WI0700260_GEO THERMAL_20120131

Permit Number
Program Category
Ground Water
Permit Type
WI0700260 /
Injection Water Only GSHP Well System (SQW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Donald R Saunders Sr. SFR
Location Address
112 Bowketcher Blvd
Hertford
Owner
Owner Name
Donald
Dates/Events
NC
R
27944
Saunders
Scheduled
Orig Issue
01/31/12
App Received Draft Initiated Issuance
12/09/11
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
01/31/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Jeffrey A. Stagg
Driller Well
636 Benefit Rd
Chesapeake VA
Major/Minor
Minor
Region
Washington
County
Perquimans
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Donald R. Saunders Sr.
Owner
112 Bowketcher Blvd
Hertford NC
Public Notice Issue
01/31/12
Effective
01/31/12
233225482
27944
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
ErA a--.-1 .... __
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Donald R Saunders Sr.
Rita·c Saunders
112. Bowketcher Blvd.
Hertford, NC 27944
Charles Wakild,P.E.
Director
01/31/2012
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0700260
112 Bowketcher Blvd.
Hertford, NC 27944
Dear Mr. Saunders:
Dee Freeman
Secretary
On 12/09/2011, 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 pemtlt 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 .021 l(u)(2). Additionally, you should contact the Perquimans 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 gers @ncdenr.gov if you have any questions. ti ~~)¥{~
Supe~~
cc: Washington Regional Office -APS
APS Central Files -Permit No. WI0'100260 1
Perquimans County Health Dept.
Jeffrey A Stagg (Pinkston Pump & Well Co., Inc., 636 Benefit Rd., Chesapeake, VA 23322)
George Harrell (George_& Co., 105 Beau Pkwy., Elizabeth City, NC 27909)
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.ncwatergualitv.org
An Equal Opportunity \ Affirmative Actlon Employer
/
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Der, 091109:47a Pinkston Geothermal
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757-42 3 -2108 P.1
Pmkston Pump & Well
P 0 Box 15492
Chesapeake, VA 23328
Qlcf- -715--60e-13
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❑ Li omt ❑ For Review ❑ Plus cuxn nee �k 0 Pkmm Rely © Pieria Raffle
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RECEIVED 1 DENR � t7111Q
Aquifer Prolectinn Svdicn
DEC 0 ", 2011
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Dec 09 11 09:47a Pin kston Geothermal
�} 7-421-2108 p.2
NORTH CAROLINA DEPARTMENT OF ENVIROV4ENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT C+ Ik OPTE L: CTION WELLS
1n Accordance With the Provisions of 1-� NCAC 02C .0200
1
CL )SED-LOOP WATER -ONLY GE OTH RMAL INJECTION WELLS
These wells circulate parable water only as peft of a g.:pihermaI heating and cooling system.
These wells are 'petrnitted by rule" and do trot require an indlyY` idual permit when they are constructed in
accordance with the rules of 15A NCAC G2C .0200 and this Notice is submitted prior to construction:.
.E
(� Print or Type fnjorrnarion and Mail to the'4i ress on rho Gast Page.
