WI0700273_GEO THERMAL_20120523

NA
NCDENR
North Carolina·oepartment of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
William Tomlinson
Margaret Alifano
4153 Dowdy Lane
Kitty Hawk, NC 27949
Charles Wakild, P. E.
· Director
May 23, 2012
Subject: ___ Notification of Rule Revisions Affecting
____ Closed-Loop Geothermal Injection Well Permit Holders
=-0 -Permit Number: WI0700273
Dear Mr. Tomlinson and Ms. Alifano:
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 ://p ortal.ncdenr.orwweb/wq/a p s.
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,
Eric G. Smith, P .G.
Hydro geologist
cc: VIC Pennit 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.ncwaterquality.org
.t,n Equai Opportunity\ Aifirmative Action Employer
Oue
North Carolina
;Vat11ral!11
Permit Number WI0700273
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facili
Facility Name
William Tomlinson & Margaret Alifano SFR
Location Address
4153 Dowdy Ln
Kitty Hawk
Owner
Owner Name
William
Dates/Events
NC 27949
R Tomlinson
Scheduled
Orig Issue
04/05/12
App Received Draft Initiated Issuance
04/16/12
Central Files: APS_ SWP_
05/01/12
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
William R. Tomlinson
4153 Dowdy Ln
Kitty Hawk NC 27949
Public Notice Issue
04/27/12
Effective
04/27/12
Expiration
03/31/17
Regulated Activities Re quested/Received Events -~---------------------
Heat Pump Injection RO staff report received
RO staff report requested
Outfall NULL
Waterbody Name Stream Index Number Current Class
04/20/12
04/20/12
Subbasin
Permit Number WI0700273
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facjlity Name
William Tomlinson & Margaret Alifano SFR
Location Address
4153 Dowdy Ln
Kitty Hawk
Owner
Owner Name
William
Dates/Events
NC 27949
R Tomlinson
Scheduled
Orig Issue
04/05/12
App Received Draft Initiated Issuance
04/16/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
04/23/12
Permit Tracking Slip
Status Project Type
In review Major modification
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
William R. Tomlinson
4153 Dowdy Ln
Kitty Hawk NC
Public Notice Issue Effective
Re q uested/Received Events
RO staff report requested
RO staff report received
27949
Expiration
04/20/12
04/20/12
Waterbody Name Stream Index Number Current Class Subbasin
,.
MA
MCDENR.
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
William Tomlinson, and Margaret Alifano
4153 Dowdy Ln.
Kitty Hawk, NC 27949
Charles Wakild, P.E.
Director
April 27, 2012
Ref: Issuance oflnjection Well Permit WI0700273
Issued to William Tomlinson, and Margaret Alifano
Kitty Hawk, Dare County
Dear Mr. Tomlinson and Ms. Alifano:
Dee Freeman
Secretary
In accordance with the application received on April 16, 2012, I am forwarding permit number WI0700273 for the
operation of a vertical closed-loop geothennal mixed-fluid heat pump injection well system located at the above
referenced address. This permit shall be effective from the date of issuance until March 31, 2017, and shall be subject to
the conditions and limitations stated therein, including the requirement to install well identification tags as specified
in Part I. Be sure to read the entire permit to ensure that you are aware of all compliance requirements of the permit
Also, please pay special attention to Part V.2. The Permittee shall retain all records of repairs, pressure tests,
maintenance, and other activities needed to maintain normal operating conditions.
In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an application
to renew the permit 120 days prior to its expiration date. This permit is not transferable to any person without prior notice
to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or [e-mail] if you have any questions about your permit.
cc: David May, Washington Regional Office
WI0700273 Permit File
Dare County Environmental Health Dept.
Best Regards,
~ IZ,._~
Michael Rogers, P.;. ~z;:;:;--
Tina Stagg, Pinkston Pump, and Well Company, 636 Benefit Rd., Chesapeake, VA 23322
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: 919-807-€464 I FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity I Affirmative Action Employer
NiWilicarolina
Jvatural/y·
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
William Tomlinson and Margaret Alifano
FOR THE OPERATION OF S (FIVE) 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 4153 Dowdy Ln., Kitty Hawk, Dare
County, NC 27949, and will be constructed and operated in accordance with the application received April 16,
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 I SA 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 March 31, 2017, and shall be
subject to the specified conditions and limitations set forth in Parts I through Vil hereof.
Permit issued this the 27th day of April 2012.
~ Charles Wakild, P.E., Director
\ Division of Water Quality
By Authority of the Environmental Management Commission.
WI0700273 UIC/5QM Conversion
Version 12/2011
Page 1 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 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.
5. In the event that there are multiple wells with separate clusters, one well identification tag per 'cluster' of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
PART II-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity .
3. The issuance of this permit shall not relieve the 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.
WI0700273 UIC/SQM Conversion
Version 12/2011
Page 2 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.
