WI0700222_GEO THERMAL_20110426

Permit Number
Program Category
Ground Water
Permit Type
Wl0700222 / ••
Central Files: APS_ SWP_
04/26/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael.rogers
Co@stal SW Rule
Permitted Flow
Facilitv
Facility Name
Francis & Martha McCarthy SFR
Location Address
132 Horniblow Point Rd
Edenton NC
Owner
Owner Name
Francis M
Dates/Events
27932
McCarthy
Orig Issue
04/26/11
App Recei ved Draft Initiated
04/21/11
Reg ulated Activities
Heat Pump Inj ection
Outfall NULL
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Jeff Stagg
Driller Well
PO Box 15482
Chesapeake VA
Major/Minor
Minor
Region
Washington
County
Chowan
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Francis M. McCarthy
132 Horniblow Point Rd
Edenton NC
Public Notice Issue
04/26/11
Effective
04/26/11
233285482
27932
Expiration
Stream Index Number Current Class Subbasin
-~A ,;;--;,~---NCDEMR "
Nort h Carolina Department of Env ironment and Natura l Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Francit McCarthy
Martha McCarthy
132 Ho miblow Point Road
Edenton, N C 27932
Co leen H. Sull ins
Di rec tor
4/2 7/20 11
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0700222
132 Homiblow Po int Road, Edenton. NC 279 32
Dear Mr. & Mrs. McCarthy:
Dee Freema n
Sec retary
On 4/21 /2011 , the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl y
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 conditio_ns 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 Chowan 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 Micbael.Ro2:ers ral ncdenr.gov if you have any questions .
cc : Wash ington Regional Office -APS
APS Central Files -Permit No. W 10 700222
Chowan County Health Dept.
Pink ston Pump and WelL lnc (Howard Cutter)
RE Whitley, l nc (Rob Wh itley)
AQUIFER PROTECTION SECTION
1636 Mail SeNice Center, Raleigh, North Carolina 27699-1636
· Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
s()T'.1's A. Q~. ·_
for Debra~ ~
Supervisor
Phone: [phone] \ FAX 1: 919-715.0588; FAX 2: 919 -715-6048 \ Custo mer Service: 1-877-623-6748
Internet: www .ncwateruuality.org
An Equal Oppor:J~;ty \ Affirmative Action E:nployer
None, C .. ortn arolma
1'1nl-u;"."'fffo V VUl,U.e,UltfJ
Apr21 11 08:15a
Aor 12 77 03,55P
p.2
p2
MOM CAROLOM
DEPART C)T' MqVlRONMt-Tr Aon -NpTUR,AL'REM=ES I'= �SR}
NOTfFIC.IATM or U TENT TO CONSTRUCT A CL O? GE
UrKERMAL
w TCR-OP9z f WH CTION WM SYSTEM"
TYpIC5- W S
In .a.cCW42= Wft the pravlsiam of NCAC T*le 15A OX-C2K PL=tc
oOmptese this notificatim and mml to aka ort the lack Pne (pka3c PM Oe MW mfrtvma mu)-
We!! 73W boa �ernrulivrr ]ors tho proposed 5ygot COMWO p0bb)c (no add itim) in
c outiauaus piping &at eampiewy isalates� the flaid fmmn the awiro men, (i.e.
c2y)?
'fees 7{ Continua conrpietin g this'fat'7an.
No Do Not complete this Ib m. ComVkte Other UIC applicantm Rwm fcw Ong
either a SA7 wt!] (gam -leap w+e�k iQ1�i1�1C potable rr►2* into the aquifer) Qr a SQM wrI (Cloaed-
lwp well ooaftIningagdIIivg. such as R 22, et6mol. or other auti rom of caTmion itrhibitrs j.
A. PROPERTY OWNIM(fiYAPPUCAN'k 5)
List mmh Property Owner listed as property deed [if owned by a tr►:siness cr ggvcrnmr�t agrncy, sane r�a+rtie of
entity and a rcFrmntm&m wiauftrity fcu sib}:
`t-
atr =^ Stamm—_Ar1 / 1. Jy �- 1.1 •j ra
1 *��►.�w
(2) Pkysical Addvm of Well Site (•rf ditfcmu than ,above)
City. Sud= —Zip Code: _ �CO= _
Hom&Officc Tole Tea_
X Ate[* RX,D AGENT OF OWi+ M IF ANY (if the Permit ApPbOW 49M nat mm the subject properry,
h a tMa from the Penpert}v atMW auftri ing Agent to msmH and operamc InC well)
Compmy Name!
