WI0700203_GEO THERMAL_20110131

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# NCWC-3538-A
1. WELL CONTRACTOR:
HOWARD E, CUTTER
Well Contractor (Individual) Name
PINKSTON GEOTHERMAL
Well Contractor Company Name
PO BQX 15482
Street Address
CHES APEAKE VA 23328
City or Town State Zip Code
c 757 l 418-2036
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# __________ _
OTHER ASSOCIATED PERMIT#(if applicable) WIQ 700203
SITE WELL ID #(if applicable) _________ _
3. WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 1/26--1/28/11
TIME COMPLETED 5:0 0 AMO PM rJ'
4. WELL LOCATION:
CITY: DUCK COUNTY DARE -='-=-a=----
148-B WHISTLING SWAN DRIVE
· (Street Name, Numbers, Community, Subdivision, Loi No., Pa~!. Zip Code)
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
litSlope □Valley □Flat □Ridge □Other ______ _
LATITUDE ~0 11 • 26.8000 "OMS OR 3x.xxxxxxxxx DD
LONGITUDE ~-·45 ' 26.0000 "OMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: lilf3ps [Jropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
CHARLES & YVONNE BURDICK
Owner Name
148-B WHISTLING SWAN DRIVE
Street Address
D UCK NC 27 949
City or Town State Zip Code
( ).....,.. _______ _
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: (6) (@. 200'
b. DOES WELL REPLACE EXISTING WELL? YES □ NO~
c. WATER LEVEL Below Top of Casing: N/ A FT.
(Use •+• if Above Top of Casing)
d. TOP OF CASING 1$ N/A FT. Above Land Surface*
*Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST_,_N=-/A......__ __ _
f. DISINFECTION: Type NIA Amount_,_N=/..._A,.__ __
g. WATER ZONES (depth):
Top N/A Bottom_N_/A __ Top ___ Bottom~--
Top ___ Bottom'----Top Bottom, __ _
Top Bottom ____ '--Top Bottom __ _
Thickness/
7. CASING: Depth Diameter Weight Material
Top N/A . Bottom N/A Ft.. __ _
Top __ Bottom __ Ft.. __ _
Top __ Bottom __ Ft.. __ _
8. GROUT: Depth Material Method
TREMi Top_O __ Bottom 200 Ft. BENTONITE
Top __ Bottom __ Ft. ____ _
Top __ Bottom __ Ft. ____ _
9. SCREEN: Depth Diameter Slot Size Material
Top N/A Bottom N/A Ft......___.._in. __ in. ___ _
Top __ Bottom __ Ft. __ in. __ in. ___ _
Top __ Bottom __ Ft. __ ln. __ in. ___ _
10. SAND/GRAVEL PACK:
Depth Size Material
Top N/A Bottom N/A Ft. __________ _
Top, ___ Bottom __ Ft.. __________ _
Top Bottom __ Ft. __________ _
11. DRILLING LOG
Top Bottom
-----'----/ ------------'---------'-------''-------'---------'-------''--------'----__ ....;/ ___ _ __ ....;/ ___ _ __ ....;/ ___ _
---'----
Fonnation Description
NO SAMPLES TAKEN!
THIS IS NOT A WATER WELL.
THIS IS A saw CLOSED LOOP
GEOTHERMAL WELL.
(6) 200' 3/4" LOOPS
FULLY GROUTED WITH
BENTONITE FROM BOTTOM
TO TOP BY PUMPING
THROUGH A TREMi LINE.
_,__ -·t:D
12. REMARKS: ot::CE.\\J~
THIS IS NOT A WATE R WE L@S'"'A SET IF Slfu~lf
saw CLOSED LOOP. . ''I\ i '
1 DO HEREBY CERTIFY THAT THIS WELL W~AS 9~mHeo IN
ACCORDANCE WITH 15A NCAC 2C ... ~~~ ~ij~ION
STANDARDS, AND THAT A COPY ctF''tHIS Ri b'RD HAS BEEN
PROVIDED TO THE WELL OWNER.
