WI0700240_GEO THERMAL_20130507

Existing Permit No.: Assigned Date: _____ _ ~ Reviewer: Date to Processing: ______ AM PM 't., D Existing jll._Unknown Owner Type: .(Zj____Non-Government _. lli-.individual D Organization ~ D Municipal D Federal D County D State ~ \ D Government ► Facility: D Proposed Facility Type: D Facility Facility Regulated Activities:________ r? g.Existing D Operation Individual D Aquifer Storage and Recovery Wells \"' oop Wells D In Situ Groundwater Remediation Wells circle one: 0 Experimental Technology Wells -. ( air sparge, passive, small scale, pilot test ) 0 Stormwater Drainage Wells D Tracer Wells D Other Wells Application Type: 0 New D TracerWells ~ .. [ t D Aquifer Rech.arge Wells ~ . t D Subsidence Control Wells ~ ~\ 0 Salinity Barrier Wells ~ . ©_ Ownership Change (\:t~ ~r D Major Modification D Minor Modification D Name Chang 1· \ D Renewal D Renewal w/ Modification D Rescission . ' · ~ 'J~ =~ ~-=-i..~, ~~ -,__ J '"\ ~~~s~.po-fv~ fi') L UIC BIMS EntryfonnJ\p1il 11, 2013 ~
Godwin, Ton ya
From:
Sent:
To:
Subject:
[DOTS] DENR Support [[e-mail]]
Tuesday, May 07, 2013 11 :36 AM
Godwin, Tonya
[DOTS] Created: (HD-727747) Change Permit Type in BIMS
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-727747
in the subject line of all 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: Change Permit Type in BIMS
Issue#: HD-727747
Issue Created: Today 11:34 AM
Issue Type: Issue
Reporter: Tonya M Godwin
Category: I have a request ...
Division: Water Quality
Location: Archdale Building
Location Details: 6th Floor, Room 6402
NCID: tmgodwin2
Number of Users Affected: 1
Phone: [phone]
Queue: Development Queue
Severity: Medium
Sub-category: BIMS
Subdivision: None
Description:
Please change the permit type in BIMS for permit# WI0700240 from Injection
Water Return Well to Injection Deemed Geothermal Aqueous Closed-loop Well.
needed for a closed-loop well. Thanks Tonya
If you require assistance, please contact the DENR ITS Solution Center at:
http://portal.ncdenr.org/group/its/
Heating/Cooling
No permit is
If you have an urgent or critical situation, please call the DENR ITS Solution Center at
[phone] after submitting your help request.
1
Godwin, Ton ya
From:
Sent:
[DOTS] DENR Support [[e-mail]]
Wednesday, May 08, 2013 11 :25 AM
To: Godwin, Tonya
Subject: [DOTS] Resolved: (HD-727747) Change Permit Type in BIMS
Issue# HD-727747 has been resolved.
This ticket has been resolved. The permit type has been changed as requested.
Please take a few minutes and give us your feedback.
DENR ITS Customer Feedback:
https://www.surve ymonke y .com /s /DENRITSFeedback
Issue Details
Summary: Change Permit Type in BIMS
Issue#: HD-727747
Issue Created: Yesterday 11:34 AM
Issue Type: Issue
Components: Desktop Support
Reporter: Tonya M Godwin
Assignee: Tom Moore
category: I have a request ...
Division: Water Quality
Location: Archdale Building
Location Details: 6th Floor, Room 6402
NCID: tmgodwin2
Number of Users Affected: 1
Phone: [phone]
Queue: Development Queue
Severity: Medium
Sub-category: BIMS
Subdivision: None
Description:
Please change the permit type in BIMS for permit# WI0700240 from Injection Heating/Cooling
Water Return Well to Injection Deemed Geothermal Aqueous Closed-loop Well. No permit is
needed for a closed-loop well. Thanks Tonya
If you require assistance, please contact the DENR ITS Solution Center at:
http://portal.ncdenr.org/group/its/
If you have an urgent or critical situation, please call the DENR ITS
Solution Center at [phone] after submitting your help request.
Email correspondence to and from this address is subject
to the North Carolina Public Records Law and may be
disclosed to third parties unless the content is exempt
1
Godwin, Ton ya
From:
Sent:
[DOTS] DENR Support [[e-mail]]
Wednesday, May 08, 2013 11 :26 AM
To: Godwin, Tonya
Subject: [DOTS] Closed: (HD-727747) Change Permit Type in BIMS.
Issue# HD-727747 has been closed.
Please take a few minutes and give us your feedback.
DENR ITS Customer Feedback:
htt ps://www.surve ymonke y .com /s /DENRITSFeedback
Issue Details
Summary: Change Permit Type in BIMS
Issue#: HD-727747
Issue Created: Yesterday 11:34 AM
Issue Type: Issue
Components: Desktop Support
Reporter: Tonya M Godwin
Assignee: Tom Moore
Category: I have a request ••.
Division: Water Quality
Location: Archdale Building
Location Details: 6th Floor, Room 6402
NCID: tmgodwin2
Number of Users Affected: 1
Phone: [phone]
Queue: Development Queue
Severity: Medium
Sub-~ategory: BIMS
Subdivision: None
Description:
Please change the permit type in BIMS for permit# WI0700240 from Injection
Water Return Well to Injection Deemed Geothermal Aqueous Closed-loop Well.
needed for a closed-loop well. Thanks Tonya
If you require assistance, please contact the DENR ITS Solution Center at:
http://portal.ncdenr.org/group/its/
If you have an urgent or critical situation, please call the DENR ITS
Solution Center at [phone] after submitting your help request.
Email correspondence to and from this address is subject
to the North Carolina Public Records Law and may be
disclosed to third parties unless the content is exempt
by statute or other regulation.
