WI0700219_GEO THERMAL_20120523

~A~--~ ----.. _•;~~--.. --.
NCDEM~-== ~~----
North Carolina -Department of-Environment and Natural Resources .
Beverly Eaves Perdue
Governor
Timothy and Susan Gillis
Post Office Bo:x: 8252
Duck, NC 27949
Division of Water Quality -
Charles Wakild, P. E.
Director
May 23, 2012
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI07002 l 9
Dear Mr. and Mrs. Gillis:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http://portal.ncdenr.org/web/wg/aps.
If you have· any -questions regarding ·your current permit-or the·rule revisions, please feel free. to.
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: 919~07-6464 I FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity\ Affinnative Aclion Employer
One North Carolina
/Vatural/11
Permit Number WI0700219
Program Category
Ground Water
Permit Type
'
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Timothy and Susan Gillis SFR
Location Address
117 Duck Ridge Village Ct
Duck NC
Owner
Owner Name
Timothy
Dates/Events
27949
Gillis
Scheduled
Orig Issue
04/04/11
App Received Draft Initiated Issuance
12/02/11
Central Files : APS_ SWP_
12/20/11
Permit Tracking Slip
Status
Active
Version
1.10
Project Type
Major modification
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Timothy Gillis
Owner
29255 Superior Cir
Easton MD 21601
Public Notice Issue
12/16/11
Effective
12/16/11
Expiration
11/30/16
Regulated Activities Re quested/Received Events -~----------------------
Heat Pum p Injection Additional information requested
Outfall NULL
Waterbody Name
Additional information received
RO staff report requested
RO staff report received
Stream Index Number Current Class
12/06/11
12/08/11
12/09/11
12/12/11
Subbasin
Permit Number WI0700219
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Timothy and Susan Gillis SFR
Location Address
117 Duck Ridge Village Ct
Duck NC
Owner
Owner Name
Timothy
Dates/Events
27949
Gillis
Orig Issue
04/04/11
App Received Draft Initiated
12/02/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Scheduled
Issuance
Central Files: APS_ SWP_
12/16/11
Permit Tracking Slip
Status Project Type
In review Major modification
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Timothy Gillis
Owner
29255 Superior Cir
Easton MD
Public Notice Issue Effective
Requested/Received Events
RO staff report requested
RO staff report received
21601
Expiration
12/09/11
12/12/11
Waterbody Name Stream Index Number Current Class Subbasin
C
ATA
HCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
December 16, 2011
Timothy and Susan Gillis
29255 Superior Cir.
Easton, MD 21601
Ref: Issuance of Injection Well Permit WI0700219
Issued to Timothy, and Susan Gillis
Duck, Dare County
Dear Mr. and Mrs. Gillis:
In accordance with the application received on December 2, 2011, and additional information received December 8,
2011, I am forwarding permit number WI0700219 for the operation of a vertical closed -loop geothermal mixed -
fluid beat pump injection well system located at 117 Duck Ridge Village Court, Duck, Dare County, NC 27949.
This permit shall be effective from the date of issuance until November 30, 2016, and shall be subject to the
conditions and limitations stated therein, including the requirement to install well identification tags as
specified in Part I. Be sure to read the entire permit to ensure that you are aware of all compliance requirements of
the pennit.
Also, please pay special attention to Part V.2. The Permittee shall retain all records of repairs, pressure
tests, maintenance, and other activities needed to maintain normal operating conditions.
In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an
application to renew the permit 120 days prior to its expiration date. This permit is not transferable to any person
without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or michael.ro<<ersencdenr.v.ov if you have any questions about your permit.
cc: David May, Washington Regional Office
W10700219 Permit File
Dare County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1E36 Mal Service Center. Raleigh, North &aroma 27699-1536
Lacation:2728 Capital Boulevard. Raleiah, No'i •:•arol;na 276CM
Phone: [phone] FAY 1:915.M-0588: FAX 2:91E-715-6041iCustomer 5ervicr
Internet www.ncwaieraualitv.arn
elt=J EV Toon_',:', .AtTIFTTFk. YF
Best Regards,
Michael Rogers, P.G. (NC & FL)
tilt�}�
N ol. t1 .� ! CarO f 1! Sia
71t'a 7.191/1/
a•

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Timothy and Susan Gillis
FOR THE OPERATION OF 6 (SIX) TYPE 5QM INJECTION WELL(S), defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(F)_ for the purpose of operating a vertical closed -loop geothermal -mixed -
fluid heat pump system. This system is located at 117 Duck Ridge Village Court, Duck, Dare County, NC
27949, and will he constructed and operated in accordance with the application received December 2, 2011, and
in conformity with the specifications and supporting data submitted December 8, 2011, all of which are filed
with the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for operation of an injection well and shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This peiznit shall be effective, unless revoked, from the date of its issuance until November 30, 2016, and shall
be subject to the specified conditions and limitations set forth in Parts 1 through VII hereof
Permit issued this the 16th day of December 2011.
A,t„t4e.- P".
." 40, 124.64...p._
Coleen H. Sullins, Director 1
C- Division of Water Quality
By Authority of the Environmental Management Commission.
UTC/5QM Conversion Page 1 of 4
Version 12/2011

PART I -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation corners) and shown on an updated Site Map. The Permittee
shall submit this updated Site Map and retain a copy on-site.
5. In the event that there are multiple wells with separate clusters, one well identification tag per 'cluster' of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
PART II-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the P ermittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART III-OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated· at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
WH170 0'.:J '' . UIC/5QM Conversion ·
Version 12 /2011
Page 2 of 4
PART IV -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART V..:. MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall retain all records of repairs, pressure tests, maintenance, and other activities
needed to maintain normal operating conditions.
3. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Washington Regional Office, telephone number 252-946-6481, any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
4. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
5. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VI-PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
WI070 021 q UIC/5QM Con.version
· Version. 12/2011 ·
Page 3 of4
PART VII -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214 , including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) . In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations .
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3 . The written documentation required in Part VII (1) and (2) (G) shall be submitted to:
WI0 7 ()!l21'
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/5QM Conversion
Version 12/2011
Page 4 of 4
Rogers, Michael
From: Tina Stagg [tina@staggenergy,com}
Sent: Tuesday, December 13, 2011 12:14 PM
To: Rogers, Michael
Subject: RE: GeoSafe
We are just going with Environal on these now
Also I am faxing Rodewald GW1 now
Thanks,
Tina
From: Rogers, Michael i mailta:michael.rooers'a.ncdenrrr. ov
Sent: Monday, December 12, 2011 3:38 PM
To: Tina Stagg
Cc: vsochomoniarahounhton.com; Slusser, Thomas
Subject: RE: GeoSafe
Biosafe is OK as it is ethanol -based, which is on the approved list of additives for closed -loop systems.
Michael Rogers, P.G. (NO & FL)
Environmental Specialist
NC ❑iv of Water quality- Aquifer Protection Section (APS)
1638 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http:I/portal, ncden r.ora/web/wq/a os/ownro/penult-applications#geothermApps
E-mail correspondence to and From this address May be subject to the North Carolina Public Records Levi and may he disclosed to third parties
From: Tina Stagg f mailto:tina(istaogenerbv.com]
Sent: Monday, December 12, 2011 2:25 PM
To: Rogers, Michael
Subject: FW: GeoSafe
Michael,
This was a email we received back in November. Please let me know what happened.
Thanks,
Tina
From: Jeff Stagg fmailto:3eff bstaogenergy,cornj
Sent: Monday, December 12, 2011 2:09 PM
To: 'Jeff Stagg'
Cc: 'Tina Stagg'
Subject: FW: GeoSafe

