WI0700223_GEO THERMAL_20120523

Beverly Eaves Perdue
Governor
A'P./'A ;;;;-;;-;, 1 ---NCD EN R __ _
North Carolina -Department-of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 23, 2012
Edward Homer
676 River Road
Callicoon, NY 12723
Subject: Notification of Rule Revisions Affecting
Closed-Loop GeothermalJnjection Well PermitHolders
Permit Number: WI0700223
Dear Mr. Homer:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http ://portal.ncdenr.or g/web/wq/ap s.
If you have any -questions regarding -your· current permit or-the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely, t~ h vvtr
Eric G. Smith, P .O.
Hydrogeologist
cc: UlC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 276D4
Phone: 919-<'107--6464 \ FAX: 919-<'107-6496
Internet: www.ncwaterguality.org
An Equal Opportu1ily \ t-.fftrmative Action Employer
One
North Carolina
;Vaturall!J
Permit Number WI0700223
Program Category
Ground Water
Permit Type
-
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facillt
Facility Name
Edward Homer SFR
Location Address
149 Yaupon Tri
Southrn Shore
Owner
Owner Name
Edward
Datos/Events
NC 27949
Homer
Scheduled
Orig Issue
04/27/11
App Received Draft Initiated Issuance
02/14/12
Regulated Activit ies
Heat Pump Injection
Central Files: APS_ SWP_
02/21/12
Permit Tracking Slip
Project Type Status
Active Major modification
Version
1.10
Permit Classification
Individual
Permit Contact Affiliation
Jeff Stagg
Driller Well
PO Box 15482
Chesapeake
Major/Minor
Minor
VA
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Edward Horner
676 River Rd
New York
Public Notice Issue
02/21/12
NY
Effective
02/21/12
Re guosted/Received Events
RO staff report received
RO staff report requested
233285482
10011
Expiration
01/31/17
02/16/12
02/16/12
Waterbody Name Stream Index Number Current Class Subbasin
Permit Number WI0700223
Central Files: APS SWP
02/16/12
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Status
in review
Version
Permit Contact
Jeff Stagg
Driller Well
PO Box 15482
Chesapeake
Project Type
Major modification
Permit Classification
Individual
Affiliation
VA 233285482
Facility Name
Edward Horner SFR
Location Address
149 Yaupon Trl
Southrn Shore NC 27949
Owner
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Name
Edward
Dates/Eve nts
Horner
Owner Type
Individual
Owner Affiliation
Edward Horner
676 River Rd
New York
NY 10011
prig Issue App Received
04/27/11 02/14/12
Regulated Activities
Draft initiated
Scheduled
Issuance
Public Notice Issu
)fie
Heat Pump injection
Outfall tJLrL!
Effective
ReQTuested/Received Events
RO staff report received
RO staff report requested
(Etta; i r)
02/16/12
02/16/12
Waterbody Name
Stream Index Number Current Class
Subbasin

A71.1
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
February 20, 2012
Edward 1. Horner
676 River Road
Callicoon, New York 10011
Ref: Issuance of Injection Wen Permit WI0700223
Issued to Edward J. Horner
Dare County
Dear Mr. Horner:
In accordance with the application received on February 14, 2012, I am forwarding permit number WI0700223 for the
operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system located at 149 Yaupon Trail,
Southern Shores, Dare County, NC 27949. This permit shall be effective from the date of issuance until January 31, 2017,
and shall be subject to the conditions and limitations stated therein, including the requirement to install well
identification tags as specified in Part I. Be sure to read the entire permit to ensure that you are aware of all compliance
requirements of the permit.
Also, please pay special attention to Part V.2. The Permittee shall retain all records of repairs, pressure tests,
maintenance, and other activities needed to maintain normal operating conditions.
In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an application
to renew the permit 120 days prior to its expiration date. This permit is not transferable to any person without prior notice
to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or eric.+'..smithfa7nadcnr.go� if you have any questions about your permit.
Best Regards,
60414/17r
Eric G. Smith, P.G.
c:
David May. Washington Rt gional Ot1ie
MO"; 0022.3 1 'ermi 1• ILL
Dare County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Sat£slsury St., Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet www.ncwateruualitY.otg
An Equal Opportunity lAtfirrrofiva Action Employer
No e hCarolina
Xatilraii

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Edward J. Horner
FOR THE OPERATION OF 5 (FIVE) TYPE 5QM INJECTION WELL(S), defined in Title 15A North
Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed -loop
geothermal -mixed -fluid heat pump system. This system is located at 149 Yaupon Trail, Southern Shores, Dare
County, NC 27949, and will be constructed and operated in accordance with the application received February
14, 2012, and in conformity with the specifications and supporting data submitted, all of which are filed with
the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for operation of an injection well and shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until January 31, 2017, and shall be
subject to the specified conditions and limitations set forth in Parts I through VWI hereof.
Permit issued this the 20th day of February 2012.
ato s
Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission.
W10700223 UICI5QM Conversion Page 1 of 4
Version 1212011

