WI0700230_GEO THERMAL_20120523

Beverly Eaves Perdue
Governor
-A7A
_c --.--.1~_,...
NC DE MR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 23, 2012
William and Patricia Baker
101 Holly Court
Manteo, NC 27954
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0700230
Dear Mr. and Mrs. Baker:
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.org/web/wq/ap s.
If you have any qttestions ·regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
cc: _ UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
One
North Carolina
;Naturally
Permit Number WI0700230
Program Category
Gr.ound Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Fac i litv
Facility Name
William and Patricia Baker SFR
Location Address
101 Holly Ct
Manteo
Owner
Owner Name
William
Dates/Events .
NC
H
I '2/:>-'J j t1
\.~sue App Received
06/16/11 12/19/11
Regulated Activities
Heat Pump Injection
Outfall NULL
27954
Baker
Draft Initiated
Scheduled
Issuance
Central Files : APS_ SWP_
01/04/12
Permit Tracking Slip
Project Type Status
Active Major modification
Version
1.10
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Afflliation
Owner Type
Individual
Owner Affiliation
William H. Baker
Owner
101 Holly Ct
Manteo
Public Notice Issue
12/23/11
NC
Effective
12/23/11
Requested/Received Events
RO staff report re ceived
RO staff report requested
27954
Expiration
11/30/16
12/22/11
12/22/11
Waterbody Name Stream Index Number Current Class Subbasin
Permit Number WI0700230
Central Files' APS SWP
01/04/12
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Status
In review
Project Type
Major modification
Version Permit Classification
Injection Mixed Fluid GSHP Well System (5QM) Individual
Primary Reviewer Permit Contact Affiliation
michael.rogers Patricia C. Baker
Coastal SW Rule
Permitted Flow
Facilit
101 Holly Ct
Manteo
NC 27954
Facility Name
William -1 Baker SFR
Location Address
101 Holly Ct
Manteo NC 27954
Owner
Major/Minor Region
Minor Washington
County
Dare
Facility Contact Affiliation
Owner Name
William
Dates/Events
Owner Type
Individual
H Baker Owner Affiliation
William H. Baker
Owner
101 Holly Ct
Manteo
NG 27954
Orig Issue
06/16/11
App Received Draft initiated
12/19/11
Regulated Activities
Scheduled
issuance
Public Notice i 1r\�1
Effective
l x i-51,0
1,
It.
Heal Pump Injection
Private residence, single family
Outfell NULL
Waterbody Name Stream Index Number Current Class Subbasin

4
NCDEN R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coieen H. Sullins Dee Freeman
Governor Director Secretary
December 23, 2011
William and Patricia Baker
101 Holly Court
Manteo, NC 27954
Ref: Issuance of Injection Well Permit W10700230
Issued to William and Patricia Baker
Manteo, Dare County
Dear Mr. and Ms. Baker:
In accordance with the application received an December 19, 2011, and additional information received December
23. 2011, I am forwarding permit number WI0700230 for the operation of a vertical closed -loop geothermal mixed -
fluid heat pump injection well system located at the above referenced address. This permit stall be effective from
the date of issuance until November 30, 2016, 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 michael.rot}ersa.ncdenr.gov if you have any questions about your permit.
cc: David May, Washington Regional Office
W10700230 Permit File
Dare County Environmental Health Dept.
AQUIFER PROTECTION SECTION
153e Mil Servipe Center, Rafaigh, North Caroline 2769g•1 Gift
Location 272B apir I Both vard. Falwah. Noctli Cardi za27E04
Pnone: 919-733.3221 l FAX 1 ! Si19-715-658b; FAX 2: 91 rT1 -61:ip8 + ,:,usromer service: 1-87; -62 -674
Internet: onAN.ncwarnrguality oro
Best Regards,
Michael Rogers, P.G. (NC & FL)
N oral Carolina
�, `rf t
15F E.gU2 JPUCirt:'1 Afnrcia':E :i::.- n Ji1:1�av

