WI0700177_GEO THERMAL_20100610 (2)

..
Permit Number Wl0700177
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
Haroldson Properties
Location Address
100 Pollock St
New Bern
Owner
Owner Name
John
Dates/Events
NC 28560
Haroldson
~
Central Files: APS_ SWP_ ~ ~
06/10/10 (J
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
John Haroldson
PO Box 1.169
New Bern NC
Major/Minor
Minor
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
John Haroldson
PO Box 1169
New Bern NC
28563
28563
Orig Issue
06/10/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
06/10/10
Effective
06/10/10
Expiration
05/19/10
Re gulated Activities
Commercial or indu.strial, other
Heat Pump Injection
Outfall M:JU.
Waterbody Name Stream Index Number Current Class Subbasin
~A ---,,.£.1
MCD ~EN~R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
John Haroldson
Haroldson Properties
P.O. Box 1169
New Bern, NC 28563
Coleen H. Sullins
Director
6/10/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0700177
100 Pollock St.
New Bern, NC 28560
Dear Mr. Haroldson:
Dee Freeman
Secretary
On 05/19/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
geothermal injection well system for the operation of a ground-source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the Craven 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.Ro gers @ ncdenr.gov if you have any questions.
cc: Washington Regional Office -APS
APS Central Files -Permit No. WI0700177
Craven County Health Dept.
~· ~){~:)
for Deb~ atts
Supervisor
Jim Cornette (Applied Resource Management, P.C., P.O. Box 882, Hampstead, NC 28443)
Patrick McKee (Airtech Mechanical Services, 153 Two Lakes Trail, New Bern, NC 28560)
AQUIFER PROTECTION SECTION
1636 Mail Seivice Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity I Affirmative Action Employer
One North Carolina
;JVaturatlu
- - KCCryIQ I Ml mwo
AQUti�'� uRnTr��,t':"110N
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENi)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-OW WELLI S 1
In Accordance with the provisions of NCAC Title I SA: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Tyne information).
DATE: MaN 14.20I0
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 X_ Continue completing this form,
No Da Not complete this form. Complete other UiC application forms for installing
either a 5A7 well (open -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).
A. PROPERTY OWNER(S)IAPPLICAINT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): _ John Haroldson - Haroldson Properties
(1) Mailing Address: P.O_ Box 1169
City: New Bern State: NC Zip Code: 28563 County: Craven
Home/Office Tele No.: 252-638-8300 Cell No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above): 100 Pollock Street
City: New Bern State: NC Zip Code; 28560 County: Craven
Home/Office Tele No.: Cell No-
-
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the .Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State: Zip Code: County -
Office Tele No.: Cell No.:
Website Address of Company, if any:
GPUIU[C 5QW Notification of intent Form (Revised W2008) Page 1