PART I -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3 . The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. In the event that there are multiple wells with separate clusters, one well identification tag per 'cluster' of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
PART II-PERFORMANCE STANDARDS
1. Th.e injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART III -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
planned physical alterations or additions in the permitted facility or activity not spcciiicaily authorized by
the permit.
PART IV -INSPECTIONS
WI0700223 UIC/5QM Conversion
Version 12/2011
Page 2 of 4
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon.
presentation of credentials, enter. and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this pemn1,' may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART V -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface .water, .or soil sampling) deemed necessary . by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee . shall retain all records of repairs, pressure tests, maintenance, and other activities
neededto maintain normal operating conditions.·
3. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge · of the
occurrence, to the Washington Regional Office,_ telephone number 252-946-6481, any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations,.such as mechanical or electrical failures;
4. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
5. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VI -PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART VII-CHANGE OF WELL STATUS
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to ISA NCAC 2C .0213(h)(l), Well
Construction Standards.
·.WI07OO223 UIC/5QM Conversion
Version 12/2011
Page 3 of4
2: · When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection. well in accordance with the procedures specified in ISA NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written document ati on r equired in Part VII(]) and (2) (G) shall be submitted to:
WI0700223
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/5QM Conversion
Version 12/20 11
Page 4 of4
Smith, Eric
From: Clark, Allen
Sent:
To:
Thursday, February 16, 2012 3:07 PM
Smith, Eric
Cc: May, David
Subject: RE: WI0700223 5QM Application
Good Afternoon Eric,
WaRO does not feel that a pre-permitting inspection is needed for this site .
We have the GW-1 for the five (5) geothermal loops that were installed at this site on December 7, 2011.
If you have any questions, please let me know.
Thanks,
Allen
Allen Clark
NC Division of Water Quality
Aquifer Protection Section
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone [phone]
FAX [phone] {attn: Allen Clark)
*E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: May, David
Sent: Thursday, February 16, 2012 2:00 PM
To: Clark, Allen
Subject: FW: WI0700223 SQM Application
Allen,
Can you take a look at this one and follow back up with Eric regarding recommendations.
Thanks
David
David May, Regional Aquifer Protection Supervisor
Division of Water Quality
Aquifer Protection Section
943 Washington Square Mall
Washington, NC 27889
1
Phone: [phone]
Fax : [phone]
E-mai l: david.ma y@ ncdenr.g ov
http://portal.ncdenr.org/web/wq/
E-ma i l correspondence to and from this address may be subject to the North Carolina Pub l ic Records Law and may be
disclosed to th ird parties.
From: Smith, Eric
Sent: Thursday, February 16, 2012 1:S7 PM
To: May, David
Subject: RE: WI0700223 SQM Application
Oops. Rookie mistake.
Eric G. Smith, P.G.
Hydrogeologist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
919-807-6407 -
919-807-6496 Fax
http://portal.ricdenr.org/web/wg/aps
DISCLAIMER : Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties .
From: May, David
Sent: Thursday, February 16, 2012 1:55 PM
To: ·Smith, Eric
Subject: RE: WI0700223 SQM Application
I didn't see the attachment.
Dav id May, Regional Aquifer Protect ion Supervisor
Division of Water Quality
Aquifer Protection Section
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
E-mail: [e-mail]
http://portal.ncdenr.org/web/wg/
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties .
2
From: Smith, Eric
Sent: Thursday, February 16, 2012 1:S4 PM
To: May, David
Subject: WI0700223 SQM Application
David:
Since Mike Rogers is out for a few weeks, I'll be assisting with SQM permits. This is my first email of this type, so if you
need anything else, let me know.
Attached is a SQM application we received 2/14/12. Do you want to do a pre-permitting inspection?
-Eric G. Smith
Eric G. Smith, P.G.
Hydrogeologist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service ce·nter
Raleigh, NC 27699-1636
919-807-6407
919-807-6496 Fax
http://portal.ncdenr.org/web/wg/aps
DISCLAIMER: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties.
3
AI TA
NCDENR
North Carolina Department of Environment and Natural Resources
Governor
Edward J. Horner
676 River Road
Callicoon, NY 10011
Dear Mr. Homer:
Director Secretary
February 14, 2012
Subject: Acknowledgement of
Application No. W10700223
Edward Horner SFR
Injection Mixed Fluid GSHP
Well (5QM) System
nary County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on February 14, 2012. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Washington Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
Sincerely.
twN
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Jeffrey Stagg — Pinkston Pump & Well Co. Inc.
Brian McDonald - Outer Banks Heating & Cooling
Permit File WI0700223
1636 Mail Servioo Censer, RaleV, North Carolina 27699.1636
location: 512 N. Safisbuty St., Raleigh, North Carolina 27604
Phone [phone] FAX: [phone]
Internet: w`Evw.ncwatereualIty.arq
An Equal Opportunity l Affirmative Action Employer
One
No hCarolina
aurally