Ro gers, Michael
From: Clark, Allen
Sent:
To:
Monday, December 12, 2011 3:14 PM
Rogers, Michael
Cc: May, David
Subject: W 10700219 Gillis
Michael,
WaRO does not feel it necessary to conduct site inspections prior to the issuance/conversion of Permit
WI0700219(Gillis), WI0700226{Frampton), and WI0700229(Turcotte) from type SQW facilities to type SQM facilities.
Thanks, Allen
From: May, David
Sent: Monday, December 12, 2011 1:25 PM
To: Clark, Allen
Subject: FW: WI0700219 Gillis
Allen,
Could you take a look at these and respond to Michael with your recommendations.
Thanks
David
David May, Regional Aquifer Protection Supervisor
Division of Water Quality
Aquifer Protection Section
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
E-mail: david.ma v@ ncdenr.q ov
http://portal.ncdenr.org/web/wg/
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Rogers, Michael
Sent: Friday, December 09, 2011 5:46 PM
To: May, David
Subject: WI0700219 Gillis
David-
1
Attached is a residential SQM geothermal application. They are converting from SQW to SQM. Please let me know if you
wish to conduct a pre-permitting inspection or not.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications#geothermApps
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
2
• NA
~C DENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Timothy Gillis
Susan Gillis
29255 Superior Circle
Easton, MD 21601
Coleen H. Sullins
Director
December 6, 2011
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI0700219
Timothy Gillis SFR
Injection Mixed Fluid GSHP
Well (SQM) System
Dare County
Dear Mr. and Mrs. Gillis:
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on December 2, 2011. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Washington Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
Sincerely,
0WtLA·~
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Tina Stagg -Pinkston Pump & Well, Inc.
Brian McDonald -Outer Banks Heating & Cooling, Inc.
Permit File WI0700219
AQUIFER PROTECTION SECTIOtl
1636 Mai! Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Bouievard, Raieigh. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Cusiomer Service: 1-877-623-6748
Internet: www.ncwaterqua!ity.org
A-:i Equal Opport.:,;~ \ fl_ffirmafive Action Employer
None n 1· _ ortb ;___;aro ma
/Vatura!ly
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 50M WELL(S1
X New Permit Application OR Renewal (check one)
DATE: 3/ S .2011
PERMIT NO.
(leave blank if NEW permit application)
A. PROPERTY OWNERS)/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): } 1r'1(l [} '1 `)1 j and LS U Sct v- j 1 l 1 {S
(1) Mailing Address: 2- 2- 55 5urei4❑tz GI j`2-C LG
City: EG 5 tt Y) State: N1 D Zip Code: Lt (O I County: -ra V$ DT
Home/Office Tele No.: '1) O — 8 22 - Z-923 Cell No.: (.7 51) - 341S - C 08 3
EMAIL Address: fit % (S Ver 7.-oh - rie-J
(2) Physical Address of Site (if different than above): a i 7 7UCI Ridge V 1 tctq e c4~.
City: DUCK State: NC Zip Code: 7-1C1County:
Home/Office Tele No.: (151) 3 45- R &3 Cell No.: (511 3i5 -q e&.
EMAIL Address: "h) I ) t f S 1 1)3 @ Verf zoo. in et
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:
R t \ Contact Person: EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No_. Cell No.:
Website Address of Company, if any:
C. STATUS OF APPLICANT
Private: X
State:
RECEIVED r DEP R
Federal: Commercial: Aquifer Prat/win', r4.
Municipal: Native American Lands: DEC 0 2 2011
GPU/UItC 5QM Well Permit Application (Revised 7/2008)
Pagel

D. WELL DRILLER INFORMATION
Company Name: PINKSTON PUMP & WELL. INC.
Well Drilling Contractor's Name: ---=H:..caO'-W""""-'A=RD=---C=U=-=-TI-=-=E=R'----------------
NC Contractor Certification No.: --~3=5-=-3-=-8--=-A~-------------------
Contact Person~ rll'l/1 S T/.J 6b EMAIL Address: VN/[e-mail]
Address: PO BOX 15482
City: CHESAPEAKE Zip Code: 23328-5482 County: CITY OF CHESAPEAKE
Office Tele No.: 757-421-2108 Cell No.: 757-438-9392
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: OUTER BANKS HEATING & COOLING
Contact Person:...: __ ___,B=RIAN==-:..=M=C=D=O=N:.o..A=L=D=------E=MAIL==c.e.A=d=d=re=s=s:'--"""'b=ri=an=@=ob=h=c=.c=o=m~ ___ _
Address: _____ ...:P_O=-=B:..::O=X..::..:.1_,_41=5'-------------------------
City: NAGS HEAD Zip Code: ---'2=7-=-9-=-5~9_ County: -----=D-=-A=RE~---
Office Tele No.: 252-441-1740 Cell No.: _________ _
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
NOT A WATER WELL
GEOTHERMAL CLOSSED LOOPS
G. WELL CONSTRUCTION DATA (Skip to Section H if this is a Permit RENEWAL)
(1) Proposed date to be constructed: tl.S a p Number of borings: (.a
Approximate depth of each boring (feet): 1.,0 D ' ~,&
(2) Chemical additives to be used in closed-loop system (only those chemicals incAe!~'tave been approved):
___ propylene glycol ___ ethanol GEO. rlttF..E ' other (other additives will need
prior approval by NCDENR before use) (; ~ V l fl-v ,J Al_
(3) Type of tubing to be used (copper, PVC, etc): __ _,HD=-~PE=---
(4) Well casing. Is the well(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES ___ if yes, then provide casing information such as~ (steel, PVC, plastic, etc.), diameter,
depth, and extent of casing appearing above ground: ________________ _
(b) NO X
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite _x__ Other (specify) ______ _
(b) Grout depth of tubing (reference to land surface): from O to 200 (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
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.
GPU/UIC 5QM Well Pennit Application (Revised 7 /2008) Page2
LOCATION OF WELL(S)
•
Attach two copies of maps showing the following infirmatton:
(1)
Include a Site ritiaP (can he dra*n) showing buntfulgai: propeity lies, ;.sue:•' r; t :mat
sources of groundwater c a i i.the ones dr d es � theroposed s)
ang existing wags) ordisposal f r *It as s p ictanks or drain fields tlot witia of
fife geothermal hOaltalittil wet sys. Label all features clemiy aid dude aria► emit
(2) The Site Map mustshow the subject property in relation to the surrounding area by using at feast two fixed
reference points suzh as muds, streams, aidfur highway intersections.
�. CERTIFICATION
Nater This Pewee Appl ention attest ba signed by each peseta rappeoring.on the
recorded legal property deed.
9 hereby certify, under penalty of Law, that I have personally fined and am famiimr with the informahwi
submitted is this document and all attachments theleto and -that, based on my _ inquiry of those individuals
immediately re able fir obtainingsaid information,' t eL v 1hatthe informal= is true, accurate and complete.
i am aware that heware sign-Ercnt penaltieinehkfmg the possal lit of him: and imprisanment for sung
fade information. I agree to c onstn ope , repairand is :appliphle, abandon the injection well and
all related appurtenance; in accordance with thearsra < � s -ocuarki ereldffions of the Permit-2'
Wnstore ' 1 rQt v OwnerfApplicant
Pit or Type Full Name and tide
:+mature oTPRI.perry OwnedApplica m
0 1- ..i f
Print or Typed Name and title
Signature ofAtnhorized Agent. if any
Print or Type Foil Name and title
Please return two copies of the completed Application package to:
North Carolina D1M- DWQ
Aquifer Protection Section - TIC Program
1636 Neil Service Center
Raleigh, NC 27699-1636
Telephone (919) 7I 935
Get three 3QW Notification of intent Form (Revised 8i2008)
Pege3
RECEIVED ! DENRO M
Aquifer Protection Section
DEC 12 Nil

