WI0700206_GEO THERMAL_20110304

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NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment arid Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3253A
1. WELL CONTRACTOR:
Jamie L. Canter
Well Contractor (Individual) Name
A pp lied Resource Mana g ement. P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Ham p stead
City or Town
( 910 l 270-2919
Area code Phone number
2. WELL INFORMATION:
NC 28443
State Zip Code
WELL CONSTRUCTION PERMIT# WI 0700206 ------------
0 THE R ASSOCIATED PERMIT#(if applicable) ________ _
SITE WELL ID #(if applicable)c-=L=o=--o=p_1_,__ _______ _
3. WELL USE (Check One Box) Monitoring □ Municipal/Public □
Industrial/Commercial □ Agricultural □ Recovery □ Injection □
Irrigation □ Other ri'(list use) Geothermal Looo
DATE DRILLED_..2~/7~/~1 ~1 ___ _
4. WELL LOCATION:
131 Main Street
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
c1TY: Bath couNTY Beaufort
TOPOGRAPHIC/ LAND SETTING: (check appropriate box)
□Slope □Valley i{Flat □Ridge □Other ______ _
LATITUDE ~•~•3o.oooo "DMSOR _____ DD
LONGITUDE 7!.__•~• 50.0000 " OMS OR DD
Latitude/longitude source: 0;PS Ofopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
David .Jnhnsta □
Contact Name
1709 Laakaut Paint
Mailing Address
Raleiab NC 27612
City or Town State Zip Code
( 919 l 847-8154
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:...,2.._5......,0'-' ____ _
b. DOES WELL REPLACE EXISTING WELL? YES □ NO r§
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use"+" if Above Top of C;i.sing)
------------
: d. TOP OF CASING IS NIA FT. Above Land Surface*
*Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
: e. YIELD (gpm): NIA METHOD OF TEST_,N_../...,_A_.__ __
: f. DISINFECTION: Type N/A Amount ~N~/A~--
; g. WATER ZONES (depth):
: Top ____ Bottom __ _ Top ____ Bottom ___ _
: Top ___ Bottom __ _ Top ____ Bottom ___ _
: Top Bottom ___ _ Top Bottom. ___ _
Thickness/
: 7. CASING: Depth Diameter Weight Material
: Top ___ Bottom ___ Fl. . . ---
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
: 8. GROUT: Depth Material
: Top_O __ Bottom.2.filL_ Ft. Thermex
Method
Tremmie
: Top ___ Bottom ___ Ft. ____ _
: Top ___ Bottom ___ Ft. ____ _
: 9. SCREEN: Depth Diameter Slot Size Material
; Top ___ Bottom ___ Ft. __ in. in. ____ _
: Top ___ Bottom ___ Ft. __ in. in. ____ _
: Top ___ Bottom ___ Ft. __ in. in. ____ _
: 10. SAND/GRAVEL PACK:
Depth
: Top Bottom ___
: Top Bottom ___
: Top Bottom ___
: 11. DRILLING LOG
Top Bottom
..... 0._' _ __,/-=55='---
55' I 125'
125' I 26 0' __ __,/ ___ _ ___ / ___ _ __ __,/ ___ _
---''----___ / ___ _ __ __,/ ___ _
---''----___ / ___ _
: 12. REMARKS:
Ft.
Ft.
Ft.
Size Material
Formation Description
Brown cla y
G ra y cla y/ sand
Limestone
• 1.1,,s,OG "'"9 Unii
: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
; 15A NCAC-22'. WELL CONSTR CTION STANDARDS, AND THAT A COPY OF THIS
R~ ~AS BEEN PROVI TOT WELL OWNER
I .......... 2/7/11
AT E GERTI ELL CONTRACTOR DATE
Jamie L Canter
: PRINTED NAME OF PERSON CONSTRUCTING THE 'NELL
Subrnitwit!Jin 30:days ,ofc::ompletion to: OivisiQil,ofWater Quality -lnfprm~tion Proce:ssing,
1617 l\ilaii ~erviee CentE1r, R~l¢igh,0 N<>21699~16t, PfionEi : (~.1~)807•630.o
Form GW-1b
Rev. 2/09
1 r O�V LLESIE1'Ir�L WELL CONSTRUCTION RECORD
r+ n
' North Camlitta Department of Environment and Natural Resaurccs- Div!sion of Water Quality
�
3 � � a ,
` t WELL CONTRACTOR CERTIFICATION # 3253A
1. WELL CONTRACTOR:
Jamie L. Canter
Well Contractor (Individual) Name
Applied Resource Management, P.C.