Comsat P CIMM. IL A
Add=".
City. Stole: zip Code: County; _-
afw Tele No_
Wobsito Address of Comparxy, if any:
REL;U to r vcltm
AGUIFFR PpflirrTI N SgciiCir
APR 2 1 ZOi1

Apr21 11 08:15a P.
Apr 92 11 03�4 3
P
empsrry t�tamc _ w
wen Dri'11er Comadot's name: L�gMLA RD P.
NC Conaaoror Celti&4tia0 NO,: D G # 53 A A.
STAGG
Corrsact P�sop'FTA .grMg�Tr J��ie�"si*tx�ir,m
City. AA_ T.ipCode: 23382 County:
❑ffice Tele No.: 757421 2108 CGII Nm:,757.438.9392
SE&T Puw cwmAcTo R v*vR*& TxoN (ifdmrasttl= diet'}
Corrosct Pcrsan- o` a'�"� _ i+..k:7'r� �r es.., l •can.
Addrm: _910
►,,ol �� _ —
Of fi= Te[e No:. 2,5 z^4s ?_-3a BO C011No :
E. STATUS OF A1PTUCANT
Frivaft: x Federal: C MW%oai:
StD= municipai: Ns6hm American Lan&-
F. LIJECTION fRQCESU M (briefly describe hnw theinjoctiou wells) will be used)
tia A WAIBR WELL- P
G. WELL C41'95 UCnON DATA
( I) Propobtd date w bG cortstt+d: ASAP -Number arfborbW.
AypM Kim=depth of tab boring {feet): ,
(2) 7YPr of acing to be used (GoP'lw PW, for
(3) Well Mmn& h the wCil(sj Cmd? (chndr o thw (4.) Yes or [tL} No Wow) —
(a) 'Yea Ef yC% then prove OtWe uTomahm below
Type: _ _ l Mood SDW bhck steal_plastsc Cher (sly!')
Casing depac From W feet (rafowrhae T4 wwd xu'Ewo)
CBsi Z COMds 10 ab ne mund
(b) Mo _x
(4) Groert Into (ate. Mai n ft wall casing =d1bz piping]:
(a) Grout N= Ccmcm Bonwidte X Other {$peeim
(b) Graut piacemut. Puazpi X _ ftemaa Mcr ^ -
{c} G tTxst 444 of tubing (r fereum to tmw surer]: fmm o to (Silt)
If w� [l her r�sixig, ,.ud[csse grout deem: from to f�e�}
APR 2
201)
aQiilFi`RA1���t'7t�]N SF{;ii�iY

· Apr2111 08 :16a
Apr 12 11 03:55p p.4
p.4
e. ~'DI)~
AU.Ch a diagJWO ~bo,iring d,.e eogiMering layout or proposed mcdificallo11 of1he injdon equi~t aud ~rior
piping/lubblg mocid:d with Ille qection· opeation. The mmu.facan:r's bn)c:burc may provid~ .supplemr.ntal;'
iruonnarion.
I. LOCATION OFWELL(S)
Anada two Cli,1pies of maps mowing attbl~ng ~
(1) [ndudc a Site Map (CID§ssbowit!g; bul"kfio&.1, ~ lines. narfaQe w.u:r bodies, potamal
soutecs of~ • · ' and 1hc orientation. of 1Dd di:,tam:c$ '.bcl,irt:cn the proposed well(s) and
any oiSlin& welI(s) or wutc filcilmes sucb as :sepdc 1:lab or clam fidds loclk:d. ~ 200 feetol
~ geothi::rma1 heat pump well • Label all &abRS c;lc:arly lllld include a n9'1J 'llffl>W.
(2) The Site Map must show the subject propaty in rclatioo to the smrounding arm by using d least two md
refcn:Gce poim such as roads,strcatns, andior ~ llllasCdicms.