WI0700273 UIC/5QM Conversion
Version 12/2011
Page 3 of4
PART VII-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part VII (1) and (2) (G) shall be submitted to:
WI0700273
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
163 6 Mail Service Center
Raleigh, NC 27699-1636
UIC/5QM Conversion
Version 12/2011
Page 4 of4
Ro gers , Michael
From:
Sent:
To:
Cc:
May, David
Friday, April 20, 2012 4:49 PM
Rogers, Michael
Clark, Allen
Subject: RE: WI 0700273 Tomlinson and Alifano geothermal
Michael,
Our office doesn't wish to do a pre-inspection.
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: david.ma y@ ncdenr.gov
htt p ://p ortal.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.
-----Original Message-----
From: Rogers, Michael
Sent: Friday, April 20, 2012 4:45 PM
To: May, David
Subject: FW: WI 0700273 Tomlinson and Alifano geothermal
David-
Attached is a SQM residential application. This site is being converted from SQW
to SQM. Let me know if you wish to conduct a pre-permitting inspection or not.
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 919-807-6406
1
http://portal.ncdenr.org/web/wq/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-----
From: Michael Rogers [mailto:[e-mail] ]
Sent: Friday, April 20, 2012 4:35 PM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 04.20.2012 16:35:16 (-0400)
Queries to: [e-mail]
2
A.VA NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
William Tomlinson
Margaret Alifano
4153 Dowdy Lane
Kitty Hawk, NC 27949
Dear William & Margaret:
Charles Wakild, P.E. Dee Freeman
Secretary Director
April 17, 2012
Subject: Acknowledgement of
Application No. WI0700273
William Tomlinson & Margaret
Alifaon SFR
Injection Mixed Fluid GSHP
Well (SQM) System
Dare County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
·doctunentation received on April 16, 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 [phone] or [e-mail].
Sincerely,
o~~·&Ovle
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Tina Stagg -Pinkston Pump & Well Co., Inc.
Mark Burbic -Outer Banlcs Heating & Cooling
Permit File Wl0700273
AQUIFER PROTECTION SECTION
1636 Mail Seivice Cente r, Raleigh , North Carolina 27699-1636
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
Internet: www.ncwaterguallty.org
An Equal Opportunity I Affirmative Action Employer
.:One ........... ::.
N~. o . hCarolina .... ··i .. -~i · .. . . . . 'tl . Ut.'tl . . -. . . . . . . ...... ····•-... ru .
03/18/2012 04:02 12524410639
RBHC
PAGE 02
p i .
?.1
NORTH CAROLiNA DEPARTMENT OF ENViRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE Av3EC ION WELLS
in Accordance With the Provisions of 1 5A NCAC 02C .0200
CLOSED -LOOP MIXED -FLUID GEOTHERMAL INJECTION WELLS
These wells circulate fluis oilier than potable water- as part of a geothermal heating and cooling system
(check one) ./ New Application Renewal* Modification
For renewals complete Parts A-C and the signature page.
Prilti nr Tj pe Will -Tertian and Mail to Mc Address an the Last Page. Illegible Applications Will Ce Returned As Incomplete.
DATE: �ij. / 02 . zn /GZ
f n
PERMIT NO. 4J /')- ! 00 G7-7f I (leave blank if New A.ppiication)
A. STATUS OF APPLICANT (choose: one)
Non- iovenmrertt: individual Residence d: Btrsiness/Orgsnization
Government: State Municipal County Federal
B. PERMIT A. 'PLICAIYT: - For individual residences, list each, owner on property deed. For all others,
state name of entity and +rains of perSan delegated authority to sign on behalf of the lushness or agency:
k�►G�t4 % 2 - TBIVUASaij
ice ekt- M - jii7111442
Mailing Address: tits-3 £ 4? V 4A"1 _
City: t1 gkelk., Stale:At- Zip de:?-79Y9 County 11
Day Tele No.:, 01.6/ — ',j Y'i Celi No.:
EMA IL Address: Fax No.'
C. LOCATION OF WELL SITE - Where the injection wells are physically located
(1) Parcel Identifitation Number (PIN) of well site:' PJ b'f rV. County-
(2) Physical Address (if different than nailing address): _
City: State: NC Zip Code:
D. WELL DR1tLLE R INFORMATION
Well Drilling Contractor's Narne: .tames Maupin
NC Well Drilling Contrtictor Certification No.: #3517A
Company Name: Pinkstvn Pump and Well Co., Inc. tla Pinksten Geothermal
RECEIVEDIDENPJDWQ
APR 16 Zu
Aquifer Protection Section
Contact Person : Tina Stagg WAIL Address: tinaP,,singgenergy.cnm
Address: 636 Benefit Rd.
City: Chesapeake Zip Code: 23322 State: VA County: _Chesapeake
Office Tvle No.: 757-438-9392 Cell No.: 757-43$-9392 Fax No.: 757-421-2108
r;ri inyiu 5QJM l'tr+ri Ariplieniiml (Revised 112412IU I P7ge I

03/18/2012 04:02 12524410639 OBHC PAGE 03
E.