Well Contractor Company Name
257 Transfer Station Rd,
Street Address
Hampstead NC 28443
City or Town State Zip Code
9L0 270-2919
Area rode Phme number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#W 10700206
OTHER ASSOCIATED f ERMIT#(itapplicable)
SITE WELL ID #trf applicable) Loop 2
d. TOP OF CASING l8 _ NIA _ _ FT. Above Land Surface*
`Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
s. YIELD (gpm): NIA METHOD OF TEST NIA
f. DISINFECTION., Type_ N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Tap Bottom
Top Bottom Top Bottom
Top Bottom _ Top Bottom
Thlcknessl
7. CASING: Depth Diameter Weight material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring I( MunicipatiPublic ❑ ; B. GROUT; Depth Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery[] Injection ❑ : Top D Bottom 2 0— Ft. Thermex Tremmie
Irrigation[]Other dust use) Geothermal LoOD Top E3ottDm Ft
DATE DRILLED 2/8/1 1 Tap Gottom Ft.
4. WELL LOCATION;
131 Main Street
(Street Name, Numbers, CummunKy. Subdivision, Lot No., Parcel, Zip Code)
ciTY: Bath COUNTY Beaufort
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
❑Slope pVatley J$`Flal ❑Ridge ❑Other
LATITUDE. 35 0 28 ' 30.0000 ` DMS OR
r■
LONGITUDE 76 ° 49 ' 50-0000 " DMS OR DO
Latitudellongitude source: V3PS Oropographia map
{location► of well must be shown on a USGS topna map anclaftaaheatto
this farm if not using GPS)
5. FACILITY (blame of the businesswhere the well is located.)
Facility Name Facility ID# of applicable)
Street Address
City or Town State Zip Code
❑a►fid Johnston
Contact Name'
1709 Lonknut Paint
Mailing Address
City or Town Stale Zip Code
9[ 19 847-8154 Area code Phone number
S. WELL DETAILS:
a, TOTAL DEPTH: 250'
b. DOES WELL REPLACE EXISTING WELL? YES p NO;I
c. WATER LEVEL Below Top of Casing: N/A FT -
(Use "+•' if Above Tap of Casing)
9. SCREEN: Depth
Diameter
Top Bottom
Ft in.
Top Bottom
Ft in.
Top Bottom
FL in.
10, SAND/GRAVEL PACK:
Depth
Size
Top Bottom
Ft.
Top Bottom
Fl.
Top Bottom
Ft.
i1. DRILLING LOG
Top Bottom
a' 1 55'
-56L I 125'
125' 1250'
1
1
- 1
- 1
Slot Size Material
in,
in.
in.
Material
Formation Description
Brown -rday- -
Cray clay/ sand
Lltnestone
1
1
1 Aly
12. REMARKS: In
►1/r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A M1y: WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF TMS
OR AS BEEN PROM 6T t YVELL OW NER.