S. ~N
Note: Tldl Peranlt Applicatio• --be ...... by .!!!a pe:t'IN appearlng on Ou:
............ psoputy...,..
"I bcrchy ccitify. wic:lcr pemlt,y of 1aw7 that l .hPe persooaily c,amincd and am. :familiat with i. information
submitted in 1his ~ .ud all anaehmcnts ___ .... d=:m,_ and that, based on my inquiry of dJCDC individuals
immediatdy rcspannole forok)iQiogsmd iaf01matioa. l bebettmti. inlolmlllimlis cr..amnteuxlcou:apa..
( am aware ttm there are sipificaat pemlties. mchldiDg the possibility of 6-and impri50llDlalt,. for submittins
f.atse infonnation. I agree to conserucr. opem1I,. IOainlllin,. n:pair7 and if a.pplicabk, abandoo the injection well and
all related appurtcmalCe$ inaccotdanee ~ ~ spedficalions llld ~tiol,J of1hc PcnniLn ~~-
~tS M \c+J~ /11 '"'~ PrintorTypcFullNacnean.dtitle ~ ~-,, ~,
I
s~FifC€
Priot/J}9L.d. ~
S'ignatnre of A uthorb=I .Agent. if 1111.y
Print or Type Full Natne and 1ilte
Pleas" n:turn two QJ]7ies of the ClOlnpleted Applicalion ,P11C1tage 10:
Nertb Carolina DENR-DWQ
Aquifer Protemon Sedion-UIC Program
1~ Mail Scn>i~Ceater
Qaldgb. NC 176'9-1636
Tdeplloae {'19) 71.5-6935
I RECEIVED I DENR I DWQ
AQUIFJ:R·PROTFr.TJON SECTION
APR 21 2011
Apr21 11 08l ea p.5
Afar 12 11 M-%P
FRANCIS M. 1 CCARTHY! MD.
A RTHA H. McCARTHY
132 HORNI&LOW POfNT ROAD
WEST W LOT44• LOT 45- EAST 112 LOT 46
MCWTPELIER AGFES
FOURTH Towlywp
040WAN COUNTY, NORTH CAROLM
sruE:r.�a ff0RUQQ=- Off
r d4Enm&kE: AM BDW IM. PAGE 199
� � rr ate' no �v�rr taaa+�w�r's car �r tam �
f- 60 c z 5
ftw i
fit
+i or
4eb lip
" r
t.;Z`
x
RECEIVED 1 DENR I Uvvu
AQU1Fr-R'PRnTPCTlh0FGTIor;
APR 2 1 2011

Apr21 11 08:15a
p.1
Pinkstoxt Pump &. Well, Inc:.
P 0 Box 1 W2
Chesapeake, VA 23328-5482
[phone] i (866) 949--1980
facsimile transmittal
Ta: Tanya Fax: [phone]
From: Debbie Sanders Dab: 04121//1
(de bbieiMstaggenergy.com)
Re: McCarthy, 132 Flomiblow Point Rd.. Pages: 5 Oncluding cower sheet?
Edenton, NC
a
❑ t l t a For PAView 0 Pmme a mrnent ❑ Mme Reply Q PWON Awycb
F*r the above referenced, following is ttte Type "a -OW weN(s) app'ticatkm and the Properly
site plan with the Proposed Geotharnal po■ed Lgop area.
Two (2) hard copies are being forwOMW today.
Thank youl
RQI1"' VED i utE v,,,
pROTrrTln"
OR 21 ZV I,
0 • - - 0 0 0 9 0 9 • 4 4 - - . a 6 4 • 0 • a - 4 • .

Apr 12 .. 11 03:55p p.2
NOR:lff CAROLINA
DEPARTMENT OF ENVIRDNMiNf AND NATURAL RESOURCES (NCDENR)
NOTJFICATION OP INTENT TO CONSTRUCT A CLOSED-LOOP G.EOO'HERMAL
WATER-ONLY lNJECTIONWEL-L SYSTEM:
TYPE 5-0 W WELL(S}
In &cordance with the proYjsions ofNCAC Title 1SA: 02C.0200, please
complete this notification and mail to address on the back page (please Print or~ information).
