WI0700213_GEO THERMAL_20110322

Permit Number WI0700213
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
Jeffrey Morrison SFR
Location Address
1451 Ocean Pearl Rd
Corolla
Owner
Owner Name
Jeffrey
Dates/Events
NC 27927
D Morrison
Orig Issue
03/22/11
App Received Draft Initiated
03/02/11
Re g ulated Activities
Heat Pump Injection
Outfall I\JJI L
Scheduled
Issuance
Central Files: APS_ SWP_
03/22/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Jeff Stagg
PO Box 15482
Chesapeake
Major/Minor
Minor
VA
Region
Washington
County
Currituck
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Jeffrey D. Morrison
590 Colony Rd
Newport News
Public Notice Issue
03/22/11
VA
Effective
03/22/11
233285482
23602
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
~A ;;-;;--;,1'-__ _
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Jeffrey D. Morrison
590 Colony R.CYdd
NeVirport News, VA 23602
Coleen H. Sullins
Director
3i22/201 l
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI00700213
1451 Ocean Pearl, Corolla NC 27921
Dear Mr. Morrison:
Dee Freeman
Secretary
On 3/2/2011 , the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-
only 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
~ystem 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 .021 l(u)(2). Additionally, you should contact the
CmTituck 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.Ro2:ers@.ncdenr.!wv if you have any questions.
cc: Washington Regional Office -APS
APS .Central Files -Pennit No. WI 0700213
Currituck County Health Dept.
Sincerely,
fo,Q~~
Supervisor
Pinkston Pump & Wdl, inc. (Jeff Stagg-PO Box 15482, Chesapeake. NC 23328)
OBX Heating & Air Cooling (Brian McDonald -PO Box 1415, Nags Head, NC 27959)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard. Raleigh. North Caronna 27604
Phone: [phone] I FAX 1: 919 -7 15-D588 ; FAX 2: 919-715-6048 I Customer Service : 1-877-623-674 8
Internet: www.ncwaterguality.org
An Equ2! Opport.1~::1 \ Affirma;;ve Acton Employer
N~rthCarolina
"Naturalq;
Fab 2,r' b. id. 2 U I l 1. HAW SlaSg
757421-MBNo.1296 P. 1/3
NORTH CAROLINA
DEPARTWNT OF ENVIRONMENT AND NATURAL RMURC65
NOTYFICATI.ON OF INTENT TO CONSTRUCT A CLOSED -LOOP OEOTHERMA.L
WATER -ONLY INJ EMON WELL SYSTEM
TYPE 5 W WELL(S)
In Accordance With the Provisions orMCAC Title I5A 02C.0200
Prim or type the required fnforuoution and nood to address on the back page.
DATE' _ 2 / . , 201L U- IV 01 000-,
Well Type Confirnrationt Does the proposed system circulate potable w tee r only (no additives) in
continuous piping that zompletely isolates the fluid fron) the environment (i.e.
Yes x Continue completing this form.
No Do Not complete this form. Completc other UIC application forms for installing
either a SA7 well Wen -loop well injection potable water into the aquifer) or a 5QM well (closcd-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A- PROPERTY OWNER(S)IAPPLICANT(S)
List each Pmparty Oirner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): r7 L/ �,_ �!1 {� n Uyll
(1) Mailing Address. 50 c.o(. D A) y �A
City: � � MI U/$ State: Zip Cede (ot)_ County:
Florae/Office Tele No.: er-5uv
� Cell No.. r -- � - U 10�
Email Address: � � We
C-0)11- - At-t
(2) Physical Address of Well Site (if different than above); _1 �_{ � 1/�tJ .P�1/4✓C-L
City: &JOALtA State' NC Zip Cade=a)!�Countyx
HamelO�ce Tcic No.: Cell No
B. AUTHOTtY2PM AGENT OF O NElt, IFAN'Y (if the Permit Applicant does not own tho subject property,
aatach a letter from the property owner authorizing Agent to install and operate UIC Weil)
Company Name;
Contact Person: EMAIL Address:
Address:
City: _ State: Zip Code: County:
Office'releNo.: Ceti No.:
1Websitc Address of Company, if any:
(PUMIC SQW NoOficakion Olntcni Form (Revised 10010 PW I
MM 0 2 2011

reo [tt a o. zo. I 1 1 1; JbANA. Stagg
757-421-2108NO.1298 P. 2/3
C. W6r9LL DRELLER INFORMATION
Company Wane:_.. Pinkston Pump & Well. Inc.