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND, NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAk 02C .0200
CLOSED -LOOP MIXED -FLUID GEO'I fi RMAL I NJECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system
(check one) New Application Renewal * X Modification
* For renewals complete Pins A-C and the signature page.
Print or Type Information and Mail to the Address on the Last Pagel: Illegible Applications Will Be
Returned As Incomplete.
DATE: 2/0612012
PERMIT NO. W10700223 (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence LC Business/Organiiation
Government: State Municipal County _ Federal
8. PERMIT APPLICANT — For individual residences, list each owner on property deed. For al! others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
Edward J. Horner I.
Mailing Address: 676 River Road
City: Callicoon
Day Tele No.:
State: NY Zip Code: 10011
Cell No.: 347 739-5257
EMAIL Address: ehfaedward i horner.com
County: Sullivan
Fax,:
C. LOCATION OF WELL SITE — Where the injection wells are physical' located:
Parcel Identification Number (PIN) of well site: 986705196304 County: Dare
Physical Address (if different than mailing address): 149 Vaupul Trail -
(1)
(2)
City: Southern Shores State: NC
D. WELL DRILLER INFORMATION
Wc11 Drilling Contractor's Name: Howard Cutter
NC Well Drilling Contractor Certification No.: 353X-A
1
Company Name: Piokston Pump & Well Co. Inc.
Contact Person: Jeffrey A. Stagg EMAIL Address:
Address: 636 Benefit Road
City: Chesapeake Zip Code: 23322
GPUIU1C SQM Permit Application (Revised 1/24/2011)
Zip
ode: 27949
tinaraStage rpi a rcv.com
Page

Office Tele No.: 757-438-9392 Cell No.: 757-912-6030 Fax No.: 57-421-2108
E. HEAT PUMP CONTRACTOR INFORMATION (if different than ilJer)
Company Name:_ Outer Banks Heating & Cooling
Contact Person: Brian McDonald
Address: PO Box 1415
City: Nags Head Zip Code: 27959
Office Tele No.: 252-441-1740 Cell No.:
F. WELL CONSTRUCTION DATA
State: N& Cou ty: I!!!£
Fax No.: 2 2-441--0639
(1) Nwnber of borings to be constructed*: ~ Depth of each bor· (feet): 100
* If existing water supply wells will be used then rovide the information in item ( 4) below.
(2) Chemical additives to be used: R-22 ___ Propylene -Iycol ___ Ethanol
Other: Environol (other additives will need prior approval by N DENR before use)
(3) Type of tubing to be used (copper, PVC, etc):. HDPE
(4) Well casing. If the well(s) will use casing then provide the ~(st el, PVC, plastic, etc.), diameter, d~
and~ of casing appearing above ground: ~
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ . Bentonite** X Othe (specify) _______ _
•• By selecting bentonite grout, a variance is hereby requestec! 10 I SA NCAC 2C . 213(d)( l XA). which requires a cement type grout
(b) Grout depth of tubing (reference to land surface): from to l,!!!! (feet)
If well has casing, indicate grout depth: from --i----to ____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indi ate distances and orientations of
features located within 1000 feet of the injection well(s). Label all ti clearl and include a north arrow.
( 1) Attach a site-specific map showing the locations of the follo wi g:
* Proposed injection wells * Buildings * roperty boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamin tion
(2) Attach a topographic map of the area extending 1/4 mile from he injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property arcel showing property lines and
structures can be obtained and downloaded from the rpplicable county GIS website.
Typically, the property can be searched by owner name or a 'dress. The location of the wells
in relation to property boundaries, houses, septic tanks, othe wells, etc. can then be drawn in
by hand. Also, a 'layer' can be selected showing topographic contours or elevation data.
GPU/UIC SQM Permit Application (Revised 1/24/2011) _ Page2
H. CERTIFICATION (to be signed as required below or by that persun's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall a signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partnei/ or the proprietor, respectively;
3. for a municipality or a state, federal, or other public age icy: by either a principal executive
officer or ranking publicly elected official; _
4. for all others: by the well owner (*.blab Means all v1 -I stecl,tn:h petty- deed;.
If an authorized agent is signing on behalf of the applicant, When supply a fetter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"1 hereby certify, under penalty of law, that 1 have personally examineii 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, 1 believe the the information is true, accurate and
complete. 1 am aware that there are significant penalties, including th4 possibility of fines and imprisonment,
for submitting false information. I agree to constructs operate, rnaimairk repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the apiroved sprr4-ific titans and conditions of
the Permit."
Signature of Property OwnerjAppli
Xd rA - T3a &I'
Print or Type Full Name
Signature of Property OwnerWApplicant
Print or Type Full Name
Signature of Authorized Agert, if any
Print or Type Full Name
Submit two copies of the compteted application package to;
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
OPURJlC SQM Permit Application ('Revised 1+24raol 1)
Page3

WOOD
RETAINING
WALL
LIMAI5QO
Cee6Q CISTERN
6Vf SN&.
FU ERS &
FUR ITCH
NOTE; EI3STING
rareR ELEVATION
MARINO wail
PRuPEFEry LJN
ON ADJACENT Silt
7Fff[ RIO MEI --^
Rom STRIP
rr/ RLIER
S rON Lil83Eit
M,ra lee
frr
141411 FENCE
OS
11
EXIST SPOT EL NAVO 8$
COST TtFO NAVD 88
PROPOSED TOPO NW 8B
sivP war a_ NAVD 88
/NM
MUTE
EE I SAXD
� BUNS
LOT Q„ Mimic 122,
SOUTHERN SHORES SUBDIVISION
18,737 SQ. FT.
GRADING PLAN
-ems
Vim
TO

