUNTY Dare
416§1 Ocean View ❑r. 27915
(StrMName, Numoers, CornmunRy, Subdivision, Lvt No., Parcel, Zip Cede)
TOPOGRAPHIC f LAND SETTING: {check appropriate tm)o
❑Slope ❑Valley jtFlat ORidge L7Other
LATITUDE 35 , 20 2o2.aaoo DMS OR 3x. xxxxxxxx Do
LONGITUDE 75 ° 30 285A M " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: PS Qropographic map
(Aocafion of well must be shown on a USGS ibpo map andatlached to
this farm if not using GPS)
5. WELL OWNER
JoanC. Strausfaauah
Owner Name
PO Box 609
Street Address
_lAm Forae VA 2A422
City or• Town State Zip Code
c 40 i 862a209
Area code Phone number
8. WELL DETAILS:
a. TOTAL DEPTH:210'
b. DOES WELL REPLACE EXISTING WELL? YES p NO P(
c. WATER LEVEL Below Top of Casing: NA Fr.
(Use '+" if Above Top of Casing)
d. TOP OF CASING is NIA FT. Above Land Surface -
"Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118,
e. YIELD (gpm): N/A mmw OF TEST NIA
1. DISINFECTION: Type. NA Amount NIA
g. WATER ZONES (depth):
Top -N/A
Bottom
lop
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Top
_ Bottom
Tt dcknessl
7. CASING;
Depth
Diameter
Weight Material
Top_NIA
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft
8. GROU7
Depth
Material
Method
Top C
Bottom 210
Ft. Bentonite
Pumped
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN:
Depth
Diameter
Slot
Size Mahertal
Top NIA
Bottom
Ft.
in.
in.
Top
Bottflm
Ft -
in.
in.
Top
Bottom
Ft.
in_
in.
= 10. SANDIGRAVEL PACK:
=
Depth
Sims
Material
Tap NIA
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11, DRILLING LOG
Top Bottom Formation Description
N/A I No Samples Taken _
1
1
f
1
1
1
1
1
1
1
1
1
12. REMARKS:
T' id Low well. No predsec0tings I_
samples were taken.
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDEQ7TOTHE W -L R. l
j 41712010
SI NATURE OF CERTIFIED WELL CONTRACTOR DATE
Randal! E. Cutter
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: ©lvWon of Water Quality - Information Processing, Form GW-1 a
1617 Mal) Service Center, Raleigh. NC 27899A61, Phone : [phone] Rev. 2109

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and NuUwal Rmurces- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818 A
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (irrdMdual) Name
Innovative Environmental Drilling
Well Contractor Company Name
6105 Rest HoMe Rd.
Street Address
r mont NC 28810
City or Town, State Zip Code
( 828 228-1695
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10700167
OTHER ASSOCIATED PERMiT#('rf applicable)
SITE WELL 1D #tr applicable) QL-3
3. WELL USE (Check Applicable Box): Residential Water Supply i]
DATE DRILLED 312312010'
TIME COMPLETED 11 :3O Alin ►( PM 0
4. WELL LOCATION:
CITY Avon COUNTY Dare
41661 Ocean View Dr. 27915
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zio Code.)
TOPOGRAPHIC/ LAND SE7ING: (check appropriate box)
17 Slope ❑ Valley ItFlat ❑ Ridge p Other
LATITUDE 35 20 2Q3.0000 DMS OR 3x.XXXXXXXXX DID
LONGITUDE 75 ^ 30 289.0000 r DMS OR 7x_xxxxxxxxx DD
LatitudeAongitude source: PS OTopographic map
(location of well must be shown on a USGS topo wrap andettached to
this form if not using GPS)
5. WELL OWNER
Joan C. 5trausbauah
Owner Nave
PO Box 609
Street Address
Qrftn Forpe VA 24422
City or Town State Zip Code
(540 862-7269
Area code Phone number
S. WELL DETAILS:
a. TOTAL. DEPTH: 210'
b. DOES WELL REPLACE EXISTING WELL? YES I] NO If
c. WATER LEVEL Below Top of Casing: NIA FT.
