WI0700205_ GEO THERMAL_20110126

Permit Number
Program Category
Ground Water
Permit Type
WI0700205 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
1200 Duck Road
Location Address
1200 Duck Rd
Duck
Owner
Owner Name
Town Of Duck
Dates/Events
NC 27949
Orig Issue
01/26/11
App Received Draft Initiated
01/24/11
Re a ulated Activities
Heat Pump Inj ect ion
Outfall NUL;_
Scheduled
Issuance
Central Files : APS_ SWP_
01/26/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Jeff Stagg
PO Box 15482
Chesapeake VA
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
G.overnment -Municipal
Owner Affiliation
Christopher Layton
Manager Town
1240 Duck Rd Ste 106
Duck NC
Public Notice Issue
01/26/11
Effective
01/26/11
233285482
27949
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly ;saves Perdue Coleen H. Sullins
Govemor Director
1126/2011
Town of Duck
Christopher J. Layton. Town Manager
1240 Duck Road
Duck- NC 27949
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0700205
1200 Duck Road. Duck, NC 27949
Dear Mr. Layton:
Dee Freeman
Secretary
On 1124J2011, the Aquifer Protections Section (APS) received notification of your intent to construct a closed -loop water-oniv
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 i4ll 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 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 021l(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.Rogers0incdennaoV if you have any questions.
Sincerely,
/a�• I] ra a�i
Sultery i Gnr
cc: Washingtov Regional Office - APS
APS Central Files - Permit No. WI07UO205
Dare County Health Dept.
Pinkstori Geothenual (Jeff Sta2e)
BLM Conti -actors dba Climaterm=er (Norman ,Monis')
AQUIFER PROTECTION SECTION
1635 Mad Service Center. Raleigh, North Carolina 27699-1g36
Location. 27H Capital Boulevard, Raleigh. North Caroima 27604
Phone: [phone] FAX 1: 919-715-o588; FAX 2: 914•715-61M$ Customer Service: 1-877-£23-6748
Internet. www.nswatemuaih , .o-:
NorP
th Carolin a
vit EoUEJ Opporfuntty 1 Afirrmanv- r�,�::ion =molnve.r