2/8111
• IGNATUR OF CER WELL CONTRA OR DATE
grain L_ GanteL
p PRLN'TED NAME OF PERSON CONSTRUCTING THE WELL
Subrriiit *thin 30 days of com letion:to: D.ir/ision of Water (wall{ information Processing, Form GW-1 b
Y P Y ' Rev. 2109
1617 !y[ait.S0rvipe Cet7ter,1 2il�lgh, NC 7698=761, Phone (879]'867-6300

�J
.! ►' ONRE,S'.f,DENYUL WRLL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3253A
1. WELL CONTRACTOR:
Jamie L. Canter
Well Contractor (Individual) Name
Applied Resource Management, P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Homestead NC 28443
City orTown State Zip Code
sue, 270-2919
Area code Phase number
2. WELL INFORMATION;
WELL CONSTRUCTION PERMIT# Wi 0700206
OTHER ASSOCIATED PERMIT#(dapplicable)
SITE WELL ID #prapplicabie) Loop 3
3, WELL 118E (Check One Box) Monitoring ❑ Municipal/Public ❑
Induslrial/Corrxnerdal ❑ Agricultural ❑ Recovery ❑ Injection ❑
Ir4gationp Other (list use) Geothermal Loop
DATE DRILLED 2/9/11
4. WELL LOCATION:
131 Main Street
(Street Name, Numbers, Communfty. Subdivision, Lot No., Parcel, Zip Code)
CITY: Bath COUNTY Beaufort
TOPOGRAPHIC f LAND SETTING: (check appropriate tax}
[]Slope []Valley irFlat []Ridge ❑ Other
LATITUDE 35 ^ 28 30.00D0 rDMSOR DO
LONGITUDE 76 48 50.00M k DMS OR DD
LatltudeAongitude source: 03PS E]ropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
S. FACILITY (Name of the business where the well is located.}
Facility Name Facility ID# (if app{lcable)
Street Address
City or Town State Zip Code
David Jnh115tan
Contact Name -
17091_onkottt Pnint _ V
Mailing Address
Raleigh NG 27612
City or Town State Zip Code
9{ 19 a 847-8154
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 250'
b. DUES WELL REPLACE EXISTING WELL? YES ❑ ND d
c. WATER LEVEL_ Below Top of Casing: NIA FT
(Use `+' if Above Top of Casing)
: d. TOP OF CASING IS N/A FT. Above Land Surface'
'Tap of easing terminated aller below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
= e. YIELD (gpm): N/A METHOD of TEST NIA
f. DISINFECTION. Type_ N/A Amount NIA
g. WATER ZONES (depot):
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thicknessf
- I- CASING: Depth
Diameter Weight Material
Top Bottom
Ft.
Top Bottom
Ft
Top Bottom
Ft-
S. GROUT: Depth
Material Method
Topes Bottom 250
Ft. Thermex _ Tremmie
Top Bottom
Ft.
Top Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top Bottom
Ft. in. In.
Top Bottom
Ft. In. in.
Top Bottom
Ft. in. in.
10. SANDIGRAVEL PACK:
Depth
Size Matarlal
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft-
11. DRILLING LOG
Top Bottom Formation Description
JQ / 55'
55' 1_125`
125' 1260'
1
1
1
1
1
1
12. REMARKS_
Brown clay
:C2Ta]' clay15Ond — —
Limsstmg
li
R. _ w
11. . i
r
r
DO HER%-T� IFY THAT THIS W1 LL WAS CONSTRUCTED IN ACCORDANCE WITH
15AJF E' G rC, LLFISTRl10' :+ S L}5, AND THAT A COPY OF THIS
4 ECORO EN OV[tt O' LOWHErL
NATURE OF ERTIFIE EL CL ONCFRAC-T0R DATE
PRiNTFr NAME OF PERSON CONSTRUCTING THE WELL
m GW-1b
Form Submit inrithirt 30.days of compietiorl to: Division of Miter Quality � Information Processing, FFor21Q9
1617 Mail Service Center, Raleigta; NC t7699-161, Phone.: 4913y 807-000

1 ■ ONRESIDENTUL WELL CONSTRUCTION RECORD � � � � ►�
i
1 North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3253.E
i, WELL CONTRACTOR:
Ja •e L. Came
Well Contractor (individual) Name
Armlied Resource Management, P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Ham stead NC 28443
City of Town State Zip Code
(910 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W1 4704206
OTHER ASSOCIATED PERMIT#(il applicable)_
SITE WELL Ira #(if applicable) Loon 4
3. WELL USE (Check One Box) Monitoring ❑ Munteipal/Public ❑
IndustriailCommercial ❑ Agricultural [7 Recovery 0 Injection ❑
krigationo Other deist use) Geothermal Loofa
DATE DRILLED 2114/11_ �T
4. WELL LOCATION:
131 Main Street
(Street Name, Numbers, Community, SubdNision. Lot No., Parcel, Zip Code)
CITY: Bath couNTYBeaufork
TOPOGRAPHIC 1 LAND SETTING: (check appropriata box)
❑Slope ❑Vahey Fiat EIRldge []Other
LATITUDE 35 a ze ' ao-M6 , DMS OR Do
LONGITUDE 76 ° 48 1 W.0000 ° DMS OR DD
Latitudeftongitude source: V3PS Effopographic map
{location of weR must be shown an a USGS topo map andattached to
this form If riot using CPS)
S. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# [if applicable)
Street Address
City or Town State Zip Code
Dayid JQbns on
Contact Name
1742 Lookout Point
Mailing Address
Ralpiah NC 27612
City or Town State Zip Code
9( 19 ) 847-8154
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 250'
b. DOES WELL REPLACE EXISTING WELL? YES O NOG/
d. TOP of CASING IS NIA FT. Above Land Surface*
`Tap of casing terminated allor below land surface may require
a Variance in accordance vMh 15A NCAC 2C .0118.