{Use "+^ it Above Top of Casing}
d. TOP OF CASING is NIA FT. Above Land Surface*
'Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
a. YIELD (gpm): NIA _ METHOD OF TEST N/A
f. DISINFECTION- Type NIA Amount NIA
g. WATER ZONES (depth):
Top NIA Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickrressl
7. CASING: Depth
Diameter Weight Material
Top NIA Bottom
Ft.
Tap Bottom
Ft_
Top Bottom
Ft.
S. GROUT: Depth
Material Method
Top 0 Bottom 210
Ft. Bentonite Pumped
Top Bottom
Ft.
= Top Bottom
Ft.
S. SCREEN: Depth
Diameter Slot Size Material
Too NIA Bottom
Ft in, in.
Tap Bottom
Ft. in. In.
Top Bottom
FL in. in.
10. SANDIGRAVEL PACK:
Depth
size Material
Top NIA Bottom
Ft
Top Bottom
Ft.
Top Bottom
Ft.
: 1t. DRILLING LOG
Tap Bottom
Formation Description
NIA I
No Samples Taken
= r
I
I
1
. r
1
1
12. REMARKS:
• This is a Geothermal closed loop well. No precise cuttings i
Samples were 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
_ PROVIZ]>; 7rp T#i : W E L
OW R.
�-020
10
St rVATURE F CERTIFIED
WELL- CONTRACTOR DATE
Randall E. Cutter
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information PrMessing, Form GWAa
1617 Mail Service Center, Raleigh, INC 27699-161, Phone : (919) S07-6300 Rev.2109

5TA7 v
ll E,S�DE�VTIAL WELL C�I�STRUCTION RECORD
Nor[h Carolina Department of Environment and Naturai Resources- Division of Water Quahty
WELL CONTRACTOR CERTIFICATION # 2818 A
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual) Name
Innovative Environmental Dri fi a
Well Contractor Company Name
6105 Rest Home Rd. _ —
Street Address
Claremont _ NC 28610
City or Town State Zip Code
8( 28 228-1695
Area code Phone number
2, WELL INFORMATION'
WELL CONSTRUCTION PERMIT# Wl0700167
OTHER ASSOCIATED PERMIT#(it applicable)
SITE WELL ID #frfapplicable) GLA
3. WELL USE (Check Applicable Box): Residentiat Water Supply ❑
DATE DRILLED 3/23/2010
TIME COMPLETED-! '- AAA ❑ AM
4. WELL LOCATION:
ciTY: Avon couNTY Dare
41661 Ocean View Dr. 27915
(Street Name, Numbers, Community, Subdivision, lot No., Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING: (check appropriate box)
ElSlope ❑ Valley (itFlat E) Ridge ❑ Other _
LATITUDE 35 ° 20 203-DOW " DMS OR 3Jt.XXXXXYJWX DID
LONGITUDE 75 , 30 292.0000 " DMS OR 7X.XX)0LXXXXX DID
Latitudetiongitude source: W�PS ❑Topographic map
flocation of wetl must be shown on a USGS fops map andattached to
this form if not using GPS)
5. WELL OWNER
Joan C. Strausbaucih
Owner Name
Pa Box 602
Street Address
Clifton Forge _ _ VA 24422
City or Town State Zip Code
t 540 862-7269
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 210'
b. DOES WELL REPLACE EXISTING WELL? YES C] NO lr
c. WATER LEVEL Below Top of Casing: M — --FT.
(Use "+• iF Above Top of Casing)
d. TOP OF CASING IS N/A FT. Above Land Surface -
"Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
g. WATER ZONES (depth)
Top NIA Bottom
Top Bottom
Top Bottom
Top Bottom
Top, Bottom
Top Bottom
Thickness!
7. CASING:
depth
Diameter Weight Material
Top NIA
Bottom
Ft-
Top
Bottom
Ft.
Top
Bottom
Ft.
8. GROUT:
Depth
Material Method
Top 0
Bottorn 210
Ft. Bentonite Pumoed
Top
Bottom
Ft -
Top
Bottom
Ft
9. SCREEN:
Depth
Diameter Slot Site Material
= top NIA
Bottom
Ft. in- in.