DATE: __ tJr,...__r_-_r __ _,. 28_.J]_
Well TypeCo11fumalion: Docs the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closecl-lOQR)?
Yes _X_ Continue completing this form.
No __ Do Not complete this form . Complete other UIC application forms for installing
either a SA 7 well {QRm-loop well iniecting potable water into the aquifer) or a SQM well ( closed-
loop well containing additives such as R-22, ethanol. or other anti:freez.e or c-OITOSion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List g&h Property Owner listed on property deed (if owned by a business or government agency. state name of
entity and a representative w/audtorityfor signature): ----------......-.,....--,--------
f/;.!tt\rJS H ' ~ M M:-'Ttffl if. B e:G-R nti
(1) MailingAddress: I 3 ci tfu E!.1J ra<m2 -Pf Rd
City: &/e~ State: ~pCode:~_-q.9 3 ~ ~: CJ.~
Home/Office Tele No.w a-~-O.:;lSt:) Cell No.~ ,J5'ol -.3;sZ>-67~5
EmailAddress: ho,""l'\,bfer,,..)@. Website:
~~;.c.,o~
(2) Physical Address of Well Site (if different than above): ____________ _
City: ________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: Cell No.:. -----------=-==='------------
B. AUTHORIZED AGENT OF OWNEB, D' ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner amhorizing Agent to install and operate UIC well)
CompanyName: __________________________ _
Contact Person:.~· -------------=E=-MAIL==A=d=dres=s:::....· _________ _
Aa~: -----------------------------City: ________ S1ate: ·_zip Code: _____ County: ______ _
Office Tele No.: _______________ C=e=ll...,N=o=.:,__ ________ _
Website Address of Company. if any:._...-___________ _
RECEIVED / OENR I D~VO
Aquifer ProtPr.tinn R ... rt,nr,
APR ~8 2011
1
Apr 12 .11 03:56p
p,3
C. WELL .DRILLER INJlORMATION
CompanyNamc: __ _,P!::.!INKS£!!!!:2.TO~N~P UMP~!...£!AND~:..2WEL~~L,~IN~C:,:_._ _________ _
Well Driller Contractor's Name: __ --!.fti~O~W.~'A:!.!RD~~B:..:. CUTTER~~~----------
NC Contractor Certification No.: ~D~RJL~~LalilN~G~#~3~5.:::::.:38-!:<..A~ __ __,H...,_-.l<.3=#2927=..,._7.:-;J=EF=FRE=Y~A=·-S-=TA=GG---=---
Contact Person: JEFF STAGG EMAIL Address: jefflglstagg energ.y.com
Address: PO Box 1S482
City: CHESAPEAKE , VA Zip Code: 23382 County: __________ _
Office Tele No.: _757-421-2108 ______ Cell No.: _7S7-438-9392 _______ _
D. HEAT PIJMP CONTRACTOR INFORllilATION ("If diff'ermttbn drBler)
Company Name: fl £ .w111 -rlli 'I $~c.
ContactPerson: T.I> ·U.;.,f .L.1 F.MAILAddn:ss: rc.wh•..,,~~,.:rre_'J ,,.-:,. GOlh
Address: 9 ID /JIit/ h~ r'A
City: u/4., ,.._. ZJpC-OQe: -'" County: --=-Z _7 ....;.1 _'3_'<-______ _
Office Tele No.: 2 s-2-f-S't.-.10 80 Cell No.: ________ _
E. STATUS OF APPLICANT
Private: A-.
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the iajectioo well(s) will be used)
NOT A WATER WELL -GEOTHERMAL CLOSED LOOP
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: ___...A=S=A-P _____ Nmnberofborings: ___ _
Approximate depth of each boring (feet):. _ _...;.2=00-=--------
(2) Type oftubing1o bel!Sed {copper, PVC, etc)! _....:BDPE==-=-------------
(3) Well casing. Is the well(s) cased? (check either (a.) Yes!!: (b.) No below)
(a) Yes ___ if yes, 1hen pn,,,ide casing information below
Type: __galvanized steel _black steel____plastic __ other (specify)
Casing depth: From ___ to ___ feet. (reference to land surfue)
Casing extends to above ground inches ---
(b) No X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Beotonite X Other (specify) ------
(b) Crout placement: Pumping_K__ Pressure___ Other __
(c) Grout depth of tubing (reference 1o land su.rmce): ftom O to 200 (feet)
If \\"ell has casing. ~dicate grout depth: from ___ to ____ (.feet)