~~~IF~W~OR ?4¥«
~4wllrd 1£ Cvr&r
NTED NAME OF PERSON CQNSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Qualitv -lnfonnation Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone]
Fonn GW-1a
Rev. 2/09
Permit Number WI0700203
Program Category
Ground Water
Permit Type
I Central Files: APS_ SWP_
01/19/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classlfication
Individual
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Charles V. Burdick Jr. SFR
Location Address
148-B Whistling Swan Dr
Duck NC
Owner
Owner Name
Charles V
Dates/Events
27949
Burdick
Orig Issue
01/19/11
App Received Draft Initiated
01/11/11
Reg ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Waterbody Name
Scheduled
Issuance
Permit Contact Affillation
Yvonne P. Burdick
PO Box 8194
Kitty Hawk NC
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Charles V. Burdick Jr.
Owner
PO Box 8194
Kitty Hawk NC
Public Notice Issue
01/19/11
Effective
01/19/11
27949
27949
Expiration
Stream Index Number Current Class Subbasin
AVA
CDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Charles Burdick Jr.
Yvonne Burdick
P.O. Box 8194
Kitty Hawk, NC 27949
Coleen H. Sullins
Director
01/19/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
PermitNo . WI0700203
148-B Whistling Swan Dr.
Duck, NC 27949
Dear Mr. and Mrs. Burdick:
Dee Freeman
Secretary
On 01/11/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
geothermal injection well system for the operation of a ground-source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Dare County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Ro gers (a .ncdenr.2ov if you have any questions.
~· doduD
for Debft-tts
Supervisor
cc: Washington Regional Office ~ APS _
A.PS Cemral Fi le~ -Pe ~-i ."\_ ,~,·n ~2-3
Dare County Health Dept.
Jeff Stagg (J.A. Stagg Energy Enterprises, Inc., P.O. Box 15482, Chesapeake, VA 23328-5482)
Scott Buchanan (Buchanan Mechanical Construction, 2200 Maritime Woods Dr., Manteo, NC 27954)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699 -1636
Location: 2728 Capita l Boulevard , Rale igh , North Carolina 27604
Phone : [phone] I FAX 1: 919-715-0588; FAX 2: 919 -715-6048 \ Customer Service: 1-877-623-674B
Internet: www.ncwaterquality .org
An Equal Opport unity \ Affir mativ e Action Em ploye r
Ni¥thCarolina
JVaturall!f
Jan 11. 11 03:1 Qp
P-1
Plnkstm F u=P & Welt,. Inc.
P 0 Box f 5452
Chcaaipeake, VA 23325-54$2
(75T) 421-21081(866) 749-1990
facsimile ftwasrrr tal.
'h+
TO! Michael Rodgers FB)c 9196-715.0598 +: _
NoO Carolina DENR-OM
From: Dabble Sanders Rabe: 01/11/11
(dowle®stagg ene rgy.Corrr)
te: 148 B WNsOing Swan Dr.. Duck, NC Pages: 5 (including rover street) �
TYPE SOW VVELLS(S) Application
CC: t #
13 U" t ❑ For Aview © Pl(We conrmesrc ❑ Please Reply ❑ MOM ftcydo 4
NOOm For the above referenced. following is this completed document Two (2) hard capies hFVe
a1
forwarded to your of ica, 02 US mail. .
r
Thank you, _
1
1
k
t �
• . . . . . . . . ■ . . . . 6 . . . . . . . ■ ■ . .

s
p-2 . ,' f•
7
Jan 11 110311 p P.2
,IGUa w + i + .v "d numwadri ..
P.2
r4Mnt CAROG A
DEPARTMEN 7 OF lrh'Vli ONA' W AND NATYJAAL 1,MURCC9
+ NOTHM A' 70N OF IN'['ENT TO CpNsMCT A CL&M95= GEOIHERXAJL
TYPE SOW RECL S-1
In Acc,0 nac WNrth the prowis:vns of NCAC Tick 7 SA C2r—=O
. F.iar ar � arac r�epo►ir4d +•+�orardio�r and �►7 � adi r� the barrE►�e.