e. YIELD (gpm). NIA METHOD OF TEST NIA
f OISiNFECTMN: Type N/A Amount. NIA
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Tap_ Bottom
Thickness)
= 7. CASING:
Depth
Diameter
Weight Material
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
:9. GROUT.
Depth
Material
Method
Top 0
Bottom 250
Ft. Thermex
Tremmie
Top
Bottom
Ft.
Tap
Bottom
Ft.
9. SCREEN:
Depth
Diameter Slot Size Materiat
Top
Bottom
Ft. in.
in.
Top
Bottom
Ft in.
in.
= Top
Bottom
Ft im
tn.
110. SANwr.RAVEL PACK:
Depth
Size
Material
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft,
11. DRILLING LOG
Top Bottom
0' 155'
55'----1_ 125'
1251 1 6Q� '
1
1
Formation Description
Brown -clay _
Gray clay/ sand
Limestone
1
1
1 -•F
1 �•ti
1
12. REMARKS: r�rr°� pro
- flWr- .. testis • ,
nn
I DO RERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1 CAC WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
ECO �,IASBIEENNO
Q THE WELL OWNER.•SG AFIED WELL CONTRACTOR DATE
c. WATER LEVEL_ Below Top of Casing: NIA FT : _,lalrlie L. _Carper _
(Use "+^ if Above Top of Casing] : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submitwithin 30 da s of &mplejlon to: Division of Water 4LW 6 lafotrpation Processing, Form GW-lb
Y ]( 9r Rev- 2109
I$17.Mali, service:Conter, R411elgh, NO 27699.161, Phone : [phone]

Central Fiies' APS_ SW P_
01127//1
Permit Number W10700206
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
Active New Project
Permit Type
Version Permit Classification
Injection Water Only GSHP Well System (5QW)
1.00 Individual
Primary Reviewer
Permit Contact Affiliation
michael.rogers
❑aina Helias
Coastal 5W Rule
PO Box 882
Hampstead NC 28443
Permitted Flow
Facility Name
Major/Minor Region
David Johnston SFR
Minor Washington
Location Address
County
131 S Main St
Beaufort
Bath NC 27808
Facility Contact Affiliation
Owner
Owner Name
Owner Type
Individual
David Johnston
Owner Affiliation
David Johnston
1709 Lookout Point Ct
Raleigh NC 27612
Dates/Events _
_ _
Scheduled
Orig Issue App Received Draft Initiated
Issuance Public Notice Issue Effective Expiration
01 /27111 01 /25/11
01127M 1 01 /27111
Regulated Activities
Heat Pump Injection
Outfall i , J_'
Waterbody Name
Stream Index Number Current Class Subbasin

NCD�l
North Carolina Department of Environment and
Division of Waier Quality
Beverly Eaves Perdue Goieen H. Sullins
Governor Director
i 1271-201 1
David Johnston
1709 Lookout Print Court
kalei;rh. NC 27612
Natural Resources
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10700206
131 5 Main Street. Batb. NC 27808
Dear Mr. Johnston:
Dee i^laeman
Secretary
On 1'25:201,1, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-ani'.
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:
The injection well system contains only potable water,
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 '
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 Bcaufon 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.Roeers0incdenr eov if you have any questions.
tSincerely,
far [zebra Watts
s u perviso."
cc: W as]zingrtoit Regional Office - APS
APS Central Files - Permit No. W10700206
Beaufort County Health Dept.