Apr 12.11 03:55p
p.4
H. JNJECrION-RELAUD 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.
I. LOCATION OF WELL(S}
Attach two copies of maps showing Ille tbl~ iafonnalion:
(1 J Include a Site Map (""' be a showing: buiklmp, propmy lines, sut&ce waller bodim. )ldallild
sourc:es of groundwater cootam • • and the orientation of and dislances between the proposed weJl(s) and
any existing well{s) or waste di · facilities such as septic tanks or drain ~ds localm within 200 f.eet of
the geothermal heat pump well sys . Label all features clearly and include a north arrow.
(2) The Site Map must show the subjedt property in relation to the swrounding area by using at least two "fixed
reference points such as roads, streains, andlor highway intersections.
S. CEKIDICATION
Note: Tbis Permit Application mast be signed by S!Sll person appearing on the
neorded 1epl property clecd.
.. I hereby certify, under penalt;y of law, that I have personally examined and am familiar with the information
submitted in 1his document and all abachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I be1ie¥etlmt the information is uue, accurate and complete.
I am aware that there are significant penalties. including the possibility of fines and imprisonment. for submitting
false information. I agree to construct, operate,~ repair, and if applicable; abandon the injection well and
aDrelatal-in-...~spociliadioo,aodomditioosof11iel'ermR."
~~---~~Jam-
P,J5~~.t1~ e:+JAD.., M. C:~
~~ H~C€ Si~ Owner/Applicant \..
M~X?JA ~Jal._ f\l\CC~
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 Cantlina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Qaleig}I, NC 27699-1636
T~phone [phone] RECE/Vf:0/0
Aquifer Pr,ot,,.,,t~NR I DWQ ,.,,,,on s .... ,_.. '-!r,<,,1on
APR 28 2011
Apr 12`11 03755P
P.5
FRANCIS M McDARTHY, MD.
A110
!1 ART fib H. McCARTHY
132 HORNIaOW PUNT ROAD
WEST 112 LOT 44- LOT 45- EAST 112 LOT 46
MONTPELIER ACRES
FOURTH TOtHIS WP
CHOW,AN COUNTY . NORTH CAROUNA
SCALE: f". Wr
21S SO Im Psi! 200
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2 J AR54 r'i616D SWMRE FEAT
9 J MUM A*S' p EvMaff sWfiQQ2adW5 QV Off OFF TMS PAWDUY.
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Apr 12 11 03:55p
p.2
N()JtlH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY lNJEcnON WELL SYSTEM:
TYPE S-QW WELL(S}
In Accordance with the provisions of NCAC Title 1 SA: 02C.0200, please
complete this notification and mail to ad4ress on the back page (please Print or~ information).
DATE: __ ~...___r _-_~ __ _,, 2o_Jl_
Well Type Co11frrmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loo!))?
Yes _X_ Continue completing this form.