DATE: Q
fell Type aron lmdlim. Dues the Proposed h,Yvcm cimulutc potable w 1x (cauddit%vCs is
:
cotiamc&4 piping tha,- complemly isofmcs the fluid from the CnviM lMCr4 (ire.
� t
Xcs X Craotinue Lem-Pk-d tg*S zbrrn,
o Da I�f at carrtpfea: this faros Compk4t oVwr U1C application forms for instting .
either a SA7 well ( -loop well .a- in potable w%Wi'► a the aquifer) or SQM well (Closed-.
kaop well containing addi cs gich as R-22. commgl, or other awdftom or oorrosion inhil tM).
A PROPERTY OW+ESt(SYAl!`!<'=CANT($}
LJ
LJ L;e Frh Pmprrty Owww Hxod on pmWrty deod (ife ned by a h12ff,;JiC!SS w s�nm 31peawy. 9=t rtame of
+
raft Pnd a rcgTrsmwcm VOSU& city for %gnatnre)
1'Q r_IZ•�+ `
i►+lailirr� I Q '� � ��C,,
(l j Ilddrt�: ,
LJ
CAy.- I �nr /fLr V r CA y;PL -% � f 7l�d[
CCmn
HowvJatreeec Tee din
Email Addrzi. Vtpp �►'slasitr.
��1rA,c:'�Ur -. ❑U Ghp�p.-,-, ��•rt� [�,� �fp�rtiCC.�9s%i, �'rl� ���1� •�1 D� -�c��lyd-�-�'7� ..
(2) Phy-ica+t A4dru ss of Wc)l Sits-, e�'diflfmrit than abave � a- �._ _ ��'
� y
1[
Coy -
S�iC Ccdsw �v/y�
Z � w
#
Hmn&O1trove TeakNa.: Qdl
,
S. ALJTMIU'MD AC.RNT OF O"M IF ANY (if the?-T rtit Apok= dd!� Trot own the su� property,
aiu,zb a ierrar from ft PMPGnY owner ZAbWWOS Agent to insists wd LITC arch)
Campanr Namc:
COMM PsrMn-
Add�3fi � �
li
Cky; �aie �ip�adt; ` COurrty:
4EIiec Tele No.: _ CdLn;r�� _ `�-
WoWOCAddmss O•CvMPMY, irany;
#
Wmrc5Qwrrw4vlawwrt osOLLv;*4m DBf'
RECEIVED I DENR i L40
Aquifer Protection 5gdlon
,BAN 11 Z011

Jan 111103:11p
C.
WELL DRILLER Vi FORHATION
Company Name. J A Stagy, Ene� Enrernrises. Inc. I ..
WAII Y?rilIerContractor's Name: Howard Cutter
NC Contractor Certification No.. 3539-A
Contact Person: Jeff Staff, _ EMAIL Address: i ff st gencn<y,coin
Address: P O Box 15482
City: Chesapeake Zip Codc: 23328-5492 County: Cir), of Chesapeake
Office Tele No.: 57A21-2I8 Cali No... 7-433-9392
HEAT PUMP CONTRACTOR 114FORMATIION (if different than driller)
Company Name -Buchanan Mechanical Construction
Cann Person: SCOtt Buchanan EMAIL Address: acau�i�7>suchananmechtaij!_cgyl
Address: 2200 Maritimo Woods Drive
City: Manteo Zip Code: 22 9S4 County:
Ott iw Tcle NU.: 252-473-1105 Cell No.: 252.441-1200
E. STATUS OF APPIJCAN1f
Private., X Federal: Commercial:
Sty: Municipal: Native American Lands:
F.
O.