F.
HEAT i'UMP ·c:oNtRA.ctq1U1'jfORl~j\TION (if different than driller)
Company Name:~ /lowf'; Flf!I.!.,~ tft I e1Qt,,1,J(,
Contact Person: ~e/_ if( 4,6 /c,,. E.MA IL Add1·es_s,..,_: ________ _
Address: t o. ffi~J,__.C/LL:(J~---------~-::;,.---~--
City; .JLH-5 t/D,IJ~_ Zip Code: J7f.Jf Sta.teA£... County: -=-/)4/lt-----=---
Office Tete No.:dft -'f 'I( -l.7Yo Cell No.: _______ Fax No .. ~-Y'tl-4:I<;
WELL CONSTRUCTION DATA
(I) Number of borings to be con~tructed"': .!J Depth of each boring (feet):_ 200 ____ _
"' (f exisOng waler .\·upply well ... w;ll he u,,;ed then pmvide lhe in.fin711c1lio11 in item (4) below .
(2) Chemical additives to be used: R-22 ___ Propylene glycol ___ ~thanol
Other_ GEO SAFE ______ (other additives will need pri(')r approval by NCDENR before use)
(3) Type of tubing to be ui;ed (copper, PVC. etc): _ RDPE _____________ _
(4) Wet! ca!'ing. Jfthe well(s) wilt use casing then provide the D'...P.e. (steel, PVC. plastic. etc.). diameJ~~-depth.
and extent of ca1-ing appearing above ground; not.ailing -geothennal closed loop
(5) Grout (mateiial surroU11ding well cc1:si1,g and/or piping):
(a) Grout type : Cement__ Bentonite"'"' ___ Other (specify)--:,..,...,.----,-----
~• By ~Cklc!ing beoronitc ,-m,ul a variance is hereby rcquc~hltl to J 5A NCAC 2C .02 J J(d)I T)(J\). which retJllirl:$ ;i i;cmcnt tyre grout.
(b) Grout depth of tubing (reference to land surface): from ____ to ____ (feet)
lfwell h~ casing, indicate grout depth: from ____ to (feet)
G. WELL LOCATIONS -Maps must be scaled ot otherwise accurately indicate distance:.; imd orientations uf
featL1res l(ltatcd within 1000 feel of the injection well(s). Label all features clearl y and includ~ a north arrow .
(I) Attach a site-specific map showing the locations of the following:
"' Propl)!,ed injection wells * Buildings • Property boundaries
"' Surface water bodies * Water supply wells
* Seplic tanks and associated spray i1Tigation sites. drain fields. or r¢pair areas
• Existing or pote11tial soul'ccs of groundwater contamination
(2) Attach a topographic map of the are:a extending 1/4 mile frcm, the injection well :;itc that indicate~ the
facility's location and the map name.
NO.TE: .l,1 most case.f, an 1terit1I phoUJgrt1pl1 oftbe property pa.reel sl1nwin.g propertJI lint!$ a11d .ftructure.r; can be
<1bl4inetf. tmd dawnlntrded from lhe appllcahle county G/S web.me. T'J,pically, U,e property can be .renrchtd by
m11ner ntrme ,,, a.ddr~~ The location 11/ tl,e well$ in relation to properly bmmdarle.v, houses, septic tank.f, otl,er
,..,e1,.,, etc. can then be drawn in by ltmul. Also, a 'la_ver' crua be ,eleded shnwing topogrt1phk conto11.n ,,,
elevalio11 data.
CiPl.1/UlC 5QM Pe1111it ApplicRticm (R~\•ised 1/2.412011)
03/10/2012 04:02 12524410639 OBF-IC PAGE 04
H. CERTIFICATION (to he signed ss required below or by thtat person-5 authorized agent)
15A NCAC 02C .021 I(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer
2- for a pa1tnership or sole proprietorship! by a general partner or the proprietor, respectively;
3. for n. municipality or a state, federal, or other puhlic agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which Means all persons listed on the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application an their behalf.
"F hereby certify, tinder penalty of law. that 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, haled on my inquiry of those indiv'dua1s
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 irprisonment,
for submitting false information. 1 agree to construct. operate. maintain. repair, and if applicable. abandon the
infection well and all related appurtenances in accordance with the approved specifications and conditions of
the f ermit...
Signature of Prt petty tjwner/Applicant ,
Nriji 1.Z4940t-i- j . 444Sar.
Print or Type Full Name
am-L-711 . at.;
Signature o roperty Owner/Applicant
MOt -ct.rd iM• Lj_fOVO
Print or T ‘pgiFilll 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
1636 _Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED/DENNWO
APR 1 6
Aquifer Protection Section
apt rn lIC 5QM Permit Anpti(a,ion (Revicd 1/24/20 I i 1 prgc .