ifATE: 1 { r r 20 t PERMfF I►i0. `I ----(to 6e filled in by DWQ)
A. STATUS OF WELL OWNER (choose cane)
- Non-Covarn rent: Individual Residence Business/Organization
Goverunem State Municipal ' County Federal
S. WELL OWNER - For individual residences, list each oer on property deed. For all others, state name of
I
entity and name of person delegated authority to sign on hel�alf of the lousiness or agency:
Mailing Address: A to 1 C /rcl�•��/ _ —
City: . fit T r`u rr c� State: &C zi irode- 2A 1'4q County:
Day Tele No.. 15—R- h 3 IS - ;0 frQ Ceti No.: !-Y 4 Ate -;,fe 4Y - ,2- 7 3 --
I
F�%4A]L Address: i!]lax No.:
r
~� C. LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel Identification dumber (PIN) of well site:T` County:
(2) Physical Address (if different than mailing address:
City: _ 1i1 Srato. NC Zip Code:
D. WELL DRILLER INFORMATION
Welt Drilling Contractor's Name: Howard Cutter
Well Drilling Contractor Certification No.: #3538
Company Name: Pinkston Pump and Well Co., Inc. Pa
Contact Person: 3eirrey & Stagg
.E
Address: 6a6 Benefit R& �I
City. Chesapeake Zip Code: 23322 state: A
Office Tele No.- 757-MS-9392 Cell No.: 75741& 2
E
l
G11L`i[JIC SQWi Ttletification (RcOsed Ylgr20r I)
E
Pinkstan Geothermal
Address: tinaCstaggenergy.com
County: Chesapeake
Fax No-: 757-421-2108
Ngr f

Dec 09 11 09A7a
Pinkston Geothermal
757-421-2108
p.3
E.
F.
G.
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HEAT PUW CONTRACTOR INFORMATION (if dhlb nt than driller)
Company Name: _ - cci C_d
i
Contact Per -son: auf J/ _ iLMAiI J+�ddress_
Address: 147 12z�
`f
d 0 � �
City: ���_ c�- �('�— dip Code- �Stat�:�l[.CountY: 7 �l
Office Telc: Ma:� .Z;mod _ Celi Na.: 1v
i�
WELL COPISTRUCTION DATA
(1) Number of barings to be constructed*. _ -7
* Ifexisting water sugi lv wells will br
(2) Type of cubing to be used (steel, PVC, etc): HDP
of each boring (feet): 200
then provide the it farmadPon fn item (4) below.
(3) Well casing. If the well(s) will use casing then p�o:�de tffhe (sleet, PVC, etc,), diameter deptiz,
and extent of casing appearing above ground: _ to a�; geothermal closer! loop
(4) Grout (material surrounding well casing an&or piping).) Closed lore_- not a water supply
(a) Grotrt type: Cement 13entanite*" V_ Other (specify)
" l3y scteatit�g bcntomte VOA variance is hereby requested to II, A PICAC 2C .4213(d)(1)(Ay, wEdch requift-s a cdncnr type grnut.
(b) Grout depth of tubing (reCerence to land surface): from I ' to 2 4) 0 f (feet)
If well has casing, indicate grout detain: from to (feet)
WELL LOCATIONS— Maps must be scaled or otherwise xc urately indicate distances and Mentafions of
features located within 1000 feet of the injection welI(s). Lab _features clearly and imlude a north arrow.
(1 ) attach a site -specific map showing the locations of the following:
* Proposers injection welts ° Sui3dingSi' * Property boundaries
* Surface water bodies * Water supply welts
* Septic tainks and associated spray irrigatin € sites= drain fields, or repair areas
' Lxisting or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 114 mile from the injection well site that indicates the
facility's location and the map name.
I
NOTE: In moist cases, an aerial photograph of the properri parcel showing property lines and structures can be
obtained anrf downfoaded from die applicable county G!S .website Typically, the properly can be searched by
owner name or address. lire location of the wells in rdavi n to prupeM houndarles, houses, septic hmks, other
wells, etc, can then be drawn in by hand. also, a `layer' can be selected showing ropographic conlears or
elevation darn '
GPLiMC SOW Notification (ktevised 3/180011 )
�tcG� F cienn Radial
FA�t
Pie i

Dec 0911 49!48a Rnkston Geothernial 757-421-2108 p,4
CERTIFICATION (to be signed as required below or bM that person's authorized agent)
1 rA NCAC 02C .0211(b) requires that all perm it applict
I. fora corporation_ by a responsible corporate M9
2_ for a partnership or sole proprietorship: by a gei
3_ for a municipality or n state, Federal, or other
officer or ranking publicly elected official;
4. for ali others: by the well o Amer i which means ;
shall be signed as follows:
l partner or the proprietor, respectively,
rlic agency: by either a principal executive
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
" I hereby certify, under- penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto a d 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, 11eluding the nossihility of fines and imp9sontment,
for submitting false information. 1 agree to construct:, operate, maintain, repair, and if applicable, abandon the
in ection well and all related appurtenances in accordance.,Mth the approved specifications and conditions of
the Permit.'