1
Heating/Cooling
No permit is
NA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory
Governor
Gregory Saine -Owner
17230 Begonia Dr.
Ruther Glen, VA 22546
Charles Wakild, P.E. John E Skvarla , Ill
Secretary Director
May 3, 2013
Subject: Acknowledgement of
Application No. WI0700240
Dolores Dewhirst SFR
Injection H~g/Cool_!!!g-
W ~~ W u-sfstem
Dare County () .
r ~ b~_,
Dear Mr. Saine: / _... ,r .. I ~ ---lJ L--7 ~ ~ , '7ru--l-MAT
The Aquifer Protection Section acknowledges receipt of your pennit application and supporting ~ ~ ;.M {
documentation received on 04/26/2013. Your application package has been assigned the number listed
above, and the primary reviewer is Michael Rogers.
Central and Washington Regional Office staff will perfonn a detailed review of the provided
application, and may contact you with a request for additional information. To ensure. maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail] .
J cerely~tQ
forDeb~atts .
Groundwater Protection Unit Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Mark Dewhirst, POA -1321 Brighton Darn Rd., Brookeville, MD 20833
Pennit File WI070024 0
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Rale igh , North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterguality.om
An Equal Opportunity I Affirmative Action Employer
NirthCarolina
Jvaturatlu
PERMIT NAME/OWNERSHIP ORANGE
Any changes made to this form will malt in the application being %IENfVuW ��LI nSFORM MAY BEM DOCCPIED FOR USE. AS ANORIGINAL)rreturn.,VEI Q
�. RLSIUIRE113 ITLAtfi Aquifer Frvt n Section
3. Submit one original of the completed and appropriately executed Permit NnrneJOwuership Change
Form. for a change ofowner'ship, the certification must be signed by both the current permit holder and the
new applicant. or D. name change only, the certification must be signed by the applicant.
2. Provide legal documentation c the tran fifer or ownership (such as a contraet, deed, article of
incorporation, etr.) t'ar ownership changes.
3. Change of Ownership Applications for Himtieawrtcrs A ssaciat.irrns (-IOAs) shall include the I IOAs
bylaws, covenants, etc. [1SA D2T .0 L l S(c)]
4. Submit a properly mounted Openttiou and Maintenance Agreement for all Single Flintily Residence
Surface Irrigation permits requesting a change of ownership.
IL CERRE34IT PERMIT INFORKATION ;
1. Permit nturnber: WIO7co2J o
2 Permit holder's name:-G��wL���'•—
Permit's signing official's name and tale:
4. Mailing address!
City_
(Person 'wily responsible for permit)
(title)
15> oi--v c-Le: 1 L (53 3
� i, Stale: %(' dip;
Telephone number: (3.1 :} ) .,'"L ? 2 < Facsimile number: ( ) i 7"r 4
�VE�LU OWN,ERllYAIVIE INFORMATION
UOr
i . This request for a permit change is a result of:
n. Changet in ownership of'prvpariylc4mpany
h. Name change only
c. Other (p Lease explain):
ai n):
urInit.r• 'ot.rnr- trtnnn:V
1

4. Mailing address:
�� I�t
Newaruner s of 33grtrrig ulI"tcta['s Haase £x![} tsC1e:_
(Person legally responsible for pennit)
(title)
]T2 D 13E6coo v l\ie
Cirri: R43 (F'f+e &[.EM I 5i,s.e: A Zip:
•2-C4
Telephone number: (54o) 45 (C25 Facsimile number: ( 54°) 1$,-9971
JV. CERNWKA i' ' Ql`+3
1, Current Permitfees Certification:
I. PlAciLlk e test that this application. for ,ramrJowner eip change has been
reviewed and as accurate and complete to the best of my knowledge. 1 uttdetstatsd that if ail required parts of
this application are not completed and that if all required supporting irtfonnation and attachments are not
included tliis appli ation_package will be reunited as incomplete. I understand I will continue to he
responsible for
wt t: r ipl with cuir&i,t permit until a new permit is issued.
I Signature: _ t r ��'
2, Applicant's Certification:
&a-f( 121 6A1�e; test that this application for name/ownership change ltas been
reviewed and is accurate: and Complete n the best of my knowledge. 1 undetstaud that if all required pang of
this nppliaation are not uomplcted an that if all required supporting information and atttelimenls are not
itir;lude1, this application package will returxred as incomplete.. I further certify that the applictun or any
affiliate lins not been convicted ofan vircntutontal crime, has not abandoned a wastewater facility without
proper closure, does t o standing civil penalty where all appeals have ben exhausted or
abandoned, are on li tt ith_ arfy naive compliance schedule, and do not have any overdue annual Ores
under Rule ZT .01k
Signature:
rate: 4 --a3 --13
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALLSUPPOR1'ING INlrO MAT1ONAND
MATERIALS, SIEOULIi BE SENT TO TIIE .FOLLOWING ADDRESS:
NORTH CAROLINA D11'ARIMENT OFENVIRONivilrNT AND NA€'UItAL RESOURCES
1llV1SION OIL WATER QUALITY
AQUIVER PROTECTION SECTION
Via US.'I'ostut Service
1636 MAIL SERVICE CENTER
1tAr,Et:CM,i ORTH CAROLINA /709-1434
FORM: PNOC: 1/10/2013 Page oft
Via Courier/ Saeeiat TWivetyl
S12 NORTH SALISB'IJJRY ST1(EET
RALEIGti, NORTH CAROL INA276O4

~HA'l'U~UF lN.tJ!A .. llV!-.. W.1!.,LL~'.l;,:,.ll!,L\l.l
Permit Number: Lt'J'o7CD2Li.D
Pennittce Name: l\:ie)flL.3S ~'\.~{-{'\.~-:--
Address: ___ 5--=o'--10-~--'--=-~-=-'HQ/)E~=· "=-..=;;u:...ew __ e::.....,-,_~_,_4..;..·e-'-~--'-"5....!P_fl-_1/_•_-X:t-'f-'-, M-!.""'-l)_AO_;f....._~=--
1
Please chec;k the selection which most clo&ely dosc,·ibes th.e c:r.trrent status of your it,,jeclio.n well system:
1) ~ Well(s) still used for injection activities. or mayb? in the future.
2) D ,w eU(s) not used for inj cctiou but is/are ui;;ed for water supply or other purposes.
