WI0700239_GEO THERMAL_20120523

Beverly Eaves Perdue
Governor
AVA
NCDE NR
North Carolina Department of E·nvironment and Natural Resources
· Division of Water Quality
Charles Wakild, P. E.
Director
May 23, 2012
William and Peggy Birkemeier
46 Duck Woods Drive
Southern Shores, NC 27949
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0700239
Dear Mr. and Mrs. Birkemeier:
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 questions regarding your current permit or the rule te'visions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydro geologist
cc: UICPermit 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', Affinnative Action Employer
One North Carolina
/Vafttrnll!f
Permit Number WI0700239
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
William and Peggy Birkemeier SFR
Location Address
46 Duck Woods Dr
Southern Shores
Owner
Owner Name
William
Dates/Events
NC 27949
Birkemeier
r
Scheduled
Orig Issue App Received Draft Initiated Issuance
09/07/11 09/19/11
Reg ulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
10/19/11
Permit Tracking Slip
Project Type Status
Active· Minor modification
Version
1.10
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
William Birkemeier
Owner
46 Duck Woods Dr
Southern Shores NC
Public Notice Issue Effective
09/23/11
Reauested/Received Events
Additional information requested
Additional information received
RO staff report requested
RO staff report received
27949
Expiration
09/23/11
09/23/11
09/28/11
10/18/11
Waterbody Name Stream Index Number Current Class Subbasin
17.74
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H, Sullins Dee Freeman
Governor Director Secretary
October 24, 201 !
William and Peggy Birkemeier
46 Duck Woods Dr.
Southern Shores, NC 27949
Ref: Issuance of Injection Well Permits WI0700239
Issued to William and Peggy Birkemeier
Southern Shores, Dare County, North Carolina
Dear Mr. and Mrs. Birkemeier:
In accordance with the application received on September 19, 2011, and additional information received September
23, 2011, I am forwarding permit number WI0700239 for the construction and operation of a vertical closed -loop
geothermal mixed -fluid heat pump injection well system to be located at the above referenced address. This permit
shall be effective from the date of issuance until September 30, 2016, and shall be subject to the conditions and
'imitations stated therein, including the requirement to install well identification tags as specified in Part 11.3
and to submit well construction records as specified in Part VII.2. Be sure to read the entire permit to ensure
that you are aware of all compliance requirements of the permit.
You will need to notify this office at least 48 hours prior to beginning construction and operation of the injection
well system. 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.roeerstancdenr.2ov if you have any questions about your permit.
Best Regards,
44cZ4i
Michael Rogers, P.C. (NC FL)
cc: David May, Washington Regional Office
W10700239 Permit File
Dare County Environmental Health Department
Tina Stagg, Pinkston Well and Pump Company, Inc., 636 Benefit Rd., Chesapeake, VA 23322
AQUIFER PROTECTION SECTION
1636 Mei: Service Center, Raleigh. North Carolina 27699-1636
Location: 272E Cap4a1 Boulevard, Raleigh, North Carolina 27604
Phone: [phone] i \ FAX:: [phone]B5: FAX 2: 919-715-60481 Customer Service: 1-877-623-6749
internei: •tivww.ncwateroualitv.ort
One
NorthC.arolhna
ti •.=GJT,: Oprar,m:: 1 AfrrnInvs

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND 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 Peggy Birkemeier
FOR THE CONSTRUCTION AND OPERATION OF 5 TYPE SQM INJECTION WELL(S), defined in Title
lSA 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 46 Duck Woods Dr., Southern Shores,
Dare County, NC 27949, and, will be constructed and operated in accordance with the application received
September 19, 2011, and in conformity with the specifications and supporting data submitted September 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 Construction and Operation of an injection well and shall be in compliance with Title 1 SA of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until September 30, 2016, and shall
be subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 24th day of October, 2011.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0700239 UIC/SQM
ver. 03/2010
Page 1 of 5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number 919 715-6166 and the Washington Regional Office Aquifer Protection Section Staff, telephone
number 252-946-6481.
2. The location o( each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
3. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III -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.
Permit #.WI0700239 UIC/SQM
ver. 03/2010
Page 2 of 5
PART IV-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 Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V -OPERATION 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.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number 919 715-6166. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
PART VI -INSPECTIONS
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. Division 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.
· Permit #WI0700239 UIC/SQM
ver. 03/2010
Page 3 of S_
PART VII-MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section -UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
252-946-6481
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Washington Regional Office within 30 days of
completion of well construction. Copies of the GW-1 form(s) shall also be given to the Pennittee and
retained on site to be made available for inspection.
3. A copy of the site map updated with manifold locations required in Part II.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Washington Regional Office within 30
days of completion of well construction.
4 . 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.
5. 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;
(C) Any loss ofrefrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. 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.
7. 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 VIII -PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit #WI0700239 UIC/SQM
ver. 03/2010
Page 4 of 5
PART IX-CHANGE OF WELL STATUS
1. The Pennittee 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, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l).
Notification shall be submitted to the addresses given in Part VII.I of this permit.
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 I SA 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 that 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 copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII. I of this permit.
