WI0700168_GEO THERMAL_20110110 (2)

Permit Number WI0700168
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
UNC Coastal Studies Institute
Location Address
850 NC 345
Manteo
Owner
Owner Name
William
D at es/Eve nt s
NC
E
27954
Bagnell
Scheduled
Orig Issue App Received Draft Initiated Issuance
03/23/10 03/22/10
Re q ulated Activities
Heat Pump Inj ection
University/College
Outfall NU LL
Central Files: APS_ SWP_
01/10/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
William E. Bagnell
Associate Chancellor Vice
1001 E Fourth St
Greenville NC
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
William E. Bagnell
Associate Chancellor Vice
1001 E Fourth St
Greenville NC
Public Notice Issue
03/23/10
Effective
03/23/10
27858
27858
Expiration
Waterbody Name Stream I ndex Number Current Class Subbasin
,.
·w•~A ~e~~.». .-.-.1'-__ _
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
William E. Bagnell
East Carolina U niversity
1001 East Fourth Street
Greenville, NC 2 785 8
Coleen H. Sullins
Director
3/2 3/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0700168
1001 East Fourth Street
Greenville, NC 27858
Dear Mr. Bagnell:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on 03 /22 /2010 ,
the Aquifer Protection Section (APS) acknowledges your intent to construct a closed-loop geothermal water-onl y injection well
system for the operation of a ground-source heat pump located at 1001 East Fourth Street, Greenville , Pitt County, NC 2 7858 . This
system is deemed permitted by rule (North Carolina Administrative Code Title 15A, Subchapter 2C, Section .021 l(u)(2)). However,
please note boreholes shall not connect separate aquifers, which have differences in water quality (e.g., shallow surficial aquifers,
saprolite, fractured bedrock, etc.) as specified in 15A NCAC 2C .0213(d)(8)(C).
Please notify the Washin gton Regional Office at (25 2) 946-6481 at least 48 hours prior t o well installation . Additionally, it is
recommended that you contact the Pitt County Health Department, as they may have additional construction or permitting
requirements for this type of system. If you modify your system at any time , including the addition of antifreeze, corrosion inhibitors,
or any other substances to the circulating fluid , you must contact the APS to verify compliance with applicable rules .
Thank you for submitting this notification. If you have any questions please call me at [phone] .
cc : Washington Regional Office -APS
APS Central Files -Permit No. WI0700168
Pitt County Health Dept.
~,~~
for Mic~ogers
Environmental Specialist
GPU-Aquifer Protection Section
Charles Dozier (Toano Well and Pump Service Inc., 1933 Forge Road, Toano, VA 231 6 8)
AQUiFER PROTECTION SECTION
1636 Mail Service Center, Rale igh , North Carolina 27699-1636
Locaiior.: 2728 Capital Boulevard. Raleigh. North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-674&
Internet: www.ncwaterquality.oro
An Equal Opportunity I Affirmaiive Action Employer
Ni~thCarolina
J\7aturall!f
03/22/2018 15:35 17575SG9073 TDAND WELL AND PUMP PAGE 01/03
NORTH CAkOLYNA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF E14TENT TO CONSTRUCT A CLOSED -LOOP GEO RMAL
WATER 91ge INJECTION WELL SYS'l FM
TYPE SQW )JEU(S)
in Accordance With tiro ProvisionS of'NCAC'T'ift 15A 02C.0200
prim nr type the required information and mail to address on the back page
DATE: 20_10�
Well Type Conf#mofion: Does the proposed system circulate potable waff gnb� (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
lose
Yes Continue completing this farm.