3) D Injection disconiinued and: a) 0 WeU(s) temporarily abandoned.
b) □ Well(s) pennanently abandoned
c) D Wc11(s) not abE,odoned
4) C Injection well(s)neverco1utru.cted
C ·c 1 f Nell i
If you cb C<l cd (2). descr.ibe 1he well use (potable water supply, hriga1ion, monitoring, etc), including p· lmping rate and othec
relevant itt o.imation. !
WellA , don c ,
If you che Ired (3)(aJ or(3Xb), deswbc the mei:bod used to abandon ·the injection well (Inchldea descl'iptkm of lww tile well
was se4 fe and tl,e type ~fmateriar used to fill the ,~ell ifpernu:mentlyaba1rdo11ed):
Permit Re; . si o:
If you che kcd (2), (3), or (4) and will not use a well fo1· injection on this site in the future, you. sbould request rescission of the
pemuc. · you wish to rescind the penuit?
0 Yes O No
Cc fficati 11:
•I hereby certify, under pemtlty t,flaw, that I have personally examined and am famitiarwith tbdnfOJ.IDaliott submitted
in thi.q d ment, aud that to the best of qiy know ledge lhe information is lrue, accurate, and compleu:,."
,~ 4k/2o,3
S1gi1ature Date
{VIM:-/-0.i~·h R-9.:'.> 7; Po A
Revfseo 5i05 GW/UfC-00
Rogers, Michael
From:
Sent:
Dawn Stultz [[e-mail])
Friday, April 26, 2013 8:20 AM
To: Rogers, Michael
Subject:
Attachments:
FW: well info for ownership transfer ...
20130423133449743.pdf
Dawn M. Stultz, Broker
E-Pro, Short Sale & Foreclosure Resource Blue Horizon Realty www.InvestinOBX.com
877-667-6865 Office/252-489-8687 Cell
To search for listings:
htt p ://dawnstultz.obxwhere.com /
-----Original Message-----
From: Dawn Stultz [mailto:dawnstultz@embar gmail.com]
Sent: Tuesday, April 23, 2013 2:03 PM
To: '[e-mail]'
Cc: 'Lisa Strydom'
Subject: FW: well info for ownership transfer .••
Hello,
I think you spoke with Mark Dewhirst on behalf of his mother's place at 9717D Camelot Street,
Nags Head, NC 27959.
Here is the transfer paperwork with new owners contact information. Please confirm that you
have received this and let me know if any thing else is needed to complete this transfer.
Dawn M. Stultz, Broker
E-Pro, Short Sale & Foreclosure Resource Blue Horizon Realty www.InvestinOBX.com
877-667-6865 Office/252-489-8687 Cell
To search for listings:
htt p ://dawnstultz.obxwhere.com /
1
NCDENR
North Carolina Department of Environment and Natural Resources- -
Division of Water quality
Beverly Eaves Perdue Charles Wakild, P. E. Dee Freeman
Governor Director Secretary
May 23, 2012
Kenneth and Dolores Dewhirst
500 Stone House Lane
Silver Spring, MD 20905
Subject: Notification of Rule Revisions Affecting
Closed -Loop Geothermal Injection Well Permit Holders
Permit Number: W10700240
Dear Mr_ and Mrs. Dewhirst:
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 abandomnent must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http:llportal.ncdenr.org/weblwq/aps.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone]
Sincerely,
t
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit Fife
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location' 512 N. Salisbury 51., Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet- www.nwvaterooality.o qr
An Equal Oo-ralunily l AF.Srmarve Action Employer
NarthCarolina
Naturally

Permit Number Wl0700240
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facili
Facility Name
Dolores Dewhirst SFR
Location Address
9717-D E Camelot Ln
Nags Head
Owner
Owner Name
Dolores
Dates/Events
NC 27959
Dewhirst
Scheduled
Orig Issue
09/07/11
App Received Draft Initiated Issuance
01/12/12
Central Files: APS_ SWP_
01/27/12
Permit Tracking Slip
Status
Active
Version
1.10
Project Type
Major modification
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Dolores Dewhirst
Owner
500 Stone House Ln
Silver Spring MD 20905
Public Notice Issue
01/20/12
Effective
01/20/12
Expiration
12/31/16
Regulated Activities Req uested/Received Events --=----------------------
Heat Pump Injection RO staff report requested
RO staff report received
Outfall NULL
Waterbody Name Stream Index Number Current Class
01/18/12
01/19/12
Subbasin
Permit Number W10700240
Central Files: APS SWP
01/19/12
Permit Tracking Slip
Program Category Status Pro;;ect Type
Ground Water In review Major modification
Permit Typo Version Permit Classification
Injection Mixed Fluid GSHP Well System (5QM) Individual
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Dolores Dewhirst SFR
Location Address
9717-D E Camelot Ln
Nags Head NC 27959
Owner
Permit Contact Affiliation
Major/Minor Region
Minor Washington
County
Dare
Facility Contact Affiliation
Owner Name
Dolores Dewhirst
Dates/Events
Owner Type
Individual
Owner Affiliation
Dolores Dewhirst
Owner
500 Stone House Ln
Silver Spring
MD 20905
0rlg Issue App Received Drift Initiated
09/07111 01/12/12
Regulated Activities
Scheduled
Issuance
Public Notice I ue
t 20P li
Re ' uested/Received Events
Effective Expi tlo
e2T51A
Heat Pump Injection
Outfall NULL
RO staff report requested
RO staff report received
01/18/12
01/19/12
Waterbody Nome
Stream Index Number Current Claes $ubbasin

' AVA AcDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Dolores Dewhirst
500 Stone House Ln.
Silver Spring, MD 20905
Charles Waklld, P.E.