Permit #Wl0700239· UIC/SQM
ver. 03/2010
~age 5 of 5
Ro gers, Michael
From: May, David
Sent:
To:
Tuesday, October 18, 2011 4:43 PM
Rogers , Michael
Subject: RE: Edwards, Birkemeir, and Chisholm SQMs
Since the project is a conversion from SQW to SQM and the wells are in, from what I recall , I would probably go ahead
and issue the permit at this t ime . We'll just use the project as an example to follow-up with Porky about grouting issues
on the Outer Banks.
Thanks
David
David May, Regional Aquifer Protection 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.
From: Rogers, Michael
Sent: Tuesday, October 18, 2011 4:32 PM
To: May, David
Subject: Edwards, Birkemeir, and Chisholm SQMs
David-
I know you are busy. Just thought I would check on the above SQMs. These were SQWs converted to SQMS. The GW-
ls submitted by Porky indicate grout was from O to 20 feet. Last time we talked via the telephone you are going to look
into that issue. Never heard anything back. Status? These permits are still pending.
Thanks
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]; Fax [phone] (put to my attn on cover letter)
http ://p ortal.ncde nr.o rg/web/wq/a ps/gw oro /oe rmit-applicati ons#geothermApps
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
Rogers, Michael
From: May, David
Sent:
To:
Tuesday, September 27, 2011 8:40 AM
Rogers, Michael
Cc: Clark, Allen
Subject: RE: WI 0700238 Edwards and 0700239 Birkemeier
Michael,
We don't wish to conduct a pre -permitting inspection.
Thanks for checking.
David May
David May, Regional Aquifer Protection Supervisor
Division of Water Quality
Aquifer Protection Section
943 Washington Square Mall
Washington, NC 27889
Phone:[phone]
Fax: [phone]
E-mail: david.ma v@ ncdenr.g ov
http://portal.ncdenr.org/web/wq/
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: Rogers, Michael
Sent: Monday, September 26, 2011 4:08 PM
To: May, David; Clark,. Allen
Subject: WI 0700238 Edwards and 0700239 Birkemeier
David-
Attached are the SQM applications for 2 sites in Dare County. We originally got SQW NOI's for these, but they are
converting to SQM. Please let me know if you wish to conduct pre-permitting inspections or not.
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]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.o rg/web/wq/aps/gwpro/permit-applications#qeothermApps
E-ma/1 correspondence to and from this address may be subject to the Norlh Carolina Public Records Law and may be disclosed to third parlies
1
Rogers, Michael
From: Tina Stagg [[e-mail]]
Sent: Friday, September 23, 2011 2:52 PM
To: Rogers, Michael
Subject: RE: W} 0700238 Edwards W1 0700239 Birkemeir geothermal permit applications
Yes again, we will grout the entire length of bore. Sorry for the confusion.
From: Rogers, Michael mailto:michael.rocerso ncdenr.ggovl
Sent: Friday, September 23, 2011 2:36 PM
To: 3eff Stagg
Cc: tina(astaggenergv.corn
Subject: FW: WI 0700238 Edwards WI 0700239 6irkemeir geothermal permit applications
3eff-see below. We received the 5QM geothermal applications for the above applicants. The applications indicate the
grout is only from 0 to 20 feet. Normally, these closed loop systems are grouted the entire length of the boring in order
to decrease the possibility of co -mingling of aquifers. Should we change these applications to indicate the grout is from
top to bottom?
Thanks
Michael Rogers, P.G. (NC & FL)
Environrnental Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]: Fax [phone] (put to my attn on cover letter)
h ttp:lloo rta l . ncd en r, orglwe blwa/a vslq wprol n erm it -a r3 pl i cati ons#q e of h e rmAp p s
E-rnaif correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parries
From: Rogers, Michael
Sent: Friday, September 23, 2011 2:11 PM
To: 'tina a staggenergy.com'
Subject: WI 0700238 Edwards geothermal permit application
Tina -
We received the application for the mixed fluid geothermal wells. The application states that grout will only be from 0 to
20 feet. Normally, these closed loop geothermal systems on the coast are grouted the entire length of the boring. That's
our preference in order to prevent any co -mingling of aquifers. Should we change, the application to reflect that?
Thanks
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]; Fax [phone] (put to my attn on cover letter)
http:llportal. ncdenr.orglweblwglaoslqwp rolpermit-applicationstioeothennApas
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

Howard E. "Porky" Cutter, MGWC
September 23, 2011
Mr. Michael Rogers, P.G.
Environmental Specialist
NC Div of Water Quality-APS
1636 Mail Service Center
Raleigh, NC 27699-1636
Re: WI 0700238 Edwards geothermal permit application!
QUOTE from Mr. Rogers: We received the application for the mixed fluid geothermal wells. The application states that
grout will only be from 0 to 20 feet. Normally, these dosed loops geothermal systems on the coast are grouted the entire
length of the boring. That's our preference in order to prevent any co -mingling of aquifers.
Mr. Rogers, I agree all geothermal closed loops should be grouted the full length. Because I understood that grouting the
top 20 feet was acceptable (there was only one upper aquifer) the Edwards, the Birkemeir and the Chisholm loops were
only grouted the top 20 feet.