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
William and Patricia Baker
FOR THE OPERATION OF 3 (THREE) TYPE SQM 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 101 Holly Court, Manteo, Dare County,
27954, and will be constructed and operated in accordance with the application received December 19, 2011,
and in conformity with the specifications and supporting data submitted December 23, 2011, 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 November 30, 2016, and shall
be subject to the specified conditions and limitations set forth in Parts I through VII hereof.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
WI07C:C3C UIC/5QM Conversion
Version 12/2011
Page 1 of 4
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.
,., 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. The location of each of the system manifolds shall be recorded by triangulation from three pem1anent
features on the site (e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall submit this updated Site Map and retain a copy on-site.
5. 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. The 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 P ermittee 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.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
UIC/5QM Conversion
Version 12/2011
Page 2 of 4
PART~IV -INSPECTIPNS
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 permit, 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
needed to 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.
WI0700230 UIC/5QM Conversion
Version 12/2011
Page 3 of4
PART VII -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
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 15A NCAC 2C .0213(h)(l), Well
Construction Standards.
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 15A 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 documentation required in Part VII (1) and (2) (G) shall be submitted to:
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 of 4
Ro gers, Michael
From:
Sent:
To:
Jeff Stagg [e-mail]]
Friday, December 23, 2011 8:39 AM
Rogers, Michael
Subject: FW: WI0700230 Baker
Attachments: NC Pnkstn GW-1 Baker , William 2010-06-07.pdf
From: Tina Stagg [mailto:[e-mail]]
Sent: Wednesday, December 21, 2011 5:11 PM
To: Jeff Stagg
Subject: FW: WI0700230 Baker
From: Rogers, Michael [mailto:michael.roqers @ncdenr.aov]
Sent: Wednesday, December 21, 2011 2:40 PM
. To: Tina Stagg
Subject: WI0700230 Baker
Tina-
We received the SQM application for Baker. Would you please provide the GW-ls for this site.
Thanks
NOTE: On January 6 th , the Aquifer Protection Section {APS) is scheduled to move to
the 6th floor of the Archdale Building located at 512 N. Salisbury Street in
Raleigh. Our mailing address will remain the same (1636 Mail Service Center,
Raleig~, NC 27699-1636). If you need to visit APS staff or review files, please
call or email in advance to e~sure availability. Please check the APS website
for updates on office nwnbers and phone nwnbers as they become available.
Michael Rogers, P~G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone] (Phone numbers subject to change after 1/6/2012)
Fax [phone] (put to my attn on cover letter)
htto://oortal.ncdenr.orq/web/wq/aos/gworo/oermit-aoolications#geothermAoos
E-ma/1 correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
1
❑ Slope ❑ Valley Of Flat
LATITUDE 35
LONGITUDE 75
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC-3538-A
1. WELL CONTRACTOR:
HOWARD E_ CUTTER
Well Contractor (Individual) Name
PINKSTON WELL & PUMP COMPANY
Well Contractor Company Name
636 BENEFIT RQAD
Street Address
CHESAPEAKE VA 23322
City or Town
( 757) 421-2108
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
State Zip Code
OTHER ASSOCIATED PERMIT#(it applicable)
SITE WELL ID Cif applicable
3. WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED 06/07/2011
TIME COMPLETED 8:00 AM I J PM LY
4. WELL LOCATION:
Crrv: MANTEO COUNTY DARE
101 HOLLY COURT
(Street Narne, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING: (check appropriate box)
©Ridge 10Other-
43.6000 " DMS OR 3x.xxxxx txxx DD
0 41 • 10.1000 ^ DMS OR 7x.XxXXXXXxx DD
54
Latitude/longitude source: [i 3PS Dropegraphlc map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5, WELL OWNER
WILLIAM & PATRICIA BAKER
Owner Name
101 HOLLY COURT
Street Address
MANTEO NC 27954
City or Town State Zip Code
t252 ) 489-1680
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 3 a 200'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I '
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS N/A FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD Wpm): NIA METHOD OF TEST NIA
f. DISINFECTION: Type N/A Amount Nlg
g- WATER ZONES (depth].
Top N/A Bottom NM
Top
Top
Bottom
Bottom
7. CASING: Depth
Top N/A Bottom N/A Ft,
Top Bottom Ft.
Top Bottom Ft.
Top
Top
Top
Sotto m
Bottom
Bottom
Thickness/
Diameter Weight Material
8 GROUT: Depth Material Method
Top 0' Bottom 200' Ft. BENTONITE PUMPED
Top Bottom Ft.
Top Bottom FL
9. SCREEN: Depth
Diameter Slot Size Material
Top NIA Bottom NIA Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth
Top NIA Bottom NIA Ft.
Top Bottom Ft.
in.
in.
in.
Size Material
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 / 200'
1
1
1
1
1
1
1
I
1
1
1
1
12, REMARKS -
Formation Description
SAND W/CLAY STREAKS
NO SAMPLES TAKEN
THESE ARE CLOSE LOOP
GEOTHERMAL LOOPS.
3 HOLES DRILLED TO 200'
AND GROUTED TO THE TOP.
THIS IS NOT A WATER WELL!
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
06/21/2011
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
HOWARD E. 'PORKY" CUTTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1817 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2109