Director
January 20, 2012
Ref: Issuance of Injection Well Permit WI0700240
Issued to Dolores Dewhirst
Nags Head, Dare County
Dear Ms. Dewhirst:
Dee Freeman
Secretary
In accordance with the application received on January 12, 2012, I am forwarding permit number WI0700240 for the
operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system located at 1917-D East
Camelot Ln., Nags Head, Dare County, NC 27959. This permit shall be effective from the date of issuance until
December 31, 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 Pivision of Water Quality. ·
Please contact me at [phone] or [e-mail] if you have any questions about your permit.
cc: David May, Washington Regional Office
WI0700240 Permit File
Dare County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mall Service Canter, Raleigh, North Carolina 27699-1636
LocaUon: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone] ·
lntemat: www,nwtergyaHty,org
An Equal Opportunity I Affirmative Action Employer
Best Regards,
::::::!::!:G. ff;;:
~~Carolina
/\ltltural/11
NORTH CAROLINA
ENVffiONMENTAL 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
Dolores Dewhirst
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 9717-D East Camelot St., Nags Head,
Dare County, NC 27959 and will be constructed and operated in accordance with the application received
January 12, 2012, and in conformity with the specifications and supporting data submitted, all of which are filed
with the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for operation of an injection well and shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until December 31, 2016, and shall
be subject to the specified conditions and limitations set forth in Parts I through VII hereof.
Permit issued this the 20 th day of January 2012.
Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission.
WI0700240 UIC/5QM Conversion
Version 12/2011
Page I of4
PART I-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the · application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire forthe facility to change ownership, or there is a
narrie 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 permanent
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
I. 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
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.
WI0700240 UIC/5QM Conversion
Version 12/2011
Page2 of4
PART IV -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. 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 RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
WI0700240 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(1i)(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:
WI0700240
Aquifer Protection Section-VIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/5QM Conversion
Version 12/2011
Page 4 of4
Ro gers, Michael
From: Clark, Allen
Sent:
To:
Thursday, January 19, 2012 8:40 AM
Rogers, Michael
Cc: May, David
Subject: RE: WI0700240 Dewhirst
Good Morning Michael,
WaRO does not feel that a pre-permitting inspection is needed.
Thanks,
Allen
-----Original Message-----
From: Rogers, Michael
Sent: Wednesday, January 18, 2012 4:11 PM
To: May, David; Clark, Allen
Subject: FW: WI0700240 Dewhirst
Please find attached a SQM modification. Please let me know if you wish to
conduct a pre-permitting inspection or not.
Thanks
NOTE: On January 6th, 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,
Raleigh, NC 27699-1636). If you need to visit APS staff or review files, please
call or email in advance to ensure availability. Please check the APS website
for updates on office numbers and phone numbers 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 919-807-6406
http://portal.ncdenr.org/web/wg/aps/gwpro/permit-applications#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
-----Original Message-----
1
~rom: Heather Jennings (mailto:[e-mail]]
Sent: Monday, May 07, 2001 6:29 AM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 05.07.2001 06:29:24 (-0400)
Queries to: [e-mail]
2
RA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Charles Wakild, P.E. Dee Freeman
Secretary Director
January 12, 2012
Delores Dewhirst
500 Stone House Lane
Silver Spring, MD 20905
Dear Ms. Dewhirst:
Subject: Acknowledgement of
Application No. WI0700240
Delores Dewhirst 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 January 12, 2012. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Washington Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact Michael Rogers at (919)
807-6704 or [e-mail].
Sincerely,
OLLin A.~
for Debra J. ~';t~
Groundwater Protection Unit Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Tina Stagg -Pinkston Pump & Well, Inc.
Permit File WI0700240
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone] \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity I Affirmative Action Employer
Ni~h Carolina
)Vatttrnl/11
12/29/2011 22:46 12524410639 OBHC PAGE 01
NORTH CAROi .!NA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATJ.ON FOR A PERMIT TO CONSTRUCT OR OPE~TE JN,JECTION WELLS
ln Accordance With the Provisions of ISA 'NCAC 02C .0:200
CLOSED-LOOP MIXED-FLUID GEOTHERMAL INJECTION WELLS
·111ese wells circulate fluids other thon potable water as part of a geothermal heating Md cooling i;yslcm
(check one) _x_ New Application ___ Renewal* Modification
* For renewal~ complete Part~ A·C arid the signature page .
Print nr Type lr/(ormafion and Mail to the Addre.$,t 011 the l,m Page. rllegible Appficatirms Wilf Be Returned A., Incomplete.
DA TE: 8122/11
PERM.IT No.UJ!.01009'jt) (leave blank if New Applicafam)
A. STATUS OF APPLICANT (choose one)
Non-Governinent: Individual Residence X Business/Organlzation __
Cfovemme11t: State Municipal ___ _ County-·-Federal
N
... )
r 1
C->
. w .
B. PERMIT APPLICANT -F'Qr individual residences. list ~~b owner on property deed. For a others;·
stat.e na111e of entity and name of perso1, delegated authority to sign on behalf of the busines:; or agency :
-----=D=el=or~s_pe'""'w"""h=ir,.,,s.t _______________________ _
Mailing Address : _ 5~0""'0'-'S""t.><on""e.._f...,:1-><ol,..,1s.,,e~L,!l:a:!.ln.:,:.e ____________________ _
City: Silver Spring __ State: MD Zip Code: __ io905 County; _______ _
Day Tele No.: 301-3 84-5319 Cell No.:
EMAIL Address:, ________ _,_F_,,·ax2..!...N~oce,.: _____________ _
C. LOCA TIO.N OF' WELL SITE -Where the i1~jection wells are physically located:
(1) Parcel lde11U-ficatio11 Number (PTN) of well site: ___ 0_71807571550 County: _Dare __ _
(2) Phy~ical Address (if different than mailing address): 9717D E.Camelot St
City : Na gs Head State: _NC__ Zip Code: 27959
D. WELL DRILLER INFORMATION
Well Dlilling Contractor's Name: __ ___:.H.;:..;:a:...:.w.:..:,a.,_rd"'-"'C=u=tte=r _________________ _
NC Well Drilling Contractor Ce,tification No.: 3538-A ---~='-'<--''--'----------------
Company Name: Pinlc.~ton Pum p & Well. Inc.
