WI0700173_GEO THERMAL_20100406

A~A. J!!J.il~~
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
James M. Cromwell
Marjorie L. Cromwell
808 Costa Grange Drive
Virginia Beach, VA 23456
Coleen H. Sullins
Director
4/6i2010
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI07001 73
3804 Elijah Baum Road
Kitty Hawk. NC 27949
Dear Mr. & Mrs. Cromwell:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
3/30/2010, 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 3804 Elijah Baum Rd, Kitty Hawk,
Dare County, NC 27949. 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 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].
Sincerely,
0~ ~
1 DI"\_/ Michael Rogers
cc: Washin§!ton Regional Office -APS
AJ>S Central Files -Permit No. \v 107001 -:.
Dare County Health Dept.
I . Environmental Specialist
GPU-Aquifer Protection Section
Jeff Stagg O.A. Stagg Energy) 636 Benefit Rd. Chesapeake , VA 23322
Jimmy Weaver (North Beach Services, inc) PO Box 181, Kitty Hawk, NC 27949
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard. Raleigh. North Carolina 27604
Phone: [phone] \FAX 1: 919•7':5-0588; FAX 2: 919-715-6048 \Customer Service: 1-877-623-6748
Internet: www.ncwateraualitv.o
i,n Equal Oppor:Jnity \ Affirmative Act,on Ernployrc
NOnel C 1· ort1 aro ... ma
/Vaturally
Permit Number WI0700173
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
James and Marjorie Cromwell SFR
Location Address
3804 Elijah Baum Rd
Kitty Hawk
Owner
Owner Name
James
Dates/Events
NC 27949
Cromwell
Orig Issue
04/06/10
App Received Draft Initiated
03/30/10
Re g ulated Activities
Heat Pump Injection
Outfall t ;· 11 '.
Scheduled
Issuance
Central Files: APS_ SWP_
04/06/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Jeff Stagg
636 Benefit Rd
Chesapeake VA
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
James Cromwell
808 Costa Grande Dr
Virginia Beach VA
Public Notice Issue
04/06/10
Effective
04/06/10
23322
23456
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT .AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5QW WELL(S)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and mail to address on the hack page.
DATE: 3 / z.-z- , 20 C cb
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes t Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well iniecting 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 each Property Owner listed on property deed (if ��
own�L t owned by a business or government agency, state name of
entity and a representative wlauthority for signature): _—'xa- '0!6 WAA rD M W4 � � -
moa. o [ ► _ - - L . _ _Cre- It-i e-k i
(1.) Mailing Address: _ %N ] � ( C% E-s C and e
City: J % r t r►%a f-a!9.6_ State: V+ zip Code: County:'�Y %me$% &M
Home/Office Tele No.: IS1 - -7 at Qn q Cell No.: ❑19 - C-A.SZ-'LS
Email Address: Website:
rnarg���r�mu.��lt� cox n4L4 --ll
'' Physical Address of Well Site (if different than above):3 � E t t Q, t] a-k
City: uJ Stater Zip Code: Z79�'{ 9 _ _Caunty:q, "f
Home/Office eie No.: Cell No.:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a fetter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL. Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company, if any: RECEIVED I DENR I DWOAQUIFFR R[]MMON SECTION
OPUARC 5QW Natifiration of Intent Form (Revised MOOS) MAR 3 0 2010 Page I

C. WELL DRILLER INFORMATION
Company Name:_ 37- 5 i 4 6,9 CN 1 a6`f E-W Y-C q( � oy
Well Diller Contractor's Name: _ �Ao wA{-p C, C-u ; T-Z 2,
NC Contractor Certification No.: A -
E,
Contact Person: --� V ' 'y &6r - - --- EMAIL Address: j
Address: Ce.3, (0 t 7 —
City_ CAE5.AR Zip Code: County: -
Office Tele Na.: _- — -- Cell No.: 7.3.
HEAT PUMP CONTRACTOR INFORMATION (if different than driller),
Company Name: lck J
Contact Person: 1 N'rM LAJ EMAIL Address. l'k► - ,
Address: 00 (91 - ---
City: i, i { t, P4-XA) F, Zip Code
Office Tele No.:
STATUS OF APPLICANT
Private Federal:
State:
Municipal:
IJCl County: D494- -
Ceti No.: c)Q 4061 173D
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
o 7- VJ C- L- - --
G. WELL CONSTRUCTION DATA U,,-q (;5r OF;
(]) Proposed date to be constructed: Number of borings:
Approximate depth of each boring (feet): 2 d
(2) Type oftubing to be used (copper, PVC, etc): f Pie
(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
>�--
(4) Grout info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite A Other (specify)
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from --Q— to ZOO- (feet)
if well has casing, indicate grout depth. from to— (feet)
GpU/[TTC 5QW Notification ❑f latrut Form (Revised 8/2008) n"._ I

H. INJECTION -RELATED EQUIPMENT
Attach a diagram snowing 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.
1. LOCATION OF WELLS) -
Attach two copies of maps showing the following information: I7
(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 b sing at least two fixed
reference points such as roads, streams, and/or highway intersections. so basing
y1tG aAIV "I rW 11 1 l
Note: This permit Application must be signed by each person appearing on the
recorded legal property steed,
1 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
Use information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in actor nee with the approved specifications and conditions of the Permit"
-Al r, - L 4 a4v.� a 4 �
Sig lure } roperty Owner/Applicant
, I- MCLt L. C_ramwk t I
Print or Type Full Name and title
I -
S 114 cu�_Q4Wo
ignature of _ operty ow7Ner!Applicant
mct \ art -z- l.. C_(C}rnW-? l 1 , cls . � QY
Print or T§e 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 RECEIVED ► DENR J DWO
Aquifer Protection Section-UIC Program A0]111rrP PRt)Tl-r.THtN SECWN
1636 Mail Service Center MAR
Raleigh, NC 27699-1636
Telephone [phone]
GPUMC 5QW Notification of Intent Form (Revised 812008) Page 3