In the future all geothermal loops will be grouted by pumping the grout from the bottom to the top of the loop! I thank
you for making this clear.
Sincerely.
664, cametep
Howard "Porky" Cutter, MGWC
Master Ground Water Consultant
800 Dryden Street, Virginia Beach, VA 23462; Ph: 757-418-2036; Email: pnrkyva{[e-mail]
Providing the Worlds Most Precious Resource... Safe Water!

(„4- 0
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NO C 3538 A
1. WELL CONTRACTOR:
HOILNARD E. CUTTER
Well Contractor (Individual) Name
PiNKSION WELL & P_LiMP COMPANY
Well Contractor Company Name
636 BENEFIT ROAD
Street Address
CHESAPEAKE
VA 23322
City or Town State Zip Code
( 757_} 418-2036
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT*
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #{if applicable}
3. WELL USE (check Applicable Box): Residential Water Supply ❑
DATE DRILLED 9/15/2011
TIME COMPLETED 6:00 PM AM ❑ PM [
4. WELL LOCATION:
CITY: SOUTHERN SHORES couNTY DARE
46 Duckwoods Drive
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley 'Flat ❑ Ridge G Other
LATITUDE 36 " DMS OR 3K.XXxxxxxxX DD
LONGITUDE 75 " DMS OR 7X.)000000OIX DD
LatttudeAongitude source: EPPS Topographic map
(location of well must be shown on a USGS topa map andatfached to
this form if not using GPS)
5. WELL OWNER
WILL,LAM_& PEGGY BIRKEMEIER
Owner Name
46 Duckwatxt$DPye
Street Address
SOUTHERN SHORES
City or Town
(252 ) 255-1008
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 5 t) 200'
NC 27949
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES EI 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'
"Tap of casing terminated et/or below lend surface may require
a variance in accordance with 15A NCAC 2C .0118.
e, YIELD (gptnr: N/A METHOD OF TEST NIA
f, DISINFECTION: Type N/A Amount N/A
g, WATER ZONES (depth):
Top N/A Bottom N/A Top Bottom_
Top_ Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
T. CASING: Depth Diameter Weight Material
Top N/A Bottom N/A Ft.
Top Bottom Ft.
Top Bottom Ft.
9. GROUT: Depth Material Method
Top 0' Bottom 20' Ft. BENTONITE POURED
Top Bottom Ft.
Top,_ Bottom Ft.
9. SCREEN: Depth Diameter Slat Size Material
Top NIA Bottom NIA Ft. in. in.
Top Bottom Ft. in, in.
Top Bottom Ft. In. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top N/A Bottom N/A Ft
Top Bottom Ft.
Tap Bottom Ft.
11. DRItLING LOG
Top Bottom
0 / 200'
1
1
I
1
1
I
Formation Description
NO SAMPLES TAKEN!
THESE ARE CLOSE LOOP
GEOTHERMAL LOOPS.
WATER CIRCULATION ONLY.
5 HOLES DRILLED TO 200'
AND GROUTED TO THE TOP.
THIS IS NOT A WATER WELL!
12. REMARKS
CLOSED LOOP GEOTHERMAL WATER CIRCULATION
ONLY!
I 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.
9/16/2011
SIGNATURE RTIFIED 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 -
1617 Mail Service Center, Raleigh. NC 27699-161. Phone : (919) 6O7-G300
information Processing.
Form GW-la
Rev. 2)09

SVA --.. ,,~~ NCD ....... EN-R
North Carolina Department of Environment and Natural Resources
Division of Wa ter Quality
Beverly Eaves Perdue
Governor
William Birkemeier
Peggy Birkemeier
46 Duck:woods Dr.
Southern Shores, NC 27949
Coleen H. Sullins
Director
September 23 , 2011
Dee Fre eman
Secreta ry
Subject: Acknowledgement of
Application No. WI0700239
William Birkemeier SFR
Injection Mixed Fluid GSHP
Well System (SQM)
Dare County
Dear Mr. Birkemeier:
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on 09/19/2011. 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 or
[e-mail].
i~cerely, ()
~11J.:-$D
fo r Debra~t s
Groundwater Protection Unit Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Jeff Stagg (Pinkston Pump & Well, Inc ., P .O . Box 15482, Chesapeake, VA 23328-5482)
Brian McDonald (Outer Banks Heating & Cooling, P.O. Box 1415, Nags head, NC 27959)
Permit File WI0700239
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard. Raleigh. North Carolina 27604
Phone: [phone]·1 I FAX 1: 919-715-0588; FAX2: 919-715-6048 Customer Service: 1-877-623-6748
Internet: www.ncwateraualitv.oro
A1 Eq:ial Opporiun:t; \ />.fi1rmaiive Action Employer
Nirth Carolina
"Naturalllf
09/03/2011 21:50 12524410639 OBHC PAGE 09
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
ln Accordance With the Provisions of l 5A NCAC 02C .0200
CLOSED-LOOP MIXED-FLUID GEOTHERMAL INJECTION WELLS
These wells circulate fluids other than potable water ;u, part ofa geothennal heating and cooling system
(check one) ':j_ New Application Renewal"' X Modification
a~vJ --~\J
* For renewal:; complete Parts A-C an J the signature page .