Contact Pcr::-on-'-: ____ ,..IA! tf Sr/t6 6 EMAIL Address TiA1/t,@staggenenzy.com
GJ>ll/1.IIC 5QM llcmiiL Applicnl.ion (Rcvi~ed 1/24/2011)
12/29/2011 22: 45 12524410639 OBHC
PAGE 02
Address: PO Box 15482
City: Chesapeake Zip Code: Z3328-5482
County: City of Chesa;,eake
Office Tele No,: 75'7: 13 939Z Celt No.: Fax No.: 757-421-2108
E. NEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:_ _ Outer Bank ,Heating & Cooling
Contact Petsolt: Brian McDonald
Address: i'O F3ox 1415
City: 9ag5 Itead Zip Code: 27959 State: NC County: Darr
Office Tele No.: _ 252-441-1, 740 Cell No.: Fax No.: 252-441-0639
F. WELL CONSTRUCTION DATA
(1) Number of borings to he constructed*: 3 Depth of each borings (feet): 200
* If existing wurer .supply wells will be rased then pruwth the it?t rmdNruz in item (4) helens.•.
(2) Chemical additives to be used: R.-22
Propylene glycol Ethanol
Other Environol (ether additives will need prior approval bay NCDENR before use)
(3) Type of tubing to be used (copper. PVC, etc): HDPE
(4) Well casing. 1r the wails) will Isle casing then provide the type (steel. PVC, plastic, etc.), diameter. depth.
and extent of casing appearing above ground: None
(5) [Trout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentoniter" X Other (specify)
'• Hy sel¢ckila bclUt !11tc grout, l v, rtnnec is hcrchy rtyuctiIud SO 15A NCAC 2C ,nRS l fd)t 1)(A). which requires a cement type wool.
(h) Grout depth of tubing (reference to land surface): from 0 to 200 (feet)
if well has casing. indicate grout depth: from to (feet)
G. WELL LOCATiONS — Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the infection we11(a). Label ale features cle wh and include a north arrow.
(1) Attach a site -specific map showing the locations of the following:
* Proposed injection wells
* Surface water bodies
* Buildings
* Water supply wells
* Property boundaries
* Septic tanks and associated spray irrigation sites. drain fields, or repair areas
* Existing or potential sources of graundwatcr contamination
(2) Attach a topographic leap of the Area extending 1/4 mile from the injection we11 site that indicates the
i'acility"s location and the map name.
NOTE, In most cases, an aerial photograph of Me properly parcel showing prrperry lines and strucfurev can he
obtained and downloaded, from the applicable county GIS webstie Typically. the properly can be searched by
owner name or address The location of the wells in relation to properly boundaries, houses, septic tanks, outer
SOM Permit Alilierainn (Rm.ris•cd 1124R011)
l'aac 2

12/29/2011 22:46 12524410639 G HC
PAGE 03
wells, etc can them be drawn In try bola Alta, a 'layer' can be selected showing fopogrephfk contours or
elevation data
H. CERTICFICATION (tn be signed as required below or by that parson's authorized agent)
15A NCAC 02C .021 1(b) requires that all peronit applications shall be sighed as foltows:
1. fora corporation: by a responsible corporate officer:
2. For A partnership or sale proprietorship: by a general partner or the proprietor, respectively:
3. for a municipality or a state, federal. or other public agency: by either a principal executive
officer or rankingZ publicly elected official;
4. for ail others. by the well owner (which meansj, ii persons Iipted on the property deed) -
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by tite
applicant that names and authorizes their agent to sign this application on their behalf.
"1 hereby certify. under penalty of law. that 1 Have personally examined and ain familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately rebponsible far 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. 1 agree to construct. operate. maintain. repair. and if applicable. abandon the
injection well and all related appurtenances in accordance with the approved.., pecifkcations and conditions of
the Permit.'
Signature o Property Owr{er/applicant
Delores Dcwhirs;
Print or Type Full Name
Signature of Property Owner/Applicant
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:
DWQ - Aquifer Protection Section
1,636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone].
rnui ;ic 5QM rennin Application tltevisrd I (24/2011)
Page

bc_r4-'‘ g-s 17 57.
5 LAO N. C .
D U
N 5
•
L

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:
HOW►ARO E. CUTTER
Welt Contractor (Individual) Name
PINKSTON WELL & PUMP COMPANY
Well Contractor Company Name
36 BENEFIT ROAD
Street Address
CHESAPEAKE
City or Town
( 757) 418-2036
Area code Phone number
2. WEU.INFORMATION:
WELL CONSTRUCTION PERMIT.
OTHER -ASSOCIATED PERMIT (f ppReame)-SITE WELL ID SO applitablel
VA 23322
State Tip Code
3. WELL USE (Chock Applicable Box): Residential Water Supply CI
DATE DRILLED 9/26/2011
TIME COMPLETED 7.00 PM
AfimO Pm it
4. WELL LOCATION:
CITY: NAGS HEAD comm., DARE
9717-D EAST CAMELOT
(Street Name. Numbers, Community. Subatv>sion, Lot No.. parent, rip Cale)
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
ursope ❑Valley °Flat °Ridge ❑other
LATITUDE 35 '51 • 364.0000 " DMS OR 3x.)040(X)0(XX DD
LONGITUDE 75 " ad • 3EE.0000 " DMS OR 7X.)00ooaoaac DD
Latitude/longitude source: j3PS ['Topographic map
(location of well attest be sham an a USGS topo map andattached to
This form if not using GPS)
5. WELL OWNER
DOLORES DEWHIRST
Owner Name
9717-D EAST CAMELOT
Street Address
NAGS HEAD
City or Town
(301 ) 384-5319
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 3 fffi 200'
NC 27959
State Zip Coda
b. DOES WELL REPLACE EXISTING WELL? YES O NO Mr
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use '+• if Above Top of Casing)
d. TOP OF CASING IS NIA Fr. Above Land Surface'
'Top of rasing terminated atfor below land surface may require
a variance In accordance with 1.5A NCAC 2C .0118.
e. MELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amowtt N/A
g. WATER ZONES (depth):
Top NIA Bohlnrn NIA Top Bottom
Top Bottom Top Bottom_
Top Bottom Top Bottom
Thicicnessl
7. CASING: Depth Diameter Weight Material
Top NIA Botom NIA Ft.
Top Bottom Ft.