Well Driller Contmetor's Name: Howard Curter
NC Contractor Certification N❑.: 3538-A
Contact Person., J-W-j4t&gv EMAIL Address: efi`�,sta "'.Elit:rrdF.C[1111
Address: P Q Box 15482
City: Ches ewe ZipCode: 2 72�8-5482 County: Clly ofChesspeake
Qffice Tele No.: 757-421.2108 Cell No.: 43392 _
D. HEAT PUMP CONTRACTOR INFORMATION (if 41fferent than driller)
Company Nawe:--o ! ' I l Ct a CDULy�y
Contact person 6ICaPW A � 0& EMAIL Address: f 4►��' _CS C
o Address:
Ci ty: (1?�f�5 p CLode- ; Q S 5 County:
offioe Tele era.: ?r ` L I Q Cell No.
G. S rATUS OR AIPPLICA.NT
pti yw- Federal: CorruncrCial:
Slate: Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe howl the injection well(s) will be used)
NOT A WATER WELL
GE 'rIABRMA] CLOSEI,) LOOP
G. WX)L ,L CON5TRUCTYON DATA
(1) Pl oposed data to be constructed: NiAnther of borings: J
Approximate depth of each boring (feet):
(2) Type of tubing to be used (copper, PVC, etc): 4'E
(3) Well wing, is the well(s) cased? {check either (a) Yes or (h.) No below)
(a) Yes if yes, theta provide casing information below
'rype: ___galVdni2Cd Steel black steel plastic other (specify)
Casing depth. Tram to feet (reference to land surface)
Cawing extrnds to above ground inches
(b) No X
(4) Gmist Info (material surrounding wrli casing a:id/or piping):
(a) Grout type: Near Cement Bentonite Other (specify)
(b) Grout placement: Pumping X Poessure. Other
(c) Grout depth of tubing (reference to land surface): from to t]j (feat)
Jf xitll has casing, indicate grout depth, from to (feet)
0PUIUlC 5QW Notification of Intent norm (Revised It2tl0E) Yaffe 2

Feb 21I cn. & 1011 I; JUAW Stagg 757-421-2108NO. 1298 P. 3/3
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/rubing associated with the injection tipemtiott. The manufacturer's brochure may provide supplementary
information.
L LOCATION OF WELVS)
Attach two copies of reaps showing the following inforinatioru
(1) l9clude a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater r..ontamitnation and the orientation of and distances between the proposed weft(s) and
any existing wells) 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 c1culy and include a north prow.
(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 Permit Application must besigned by each person appeariag un the
recorded iega( property deed,
1 hereby certify, under penalty of lava, that i have personally examined and am familiar with the information
submitted in this document and all attachments thereto and /hat, based on fey inguby of those individuals
immediately responsible for obtaining said infannation, I believe that the information is true, acaurate and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I agree to construcl, operate, maintain, repair, and if applicable. abandon the injection well and
all related appurt&iances in accordance witAs e specifications and conditions of the Permit."
F'raperty dvvnerlApplic$[lt
Print Type Full Name and title
Signature of Property Owner/Applicant
Prim or Type Full Nome and title
Signature of A uthorized Agcnt, if any
Print or Type Full Name and title
Please retum two copies of the completed Application package to:
North Carolina l3ENR-DWQ
Aquifer Protection Section-VIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
MAR o 2 mt
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Map of 1451 Ocean Pearl Rd, Corolla, North, Carolina I MapQuest
Page 1 of 1
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Map of:
1451 Ocean Pearl Rd
Corolla, NC 27927
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Map of 1451 Ocean Pearl Rd, Corolla, North. Carolina I MapQuest
Page 1 of 1
mapq uest' Notes
Map of:
1451 Ocean Pearl Rd
Corolla, NC 27927
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All r6ghts reservers Use subject to LicenselCopvrie_ht
Directions and maps are inforrnational only. We make no warranties on the accuracy of their content, road conditions or route usability or
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MapQuest. Your use of MapQuest means you agree to our -terms of Use
hq://www.mapquest.com/print?a=app.core.dc76aa7de93c81 f7de46095 2I28/2011

Feb 28 1,~ 08:59a
• •
Jeffrey A Stagg 757-421-2108 p .1
Pinkston Pump & Well
PO Box 15482
Chesapeake, VA 23328
757-421-2108 I 866-749-1980
facsimile transmittal
To: Tonya Godwin, NCDENR
From: Tina Wyatt
Re-: Morrison, 1451 Ocean Pearl
Typ e 5QW Wells
CC:
Fax: 91S-733-9413
Date: 02/28/11
Pages: 7 Oncluding cover sheet)
□ Urgent □ Fa-Review □ Please Ccmrnent D Please Reply □ Please Recycle
• • • • • • •
Notes:
For the above referenced, foUowing is our Permit Application for Geothennal Installation .