Rogers, Michael
From: Clark, Allen
Sent:
To:
Thursday, December 22, 2011 2:52 PM
Rogers, Michael
Cc: May, David
Subject:
Attachments:
WI0700230, WI0700234, W10700257
Baker WI0700230 GW-1.tif
Michael,
WaRO will pass on conducting an inspection for Permit #WI0700234 (Rodewald), #WI0700257 (Hliderbrant), and
#Wl0700230 (Baker) facilities.
See the attached file which contains the GW-1 for Permit facility #WI0700230 (Baker}.
Let me know if you need further info.
Merry Christmas,
Allen
Allen Clark
NC Division of Water Quality
Aquifer Protection Section
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone(252}948-3847
FAX [phone] (attn: Alien 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: Tuesday, December 20, 2011 4:47 PM
To: Clark, Allen
Subject: FW: WI0700234 Rodewald
Allen,
Could you follow back up with Michael. Unless you see something out of the ordinary, we could probably pass on the
inspection.
Thanks
David
Davi d May, Regional Aquifer Protection Supervisor
1
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
December 19, 2011
William. H. Baker
Patricia C. Baker
101 Holly Court
Manteo, NC 27954
Dear Mr. and Mrs. Baker:
Subject: Acknowledgement of
Application No. WI0700230
William H Baker SFR
Injection Mixed Fluid GSHP
Well (5QM) System
Dare County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on 12119/2011. 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 michael.rogers@,ncdenr.gov.
Sincerely,
CA0z0L, A. ;c4Di,i
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Tina Stagg — Pinkston Pump & Well, Co.
Mark Burble - Outer Banks Heating & Cooling, Inc.
Permit File W10700230
AQUIFER PROTEOTIOM SECTION
1636 Mail Service Cente,, Raleigh. North Carolina 2764E-163c
'_ot:aliorr: 2728 Capital Boulevard, Raleigh, Norm CerolioL 27604
Phone: [phone] i 1 FA)! 1! 41a-715-1}5$N; FAX r" 919-715 3U4 61 customer rvT' 1-877-62 6746
Internet. www.r cwatermualltv.or
Nor hf; aro mL
Oort:Jr , kirirma'.vE kr. o-i Employe.

- 1 L DYE ' do jC Appn_,0 V19, L
1
RECEIVED/ o 1CWo
Aquifer Prater/inn swim41 - NCO Sme-EbtlicAif tWP QwV-i— Z OEC 19 20i
NORTHCAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP MIXED -FLUID GEOTHERMAL INJECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system
(check one) X New Application
Renewal's Modification
* For renewals complete Parts A-C and the signature page.
Print or Type Information and Mail to the Address an the Last Page. IIlegible Applications Will Be Returned As Incomplete.
DATE OSInbi PERMIT NO. Vim' O1 . 5C
leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non-Goverrunent: Individual Residence 1( BusinessfOrganization
Government: State Municipal County
Federal
B. PERMIT APPLICANT - For individual residences, list each owner on property deed. For all others,
state name of entity and name J}person delegated authority to sign on behalf of the business or agency:
�c' fti , t -- IMfCLa _I - }�
Mailing Address: ILLj4 CI( -
City: /14]'1/P0 State: AC —Zip Code: .f`V County:
Day Tele No.: di-2-7 Yril -1 o Cell No.:
EMAIL Address: Fax No.:
04A-11-
C. LOCATION OF WELL SITE - Where the injection wells are physically located:
Parcel Identification Number (PIN) of well site: Vent 3/30 3 County: .0
Physical Address (if different than mailing address): _
City:
State: NC Zip Code:
D. WELL DRILLER INFORMATION 2f �-E' !/j ��r�
Well Drilling Contractor's Name:
NC Well Drilling C4I75JA)
rtracctorCerti'f ation No.: _ 3 ?—A
Company Name: VLt. sup 14,1 _ -lk, i11c - --r ,
Contact Peron: Y/N A j T19'6 6 EMAIL Address: 11,i4 YJ e I�� .11,mi
Address: K O . 10O)C InT12.- 'r
City: C& I1 f eit Zip Code: )3j- -- tate: 114 County:
Office Te1e No.: 1S7 - - � VCell No.:/5-6 " (3 5 L Fax No.: 751 ttil, - r} LQ
enn, frTOn c/1/4 n._:a aL....e:..Mi..n l!1
Page 1