Sigttattire of Pro erty dwrzerfApplicant
Print or Type F Name
,1
I
Sie ature ofProperty Owner/Applicant
Print or Type Full Name
Signature of AudLorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DW¢ - Aquifer Protection Section
1536 Mail Service Q-enter
Raleigh, NC 27599111,53E
Telephone [phone]
I
tiP{Irt1iC 5QW N06FCa60a (rRcv&d 3f I U20 t 1)
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DEC 0 (4- Z011
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Dee 0911 09:48a Pinkston Geothermal 757-421 2106 p.5
I
OON A L D R * B R ITA C.
PERQUlh1ANS COUNTY, NORTH CARO
NEW HOPE TO1VNSH I P
LOT ! ON MAP- OF N'5. FULEOR❑ HEI
RECORDED IN h4AP BOOK PACE
SCALE I 'NCH= 50FEET MARCH SJS
a za 4a as 120 fro
SAL) N DERS
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DEC 4 a 201I
1

NORTH CAROLINA DEPARTMENT OF ENVIRONNENT AND NATURAL RESOURCES
NOTIFICAUON OF INTENT TO CONSTRUCT R OPERATE INJECTION WELLS
In Accordance With the Provisions of 1 rA NCAC 02C .0200
I'
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "Permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this' Notice is submitted prior to construction.
Print or Type Information and Mad to the I ddress on the Last Page.
DATE: ! 1 f r[] 1 , . 20 11 PERMIT No. to he filled in by DWQ)
A. STATUS OF WELL OWNER (choose one) j
Non -Government: Individual Residence Business/Organization
Government: State Municipal County �.— Federal
---�� H. WELL OWNER — For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
Mailing Address: ��/ 1 0U/ t7k 7r-j1xn a�'V
City: State: Zip Code: jAJI 3 y Y County:, G d
Day Tele No.: S - P-9 0 Cell No.: !-+ amp i�*a- H `.L 7 6 3
1
EMAIL Address: ! Fax No.:
i A
C. LOCATION OF WELL SITE — Where the injection wells are physically located: 5��& ' r 5 ��(!�i✓
(1 ) Parcel Identification Number (PIN) of well site: i _____County: _-
(2) Physical Address (if different than mailing address):
City: -- _-.- State: NC Zip Code:
D. WELL DRILLER INFORMATION RECEIVED r DENR f oWQ
Well Drilling Contractor's Name: Howard Cutter Aquifer Protect& SertOn
Well Drilling Contractor Certification No.: #3538 DEC 14 2011
Company Name: 1Pinkston Pump and Well Co., toe. tla Pinkston Geothermal
Contact Person: Jeffrey A. Stagg EMAIL Address: [e-mail]
Andress: 636 Benefit Rd.
City: Chesapeake Zip Code: 23322 State: VA County: Chesapeake
Office Tele No.: 757-438-9392 Cell No.: 757-4I8-2T6 Fax No.: 757421-2148
GFUNIC sQw Notification (Revised 3118/2011) I Page t

F
r"
I[EwAT PUMP CONTRACTOR INFORMATION (if dirterent than driller)
Company Name: -ec , Cad
Contact Person: .lc� EMAIL Address:
Address: 1 U S & .1+1a J
City: C L %Ve-, Zip Code: )V42 State County: V �(��
Office Tele No.) ,<Q �,��F F/ 6 Cell No.: --- - Fax No.:.