Permit Number
W10700273 V
Central Files: APS SWP
04/05/12
Permit Tracking Slip
Program Category
Ground Water
IJ jeLtiUi1 VlratelCol uyr VVeeit ?s.eso • 5 Vdj
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
William Tomlinson & Margaret Alifano SFR
Location Address
4153 Dowdy Ln
Kitty Hawk NC 27949
Owner
Owner Name
Wiliiarn
Dates (Events
Status Project Type
Active New Project
Permit Contact Affiliation
Tina Stagg
Driller Well
PO Box 15482
Chesapeake VA 233285482
Major/Minor Region
Minor Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
R Tomlinson Owner Affiliation
William R. Tomlinson
Orig issue App Received Draft initiated
04/05/12 03/21/12
Regulated Activities
Scheduled
Issuance
Heat Pump Injection
Outfall NULL
Woeh rbody Name
4153 Dowdy Ln
Kitty Hawk
NC 27949
Public Notice issue Effective
04/05/12 04/05/12
Expiration
Stream Index Number Current Class Subbasin

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water O',RliIv
April 5, 2012
William Tomlinson
M argaret Alifano
4153 Dowdy Lane
Kitty Hawk, NC 27949
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0700273
l 1 3 Dowd:, .:ri{'., :ti i} f +, I lilwk, NC ' "N,1q
1111 diotu �.�.
On March 21, 2012, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-Ioop water -only.
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 far this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
P3easn contactA4ixre 'Rogers at (919 807-6406 of ATichael,Rogors�a`7J,.rcdin .pnv if you have any q,iestions
Sincerely,
for Debra W
Supervisor
cc: Washington Regional Office - APS
APS Central Files - Permit No. W10700273
Dare County Health Dept
Pinkstutl Pump and Weil Co (Tina Stagg)
Outer Banks Heating and Cooling (Mark Burble)
AC}UIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27804
Pone: 919.807-6464 l FAX: [phone]
Internet wuw,ncvraterauaitv.org
An Egad Opportunity Affinnalue Arlon Employer
One
NorthCaroxina
atrralli

03/18/2012 04:02 12524410639 OBHC
. NORTH CAROLINA DEPARTMENT OF ENVJRONMBN1" AND NATURAL RESOURCES
NOTIF.T.CA TION OF INTENT TO CONSTRUCT OR OPERATE JN,JECTIO~ WELLS
In Accordance With the Pr(lvi:;ions of 15A NC/\C 02C .0200
CLOSED-LOOP WATER-ONLY GEOTH ERMAL INJECTION WELLS
These wells circulate potable water (Inly as part ofa geothermal heilting and cooling system.
These wells are "permitted by rule'' and do not require an individual permit when they arc constructed in
ar,cordance with the rules of 1 !'iA NCAC 02C .0200 iind thi~ Notice i~ submitted prior to construction.
Print,,,. Type lnfol'motirm and Mo;/ lei fhe Addre.'i.t rm the lust T'age.
PAGE 05
DATE: __,.3_,_-__./'---#-9 __ . 20~ PERMIT NO. \NCO 1 oo a 'l3 (to be filled in hy DWQ)
A.. ST A TUS OF WELL OWNJR (choose one)
Non-Government: lndivid1.1al Ree-ide11ce _x_ Business/Organization __
Government: State Municipal __ _ Count}' __ Federal
D, WELL OWNE:8 -For individual residence:,. li~t each owner on property deed. For all others. state name of
entity and name of pel'$on delegated authority to sign on behalf of the businE:$S or agency:
__ IVIUI~ 12. · TPIA/4,-16....._fJ_,v _______________ _
~'Lr A1. ffit;u.,,I)
Mailit1g Address: Y/J-3 J/ol.t.11) Y fAII/€
City: J;.!4 &:'L State: U:-Zip Code: "1 2 'ti. __ County: /)Aec,. __
Day Tele No.: _,J._Ji.. -.'),(, l -\/,J . Ye/ Cell No.:
EMAILA.ddress: _____________ """r:_..a:,.._:t ""'N ""'o .:..:...: ____________ _
c. J..OCATiON' oir w.tu:sttE-Where the i11jection wells are physically localed:
(I) Parcel ldenLiftcation Number (PtN) of wel -1 sitc:.9l.'-.~_i '/ 7.S-S!-74/ County: /J4.Jl-,t,
(2) Phy.sic~! Address (if different than mailing addre:.-s): ______________ _
City:-------~------State: NC Zip Code : ________ _
D. W.ELL .ORlLLER .INFORMATION
Well Drilling C.:ontractor•:; Name: James Maupin
Well D,·ming Contractor Certification No.: #J5t.7A
Company Name: Pinkston Pump nnd Well Co., Inc. t/a Piakston G~othnmnl
RECEIVED/DENR/DWQ
MAR 2 1 2012
Contact Person; Tina Stagg
I\Jdre._c;!-: 636 Benefit Rd.
!-:MAIL Address: [e-mail] Aquifer Protection Section
City: Chesapeake Zip Code : 23322 State: VA
omce Tele No.: 757-438-9392 Cell No .: 757-438-9392
(il't l/lJIC SQW N11lifil:a1i,1n (Revi~e<I .1111.11201 I)
County: Chesapeake
Fax No.: 757-421-.2108
03/18/2012 04:02 12524410639 OBHC PAGE 06
E.