= Top
Bottom
Ft. in. in.
Top
Bottom
Ft. in. in.
10. SANDIGRAVEL PACK:
Depth
Size Material
Top NIA
Bottom
Ft,
Top
Bottom
Ft_
Top
Bottom
Ft.
11. DRILLING LOG
Top
Rottom
Formation Description
WA I
No Samples Takers
i
1
1
1
1
r
1
1
12. REMARKS:
This is a Geothermal dn-IiPd looms well. Na aret� Osttin-qS C
samples were taken.
100 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
PROV119�D TO THEYVELL OWNER.
JJ"��'
GNATUR'E OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD (gpm) NIA METHOD OF TEST NIA : Randall E. Cutter
f, DISINFECTION: Type NIA Amount NIA PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 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. 2109

V RESIDENTIAL WELL CONSTRUCTION RECORD
�5 North Carolina. Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818 A
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual) Name
Irinovative Environmental Drillina _
Well Contractor Company Name
-
6_1 05 Rest Home Rd.
Street Address
Claremont NC 28616
City or Town State Zip Code
sr 28 228-1695
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# UW10700167
OTHER ASSOCIATED PERMIT#(tt applicable)
SITE WELL ID #(if applicable) GL-5
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 3/23/201 0
TIME COMPtF=D 4:00 AM ❑ PM
4. WELL LOGAMN:
CITY: Avon couNTY Dare
41661 Ocean View Dr. 27915
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING; (check appmpriate box)
DSiope [3vailey fieFiat D Ridge C30ther
LATITUDE 35 20 206-MM DMS OR 3x.xxxxxxxxx bD
LONGITUDE 75 = 30 297.0000 » DMS OR 7x.xxxxxxxxx DID
Lafifudellongitude source: R�.Ps Qropographic map
(lacatmn of well must be shown on a USGS fopo map andattached to
this form if not rasing GPS)
5. WELL OWNER
Joan_C. Straushauah
Owner Name
PO 13ox609 ..
Street Address
ii vn Fore VA 2"22
City or Tom State Zip Code
5c 40 862-7269
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 21 0'
g. WATER ZONES (depth):
Top NIA Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thicknessf
7. CASING:
Depth
Diameter Weight Material
Top NIA
Bottom
Ft.
Top
Bottom
Ft.
= Top
Bottom
Ft
S. GROUT:
Depth
Material Method
Top
Bottom 210
Ft, Bentynite Pumped
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN:
Depth
Diameter Slat Site Material
Top NIA
Bottom
Ft. in. in.
Top
Bottom
Ft. lit in.
Top
Bottom
FL in. in. _
ID. SANDIGRAVEL PACK -
Depth
size Material
Top NIA
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft,
11. DRILLING LOG
Top Bottom
NIA 1
I
I
1
1
r
1
1
1
Formation Description
No Samples Taken
12. REMARKS:
This is a Geothermal_ closed iaap well. No precise ctrttiMA 1
samples were taken.
b. DOES WELL REPLACE EXISTING WELL? YES L7 NO ! - I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: NIA FT. - ACCORDANCE WMH 15A NCAC 2C, WELL CONSTRUCTION
(Use "+' if Above Top of Casing) STANDARDS, ANO THAT A COPY OF THIS RECORD HAS BEEN
PROVIDEP'fO THE WELL OWNER.
d_ TOP OF CASING IS NIA FT, Above Land Surfaoe'
`Top of Lasing terminated attar below land surface may require�� 41212010
a variance in accordance with 15A NCAC 2C .0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YlELO (gpm): NIA METHOD OF TEST NIA Randall E. Cutter
f. DISINFECTION: Type N/A _ Amount NIA PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form CW-la
1617 Mai! Service Center, Raleigh, NC 27699-161, Phone : [phone] Rev. 2M9

Joan C_ Strauahaugh
41661 Ocean View Dr.
Avon, NC 27915
Driveway
Ocean View Dr.
701
f---- I- GL-1
GL-5
15.0'
~10.0"'--f