Parcel Card Page 1 of "_
Parcel Number: 021687000
County of Dare, North Carolina
Owner information:
HORNER, EDWARD J
676 RIVER RD
CALLICOON NY 12723
Parcel Information:
Parcel: 021687000 PIN: 986705196304
District: 20 - SOUTHERN SHORES
Subdivision: SO/SH SOUND BLKS 112 122 123
LotBlkSect: LOT: 4 BL1S: 122 SEC:
Multiple Lots: -
PlatCabSlide: PL: 2 SL: 175A Units: 1
Deed Date: 11 /5/2007 BkPg: 1746/0205
Property Use: Single Family Residential
BUILDING USE and FEATURES
BUSE: Single Farn
Exterior Walls
Interior Walls
Floors
Roof Cover
Roof Structure
Heat -Fuel
Heat -Type
Air Conditioning
Dwg
Wood Shingles - Hardy Plank
Drywall - Custom Wood
Ceramic or Quarry Tile - Hardwood
Asphalt Composition Shingle
Gable or Hip
Electric
Forced Air / Duct
Central Air
MISCELLANEOUS USE
Muse1: Bulkheading
Muse2: Dock Or Sm Pier
Muse3: Dock Or Sm Pier
Muse4: Dock Or Sm Pier
Muses: Cvrd Dck/W1k/Water
LAND USE
Print Date: 2/16/2012
loso
149 YAUPON TRL
Building Billing Value: $0
Actual Year Built: 2011
Baths: 2.5
Bedrooms: 3
FINISHED SQ FT: *please see notes below'
drawingl = 2924
LUSE: 20-Creekfront Lot
Luse2:
Luse3:
Luse4:
Luse5:
Luse6:
LAND AREA: *please see notes below 19000 Square Feet
Min Billing Value: $6,900
Land Billing Value: $493.800
Total Billing Value: $500,700
Due to the revaluation work being done this year, we will not be updating the land size or area this year
after this update. The Building, Misc and Land data is reflective of 2012 billing data (that information won't
get updated for new construction or anything that gets billed in 2013), again due to revaluation.
littp;//www.darenc.corn/public/parcelcard.asp?Parcel-021687000
2/16/2012

ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, RE. - Dee Freeman
Governor Director Secretary
February 20, 2012
Edward J. Homer
676 River Road
Callicoon, New York 10011
Ref: Issuance of Injection Well Permit WI0700223
Issued to Edward J. Homer
Dare County
Dear Mr. Horner:
In accordance with the application received on February 14, 2012, I am forwarding permit number WI0700223 for the
operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system located at 149 Yaupon Trail,
Southern Shores, Dare County, NC 27949. This permit shall be effective front the date of issuance until January 31, 2017,
and shall be subject to the conditions and limitations stated therein, including the requirement to install well
identification tags as specified in Part I. Be sure to read the entire permit to ensure that you are aware of all compliance
requirements of the permit.
Also, please pay special attention to Part V.2. The Permittee shall retain all records of repairs, pressure tests,
maintenance, and other activities needed to maintain normal operating conditions.
In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an application
to renew the permit 120 days prior to its expiration date. This permit is not transferable to any person without prior notice
to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or eric.g.smithj2ncdenr.gov if you have any questions about your permit.
cc: David May, Washington Regional []Bice
WI0700223 Pcrnnit File
Dare County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1036
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] FAX [phone]
Internet vesw.ncwatereualtly.osg
An Equal Opportunity 1Atrirrnalivo Aclian Employer
Best Regards,
Lip id177'7,
Eric G. Smith, PG.
No e hCarotina
?atarall

ono ? 7
Rogers, Michael
From: Tina Stagg ftina a©staggenergy.cornj
Sent: Tuesday, November 29, 2011 9:19 AM
To: Rogers, Michael
Subject: Opps sorry
Attachments: Homer Revised.pdf
Forgot to attach
Tina M. Stagg
-Vice President
T'inkston. geothermal
T'iazkston. Pump & el Inc.
J-5 Stagg Energy Thtcrprises, Inc.
P n 13O-w 15482
Chesapeake,, V,4 23328 -5482
757-438-9392 0ffr..cu
757-42/-2/08 faux,
[e-mail] n

Rogers, Michael
From: Tina Stagg [[e-mail]]
Sent: Tuesday; November 29. 2011 9:19 AM
To: Rogers, Michael
Subject: Horner Revision
Mike,
I have a revised drawing attached for:
Edward Horner
149 Yaupon Trail
Southern Shores NC ( Dare County)
This original permit was issued 4/27/11.
The homeowner is ready for us to install but had changes.
Thanks..again....
Tina .M. Stagg
Tice President
• MI
r
PittIistont Caeothermal
Pin.iston Pump $ Neff Inc_
J Stagg Energy Enterprises, Inc.
I' 0 O%w 15482
Che .cGpea.ke', VA 23328-5482
75 7 -438 -9392 Off-:ce..
757-421-2108 Few
tinca @staggenergy. c om
1