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MUH CAROUKA
MMIMAUM tW INyM ] Q Cop igrgUCT A__jQgCWjj
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In Aoeatds=W-th theProvWan*fNCAC Tile 15A Q2CWM
Niw or 4w At Ord kferrauon Md wail so add.= an d w bantpow
wd, TAM cs4bwMwjz: DM tm proposed systm cm=h to pmbk q& (no additives) in
69+MPTeh* isok*m its fkw hem Theenwituarnrall {i e-
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N,*_DDNotcampktc"fb-rw Corrrph t adw UfC appacifion faz= *r iwWjmg
cilhcr a 5A7 vMH(q,-loop vmU jphVkg parable wakr buD ft agtdfer) or a 5QM well (clogetl_
%DOp waU watair *adds sa& as R 22s cbwok or*&a a a&wm or emmsioa b►hibiw4
A. PROPERTY OWN a
Lia car F*40 y Oww listed as pevputy Mead {rf owl by a brrsirress or agrw y, sf Warne of
Taw•% btbick vjarle,
- - - - c4! ; n Q 1� �N ncE�AG _
C►3 A S ��O ��il..�
(2) Pbyskd Add= d Won stile Cif different than abovejc _ I Z o 0 i] U e- k - .
Cig: _ t~tL srA C 4 cbde: x
B. AUMORQ.P.D AGUff OF OWNM IF ANY (if The Permit Applicant dnesAJI-I owu the S*cd props%
sltaeh a kwT 5om the sty owner arm AgeM to iersteti and opCrare UIC'%O�
tvmgaayN—'--
C'ulaaq Ftrscxa: PJIA Arf Iddress
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WYLL GNU-iSiRUCTWN DATA
(i) ksxrpa�ed dace to He Oonsnvtxed: �& E ,74rt :�}>anbar oi€ hoping;; � a
AMmdm
gtc:dcptk o"embWn
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(2) Type of WbinglD be used (COMM, FVC, 04
(3) Wal crag' h the wWs) cwd1' (cbwk CWMW (8-) Yes ow (b) Igo,
(a) Yea if yes, men Pruvidn casing sufou nasson betow
Type: __Vtnnbmd sted b1m* 3ftl(scaly}
F m fact (r+eEMM W laod wrflKz)
wftnds ID *m grWd kwbs
(b) we x
(4) CftW 116 (material mwvmft VmU =k4 PVnlgt
(a) Groetlm= Neat cknown lwwwmik x Orr (spxify)
(b) aMUd VACVMC= P.P . nvm= Omar
[c) aroma depth aftubiwg (ceicrer w to teed =Eb=). fi m >D 7 5-0 (kM)
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II. IN.li:CTION-.RELATED &QUIPMEt~
~a~ ~~e ~ Ja.)'Ollt~ propmed modificatioo oftlle iqJeclion equipment ml enmo, ~ associa1t:d Wi1h the D'JediOo opcra!ion. The ~s brocimm ~ provide suppfemealaly
L LOCATION Ol"wt:Ll.(S)
AUBch two copies of maps sbowingthe following mwnnatioo:
{1) Include a Sile Map (am he drawn)~ buildi~ property lines. sur:r.. water bodies, pob!ntial
soon:csof ~C01dal.UD8tioo and die ~Oil of and dimmces between the proposed we11(s) and
any exisdng weU(s) or wasle disposal 1ilcili1ies SIJCll. as septic 1anls or dmiD fields located within 200 .feet of
the. geolbamalheai pump well sy51em. Label all featmesdeadyaadindudearqdl arrow.
(2) The Sile Map JDIISlsbow 1he-Sllbject popeny in ldation tQ 1be SlmJIIPdio& ara by IISiQg at least two fixed
Mftiw pairGsudtas mads. streams, endloi-.lugb.wayhm::rscctions
I. CD'l'MCATION
Note: TJlis Pend.A • mast be liped l,y aa.--. appeums • tlle
nconled heal deed.
""J lll!leby eedy. under i,enalty of Jaw, dml: I liaw pe,sonaly mramined mil am tianiliar with 1he infimnatioo
submidal .in lhis cJoanncnt and aP anac:bmtds tllc:mm mMJ tbat, basal on Ill)' inquiry of 1hose iftdmduals
immcdia11:ly n:spouibfe At,,-oNaiRlng9d in1inllllim, I believe that tk information is ~m:urale and complete..
1 am awere that a.re an: 1:,iguificant ~ inchading 1lle possibilir;y-of fines and imprisomncot,. tor submiUmg
-&1se iatilrmalicm. 1 atglllD to ~ opc:ndf:. Dlllildain. replr, aad if applicable. abamJoll Che injeelioa well and ·----.. --:~ ..... ---
C.h,;~tah[ J-'-o.y1~1 II>~" rrlaA41it,...
Printer Type Foll Name and 1ide
SipablreofPmperty OwnedApplicant
PrintorT)IJO Full Name and title
Sjgmlluroof Aulborized~ ff any
PliDt or Type Pull Nane and title
Please 1d1IDl bro .:opies Qftho GOmPlel=d Applicalioe package 10:
Nordl Cuvlina D~"R-DWQ
Aquifer Pnt.edfoa Secooo-UIC Prognua
1636 Mail Serviee Cater
RaleiglarNC .2709-1636
Telephone [phone]
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2. ECiI VALVE Pfi
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zvU Lium xoaa, lluck, NC - Uoogle Maps
Page 1 of I
Address 1200 Duck Rd
' -1 maps Duck, NC 27949
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Doc 30 10 0928¢ JWrey A. Stagg 757-1-aloe g.?
MRTFi CARQLNA
DEPARTMENT fJF FNYIROMdEtV'[' AND tjAnW AL REKXRRCK,-
M( TIMAT3i N (F KTXM TO CONSTRUCT A QPMRIQM GEOTIUMM L
HAMR;QMX iNJEMON VMLL SYs7['EM.
10 Amrdaw,: Wish dw Provisions of NCAC Tele 15A o2e.0200
Prpx OrWe ube r"mhO mf rwalmn and wag!a add= ae die &a *page
DAM �� l'S� : xsta
Well Type C&VWwu0cv- Dm fit proposed system cimdaW potable wame� onfvonfv (no aWihvcs) irj
CMUMMM 0091h d c=pld#ety MIales the mist fiom the euvin nl (i.e.
Ycs�L cbnti me 0ouqAefing this forte
Na Da Not eouspletathis fonIL Caplets orbr UlC sW=tKM form fbr irk IM9
eiWcr a 5A7 weil -!stop wa +r uyg parsbic water iota tk arquifcr) s 5QM MR {etc
toop vmll crosnaiag ad U—m sac* as R 2:2, odew L at other and or corrosion inhibiba4
A. PROPEM OWI IAPI ICA34IX8)
w sorb Pmpertp oww fistod oa paapc7tY deed (f ww ned by a budnm t Bovenvusl sgea6y, 30ft mmu of
emty mw axcFwenft6►rt wdwdwity br swmmare): bw n b� bi L, -
CCU611',AQ IOWA 11311a[IVAQ1.e�_
Cl)`' Adfic5s,
C-� 1]r��l. Stete� 77�p Cade: � Com►1Y'._�
HomzKMw TeleNcL: a5a �55
EuiaA Adores
(2) 1Phgsicd Address of Well site Cif diMrent ton eboue): -L-ZoD �_.7 v C-k—
City: �f d tL stagy —NZ: dip Coder _ 'Coaaxy:
Home0oti5ae Tele Na: Q-6l M-. -
B. AIUMOR l'® AGE'[' OF il}V44M IF ANY (if *c PawitApplicant d_ ow sot own the subject p[nperV,
al "a lesser Stu the ptaperty owner auftxL&* Agent to inslsl] and operate UlC wdi)
Company Name: rl l 4�
Caosaet Pea+.,an kMAiL Addrrgs: �w
Address:
C'dT- -- .— - st8 = Tip Code: Caavty_ _
O f= Tde W- : ��['ell
Wcbsscc Address of Company, if any= --