If you have any questions, please contact me@ [phone] or [phone]
RECEIVED/ DENR I uWQ
Aquifer Protection ~~r.tlon
FEB 2s 2011
•
. . . . . ~ . . . . . . . . . . .. . . . . . . . . . . .
IJf—tG 1-4jvaH1... I L,0 r, I/ )
-- _ - I. .. --tea
NORTH CAROLINA
DEPARTM>;M OF ENVIRONMENT AND NATURAL RESOURCES
I+ OTMCATILO ►1' OF rNTENT TO CONSTRUCT A CLOSED-L OUP OEOTHERMALL
WATEIL OI►t 'V WEC'> 1ON WELL SYSTEM I
TV 5c�w wcL,L �
In Accordwee With the Provisluns ofNCAC Title 15A 02C-0200
Prinz or type eite're0T&-ed infiwamaran and nzarf la address on the back page.
DATE:_ 20-LL_
Welt .p,Ve CanfrrrrmaF1orr. Toes the proposed system circvlate potable watbr vn X (tic additiva) in
contiouovs piping that completely isolates the fluid from tlieenvironment (i,c.
c9 e-�03?
Yes X Contlaue completing this form.
No Do Not curnple#e this form. Complete iAher WC application forms for installing
eitiiex a $,dz7 we] l{omen-loop well in�Iectiipotablc water into The aqur er} or a SUM well (closed
loop well contailiipg additives such as R-22, ethannI, or other ant finezt� or Corrosion inhibitors).
d. PROPERTY OWNER(S)M,L'P7.rCANT(S)
+' List n4.�h Property Owner listed o» property deed (if owned by a business or government agency, state name of
entity and a represen#ativc w/authority for signatuvc): `
.' (1) MailingAddrress: _Go ❑ � �.. �_ -
r ���, r�,� -
f City: ' `L O i�� 1 �W r State: l,�,�
� Zap Cade:0�-_ County:- --._
HumrJOffice. Tefe No.: 3 Ycell No. �_ -T 1. - U 7 ql�
-
B=itAddress. ����y�ft"Ov Website:
kj
.`
� (2) Ptlpsicat Address of Well Sirc (if diffcrerlt than aba►�e):i
t
City: 11VULLA — State: NL Zip Codo:��Couwy:
Huma/Office Tcic No.: _ Cell
S, AUTHORIZIED AGENT OF OWNETt, IF ANY (if the Perm it Applicant does not own the subject propeAY,
actech a letter from the properry owner authorizing Agent to install and operate UIC well)
Company Name:
t,iio Contact Person: _ EMA rL AddT rpw; _
Address:
City: State: dip Code: County.
Office, Tele Nc.: Cell No.:
Website Address OfCoatpa.ny, ifany-
GPUfUIC SQW Nedficalion Grim:nl F-Mm (Revised W00a) Aquj(I p.)DENR Q P6 t
'44u�er a�ectra �
�+ Section
g d 907 7,-2-V-L5L FI 28 20i, 66t:15 -V Aej}}ef ?65:80 6 L BZ qe�

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C, WELL DRn-L' R UVOlf RATION
Company Natue:_ f'"snkston Pump & Wel Inc. _
Well DrOlcr Contractor's Nuna: ( r)ward Cumer
NC Contractor Certificatdon No.: 353E-A
C:ontaet Person: Jeff Stu a. _ EMAIL ddres5: 'LeRgwa�aci
Address: t d j cx 15492
City: ChruancaM pep Cade: Z IZEL482 County-. City of Clicgpeake „
O fice TeleNo., _75T- -21t18 Cell No.; _IIZA33.9392
Z-
HFAT 1pC)MT CONTRAMIR WORMATION (if 4i[ferent thAtt driller)
Corr:pany l+IsrrJf�r �+ �� A!T'iE r--�O0
Contact Person-- 6cf4w AGAW&O EMA[I.Address--�
Address- ru Lw
City: P 3 Et,�ilt�4 ,dip Coda. .; Q s
Office Tele mo-: ark yN D Ccll No.:
STATUS OP APPLICANT
Pr, vate: Federal:
Cnnniy:
Corruncrcial:
State: Municipal; Native Americau Lands.