Top Bottom Ft
B. GROUT: Depth Material Method
Top 0' Bottom 200' FL BENTONITE PUMPED
Top Bohm Ft
--Tap Bottom - - Ft. -
9. SCREEN: Depth Olarnalttr Slot Site Material
Top NIA Bottum NIA Ft in. in.
Top Bottom FL tn.
Top Bottom Ft ii�. _ in.
10. SANDIGRAVEL PACK:
Depth Size Malarial
Top NIA Bottom N/A Ft.
Top Bottom _ Ft
Top Bottom Ft
11. DRILLING LOG
Top Bottom
0 1200'
Formation Description
NO SAMPLES TAKEN!
I
1 THESE ARE CLOSE LOOP
1 GEOTHERMAL LOOPS.
1 WATER CIRCULATION ONLY.
1
3 HOLES DRILLED TO 200'
I AND GROUTED TO THE TOP.
!. THIS 15 NOT A WATER WELL!
1
1
1
1
12. REMARKS:
CLOSED LOOP GEOTHERMAL WATER CIRCULATION
ONLY!
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.
jj 9/27/2011
SIGNATURE FIED WELCCOFITRACTOR DATE
HOVVARD E "PORKY" CUTTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 a
Rev. 2109

Permit Number
Program Category
Ground Water
Permit Type
WI0700240 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Dolores Dewhirst SFR
Location Address
9717 D E Camelot
Nags Head
Owner
Owner Name
Dolores
Dates/Events
NC 27959
Dewhirst
Scheduled
Orig Issue
09/07/11
App Received Draft Initiated Issuance
09/06/11
Re q ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
09/07/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification·
Individual
Permit Contact Affiliation
Dolores Dewhirst
Owner
500 Stone House Ln
Silver Spring MD
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Dolores Dewhirst
Owner
500 Stone House Ln
Silver Spring
Public Notice Issue
09/07/11
MD
Effective
09/07/11
20905
20905
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Caleen H. Sullins Dee Freeman
Governor Director Secretary
09/07/2011
Dolores Dewhirst
500 Stone House Ln.
Silver Spring, NC 20905
Subject: Acknowledgement of Intent to Construct Type 5QW Injection We System
Permit No. W10700240
9717D E. Camelot St.
Nags head, NC 27959
Dear Ms. Dewhirst:
On 09/06/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl'.
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 1SA 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.Roeerscu ncdenr.e ov if you have any questions.
S't cerely_
for De / acts
Supervi
cc: Washington Regional Office - APS
APS Central Files - Permit No. WI0700240
Dare County Health Dept.
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
1536 Mail Service Center, Raleigh, North Carolina 27699.1536
Location._ 27211 Capital Malayan), Raleigh, North Carolina 276{)4
Phone: [phone] t FAX 1: 914-715.058E. FAX 2' 919-715£O481 Customer Service: 1-877.623.674S
Internet www.namateronality.nrn
An Equal Onporruii;y AtPrmsivs Actor Emolayer-
One
NorthCarolfna
,Nat ratf

Sep 06 11 01:24p
Pinkston Geothermal
757-421-2108 p.1
• Pinkston Pump & Well
• P O Box 15482
Chesapeake, VA 23328
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RECEIVED / DENR 1 DWC
Aqutter Protection Section
SEP 06 2011

Sep G6 11 01 :24p Pinkston Geothermal
·09/03/2011 13:35 12524410639 DBHC
757-421-2108 p.2
PAGE 10
..
vfI01~0
NORTH CAROLINA
DEPARTMENT Of ENVIRONMENT A.ND NATURAL RESOURCES
NO'I'IFICATION OF INTEN'r TO CONSTlllJCT ~ ClpjED-LQOI' GEOT.RERMAL
WATER-QNl.l INJECTION WELL SYSTEM
DATE: •22:u
TYPE sow WELL@
lu Accordam::e With the Provisions cf NCAC Title ISA OlC.0200
Print or o,p. the r~ired infarmalkm and mail n, at/dreu ~n the baa. page.
Well Typt ~•: Does the proposed system circulate potable wa.w, fflb! (.110 additives) in
continuous piping that c:omplcteJy isolates tne fluid from the environment (i.e.
ctosed-lgpj!)?
Ye.. X Continue completing this form.
No __ Do Not complete this fonn. Complete other UJC ap-plication forms for installing
either a SA 7 welt ~-loop woll imting potable water into the aquifer) Qr a SQM well (closed-
loop well oontainins ~ such as R-22, ethanol, or other anti.freeze or corrosion inhibitors).
A. PROPERTY OWN'D{S)fAPPLICANT(S)
Li.~t each Property Owner listed on property deed (if owned by a business or govm,ment ag-ency. state name ct
entity and 1:1 repn:sentative w/authorky tbr signaturt): _ ___,Do~J~om""'""Qew"""'"'""'hi...,' rn""t,,,_ ______ _
(1) Mailing Address: 500 S19ue House Lane
City: Silver Sprjng State: ...}IL Zip Cod~:20905 C_ounty:. ____ _
Home/Office Tele No.: 301 -3&4-53 l 9 Cell No.:
Email Address: W pbsite:
(2) Physical Address of Well Site (if different than above): 97170 £.Camelot
City: Nags Head State: NC Zip Code; ~County: -----=D::ar:.,;e___..
