WI0700214_GEO THERMAL_20110325

Permit Number
Program Category
Ground Water
Permit Type
WI0700214
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Shelton Toler SFR
Location Address
145 Paradise Acres Dr
Ernul
Owner Name
Shelton
Dates/Events
NC 28527
Toler
Central Files: APS_ SWP_
03/25/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Shelton Toler
Owner
423 Pine St
New Bern NC
Major/Minor
Minor
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Sheiton Toler
Owner
423 Pine St
New Bern NC
28560
28560
Orig Issue
03/25/11
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
03/25/11
Expiration
03/04/11 03/25/11
ReQulated Activities
Heat Pump Injection
Private residence, single family
Outfall
Waterbody Name Stream Index Number Current Class Subbasin
NCDEMR
North Carolina Department of Environment and Natura
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
03125/2011
Shelton Toler
Sherri Toler
423 Pine St.
New Bern, NC 28560
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10700214
145 Paradise Acres Drive
Ernul, NC 28527
Bear Mr. and Mrs. Toler
Resources
Dee Freeman
Secretary
On 03/04/2011 the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-ordy
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 suet;
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 accuratcly submitted.
Failure to comply with all of these conditions constitutes a violatio-n 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 Craven County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulal ions may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Rogersrer:ncdenr.L-,o►• if you have any questions.
5inc rely,
r. for Debr W
Supervis
cc: Washington Regional Office - APS
kPG 1, entral F =ie- -Perim, \c. VV'01"14
Craven County Health Dept.
Jim Comette (Applied Resource Management, P.C., P.O. Box 882, Hampstead, NC 28443)
Rick Lilly (Lilly Enterprises HVAC, LLC, 687 Piney deck Rd., Vanceboro, NC 28596)
AQUIFER PRAT EC ri ION 5EM1011;
16?6 f 9a Service Ue+iler. Raleigh, North G8ro1Ina 27699-1 s636
t acatipr: 2728 Caellal Boulevard. RaL-9h. Hatt Carolina 2778(y �,�i nZ
Phono. 91A-733ti221 I FAX P19-715-0583. FA.'; 2: G15.7l5-604a' CU8:0liG 5erviu.: 1$77-6Z31-"a70 l\kQrthCaroI i n a
Intermet www.nguuateruuafity-of