IKJECTION PROCEDURE (bricfly describe haw the injection wells) will be used)
NOT A WATFR WELL _
GEOTHFR1.MAL CLOSED LOOP
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed:
Number of borings: 6
Approximate depth of each boring (feet): 200,
(2) 'Type of tubing to be n_:ed (copper, PVC, etc): HDPE
(3) Well casing. is the well(s) cased? (chock either (a.) Yes or (b.) No below)
(a) Yev if ycs, then providc easing information bciow
Type: ____galYanized swel black steel plastic ,.`other (specify)
Casing depth: From to feet (rofercnce to land surface)
Casing extends to above ground ____-__inches
MAP
(b) No X
(4) Grout Info (malarial surm=ding well casing and/or piping):
(a) Grout type: Neat Cement Beratoni:ta X der (specify)
(b) Grout plwment: Pumping X Pressurc:Other
(c) Grout depth of tubing (reference to land surface): from 0 to 200 (feet)
If well has casing. indicate grout depth: from to — feet)
GMUIC SQW Notificatim of lutcm Farm (Rcviscd sizoos) t'sge 2

Jan1,111 ,03:11p'
Jl.111 V..J I I I I, I UH r:,ucinamm
o-,~221 o o~;-5~
(2) ihc Sile Map' nut shew the subject prapcny in nJatiOD ,:ci tile Jurroundir,g -.a by LIRI&~ ~ •~ fiX$:1
'l'Q~,.,nc~ ~i~ smell• roods. r.reatN, and/or highway -wsi:crioru., · , .
;
J. CUTJl'lCAT(ON ',
N'o&I:: n. PcnDit Applk:atioa m11at '-•peel W m!!,t)C,,.. ..-~c oa 81c
rel:OYded lepl propnydted.. 1
RECEIVED I DENR I DWQ
Aquifer Protection Section
JAN 11 20ft
... ..
' .
Jan 1111a-.11P'
Jan uD 13 73:4os t�tjcnsmmn
M-v outm
7
1�1441-4,�'i
a{,w1a4'A Ft
r T:
P.6 k
p,
Page f of?
Lopmad
,. I
_. I .
W f L..a OP AQL. —A G �r'r
`f ao V tcd
W l�.rER. 01%1 try
i�,rc�cr►- I III �� 541► Saran f A�xk, NC• �� 4�
p 3� t tk
hctp:lldad+vges,darcrtc.comlserv�etic[�m.esri..�-itnaF-C.srimap'�Servi�c-�]nad8e�,�ientv�r... ���17Qt1

Jan 03 11 11:09a 8achanan
DQ-5 2210 06:530
252-441-4217 p.2
p.2
NORT11 CA ROLW A
DEPAR1WM, 'T OF ENVIRONMENT AND NATURAL RESCUFtCFS
N>a''i MCATION OF T TfENT TO CONSTRUCT A CLOSED-L" GEOTHERMAL
WATF,"NI V iMJXCno r( WELL SYSTEM
T"
K SOW WF,f�f.(S]
Ill ACCardmcc With the Provisiom of NCAC Tine 1SA 02CO20
1'r+nf or type the required irfarmauon and malt m addmts an lke hack pagr
t)ATE• A�_ 11 2011
Well Type Casrfermasron: DUC$11W proposed system circulate potable: watc[ostfv (no additives) in
continttoas piping that completely isolates tite fluid from the environment (i.e.
closed -looms)? -
Ycs 7C Continue compktgtg this form.