If B:
WOOD
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afr it
i COMO MIMI
oe41 15rio G
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LOT 4, BLOCK 122,
SOUTHERfi SHORTS SUBDIVISNN
18,737 SQ. FT.
GRADING PLAN I

Permit Number
Program Category
Ground Water
Permit Type
WI0700223 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Edward Horner SFR
Location Address
149 Yaupon Tri
Southrn Shore
Owner
Owner Name
Edward
Dat es/Ev e nts
NC 27949
Horner
Scheduled
Orig Issue App Received Draft Initiated Issuance
04/27/11 04/26/11
Regulated Activities
Heat Pump Injection
Outfall 1~U!..L
Central Files: APS_ SWP_
04/27/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Jeff Stagg
Driller Well
PO Box 15482
Chesapeake
Major/Minor
Minor
VA
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Edward Horner
676 River Rd
New York
Public Notice Issue
04/27/11
NY
Effective
04/27/11
233285482
10011
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
ri A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
4/27/2011
Edward Harper
676 RivcrRoac$
Callicoon, lam' 10011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10700223
149 Yaupon Trail. Southern Shores, NC 27949
Dear Mr. Homer:
On 4/26/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
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 constructionand 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,-0211(0(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.Rovers(ncdenr.eov if you have any questions.
Sincerely,
0
,for. Debra Watts
Supervisor
cc: Washington Regional Office - APS
APS Central Files - Permit No. WI0700223
Dare County Health Dept.
Pinkston Pump & Wen (Jeff Stagg)
Outer Bank Heating Si Cooling, Inc (Brian McDonald)
AQUIFER PROTECTION SECTION
1636 Mai! Service Center, Ralegh, Narth Carolina 27699-1636
Location: 2728 Capita; eouievar, , Raleigh. Noun Carolina 27604
Phone: [phone] FAX 1: 919-713-0588; FAX 2! 919.715.6048Customer Service:1-677-623-6748
Internet: ww,v.ncwateraualitv.DM
A� eariai fippar_.,, ? 1 Aftiri !ve Employe!
6cor„
No 17 Carolina
atu,'aIi

Apr 2011 09:322 p.2
NORTH CAROLINA
DEPARTMENT OF EIWIRONMEIsIT AND NATURAL RESOURCES (NCOENR)
NOTIFICATION OF INTENT TO CONSTRUCT A SD -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLuS)
In Accordance with the provisions u fNCAC Title I SA: O2C.02OO, please
complete this notifiention and mail to address on the back page (pleaso bat or Type information).
DATE: [ 2 S'
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that comple ly isolates the fluid from the environment (i.e.
cloyed -loon)?
Yes 3C Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either n 5A7 well (open -loop well iniectiag potable water into the aquifer) or a SQM well (closed.
loop well containing adsliiiveI such as R 2Z, ethanol, or other antifreeze or oacrosion inhibitors).
A. PROPERTY OWNER(SYAPP'LICA.N T(S)
tiVarr.)1;004*..iiigkreN listed en property deed (if owned by a business or government agency, state name of
eorily and a represent tine wlautimtity for sigh ture); Edward J._Hor cr
(l)ii:ai�._ 676
.iliVes_ Raid
Oilyi licoon RE NY t : i001l Ma* Sullivan
gatkIWWWW inicni 347.739.525?
i Weber:
(2) i?O'taf gMefF (if different than above): 149 Yawooa Trail
Southern sboctis NC Mif : 271ViA�....*e
ggrotrgir4M Ci4o4; 347.7395257
S. AUTHORIZED AGENT OF OWNER, W ANY (if the Permit Applicant duet' of own the subject property
attach a letter from the property owner authorizing Agent to install and operate LAC welt)
CompanyName:
Contact Person: EMAIL Adds=
Address:
City: State- Zip Cade: Cotmiy:
Office Tele No.: Cell No.:
Websiie Address of Company, irony:
GTU(JiC 5QW No6fivition amain For gtevisad'$Jx00)
hirt