No Do Not complete this form. Complete other UIC application forms for installing
either a SA7 well Lo.Mn-Ioop well Lniecti potable water into the aquifer) or a 5QM well (ciosed-
Ioap well containing addi ' -cs such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. MOPERTY OWNER(SYA"LICANT'(S)
Fist each Property Owner listed au property deed (if owned by a business or government agency, state name of
entity and a representative w/aut#to,-ity for signature): A,rgA-Okry keft�-
(1) Mailing Address- too I
City: Sterol CC. Zip
1-IotnelOffice Tele No.:-
l?rtxail Addrrss:�A.g, - Wh t
rrJJ Q ��Pr�0—
(2) Physical Address of Well Site (If different than above): _
City: _ State Zip code., Courtly: _
Home/Office Tole No.:---
B_ AUTHOWEI] AGENT OF OWNER, JF ANY (if the Permit Applicant does n own the subject proparty,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person- _ EMAIL Adc4=1
Address:
City: State: Zip Code: County:
Office Tele No.: Ca No_:
Websitc Address of Company, if arty:
GPUARC SQW Nodfiicatiw oftn=t Form (Revised Rl2we) i EL;EIVED i OENR I DWQ Pw i
AQUIFF'R PP07Ff:TION SECTION
MAR 2 2, C010

03/22/2010 15:35 17575669073 TOAN□ WELL AND PUMP PAGE 02/03
C. WELL DRILLER INFORMATION
Company Name: ToMo Well and Pump Secyice Inc.
Well Driller Contractor's Nmne: A._~_v_L____.(J""l''--'~:.;,_.r::$0'---'°'--------------
NC Contractor Certification No.: ....:3:::;.1./,.!.....!f:.-I _________________ ~_
Contact Penon: Charles Dozier EMAIL Address: ood [e-mail]
Address: P.O Box :306. 1933 Forge Road~--------"-----~------
City; Toan o Zip Code: 23168 Cotmty: JamesCityCountyVlrginia~---
Office Tele No.: _7S7-566-0377 _____ Cell No.~ _757-784-4941. _______ ~_
D. BEAT PUMP CONTRACl'OR INFORMATION (if different than driller)
Company Name:. ___________________________ ~
ContactPcrSOni...~-----~----------!=E,cMA=l~L.!,,JA~dx,dres.,"""""'-: _________ _
Address: ________________________ ~-----
City: ________ Zip Code: ____ County: ___________ _
OffiC(') Tele No.: Cell No .: ________ _
E. STATUS OF APPLICANT
Pr~:
State:...X:
Federal: __
Municipal:_
Commercial:~
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the ·injection well(s) will be used)
.lnSfa.ll lcl9sed Qeo-ThemUJJ IoQp to measun, the the,rmal conductivity oflbe aound.
G. WELL CONSTRUCTION DATA
(1) Ptoposed dale to be construoted: J/:J/L 10 Number of borings: _1 __ _
Approximate depth of each boring (f'eet):_300 _____ _
(2) Type of tubing to be used (copper, PVC, etc): _3408 HOPE ___________ _
{J)'Wcll casing. Is the weU(s) cased? (oheelc. either (a.) Yea m: (b.) No below)
(a) Yes ___ if yes, then provide C8$ing infonnation below
Type: __galvanized steel _black steel_plastic_other (specify)
Casing depth: from ___ to ____ feet (reference to land surfaQe}
Casing extends to above ground __ ......:inches
(b) No _x_
(4) Grout Info (marerial ~unding well casing and/or piping):
(a) Grout type: Neat Cement_ Bentonite _X_ Other (specify) _____ _
(b) OroutpJacement; Pumping___X~ Pressure_ Other~
(c) Grout depth of tubing (merence tn land surface): 1mm _o_ to __ 300_ (niet)
If well has casing. indicate grout depth; ftom ~--to ____ (feet)
GPU/UIC SQW Notification of Intent Form (Rcvi:5Cd 8120-08) P11ge2
03/22/2010 15:35 17575669073 TOANC) WELL AHD PUMP PAGE 03/03
H. INJECTION-iRELATFI) EQUUnYWANT
Attach a diagram showing the engineering layout or proposed tnodificstian of the injection equipmwt and exterior
piping/tubing assvciawd with ft injection operation. The manufacturer's brochure may provide supplementary
information.
L LOCATION OF W19L14S)
Attach two copies of maps showing the following infarms>son:
(1) Include a Site Mafia (can bt:. drawn) showing: buildings, property lines, surface water bodies, pmntial
sources of groundwfatar contamination and the crientatian of and distances between the proposed well(s) and
any existing well(s) or waste diVosal facilities such as septic tanks or drain fields Inested within 200 feet of
the geotf heal hew pump well system. Label all features clemly and include a north arrow.
(2) The Site Map must show the sutr ect property in relation to the surrounding area by using at least two fixed
refemnce paints such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legsd property deed
41 hereby certify, under penalty of law, that l have personally examined and am familiar with the informations
submitted in this document and all aMehments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is trite, accurate and oomplete.