Print or Type Information and Ma;/ to tire Addre.1·J· on the lasf Page. Illegible Applications Will Be Returned A.f f11comple1e.
DA.TE: Sept1:mbcr 2, 2011
PERMIT NO. V:l, U 'J ~2....,3 o/ (leave blank ifNew Application)
A. STATUS OF APPLICANT (choose one)
Non-Government: lndividual Residence X Business/Orga.ni1.ation _
G(wemment: State Municipal __ County_ Federal
B, PERMIT APPLICANT -For individual residences. list each owner on property deed. For all others.
state mime of entity !l,_nd ,,ame of person delegated authority to sign on behalf of the business or agency:
___ W~ilU.~!O & Peggy Birkemeier
Mailing. Address: ___ 4:.,,6:...,D:::..,u,._,c,.,k..:..:w""o.,,.;od,,.,s...,D=1,.,_·iv.:..:e,.___ ___________________ _
City: Southern Shores State: NC Zip Code: 2794 9 County:._=D=ar::..:,e,_ ____ _
Day Tele No.: ~S..2..:2=6..:..1 ·-=-3=38,._,6'-----------'C.ell No.:
EMAIL Address : ________ _,_F~-~ No.:
C. LOCATION OF WELL SIT.E-Where the injection wel 111 are physically located:
(J) Parcel Identification Number (PIN) of well site: 9867 J 9621322 County ; _Dare __ _
(2) Physical Address (if different than mailing address):
City: __________ State: ~NC __ Zip Code: __________ _
D. WELL .D:RILLER INJl'ORMA T.tON
Well Drilling Contractor's Name: ___ .,,_,H""ow=ar,..,,d,_,C""'t,,,.1tt.,,e"-r ________________ _
NC Well Drilling Contra.ct~ Certification No.: ___ __,3'""5..,,_3=-8--'-A~-------------
Company Name: PinkstoJ.:.1 ._P=u1=n..._p..,,&"--W-'-'-=e=lli.c, l=n=c·~------------------
Contact Person: .leff S~---------=E=· M'-=-'A=lL~A=d=d"~e:-tieJ.l@s~~nergy.com
Address: PO Box l 5482
G1'll/UTC 5QM Pennit Application (Revised 1/24/2011) RECEIVED/ OENR / OWQ
Aquifer Protection Section
SEP 19 2011
09/03/2011 21:50 12524410639 OBHC PAGE 10
City: Chesapeake Zip ~ode: 23328-5482 County: Ci ty of Chesapeake
Office Tele No.: 7S7-421-2 l 08 Cell No.: 757-438-9392 Fax. No .. : 757-4~1-2108
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: OL1t~,:!..r.!,B~a:~n~lc.s~H,:,:;ea~t1~·n!Jiig..:!&~C~o!.><0C!.!li ..... ng _________________ _
Contact PersOTI,;_8-.r:ll!•~nM~c,,__,D,c,o~n.!!!atuld,!__ ________________________ _
Address: ___ P!..-'O""---"B<->o,,,x'--'lC:!4..,_15"'----------------------------
City: Nags Head 2.ip Code: 27959 State: NC __ County : Dare
Office Tele No.: 252-441-1740 Cell No.: ______ Fax No.: 252-441-0639
F, WELL CONS'l'RUCTION DAT.A
(l) Number of borings to be constmcted"': 5 Depth of each boring (feet): 200
• lf existing water supply wells will be used then provide the informatio,r in item (4) below.
(2) Chemical additives to be L1sed: R-22 ___ Propylene glycol___ Ethanol
Other EnvirQ.t1.!)..I {otl1er additives will need prior approval by NCDENR before use)
(3) Type oftuhing to be used (copper, PVC. etc): _HD~P...::E::._ ___________ _
(4) Well casing. l.fthe wel!(s) will use casing then provide the~ (steel, PVC, plastic, etc.). diameter, depth.
and exte11.t of casing appea.iing above ground: N,.....,.oc.:.ne.._ ______________ _
.. ~~@_
(5) Grout (material surrounding well casing and/or piping): ~ @
O~v 0:-;~ (a,) Grout type : Cement__ Bentonite*"' ~')J.-Other(specify) _...,..::....,;,''-""7".,..,..-----:---~
*• By !<electing hcntQnitc ~nmt. :i variance is hcrei,y rcquc.~tcd tn l 5A NC:AC 2C: .0213(cl)(l)(A). which require.~ n ~tl>'flc grout.
(b) Grout depth of tubing (reference to land surface): from 0 to ~, (feet) ~ 0 -
If well has casing, indicate grout depth: frotn to (feet) -------
G, WELL LOCATIONS-Maps must be scaled or otherwise accurately indicate distances and orientations of
fcatL1res located within 1000 feet of the injection well(s). Label all (.~tures clearly and include a north att()~.
(1) Attach a site-specific map showing the locations of the followh1g:
* Proposed injection well$ * 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
)-o't'-1
(5-w·-I
(2) Attach a topographic map of the area extending 1/4 mile from tlie injection well site that indicates the
facility·s location and the map name .