Dec 08 11 11:41 a Pinitstorr Geotherma4
757-421-2108
p.21
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TOTAL COVENACENtF-A-4,55asq-11. (15.1%./
DUCK RIDGE
VILLAGE GIRT
ASPHALT CUL-DE-SAC
LEGEND
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L dAUUgF !URN CERTFY MARINER KY
DP C11Q LAND SUPERVISION TH13 PLAT WAS
DRAWN F.ROA1 AN A 1 T[L4 L FIELD SURVEY A S PER
RECORaEO DESCRPPTk3N: 77•154117i6 I ❑ OF
IGCIL AT PRECISION AS CAED rs 7.14.000+,- TI!A T TFA'S
eitAr WAS PcoutR O IN ACL7FAANCE VI1TH
N C.A.C. TrILE27, Cf4APTER 56. SEOTrQIV I60R
WrIvE .sAlrrw et eso 4Fa 7
1F1Ka awexpauir rfimaL1 &MA? C R J
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CG.1.1w.e..OraaitOmpGf.MOau
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T6FSISP '
'Mr
SITE PLAN FOR
Timothy G. Gillis
& wife Suzan L. Gillis
Lot 10
Duck Ridge Village
ATLANTIC 70XIN:HIP
DARE GOON
NORTH CAROL/No
EASTERN
GEOMATICS, PLLC
PROFESSIONAL SLIFVEYIIVG SERVICES'
P_0. BOX 1026
005 Saver iew Drivel.
KILL DEVIL RILLS. N. . 27948
FIRM UM P-7733
Phi0ANE/FAX` 252 441-4590
FCENED ! OEM / p
Mit
quiferProtnj Se 0
DEC4 S 2OU

Dec 0811 04:35p Pinkston Geothermal
757-421-2108
p.3
RESIDENTIAL WELL CONS RUCTION RECORD
North Carolina Department ofEnvironmenl and Natural
WELL CONTRACTOR CERTIFICATION # N'
i. WELL CONTRACTOR:
IHOWARD E. CUTTER
Well Cow (individual) Name
PINKSTON ]PIECE $c FUMP COMPANY
Well Contractor Company Name
$30 8 IEFJT ROAD
Sired address
CHESAPEAKE V4 23322
City or Torvrr Slate Zip Cade
r 757, 418-2036
Area code Phone number
2. WELL INFDRMATIoil:
WELL CONSTRUCTION PERM1TT
OTHER ASSOCIATED PERMtT#tu appiirmi4ep 0TQ0219
$REY1rELI, Ill tt{Aaocablai
3. WEL1. USE (Check Applicable Doxr Residential Water Supply p
DATE CRUED_0i/Q012011
TIME COMPLETED 5:00 AM © PICA ffir
d, WELL LOCATION:
CITY: DUCK couNTYDARE
117 DUCK RIDGE VILLAGE COURT
IStreetNenre, Numbers, Corrnnw ity, Lot Nu.. Parcel. Zip Gado
TOPOGRAPHIC f LANO SEi TING: ides ap9rarnate box)
❑Slops ❑Vail) IFiet ❑Ridge °Other
LAT}TUDE 36 " 11) ' 55,11074 ' CMS OR 3X-XXXX.tx XX CO
LONGrwoE 75 45 ' 1eletia " DMS OR 7X.00c(xxxiot CO
Latitudelbngilude sOLren: tiGPS Dropographin map
(aocation or wee must be shown on a USW topo mop andatlached to
this tow: if not using CPS)
d. WELL OWNER
TIMOTHY & SUSAN GILDS
Owner Name
117 DUCKRIDGE VILLAGE COURT
Street Address
DUCK N, 27949
City or Town State Zip Code
Area code Phone number
I. WELL OVALS:
a. TOTAL DEPTN:6 200'
b. DOES WELL. REPLACE EXISTING WELL? YES o NO g
t~ WATER LEVEL Wow Top cf Casing NIA FT.
(Use "4• dAbove Top of CaslrtgJ
d. TOP of CASING Is NIA FT. Above Land Surface'
'Top at casing terminated alter below land reface may naquire
a variance in accordance oi71 15A NcAC 2C .9119.
e. YIELD (Or Nf& METHOD of TEST NIA
I. DISINFECT1OIL Type N/A Amount N/A
woos- Division of Water Quality
WC3S38-4
g. VIAL ZONES blepthy
Top NIA Bottom NIA
Top Bottom
Top Bun
r_ CASD$: Depth
Top WA Bottom NfA FL
Top Bottom
TopBottomBottom
Ft.
Ft.
RECEIVED L'LNF ! OW❑
Auulte F'mrpr11r�11 Se ion
DEC 4 8 2011
Top Bottom
Tap Bottom
Top Bottom
Thickness/
Diameter Pk lgttt Ma%rlal
a. GR Depth Material
Top 0' Bottora20nr Ft. BENTONITE
Top Bottom Ft.
Tip Bottom R. '
Method
PUMPED.
9. SCREAM Depth Cilerrmar Slot Sixo Meterltl
Top NIA sottiun NIA Ft in. in.
Top &Atom FL_in. in_
TopL Bottom Ft in. in.
10. SANDGRAVEL PACK:
Depth Size M1aaderial
Top NIA Bottom NIA
Ft
Top Bottom Ft.
Top Bobom Ft.
11. GIRL NG LOG
2
Top Bottom Formation Description
0 00' NO SAMPLES TAKEN'
THESE ARE CLOSE LOOP
GEOTHERMAL LOOPS.
WATER CIRCULATION ONLY.
6 HOLES DRILLED TO 200'
AND GROUTED TO THE TOP.
THIS IS NOTA WATER WELLI
12. l RRK,S-
clO$Ep LOOP QEOTIJEMALIMELICRCuLATION
ONLY! j
l CO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH ISA NCAC 2C, WELL CONSTRUCTION
STANDARDS. AND THAT A COPY OF THIS RECORD t4AS BEEN
PROVIDED TO THE WELL OWNER-
,/ R,e � orEai t
SIGNAT[#REOF ERTTFiEU WELL.WELL.DAT
ONTRACTOR DATE
HENNA 1l D E PORKY' CUTTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of COmplPtion to: Division of Water Quality • infomlalion Processing,
1617 Mail Service Center, Raleigh, NO 27699-161, Phone : I919) 1107-6300
Farm GW-ta
Rev. 2109