Home/Office Tele No.: ______ ,___ ___ __,.C~elM,l....,N,,,o,,.,_: __ ~-------
B.. AVTBOIUZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own tile subject property,
attach a letter from the property owner aut)1orizing Agent to in5tall and operate U.TC well)
CompanyName: ___________________________ _
Contact Pel'$on.,_: -----~------...-E:..:MA=JmL...,A..,d .... dress._ia..i _________ _
Addre,s; _____________________________ _
City: ________ State:_ Zip Co<k: _____ County : ______ _
Office Tele No.: Cell No .:
Website Address of Company, ifa.ny:. _____________ _
OflVIUIC .SQW Nntifii:alion of ln1cn~ F'orm (R~11iscd lflOOI) RECEIVED I OENR / DWQ
Aquifer Protection Section
SEP 08 2011
Sep G6 11 01 :25p Pinkston Geothermal
,09 /03/201 1 13:35 1252 4410639 OBHC
757-421-2108 p .3
PAGE 11
C. WELL DRILLER INFORMATION
Conipany ~ame: Plakl ta n PUPR Hd WdI. Ille,
Well Driller Contract~r•s Name: __ ___.,H=o="=•...,[d=-Ca=•----------------
NC Contractor Certiftcation No.: ____ .........,l=ffl:~A .. .._ ________________ _
Contact Person: J.2 ;y;q 6TP,{., 0 tMAIL Addtess: lir4ft@.mo eaem:.com
Address: fO b 1$4U
City: Clleqpealg. Slate: ¥.A Zip ~i Z33M412 County: ______ _
':+-"-:). , 3 0 C , . _} -"'1-~) .,· . OfficeT!leNo.: .LJ / L/. ,::J .! ..... 2~'-,~2.c.....-__ Cc:IINo.: J J .JO'-!_ 76?---=•j ___ _
D. HEAT PUMP CON'mACTOll lNJ'Oll.MATION (lfdiffereat1ba "111n)
Company Name: Qpt\11' Jlfnlp HmiD1 a Cootinz
Con~ Person; Brlp Mdlan ■kl E-MAIL Address: _ ___,1bria=·==11.illl:@p_.,,bhe.C::::§!O=r.1!!P!!!.--___ _
Add~s: __ _.POc.=-.Bo""""'x,"'-'J=4,.,..15..___~------------~--------
City: &ti IJMSI Stat~ ___..N...,C...._ __ Z:Tp Code: J7ffl Counly. c.lh=tt""-------
Office Te!e Na.: l fl-441-1740 Cell Ne.~-------~
E. STATUS OIi' APPLICANT
Private~ ....z_
StatJ:
Federal:
Municipal!_
Commercial :
Na1ive American Lands:_
F. INJECTION PROCEDURE (brictli describe how the injec.tion welf(s} wiU be used)
eeoti,enm1 c;wm Loop
G. WELL CONSTRUCTION DATA
(I) Proposed date to be constNcted: _ __..A,_SAP ________ NI.Ul'lber of borings: _ 3
Al)prmtimare depth of each boring (feet):, ___ UMV.__t ____ _
<2) Type ()ftubing to be used (copper, PVC.~}: __ _.BD::m::.R-.. __________ _
(3) Well casing. ls the well(s) wed? (check either(a.) Ya :PL (b.) No below)
(4) Yu ___ ifyeS:, then provide casing infomiation below
Type: _pht8Aized steel _black steel_._ plastic _other(specify)
Casing depth: From ___ to ___ feet (rderenoc 10 land surface)
Casing extends tu above ground ___ inches
(b) No X
(4) Grout [nfo (ms.terial surrounding well casing and/or piping):
(a) Grout type: Neat Cement_ Berrtonite X Olher (specify) _____ _
(b) G~ placemet1t t Pumping X Pre!.sun: __ {)d11!J __
(c) Grout deptt, of tubing'{reference to ta11d surfiice): from 01 to _,!q / _ (feet)
?fwctt has casing, indicate grout depth: from ___ ID ____ (~et)
OPWUIC !QW Noti:ficgtion ofln\ent Fonn (~lied 81'ZOOR) Page 2
Sep 06 11 01:25o Pinkston Geothermal
091012011 13.35 12252441E634
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p,4
PAGE 12
N. INJECTION-Rl ' L ATED 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 !moollurc may provide supplementary
information.
L LOCATION OF WELL(S)
Attach two copies clamps 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 welts) and
any existing well(S) or waste disposal facilities such as septic tanks or drain Melds located within 200 feet of
the gevthernrai heart pump well system. Label ail fees clearly and i rciyde a rxsrth arrow.
I:2} The Site Map must show the subject property in relation to the surrounding area by using at teas! two fixed
re Femme points such as read& stream& andlor highway intersections.
.t. CF41TIFICATION
Note: Thie Permit App ankle a mat he Aligned by each person appesrriag on the
recorded !not property deed_
"l hereby certify, under penalty of law, that I nave personally examined and am familiar with the informaticm
stibmitte4 in this document and all .attachments thereto and thst, bi seri on my inquiry of those individuals
immediately responsible for obtaining said infarmatiost,1 believe that the information is trite, accurate and complete.
1 am aware that there ate significant penalties, including the possibility of tines and imprisonment, for submitting
false information. 1 agree to construct, operate, maintain, repair, and If applicable, abandon the injection well and
all t;efated appurtenances in accordance with the approved specifications and conditions of the Permit,"
Signature of Property OwnertAppf'cant
Dolma riewhirat
Print or Type Full Nxrne and title
S grrah re of property Own kAppiicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name end title
Please return two copies of the convicted Appliicatian package to
North Ctar&iaa DENR-DWQ
AquifcrPrt►tection Section-1;1EC Program
1636 Moil Service Center
Raleigh, NC 27699-1636
Test [phone]
CPt!IUTC sqw tamilleeriee of laFtnt Farm (Fi vired 8f2Q 4)
RECEIVED r DENR 1 DWQ
Aquifer Protection Section
SEP 06 2011

Sep 06111 01:25p
Pinkstvn Geothermal
757-421-2108
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IT t:14.000i AM It war`%4 11-1
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This He•Y+-A day of MA.D. 19 '
d•'.'PUBLIC U

Sep 00 11 01:25p Pinkston Geotherrna!
`/ i tRSt Lames DE ai eei, 1Viigs IT1ea 1, 1+t— 11.)y - uougIC 1VI,it1.iS
757-421-2108
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1fAddress S717 E Camelot St
AIL maps Nags Head, NC 27959
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PAGE 10
09/03/2011 13:35 12524410639 OBHC
NOR.TH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RE&lURCES
NOTMCATION OF INTENT TO CONSTRUCT/.. gpsgn-LOOt GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM
DATE: 1-%2::11
TYPE sow WELL@
ln Accordance With the Provisions ofNCAC Title {SA 02C.0200
l',tnt or typ« the ,.Ired in/ormatior, and mall to adllress cm the~ page.
