WI0700171_GEO THERMAL_20100331 (2)

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NCDENR
North Carolina Department of Environment and Nat ura! Resources
Division of Water Quaiity
Beveriy Eaves Perdue
Governor
David Higginbotham
PO Box 130
Merry Hill, NC '27957
Coleen 1-:. Suliins
Director
3/31/'2010
Subj e ct: Acknowledgemen~ of Intent to Construct Type SQW Injection Well System
Permit No. WI07001 7 1
149 Salmon C reek Lan e
Merry Hill , NC 2795 7
DearMr. Hi gg inbotham:
J
Dee Freeman
Secretar y
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
3/:29 /2010, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed-loop geothermal water-
only injection well system for the operation of a ground-source heat pump located at 14 9 Salmon Creek Lane. Merry Hi ll ,
Berti e County, NC '27957. This system is deemed permitted b y rule (North Carolina Administrative Code Title 15A,
Subchapter 2C, Section .021 l(u)(2)).
However, it i s recommended that y ou contact the Benie County Health Department, as they may have additional
construction or permitting requirements for this type of system. If you modify your system at an y time, including the
addition of antifreeze, corrosion inhibitors , or any other substances to the circulating fluid, y ou must contact the APS to
verify compliance with ~pplicable rules .
Thank you for submitting this notification. If you have any questions please call me at (919 ) 715-6166.
cc : Washington Regional Office -APS
APS Central Files -Permit No. W I070017 '
Bertie County Health Dept.
Sincerel y,
+()~~
M ichael Rogers
~nvironm~mal Spec1,~11s t .
GPU-Aqmfer Protection Section
Jeff Stagg (JA Stagg Energy) 636 Benefit Rd, Chesapeake, VA 23322
Ric H0ggard (Hoggard Heat-Cooling & Electric Svc, Inc) PO BoK 245 !3G N:'.:_' 45 N. Merry Hill, N :,_7957
AQUIFER PROTECTION SECTION
1636 Mai! Service Center, Raleigh, North Carolina 27699-163G
Location: 2728 Capital Boulevard, Raie:gh, North Carolina 27604
Phone [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service 1-877-623-6748
Internet: www.ncwateraualitw rg
A1 Eq:1al Opportunity\ Affirmative Acfon Er.iployer
Permit Number WI0700171
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit •
Facility Name
David Higginbotham SFR
Location Address
149 Salmon Creek Ln
Merry Hill
Owner
Owner Name
David
Dates/Events
NC 27957
Higginbotham
Central Files: APS_ SWP_
03/31/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Howard E. Cutter
636 Benefit Rd
Chesapeake VA
Major/Minor
Minor
Region
Washington
County
Bertie
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David Higginbotham
PO Box 130
Merry Hill NC
23322
27957
Orig Issue
03/31/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
03/31/10
Expiration
03/29/10 03/31/10
Re a ulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
l.` E)'+DC) IA- I
RECEIvEl)1 DENR IDWO
Ai)UiFM PRnTFrT1nR SFCTMN
MICR 2 g 2019
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5QW WELDS �
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and mail to address on the track page.
DATE: 3i � t -- - .2010
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes Continue completing this form.
No Do Not complete Ibis form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well iniectinpotable 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 gave iment agency, state name of
entity and a representative wlauthority for signature):
Y
(1) Mailing Address: �. �3. -4 3 0 --
City: gEA'q�.�ki 0-A- State: Ae Zip Code: 217 4 c;-- VColony: I c
Home/Office Tele No.: Z S Z y a 2 3 V y T Cell No.:
Email Add&6t-,QF ,QA,rN 1, w (22- Website:
14 .Cc Al
(2) Physical Address of Well Site (if different than above):
City: yerin I ► L sr State: PC Zip Cade: 7 7 GF County: 8,L;F QT t_
Home/Office 1 ele No.: '2- 5F 2 9 fs 2 3 y y r Cell No.:
B. AUTHORIZED AGENT OF OWNER, UP 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:
GPUIUIC 5QW Notification of ffent Fomu (Revised 812008) Page 1

C. WELL DRILLER INFORMATION
Company Name:_ _ T A.
Well Driller Contractor's Name: _ �Ag v',A � . �" ^rIEY2-
NC Contractor Certification No.: ,— A
Contact Person: -56SI-)II6.6 EMAIL Address: &,� . CDrA
Address: l P j rIUEEt Tr- e-b
City: wS.Ap � 1�A Zip Code: 2,-; 3Z Co": _
Office Tele No.: — Cell No.: ?6-7? -- 4 3%--4�14-
D. HE, AT PUMP CONTRACTOR INFORMATION (if different than driller),
Company Name: {{}} TT � L SNC, �Tr .
Contact Person: i oEMAIL Address: AyAc comtr-.)
Address: Co a cx- � yS ► 3 l 1,—Vc %� K
City: M—&—n4—+141 NC Zip Code: • T?1s7 County: Bf,-4,e- -- --
Office Teie No.: ,)S2 ��6,5T Cell No.: S—
E. STATUS OF
Private: Federal:
State:
Municipal:
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection welI(s) will be used)
C E zsr�A­C--� N(- G L o S tE7- D o P -
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: r_ �f Number of borings:_ -
Approximate depth of each boring (feet): Z - 00-
(2) Type of tubing to be used (copper, PVC, etc):. H 1� Q C _
(3) Well casing. is the well(s) cased? (check either (a.) Yes or (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--
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite A Other (specify)
(b) Grout placement: Putnpi Pressure Other
(c) Grout depth of tubing (reference to land surface): from 0 to 2-0 o (feet)
if well has casing, indicate grout depth; from to (feet)
GPU/ulC SQW Notification of Intent Form (Revised 8/2008) P'"