No Do Not complete this fnrni. Complete other U1C applicvtion forms for installing
either a 5A7 well (am -loop well i*Lentirs potable water into the aquifer) ora 5QM well (Clmed-
laop well containing additives such as R-22, cilia riol, or other auffreeze or corrosion inhibitors),
A. 0 PROPFRTY OWNNER(SYAFPUCAN T(S)
l.iya rash Pmpetzy 0wr= listed on property deed (it tweed 6y a hwinp; yr gFFv+Raz�eat agency, mute rtamc Of
entity and a represen
t
ative w/authorittyf for %ignatura)��111R'�c' S
(1) Mailing Addrewcti f 1 o . 3,ok � / ,� /
City_ i4 9t WA- + CTP Co _ ;- -7 5 `I Cann
HwurJO f-kc TekNo.0 cell 1O.:
Email Addra9: k1 _ websitr-
Bur4, A-,, Mt?.c. %Aft, -caiCe s� •,a; -+f�3-lets;
` I�87
' Physical seal Address of Well Site (;rdigemnt them above;):
Cit; - _ _ --- _ 1 `^t c k 5tsu : YC Zip Code: 37%44 Coumy: er4
Hami:VOf!-uc Tole No.- Cell No.:
K AUTH04UZ>Eb AGENT OF OVVNM IF ANY (if the Permit. Applicam does not own the subjcd property,
atit►eh a tester from it+ - praperty owntr authorizing AgCnt to install and O MBte U[C well)
Company Name:. -
Contact Person, EMAIL Addn=
Addrex;- _ _
City: _ 5mLL:: Zip Grade' County:
Office Tele No- Cel N
Website Addnm of Company, ifanr:
GPt]fi C 5QW Ziotif ititm tr liftal Fenn (Revi+Jwi 1V2608) P118C I
RECEIVED 1 DENR / DVVU
Aquifer Prolection Section

C. WELL DRILLER INFORMATION
Company Name: J A Stagg Enerc3 Enterprises. Inc.
WP11 Driller Contractor's Name: Howard Cutter
NC Contractor Certification No.:
Contact Person. Jeff Stages _ EMAIL Address: jefF(a1sta gene_ r N .com
Address: P O Box 15482
City: Chesapeake Zip Code: 23328-5482 County: Citr ❑fChesapeake
Office Tele No.: 757-421-218 Cell No.: 757-439-9392
D. HEAT PUMP CONTRACTOR INFORMATION (id different than driller)
Company Name: Buchanan Mechanical Construction
Contact Person: Scott Buchanan EMAIL. Address: scottrri!buchananmechanical_com
Address: 2200 Maritime Woods Drive
City: Manteo _ Zip Code: 27954 County:
Office Tele No.: 252-473-1105 Cell No.: 252-441-1200
E. STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: Native American. Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
NOT A WATER WELL
GEOTHERMAL CLOSED LOOP
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _ MAP Number of borings:
boring 5 _
Approximate depth of each bng (feet):
(2) Type of tubing to be used (copper, PVC, etc): i I.DPE
(3) WeIl 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 Bent0nite X Other (specify)
(b) Grout placement: Pumping__X__ Pressure Other
(e) Grout depth of tubing (reference to land surface): from 0 to 200 (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/UtC 5QW Notification of lnEcat Form (Revised 8/2008) Page 2

Jan 03 11 1110a Buchanan
01Oc2210 05:53p
252-441-4217 p.4
p.4
D. TN1MTION-RELATED EQUiP"FlVT
Atlaeh a diaWam showing, the engineering *01A or propascd mQdificaiios+ of the injattiott equipment and cxtcri0t
:. _.�z`,inL► associated with the inieclion orciadom The manufacturres tmochurc n7kiv arrrvi&, 5,uoo#u.00AWry
informatiom
I. LOCATION OF WELL(S)
Attar: two topics of Maps showing the Wowing irifi7miltkn:
(1) sniclude a Site Map (can be drawn) snowing: buildirt�;s, �roopeny fines, surface water bodies, gaterrtial
sources of groundwater tonu minotion and the orientation of and distances between, the oropoved ►ucl1(5) and
anT existing weil(s) or wade disposal facilit=cs such as septic tanks or drain fields IQcated withia 2D0 lee:, of
the gcotherrrml h=at pump well system. Label all features cicwIy and ioclude a ww* awnw-
(2) The 5 i1c Map must show the subject pruprrty in reFartion to the surMunding area by using a =east two fixed
mrerencc points Such as ttwds, srmms. artdlor hIgihway inscrswtion s.