F.
UAT Pl.IMP CONTRACT.OR INFOB.MATtON (if different than driller)
Con1pa1,y Name : (Ju.:,re_ JM.IS l/,f,471,-J(i A-M:d Cl)~t;, .
Co11tact. Pe'Ro11~/J_~,AJ::,, EMAIL /\d_d.rcss :ftk • /Ju ,eJ,"-~d,/..~ · c.,.-._
Address: J!O. ~~
City: ~l(J ___ Zip Code: .1:79'/J State~ County: _/)IIIIJ,,____ ______ _
Office Tele N(l .: _Jn_-W/-/7'111 Cell No.: _______ f._a.x No.-):r2--YY/-fl{,1f
WELL CONSTRUCTION DATA £
(I) Numher of borings to be constructed"': ---~---Depth of each boring (fcet): __ 200
"' (lexi.~tinr.. water .,unplv wells M1ill be us.,ed then provide tl1e i'l'l:fim11ahrm in item (4) below,
(2) Type nftubing to be used (steel. PVC. etc): __ HDPF, ___________ _
(3) Well casing. If the wcll(s) will L•se casing then rrovide the tvpe (steel. PVC. etc.), diameter, dep_tJ1.
and extent of casing appearing above ground : _ No casing-geothermal dosed loop
{ 4) Grout (material surrounding well casing and/or piping): Closed loo p -not a water supply
(a) C.,roul type: Cement__ Ac1,to11ilc*"' __ Other (specify) _______ _
"" 13y sclcc1in~ hcnlnnilc i;rnul a ,·o!innce i~ hcrc:l:ly rcquc~l!!d In 1 SA NCAC 2C .0213((1)( I)(/\). which requires a cement lypc ~ront,
(b) Grout depth of tubing (ref-et·cncc to land surface); from __a_ ___ to Z .0::) (feet)
If well has ca$i1,g. indicate grout depth ; from ____ to ____ (feet)
G. WELL LOCATIONS-Maps must be scaled or otherwise accmately indicate distance~ and orientations of
features located within IO00 feet of the injection well(s). Label all fcat_µ_i:_es clearl y and include a nortlu1.rrow .
(1) Attach a sife-~pedfic niap showing the locations of the foll,lwi11g :
"' Proposed injection wells
+ Surface wa.t£r bodiet1
• Buildings * Properly boundaries
"' Water supply wells
* s·eptic tanki; and associated spray irrigation ~ltcs, drain fields, or repair area.$
* Existing or potential sources of groundwater c(lntami11ation
(2) Attach a topographic map of the area extending 1/4 mile from the i11_iectio11 we[! site that. indicates the
facility's location and the map name .
NO TE: In nwst caires, tui aerial pl1otograpl1 of tire property parcel .'rho111big property line:, amt ltrll.dure., can be
obtained and dow,rloaded from tlle applicable co11.11ty G/S website. Ty_pically, tl1e prnpef1JJ ca11 be sea.rc.hed b.v
mf!1ttr na,,,e or addresi. Tl,e locntlo11 of the wells in relation to property boundarleJ, laouse.'i, .,eptic tank.t, ntlter
wells, etc. can tlien be drawn in ~•' l111nd. AL'io, a 'layer' cnn be St!kcted sllm.,btg topogrnphk c11Htour, or
elnnlin11 data.
CrPlJ/IJIC SQW Nolilkalion (Revi~ed 3/18/2011)
03/1B12012 e4:02 12524410639 ❑BIHC PAGE 07
H. CERT.IFICATION (to be signed as required below or by that person's authorized agent)
15A NCA.0 U2C .021 I(b) requires that all permit applications shall be signed as iollows •
I. fair a corporation: by a responsible corporate officer:
2. for a partners -hip or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other publicagency: by either a principal executive
officer or ranking publicly elected official;
4. for all others; by the well owner (which means all_persons listed on the Property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"1 hereby certify, under penalty of law. that 1 hove 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 inforration is true. accurate and
complete. I am aware that there are sigriiiicant penalties. including the possibility of fines and imprisunlnent.
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 specifications and conditions of
the Permit."
1oaturedf fro er�y pwner/Applicant
Print or type Full:Name
1 aetiifk444
Signature o Property OwnerlApplleant
Mar [ + M. IA Lit
Print or TytT& Full Name
Signature of Authosized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED/DEW/CN
MAR 2 ?
Aquifer P,wectiort
CWFIJ! UTC 4pw Vm1tiCStIo i (Revised 3/ I R/)RI I)
Pogo 3

03/18/2012 21:52 12524410639
OBHC
PAGE 02
oo+rv+r u+
SITE -
3
+w ur
VIa Nirf MAP
N1'S
GC 0.71-61-0V4-1-2Cabiu
fit" 5CC (#
fl A
(c) 2.vo Irr
�s
Fu►a.�
74' AEC
315' C,A,V.A .