E.
F.
REC.EIVE.IJ J Dt::NR t UVVQ
Aquifer Protection Section
DEC 1 P 2011
HEAT PUMP CONTRACT(J,R lNfORJ\'JATIO~ (if ditlcrcnt tha1~ driller)
Company Name: Oc.Jf « ~S _tf~y1J <t-Ce,0/1,, . .
Contact P~~on: jllW,R..-k-B tfe.BIC: EMAIL Address:M~k, bwJ,e-(!1 olik-4 61
Address: y,t·O-&Jx. /C//J
City: Al~ 5 lf-l"M A&::: Zip Code: _'),. 7 'if7'! State: llvcoanty: _n~~-·'lr ____ _
Office Tele No.: )52 -YL// -(7 't{) Cell No.: J;r2.--S-7~-(j''{l,2, Fax No.:.)..f"2..-1/'tl-0'1J~
WELL CONSTRUCTION DATA
(1) Number of borings to be constructed"': :J Depth of each boring (feet): 20(? --------* If existing water supply wells will be used then provide the information in item (4) below.
(2) Chemical additives to be used: R-22 ___ Propylene glycol ___ Ethanol
Other ~JIJO (other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): --+.lf-D~e~~~---------
(4) Well casing. If the well(s) will use casing then provide the !YP~ (steel, PVC, plastic, etc.), diameter, g~.!h,
and extent of casing appearing above ground: A.JOAJ'f_ ----~~------------
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type : Cement_ _ Bentonite*·,., _,X__ Other (specify)
.... By selecting bentcmite grout, a ,·ariattct is hereby requested to ISA NCAC 2C .0213(d)(I)(A)-, w-h-ic--h-rec-1u-i-res_a_ce_m_e_n_t ty-pc g1out.
(b) Grout depth of tubing (reference to land surface): from O to 2-W (feet)
If well has casing, indicate grout depth: from ____ to ------'-(feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate tlistances and orientations of
features located within 1000' feet of the injection well(s). Label all features clearly and include a north arrow .
. (1) Attach a site-specific map showing the locations of the following: .
I
* Proposed injection wells * Buildings * Property 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 contamination .
(2) . Attach a topographic map of the area extending 1/4 mile from the injection well site that indica.tes the
facility's location and the map name.
NOTE: In most cases, a11 aerial plwtograph of tlie property parcel showing property li11es and str11ct11res Clln be
obtai,red and downloaded from tlle applicable county GIS website. Typically, tlie property ca,r be searc•J,ed by
owller name or address. Tlie locatio11 of tlte well~ i11 relation to property boundarie.,;, Jw11ses, septic tanks, other
wells, etc. ca11 the11 be drawn i11 by hand. Also, a 'layer' can be selected showing topograpl,ic contours or
elevatio,r tlata.
GPU/UIC 5QM Pennit Application (Revised 1/24/2011} Page2
RECEIVED / DENR I DWC
Aquifer Protection Section
DEC 1? 2011
H. CERTIFICATION (to be signed as required below ur by that person's authorized agent)
I5A NCAC 02C ,O211(h) requires that all permit applications shall be signed as follows:
I. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. fur a nrunicipa]ity or a state, federal, or other public agency_ by either a principal executive
officer ur ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed oil the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am f'arniliar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible fur obtaining said information, I believe that the information is true, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of tines and imprisonment,
for submitting false information, I agree to construct, operate, rnaintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Penn it."
Signature o Property Owner/Applicant
Print or Type Full Name
Signature of Property Owner/Applicant
0` f"7_-r
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
1]WQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UWC 3QM Permit Application (Revised I/24/201 I
Paige 3

May 23 11 03:40p Jaffrey A. Stagg
757-421-2108
p,8
r.:� • r;
r r. T_ :
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5 - : F
9of'64
• •
1,
i
s..-tiy f
RECEIVED / DENR I DWQ
Aquifer Protection Seron
DEC I P 20 fi
Aj
'S
ii 1 •• is .. .1' .. - -1 •
I { S F6 is is
��y
4)///

Godwin, Tonya
From:
Sent:
[DOTS] DENR Support [[e-mail]]
Wednesday, January 04, 2012 10:36 AM
To: Godwin, Tonya
Subject: [DOTS] Resolved: (HD-516235) Need to have application in BIMS deleted
Issue# HD-516235 has been resolved.
This issue has been resolved. The application has been deleted as requested.
Issue Details
Summary: Need to have application in BIMS deleted
Issue#: HD-516235 ·
Issue Created: Today 09:57 AM
Issue Type: Issue
Components: Desktop Support
Reporter: Tonya M Godwin
Assignee: Tom Moore
Category: I have a request ...
Division: Water Quality
Location: 2728 Capital
Location Details: Room lC 211
NCID: tmgodwin2
Number of Users Affected: 1
Phone: [phone]
Queue: Development Queue
Severity: Medium
Sub-category: BIMS
Subdivision: None "---
Description:
Please delete the, "In Review", application ONLY for permit# WI0700230 in BIMS for William H
Baker. A new application was entered in error. A new application has already been entered.
Please call me with any questions @ 919-733-3221. Thank you. Tonya
If you require assistance, please contact the DENR ITS Solution Center at:
htt p ://portai.ncdenr.org/g rou p/it s/
If you have an urgent or critical situation, please call the DENR ITS
Solution Center at [phone] after submitting your help request.
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.
1
Godwin, Ton ya
From:
Sent:
[DOTS] DENR Support [[e-mail]]
Wednesday, January 04, 2012 9:58 AM
To: Godwin, Tonya
Subject: [DOTS] Created: (HD-516235) Need to have application in BIMS deleted
This message has been automatically generated in response to a Help Request regarding:
"Ticket Submitted from Portal", a summary of which appears at the bottom of this email.
There is no need to reply to this message right now. Your Help Request has been logged at the
DENR ITS Solution Center. Staff are being assigned and you will be contacted if we require
further information or when your request has been completed.
Please include the text: HD~516235
in the subject line of ~11 future email correspondence about this issue. To do so, you may
reply to this message.
NOTE: TICKETS SUBMITTED AFTER 5 PM WILL BE ADDRESSED THE NEXT BUSINESS DAY.
Sincerely,
DENR ITS Solution Center
Issue Details
Summary: Need to have application in BIMS deleted
Jssue#: HD-516235
Issue Created: Today 09:57 AM
Issue Type: Issue
Reporter: Tonya M Godwin
Category: I have a request ...
Division: Water Quality
Location: 2728 Capital
Location Details: Room lC 211
NCID: tmgodwin2
Number of Users Affected: 1
Phone: [phone]
Queue: Solution Center Queue
Severity: Medium
Sub-category: BIMS
Subdivision: None
Description:
Please delete the, "In Review", application ONLY for permit# WI0700230 in BIMS for William H
Baker. A new application was entered in error. A new application has already been entered.
Please call me with any questions@ 919-733-3221. Thank you. Tonya
If you require assistance, please contact the DENR ITS Solution Center at:
htt o ://portal.ncdenr.org/grouo/its/
If you have an urgent or critical situation, please call the DENR ITS Solution Center at
(919) 715-033J after submitting your help request.
1
E-mail correspondence to and from this address may be subject to the North Carolina Publlc
Records Law and may be disclosed to third parties :
2
Smith, Eric
From: Smith, Eric
Sent:
To:
Wednesday, November 30, 2011 8:45 AM
Craig Justus
Cc: 'Kim Gentry Justus'
Subject: WI0100046 Renewal Needed ASAP
Importance: High
Mr. Justus:
If you have not already done so, please send the renewal application for your geothermal well permit (WI0100046) as
soon as possible to avoid a notice of violations. Since both you and your wife are listed on the permit, the notice of
violations would be issued to both of you.
On your renewal, please indicate that you no longer want Kim's name on the permit.
Thank you.
-Eric G. Smith, P.G.
Eric G. Smith, P.G.
Hyd rogeologist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-6196
919-715-6048 Fax
http://portal.ncdenr.org/web/wq/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.
1
Permit Number
Wl0700230 r .�
Central Files: APS SWP
06/16/11
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (50W)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Fecilitu
Status
Active
Project Type
New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
William H. Baker
Owner
101 Holly Ct
Manteo
NC 27954
Facility Name
William H Baker SFR
Location Address
101 Holly Ct
Manteo NC 27954
Owner
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Name
William
Dates/EventE
H Baker
Owner Type
Individual
Owner Affiliation
William H. Baker
Owner
101 Holly Ct
Manteo
NC 27954
Orig issue
06I16/11
App Received
06/07/11
7:e0u{ated Activui.z.
Draft Initiated
Scheduled
Issuance
Public Notice Issue Effective
06/16/11 06/16/11
Expiration
Heat Pump Injection
Private residence. single family
OutfaiI N
Waterbody Name Stream Index Number Current Class Subbasin