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-OW 'WELL(S)
In Accordance with the provisions of NCAC Title 15A; 02C.0200, please
complete this notification and mail to address on the back page (please Print or Type information).
DATE: Februan 16. 2011
Well Type Confirmation: Does the proposed system circulate potable water onk (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
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 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 owned by a business or government agency, state name of
entity and a representative w/authority for signature): Shelton & Sherri Toler
(1) Mailing Address: 423 Pine Street
City: New Bern State; NC Zip Code: 28560 County: Craven
Home/Office Tele No.: 252-633-0847 Cell No.: 252-617-7940
Email Address: Website:
(2) Physical Address of Well Site (if different than above): 145 Paradise Acres Drive
City: Ernul State: NC Zip Code: 28527 County: Craven
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: EMAIL. Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company, if any:
OPUIUIC 5QW Notification of Intent Form (Revised 912008) MAR 9 4 Mi f 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=e~l S=a=g--=e ________________ _
NC Contractor Certification No.: ___ 2~5~3 _1-_A ____________________ _
Contact Person_: _J_im_C_o_m_e_tt_e ___________ E_MA_I_L_A_d_dr_e_ss_:_J_im_A_RM_@._._.b~e_lls~o~u~th_._ne~t __
Address: P.O. Box 882
City: Hampstead Zip Code: 28443 County: Pender
Office Tele No.: 910-270-2919 Cell No.: 910-512-4890
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: ___ L_i_ll-y_E_n_te_r-+-p_ri_se_s_H_V_A_C~._L_L_C __________________ _
Contact Person"-: ---=Ri=·c=k"-'L=i=ll.,_y ________ -=E=MA=-=I=L"--'A'--=d=dr=e=ss=: __________ _
Address: 687 Piney Neck Road
City: Vanceboro Zip Code: 28586 County: _____________ _
Office Tele No.: 252-244-0038 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 ystem. Water only. Qrouted along the loo p's entiretv .
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 3/7/11 Number of borings: __ 4 ___ _
Approximate depth of each boring (feet): ___ 2_00_' _____ _
(2) Type of tubing to be used (copper, PVC, etc): __ H_D_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 -~2=0-=-0 __ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page2
Fab. 14, 2011 5.54241 Craven County Ii spec# ions Dept.
No.5050 ' )
K INJECTION -RELATED EQUIPMENT
Attack a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipirtgJtubing associated with the injection operatiaa. The manufacturer's brochure may provide supplementary
infWmarion.
I. LOCATION OF WELVS)
Attach two hies of maps showing the following information:
(1) lactude a Site Map (can be brawn) showing: buildings, property lutes, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed wall($) and
any existing wells) or waste disposal facilities such as septic tanks or drain fields located within 20Q feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) 'Dr Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, stream;, an(Vor highway ir►tersections.
J. CERTIFICATION
Note; This Permit Application must be signed byeacb person appearing an the
recorded legal property deed.
N hereby certify, under penalty of law, that l have personally examined and am familiar with the information
submitted in this document and all attachments titereta and that, based on my inquiry of those fadividusis
unraediatety responsible For obtaining said information, I believe that the information is true. accurate and complete.
I am aware that there are significaot perrslties, ineluftg the possibility of fines and imprisonment, for submitting
false nformation. I; agree to caostruc% operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Pe- m I."
5igna ttre of Property Owjam/Appkcant
Print or Type Full Name ead title
�"- ._
Signature of Property 4wnerlApplicant
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:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
3636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
0YUNIC SCOW Nvtificnion of irsierl Form (Revised $2008) PW g
Z'd eoc:zo ll 91. q9A

Craven County Geographic Information System
Craven County does NOT warrant the information shown on this page and should be used ONLY for tar, assessment purposes.
This report was created by Craven County GIS reporting services on 2116!2711 1:56 59 Phi
Parcel ID :
2-045-1 -13001 Akal
Owner:
WX
TOLER, SHELTON P & SHERRI L
Mailing Address :
423 PINE ST NEW BERN NC 28560
r•
Property Address :
145 PARADISE ACRES DR
Description
TRACT 1 DIVISION FOR SHELTON TOLER & HENRY 1712
WAYNE MURPHY
Lot Description :
Assessed Acreage :
0.000 Calculated Acreage: 4.800
Deed Reference :
2712-0706 Recorded Date., 4 92008
Recorded Survey :
H-118-A
Estate Number,
Land Value :
$29,500 Tax Exempt : No
Improvement Value :
$35,490 # of Improvements : 1
Total Value: $64,990
City Name: Fire tax District: LITTLE SWIFT CREEK
Drainage District : Special District
Land use: VACANT -RESIDENTIAL TRACT
Recent Sales Information
SALE DATE Sellers Name Buyers Name Sale Type Sale Price
4/9/2008 LEWIS AND TOLER, SHELTON P & STRAIGHT $22,500
ASSOCIATES OF NEW SHERRI L TRANSFER
BERN
List of Improvements to Site
Type of Structure Year Built Base Area Value
2010 1800 $35,490

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Approximate Property Lines
Approximate Septic Area
- - - Approximate Building Perimeters N
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public water and private septic.
2. Well locations are approximate and will be a minimum of 20' apart and 25' from the building.
3. Adapted from Google Earth and Craven County GIS Map, February 2011.
TITLE: SITE MAP FIGURE:
died Kesource Mana ement PC 145 Paradise Acres Drive
Box U82, HarrpVead, NC 28443JQB: SCALE: (DATE: DRAWN BY:
[phone] FAX [phone] Toler 1 -200' ! 2/1 bj11 DNH