■re
o'
N.N% - \ Z� ,tom_ �� �IN 1NI\ Z �N.N. N.. -tiNN-
Tn �s le -cm/. H ask
ApprcE� r . • 1d
f`li,1111i—
t'
M1 Q'39'49-E
DOWDY LANE
(60'R/W)
ASPHALT ROADWAY
Halo NAB 71.041
SET IN cane. • o R
s001
C1
C2
RADIUS
4-50.00'
720.00
LENGTH
14.55'
5.20'
CFIORO
14.01'
5.20'
- REARING
N 19•0.3'44'E
N10O52' 14 "E
1NF
•
CDNC DRIVE
0.6' Mau PL
SJ6 1RF
OS BELOW FC
i![ .$W TO
N15'0
Pk1NO.
'm. En L+r
LOW.
oate.WM.
• TATEP "IMP
• UTILLS. PED.
!C FI#lsStr MADE
✓ W RMMT OF VrAr
MS NOT TO SCALE
• 1IVOIJ I OUALOANC J►E
-THIS SURVEY DEPOTS !141S SITE
'AS eurtr
--PROPERTY 15 LOCATED IN A FIRM.
ZONE AgE11008JECT 10 LSIMGE Ere F.E.M A.)
PAWL 37;O9DAS5VEN 9RO/E - ELF.E.-a]•
-AREA-15.954sq.ft,(CO0RD)
COVERED AREA -3,817sq.0..(24
COVERED AREA IN A C(8,4534q.t.)
..1.298mq.R,(1 5511)
-PaF. empiric UNES PER CURRENT
CONNING •
-DARE CO. PINT. 0865(o60 47 4790
(Gib] OOPIDY LANE)
REV• /0 4/11 - AEC/TAMA%PANE1.

.. 03/18/2012 04:02 12524410639 OBHC PAGE 05
NORTH CAROLJNA DEPARTMENT Of tNVIRONMEN1" AND NATURAL RESOURCES
NOTIFICATION OF J.NTENT TO CONSTRUCT OR OPERATE JN,JECTIO~ WELLS
In Accordance With the Pnwisi(lns of 1 SA NCAC 02C .0200
CLOSED·LOOP WATER•ONL Y GEOTHERMAL INJECTION WELLS
These wells cin:ulatc potable water Qnly as part of a geothennal heating and cooling sy$tem.
These wells are "permitted by rule'' and do not require an individual pcnnit when they arc constructed in
acCQrdance with the rules of 15A NCAC 02C .0200 and thi5 Notice i~ submitted J)rior to construction.
Print ,,r Type /nformotfon and Moil It• the Addreu rm lhe Lu..~ flo,if!.
~
C:
at ....
l ~ o· ::,
g>
a
DATE: _..,3"----..L../9 ____ . 20 / ;i PERMIT NO. ________ (to be filled in hy DWQ)
A. STATUS OF WELL OWNER (choose one)
B.
Non-Government: Individual Residence _x_ 8usilu?s.o;JOrganization __
Government: State M\lnicipal __ County __ Federal
WELL OWN.Ell -For individual resiclences. li!lt each owner on property deed. For all others. stale name of
entity and name of person delegated authority to sign on behalf of the b~15ines.s or agency:
__ IUIUI 4,/111. E. · lQM/.,f,-J6tPJ
~c.r Af. ffi/A,µ~
Mailing Address: Y/J-3 ~I) Y fAlv£
City: ..Iii!, !4--:l_
OayTeleNo.: }-S,..--'-<,l-
State: J1C.. Zip Code: '-19 'tt_ __ County: /)Al!t:,
'CJ.Vl/ Cell No.:
EMAILAdd,-e..~: _____________ --'-'ax=N:...:.o"".'-'---: ____________ _
C. LOCATioN· OFWEU:sttE-Where the i~jcction wells are physically located:
(I) P;Ua:I ldenli ficatinn Number (PIN) of wel I site: -~j '/ 7.rP?'-/ C<iunty: ~
(2) Physical Addrest: (i r different than mailing address): ______________ _
City: ________________ State:~ Zip Code: ________ _
D. WELL DR1LLER INFORMATION
Well Drilling Contractor•s Name: James Mllupio
Well D1iJli11g Contractor Certification ~~~'iJ51.7A
Company Name: Pinkston Pump and Wen Co .• Inc. t/a Pinkston Geotbermal
Contact Peraon; Tioa Stagg
Addre..c:s: 636 Benefit Rd.
1-:.MA II. Address: tina@stoggeneY"gy.CIJII\
City: Che!!apeakc Zip CQde : 23311 State: VA
Office Tele No.: 757-438-93,2 Cell N<1.: 757-438-9391
GPI 1/UIC SQW N"lifi,:al!llll (Re-.iH<I 3/1 tl/21111 J
Colmty: Cbcsape11k.e
fax No.: 757-42.1-2108
::0 m
0
~ m
J> ~ .::::0
b:) ~ 00
"' m
c::::, z
N i 0
03/18/2012 04:02 12524410639 OBHC PAGE 06
E.
r.