"'-.,,A s ,,p.~
NC DENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
William H Baker
Patricia C Baker
101 Holly Ct.
Manteo, NC 27954
Coleen H. Sullins
Director
06/16/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
PermitNo.WI0700230
101 Holly Ct.
Manteo, NC 27954
Dear Mr. Baker:
Dee Freeman
Secre tary
On 06/07/2011, 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 .02ll(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.Ro e ers1amcdenr.!!ov if you have any questions.
j'~~
cc: Washington Regional Office -APS
APS Central Files -Permit No. Wl0700230
Dare County Health Dept.
for Debra ~
Supervisor
Debbie Sanders (Pinkston Pump & Well, Inc., P.O. Box 15482, Chesapeake, VA 23328-5482)
Mark Burbic (Outer Banks Heating & Cooling, P .O. Box 1415, Nags Head, NC 27959)
AQUIFER PROTECTION SECTION
1636 Mail Service Genier, Raleigh, North Carolina 27699-1636
Lccation: 2728 Capital Boulevard , Raleigh. North Carolina 27604
Phone: [phone] I FAX t 919-715-0588; FA X 2: 919-715-6048 \ Cusiomer Service: 1-877-623-6748
internet: www.ncwateraualitv.oro
A, Eq:.i a: ()ppo ~iu r.\· \ Af'rmativs Acf'Jn Employe r
None , .,...., •. ortnLarouna J,,,"' ,. t!f . ,1 ,1arurauu ~,
Jun 0711 10'59a Pinkston Geothermal 7574212108 p,1
Pinkston Pump & Well, Inc.
POBox15482
Chesapeake, VA 23328-5482
•
(757) 421-21081(866) 749-1980
facsimile transmittal
To: Michael Rodgers
North Carolina DENR-DWQ
Fax [phone]
From: Debbie Sanders Cate: 06/07/11
(d eb bie@ staggenergyco m)
Re: 101 Holly Ct., Manteo, NC (Dare Co.) Pages: 5 (including cover sheet)
CC:
0 Urgent El For Review 0 Please Carnrnen* ❑ Phase Reply ❑ Please Recycle
Nos For the above referenced, following is the TYPE 50W WELLS(S) application. Two (2) hard
copies will be forwarded to your office, via US mail.
"PLEASE CANCEL THE 5RM APPLICATION PREVIOUSLY FORWARDED TO YOUR OFFICE"
Thank you,
.RECEIVED/
AQuIrFFit PR FCTIC)A1 I t
JUN 0 7 2011