Permit Number WI0700219
Central Files: APS SWP
04/04/11
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael-rogers
- Coastal SW Rule
Permitted Flow
Facility
Status
Active
Project Type
New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Jeff Stagg
Driller Well
PO Box 15482
Chesapeake
VA 233285482
Facility dame
Timothy Gillis SFR
Location Address
117 Duck Ridge Village Ct
Duck NC 27949
Qwngr
Owner Name
Timothy
Dates/Events
Gillis
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Timothy Gillis
Owner
29255 Superior Cir
Easton
MD 21601
Orig Issue
04/04/11
App Received
04/04/11
Ienulated Activitle
Draft Initiated
Scheduled
Issuance
Public Notice Issue Effective
04/04/11 04/04/11
Expiration
Heat Pump Injection
Private residence, single family
Outfall I `LiLI-
Waterbody Name Stream index Number Current Class Subbasin

ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coieen H. Sullins Dee Freeman
Governor Director Secretary
04/04/2011
Timothy Gillis
Suzan Gillis -
29255 Superior Circle
Easton, MD 21601
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0700219
117 Duck Ridge Village Court
Duck, NC 27949
Dear Mr. and Ms. Gillis:
On 04/04/20I1, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onh
geothermal injection wel] 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 wel] system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter.021.3, and
3. The required notification form and associated reaps 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.Rorers:a.ncdenr_t ov if you have any questions.
Sin rely,
for Deb tts
Supervis
cc: Washington Regional Office - APS
APS Central Files - Permit No. WI0700219
Dare County Health Dept.
Jeff Stagg (Pinkston Pump and Well, Inc., P.O. Box 15482. Chesapeake. VA 23382)
Brian McDonald (Outer Banks Heating & Cooling, P.O. Box 1415, Nags Head, NC 27959)
AQUIFER PROTECTION SECTION
1636 MOH service Center, Raleigh, Nary} Carolina 27699-1633
Laotian: 2728 Capital Boulevard, Raleigh. North Carolina 276Og
Priori : 919 33-3221 I FAX 1.919.7 i5.D588: FAX [phone] Guslorner Service: 1.877-523-6746
Internet. www,newateaivaltt.aro
- Ea,:. is^ xr:.• Amrma;,ve r. ue Emrnrnr.
NorthCar©lina
,Vaturall

Apr 04.11 01 58p
p.1
Pinkstan Pump & Well, Inc.
P Q Box 15482
Chesapeake. VA 23328-5482
(757)421.21N 1(556) 749-1980
facsimile transmittal
To: Tvnya Fax [phone]
From: Debbie Sanders Date: 04/04/11
(debbienateggenergy com)
Re: Gillis, 117 Duck Ridge Village Court Pages: 5 (including cover sheet)
CC:
0 Urgent 0 For Review ❑ Please Comment 0 Please Reply ❑ Please Recycle
•♦ ■ ■ • •
For the above referenced, following is our application for Type 5-QW Wels/Geothermal
Closed Loop with property site plan and will be forwarding two (2) copies, via US meii
today.
Thank you for your time: Tonyal
RECEIVED 1 DENR I I]WU
AQUIfFR pROTFCTInN SFCTIO
APR 04 ZOit
1 •

Apr 04,11 01 58p
1Zina)DJ 9
p2
NORTII CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDE1JR)
NOTIFICATION OF INTENT TO CONSTTUC ' A cUOSED-Labe GEOTHERMAL
WATER -ONLY INJT CflON WELL SYSTEM:
TYPE 5-Ow WE1.14S)
In Accordance with the provisions ofNCAC Tide I SA:O2C,62QO, please
complete this notific .lion and mail to address on the back pap (please ekat or Tyre, information),
DATE.: try i-' , 2Y i
Wr11 Type Confirmnari n: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid firm the onvirnnmeat
dosed -Ivor)?
Yes X_ Continuo completing this form.
Na .... Do Not complete axis farm, Complete other UIC application forms for installing
either a SA7 well (open -loop well fnjeoting potable water into the aquifer) or a SQM well (closed -
loop well a mtaining additives such as R•22, cthanoi, or other antifreeze or corrosion inhibitors).
A. PROPERTV OWNFR4S)IAPPLICANT(S)
List cash Property Owner fisted on property dead (if owned by a hucinees rrr gc►varnment agency, MAU name of
entity and 6 reptc5entat:ve wfnthhority for sigiature): Timothy and Suzan CI- illis
(1.1 Mailing Address: 29255 Superior Circle
City: i astro% Starr; MD Zip Code:
Hots Offce Tele No.: 4M-822.2923
216D I County: Talbot
Cell No.:757-345-9883
Email Address: tgillis lO sfuvverizon.net Wehsftc:
(2) Physical Address of Well Site (if different than above): i ] 7 Du&hRic Vslla2e Court
City: Me State: NC, Zip Code: 27949 County:
4omc/Ofiiee Tele No.: "`AI-345-0883 Coll No.:157-345-98$3
Dare
$. AUTHORIZED AGENT OV OWNER, IF ANY (if the Permit Applicant does not owl! the subject property,
attach a letter from the property owner authorizing Agent to install nod operate UIC well)
Company Mane
Contact P+erson: FMA1L Address:
Address;
City; State: Zip Code: County:
Office Tele No.; Cell No.:
Website Address of -Company, if any:
GFU� tC SQW Notification o(1 n: fnrmfRvri cd RRUatI
RECEWEO+CIE* r(}Vlll.1
AratlIFM'PRtiT�'.i1C111 SFC ION
APR 0 4 20t1
Pit

Apr 4d 11 01.58p
p.3
C. WELL DRILLER tNPORMATION
Company Name: PINK TON PUMP AND WELL, INC
Well Driller Contractor's Name: HOWARD E. CUTTER
NC Contractor Certification No,: DRILLING #3538-A H-3 #2Q3277 JEFFREY A STAGC
Contact Person JEFF STAGE EMAIL Address: ie1rOstaf £enerr com
Address: PO Box 15482
City: C i{ESA PEA K 4. VA Zip Code:. 33$2 County:
Office Tele No.: 7S7-421-2108 Cell No.. 757.438-9392
D. HEAT PUMP CONTRACTOR HIFORMAT1Ur1i (tidtit%-cat than driller)
Campary Name: OuteraanIcs Heatin&& Coolin
Contact Person: Brian McDonald . _ EMAIL Address: brian,+7a.obhc.com
Address: Po Sox 1415
City: Napa kiead _ Zip Code: 279S9 County: Dare
Office Tele No.: — 252-44 i-1 740 Celt Net:
E. STATUS OF APPLICANT
Private: X FcdcrAi: Commercial:
State: Municipal: Native American Lands: —
F. INJECTION PROCEDURE (briefly describe how the hijeetion well(;) will be used)
NDT A WATER WELL - GEOTHERMAL CLOSED LOOP
G. WELL CONSTRUCTION DATA
(i) Proposed date to be constructed: ASAP Number of borings:
Approximate depth of each boring (feet): 200
(2) Type of tubing to be used (copper. PVC. etc): IMRE
(3) Well casing. Is the well(s) cased? (check either (a.) Yes 111 (b.) No below)
(a) Yes if yes. then provide casing Information below
Type: __galvanized steel black steel_ 'pilltie other (specify)
Casing depth: Fran w feet (reference to land surface)
Casing extends to above ground inches
(b) Na X
(4) Grout Info (material surrounding welt casing andlorpiping):
(a) Grout type: Neal Cement Bentonite X Other (specify)
(b) Grout placement: Pumping X Preesure Other
(c) Grout depth of tubine, {reference to tend cur acv): from 0 _ to 200 (feet)
If well has casing, indicate gout depth: Horn to (feet)
GPUNIC 5QW NotiGaerioct of IALsrt Farm (Rcvisad snoop
REDENEDfDEW iADIU4
FFRpRD';>~C:Z01
APR 042.011
PI2