Apr2611 O9:32a
p.3
G WELL DRILLER DEFORMATION
Company Name; PINKSTON VILYNED WEL-IJNC - Well Driller Contractor's Name; t OWARD E CUTTER
NC Contractor Certification No.: pitiLLENe #3538-A 143 #29277 3EFFREY A. STMCG
Contact Person: EEFE SI AGG ..-_ EMAIL Address: 3estaggenertiv.carn
Address: PO Box 1554$2
City: CHESAPEAKE.VA Zip Code: 23382 County:
Office Tele No.: 757-421 2 t D8 Cell No.: 757-438.9392
D. titAnglOWN4atiiMINtbkitildikif'ddilTerent than. driller)
Company Name _ Durt s Banks Heating& Coaling
Conrad Person; Brian McDt nakl
Address: Fp1475
City: Naas lid
Office Tele No.: 252-441-1740
EMAtLAddress: [e-mail]
Pap Code: 27959 County: Care
Cell No.:
L. STATUS OF APPLICANT
Private: X
Slate:
Federal:
Municipal:
Commercial:
Native American ids:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
NQT A WATER WPi,L - GEOTHERMAL CLOSED LOOP
G. WELL CONSTRUCTION DATA
(I) Proposed date to be oonaucted: A A Number of borings:
Approximate depth of each boring (feet): 260
(2) Type of tubing to be used (copper; pvc, etc): HDPE
(3) Well casing, Is the well(s) rae•Ftd? {check either (a.) Yea A (b.) No below)
(a) Yes if yes, then provide casing information below
Type:alvanizcd steel black steel plastic other (specify)
Caging depth: From to feet (reference to land apace)
Casing extends to above ground inches
(b) No __X_
(4) Grout infer (material surmundhig wen casing atulfor piping):
(a) Grout type. Neat Cement Bentonite R Other (s ift')
(b) Grout plaoement Pumping X Pressure _ Other_
(c) Grout depth of tubing (reference to land surface): from 0 to 200 (feet)
If well has casing. indicate grout depth: from to (feet)
GPUNIC 5QW Notification of latent i;ont alevizad MOM
Phge2

Apr2611 O0:32a
p.4
II. iN4d1CTION-RE%.ATED EQUIPMENT
Attach a diem showing the engineering layout or proposed modification of the injection equipment and cad
pipingltubiug associated with the injection operation_ The manufacturer's brod+ure may provide supplemcn
information,
L LOCATION Or W EIMS)
Attach two copies of maps showing the following informs t on:
(1)
_ : of tprir ^""V_ 7' ;'+ • a 4 ,� a Z• +T .��{
n- ti�
400* "i•.1 •f a ; t. ;77 . ���i jr:, r.., 4: i•.
k ... 11.: 2. Label ni1 features clearly and igclude a flvrth arrow.
(2) Nan* must show the subject property in relation to the sumaanding area by using at least two
reference points such gm stream, and/or haffifiebeag.
3. CERTIFICATION
Note: T41s remit Applicattan mist be signed by each perrsoa appearing ors the
recorded legal property deed.
"I hereby certify, under penalty of law, that 1 kurve pa -socially examined and am familiar with the fnfwma
submitted in ibis document and till attachments thereto and that, based on my inquiry of those individ
immediately responsible for obtaining said information, I believe that the information is true, accurate and oom
I am aware that that are Significant penalties, ritsctuding the possibility of fines and imprisonment, for salmi
false information. I agree to cOnatThet, opmate, rnaintain, repair. and if applicable, abandon the injection well
all related appurtenances in accordance with the approved -specifications and renditions of the Penna."
Signature of Property Owner/Applic
. Lsr-VA e
Punt or Type
1 r and title
Signature of
Print or Type Fyll
Owner/Applicant
and title
Signature of Mtftvrhzed Agent, if any
Print or Type FUR Name and title
Please return two copies of the completed itpplication package to:
North Carolina DENT�IDWQ
Aquifer Protection Seetion-MC Program
1636 Mail Servie Center
Raleigh, NC 27 -1636
Telephone (91 SM); 7'15.6935
GPJINEC 5QW Nodf ration of Naomi Fan (Reviaed MOOS)
RECEIVED + DENR I 01N4
Aclulfet ProM1edian gerUnn
9 I)11 pagio
Is
Lad `.

Apr 2611 09:33a
p.5
W000
RETAINING
WALL
T
45'
UCc MET O
COWL L75iERN
PU a PIMP
FOR I'#I.R44,1101I
NO1E COSMIC
1RO401 ELEvAllOR
REDORI G IV u
Y PROPERTT L!iE
ON ADJACENT SITE
RICEXC'
IRK AND RIVER
AGO% SERF
w, MIER
CLOTH Linen
CAW
oT tZg4111VR./ 60,-0) "'d
.
141 ¥WIAIN 4
B V DIFF FROM SRC
T4 Tim of oUV W
4' HIA$ 'EKE
W/ 3 MOLE
SECORIIT WNW
E]OSr SPOT g
COST TOM NAND BR
PROPOSED TEIPO MVO 88
PROP SPOT EL NAVO 88
LOT 4, BLACK 122,
SOUTHERN SNORES SUBorY1SION
18,737 SQ. FT.
GRADING PLAN
T
PURAFLO
AREA
SP
AR qEctrip, R NRf0
APR 26 2011

Apr2611 Og 32a
p.1
Pinkstan Pump & Well, inc.
P4Box 15482
• Chesapeake, VA 23328-5482
• (757) 421-21G8 I [phone]
facsimile transmittal
To: Tonya Fax: [phone]]3
From: Debbie Sanders Date: 04126111
(d a bbi eG stag g ene rgy. com y
Re! Homer, 149 Yaupon Trail, Pages: 5 (including Cover sheet)
Southern Shores, NC
CC:
❑ Urgent D For Retail 0 Please Comment 12 Please Reply 0 Pease Recycle
• . • a
Note*
•
For the above referenced, following is the Type 5•C1W Well(s) appiicaiion area the property
site plan w*lh the Proposed Geothermal Closed Loop area.
Two (2) hard copies are being forwarded today.
Thank you!
*CeIVE0
MOW Poo.ectOnS6don
PR26all