, l
Jun 07 11 11 :00a Pinkston Geothermal 7574212108 p.2
vJJtnoo(PD
NORTH CAROLINA
DEPARTMENT OF JJNVlRONMEN't AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSmUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM -
TYI1 E SOW WELUS)
ln Accordance With the Provisions of};CAC Title l5A 02C.0200
Pri11t or type the r"equired information and mail to address rm the back page.
DATE: _jJllHf. )?, , 20..J/_
Well Type Confrnnatio,r: Docs the proposed system circulate potable water only (Tio additives) in
continuous pi1,ing that completely isolates the Ot1id frl11n the environment (i.e.
closed-loo p )'!
Yes k Continue completing this form.
No ___ Do Not complete this form. Complete other UTC appJication fonns for installing
either a 5 A 7 well {~-loop well injc.:ti.ng ootable water into the aquifer) or a SQM well {dosed-
loop well containing additives such as R-22, ethanol, or other antifn:tm: nr corrosion inhibitors).
A. PROPERTY 0WNER(S)/APPLICANT(S)
List each Property Owner listed_ on property deed (if owned by a business or gove~t agency, _sta1:e name of
enti1y jl)d a representative wlauthority tiJT signature): /1,u.lftAe'.'!1 /I. +-/JfY',2,u,;, C..
rJ.Ak-1?1
(i) Malling Address: _ _/.il a //'f if· ·
City: ~ State: A,kZip Code:_}.-,.2_y_S_Y ___ County:~-
l lome/Office Tele No.: l/.,ftj -/ {J. (j(} (z.s-2.:) Cell No.:
Email Addrcss: ________ __,_\\,__,'e..::bs""'i~te:::..: ____________ _
(2) Physical Address of Well Site (if di!ferent lhan above):----------,--------
City: _________ State: __ zjp Code: ______ County: ____ _
Home./Officc Tele No.: __ __ CcH ~.Q.,.,: __________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant doQ.s no1 own the subje.ct property,
attach a letter from the property owner authoriziflg Agent to install and operate lJIC well)
Company Name: __ _
Contac1Pcrsoo~: _____ _ EMAIL Address:
Addres~: ____ -----··--·----__ -------------·--------
City: _________ State: __ ZipCode: ______ County: _______ _
Office lclc No.: Cell NQ,.:. _________ _
Website Address of Company, if any:. _____________ _
RECEIVED I DENR / OWQ
Gl>UiUIC 5QW Notification of lrrlcnt Form (Revised R/1008) AQUIFf=R•PROTFr.TION SECTION Page 1
JUNO 7 2011
Jun071111 :00a Pinkston Geothermal 7574212108 p.3
C. WELL DRILLER JNF0RMA TI0N
CompanyName: P,ll/c$'tv,.J f~ .f UJeJ/ k
Well Driller Contractor's Name: 1/avA,ll,t/.. c:JJi.
NC Cootractor Ce:1ifica9on No.: __ ..... 3:...,,,'>:-=-~-=---A""-----------....-+----..----
Contact Pe,Q°": Jl Jih1 :( 5-t-v,.~ __ pMI\IL Addres s : JJebbt-r=,.e]'"Jj~-t"t;H.
Address: _ (>_ 7£i. I. H rz.. ' I
City: C~c/J .... 7.ipCodc:J.~~..rt~unty:C,l.;__ ,f) ch~
Office Tele No.: 7 57 -'-(2.,,( -Jwf""cell No.: 1S( -'(_~f' .... f ffz.
D. HEAT PUMP CONTRACTOR INFOR.!.'1AT10N (if different than driller)
Company Name: o,,Jf'/1 ~G /fc4/-,~ '4-&Jaf, o/ .
ContactPerson:A'14:&I< Au/Ullc EMAIL Address: /4,,el.. 611~1e €2 uh k,cc,111
Address: IJL~_f!fJ.) I
City: JJ.~ 1/fA--rL_, __ Zip Code)-.2tzf9 County: --!¼-?...._· -; ______ _
Office Tele No.: J:f'Z.-'('t/-( 7 'ti.I Cell No.: 20-,at,""t; {--S7~--'j't~ Z...
E. S'f ATVS r?.r APPLICANT
?tivate: ~ Federal: __ Comme rcial:
State: _ Municipal:__ Native Arne:-ican Lands: __
I F. .INJECTION PROCEDURE (briefly descr ibe how the injection well(.s} will be !u.c;ed)
I
G. WELL CONS'fRUCTION DATA
( l) Proposed <late to be constmctcd: ________ Number of ~otings: --'--_3_-__ _
Approximate depth of each boring (feet): WO
(2) Type of tubing to be used {ccpper , PVC, etc): ___ H-Q __ f~£~---------
{3) Well casing. T.s the wcll(s) cased? (check either (a.) Yes m: (b.) No below)
(a) Yes ___ if yes, then provide casing infottnation below
Type: __ galvanized steel __ black. steel_p1astic __ other (specify)
Casing depth: From ___ Ip __ ..fr.ct (reference to Ian<! surface)
Casing extends to above ground ___ inches
(b) No
( 4) Grout lnfo (material surrounding well casing and/or pipittg):'1
(a) Grout type: Neat Ccmcn~--Bentonite ...A._ Other (specify) _____ _
(b} Gro _utplaccment: Pumping__ Pressure__ Olhcrj_
(c) Grout. depth of tubil1g (reference to land surface}: from Q !to 'le)O (feet)
lfwell has casing, i11<licate groul depth: _from ___ to _I ______ (feet)
GPt.rte·JtC SQWNolilkaliot1 orlnt<;llt for:n (R<:visc<l 8/2008)
!
!
Pag.c 2
Jun 07 11 11:O0a Pinkston Geothermal
75742121 08 p.4
H. INJECTION -RELATED EQL LPMI+.NT
A7„ach a diagram showing [lie engineering layout or proposw.l modification of the injection equipment and exterior
piping/tubing Essnciated with the injection operation. The manufacturer's brochure may provide sttpptementarr:
information.
I. LOCATION OF WILL(S)
Attach two copies of maps showing the following information:
(1)
(2)
Include a Site Map (can be drawn} showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing weli(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Labe: all features clearly and include a north arrow.
The Site Map must show the subject property in relation to the surrounding, area by using at !east two fixed
reference- points such as roads, sirenms, aneor highway intersections.
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 1 have personally examined &i►d 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, l believe that the information is true, accurate and complete.
I yarn aware that there are signiftc.aut penalties, including the possibility of fines and htnprisonment, for si.:..bmitting
false information. I agree to construct, operate, maintain, repair, and if appli:mbie, abandon the injection well and
aII related appurtenances in accordance with the apprmvtx specifications and conditions of the Permit,"
\\ti
Signal re of Prrs'+t
Print or Ty e Full Name and title
Signati-trc of Property Owner/Applicant
Print or Type Pull ;game and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Apptiecion package to:
North Carolina DENR-DWQ
Aquifer Protection Section -WC -Program
1636 Mail Service Center RECEIVED i OENR i 0WfI
Raleigh, NC 271699-1636i AQUIFFR'PPMF[.T10N SF(;TfON
Telephone [phone] JUN 0 7 Z011
C;Pli;ilIC5QW Notification of'lntent Fa! n atovisod 13"2t OP.) Pagel