Apr041101:50p
p.4
< Punllc 5QW Notifimitioli o1 bud Farm Otev;sedi RRaaa)
11. INJE CT1ON-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment aid exterior
pipinzitubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
1. LOCATION OP WELL(S)
Attach two crvies of maps showing the following information:
(1)
Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources ofg-oundwater comamination and the orientation of and distances between the proposed ► elt(s)and
any existing well(s) car waste disposal facilities such as septic tanks or drain yields located within 290 feet of
the geothermal heat pternp well system. Label all features clearly and include a ndrt ,,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, andior highway intersections.
J. CERTIFICATION
Note: This Permit Application most he signed by each person Appearing on the
recorded lima property deed.
"1 hereby ee11fy, under penalty a( law. Chat 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 nesponsible tar obtaining said information. l believe that the information is true. accurate and complete,
1 am aware that there are significant penalties, including the possibility of lines and imprisonment, for submitting
false information. I agree to construct. operate. maintain. repair, and if' applicable.. abandon the injection well and
all rebated appurtenances in accordance with thnppror tines and ennditirmc of the Perro
AireAr
•
gnature . Party nwncrfApplicant
a 7 471 S4cr.;4/
i'rintorType Full .Name and title / •W°j
i '''gyp{
S;grmture oT Property fhvnerJAppiieant
. 4 / r
Print or Type tall! Name aid title
Signature of Authorized Agent, Warty
Print or Type Pull 'Marne mad title
Please return two copies of the completed Application package to:
North Carolitcta DENR-DWQ
Aquifer Protection Station-LUIC Program
I636 Mail Scrricc Center
!Weigh, NC 27699.1636
Telephone [phone] RECEIVED I UF.tyR. I uvU
AOUTVz PRiiTFr.l( i sFcT3oN
MR 04 1O11 Pagel

Apr 04 11 01 59 p
p-5
5EZ Lcof A+2 A rt2.
6.f
r
MAE
1. AREA SVCOGRDIMAT£COMFVTATA7ry•i0.O3ti ,A.
2. F I,aM, $ONg Si1BJECT TO ONANGE SYF, E.MA.
S. IT1S TILE SOLE RESPON51k11t7YOF TFIEPEI irriNG
ARINTCIPA GTY TO VERIFYSITE COMPLIANCE MN ALL
•OPINMSNO6S. ZONING, 4 9ETE14Gf$REQUIREMENTS
MCA TO 71-EJSSUANCE OFPERMITB. SURVEYOR,S{k)fES
NO GERTrFICATlONAS TO COMPFLIANCESErtHERSHOWY
OR IMPLIED.
4 MIS SURVEY ISS TcaVYFACTS Par MAY HE
OfSCLOBL'OBYAPULL AHOAGCINATETI-ra,S AR H
6c cvanRCY$AREA
fmle—L WO AREA • 1, R74.ra k
CDVT.Z2ECK4REd.p4459
MTA MIRA GE A REA.2 ,SIONg.0.0E1W
DUCK RIDGE
VILLAGE COLJ1 T
(30' PA41
ASPHALT CC1L.OE--SAC
_ M.`.:
...I., ..A �s• ;;•'4r.
PRIwft.
u.arrr
LEGEND
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POa+rAJ
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11
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▪ C.E,aerrn
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CURYE TA9LE
CURVE j CEr>rP1
RAD/OS DIRECTION
as ca
Nacanyws
=TANG/ 4
31.9A'
f.04c•c nlsrevehar
RG E. SA. 7dr rH?
9
Nr5
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fltl�rrr
y � Mwilrliwl
f !D
SCHOONER Row PH $E
tP.0 a. sL.39Y1
g
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50
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965Nnta 4,13
r1Jerrf
D 198
•!1 r IOa
1.
00901120N2
.1.1•. wr
L.gri
-Mac E Otr CERTIFY NMAT LINCFRMY
Q ECTrONANO SLNERVISICN RIG PLAT WAS
ORAi4N MON A N AG TL41 L PIEf.!? SURVEY AS PER
riECCFPQEOCEBCYYPTRA. MAT Tr1E Mr10 OF
P'wC iahav AS CALCW.ATED IS 1, 10,000+. TWI4T NZ
PLAT LigoW PREPAREaINACICMANC; Vnrrl
N.C.A C. PIA 24, O AP'r # 56, sECrlow 1640
Au K1SP
BUM
krIC
sa P2VY
Timothy JG. Gillis
& wife Suzan L. Gillis
Lot la
Duck Ridge Village
ArL4Nr7C 71 f,VA SKA'P
DARE COWRY i 114,4771 CAROL/NI
EA STERN
GEOMA TICS, PLLC
'PROFESSIONAL 5UR'vffv!NVG SERV CES"
o SOX lots
(305 Soundvrew Onve)
KILL DEVIL KILLS, MC. 27948
ALL
FIRM LIC#: P.Q733
PF1ONE 1 FAX. [phone]M
CE$VEL7 / DENR t
PP' PPfl Ff'TION RFCTION
APR 4 4 2011