Well 1'JJ¥ OJ~: Does the proposed system cin:uJate potable water onJ:r (no additives) in
continuous •pipina that completely isolates the fluid from tl1e environment (;,e,
closed-lOOJJ)?
Ye11 X Continue completing this fQffll.
No __ Do Not complete this form. Complete other UJC application forms for installi.ng
either a SA 7 well (Qu&-loop well injocting potable warer into the aquifer) or a SQM well ( closed-
loop well containin1 additives such as R-22, ethanol, or other antifreeze or ~orrosion inhibitors).
A.. '1lOPKRTY OWNER(S)IAPPLICANT(S)
Ust each Property Owner listed on property deed (if owned by a business Ol' government agency, .state name of
entity and a repn:sentatiw w/authority 1br signature): _ __,Do_Jore9=~1&w-.... h=i m""'· =---------
(1) Mailing Address: __ _,,S""'O_,,,O..,.S_to"""n.._e,._.H.,.,ous-"-e-==L=ane..,,.__ _______________ _
City: Silver Spring State: ~ Zip Code:20905 County: ____ _
Home/Office Tele No.: _,3_.Q .... 1--3-=84-....._.53,...!=9 _________ C=e=IJ~N-o...,.: _________ _
Email Address: _____ _,,W,_,e..,.l>..,si=te"--: ________________ _
(2) Physical Address of Well Site (if different than above): 971 70 £.Cam elot
I
City: N39 Head State: NC Zip Code: ~County: ___ D=ar=--e-
Home/Office Tele No.: __________ ___,C...,e""U.,..N~o,.,_,.: _________ _
B. AlITBORJZED AGENT OF OWNER, IF ANY (if the Pennit.Applicant does pot own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UlC well)
Company Name: ___________________________ _
Contect Person,.,_: ____________ ---,jE~MA"""'-',..IL,s.;Ai.a.d..,d.,..rg:1111:1oas;._ _________ _
Address:-------------------------------
City: -·----..-------State:_·_·_ Zip Code: ______ County ~ _______ _
OfficeTeleNo.: ----------------C=e=ll .._N,...o,.,..: _________ _
Website Address of Comp,ny. if any: _____________ _
OPU/\JlC .SQW Nntificalion of Intent Fonn (R~ K/2008) Page I
12524410639 OBHC PAGE 11
09/03/2011 13:35
C. WI.LL DRILLER INFORMATION
Cornpany ~ame: Pl;IIICUq f'gmp 1,id Well. Iu.
Well Driller Contractor's Name: __ __,,H,,,,o="=•:Q,rd~CJl:.=uttu:az-______________ _
NC Contractor Certification No.: -----=3=SJ,...8:..._..A,...___ ________________ _
Contact Person: II Cl f} am-o 6 EMA IL Add,w: lefl@mgeaem,wm
Address; __ _.PO....,,_=Bo...,1,....1,.,,541...,,..,2 ________________ -,--______ _
City: C11t,:11pealcl State: YA Zip Code: 23328:§411 County: _______ _
Office Tele No.: 5 r 4 3 z3 9 '"'".-;...L..9 -=2"----_ Cell No.: 25 7 :J'OCI _ 7 6 9 ~-5 __ _
D. HEAT PUMP CONTRACTOR INll'ORMATION (If differeat 11la114rtller)
Company Name: Qllter Baul Heatin & CQQHnr
Conlac1 Person; Brig MdJgpld E-MAIL Addre!IS: __ b=na=-=·==• ... @obl.....,=L""'co..,.m,.._ ___ _
Address~ PO Bo1 1415
City: NHI Rpd State: ___.N .... C ___ Zip Code: 27ffl County: ~»-~r:cll,!<..... _____ _
Office Tete No.: 252--441-17 40 Cell No.: _______ _
E. STATUS OF APPLICANT
Private: _lL_
Stal.):
Federal:
Municipal:_
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injei;tion well(s} will be used)
Geoth erma l c191e0 Loop
G. WELL CONSTRUCTION DA'l'A
(!} Proposed date to be constructed : _ _..A_SAP_~----Number of borings: _ 3
Approximate depth of each boring (feet): ___ 200_, ____ _
(2) Type oftubing to be used (copper, PVC,~): __ __.HD=-::; .. PE ___________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes 9J: (b.) No below)
(a) Ye1 ___ if ye~ then provide casing infonmmon below
Type: __galvamzed steel _black steel_._ plastic _ other (speeify)
Casing depth: From ___ to ___ feet (n:ference to land surface)
Casing extends to above ground ___ inches
(b) No X
(4) Grout lnfo (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonitl! X Other (specify) _____ _
(b) Oro~ plamt1ent: Pumping X Pressure __ Odle,-__
(c) Grout depth oftubing'-Creference to 1and surface): from 0' to _A 1 _ (feet)
lf weU has cming, indicate grout depth: from ___ to ____ (~t)
GP1.l/U1C !QW Notificltl1111 of lment 'Fonn (Re\lised 8/2008) Pa~2
09/03/2011 13:35 12524410639
08HC
PAGE 12
H. PIJECTIDN-RELATED EQUXPMENT
Attach a diagram slowing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure rosy provide supplementary,
information.
L LOCATION DP WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (cart be drawn) showing: buildings, property Lines, surface water bodies, potential
sources of groundwater contamination and the orientation Gland distances between the proposed well(s) and
any existing welt(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat p mtp well system. Label all rearms 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. assdfor highway intersections.
�. CERT/FICATION
Note: This Permit Appftcation must be (nosed by tads person appearing en the
retarded legal property deed.
"1. hereby certitj+, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and ail attachments thereto and that, based on ray 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. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
Tgnawre of Property Ow erIAppiieant
Dt2i9V3 Dewj1irst
Print or Type Full Name and titte
r-.
Signature of Property Own . App leant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and tide
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 [phone]
OVWUIC SQW 1otrrtciulon of Wert Fort iRovrrzeri U2OD8) Page 3

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that the error of closure as Calculated by latitudes and daparturas is I:10,000; !hat If wa %p��p4d(pd �'SSL`I%.
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Nags Head, NC 27959
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