1 am aware titer there are significant penalties, including the possibility of fines acid imprisonment, for submitting
false id6rmation. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specificatjonB and conditions of the Permit_"
5igrsaturG of Property t?wner plica;st
Print or Type Full Name and title 4r~ 12 S oipe� -S
Signrntlxne of property Owner/Applicant
Print or Type Full Name and title
Signature of Authorised Age- . if any - -
1?rirrt or Type Fu11 Name acid title
Please return two copies of the Completed Application package to:
North Carolina DENIM-DWQ
Aguiifer Protection Section-UTC Program
1636 M29 Ser►iee Center
Raleigh, NC 27699-1636 RECEIVED r DENR I DWO
Telephone [phone] AQU1FFQ-PRnTl=rTrN SECT10N
GYUaC 5OW Nutiflca6m of Iutm Form (Raviaed gnmg) !ogle 3

o:1
To: North Careffim DENR.DWQ
ATTN: Nike Rodgers
FAX: [phone]a
k Bate: March 1 2, 20 1 0
A facsimile from
Toano Well & Pump
Service, Inc.
PO BOX 306
TOANO, VA 23168
757-566-0377 PHONE
757-566-9073 FAX
Regarding: 5QW Form
Number of pages including cover: 7
Here is the 5QW form. I have an appointment with Drew Morgan on March 30. I am not sure of the
NC Driller l am going to we. Please Call with any questions_ 757-784-4941
vl'-akd "'y8-3 �' - 4j C
RECEIVED f DENR 1 DWa
Aquifer Protection Section
MAR 12 2010
20/T0 39dd d4n6 QNd -175M ONdOI EL06999LSLT ST:ZT 0T2Z/ZT/E0

NORTH CAROLrNA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOMCATYON OF rMNT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
ATER• NLY INJECTIO, WELL SYSTEM
TYPES W WELL
In Accordance With the Pmvisions o€NCAC Title ISA 02C.0200
Prins or Nw the repired i►rfornwian and maid to adth ass on Me bx* pale.
DATE: 2125 , 20 10
WeN Type Co►rfumation: Does the pruposod system circulate potable manly (no additives) in
continuous piping that complawly isolates the fluid front the environment (i.e.
closes]?
Yes JC Continue completing this form.
No to Not complete this form. Complete other UIC application #orrns for installing
either a 5A7 well (opt} -loop well irtLcting potalste water into the aquifer) or a $QM well (closed -
loop well cor[taimrig additirres such as R-22, ethanol, or other ante= or corrosion inhibitors).
A. PROPERTY 0Wi+rER(S)IAPP1JCANT(S)
List each Property Owner listed on property deed (if awned by a business or government agency, state name of
emit and a represenudive wlauthority for signature) � i � `
Z
(1) NWIing�Addrew: f
City: Stale; &C- Zip Cade; 2?rG*'R' CourzW Je
Horne/Office Tele No.: 5 r Cell No
. -
Email Address: ha 4 Old ALI & W'c site:
Qe& .,04A-
(2) Physical Address of Well Site (if different than above).
City: State: Zip Code.• _ County:
Home/Office Tele No.: . Ce!l No.:
t L AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not awn the subject property,
attach a letter Fmm the property owner authotiaing Agent to install and operate UIC well)
Company Name-.--
CmUct Pelson: F. [w�A i +Address:
Addraxs- _ - —
City: State: — Zip CC& County:
Office Tole No.: _ Coil N
Website Address of Company, If any:
OPUA RC SQW Norifata on of Intent farm (Revised 8/2008) RECEIVED I DENR 1 DWQ PW I
AquIf& Protection Senbon
LB/Z9 3DVd cMnd GN'd -173M ONVDI MAR 12 2��06995L9L ti S; z : z i 0I0Z jZ i/£0

j C- WELL ]DRi1i,LER INFO ZVIATION
Company Name: Taano Well srd,Pump SgV!� Inc.
+' -- - --
Well Driller Contractor's Name:
NC Contractor Cer ifica#lon No.: — --
f� Contact person: — Ciia+les Dozier______-- —EMAIL Address: bodwd ail.cam — -
r AdJy&ss: F.G Box 306, 1933 Forge Road
City: Tosno Zip Code: 23 168 County: Iaum City County VV'u-gini4
V' Office Tele No.: 757 W-037"7 Cell No.: _757-784-4941 _.