.NOTE: In moll c,ue.J, an aerltll photograph of lht propt!rty parcel showing property lines and structure., can be
obtained and dpwnloaded from the applka1Jle co,m~ GlS website. Typically, the property can be searched by
owner name or addre.u. T/1e location of the wells h, remtion to propert, hnu.t1dt1.ries, house.,, !rt!plic ,_11:.t_. ntber
wells, ate. can tl,en be dr(I.Wr, in by hand. A.l.,o, a 'layer' can be selected .,hnwlng 1opogrtrp/1ic r:nrrto11:rs or
ele11aJlo,, ti.ala.
til'U/UIC SQM Pcnnit Application (Rcvi:scd 1/24/2011) P~ge 2
09/03/2011 21:50 12524410639 08HC PAGE 08
iH, CERTIFICATION (to be signed as required below or by tlmt person's authorized went)
15A NC.AC 02C .021.1(b) requires that all permit applications shall be signed as follows:
1. fora corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, fedeiai. ar other public agency: by either a principal executive
officer or ranking publicly elected official:
4. for 811 others: by the well owner (which means all oersons listed on the iroperiv 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.
"1 hereby certify. under penalty of law, that I have personally examined and am t'amiIiar with the information
submitted in this document and all attachtnerts thereto and that. based on my inquiry of those individuals
immediately responsible for obtaining said information. 1 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. i agree to consEnlct. operate. maintain, repair, and if -applicable. abandon the
injection well and all related appurtenances in accordance 1.wwith the approved specifications and conditions of
the Permit."
Signature of Property OwlierlApplieant
William Birkemeier
Print or Type bull Name
ithats-"44
Signature fProperty Owner/Applicant
Perky Birkemeier
Print or Type Full Name
Signature cif Authorized Agent if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
CPUfille StjM Permit Applicetion (Revised 1/24(2111 I
RECETI/Er)/
Agtlifor pr,�i'j�section
SEP I
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Perm it Number
Program Category
Ground Water
Permit Type
W10700239 / Central Files : APS_ SWP_
09/07/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
William Birkemeier SFR
Location Address
46 Duckwoods Dr
Southrn Shore
Owner
Owner Name
William
Dates/Events
NC 27949
Birkemeier
Orig Issue App Received Draft Initiated
09/07/11 09/06/11
Requlated Activities
Heat Pump Injection
Private residence , single fam ily
Outfall NULL
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
William Birkemeier
Owner
46 Duckwoods Dr
Southrn Shore NC
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Afflllation
Owner Type
Individual
Owner Affiliation
William Birkemeier
Owner
46 Duckwoods Dr
Southrn Shore NC
Public Notice Issue
09/07/11
Effective
09/07/11
27949
27949
Expiration
Stream Index Number Current Class Subbasin
RA
MCDENR
North Carolina Department of Environment and Natural Resources
Divisio n of Water Quality
Beverly Eaves Perdue
Governo r
William Birkemeier
Peggy Birkemeier
46 Duckwoods Dr.
Southern Shores, NC 27949
Coleen H. Sullins
Director
09 /07/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No . WI0700239
46 Duckwoods Dr.
Southern Shores, NC 27949
Dear Mr. Birkemeier:
Dee Freeman
Secretary
On 09/06/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl y
geothermal injection well system for the operation of a ground-source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following 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(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 gerscm.ncdenr.2:ov if you have any questions.
cc: Washington Regional Office -APS
APS Central Files -Permit No. WI0700239
Dare County Health Dept.
S12_c~~ely , , () 1_ --._
y]L¼ -nxtLSr0
for Dehl7 atts
Supervisor
Tina Stagg (Pinkston Pump and Well, Inc., P .O. Box 15482 , Chesapeake, VA 23328-5482)
Brian McDonald (Outer Banks Heating & Cooling, P .O . Box 1415 , Nags Head, NC 27959 )
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] I FAX [phone]; FAX 2: 919-715-6048·\ Cusiomer Service: 1-877-623-6748
internet: www .n cwaterauali 11•.oro
An Eq:ial Opportunity) Afiirrraiive Acton Empioyn
NOnehC . ort. arohna
/Vaturall!f
Sep 0611 12:57p
Pinkston Geothermal
757-421-2108
P.1
Pinkston Pump & Well
P a Box 15482
Chesapeake, VA 23328
facsimile transmittal
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Date: ;:f
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Notes:
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6 2011

Sep.06 11 12:57p Pinkston Geot~ermal 757-421-2108 p.2
09{03/2011 21:50 12524410 639 OBHC PAGE 06
\tJn)l{)W37
lJATE:
_______.
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT A.ND NATURAL RESOURCES
NOTIFlCA TION OF INTEN'l' TO CONSTQUCT A CLO SED-LOOP GEOTHERMAL
WATER-ONLY lN,JECTION WELL SYS'l'l:M
TYPE SOW WELL{S )
In Acc.ordRnce With the Provisimi:; of NCAC Title I SA ()lC.0200
Prir,r or typl! rl,e required ir1fr:,m1r1lirm and moiT l,) add,·es.r 011 the f,ackpc1tt,
Septanber 2 , • ,..:20=1=1 __
Well Type Confumation: Does the proposed system circulate pouible water Q.~ (no add itive.s) in
continuous piping that cornµletely i$olates the fluid from the envfronment (i.e.