C. WELL DRILLER INFORMATION
Company Name: A pp lied Resource Management, P.C.
Well Driller Contractor's Name: ~H~. M~ic~h=a~el~S~a...._g=e ________________ _
NC Contractor Certification No.: 2531-A
Contact Person: Jim Cornette EMAIL Address: Jim [e-mail]
Address: ----=-P""'"'.O"".'-'B""o""'x-=--8=8=-=2'---------------------------------
City: Ham pstead Zip Code: 28443 County: ----=P--=e-=nd=e=-=r ________ _
Office Tele No.: 910-270-2919 Cell No.: 910-512-4890
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: __ ----'A'--=-=irt=e=c=h-=-M=e=c=h=an=i=c=al'-'S""'e=rv"'-'i=ce=s'-------------------------
Contact Person-=-: ----=-P=at=ri=c=k -=-M=c=K=e""'e'-------~E=MA~I=L~A~dd=r~e=ss""': __________ _
Address: ___ l-=--53'-------T_w~o~L=ak=e-=--s -=-T=ra=il'-------------------------------
City: New Bern Zip Code: 28560 County: --~C~ra_v_e_n ________ _
Office Tele No.: 252-636-5841
E. STATUS OF APPLICANT
Private: Federal:
State: Municipal: __
Cell No.: --------
Commercial: _X __
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed loo p geothermal system. Water only, gro uted alon g the loo p 's entire t .
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: __ 6_/1_/_I0 ______ Number of borings: __ 2_5 __
Approximate depth of each boring (feet):'--...,;2=-=5c...::0_' ______ _
(2) Type of tubing to be used (copper, PVC, etc): _ _;.HD=P~E=--------------
(3) Well casing. Is the well(s) cased? (check either (a.) Yes Q! (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: _galvanized steel __ black steel__plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement __ Bentonite Other (specify) Thermex
(b) Grout placement: Pumping __ Pressure X Other --
(c) Grout depth of tubing (reference to land surface): from 0 to 250 (feet)
If well has·casing, indicate grout depth: from to (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 2
JAN731-2010 04:01 From:Haroldson Properties Tc:191027099$$ Pase:3f3
II. I1v.TEC'nON-RFLATFD FQtfl['MKNIT
Attach a diagram %hawing, the engineering Layout or proposed modification ofthe inje"ion equFpttteni and txtcrior
pipingltuhing associated with the injection operation, The manufacturer's bruchurc may pruvidt .upplemenrary
information.
1. LOCATION OF WELL(fi)
Attach two copies of snaps showing the Following information:
(1) include a Site Map (can be drawn) :ihowwg: buildings, prupcny line%, surface water bodies, potential
sources of groundwarer conmmination and the orientation of and dixtsnecx hcrwmn the proposed well{s) and
any existing weI1(5) ur w}astr dispusul facilities such as septic tanks or drain fields locrlted within 200 t'ert of
the geotherme] heat pump well 9ystcm. L.shcl all t'oarurea clearly and include a north arrow.
t2) The Site Map musr show the subjeci property in rr l Ilion to the surrounding aroa by using of least two fixrd
reference points such its roads, streams, kind/or highway inter%ectiotis.
J. CERTIFICATION
Nate: This Permit Application must be signed by Inch person appeathig ou the
warded legal property deed,
"T hereby certify, udder penalty of law, that 1 have personally extunined Farad am familiar with the information
submitted in this dvcwnent and all attachme:its lhumto and that, bmcd on my inquiry of those individuals
immudiatcly responsible for obtaining said information, I brIieve that the information is true, acc.urute and complete,
T am aware this there tare significant penalties, including the possibility of Cana and impmonment, for submitting
false information. I agree to construct, operate, tnaintuirl, repair, and if appIicahlc, abandon the injection weal and
al related appurtenances in accordance with the approved sp;�2=
if-ndiIions of the PGrmil."
40. —
Si X—,
l'1'toperty OwnerlAppliu-xnt
R�IvED!Tmiawe a4% 0_dgro US?)^
!Tint or Type Full Name and bile
YAY 19 AM
5igllulure of Fruperly OwncrlAppliLaw
Print or Type Pull Name and title
Signaturc ol'Aulhorizcd Agent, ifany
Print nr Type Hutt NaMe and tit€e
Please return Iwo eopicK of the completed Applies kw package to. -
North Carolianr DF,N11-UWQ
Aquiree Proleuliun Section-UIC Program
3636 Mail service Center
Raleigh, NC 27699-1636
Telephone (919) 71,"935
GPUIUTC SQW NoIificatlim of Intml Form {Revised H12MA1 ftgc 3

INFORMATION
PARCEL ID: 8-002-A -232
Owner:
Mailing Address:
Address of Property:
Property Description:
FRONT STREET DEVELOPERS LLC
PO BOX 1169
NEW BERN NC 28563
100 POLLOCK ST
TRACT 2 SURVEY FOR FRONT STREET DEVELOPERS
Page 1 of 1
Assessed Acreage: 2.210
1488 0460
H-51-C
Calculated Acreage: 2.219
Deed Book Page: Deed Recording Date (m d y): 1115 1995
Recorded Survey:
Estate File (Will) Year-E-Folder:
Total lmprovement(s) Value:
Number of Improvements:
City Name:
Drainage District:
Special District:
$1,184,600
5
New Bern
New Bern Mun Service
Life Estate Deed Book & Page:
Land Value:
Total Value:
Tax Exempt (YES/NO):
Fire Tax District:
Lot Description:
Land Use:
Craven County does NOT warrant the information shown on this page and
should be used ONLY for tax assessment purposes. May 13, 2010 9:50:05 AM
~ttp :// gismaps.cravencounty .com/maps/m·ap _ cama.asp?pid=8-002-A -23 2
$2,144,350
$3,328,950
NO
COMM-GENERAL COMMERCIAL
USE
5/13/2010
Approximate Property lines
Approximate Closed Loop Locations RECEIVO) I DENR I DWO
AQUIFFR'QRnTFrT1ON SFC710tii
MAY 19 2010.
Notes:
l . Subject property and surrounding area are currently serviced by public water and sewer
2. Geothermal well loccfions are approximate and will be a minimum of 20' ❑part.
Adapted from Carteret County GIS Map, April 2010.
TITLE: SITE MAP FIGURE;
lied Kcoou roe Manaq ement PC 100 Pollock Street
H.U. Box 62, Hampstead, as Jan: SCALE; DATE; DRAWN BY;
A910);
27D-2419 FA}C 27a 24B8
Persimmons NTS 5/14/10 DNH L

Approximate Property Lines
Approximate Closed Loop Locations
RECEIVED I DENR I DWO
AQUJFFR-RRnTFC',VnN gFCTION
.MAY 19 'lulu
Notes:
1. Subject property ❑nd surrounding area are currently serviced by public water and sewer.
2. Geothermal well locations are approximate and will be a minimum of 20' apart.
(Adapted from Carteret County G!S Map, April 2010.
7 lied Ke5ource Mana=nerit PC
LPU Box UU2, Humpsteod,
[9101 270-2919 FAX [phone]
TITLE:
JOB:
SITE MAP
100 Pollock Street
SCALE: ❑ATE:
NTS 5114110
DRAWN BY:
DNH
FIGURE:
2