J. CERTMCATiON
Note: This Pcmit Apapb"rioa must be sigseel by taelt pernm appearing en the
recorded legal propeM domL
"I hereby certify, under penalty of lmw, that l have personally examiners and arm tarnitiar witty thy: infontnation
submitted in this document and all attachmer93 lNucco and that, twod on my inquiry of those indWduaLr,
irnmodintcly r�ponsblc for obtaining said information, 1 bdicw that rite information is true. me-urate and cpmplctc.
l am aware !fiat there arc signiflctent penalties. including the possibility of fines and imprisonrneM Tor subrnitlino
false information. I agree to conswuc[, 4peratc. mai !min, repair, and ifapplicsble, ahandon She injection well and
all relawd apptetcnanccs in awprdance .with the apprrared specificatjons and conditions of the Permit."
'-Si --
�]pEttIFTG of 1'ropeaty flWrk'�pp#TCaltl
Print orTvpc Fall Name and title
ignatV Party+ 0v►M0AplDH=t
, int or Type Full Nr„c and tide
S l'anaiurc of AtathoTized Ageat, if any
Printer Type Full 'Name and title
Neasc return two copies of the i;QMP1eted Applicalkn package To:
North Carolina DENR-DWO
Aqui4r Protection S"tioa_UIC Pr4grnm
1636MWI Service C"ter
RalcigX NC 276"-3636
FeLrpbonc (9]9) 715-6935
RICEIVED 1 pEhR 1 C►W.
Aquifer Pmtr_cibn 5�ctto,,.
GFUMIC JAN r
1 Ifll1

yarn U5 1 I i 1:4ba ciucnanan
my output
ZpZ-44'I-42-1 I
I
page I of I
Dare County, NC
-- _rT _
_ - l
t rr
5
�t sem G�Liv GLC-�5cz
L-ca4) A(Le-A (& ) mo o q:r
�... Y G0-0 u r�-ra
http:, Idaregis.d arene. r-aulserviedcom. esri.esrimap.Esrirnap? 5ervicelvame---flaad&ClientVer-.. I i3I20 31

• Jan 03 11 11 :09a Buchanan 252-441-4217 p ,2
p.2 De<; 2210 0S:53p
NORTl·I CAROLINA
DEPARTMGNT OF ENVlllONMENT AND NA'RJRAL R.ESOURCF.S
NOTIFICATION OF INTENT TOCONSTJWCI ACLOiED-LOOP GEOTIIEBMAL
WA Tr.lM>NL Y INJECTION WELL SYSTEM
TYPE SO W WELL(S)
In Accordaru:e W"dh &he 'Pto'visioas GfNCAC Td.lc 15A 02C.D200
Pritu or 1J1fJf! lb#! reqaind it/fonnat/On and llfflil ,o oddn.ff m tJ,cbadpap.
DATE: ~ I I • :zo .1L
WeU TJIIW Corrft"""1it,n: Docs tlac pr~ s~ circulate polablc warcroory (no additives) in
c-ontmucHIS piping that ex>mpl=Jy isolates the fluid from the environim,nt (i.e.
closed-loopl7 ·
lla X Continue compledngthi& fonn.
No -~Do Net complete this fonn. Complete 0CheJ' UJC a,,pJication forms for installing
eilher a SA 7 we.ti umm-loop weU inieetin,g. DOlable war ;nto the aquifer) or a SQM well (c.losed-
loop well ~ontaining additives SIJCh as R-22,, odtanol,. or other aatifteen: or corrosion inhibitors).
A. @ PROPERTY OWNER(S}/ArPLICANl'(S)
List ciu:h PN>pt:ny Ovmcr liStcd on property deed (if o llCd by a b11$i~ OT govcmmenr: ai.rency. state name of
cntio/ {'d a ~n:sentSlivc w/alJlt,ority :or ~gnaturi:)~----; .... ,-"-1H..;:..Y....L..C'-l=J"-_V: __ , ____..•"'-· .;;..:Vi:..;;..V.=,/,..;;,;c.=~f..;....•___,,,J...,ir'---'-, -r---
LJ:$ /4 4 L P B« rtlic..~
D.