Applicd Rc-sourrg Mamrgonem_ PC (Diana Hellas)
%irteeh MFclmrrical Services Wan ick h4cKee l
AQUIFc7 FIR QTEGTIDIN' SECTION
1636 Nail Service. Canter, Raieigh. North rAmIlna 27699-16M
Location; 2728 Capital Boulevard. Raleigh, Nodh Carolina 27604
Phone! 919-73'1-3221 I =nX 1: 919-715-0688. FAX 21 S19.71�-&346 1 Ctssomer SeMM 1-877-M-6745
Itrtenn t: WWYj.ncwaterjUa1y.art
An EUtW Ojpen.:nP% . n4rr a: Kr_" 7_ _r Vmn
One
N orthCarollIula
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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 .D'.illl. information).
DATE: January 5. 2011 'S{:L O'l O0a-Gl/J
Well Type Confirmation: Does the proposed system circulate potable water onlv (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 5A7 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): ___ D_av_i_d_J_ohn_s_to_n
(1) Mailing Address: ___ 1-'-70~9_L~oo~k~o~u~t _P-'-01~·n~t -=-C~o=urt~--------------
City: _R_a_l_ei-gh ___ State: NC Zip Code: 27612 County: Wake
Home/Office Tele No.: _ __.a.9-=-1"""9--=8'""4-'-7--=8=1=-54-'------------'C""'e=ll'---=N--'-'o=.-'-: ___ 4"""'1""'"0--"-9--"1""'"6"""'-0"""3-=-3=-8 _____ _
Email Address: johnstonscs <-.nc.rr.com Website:
(2) Physical Address of Well Site (if different than above): -~1=3-=-l~S~·-=-M=a=in=Str~ee~t _______ _
City: Bath State: NC Zip Code: 27808 County: Beaufort
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.-'-: --------------~E=MA~=IL~A~d=dr~e-'-ss~=------------
Address: ----------------------------------
City: _________ State: __ Zip Code: ______ County: ________ _
Office Tele No.: -------------------=Cc..=e=ll'---=N-'-'o=.-'-: __________ _
Website Address of Company, if any: ______________ _,,,,=y.,..., ~V~U _f Dl::1\J~/ OWQ
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) JAN 2 5 2011 Page I
C. WELL DRILLER INFORMATION
Company Name: A pp lied Resource Management. P .C.
Well Driller Contractor's Name: ~H~. M~ic=h=a~el~S~a""g""e ________________ _
NC Contractor Certification No.: ___ 2~5_3~1-~A~--------------------
Contact Person: Diana Helias EMAIL Address: Diana ARMl@ bellsouth.net
Address: __ __._P.:.a.O=."""B=o=x:...;8::..:8=2'----------------------------
City: Ham pstead Zip Code: 28443 County: --""'P....::e=n=de=r ________ _
Office Tele No.: 910-270-2919 Cell No .: ------
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Airtech Mechanical Services
Contact Person: Patrick McKee
Address: 153 Two Lakes Trail
City: New Bern Zip Code:
Office Tele No.: 252-636-5841
E. STATUS OF APPLICANT
Private: _x_
State:
Federal:
Municipal: __
EMAIL Address:
28560 County: --~C=r=av~e=n~--------
Cell No .: _______ _
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed loo p geothermal s vstem. Water onl y. grouted alon g the loo p's entire ty .
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _ _cl~/2=6~/2=0~1~1 ______ Number of borings: __ 4 __
Approximate depth of each boring (feet): ___ 2~0~0_' ______ _
(2) Type of tubing to be used (copper, PVC, etc): __ HD_P_E ____________ _
(3) Well casing . Is the well(s) cased? (check either (a.) Yes m: (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 Other (specify) __ T_h_e_rm_e_x __ _
(b) Grout placement: Pumping Pressure_X_ 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
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.
1. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing: buildings, property tines, 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, and/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 Iaw, 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, rep . and if applicable, abandon the injection well and
all related appurtenances in accordance with the a rf c on, and conditions of the Permit."
Signature of Pro rty D►vr►erlAppliean#
J' AI [D QRUT- \) H N 570 � YVIY�F�
Print or Type Pull Name and title ���
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Feral Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ Dy%%)
Aquifer Protection Section-UIC Program �uiferr�►tr��riy;co
1636 Mail Service Center JAN 2 6 Z��I
Raleigh, NC 27699-1636
Telephone [phone]
GPUIMC 5QW Notification of lutent Form {Revised 812W8) FW 3

M
Approximate Property Lines
------ Approximate Building Perimeter
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services,
2. Geothermal well locations are approximate and will be ❑ minimum of 20' apart,
Adapted from Google Earth and Beaufort County GIs Map, December 2010,
AP.