~ losed-loop}?
Yes X Continue completing this foi:i-r,.
No ___ Do Not complete th is foran. Complete other UlC application fo1·ms for insial ling
either a 5A 7 well (~-loop well injecting potE1b1e water into the aquifer) or a SQM well (closed-
loop wel I cc,ntain ing ~\lditives such as R-22. ethanol, or other antifree7.e or corroiion inh ibitars).
A. PROPERTY OWNER(S)/APPLICAl''T(S)
List each Property Owittr 1 istcd on property deed (if owned by a busine~s or government agency. !ita.te name of
entity and a l'epresentative wlauthority for signature); Willistn & Pem Bi '2...lllf r<' ~I dt.
(1) Mailing Addrcs!;:: ----=-46><-=D=u=ck=w.:..:o=o=d.s"-=D,ri~ .... ve=----------------
City: _S_•~Ihern Shores Stal:e: ~ Zip Code:27941) County:._.D._.a""re,e__ __ _
Home/Office Tete Ni;,.: 252-261 -3386 (;_~IJ.-'N--"o""'.'-: _________ _
Email Addresi;:. ______ .... W_,e,.,,b""'si""te'-'-: __________________ _
(2) Physical Address of Well Site (if different than ai,ove): ______ _
City: ______ Slate: __ Zip Code: ___ Ccunty: _____ _
Home/Office Tele No.: C'.~IJ No .:
B. AUTHORIZED AGENT OF OWN.ER~ IP ANY (if the Permit Applicant does 1:,pJ: own the subject properly.
a:ttach a lettel' from the property owner authorizing Agc11\ to install o.nd operate UlC well)
Company Name: _____________________________ _
Contact Person: EMAIL Address:
Address: _______________________________ _
Cicy: _________ Stflte: __ ZipCode: ______ County; _______ _
Office Te le No.: Cell NA.,.,_: __________ _
Website Add,·e..~ ofCompMy. if~ny:~.~-------
Gl'IU/1.JIC :iQW Notific.it i<t n of Trll.:nt Fnrm (Rtviscd 8/20M} RECEIVED/ DENR / owa
Aquifer Protection Section
SEP 08 2011
Sep, 0611 12:58p
09/03/2011
Pinkston Geothermal
21:50 12524410639
C, W:ELL DRU.LE~ lNFORMATlON
757-421-2108
DBHC
p,3
PAGE 07
Company Na111e: ___ r,_..,.·=n=ks=to=n~P~um==-p~•n=d=--W.,_e..::l=l,-=lll=c:=·------------------
Well Driller Concr.1.ctot's Name: ___ H=o~w~•=nl~C=u=tt=;;e..,r ________________ _
NC Co~ctor Certiflc&ion No.: ----'~~3""8-,-=A.,,___ ___________________ _
Contact PersOfli. Tl rv /I 1.5,_F.:...R.c..;'[~;,·· ....:ao=--·· -------""E"-'M.,,A_.,lco,L'--"A..,_,d::.:d::..r~e~~~~: Tirv,q®,tageenem.c::run
Address: PO Bo1:J S482
City: Chesa pe ake State: VA ZipCode: 23328-5482 County: _______ _
Office Tele No .: :::.l:2-7 -if 3 3 ' 9 j 9 2 Cell No.: ;;J--5-f_ -j(; 'I --:76 (} 5
D. HEAT PUMP CONTRACTOR INFORMATION (if dif:f.erent than driller)
Company Name: Ontcr Ban ks Heatin g & Coolin::
Contact ~on: Brian McDonald E-MAIL Addrcs~: __ ..,,b""na=· "'n""l@o=b=h=c=.w=m..__ ____ _
Address: PO .Box 1-415
City: Nap Bead State: -.:.N~C=-----Zip Code: 27959 Co1.mty: =eD=a=-=re"--------
Offic.e Tele ~o.: 25,.2-441-1740 Cell No.: ________ _
E. STATUS OF APPLICANT
Privlltc: J_
State:
Federal:
Municipal: __
C~mmercia l :
Native American Lands:
F. JN,JECTION PROCEDURE (briefly del!lcribe hQw the injection wcll(s) will be used)
Geetp emal Closed Loop
C. WELL C0NSTRUC'l'ION DATA
(1) PropO!ied date to be constructed: ____ A~S=A=P=--_____ Nunibe:r of borings:-~-F1Vi:'
Approximate depth of each boring (fect);,__ _ __,l=-=0""0-' ____ _
(2) Type oft1.1bi11g to be used (copper, PVC. etc): --~HD~~P=E ____________ _
(3) Wr.,11 casi:,g. I~ the well(~) cased? (check either (a.) Yi:s 9.! (b.) No 1,elow)
(a) V.es ___ if yes, then, provide casing inf-onnation below
Tyi,e: ___galvanized 11tcd __ black steel __ pla.."-tie __ other (specify)
CasiT1g depth: From ___ to ___ feet (ref'enmceto land surfa.ce)
C::ising extends to above ground ___ incites
(b} No X
{4) Grout Info (matedal st1rrounding well easing anc/or piping):
Grout type: Neat Cement__ Bentot\ite X ()(lier (specify) ______ _
Gro1.1t placcmcrit: T\lmping X Pressure __ Other __
(ti)
(b)
(c) Grout depth of tubing (reference to land $tirface): from -~$-'~-to ~_W_' (feet)
If well hll!'; ca..~ing, indicate groutdept.h: from ___ to ____ {feet)
OPU/lllC SQW ~olifa:aLii,n <>f' Intent f'oi:m (Rcviu:d ~120/lll)
--·----·-··· ---------··--·-·------·~---
Sep 0611 12'S8p Pinkston Geothermal 757-421-210S p.4
9°/03r2011 21:50 1252d4I0639 OBHC PAGE 11
GT+1111i1> 5Qw Non nevi or, or IltIcal Perm i ReviNal $ no$y
IL riSECTION-RELATED EQLifPMENT
Attach a diagram shouting the engineering layout or proposed modification of the injection equipment end exterior
pipingJtubing associates with the injection operation. The manufacturer's hrnchurc may provide ss1ppternentary
information.