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3804 eiijah baum rd, kitty hawk, no 27949 - Google Maps
Page 1 of 1
GougleI� $ S Address 3804 E]Qan Baum Rd
Kitty Hawk, NC 27949 Get Google Maps on your phone
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http:llmaps.google.comlmaps?fi=--q&source=s_q&hl=en&geocode=&q=3804+etijah+baum... 3/26/2010

3844 elijah baum rd. kitty hawk, nc 27949 - Google Maps
Page 1 of 1
Address 3804 Elijah Baum Rd
O I) C maps Kitty Hawk, NC 27949
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTII41CATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5 W WELL(S)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Prim or type the required information and mail to address on the back page.
DATE:
WeU 7vpe Confirmation: Does the proposed system circulate potable water orilv (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loon)?
Yes 7x- Continue completing this forth.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well Co en -loop well inie� cting 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(5)IAPPLICANT(S)
Fist each. Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): � MR" -,[. Oro Im LIA t(
(1) Mailing Address: -c-P.LiCL Giromde
City: '*, I l C9 c n 'i a trf U r* State: & Zip Code: County: { � [►t a
Home/Office'TJele No.: `1 - -7 - 1 Cell No.: -7 - -asas
-
Email Address: Wehsite:
ti'�14 r� t� e>ro tY1 u1411 CQ ic n *{ - '`j
-- 2) Physical Address of Well Site (if different than above<-110� � � t lcx`v] �nwy ok
City: t, State:l�& zip Code: t.7q H 9 county:-pa.r .(_
Home/Office ele No.: 59;&m4- OL % Ckov_.4?, Cell No.:
E. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a Ietter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL. Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company, if any: ENR I DWO
ACUIFPR-Pun T P1-TnN SFCTICN
GPUlUiC 5QW Notification of tntmt norm (Revised 812008) MAR 3 0 2010 Pegs 1

C. WELL DRILLER INFORMATION
Company Name. TA, 'S i A a C--N 0-GC--W I-Ca-KA S �r� ! ►�i .
Well Driller Contractor's Name: IAA w A l =D 1� - ; -EE L
NC Contractor Certification No.:3:5-3 16-
Contact Person: K S 7r 0�, & EMAIL Address- � egr@ Corn
Address: 3 (,p l 'r-
City: 5�C� IVA Zip Code: County:
Office Tele No.: Cell No.: -7 S -7 43�<_R Y1 Z
HEAT PUMP CONTRACTOR IlNFORMATION (if than driller),
Company Name: I
Contact Person: li' m EMAIL Address.
Address: f,91
City: _ Zip Code: County:E _
Office Tele No.: �{� �16 Cell No.: t�Q c� 7 _
E. STATUS OF APPLICANT
Private Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA we C a�
(l) Proposed date to be constructed., yt�.Number of borings:
Approximate depth of each boring (feet): '7_C-> a
(2) Type of tubing to be used (copper, PVC, etc): Pc
(3) Well casing. b the well(&) eased? (check either (a.) yes yr (b.) No below)
(a) yes ifyes, then provide casing infbmation below
Type: galvanized steel black steel !_plastic other (specify)
Casing depth; From to feet (reference to Iand surface)
Casing extends to above ground inches
(b) No >�_
(d) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite XOther (specify)
(b) Grout placement: Pumpin Pressure Other
(a) Grout depth of tubing (reference to land surface): from __Q__ to Z�G_a (feet)
If well has casing, indicate grout depth: from to (feet)
C1PUAnC 3QW tvvtittCati09 of inIdat Fnrm CR&ArM R17flflQ%

H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the ellgineering layout or proposed modification of the injection equipment and exterior
fipin~bing associated with the injection operation. The manufacturer"s brochure may provide supplementary
infonnat1on.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information: ,........--h ~ ~
(1) Include a Site Map ( can be drawn) showing: buildings, property ~ water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed weJI(s) and
any existing well(s) or wast.e disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothennal 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 bXJ!Sing at least two fJXed
reference points such as roads, streams, and/or highway i~~!Secti~~: __ :-=--S~'zy_€ ¥
.. --------~---.. =--,,.~ • ..., .. __
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 infonnation, 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 infoJmation. I agree to construct, operate, maintain. repair, and if applicable, abandon the injection well and
all related appurtenances in acco~e with the approved specifications and conditions of the Permit"
~ ~°"'~ ~~.u ~ srtute Pi'opertyer/Appl1cant
j · fV\.QJ ls.. C .. xornv,j,Q_ ( f i Qt .,)00 r
Print or Type Full Name and title '
, Hu'¼.~,~ ~tu ..
Signature _of opertyO er/Applicant .
P\o.<~~\-g_ L . (_rOM.W't l) 1 ai, n <Lv
Print or T e 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 Seetion-UJC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC SQW Notification of lntcnt Fonn (Revised 8/2008)
RECEIVED/ DENR / DWQ
AQUIFl=R'PROTFr.r1nN SECTION
MAR 3 0 2010
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3804 elijah baum rd. kiriy hawk, nc 27949 - Google Maps
Page 1 of 1
GO� Js c maps Address 3804 Elijah Baum Rd
Get Google Maps on your phone
Kitty Hawk, NC 27949
,�"� Textthewad GtiRAPS"m46G453
http:llmaps.google.comlmaps?f=q&sou.rce=s_q&hl=en&geocode=&q=3844+elijah+baum... 3/26/201 d

3804 elijah baum rd. kitty hawk, nc 27949 - Google Maps
Page 1 of 1
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