cHM Kesource P1ana�ement PC
Sox 2, ampsiea , N 44
270-29 ] 9 FAX [phone]
TITLE:
GIS MAP
131 S. Main Stree__t
JOB: SCALE: DATE: DRAWN BY
Johnston As Shawn 1/5/1 I DNH
T�'
FIGURE:

Page 1 of I
Site: 1 LT (.29 AC) JOE S JACOBS JR ETUX
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997 f
Property Details:
PIN D6018799 G PIN 6653-04-6997
GPINLONG 6653-04-6997 NAME1 1JOHNSTON DAVI❑ G
NAME2 JADDRI
ADDR2
STATE
PROP ROAD
ACCT_NBR
NBR BLDG
DEIPG
BLDG VAL
TOT VAL
NSHD DESC
1709 LOOKOUT POINT CT
CITY
11 RALEIGH
NC
ZIP
1127642
MAIN ST
ACRE$
O
87 2259
MAP -SHEET =1665313
1
1 DATE
1 10171200 4
1418/0848
LAND VAL
1253890
4600
1 DEFR VAL
0
258490
INBHD CDE
BATH1
BATH
SI1B CDE
SUB DESC
ISTAMPS
11440
SALE PRICE
1220000
ZONE
R-2
LAND -USE
I DISTRICT =1
06
PROP_DESC
t LT j.29 AQ JOE S JACOBS JR ETUJC
MBL
166531383
EXIMPT PROP
EXMPT AMT
0
ROAD_TYPE
P
CENSUSBLK
PREVASSESS
0
..,.... 7--,se maps and information either in dlgifai or hardcopy format are provided solely as a public service and they do not meet surveying accuracy standards Thls map
ta m prepared from the invemory of real property found urchin this JunsdicWn and Is Compiled from recordedre deeds, plats, and other public cords and data, Users of any maps
L...
Lnr3rated ❑n thissite are hereby nolified that the aforementioned public primary information sources should be consulted for verficatidn of the Wormatiorr contained on any maps- The
unN ❑f BeaufdA assumes no legal responsibility far the informalon contained on these maps.
http://www2.undersys.comiscriptsltestadvlusiwebbyd.dlllusi?formis=ptmap&MouseX=28... 121612410

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-0W 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~ information).
DATE: January 5, 2011
Well Type Confirmation: Does the proposed system circulate potable water onlv (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 5A7 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): __ D~av_i_d _Jo_hn_st_o_n
(1) Mailing Address: --~1~7=09~L=oo=k=o~u=t=P~o=in~t~C~o=urt~--------------
City: Ralei gh State: NC Zip Code: 27612 County: Wake
Home/Office Tele No.: 919-847-8154 Cell No.: 410-916-0338
Email Address: johnstonscs @nc.rr.com Website:
(2) Physical Address of Well Site (if different than above): __ 1~3~l~S=·~M=ai=n~S~tr~e~et~-------
City: Bath State: NC Zip Code: 27808 County: Beaufort
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.~: --------------~E=MA=I=L~A~d=dr~e=ss~: __________ _
Address:----------------------------------
City: _________ State: __ ZipCode: ______ County: _______ _
Office Tele No.: ------------------=C=e=ll-=N-'-'o=•e.-: __________ _
Website Address of Company, if any: _______________ REC_EIVED I DENR I DWQ
' qu,fer Protection Section
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) JAN 2 fi 2011 Page 1
C. WELL DRILLER INFORMATION
Company Name: A pp lied Resource Mana gement. P.C.
Well Driller Contractor's Name: ~H=-=-'. M=ic=h=a=e=-1 S=a=g=e'-------------------
NC Contractor Certification No.: 2531-A
Contact Person: Diana Helias EMAIL Address: Diana ARM @bellsouth.net
Address: -----=P~.O=-·~B=-o=x=-8=-8=2~--------------------------
City: Ham pstead Zip Code: 28443 County: --~P~e_n~de~r ________ _
Office Tele No.: 910-270-2919 Cell No.: _____ _
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyName: __ ~A~irt=e~c=h~M=e=-c=h=am=·=c=al~S=-e=rv~i=c=es~------------------
Contact Person~: ___ P~atr_i~ck_M_c~K_e~e _______ E_MA_IL_A~ddr_e_ss_: __________ _
Address: __ ____:.1=53:::......:,T_,_w:...::o:....:L=a=k=e=-s..:.T=ra=il"--------------------------
City: New Bern Zip Code:
Office Tele No.: 252-636-5841
28560 County: ----=C=r=av"""'e=n~--------
Cell No.:
E. STATUS OF APPLICANT
Private: __,X_
State:
Federal:
Municipal: __
--------
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed loo p geothermal s vstem. Water onl y. grouted alon g the loo p's entire ty .