1%+. •~ D. HEAT PUMP CON )RACiOR INFORMAMN (if different tbxn driller)
Company Name:
Contact Person: EMAI . Ad
Address:
city:
Office Tele No.:
Zip Code: County-:
E. STATUS OF APPLICANT
Private: Federal:
State: X Municipal_
Cell No.:
Comnmemial.
Native American Lands:
P. IN3EMOIi PROCEDURE (briefly describe how the Infection well(s) will be tensed)
In ! ] glyod Geo-Thermal IM to measure the the=W cgjjducti ' of the Uqund.
C. WELL CONSMUCTION DATA
(1) Proposed datc to be constructed: r'3a Number of borings: 1
Approximate detach of encii boring (*K) -300
(2) Type of tubing m be used (copper, PVC, etc): —3409 HDFE _
(3) Veit casing, Is the wells) cased? (check either (a.) Yes or (b,) No below)
(a) Yes - if yes, then provide casing information below
Type: ___glvwn zcd steel black stcelplastic other (specify)
Casing depot: 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 $entonite —X Otter (specify)
(b) Grout placement: Pumpin&_X_ Pressure Other
(c) Grout depth of tubing (rcference to land surfacc): from 0 to 340� (feet)
(f wzll has casing, indicate grout depth: from to Oact)
GPU/UIC SQw hudfieaiicn of Intent farm (Revised "00) PW 2
1_01E@ 39t1d dNncl CINV 133M ONVOl E1e699SL941 ST:ZT 0106/ZT/E0

1L INJE&ION-RELATED EQUHN ENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The tnanufacturves brochure may provide supplementary
information.
L LOCATION OF WEL1.,(S)
Attach two copies of maps showing the following Information-
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodim pots mial
sources of groundwater comamination and the orientation of and dismnces between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal treat pump welt system. Label all features clearly and include a north. arrow.
(2) The Simi Map must show the subject property in relation to the surrounding area by using at least two fixed
roforenw points such as roads, streams, and/or highway intersections.
J. CERTMCATION
Note: This Permit App>lention must be signed by each persona appearing on for
recorded legat property deed,
"I hereby certify, under penalty of law, that i have persorolly examined and am familiar with the information
submitted in this document and all a=chrnernts thereto and [holy based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is ere, accurate and complete.
l am aware that those arc signi#icmt pcnaltics, including the passibility of fines and imprisonment, for submitting
false information. I agree to ctrnstruct, operate, maintain, tepair, and if applicable. abandon the injection well and
ail related appurtenances in accordance with the approved specifications and Conditions of the Permit"
UJ-4-, f &'.-W
Signature of Araperty Owner4&Plimt
Prim or Type Full Nffic and title r. 61to owe per S
Signature of Property Owner/Applicant
PrirA or Type Full Name and title
Signa'tm of Autharimd Agent, if *ny
Print Or' Type K;1l Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer ProteWon Section -MC Program _u ravt:t� I C1ENR'I V1/tU
1636 Mail Service Center r1�}tttl�i Prnturti�n c ecGG�
Raleigh, NC 27699.1636
Telephone [phone] MAR 12 201 d
❑PUARC 5QW Notifi=Uom or larem Form (Revised V2008) Pop 3
L13/tb0 20va d4nd QNd _1�M ONCOI EZ-OS99GLGLI �A :zT OZOZ/ZT/FO

03/12/2010 12:15 17575669073 TOAN □ WELL AND PUMP PAGE 05/07
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Rogers, Michael
From; Shoemaker, Gina [[e-mail]]
Sent: Monday, December 20, 2010 1:03 PM
To: Rogers, Michael
Cc: Bagnell, William Everett; Nobles, Lloyd B
Subject: CSI test well information
Attachments: GW-1.pdf
Mr. Rogers --
The physical address of the site is: ZINC Coastal Studies Institute, 850 NC 345, Manteo, NC 27954.