RECEIVED/DENR/OWQ
BEAT PUMP CON'tltACTDit tNFOllMATlON (lf different than driller} MAR 2 8 2012
Company Name: /)tA,TrL JA4.f ~' ,A:!'4 0,QUrl&, Jinn1fl1If mlecUtJJ 1 Se t on
Contact PCR<_ln~~'/C, EMA IL /\d_dJcss:"4k • ·01.__P ____ ----"~""""",gJ.,..J. ,..~ • ....,
Address: J!O. ~ k,,..mr '
City: ..Abft_ /iM Zip Code: ,l;-,t'(fJ Statc,-1,t, Cou1ny: __,/k&,:c....;;.......::..... ____ _
Office Tele N<1.: -~-W/ -/7VII Cell No.: --~-----fa."'-No.;JrZ-YY/-t/6,~f
WELL CONSTRUCTION J>ATA
{I) Number of borings to be constructedtt: b Depth of each b(lring (fcet): __ 200, ___ ~-,--
. "' (f exisfir,p, water !iu.pplv well5 will be llttd then pr<Mde the infimnatfrm in ifem (4) below.
(2) Tyr,e nftubing to be u..~ (steel.:PvC. etc): HDPE P '1::.-L/7 10
(3). Well casing. If the wcll(s) wilt use ca~ing then provide the~ (steel. PVC. etc.), dirunete1-, ~-
and ~ of casing appearing above ground: _ No Hsing -geothermRI closed loop
?!f,O-r\k"--IY\4 (]¢~ 4flp
( 4) Ci rout (matvial surroundi11g well casing and/or piping): Closed loop -not a water supply
(a) C.iroul type: Cement_·__ Rentonitc*"' __ Other (,pl.':cify) __, __ --,-___ _
u ay scler.1ing bc:nlf\nile !,!l'11ul o ~wnce is hcrclly rc'll•~~,cc1 kl I SA NCAC 2C .Q2l 3(dl( l)f A). whidi requires a cement l)•pc srnnr,
(b) Grout depth oftubing (reference ta land surface): ii'oin S.Af_ to ~00 (feel)
If well has casing. intlicate grout depth: from ___ to ____ (feet)
G. WELL LOCATIONS-Maps must be scaled or otherwise accurately indicate di:;t,nce.., and orientations of
features located within I 000 tee:t Qf li1t: injection well(s). Label all rea~u_rel> clearly and indude a nort1,_a,rrow.
( 1) Attach a site,;~pecl"fic mai, showing the locations of the folll.lwing,:
"' Proposed injection wells • Buildings • Pr(li,erLy boundaries
• Surface water bodi~ • Water supply wells
* Septic tanks and associated sprity irrigation sites. drain fields, or repair areas
• Existing or potential sources of groundwater-contamination
(2) Attach a topographic map oithc area extending 1/4 mile from th~ injection well site that indi~ the
facility's location and tlie map name.
NOTE: In mnn cases, n,1 aerial photograph nf th~ pt'tlp~flJ• ptrrcel $/rowbig prape,tJI Hmt.'f anti ~trll.d.11.re.f Cflll be
obtal,,etl and dot111JlotHl14 /rfm, tile applitable COIUl'JI GIS website. T.vplcally, the propaf'tJ) cm, he seo.rch.ed b.v
m11,ie, na•t ,,, add.ten. The location of the wells m relnlion to propeny 1Jo111,,l111ks, houses, septit tllnk.t, ,,,her
wells, ek. can tb.m be tbmt,n in l!JI l1mul. .A!fo, a 'loym-' cm, be stkcud shot11ing tnpngraphk co,,r.oun or
eltffiftinll data.
GPtlllJIC 5QW Nntili~linn (Rev~ed 3/1 $12011)
03/18/2012 04:02 12524410639 OBHC PAGE 07
B.
~
~ ~ 3::
CERTIFICATION (to be signed as required below or by that person's authoritcd agent) -0 l>
~ ~
l 5A NCAC 02C .02 I I (b) req\Jires that all pennit applications shall be signed as follows: g-~
I. far a corporation: by a 1-c..11ponsible corpora1:e officer: ::, ~
2. for a portnel'$hip or sole proprietor$hip: by a general partner or the proprietor, respective I~ f'->
3. for a municipality or a state, federal, or other public agency: by either n principal e;&utive
officer or ranking publicly elected official; g
4. for all others: by the well owner (which means al.I persons listed 01, ~~e propeny deed).
H an authorized •~nt is signing on. behalf of the applicant, then supply a Jetter signed by the
applic:ant that :names and aathorizes their agent to aign this application n.n their behalf .