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLS'
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Tvpe information).
DATE: ! � 20 I!
Well Type Confirmation: Does the proposed system circulate potable water ordv (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes X Continue completing this form.
No Do Not complete this form_ Complete other UIC application forms for installing
either a 5A7 well (open -loop well injecting 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)IAPPLICANT(S)
listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): Edward J. Homer •
(1) tagetedin 676 River Road
Callicoon
NY— 10011 �r�. Sullivan
Cril!No:: 347.739.5257
3. z�
eIirczled' ardjhorrier_com Website:
(2) k - -F. _ y ..., (if different than above): 149 Yauvon Trail
Southern Shores BRO _NC_ eiRait 27949
iLIKH_,� �0.:
347.739.5257
S. 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.: Celt No.:
Website Address of Company, if any:
• L».L •.�
GPUIUIC 5QW Notificslion of intent Fonn (Revised $f200S)
An 28 7411 P8ge I

C. WELL DRILLER INFORMATION
Company Name: PINKSTON PUMP AND WELL, INC
Well Driller Contractor's Name: HOWARD E. CUTTER
NC Contractor Certification No.: DRILLING #3538-A H-3 #29277 JEFFREY A. STAGG
Contact Person: JEFF STAGG EMAIL Address: jeffcusiagLgenerty.com
Address: PO Box 15482
City: CHESAPEAKE. VA Zip Code: 23382 County:
Office Tele No.: _757-421-2108 Cell No.: 757-438-9392
D. ttaltSr:Tniter --: i (if different than driller)
Company Name: Outer BanksHeating & Codling
Contact Person: Brian McDonald EMAIL Address: briaitrd+obhc.com _
Address: PO Box 1415
City: Nags Head Zip Code: 27959 County: Dare
Office Tele No.: 252-44I-1740 Cell No.:
E. STATUS OF APPLICANT
Private: X Federal:
State: Municipal:
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
NOT A WATER WELL - GEOTHERMAL CLOSED LOOP
G. WELL CONSTRUCTION DATA
(I) Proposed date to be constructed: ASAP Number of borings:
Approximate depth of each boring (feet): 200
(2) Type of tubing to be used (copper, PVC, etc): HOPE
(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 X
(4) Grout Info (:material surrounding well casing and/or piping):
(a) Grout type: Neat Cement _ Bentonite X Other (specify)
(b) Grout placement: Pumping X Pressure Other
(c) Grout depth oftubing(reference to land surface): from 0 to 200 (feet)
If well has easing, indicate grout depth: from _ to (feet)
GPUIUIC 5QW Notification of Intent Form (Revised 812008) Page 2

H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and e
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplemen
information.
L LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) ludr ! :i3Fr1='? is showing: ee fin, _ eT �'s 4: _E�_..�' _5iiTFii .:4a r' -' ti.•Vi
91124$ **Mi: 1110604 l4Vete.a e-.pfdr• i 4. e a
.! .scptie or d . i N: t' ` t;s
Label all features clearly and include a north arrow.
(2) Mirethl must show the subject property in relation to the surrounding area by using at least two t 'r(i
reference points such as .1,L-.-=k, streams,, and/or - -
•
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"1 hereby certify, under penalty of taw, that I have personally examined and . am fauniliar with the informa i n
submitted in this document and all attachments thereto and that, based on my inquiry of those individ Is
immediately responsible for obtaining said information, l believe that the information is true, accurate and comp
am aware that there are significant penalties, including the possibility of fines and imprisonment, for submi
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
Please return two cop
Signature of Property Owner/Applic
4-4
p - orofkr4.t'la--- uC ewe
Print or Type Full N
and title
Signature ofPrpe
Owner/Applicant
Print or Type Flail Name
i
and title
Signature of Aiathonxed
Agent, if any
Print or Type Full
ies ofthe competed
Name and title
kpptication package to:
North Carolina DENR-DWQ
Aquifer Protection Section-VIC Program
1636 Mail Se Center
Raleigh, NC 27 99-636
Telephone (919) i 71 6935
ACkairttr Freltr,r' �,
rc+,�r , � •rr „o
OPUMC 5QW Notification of Intent Form (Revised 812008)