\f\J \ {)"'100 c}.\9
. . N0RTII CAROLINA . . · .
DEPAR.TMENTOFENVIRONMENTANDNATURAL RESOUR.CES (NCOONR) .• ·
NOTIFlCATION OF JNTENTTOC!ONSTRUCf ACLOSEJ>..y)OP GEOTIJERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-0W WELL(S l
In ACC()t'dance with the provisions ofNCAC Title lSA: 02C.0200, please
complete1hisnotification and mail to address on the back page.(please Print or .~ information).
DATE: ----'-~-diY{.h __ a-....;;;·~-· _ __, 20.Ji..
Well Type Conjirmatiow. Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates tne fluid irom the environment (Le.
closed-loop)?
Yes _X_ Continue completing this form.
No __ Do Not complete this fonn. Complete other UIC application forms for installing
either a SA7 welt ~-loop well injecting potable water into the aquifer) or a SQM well(closed'.'"
loop well containing addith1es such as R-22, ethanol, or other antifreeze or <:orrosion inht'bitors).
A. PROPERTY OWNER(S)/APl'LICANT(S)
List each PropertyOwner lisred on property deed (if owned by a busines.,; or government agency. state name of
entity and a represen1ative w/authority for signature): Ttmothy and Suzan Gillis
(I) Mailing Address: __ -=2~9~25,:.,,:5=-.!,S~u~pe~n..,,·o~r C~ll'C~-~le,,,__ ______________ _
City: Easton State: MD . ZipCode:. __ --=21 .... 60=-=-t-· Coonfy:._,,1'-=albo=· :=t'----
Home/Office Tele No.: 41 0-82 2-2923 CeU No i:757-345-9 883
EmailAddreSs:. tgil1is [e-mail] Website:
(2) Physical Address ofWeU Site (if different than above):· _ __,l....,1.!..7...,D'""'u,,.,,ck"'"'R""i""'dg=-==e,_Vi,,_,iD,.,,ag=e_,,C::eo~llit~· ·---
City: . Duck State: NC XtJHZooe: ----=27:..::9;._,.49~. County: Dare
Home/OfficeTelaNo.: --'-75=-7""'-3-4=5_,•9=8=83=------=C=ell='=N=o•::;.:7:.::SC!.7--==3'-".45"'--=98,.,,8=3'--------
B. AlJTHORIZED AGENT OF OWNER, IF ANY [tftbe Permit Applicant does not own the subject property,
attach a Jetter from the property owner authorizing Agent to install and operate UIC well)
· Company Name:
Contact Person: EMAJL Address:· -~-------------=====ee._ ________ _
Address:~----------------------------
City: . . State: __ ZipCode: ______ County: _______ _
Office Tele No.: _______________ Ce=ll:..:N~O:,a:;-=-: ----------
Website Address of Company, if any:. _____________ _
GPU/UIC SQWNotificatioo oflntenl Fonn(Rmscd 8/2008)
RECEIVED/ DENR / DWQ
Aquifer Proter.tion Section Page 1
APR O 8 2011
C. ·• WELL DRILLER. INFORMATION
Company Name: PlNKSTON PUMP AND WEL L.1NC
Well DrillerContractor•s Name: __ _..!.H£!O~W.~ARD=~-~E.~CUTTER~..!..!:::=-------------
NC Contractor Certification No.: .... D~R~IL~L:!!.ING~. :!::.·#!t:3!::!5~382::-Aa· ___ · ·....!H~.:.~3 .!!:#2:::92::!!:· c!..77!..c:J:2:2.BFFRE-~·=y~--..£.A=·~S~TA..,.G=·· ·=o _· __
Contact Person: JEFF STAGG EMAIL Address: je ff@.sta ggenergy .com
Address: _-"--....!PO~B!::!:ox!:!'2..;t!.::5::!48~2~-----------------------
City: CHESAPEAKE, VA Zip Code: 23382 County: ___________ _
-Office Tele No,: _757-421-2108_~---· __ Cell No.: __ 757-4js.:.9392 ___ -"--___ ..;,._;._____;_
D. HEAT PDMP .(:ONTJlAciORINFO~tlONflf differenttbiln driller)
Company Name: Outer Banks H eating & Coolin g
ContactPerson: _Brian McDonald ___ _ ____ EMAIL_Ad~:___ _ _____ l>mu.i@ol>~~.:~m,. __
Address: PO Box 1415
City: N ags Head _ Zip Code: 27959 County: __,Do:<lare=-________ _
Office Tele No,: 252-441-1740 Cell No.: ________ _
E. STATUSOFAPPLlCANT
Private: .x_
State:
Federal;
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (brieflydescn"'be how the itijemon well(s) will be used)
G.
NOT A WATER WELL --. GEOTHERMAL CLOSED LOOP
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: __:..A=S,.__,A"',-.P ___ _...,;._Numberofborings: ___ _
Approximate depth of each boring(feet):._.....c..::2=00::....,;_. _____ _
.(2)_ Type of tubing to be used (wpper, PVC, etc): -_-'-. a=·=n·=PE=--------------
(3) Well casing. Is the well(s) cased? (check either (a.) Yes !JI (b.) No below)
(a) Yes ___ if yes, then.provide casing information below
Type: __galvanized steel __ black steel____plastic __ othcr (specify)
Casing depth: From ___ to _..;___;feet (reference to land surface)
casing extends to above ground __ ....:inches
(b) No X
{ 4) Grout lnfo (material surrounding well casing and/or piping):
(a) Grout type: Neat Cemcmt_-_ Bentonite x Other (specify). _____ _
(b} Groutplacement: Pumpin g X Pressure___ Other_-_
{c) Groutdepthoftubing(refere~to1andsurface): fiom O -to . 200 (feet)
If well has casing. indicate grout depth: from ___ to (feet)
GPU/UIC SQWNotific:ation oflntent Fonn(Revised 8/2008) Page2
IL 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.
L LOCATION OF W ELL(S)
Attach two copies of maps showing the following information:
(]) 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 vueil(s) and
any existing well(s) or waste disposal facilities Rich as septic tanks oi• drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a worth 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 mast be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of .taw, that i have personally examined and am familiar with the information
submitted in this document and ail attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, ) believe that the information is true, accurate and complete.
1 am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I agree to construct operate. maintain. repair, and if applicable. abandon the injection well and
all related appurtenances in accordance with th rov +' inns and conditions of the Permit."
•
_
'3ignature o Property Owner/Applicant
Print or Type Full Name and title
?/?--17//
Si6iature o Property Owner/Applicant
0 .%Ait-r-a <1.k"" 3 ZiF,//:',
Print or Type Full Nave and title {
r
Signature of Authorized Agent. ifany
Print or Type Full Name and title
Please return two copies ofthe completed Application perk to:
North Carolina DENR DWQ
Aquifer Protection Section-U1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Aquifer Am
iectian S5r�i+at?
APR 0 8 2011
GPU/UNC SQW Notification of Intent Form (Revised 812008)
Palie3