I
Jun 07 11 11 :01 a Pinkston Geothermal 7574212108
RECEIVED/ DENR / DWQ
AQUIA=R"PROTFr.TION SECTION
JUNO 7 2011
--·------~----~
p.5
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5QW WELLSSi
In Accordance With the Provisions of NCAC Title 15A 02C.0290
Print or type the required r►sjormatian and mail to address an the back page_
DATE:
01-3 .2f1 LxI0-10OZ30
Well lype Confirmation: Docs the proposed system circulate potable water aarst' (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -look)?
Continue completing this form
No Do Not complete this form. Complete other €UC application forms for installing
either a 5A7 welt (oiler; -loop well injecting potable water into the aquifer) or a 5QM well (closed-
Ioop well containing additives such as R-22. ethanol, or other anti fie ze or corrosion inhibitors).
A. PROPERTY OWNER(S)IAII'PLICANI'(S)
List e.Nh Property Owner listed on property deed (if owned by a business or governmAI agenny, state name of
entity d a representative wiautharity for SigoaWre): .4•prr 4- Li:, a.
(1) Mailing A ddress: __ f t) l J4 14 C •
City: A'kState: Zip Code: ..2J SY County:--J
I loineiOffice Tele No.: ktak— /(i (2 Ce11 No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County: _
Home/Office Tele No.: — — Ceti Np.:
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 U1C well)
Company Natne: _
Contact Person: EMAIL Address. -
Address:
City: _ _
Office Tele No.:
_ State: Zip Code: County: _
Cell No.:
RE-L,iL )/DENh/AQUIFFR DRnli-r.111%1 RFC DON
liWa
JUN 9 9 24H1
Website Address of Company, if any:
(RUNIC 5QW Netifiratinn of Went Fnrm (Revised Rf2O1(18)

C. WELL DRILLER INFORMATION
Company Name: PtnLslwti P well
Well Driller Contractor's Name: /160/vzI CtAllet
NC Contractor Certification No.:
Contact Peron: A d-e45 EMAL Address: bk7e{ffzuily.e,04
Address: kG.1 LY
City: -- Zip Code) I tnity:
Office Telc No.: -757 — `l2-4 — iced No.: 1'1 — Y3r- 4Z
D. HEAT PUMP CONTRACTOR INIFORMAT1ON (if different than drifter)
Company Name: 0,4/10i 6445 ArAtif (4"f e 604649
f
Contact Person: 1 k k€€BIC EMAIL Address: > Dff cik . C�jn,
Address: /0. �l y15
ty: 17
Ci �Af� Zip Cacie��� County: ��- —
Office 'f ele No.: —Wl --C % YJ Celt No.: 2r-2_ --- ,:ttit` 575 - IC v G
E. STATU8 0 , AF?LICANT
Private: i{(*,[� Federal: Commercial:
State: Municipal: Native American Lands:
P. INJECTION PROCEDURE (briefly describe how the injection weii(s) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: Number of borings:
Approximate: depth of each boring (feet): "2190
(2) Type of tubing to be used (copper. PVC, etc): P
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (is_) No below)
(a) Yes if yes, then provide casing information below
Type: _ galvanized steel black steel_ plastic other (specify)
Casing depth: From
to feat (reference to land surface)
Casing extends to above ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a)
(b)
(c)
3
Grout type: Neat Cement Bentanite Other (specify) -
Grout placement: Pumping _ Pressure Ottier
Grout depth of tubing (reference to land surface): from to '200 _ (feet)
if well has casing, indicate grout depth: from to _ (feet)
GPIOJIC 5Qw Notification of intent Porn (Re.1sett 812008)
Par 2