02/23/2011 14:36 2526361474 ENVIRONMENTAL HEALTH PACE 03103
4ltillf�rk'}L1�-pia �d�'2006 �
Septic Lay -taut for homes an Tract 9 of PIS 2-0, 4000 off Cool Springs Rd.
Note: Water lines most remain at least IOft from the septic s sterns and repair areas.
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CRAVEN COUNW HMLN DEPAMI NT
APPRUM
Perms 5
NW8C - 5-5, -r—
SATE
iY4� �.
P irriagy Sys3em!�.: # Bedroom Home
Type: ConvGnti l Trent-h
LTAR: 0_8 gpdftq1#
Linear heat of Dram Line: 201'
Number of Drain Lines, 3
Length of Each Drain Lute: 67,
Repair Area: Same as Primary System
repwred w9h sathwaft 6Y Crsv + CauMy
p vm,�+.
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RrEa
aT
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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 5-0 W 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: Februarv 16 . 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): ___ S_he_l_to_n_&_S_h_err_i T_ol_e_r ________ _
(1) Mailing Address: ___ 4_2~3 _P_in~e_S~t~re~e~t ____________________ _
City: New Bern State: NC Zip Code: 28560 County:_C~r~av_e~n ___ _
Home/Office Tele No.: 252-633-0847 Cell No.: 252-617-7940
Email Address: __________ W'-'--"-eb=s=it=e~: _____________ _
(2) Physical Address of Well Site (if different than above): 145 Paradise Acres Drive
City: Emul State: NC Zip Code: 28527 County: Craven
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: __ ZipCode: ______ County: _______ _
Office Tele No.: --------------------=Cc..=e=ll'--"N--'-'o=._,_: __________ _
Website Address of Company, if any: _______________ _
MAR O 4 2011
GPU/UIC 5QW Notification oflntent Form (Revised 8/2008) Page 1
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: Jim Cornette EMAIL Address: Jim ARM@.bellsouth.net
Address: P.O. Box 882
City: Hampstead Zip Code: 28443 County: --""'P...cce=n=de=r ________ _
Office Tele No.: 910-270-2919 Cell No.: 910-512-4890
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: __ ~L=illc..Y...ccE=n=t-=e rp=ri=se=s'""H=V""'-"-'A"""C'""".""'L=L"""C'---_________________ _
Contact Person.~: ---=-R=ic=k~L=i=ll-y ________ -=E=MA-===IL~A=d=dr:..ae=ss~=-----------
Address: ___ 68_7_P_in_e~v_N_e_c_k _R_o_a_d _______________________ _
City: Vanceboro Zip Code: 28586 County: _____________ _
Office Tele No.: 252-244-0038
E. STATUS OF APPLICANT
Private: __x__
State:
Federal:
Municipal: __
Cell No.: --------
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed loo p e.eothermal system. Water only. grouted along the loo p 's entirety .
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _3_/_7 /_1_1 ______ Number of borings: __ 4 ___ _
Approximate depth of each boring (feet): 200' ----------
(2) Type of tubing to be used (copper, PVC, etc): _.;HD=P:..aE=--------------
(3) Well casing. Is the well(s) cased? (check either (a.) Yes Q! (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
(b) Grout placement: Pumping__ Pressure X
Other ( specify) --'T"""h=e=rm=e=x.a...__ __
Other
( c) Grout depth of tubing (reference to land surface): from O to _ _;2=0-=.,0 __ (feet)
If well has casing, indicate grout depth: from ____ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 2
Fed, 14. 2411 5:54PM Craven County Inswe ions Dept. No. 5450 ? 7
IL INJECTION -RELATED EQUFPMENT
Attacft a diagram showing the engineering layout or proposed mudif"wation of the injm ion equipment and exterior
pipi gltubing associated with the injection operation. Thr maTIL[hCWTer's brochure may provide sunplernentary
itmfww'lun-
I. LOCATION OF WELLS)
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
smces of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing welgs) or waste disposai facilities such as septic tanks or drair. fields iocated 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 lean two fixed
reference points surh as roods, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by eacb person appearing on the
recorded legal property dcerl.
"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 Bey inriairy of those imdividua;s
immediately respmmibie for obtaining said information, l believe that the information is true, accurate and cornplete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I zgree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appiuterrancex in accordance with the approved specifications and conditions of the Permit."
46;4v--k 7.�� - - - .- -
Signature of Property ❑wna[Appkmw
4�el)�Z_1'--1J?1ef--- - - - - -
Print or Type Full Name and title
Signature of ftperty Owner/Applicant
—
Print or Type Full Name and title
Signature of Authorized Ageat ff any ~�
Print or Typo Full Name and title
Please return two copies of the compteted Application package to.
North Carolina DENR-DWQ
Aquifer Protection Secfitan-UIC Program
1636 Mai] Service Center
Raleigh, NC 27699-1636 �,� 2
Telepitene (919) '715-6935 1
GFUNIC 5QW N001cetion of Intcnt Form (Revised MW8)
Z,d e0CIL0 1, L 9L qe-�

Craven County Geographic Information System
Craven County does NOT warrant the information shown on this page and should be used ONLY For tax assessment purposes.
This report was created by Craven County GI5 reparting services on 2116/2011 1.56:59 PM
Parcel ID :
2-045-1 -13001
Owner:
TOLER, SHELTON P & SHERRI L
Mailing Address :
423 PINE ST NEW BERN NC 28560 •*�'*•�
Property Address :
145 PARADISE ACRES DR
Description
TRACT 1 DIVISION FOR SHELTON TOLER & HENRY 1712
WAYNE MURPHY
Lot Description :
Assessed Acreage :
0,000 Calculated Acreage: 4.800
Deed Reference:
2712-0706 Recorded Date: 492008
Recorded Survey : H-116-A
Estate Number :
Land Value : $29,500 Tax Exempt: No
Improvement Value : $35,490 # of Improvements : 1
Total Value : $64,990
City Name: Fire tax District : LITTLE SWIFT CREEL{
Drainage District : Special District
Land use : VACANT -RESIDENTIAL TRACT
Recent Sales Information
SALE DATE Sellers Name Buyers Name Sale Type Sale Price
4/9/2008 LEWIS AND TOLER, SHELTON P & STRAIGHT $22.500
ASSOCIATES OF NEW SHERRI L TRANSFER
BERN
List of Improvements to Site
Type of Structure Year Built Base Area Value
2010 1800 $35.490

;-I
Approximate Property Lines
Approximate Septic Area
- - - Approximate Building Perimeters N
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public water and private septic.
2. Well locations are approximate and will be a minimum of 20' ❑part and 25' from the building.
3. Adapted from Google Earth and Craven County GIS Map, February 2011.
TITLE: SITE MAP FIGURE:
lied Kcoource Management f C 145 Paradise Acres Drive
BOX HOMPSteod, a JOB: SCALE: DATE: DRAWN BY:
A(910)l270-2919 FAH 270-2988 Toler 1 = ----209 2/f 6/11 1 DNH.H

02/23/2011 14:36 2526361474 EHVIRONMENTAL HEALTH PAGE 63103
L;•k& ��- 'Pra G9-rad�2L7QQ
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Septic Layout for ► homes on Tract 1 bf PID 240 . . 4000 off Goof Springs Rd,
Note, Water tines must remain at least 1 Oft from the septic sTstems and repair- arees.
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APPROVED
Permit
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Primary Systern3 4 Badroorn Home
Type- Gonvsti#oviat Trench
LIAR: 0.8 gpdfagft
Linear Proot of Drain Lime: 201'
Number of Dan Uries- 3
i..ength of Each Drain Bite: 67'
Repair Ataa: Same as Primary System
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