!. NOTES
t AREA BY COORDINATE COILIPUTATTON=16,0 31sq.Y
2 FIRM ZONE SUBJECT TOQMN EBYF_ERHA
3 IT IS THE SOLE RESPONSIBILITY OF TIE PEAMfl 1NG
MUNICIPALITY TO VERIFY SITE COMPLIANCE VVITH ALL
ORDINANCE% ZONING, 8 SETBACKS REQUIREMENTS
PRIOR TO THE ISSUANCE OF PERMITS SURVEYOR HAKES
No CERTIFICATION AS TO COMPLIANCES EITHER SH0YV14
OR IMPLIED.
4. TEAS SURVEY IS SUBJECT ToANY FACTS THAT Amy 8E
DISCLOSED 8Y A FULL AND ACCURATE 7TTLE SEARCH
5. COVERAGE AREA
DWEUING AREA.1.45i$q.1
COVERED DECK ARRA-0441 4
TOTAL COVERAGE AREA 2,4pDSg2.{fa1%)
DUCK RIDGE
VILLAGE COURT
(30' RMO
ASPHALTCUL-0E-S4C
IYCv4714Sa4./
S64'1437'W
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179111
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11
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SITE s
127.E
is
V
CURVE TABLE
—CURVE
LENGTH' RADIUS I
DIRECTION
f DISTANCE
CT j
3Z.25' 40.00' i
MI'EF D`5579
37.38'
A
mar zwr.
P.0 8 SL 767-762 1485.9I21354 f5
P.
7fd97'1
9
VICINITY MAP
NTS
15
Ficiazda f73trx.t
Septic Talk
14
L""'
S87'51'04 W
6.12'
z
orfr
4 r„
i
0
0
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13
% Q
SCHOONER RIDGE PHASE 1
(P.C. E. SL 381) REY. 2N41f I Septic Layer
SITE PLAN Fa
Timothy G. Gillis
& wife Suzan L. Gillis
FScxxnrfo
D.EL I82Z P&..R48
r 1A U lrar
7C"
0091918Df0
PARA/ SUP
3120285900.1
7426YSP
aws
l"= 4ltf'
I, .IAM,F F FUPR CERRFY THAT UNDER MY
DIRECTION AND SUPERVISION THIS PILA.TWAS
DRAWN mom ANACTUAL FIE DSJRVEIASPER
RECORDED AESCRIP7?0N MAT THE RATIO OF
PRECISION AS CALCULATEDISS 1 fO00ti ,:74AT THIS
PLAT WAS PREPARED IN ACCbRDANCE H?TN
N.CAC. T[11: 27. CIiAPIEF}T36.:8EGTIQN /WO
IVIT AiY►fAA .4ME! =
;ullfl' - ACLar =-JW
7L. - 2011
1A rase Sal-SAMS<rlwl n.�fu >t2'
PaLAVALR ..Avr 71,9E11537 .67a;1 w-
CRA51," 7
ASe
Lot 10
Duck Ridge Village
ATLANTIC R9i'lNSWIP
D4RECOIAWY IYL7MPTWC4ROLAYA
EASTERN
GEOMATICS, PLLC
PROFESSIONAL SURVEYING SERVICES"
P.O. BOX 1025
(305 SauncIvIew Drive)
KILL DEVIL FULLS, N.C. 27948
FIRM L1C#: PI.0733
PHONE I FAX: [phone]

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 WELLS}
In Accordance with the provisions ofNCAC Title 15A: 02C_0200, please
complete this notification and mail to address on the hack page (please Print or Type information).
DATE: t Offikt a 2e I (
Well Type Confirmation: Does the proposed system circulate potable water city (no additives) in
continuous piping that completely isolates the fluid from the environment (Le.
closed -loop)?
Yes X Continue completing this form.
No _ Do Nat 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)/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 wlaathority for signature); Timothy and Suz n Gillis
(1) Mailing Address: _ 2925S Superior Circle
City: Easton State: MD Zip C 21601 County: Talbot
Home/Office TeleNo.: 410-822-2923 Cell .No,;7 345-9883
Email Address: tgiilis1034verizon.net Website:
(2) Physical Address of Well Site (if different than above): 117 Duck Ri&e Wive Court
City: Duck State: NC Zip Code: 27949 County: Dare
Home/Office Tcle No_: 757--345-9883 Cell No.:757-345-9883
S. 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 Narne: -
* Contact Person___ - EMAIL Address:
Address:
City:
Office TeIeNo.:
State: Zip Code:
Website Address of Company, if any:
GPTilUiC 5Ql[' Notificaticn of Intent Torn (Revisal 8/2008)
_ County:
Ce11 No.:
RECEIVED / DENR NOWt
Adler Prrtter.Iion Section Foci
APR 9 8 2011

.c. -. WELL DRILLER INFORMATION
Company Name: PINKSTON PUMPAND WELL INC
WeUDrillerConttactor•s Name: ..;__c_ _ __AH~O~W.!.!.,A~~RD~E,!!,... ~C~UITBR..!..· ·..!.!:!:~·----------
NC Contractor Certification No.: DRILLING #3538-A . H-3 #i29217 JEFFREY A. STAGG
Contact Person: JEFF ST AGO EMAIL Address: jeff@s ta ggene rgy.com · ·
Address: __;-'--_.c!P~OB!::!.o:!:!!K~l!,::5~4~82~-----------------------
City: CHESAPEAKE.VA ZipC-0de: 23382 County: ___________ _
Office Tele No.: _757-421-2108 ---------·-··--_ CellNo.: _757-438-9392 _________ _
D. HEAT PUMP <:::ONl:JIA.CTORINFOR.MATION (if different than driller)
Company Name: Outer Banks Heating & Coolin g
ContactPerson: BrianMcDonald _______ -•-·----~EMA= _U,A!;ldress;_____ bP!IDJ'@obhc.co111.,_. __ .
Address: __ _,,PO:...:::~B:.o:::::oK~J...,4:-=15"'-----------------,----
City: N ags Head Zip Code: 27959 County: ~D-· =are~--------
Office Tele No.: 252-44-1-1740_ Cell No.: ________ _
E. STATUS OF APPLICANT
Private: ..x_
State:
Federal:
Municipal: __ .
Commercial:
Native American Lands:
F~ INJECTION PROCEDURE (briefly desenl>e how the injection well(s} wiU be used)
NOT A WATER WELL-GEOTHERMAL CLOSED LOOP
G. WELL CONSTRUCTION DATA
(1) Proposeddateto be constructed: __,,_A=S=A=P _____ Numberofborfugs: ____ _
Approximate depth of each boring.(feel): _____ 2-00 _________ _
(2) Type of tubing to be used (copper, PVC, etc): HDPE -------------------
( 3 J Well casing. Is the well(s) cased? (checkeither (a.) Yes m: (b.) No below)
(a) Yes -_...;..___ ifyes,thenprovidecasinginformation below
Type: ___galvanized steel_-_blaek steel_J]astic __ 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) Grounype: Neat Cement_-_ Bentonite X Other (specify} _____ _
(b) Groutplacement: Pumping X Pressure_ Other __
{c} Grout depth of tubing (reference to land surf~): from .0 to 200 (feet)
If well has casing, indicate grout depth: ftom ___ to ____ (feet)
GPUIUIC SQWNotification oflntent 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
pipingltubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
L LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (canbe drawn) showing: buildings, property.11nes, 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 NO feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
rthrence points such as roads, streams, and/or highway intersections.
L CERTIFICATION
Note: This Permit Application must be signed by each person appearing en the
recorded legal property deed.
(2)
"I hereby certify, under penalty of law, that 1 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 infw-ruation is true, accurate and complete.
1 am aware that there are significant penalties, including the possibility of runes and imprisonment. for submitting
false information. I agree to construct, operate. maintain. repair, and if applicable, a.bandon the injection well and
all related appurtenances in accordance with thspnnv ' . ,loons and conditions of the Permit"
Signature ot.'Property Owner/Applicant
77,1f �
Print or Type hull Name and title
5i¢reattire or Property Owner/Applicant
per.a (� . : leaf
Print or Type Full Name and title
I
Signature of Authorized Agent. if any
Print or Type FuII Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-106
Telephone [919) 715-6935
RECEIVED DENT? 1
Oft
miter Prrltpclson Se
APR 0 B mu
GAUMC 5QW Notifintinn of latent Foam (R wised 8t24O8)
Rge.3