H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
1. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1)
(2)
Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or dram fietds located within 200 feet of
the geothermal heat pump well system. Label all features dearly and include a north arrow,
The Site Map trust show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application most be signed by each person appearing on the
recorded legal property deed.
"1 hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete.
am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
fatse information, I agree to constnict, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approve4spccifications and conditions oldie Permit."
Signature of P
tk.J•'I t &'nr'
Print or Type Full Name and title
Signature of Property Owner/A ppl icant
r
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Fall Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (9I9) 733-3221
RECEIVED I DENR ! t 1Vfj
AQUIFR PROTF(77lot SECTION
JUN 0 9 2011
GPUNIC 5QW Notification of -Intent Form (ltm-iscd W21108)
Page 3

:41
• .
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— •cr ; - ,
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NORTH CAROLINA
DEPARTMENT OF I N V IRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT NT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5(W WELL(S)
In Accordance With the Provisions ofNCAC Title 15A 02C.0200
Print or type the required fraformation wrd mail to address on the funk page.
DATE:
0113 , 2o4
Weil bye Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes
Continue completing this form.
No Do Not complete this form. Complctc other UCC 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 antirree7e or corrosion inhibitors).
A. PROPERTY OW N ER(S)IA PI' L l CA M RS)
List each Property Owner listed on property deed (if owned by a business or governm • t agency, state name of
entity •:r] a�representativo wlautharity for signature): � ): �� Ix ,
�c,C.
K
(1) Mailing Address: __/1 f h /4 c'
City: j4Mitto State: Le, Zip Code: ):2' 5Y Count}':— �—
1 tome/Office Tele No.: ! 16 (2 1j Cell No.:
Email Address: _ _ Website:
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County:
Home/Office Tele No.: - - Cell Ng.:
B. AUTHORIZED AGENT OF OWNER, IP ANY (lithe 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: Slate: Zip Code: _ County:
Office Tele No.: _ _ Cell No.:
Website Address of Company, if any:
GPu!u1C 5QW Notification of intent Form tRevised Ft12008)
RECENEt ► CENR I OWQ
kCitj4*=R p r lT('T m sPrTlON
JUN 0 9 2011..8.1

C. WELL DRILLER. INFORMATION
Company Name: _
Well Driller Contractor's Name:
NC Contractor Certification iNio,: 3f+31r-4
Contact Person:Vb S -t t ee5 EMAIL Address_ e-6k'GC, f •COK
Address: 12-C_ Y
City:
Zip Cede: .Ant
�� _ � uttty:
Office Tele No.: 75-7 - Y2-4 -aidCell Na.: -- 751 - `i. r
rn 5 P well Ifiec
Wtia
D. HEAT PUMP CONTRACTOR INFORMATION (if different thin driller)
Company Name: 6101i,
a ,� � r , '- r
Contact Person: 5� it R /C EMAIL Address: / a l UcI C G . Com
Address: /1 .5.---
City: , L - - Zip Coded-N5 County:
Off ee Tele No.:+/.-(] Yij Ceti No.:
E. STATUS 0 APPLICANT
Private: Federal:
State:
Commercial: _
Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(I) Proposed date to he constructed: _ -- Number of borings_
Approximate depth of each boring (feet)__
(2) Type of tubing to be used (copper, PVC, etc): f-' PE
(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: Frain
to feet (refcmnce to land surface)
Casing extends to above ground inches
(b) No
(4) Grout Info (material surrounding well easing and/or piping):
(a)
(b)
(c)
3
Grout type: Neat Cement Bentonite Other (specify)
Grout placement: Pumping Pressure Oilier
Grout depth of tubing (reference to lead surface): from - - _() _ to i2o- c) (feet)
if well has casing, indicate grout depth: from _ to (feet)
GPU tJYC 5QW NatificRtion of Intent Farah (Revised 812008) Page 2

H. INJECTION -RELATED EQUIPMENT
Attache diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
L LOCATION OF WELL(S)
Attach two copies of imps showing the following information.
(I) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed rveil(s) and
any existing wells) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. label all features dearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, T believe that the information is true, accurate and complete,
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information, { agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approv{s c ifications and conditions of the Pennit"
Sig�rat .# rE of P
t�+
Print or Type Pull Name and title
Signature of Property Owner/Applicant
Print or Type Pull Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DLN1 -DWQ
Aquifer Protection Section-U1C Prograin
1636 Mali Service Center
Raleigh, NC 27699-1636
Telephone [phone]
REOENECI I DE>'IR l £ WO
A►QUtF PPPr r.r•t►r At R.FtInntii
JUN 0 9 2011
GF UIUIC 5QW Notification aliment Form (Rtieisrd WOOS)
Page 3

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