1 31IlllfiLl�►f.i k111,1t0IIU3ce17:1111:1
(1) Number of borings to be constructed*: -_ Depth of each boring (feet): 200 •
* If existing water sypj_ l , wells will be rued then provide the information rn item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): iIDPF.
(3) Well casing. 1f the well(s) will use casing then provide', the tape (steel, PVC, etc.), diameter; depth,
and extent of casing appearing above ground: _ No casing - geothermal closed loop
(4) Grout (material surrounding well casing and/or, piping),, Closed lawn - not a water supply
(a) Grout type: Cement gentonite**� ()ther (specify)
*" By selecting bentonite grout, a variance is hereby requLsted to L' A NCAC 2C-o213(d)(1)(A), which requires a cement type gmut-
(b) Grout depth of tubing (reference to land surface): from �� r to (feet)
If well has casing, indicate grout depili: from to (feet)
WELL LOCATIONS - Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s)_ Labdl all features clearly and include a north arrow.
I
(1) Attach a site -specific map showing the locations of- the following:
* Proposed injection wells a Buildingsi Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigating sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/�4 mile from the injection well site that indicates the
facility's location and the map name.
f
NOTE: In most cases, an aerial photograph of the propernr parcel showing property lines and structures can be
obraured and downloaded from the applicable county CIS I webcite. Tpple ally, the property can be searched by
owner name or address. The location of the wells in reladinn to property boundaries, houses, septic tanks, oilier
wells, etc can their be drawn in by hand Also, a 'layer" can be selected showing topographic contours or
elevation data_
I
I
GPUMC SQW Notification (Reviscd 311812011) 1 Page 2

IL
I
CERTIFICATION (to be signed as required below or~ that person's authorized agent)
I
I
15A NCAC 02C .021 l(b) requires that all permit applic~ ions shall be signed as follows:
I. for a corporation: by a responsible corporate offi cer;
2. for a partnership or sole proprietorship: by a geF.!1eral partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other ! ublic agency: by either a principal executive
officer or ranking publicly elected official; j
4. for all others: by the well owner which means a:11 ersons listed on the ro e rtv deed .
i .
H an authorized agent is signing on behalf of the :, pplicant, then supply a letter signed by the
applicant that names and authorizes their agent to sit this application on their behalf.
"I hereby certify, under penalty of law, that I have person , ly examined and am familiar with the information
submitted in this document and all attachments thereto 11 d that, based on my inquiry of those individuals
immediately responsible for obtaining said information, 11 believe that the information is true, accurate and
complete. I am aware that there are significant penalties, i eluding the possibility of fines and imprisonment,
for submitting false information. I agree to construct, ope1 te, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in ac~ordance j'with the approved specifications and conditions of
the Permit." ,
d, i.YL~L--
Signature of Property Owner/Applicant
Oow A-l bl J~ <g 41,t_,,..,Jens c; t,,,.,
Print or Type Ful.l Name
Signature of lerty Owner/ Applicant
Print or Type Full Name
Signature of Autf orized Agent, if any
Print or Type Fu ll Name
I
Submit the complete application package to: I
DWQ -Aquifer Protection Section
1636 Mail Service Senter
Raleigh, NC 27699:01636
Telephone [phone]
GPU/UIC 5QW Notification (Revised 3/18/2011)
RECEIVED/ DENR / DWQ
Aquifer Protection Section
DEC 14 2011
Page3
DONALD R B RITA C. SAU NDERS
PERQUIMANS COUNTY, NORTH • CAROLI NA a
i NEW HOPE TOWNSHIP t.�f�cEQ
LOT I ON MAP -OF N.S. FULFORD HEIRS fl!ltrk
RECORDED IN MAP BOOK PAGE
SCALE I INCH = 5OFEET MARCH 6,1987
p 80' 120 1EeD 20CFEET
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`r RECEIVED I DENR I D
Aquifer Pratsction Sedo
A DEC 14 2011
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