FIRM
F. 11V'M- MON PROCEDURE (briefly describe how the injection well(s) will be wed)
. _. NO A WATBR W%AL _—
GCur I :R mm, cLosF-D;LOOP
G. WELL CONSMUCiTiON DATA
(t) Proposed date to be consmtctcd: Number oFDoriMs: _
ApprOKimate depth of each bo ing (feet):
(2) Type of tubing to be used (copper, ('VC, etc): APE
(3) Well rasing. is the wel I(s) cased? (check either (a) Yes rE (b.) No below)
(a) Yes if yes, then provide Casing information below
T+ape, __-_,gahrani=d steal bisrk steal plasfic other (Spoaify1
Casing depth: From to feet (refemate to land surface)
Casing extends to above ground inches
(b) No X ,
(4) Oroul Info (material surrounding well casing and/or piping)_
(sj Crroui type: Neat Cernent Sentouite X Other (specify)
(b) Grout p!$eement: Farnputg X Frossure Other
(c) Gioot depth of tubing (refefenea to land surface): form to j (feet)
If well has Casing, Indicate grom depth: fmi-a to (fter)
GPUML SQw ;�+otir=cnibrr of fnicn:l=orm (Rc►risca 3r�UuR1
eflp 3.
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H. INJECTION -RELATED EQUIPMENT
Att h a diayw showing thr, engine ring layout or proposed modifaation of the ittjewon equipment and exterior
piping/rubing associated with the inpOon operation. The manufactzrrWs brochure may provide supplcmeivary
information.
I. LOCATION OF WELL(S)
A ttach two copies of maps showing thIe fallowing infonration:
(1) Include a Site Map (sari lye draw») showing: buildings, property lines, surface water bodies, potential
sources of grormdwatcr matamination and the orientation of and distances bttween the proposed well(s) and
any existing weil(s) or waste disposal 'facilities such as septic tanks or drain fields located ivi,t:Wii 200 feet of
the, gmthennall heal pump ► e-11 system. Label all features elmly and include a not_ arrow.
(2) The Site Map must show the wbject property in relation to the surrounding area by using at leasT two fixed
referenre points such as roads, streams, audfor highway int=ections.
J. CLRTTFICATION
Not= This IPermil Application must be signed b-y each person appearing an the
recorded legal prop arty dced.
"I hereby certify, under penalty of law, that i have personally examined and am familim with the information
Submitted in this documot and all attachments thereto and that; based an my inquiry of those individuals
immediatdy responsible for obtaining said infonnarinn, I believe that tftc information is trite, accurate and cornplcte.
i 8m aware that there are significant peiWtiA. including the possibility of fines and imprisonment, for submill4le-
false information. f agave to construal, operate, nomintain, repair, and ifapplicabie, abandon the injection well and
all related appuric"Arms in amardanre with the rove• specifrca#ions and conditions of the Permit"
Ssgne o Property OwnedApplfcant
l _
Print Type Full Name and title
siptar m-c of Property Owne dA pplicant
Print or Type Full Name and title
Signaht,e of Authorized ,Arent, if any
Print ar Type Pull Nary and rule
Please return nvo copies of the completed Application package to:
North Carolina DENR-DWQ RECEIVED t ❑ENR I DINQ
Aquifer Protection Sectcoa-UIC Program Aquifer Prmedlon Sectlon
1636 Mail Service Center FEB 28 L Q 11
Raleigh, NC 27699-1636
Telephone [phone]
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Map of:
1451 Ocean Pearl Rd
Corclla, NC 27927
NORTH CAROLINA
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expediiiousriess. You assume all risk of use. &%;)Quest and its suppliers shall not be kableto you fvr any lass or delay resulting from your use of
Map QuesL Your use of MapQuest meant you agree to our Towns of Use
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1451 Ocean Pearl Rd
Corolla, NC 27927
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