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: __ 1_/2_6_/2_0_1_1 ______ Number ofborings: __ 4 __
Approximate depth of each boring (feet):_--'2"""0"""0_' ______ _
(2) Type of tubing to be used (copper, PVC, etc): _ __ccHD~P~E=c_ ___________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes m: (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 Other (specify) Thermex
(b) Grout placement: Pumping __ Pressure X 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)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page2
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
arty 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 mast 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. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of Iaw, 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, rep4i4 and if applicable, abandon the injection well and
all related appurtenances in accordance with the a i "ca on and conditions of the Pernvt."
Signature of Pm Owner/Applicant T
DAVI D G4UT- \JOH N S7a t- ® WUP-
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 the completed Application package to;
RFi:E1 p �'D i
North Carolina DENR-DWQ �t1� p!`f�'R 1 �+nrDE vj�
Aquifer Protection Section-UIC Program
1636 Mail Service Center colt
Raleigh, NC 27699-1636
Telephone [phone]
GPUAJIC SQW Notification of tntenr Form (Reviqed 8f2o[38) Pairs 3

w�
0,
cry
Approximate Property Lines
--- Approximate Building Perimeter
* Approximate Closed Loop Locations
Notes:
1, Subject property and surrounding area are serviced by public sewer and water services.
2. Geothermal well locations are approximate and will be a minimum of 20' apart.
Adapted from Google Earth and Beaufort County GIS Map, ❑ecember 2010.
TITLE: GIS MAP FIGURE;
7 0. lied f�e5aarce Ma�aoement �'G 131 S. Main street___
x 882 r HOmp eOdr NC 219 44 3 JOB: SCALE: -- DATE: ❑RAWN BY:
[910) 270-2919 FAX [phone] Johnston As Shown 1/5111 DNH

Page 1 of 1
Site: 1 LT (.29 AC) JOE S JACOBS JR ETUH
- - 4 -..
r=
�.'
9197
r
_
Property Details:
PIN
106018799
C,PIN
6653-04-6997
GPINLONG
6653-04-6997
NAME1
JQHNSTpN OAVI€7 G
HAME2
JADDRI
ADDR2
1709 LOOKOUT POINT CT
CITY
RALEIGH
STATE
NC
ZIP
27612
�PR=OP—ROAD
WAIN ST
ACRES
0
CCi_NBR
870259
IAAAP_SHEET
065313
INSIR BLDG
1
DATE
1101712004
DO —PG
1141810846
LAND VAL
253890
BLDG VAL
4600
DEFR VAL
10
TOT VAL
�258490
11
NBHD CDE
BATH1
kBHD_DESC
BATH
SUB CDE
4-40
SUB DESC
ISTAMPS
SALE PRICE
11220000
ZONE
R-2
LANI] USE
I DISTRICT
1106
PROP DESC
111 LT (29 AC) JOE S JACOBS JR E
JMBL
166531383
EXMPT PROP
I EXMPT AM7
ILO
ROAD TYPE
I P
CENSUS BLK
PREVASSESS
110
- .. _.� ;•.cd�l= . - �r.:;, s ena,1%'0 T j'- �rt �nc�- 1n :;.ghat er fia4dc�py rcrra; are providou solely as a public service and They do not meet survoymg accuracy standards This map
data Is prepared from the inventory of real property found within thls jurisdiction and is compiled from rawrded deeds, plats, and other publC records and data. Users of any maps
generated on this site are hereby notified that tha aforementioned public pnmary Worma6an sources should be consulted for verification of the information contained on any maps. The
caunry of Beaufort assumes no legal responsibility for the information contained on these maps.
http:llwww2.andersys.comiseriptsftestadhvlusiwebbpd.dlllusi?formis=ptmap&MouseX--28... 12/6/2010