WOOD
RETAINING
WALL
45'
UCNO 1500 G
CONC IISTERN
W/ SCEEES.
FILTERS & PUMP
FDR IRM TON
NOTE FASTING
HID-1ER ELEVATION
RETAINING WALL
e PROPERTY LANE
ON ADJACENT SITE
3' 'MOE X if
THK RND RIVER
ROCK STRIP
w/ MIER
CLOTH UNDER
CATV
Looe (*EA
1
(i-) 2-..c) alors
6 6.31../71
MR & FG. 188
tini FENCE
W/ 3' ;WOE
SECURITY WINGS
W FR_
C.LOTI1 UN
STCRMWA
iNFURATION
AREA: SHAPE
AS REM '3
FOR ai0 CF "
VOLUME
EXIST SPOT EL NAVD 88
MST TOPO NAVD 88
PROPOSED TOPO NAVD 88
mw
PROP SPOT EL. NAVD 08
NOTE MAINTAIN 4'
aar C(FF FROM Skip
TO TIP Cr EILKHD
'+/-
LOT 4, BLOCK 122,
SOUTHERN SHORES SUBDIVISION
18,737 SQ. FT.
GRADING PLAN
=. 30'
.o"
58 SF
"We/3M
ist) 29
INIE • 3'
Mt; LAT
INV. 5. ).
PURAFU)
REPAIR AREA
375 SF
XIOWLES

uLyi)uo22-3
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCD1 NR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL{S)
In Accordance with the provisions ofNCAC Title 15A: 02C-0200, please
complete this notification and mail to address on the back page (please Print or Type information).
DATE:w.
2011
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 Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well injecting 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(SyAPPLICANT(S)
listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): Edward J. Horner
(1) =rtigilkiallia 676 River Road
Callicoon
airitgregMle
y NY _ 3.0411 Sullivan.
(re -/LIMO 347.739.5257
ehjedwardjhomer.com Website:
(2) .11:filiratMEMN y #tt (if' different than above): 149 Yauoon Trail
kig Southern Shores k :3 it NC_'.Z1 $ k 27949 Dare
li.WaM4It7 Ce111467 347.7395257
S. 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:
GPUIUIC 5QW Notification of Intent Form (Rcvised 8f200S)
Page 1

C. WELL DRILLER INFORMATION
Company Name: _ _ PINKSTON PUMP AND WELL INC
Well Driller Contractor's Name: HOWARD E. CUTTER
NC Contractor Certification No.: DRILLING 43538-A H-3 #29277 JEFFREY A. STAGG
Contact Person: JEFF STAGG ETyIAR. Address: [e-mail]
Address: PO Box 15482
City: CHESAPEAKE_ VA Zip Code: 23382 County:
Office Tele No.: _757-421-2108 Cell No.: 757-438-9392
D. ,..z,.,. _..... 'rdl' (if different than driller)
Company Name: Outer Banks Heating & Coolin;
Contact Person. Brian McDonald EMAIL Address: 1:[e-mail]
Address: PO Box 1415
City- Nags Head Zip Code: 27959 County: Dare
Office Tele No.: 252-441-1740 Cell No.:
E. STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
NOT A WATER WELL - GEOTHERMAL CLOSED LOOP
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: ASAP Number of borings:
Approximate depth of each boring (feet): 200
(2) Type of tubing to be used (copper, PVC, etc): ®PE
(3) Well casing. Is the wells) cased? (cheek 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 X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite X Other (specify)
(b) Grout placement: Pumping X Pressure Other
(c) Grout depth of tubing (reference to land surface): from 0 to 200 (feet)
If well has casing, indicate grout depth: from _ _ to (feet)
GPUIUIC 5QW Notification of Intent Form (Revised WOOS) Page 2

H. INJECFION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and ext
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplemen
information.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(i)
Pr
arY
shawt #Y EY,I}cS...,,:,..2.,, 6: 1 � H � '
.-,-•a wi SST.. , yr ,-�y-►�y..�i,.,�},, p;_ _-• , _ 74
r. -c _" R4-' -..1 �7hF_ y �'{'.z��yy�� ✓-�.'.: 6c'. ^ter a y!T' ,y. H
�' 1. Lleq, 1p7 �- 14,0" TIDA „Or '- n.l.- -rC 6,..i.'6 0n3 :. .t
Label a!1 features clearly and include a north arrow.
(2) TiTegreittai must show the subject property in relation to the surrounding area by using at least two fi
reference points such as Fai, streams, and/or cfI '=
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined andam familiar with the inform
submitted in this document and all attachments thereto and that, based on my inquiry of those individ - is
immediately responsible for obtaining said information, I believe that the information is true, accurate and comp ale.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submi i ig
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well : d
all related appurtenances in accordance with the approved specifications and conditions of the Permit"
Signature of Property Owner/Applic
Pdu 4114 f': fa6kateL Oc e &
Print or Type Full Mune and title
Signature ofPterty Owner/Applicant
Print or Type boll Name and tide
Signature of Authorized Agent, if any
Print or Type Fp li Nhrne and title
Please return two copies of the compacted Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section- C Program
1636 Mail Servile C ter
Raleigh, NC 27699-I636
Telephone [phone]
GPU/UFC 5QW Notification of Intent Form (Revised 8/2005)
Page 3

1-4c)Q-1,5 E4Z
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INV. 5. '
••••
AVEMENTtak
E)(IST SPOT EL NAVE) 88
EXIST MPG RAW 88
PROPOSED TWO NAVI:1 88
PROP SPOT EL. NAVE) 813
LOT 4, BLOCK 122,
SOUTHERN SHORES SUBDIVISION
18,737 SQ. FT.
GRADING PLAN
i• - 30•
AREA
SF
ULES