NOTES
ARE4 BY COORDINATE Cc PLITATIO=1B4O31$q.@.
2, F.I AI ZONE SUBJECT TO CHANGE BY1FEJriA
3. f IS THE SOLE RESPONSIBILITY OF THE PERM-TING
MUNICIPALITY TO VERIFY SITE COMPLIANCE W 4 ALL
ORDINANCES ZONING. & SE79ACKSREQUJRc+IRENTS
PRIOR TO THE ISSUANCE OF PERMITS_ SURVEYOR MAKES
N[J CERT7FICATOON AS TO COMPLIANCES EITHER SHOWN
OR IMPLIED.
4. TTiIS SURVEY IS SUBJECT TPANY FAC7S THAT MAY BE
QISCLOSED BY A FULi. ANO ACCURATE TYRE SEARCH
5. COVERAGE AREA
DWELLING AREA=7,956sq.L
COVERED DECK AREA $44strit
TOTA1, Wye -RAGE AREA=2,90Rttlit ['i8. 775)
DUCK RIDGE
VILLAGE COURT
{3O' RM
ASPHALT CUL-DE-SAC
Er=y-as &1.�,1i
,p0 f -,.rA
LEGEND
S64'14571AI
27.53'
Pm:ward Peal
Repair AMA
fmcaBj
FkrAramml Pls'aux
Cvard Q+irs...rkiag Area
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p-[phone]s*7
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1,.IQ A 2A
AE
127_22'
(LIT FEET )
1 la. _ to ft
CURVE TABLE
CURVE
LENGrrI RADIUS }'
DIRECTION
DISTANCE
Cr
3223' J} a i o3' 1
11170'511B'E
31.38'
asxaaeER
Pa Er St. 2122 985912EE4415
9
LOW
J ,Allow Rill
a
IP
SITE
YJ A�Av
VICINITY MAP
HITS
I
/ 1a
SCHOONER RIDGE PHASE 1
1 . 1
Puma goe
tat f87iR Pa 3di9 00981801D
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unmogra
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13
{P 8. SZ_ 30J REV. 2114171 SCpricLar-out
SITE PLAN FOR -
Timothy G. Gillis
& wife Suzan L. Gillis
1, JAWE F ,frt#2R CERTIFY MAT UNDER MY
DIRECTION AND SIIPB4VISION THIS PLAT WAS
DRAWN FROM AN ACTUAL FIELD SURVEY AS PER
RECORDED DESCRIInqk THAT THE R4TIo OF
PRi_COoNAS OAK:I/.AMB S411O,000+I THAT MS
FLAT ',VASPFOAREpINA 14,7714
N GA C TIY[ 2�: C9 4PTFW5&.SECJ N /Eva
1417 ESSi FfLlAiCFAIVO$54{ 7118
f'�F _ efp r� 2DIv
e Ylae;WLRp4EFHr. iie3 FJSTSiaft__
A.RE41,441464 4511D Bpbs3 FM.-7 ago
✓iEP
Lot 10
Duck Ridge Village
ATLANI7C 70I ISAYP
LARECQMVTY
EASTERN
GECMA TICS, PLLC
PROFESSIONAL SURVEYING SERVICES"
P.O. BOX 1026
(306 Sourxivievr Drive)
KILL DEVIL KILLS, N.C. 27948
FIRM LICO: P-0733
PHONE/FAX [phone]

Howard "Porky't Cutter
800 Dryden Street
Virginia Beach, VA 23462
RE-CE-:IVED / DE:NR / oyva
AQuifer Protection Sec ion
JUL 11 2011
Mr. Michael Rogers, P. G
DWQ-Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC3538 A
1. WELL CONTRACTOR:
HOWARD E. CUTTER
Weil Contractor (Individual) Name
P_INKSTON WELL & PUMP r..OMPANY
Well Contractor Company Name
Q36 BENEFIT ROAD
Street Address
G_HFSNDEAKE
City or Town State Zip Code
( 757) 418-2036
Area Code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMITS
OTHER ASSOCIATED PERMfTS(it applicable) W IQ7QQ219
SITE WELL ID iklf sppacsalal
VA 23322
3. WELL USE (Check Applicable BOx): Residential Water Soppy
DATE DRILLED 07[O6/201 i
TIME COMPLETED 5:QQ_ A i p PM ai
4. WELL LOCATION:
CITY: DUCK courny DARE
117 DUCK RID_Qg VILLAGE COURT
(Street Name, Numbers, Corrmwnity. StradtrIslori. Let No., Parcel, Zip Code
TOPOGRAPHIC 1 LAND SETTING: (check appnoprlete tax)
Slope E Valley 2rFlat p Ridge ° Other
LATITUDE 36 ' 14 ' 55 0000 " DMS OR 3Kit/000000X DO
LONGITUDE 75 e 45 • 1e10000 ^ DMS OR 7x.acix 00000t 17O
Latitudeftongitude source: itPS [)Topographic map
(location of well must be shown on a USGS topo map andatfached to
this form if not using GPS)
5. WELL OWNER
TIMOTHY & SUSAN GILLIS
Owner Name
.117 DUCK RIDGE VILLAGE cOJRT
Street Address
PUCE NC 27949
City or TWO State Zip Code
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 6 {$2Usl'
b. DOES WELL REPLACE EXISTING WELL? YES Ci NO
c. WATER LEVEL Below Top of Casing: N/A FT_
(Use "+' If Above Top of Casing)
d. TOP OF CASING IS N/A FT. Above Land Surface'
'Top of rasing terminated a11or below land surface Trey require
e variance in accordance with 15A NCAC 2C .0118.
a. YIELD (gem): NIA. METHOD OF TEST NIA
f. DISINFECTION: Type NIA Amount N/A
p. WATER ZONES (depth):
Top NIA Bottom N/A Top Bottom
Top Bottom Top Bottom
Top — Bottom Top Bottom
Thickness/
7. CASING: Depth DIarraater Weight Material
Top NIA Bottom NIA Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Malertal
Top DI Bomam200' Ft. BENTONITE
Top Bottom FL
Top Bottum Ft.
Method
PUMPED
9. SCREEN: Depth DlaMater Slot Stw Material
Top NIA Bottom NIA Ft In. tn.
Top Bottom Ft — In. in.
Top Bottom Ft in. in.
10. SAND/GRAVEL PACK:
Depth Sire Mate rlal
Top N/A Bottom N/A Ft,
Top Bottom Ft
Top Bottom FL
11. DRILLING LOG
Top Bottom Formation Description
0 120O' NO SAMPLES TAKEN!
r
I
I
I
1
1
I
1
I
THESE ARE CLOSE LOOP
GEOTHERMAL LOOPS.
WATER CIRCULATION ONLY.
6 HOLES DRILLED TO 200'
AND GROUTED TO THE TOP.
THIS IS NOT A WATER WELL!
12. REMARKS:
CLOSED LOOP GEOTHERMAL WATER CIRCULATION
ONLY!
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C. WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
SIGNATUR OF Wit/WELL CONTRACTOR
HOWARD E. "PORKY' CUTTER
01(07/2011
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mall Service Center, Raleigh, NC 27699.161, Phone : [phone]
Form GW-la
Rev. 2/09