Also, please let me know if the attached information is sufficient,
Gina 5koawalcr, ii- LF.E.1) Ar
Interim Assistant Direetor
East Carolina university
�aezliti�s En,P�neerine,_,bArc�itrctural5crvires
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1212�,!201e 99.23 27575669073 TOAND VC-LL AND POMP PAGE 01/el
� v
WELL CONSTRUCTION RECORD
North Carolina Department of Enviro=efd and Natural Resources • Division of Water Quality
WELL CONT"CTOR M I ADUAL) NAME [P }ice � r5 � r5i� _ Cb3tTIFICATIOIY b :JL�ti i iS pt WO
WELL CONTRACTOR cUhfPANY NAME Iroa tAJr LG PHONE# ]
STATE WELL CUNSTRUC3'IONPERMTf* ASSOCUTED WQ1MrelsM -- -- —
{il�pglicatbl� fi1'snalicelrle)
WELL USE (Check Appli ie Box)_ Rssidevtiai 12 Muni6paYPubhc ❑ Industrial ❑ A@icuituml ❑
Monitoring© iC¢Heat Pump Wdter InjectionX Otber 0 If ❑ther, List Use
2, WELL LOCATION:
Nearest Town: &_&, ► aj_o&_�e County C
(Stm et Name, Numtras, Gm=xrly, 5uhdivmo , Let Nu., gip Code)
(F�-'�,
3. O-Awm: it
[strxt ar Route ziv.)..
City at Town &tam Zip Cock —
Arai aode-Phc.�e numt�c
4. DATE DRILLED H - I 1 a
5. TOTAL DEPTH: 3o _
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO �3
7- STATIC WATER LEVEL Below Tqp of Casing: FT-
Nsc'+ if A.tgm 1 op ofCasingl
9- TOP OF CASING IS FT. Above Land Surface*
'Tap er "MS Wuumtird attar bet M bard mrhwc regetEm a
vmko" la oeml nwe with MA NCAC xC .6 M
9, YIELC1(gpm). METHOD OF TEi ST --
10- WATER ZONES (depth):
11. DIMMECITON: Type Amount _
12. CASING. Walt Tbkkaess
Depth I?larx CW or WCighffL
from
From
To
Ft,
From
To
Ft.
I3. GROUT:
Depth
Material
From 6
To a!2�L_
Ft. �!n� Y - 1
From
To
Ft.
14. SCREEN-
Dclth
Dwne ' SIM Sim
From
To —Ft.
From
To
Pt- m_
15, SANT)IGRAVEL PACK:
in.
in.
Depth ,SLM N1ate�isl
From To Ft.
From To Ft.
Topographic/Land setting
Midge CISIope Malley IKat
(abxk appz"ate box)
Latitude/longitudc of well location
(drritusteslaaoonda]
Latitudellongituda nap
D 1- DRILLING LOG
From To Formation Description
LO-CAnM SKExc
Show direction and distance in miles from at least
two Stara Roads yr County Roads. Imtude the road
nutnbers and common road names -
Material �
hj!}GdrGi�j
Mcthaad
tJ �
IUt;h.�I
ib. REMARKS: Li�i= e�rc L o.sa �o Ti.rr,-►R� e
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTMUCTFD IN ACCORDANCE WFM I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TFUS RECQP-1) HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OP PLMON CONSTRUCTING THE WEt L 1)AxE
Submit the original to the Division of Water Quality, Attn: luformatign Mamgement, 1617 bl" Service Center,
Raleigh, NC x769�1617, Phone No. (?I9) 733.7015, witWn 30 days.
GW-i REV
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State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
C�
Beverly Eaves Perdue, Governor
Dee Freeman, Secretary
Coleen Sullins, Director
Division of Water Quality
Aquifer Protection Section
Location: 2728 Capital Blvd.
Raleigh, NC 27604
Mailing Address: 1636 Mail Service Center
Raleigh, N.C. 27699-1636
FAX: [phone]
[phone]
Date:3 4 i
FROM:
PHONE:
NO. OF PAGES INCLUDING THIS SHEET:
0--
, 0 I'll 00 � US
if you receive this fax by mistake call: Aquifer Protection Section @ 919-733-3221

DATE,TIME
FAX NO./NAME
DURATION
PAGE(S)
RESULT
MODE
.
TRANSMISSION VERIFICATION REPORT
03/25 23:23
917575669073
00:00:39
02
OK
STANDARD
ECM
TIME 03/25/2010 23:23
NAME NCDE&NR/WATER QUAL
FAX [phone]
TEL ~19-733-3221