.. , hereby certify. under penalty af law. that 1 have personally examined and am familiar whh the information
submitted in this document and all :attachments thereto and that. based on. ,ny inquiry of th(lse individuals
immediately responsible for o~ining said information. I believe thaJ the information ii-true. accurate and
complete. I am aware that there are significant penaltic..,;. includ;ng the pos,sibility of fines and imp1iso11111ent.
for submitting false inforMation. I agree to construct. apcrate. maintain. repa.ir. and if applicable. abandon the
injection well and all related appurtenances in accordance with the approved specification$ and conditions of
the Permit:· ~ . /_ _ ..._ tffftl~ . -,-,;:;~
W•C...W,,,.,,... {µ JQ,,,. '-•~~=;.__;::.)~----
Print or T-ype FuU:Nai:ne -~~
.:►':
'l\i~~ ~. IA..Ui.lA.U.4
Signatureo Pro~1erty Owner/Applicant
Mtxv:Q.~~t M. i\Lif tA.t\o
Print or T~ Full Name
Signature of Authorized ~e11t, if any
Print or Type Full Name
Sl1bmit the complete application package to:
DWQ -Aq_uifer Protection Section
1636 Mail Service Center
Ra1eigh, NC 27699-1636
Telephone [phone]
Gl'tl/llTC 5QW Natilication CRcvind 3/18/l0I I) Pa!IC l
:::c p;:
m
~
~ m :z
~ ~
RESIT ENTLAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 3515-A
1. WELL CONTRACTOR:
James Lee r auoin
Well Contractor (Individual) Name
Pinks_ on Welt & o mo Company
Well Contractor Company Name
636 Benefit Road
Street Address
Chesapeake
City or Town
i 757 i 621-0396
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#{if applicable}
SITE WELL ID #f d applicable)
VA 23322
State Zip Code
3. WELL USE (Check Applicable Box): Residential Water Supply D
DATE DRILLED21-22 Mar 12
TIME COMPLETED 1700 AM p PM 11
4. WELL LOCATION:
CITY: Kitty Hawk COUNTY Dare
4153 Dowdy Lane
(Street Name. Numbers, Community. Subrivisinn, Lot No., Parcel. Lp Cade)
TOPOGRAPHIC 1 LAND SETTING: (check appropnale box)
D Slope ❑ VaIEey grFlat ❑Ridge Li Other
LATITUDE 36 ° 3 • 47.6U0o ^ DMS OR 3x.xxxxxxxxx (3D
LONGITUDE 75 " 44 ' 01O DMS OR 7x.xxxxxxxxx OD
Latih,deltongItDde source: litGPS Oropographic map
(location of (yell must be shown on a USGS topo map andattached to
This form 1f not using GPS)
5, WELL OWNER
William R. Tomlinson
Owner Name
41 Dowdy Lane
Street Address
Kitty _Hawk
City or Town
f 252 1 261-4344
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 50200
NC 21949
Slate lip Code
h. DOES WELL REPLACE EXISTING WELL? YES p NO If
c. WATER LEVEL Below Top of Casing: n/a FT.
(Use `+•` if Above Top of Casing)
d, TOP OF CASING 15 n/a FT. Above Land Surface'
\
'Top of casing terminated atlor below land surface may requir
a variance in accordance with 15A NCAC 2C .0118,
e, YIELD (gpm): n/a METHOD OF TEST n/a
f. DISINFECTION: Type n/a Amount nJa
g. WATER ZONES (depth):
Top 20 Bottom 60
Top 145 Bottom 200
Top Bottom
T. CASING: Depth Diameter
Top-4 Bottom 200' Ft, 2/ 314
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top _4 Bottom 200'
Top Bottom Ft.
Top Bottom Ft.
a
.c2
co
se t.;
a ry
Top 90 8ottoradoi—
Top Botlimr'
Tap Bottom
Thickness)
Weight Material
03035 pe-4710
Material
FL Guide Grout
9. SCREEN: Depth Diameter Slot Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
Method
pumped
Material
in_ in.
in. in.
in. in_
10. SANDEGRAVEL PACK
Depth
Tap Botlom Ft.
Top Bottom Ft.
Top Bottom Ft.
Size Material
11. DRILLING LOG
Top Bottom
/5
5 /15
15 /60
60 /90
90 /145
145 /150
150 /200
/
i
Formation Description
topsoil
dark brown peat moss
gray course sand
gray clay
gray sand
pea rock/ hard spot
fine sand &silt mixed
12. REMARKS:
There were 5, 200' dosed Loops water only that were
installed 15 apart
IDO-HEREBY CERTIFYTHATTHIS WELL WAS CONSTRUCTED IN
ACCORDANCE WI 15 • CAC 2C, WELL CONSTRUCTION
STANDAR ti * , AND T . T A ORIr 0 THIS RECORD HAS BEEN
PROVIDED * THE L • N
ry t7 ERTIFI D WELL CO CTO DATE
TEO NAME OF PERSON CON TRUCTING E WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing,
Form GW-la
Rev. 2/09

Pinkston Geothermal
Mar 2612 08:58a
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