No ___ Do Not complete this form. Complete other lJ1C application forms for installing
either a SA 7 well (~loop weU iniecting potable wat.er into the aquifer) or a SQM well (closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List~ 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): ------...---,--,----=--------
fC--fcf\)CJS K , -;-M A-t.-!1-tA if . MCW7117
(1) MailingAddress: / 3 ci tfueJv 1&m) {¥ ,Zd
City: etle,.,d.-e ~ 'State: Acnp Code:a:9::::9 3 ~ County: CJ~
Home/Office Tele No.~sa-4&:2 ..-c,dSt) Cell No.: ,.15~ -3~~ -6 7<J.S
Email Address: ho )"l'\\ h (e-t.2,@ Website:
~c.h.s l , C.D~
(2) Physical Address of Well Site (if different than above): _____________ _
City: _________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: ------------=C=el ..... 1-""'N=o·=-=-----------
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 lJlC well)
Company Name: ____________________________ _
Contact Person.;:...: --------------=E=MA==IL~A-=d=dre..=s=s: _________ _
Address: ______________________________ _
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company. if any: ______________ _ RECEIVED/ DENR / DWQ
Aquifer ion Section
APR 2 8 20!1
Apr 12 1 1 03:55p
p.3
C. WELL DRILLER INPORMATION
Company Name: PIN]{STON PUMP AND WELL, INC
Well DriUer Contractor's Name: ___ H=O=-W ........ A=RD=-=E=•--CUTTER__,_--"=-------------
NC Contractor Certification No.: DRILLING #3538-A H-3 #2CJ277 JEFFREY A. STAGG
Contact Person: JEFF STAGG EMAIL Address: je ff@ s taggenergy.com
Address: __ --=PO=-=-B=ox::...:.,lSc..4_.82=--------------------------
City: CHESAPEAKE. VA Zip Code: 23382 County: ___________ _
Office Tele No.: 757-421-2108 _______ Cell No.: _757-438-9392 ________ _
D. HEAT PUMP CONTRACTOR INFORil!rATION (if diff"erent than driller)
Company Name: fl £ .W ~ 1"Ui '/ :j;~e,
Contact Person: f. b . .J. ;.,,f .c.1 F.MAILAdmasi ,~~h·"--11~-'t vrf!.~tw>:J. c.on.
Address: q IO lj ,JI,~ r'rl.
City: u/4., ?'.' ZipCode: ,,vc... County: --=--Z._7"""'"'1'_3_'<--______ _
Office Tele No.: 2 S"2-4S"l..-1o 80 Cell No.:
E. STATUS OF APPLICANT
Private: ....x_
State:
Federal:
Municipal: __
----------
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
NOT A WA lER WELL -GEOTHERMAL CLOSED LOOP
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _A_S~A_P ______ Nmnber of borings: ____ _
Approximate depth of each boring (feet): __ 2~00 ________ _
(2) Type of tubing to be llSed (copper. PVC, etc): __ HDPE._.... ____________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes!! (b.) No below)
{a) Yes ___ if yes, 1hen 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__ Benlonite X Other (specify) ______ _
(b) Grout placemen1: Pumping X Pressure___ Other __
(c) Grout depth of tubing (reference to land surface): from O to 200 (feet)
If well has casing. indicate grout depth: from ___ to ____ (feet)
Apr 12 11 03:55p
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H. IKJECtION-Rn ATED EQLlI1 MENT
Attach a diagram showing the engineering layout or proposed modification or the injection equipment and exterior
pipingftubing associated with the injection operation. The manufact=r's brochure may provide supplementary
information_
I. LOCATION OF WELLS)
Attach two copies of ntraps strowing Wee follpwing inftarmation:
(1) Include a Site Map (can be drawrq) 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 dispD�,at facilities such as septic mnks or drain 5eids Irked within 200 feet of
the geothermal heat pump well systern. 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, andlor higbway intersections.
Y. CERIii it[CATION
Note: This Permit Application must be signed by each person agpeariag 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 aD attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtarning said information, I believe Heat the hdorrttation is true, accurme and complete.
I am aware that there are significant penalties, including the passibility of lines and imprisonment, for submitting
false information. I agree to construct, operate, mainudn, repair, and if applicable, abandon the injection well and
all related appurtenances in acmalance with dr oppro ved spec fcatiom and eottditions of the Permit_"
`�igrtaGm of Property Own lwam
1-5 ClAA-t-E-�, 2P�CCPrP--7-"
Print or Type Full Name and title
WI'EN
Signature of PnnwTty OwnerlAppli:cattt
Print or Type !"ill blame and title
Signature of Authorh ed Agent, if any
Print or Type Full Name and title
Piease return two copies of the completed Application package to:
?North Caroiiinat DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 276"-163
RMEivE�PlR
Telephone [phone] r�� lf�
Rt�il'�r F�aaw'll�n i�1Ct���

Apr 92 91 03.55P
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FRANCIS M. McCARTHY, MD.
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11 ARTHA H. McCARTHY
132 I*WNIMOW POINT ROAD
NEST 1/2 LOT 44- LOT 45- E4ST 112 LOT 46
MONTPFL FFR ACRES
FOURTH TOWNSHIP
U40WAN COUNTY, NORTH CAR A
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