Rcuc.tvra. ia,F-nf /Uld 'e1: 414 Zb2j 33726 C.IMATVAASTERS
Dec 30 10 092$P Jeffrey A. Sbgg 757-21-2108 P.3
C. WILL DRUAER TIWFDRKMON
Coff4mty N&nL:_
Welt Drier Comraawes Mai= w "Ltl _� u
NC Cmbiavtor CerOcaRon No.: 3.5 3 8
Corot perm aw -SlELF Par, EMAIL Adftn
; e
Address: P o ?—
City. C%ACS Ie ake g YA up co - cmst7:
Of5mTeele2NIG.• 757-`tZ� ZI CeD ND-: 7_ S?—L13%:n V9'L
D. HEAT P
UMP
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O Igaut
Addres
UfFce ele
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E STATM Of APiPI IC-4W
Privy.; _ Federal:
CtarrrmcreiaL-
Natire Amakaai ate:
P. MEC.'TflON PROC'I DUM (brielty deg mh-- Crow the irgmdon wcWs) wd t be used)
N D T P► Loa W elw .
C-L-05.ed Ux� , ' 4oR� L-kOL'e.�
Q WELL CONSTRUCTM DATA
(l) Proposed acts to be mod: F�C3 1.-.arl Number of horings; S
App=dmaYe depth of such boring 5-10-
(2) Type of UML14 to be used (mpper, PVC. eu): 6 P 1E
(3) Watl nosing. Is tho wufl(s) cased? (chca ester (a.) Yes aA (b.) No Wow)
(s) Yes ff yes, thm provide casing infonmagoa betnwr
Type' ____glvaonimd steel bkck s1a7! plastic crtltcp (Sgacify)
Casrog depot: From _ to *t (Mt== to land sarf ace)
Using ids to above gra and ftwb s
fb) No
(4) Groat Into (material saurlou"rtg VIC] Mke SMUOr p+iphy):
(a). Gwut type: beat Cemesrt Betftnife x Other (-g=ifY)
(b) Grout placcmcat: Prtm*&>C Praw= Otttcs_
(c) Goin depth of tubirg (mie re xt to land mbcc). frm a
if well fm casing, :r■boac W od depth: f m
-&D O- (>a)
(feet)

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Doc 30 14 09.29p Jeffiw A SUm 757-421-2108 p_4
R INJECTION -RELATED EQtrWMF,YT
AMCh a ding M AOWhW the atg'u>=u* iayvut or prapused mudifrcW ioa ofthe inlectinn cquipmeut mid eximay
*W*ng associated wbh the irjedson operation. T& miumfix1mes bramttm may provide supp&mmikuy
iru6o�maeiam
L LOCATION OF WM48)
Attach tm eopiesernm n Shatil tthe following information:
{i) 1nc3ude a Ste Map (cm be drawn) shnwiW buWj gs, property ham, surface water bodies, powibal
same of gfou x1%- W oatetmnirtrMn and fine orkntadoc of =d distar m bcmvm tk proposed w+e)Ks) ad
ao v existing wd](s) or waste d4mM f>a,eitities Im& as septic tm *s or dram fields located whh m M feet of
the gaffdmmml heart PMP vPdl system. Lahr) all feahues clearly and it _a r r vr.
(2) The Ste hbp must sbaw the subjeapoperty in Wawa to the su oundoRg area by m g at least gran fixed
fefnrame point= su& as roads, smmm% andfnr highway iNbrsmhom
NOW This Pensid Appfsfiom mast be sigae+d by IM& parma appenin an am
rmorded kV1 property deed.
Qi hmby cry, radar penalty of faa, that 1 hm personm)tty mtanamd and am fmniiiar with fha tttfatm=oq
WDmifded im this dormuatt and aH XU& mcKa theta and that, bayed -n f" inquiry of those uadvid S
itmmediatdy red mm--bie fnr obtain g said unfufmaAri, 1 befien the the irffnt7mstinn is trite, soar" mW =T16--
l am ayme dart there arm siggi5rant pendbM hdludmg tilt ptrsst"hft of fines and imprisomrreM for xdmiifing
false ittfarma tim i agree to tuos> mca , opm e. vita, repair, and if applicable, abandon die iuiecu m we]t mW
all sdamed appumwmxxs im ao omism v/A WWff^ld spizifamd zm&bom of the Pcrmir
�gnip�e af>�r<�aly�wr�erlAgpli�rra
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Print or Type -uu Name raid We T
S*mWm cri'A+operty OwuedApptiimt -
Ptint w Tin* ptQ RT&= slid title
SWulure of AaNaarizW Hulk i fWY
PMnt criype Full Aittiaie and title
Piem mium two copies of the cai*ktod Application pares W_
North Ca uHua. D EltiR-DWQ
Agtdfesr,Pseteefim Sce im-UIC Progmm
1636 Mail Service Gcle er
Rick h, NC 27699-1636
Tdg3bme [phone]

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Page I of I
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