RECEIVED I DEhR I IMQ
AQUFFR'PFn1'Ff TlrfN SEM
H. 1N3CCTION-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 WELL(S)
Attach two copies of snaps showing the following information:
(I) Include a Site Map (can be drawn) showing: buildings, property limes, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system, label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by egch person appearing on the
recorded legal property deed.
"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 my inquiry of those individuals
immediately responsible for obtaining said information, I believe than the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
Use information. I agree to construes, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in actor nce with the approved specific4tions and conditions of the Parnit"
Signature o &Applicant
rfi I/'1 o V )Vq
Print or Type Full Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
OPU"C 5QW iNoditcation of lnteat Form (Revised V2008) Page 3

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DATE:
A.
B.
RECEIVE)1 DEER i Dwo
AQUiFr-P PpnTFrT1rlN .�FCiTOM
MAR 2 g 2010
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY ]INJECTION WELL SYSTEM
TYPE 5OW WELL(S)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and mail to address on the back page.
2OL
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-laony?
Yes Continue completing this form.
No Do Not complete this form. Complete other UlC application forms for installing
either a 5A7 well (oven -loop well in'ectin 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).
PROPERTY OWNER(S)IAPPLICANT(S)
List each property Owner listed on property deed (if owned by a business or gove ent agency, state name of
entity and a representative Wauthority for signature):
Ej
1
(1) Mailing Address: 130
City: dtr���• I- e- State: k-If Lip Code: 2 17 - � County:
Home/Office Tele No.: 2 ti Z yfF 2 3 !V Sr Cell No.:
ess:
{ 4 s g 1rJ1lt W (11-
Email Add Website:
.GaAl
(2) Physical Address of Well Site (if different than above): I ±/Z I re M. o A. , /? EamZAL
City: State: A)I' `Lip Code: 2 14 ! 7 County: --a i kT/
Home/Office Tele No.: 2-5-2 4' S 2- 3 r y Cell No.:
AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does nQt 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: Lip Code:
County:
Office Tele No.: Cell No,:
Website. Address of Company, if any;
CPUMC 5QW Notification of intent Form (Revised 812008) Page 1

C WELL DRUMM INFORMATION
Company Name: T A, sq G 'N � 2-�R � a►i .
WeD Driller Contractor's Name: �-ko wA [uD C - —,7-EYL
NC Contractor Certification No.: 46 —A
Contact Pers❑ • EMAIL. Address:-t[� Cara
Address:
City: CAAC- _S.q�ACAV—CVA Tap Code: ?-4 County:
Office Tele No.: Cell No.: -7 9�
D. HEAT PUMP CONTRACTOR INFORMATION (if different than drWer),
Company Name: C {� 0 H� s?-1C�� _ t C�� _ l iri- soc- -
Contact Person: R —W0 r C,,q EMAIL Address: �KC s �c� Carer:•►
Address: l- o 6.0y-
L/
5- V
City: 1r1M&Lr q- 4-1► 11 -MC- Zip Code: X7 County:
Office Tele No.: ,Wd, WZ 65'3 _] _ Cell No.: _ YX 3-257 (Y7)?
E. STATUF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
N o w AyJ A \►' f-U-
ear"--fLcy)N(- C- o s : b LI-D o{P
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: �" 1 � ) Number of borings:
Approximate depth of each boring (feet): D o
(2) Type of tubing to be used (clipper, PVC, etc): "Z) e
el—
(3) Weil casing. Is the well(s) cased? (check either (a.) Yes .Qr (b.) No below)
(a) yes if yes, then provide casing information below
Type: _�alvanzzed steel black steel_ --plastic other (specify)
Casing depth; From to feet (reference to land surface)
Casing extends to above ground 'ouches
(b) No
(4) Grout 146 (material surrotuzdiuig well casing and/or piping):
(a) Grout type: Neat Cement Bentonitex Other (specify)
(b) Grout placement: PumpinPressure Other
(c) Grout depth of tubing (reference to land surface): from 0 to O 0 (feet)
If well has casing, indicate grout depth: from to (feet)
l7PIWirc 50W Nnrif—tinnF'•,••••• fn. J_.. nr+n

RECEIVED I DEER I DWO
AQUIFFR'pRnxi+ MON RFCTION
FL INJECTION -RELATED EQUIPMENT
I.
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipingftubing associated with the injection operation. Tke manufacturer's brochure may provide supplementary
infomnation.
LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal treat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, andfor highway intersections.
J. CERTHWATI[ON
Note: This Permit Application must be signed by etc person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of taw, that I have personally examined and am familiar with rite information
submitted In this document and all attachments thereto and that, based on my inquiry of those Individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false infon-nation. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accor nce with the approved specificptions and conditions of the Perruit"
tiJ f 00 w
signature!! of rop y %er/Appliiccant r
Print or Type Full Name and tide
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1.636
Telephone [phone]
GPUMC 5QW Nod6cadon of Intent Form (Rex7sed 8/2008) Pxae 3

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149m salmon creek lane merry hill, NC 27957 - Google Maps
Page 1 of 1
Address 149 Salmon Creek Ln
Got) � rn a p� Windsor, NC 27983
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Teatheword"GMAPS"to466453
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