I. 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 bodes. potential
sources of -groundwater contamination and the orientation of and dis•t mces between tite proposed weil(s) and
any existing wells) or waste disposal facilities such at septic tanks or drain fields bled within 200 feat of
the geothermal heat pump well system. Label ail features clearly and includc a north arrow.
The Site Map must show the subzecl property in relation to the surrounding area by using et !east two fixed
reference paints such as reads, streams, and/or ltigitway intersectrwts-
3. CERTIF1CATIOIX
Note; This Permit Application moat be signed by each person appearing op the
recorded legal property deed.
"I hereby certify, under penalty of law. that l have personally examined and am familiar with the information
submitted in this document and ail attachments thereto alid that, based an my irtgltiry of those Individuals
immediately responsible for obtaining said information, 1 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 gtrbmilting
false 'nforination. l agree to construct, operate, maintain, repair. and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specific Lions and conditions cf the Permit."
Signature of Property Owner/Applicant
William 13irkeineier
Print or Type Full Name and title
Signaturedi- Property (hiener/Ap.)lmcsnt
P egv ,6'rkemeier (tj a�--)
Print or Type Full Name and titre
Signature of Authorized Agent. if any
Print or Type Ftlll Nalne and title
Please return two eopie_s o'the completed Application trackage to:
North Carolina DENR-DWrQ
Aquifer Protection Section-U-1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone] RECEIVED r DENR r D
Aquifer Protection Sermon
SEP 08 2011
rogc 3

Sep 0611 12:58p Pinkstan Geothermal
09/03I2011 21:50 1252441E1539
0E IC
757-421-2108
p. 5
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09/03/2011 21:50 12524410639 OBHC PAGE 06
DATE:
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT A.ND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLO SED-LOOP GEOTHERMAL
WATER-ONLY IN,JECTION WELL SYSTEM
TYPE SOW WELL(S )
In Accor<fance With the Provisions of NCAC Title 15A 02C.0200
p,.;.,,, or 1y1,e rhe required in_formulirm a1'd moil to oddras.r on the hack page.
Se ptember 2. . l=o=•=•--
Well Type Confirmation: Does the proposed system circulate potable water o_n~ (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
~losed-loop)?
Yes X Continue completing this foi:l'n.
No ___ no Not complete thi~ form. Co1nplete other UIC application forms for installing
either a SA 7 wcl I ~-loop well injecting potable water into the aquifer) or a SQM well (closed-
loop wel I containing .~Qditives such as R-22. ethanol. or other antifreeze or corrosion inhibitors).
A. PROPERTY O\VNER(S)/APPLICAN1'{5)
List each Property Owner listed on property deed (if owned by a business or government agency. state name of
entity and a representative w/authority for signati1n:}; William & Pe_gru: Bi R..'ll€ rr,el di...
(1) Mailing Address: __ .......:.;46><...00:D_,,u=ck=w~o=o=ds=--=D'"'ri·;..;.v.::.e ______________ _
City: _S_q_t_hern Shores Sta"te : ~ Zip Code:27942 County:-=D~a=re~---
Home/Office Tele No.: 252-261-3386 C:~1.1 . ..:N""o"-'-. .,__: _________ _
Email Ad.dres$: ______ _,_W'"'e""b""si~te.,_: __________________ _
(2) Physical Address of Well Site (if different than above):----~--
City: _______ State: __ Zip Code: ___ County: _____ _
Home/Office Tele No.: C,.eJJ No.:
B. AUTHORIZED AGENT OF OWN.ER, IF ANY (if the Pe.rmit Applicant does l'.IP.!' ow11 the subject property.
attach a letter from the property owner authorizing Agent to install and operate UJC well)
Company Name: _____________________________ _
Contact Person.,__: _______________ E,.,M""'. :...A..,_l ,..L _,_A,..,d=d=re=s,,,__,s: __________ _
Address: ________________________________ _
City: _________ State: __ Zip Code: ______ County; _______ _
Office Tele No.: Cell NQ..-'-: __________ _
Website Addre$S of Company. ifa.ny:_, _________ _
GPU/UIC 5QW Nntifrcation of Tnl~nt Fmm (Revised ll/200R) REC_EIVED I DENR / DWQ
Aquifer Protection Section
SEP 08 2011
r~g.e I
09/03/2011 21:50 12524410639 OBHC PAGE 07
C. WELL DRILLER lNFORMATION
Company Na1ne: ___ Pwc1=nks=to=n"'-=-Pu=m==,,p~a=n=dc._W..,;,,,,;::.el=l,._.111=c:·~----------------
Well Driller ConLTactor's Name; __ ___,H=ow=ar:..:d=-C=utt=e=r,..._ _________ ~------
NC Contractor Certification No.: --~t5-3""8-...,A=--------------------
Contact Person_;_ Tl rv r} J ,,_m:....,..:6~6'---____ --=E=M.,,,_A=l=L..:.;A=-:::;d.=dr:.::e.,.,$S.,._:Zirv"1 <i2staeeenerl3'.COm
Address: PO Bo :1 1 5482
City: Chesa peake State: VA Zip Cocl.e: 23328-5482 County: _______ _
Office Tele No.: .1,2 7 ~ if 3 3, ' 9 3 9 2 Cell No.: ;_;---_5 ·,--:JO l/ -76 9 5
D. HEAT PUMP CONTRACTOR JNFORMA TION (if different than driller)
Company Name: Oater Ban k! lleatiil & & Coolin e
Contact ?cn,on: :B rian McDonald E-MAIL Addresi1: ---==b::..:ria=n""@=o=b=h=c-=co=m=------
Address: ___ P.,..0=--=B=o=i;,_,l"-'4=1=5 _________________________ _
City: ,N a2s Head State: ___,_N~C=---Zip Code: 27959 County: =D=ar~e ______ _
Office Tele No.: .2.Sl -441-1740 Cell No.: _______ _
E. STATIJS OF APPLIC~NT
Federal: Commercial: Private: _L
State: Municipal: __ Native American Lands:
F. JN,JECTION PROCEDURE (briefly describe how the in.iection wcll(s) will be used)
Geot hermal Closed Loop
G. WELL CONSTUUCTION DATA
(l) Proposed date to be constructed: --=-A=S=AP=-------Number of borings: ----· F, V c
Approximate depth of each boring (feet): _____ l.,.O.,.0_' ____ _
(2) Type of tubing to be used (copper, PVC. etc): ____ BD~=P_E~------------
(3) Well casing. Is the well(s) cased? (check either (a.) Yc!!l .!!! (b.) No below)
(a) Yes ___ if yes, then provide casing inforrnatio11 below
Type: ___galvanized steel __ black steel __ pla..~ic __ other (specify)
Casini depth: From ___ to ___ feet (refen,nce to land surface)
Casing extends to above ground ___ inches
(b) No X
(4) Grout Info (material surrounding well casing and/or piping):
Grout type: Neat Cement__ Bentof'lite X Otber (specify) ______ _
Grout placement: Pumping X Pressllre __ Other __
(b)
(b)
(c) Grout depth of tubing (reference to land surface); from --"0-' __ to __ ,_'JSl' {feet)
If well has ca.sing, indicate grout depth: from --~to ____ (feet)
OPU/1 l!C SQW NoliliC~lion of Intent fonn (Revised R/2001.1)
e9/6312011 21:50 1252a41e639 OBHC PAGE 11
H. INJECTION -RELATED EQUIPIVCENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipinWtubing associated with the injection operation. The manufacturer's brochure may provide suppiernentary
in formation.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1)
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 wall(s) and
any existing well(s) 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 clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads. streams, andlor highway intersections.
J. CERTIFICATION
Notes 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 and am familiar with the information
submitted in this document and all attachments thereto and that, based en my inquiry of those individuals
immediately responsible for obtaining said information. I 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. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the iniection well and
all related appurtenances in accordance with the
1pr
approvedap�specific tons and conditions of the Permit."
Signature of Property Owner/Applicant
William Birkerneier
Print or Type Full Name and title
Signature Property fwnerJApplicant.e.1
peBirkemeier l
Print or Type Full Name and title
Signature of A.uthorixed Agent. if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Caroliilaa DENR-DWQ
Aquifer Protection Section-U1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
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1 AREA . 23.243 IF, 0.53 AC (DMD)
Z PROPERTY LOCATED IN A PRY ZONE A3.
3 DARE CO. PIN NC. 30-90709)&2-1322
4 HUG. LINES PER TOWN ZONING ORDIN►INC£.
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LOWEST FLOOR WANC AREA M a.SR'
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AS SHOWN IWTH REPESIENCE ID 1d5 3. PG 141.
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FROM AA! ACTUAL fELa LAND StJRVE1"
AND THAT TNIS NAP is Nor FOR AE'C6p1AT10Ar.
Nf ►NESS fir WAND AN SEAL *Ns
6lY1 PAY OF .I le
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L— 3339
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II On_ LTa, ANY JNAUTHOiCIEE USE OR
..RUI INC L1RE7S s*1 I HLP[ON rysT : VERRW9.
T4fE 9URVFF'1R MAUL9 NO CERTNICAYIE1 A.S TO
ZONING ANO/RR RFSYFIIC11SE COYERANT SETZIAGNF,
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