(I) MailingAddnss:00 P. 0. Bok B7 tt:J '/
Cily:@ /6:.+ly J.4 l"w' IL-J. B[a;p cJ :). ' 'i 'I o/ Couo @; Va ,-e_
Home/Off"icc TeJc No.0 Cell No.:~
(2)
F.rnaiJ AdclrQ;5: t) Website t)
U\-'\~,-: 6u~ ~-cv u-nt~/;Nl nJ -411-oor; ~rx~)-<n-J-
Phys1ca1 AddressofWeJl Sitc(ifdiffinnt1haaabove): ~-LJ/i.E W/,:SJ1,~,.,sw"lrt l>r, /IS?
Cit.·---. --Duck.. St.aw. NC ZipCode: 27949 County:_Darc=-"'----
Hmnc,'00-JCC Tele No.: __________ _.:Cd_=l-"-Nts=·=----------
AllTHOIUZID AGltNT OP OWNt,t. IF ANY (&fthc P\.'mlit Applieam does not own the subject property.
81laCG .i lca.er from ~ propmy owner authorizing Agent. to in51111 and opcraie UIC well)
Company Name: ----------------------
Coatacl Penon:.._· ____________ _jF.MA~!!,IL~A~ddi!!;!~ess.~----------
Add,u;! _______________________ _
City: _________ Swc: __ z1·p.,.-•-
'-UUI._ _____ County: ______ _
Office Tel¢ No.: ceu No .~
Website AddR:55ofCompany~ if any.. ____________ _
GPU/UJC SQW N~ o:Jaa: Fann (Rcviul K12f08.
RECEIVED/ DENR / DWQ Puec 1
Aquifer Protection Section
JAN 14 2011 i
C. WELL DRILLER INFORMATION
Company Name:: __ ___:!J~A:!...QStagg~!:',..BEn~e~ragyLE!::!n!!!:teEem!.U!!ris~e!!£!s:i....:, In!!:!!!,c.,.__ ____________ _
WP.11 nri.ller Contractor,s Name: --~H~o~w!!..!ard=~C~u~tte~r ___________ _
NC Contractor Certification No.: --~3~53~8!:.:-A~-------------
Contact Person: Jeff Stagg EMAIL Address: jefl@staggenergy .com
Address: P O Box 15482
City: Chesapeake Zip Code: 23328-5482 Cotm.ty: City of Chesapeake
Office Tele No.: 757-421-218 Cell No.: 757-438-9392
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:Bucbanan Mechanical Construction
Contact Person: Scott Buchanan EMAIL Address: [e-mail]
Address: 2200 Maritime Woods Drive
City: Manteo Zip Code: 27954 County: ___________ _
Office Tele No.: ---=2=5=2-4~73~-~l =10=5 ____ Cell No.: 252-441-1200
E. STATUS OF APPLICANT
F.
G.
Private: __x_
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
NOT A WATER WELL
GEOTHERMAL CLOSED LOOP
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: ASAP Number of borings: -~6 _____ _
Approximate depth of each boring (feet):_-=-20~0_, __ _
(2) Type of tubing to be used (copper, PVC, etc): ----"'HD=P=Eaa.......... ____________ _
(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) Grouttype: NeatCement__ Bentonite X Other(specify) ______ _
(b) Grout placement: Pumping X Pressure__ Other __
(c) Grout depth of tubing (reference to land surface): from O to 200 (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page2
jan Uto 11 11;4Ua � uuc[arm Y 447-4+eY r P. x
Nlap output pap 1 of Z
Dare Cou n , NC
®ripi5sOff
fs'
Y Clue
L-34NT-.. Ota wY
http:lidaMis.dart=.camiservlettwm.esri_esriva X,Tioup?Smviueitiame—�ood&ClientVer... I►3/2011