WI0700243_GEO THERMAL_20110920

Permit Number
Program Category
Ground Water
Permit Type
WI0700243 I
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit ,
Facility Name
Richard W Quarles Jr. SFR
Location Address
204 Gangplank Rd
New Bern
Owner
Owner Name
Richard
Dates/Events
NC
w
28562
Quarles
Scheduled
Orig Issue
09/20/11
App Received Draft Initiated Issuance
09/19/11
ReC1ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
09/20/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Mike Hadley
Driller Well
102 Middle St
Jacksonville NC
Major/Minor
Minor
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Richard W. Quarles Jr.
Owner
204 Gangplank Rd
New Bern NC
Public Notice Issue
09/20/11
Effective
09/20/11
28546
28562
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
!,_';'A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Richard W. Quarles, Jr.
204 Gangplank Rd.
New Bern, NC 28562
Coleen H. Sullins
Director
09/20/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0700243
· 204 Gangplank Rd.
New Bern, NC 28562
Dear Mr. Quarles:
Dee Freeman
Secretary
On 09/19/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
geothermal injection well system for the operation of a ground-source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a viol_ation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the Craven 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.Rogers@.ncdenr.e ov if you have any questions.
cc: Washington Regional Office -APS
APS Central F ib, -Permit_ o. \\'10 00 2-C
Craven County Health Dept.
_j;r ly, -&i w~
forD~~ tts
Supe~
Mike Hadley (Coastal Geothermal, I 02 Middle St., Jacksonville, NC 28546)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwateraual itv .o rg
An Equal Opportun\y I Affirmaiive Action Employer
Ni¥thcarolina
Jvaturall!f
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONMUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-aW WELL(S)
In Accordance with the provisions of NCAC Title 1 SA: 02C,0200, please
complete this notification and mail to address on the back page (please Print or Type information).
DATE: 15 September 2011
We11 Type Confirmation: does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes - X Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well injecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): Ric Quarles
(1) Mailing Address: 204 Gangplank Road
City; New Bern State: NC Zip Code: 28562 County: Craven
Home/Office Tele No.: 252-635-6290 Cell No.:
Email Address: i�wquarlesit�sudderilink.net Website_
(2) Physical Address of Well Site (if different than above):
City-
Home/Office Teie No.:
State: Zip Code:
County:
S. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person:
Address:
City:
Office Tele No.:
State
Website Address of Company, if any:
GPUIOTC 5Q'W Motif caiion of Intent Foam [Revised 8/2008)
Zip Code:
EMAIL Address:
County:
Cell No.:
RECEIVED 1 DENR 1 DWQ
Aquhr Prot000n Section
SEP 19 2011 PW I

C. WELL DRILLER INFORMATION
Company Name: ___ =C-=-oas=ta=l-'G""'e"""o""th=e=rm=al=----------------------
Well Driller Contractor's Name: ~S=an=fi=o=rd~S~w~e~et=in=g;,..._ _______________ _
NC Contractor Certification No.: 2082 ____________________ _
Contact Person: Mike Hadley EMAIL Address: mhadle y@ bizec.rr.com
Address: I 02 Middle Street
City: Jacksonville Zip Code : 28546 _____ County: Onslow __ _
Office Tele No .: 9=-1"-'0'"""-3"-"5"""3"""'-9'"""'0""""4""""0 _______ Cell No.: 910-376-1100
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:Climate Control Heatin g & Coolin g Co .. Inc.
Contact Person~: -=Dc...=a=le=-W--'-'---"a=lk=e"'-r _______ -=E=MA~=IL~A=d=dr~e=ss=:=dw~al=k=er""'@_..c=l=im=at=e--'c~o=ntr=ol~-i=n=c.=c=om=
Address: 102 Middle Street
City: Jacksonville _____ Zip Code: 28546_ County: Onslow _________ _
Office Tele No.: 910-353-9040 Cell No.: ___ 9_1~0-~3_76_-_05~1~3 ______ _
E. STATUS OF APPLICANT
Private: __ X_
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p Geothermal Heat Transfer Systems
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _S_,e p,_t_em_be_r_2~0_1_1 _______ Number ofborings: ~
Approximate depth of each boring (feet): 250
(2) Type of tubing to be used (copper, PVC, etc): ----------------
( 3) Well casing. Is the well(s) cased? (check either (a .) Yes Q! (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: _galvanized steel __ black steel __ plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite X Other (specify) ____ _
(b) Grout placement: Pumping X Pressure__ Other
(c) Grout depth of tubing (reference to land surface): from _o_· __ to 250 ___ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page2
K INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
1. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or 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, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, 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."
Signature of rope_ Owner/Applicant
Print or Type Full Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED I ❑E NR 1 DIN(
Aquilerprowlion 5e06on
SEP 19 2011
GPUIUIC 5QW Notification of Intent Form (Revised 8/2008) Page 3

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