WI0700274_GEO THERMAL_20120417

\ ..
Permit Number WI070027 4
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
] <;.:. ~ o b · Of'
~ t.-(L.f. L{ f
Facility
Facility Name
William & Joan Morgan SFR
Location Address
2036 Martin's Point Rd
Kitty Hawk
Owner
Owner Name
William
Dates/Events
NC
F
27949
Morgan
Scheduled
Orig Issue
04/05/12
App Received Draft Initiated Issuance
04/16/12
Regulated Activities
Heat Pump Inj ection
Outfall NULL
(_,...J / a /J. .. j:::....-Central Files: APS_ SWP_
(
1
LA,,. J ~/. _ 04/17/12
Permit'tracking Slip
Status
In review
Version
%s~
Penn it Contact A
Tina Stagg
Driller Well
PO Box 15482
Chesapeake
Major/Minor
Minor
Project Type
Major modification
Permit Classification
Individual "' ,
o2e~ :t-f
liation ./
. OJ-JO yo
~Jr&
VA 233285482
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
William F. Morgan II
2036 Martin's Point Rd
Kitty Hawk
Public Notice Issue
NC 27949
Effective Expiration
Waterbody Name Stream Index Number Current Class Subbasin
03/25/2012 21:49 12524410639 OBHC PAGE 04
NORTH CARQIJNA iJEPA RTMENT OF ENVIRONMENT AND NATURAI- RESOURCES
APPLICAInO.N FOR ,rA PERINVIT TO CONSTRUCT OR OPERATE INJECTION WELI-S
to Accordance With the PrpvisiOns of 1 SA NCAC 02C .4200
CLOSED -LOOP MIXED -FLUID GEOTHERMAL 1N-TECT10N WELLS
These well, circulate fittids other than potable water a% part of a geothermal heat' rg and Coaling sysiem
(check one) t/ New Application Renewal* modification
* For ronewals corn plcte Parts -+C Otte'the signature page.
Print nr rvne lnArmalion and Mod to the ATidres:c or; the Last !'aee. llleeible Annlicalinns rivill Be Returned As h7crimi
DATE:
r
PERMIT NO_ [] q [leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: individual Residence Business/Organization
CGovernrncnV State Mtiizicipal County Feder -of
13. ft". IT A''PLIOANT - For isidiv+dual residences. List each Owner ail property deed. For all t}thers.
state name of entity tid'Tame of person delegated auh authority to sign oil bealf of the business or agency
A,J ei-7 Ili006.1
City: ►siu. 5tate:JWt %ip codeX71 It County:_ -
Day Tele No.-. Cell N�,:
EMAIL Address: Fax N43.:,
C. LOCATION 0jrWE J., S.tTE- Where the iitiiection wells are physically Iocated:
(1) Parcel ldentification Number (PIN) of well site:qpip 41 County: -,
(2) Physical Address (iFdiflerent than nailing address):
City..
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Naine: James Maupin
N(' Well Frilling Corrtractor Cettification No.: #13517A
State: NC Zip Code:
RECEIVEUIDENRINQ
APR 16 2012
Company Name: Piekstun Pump and Well Co., Inc. da Vialuton Ceotbermal
Contact Person : Tina Stagg EMA(1, Address: tins stmggeaeo4tu" protection Section
Addjvgs- 636 Benefit Rd.
City: Chesapeake Zip Code: 23322 State: VA County: _Cherapenke
Office Tele No_ 7574GS-9391 Cell Nn.: 757-435--9392 Fa,Y Na,: 757-42t-2148
GPI ilill:30M Pamir A,pplieatinv ftviacd V741241111 rage I

03/25/2012 21:49 12524410639 OBHC
E. HEAT MAP CONS CTO INF iON (if different
Company Namc:� $ eL
Contact Person: AW � " [ EMA
Address: _,V &C Aa-f— _
City Zip Cade; State: County:
Ofiice 1Ve NQ.;-YYl-4?Y0 Cell No.:
PAGE 05
(7-0^
F. WELL CONSTRUCTION DATA
(1) Number of borings to he constructed'': _ Depth of each boring (feet):_X 200
* fjeristiltg water supp v wells will be used doers provide fhe it fnrinalion hi item (4) fielnw.
(2) Chemical additives to be used: R-22 propylene glycol Ethanol
Other _ GEO SAFE (other adddhives will need prier approval by NCDENK IW-ore use)
(3) Type of tubing to tic wred (copper. PVC, etc): y► HDFE
(4) Well ca-sing. If the well(s) will use casing then provide the = (steel. PVC. pl&atic, etc.), diatnctc[. depth.
and oteni of casing appearing above ground: no easing - geothermal closed loop
(5) Grout (material surrg ntding well casing andlor piping):
(a) Grouttypc: Cement Bentonite" — then (specify)
•* ny selecting honinnitt gMUL a vnrIOncc r5 $icm iy rcqucsted Io 1 SA NCAC 2C .0213(d)( I )(A), wiueh souitu n ecincol 11•lrc grntit
N) Grout depth of toting (reference to land surface): from to .- - (feet)
If well has casing, mclicate grout depth: ftotn to (feet)
t
G. WELL LOCATIONS -Maps must be sealed or otherwise accurately indicate distances and orientations of
features located widiin 1000 feet of the injection wells). Lpbel all fcaturcq clearly and inplude a north arrgw, A
y
f I ? Attach aElse-specific map shawingt the locations of the fallowing:
* Proposed miection wells " Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sitcc, drain fields, or repair nmcas
* .Existing or potential sources of groundwater contamination
(2) Attach a topographic snap of the area extending 114 mile from the iriection yell site that indicates the
facility's location and the enap name,
NOTE: In ■ exrt cares, an aerial,pholograph of the propeny parrel showing prppeny Ilnea and structures can be
nbtaMed and downloaded jrnm the applicable couYUy GIS r►+ebstre. Typically, the propely can he searche4 by
owner came or address; The location of the wells in relation to properly boundaries, houses, aeptir tanks, outer
wells, M can lien be drawn Y)t kv hand ALco, o 'layer' con be selected showing topographic contours or
elt iwfirm dorm
IrP1.UtiiC 5 Q M Pcrsrtih Apptiwlinn (ltevisekl 1124)2(it 0 1 Psgr 2

03/25/2012 21:413 12524410639 DSHC PAGE @6
11. CERTTFICATION (to be sighed as reouired below or by that persnn's authorized agent.)
15A NCAC 02C .021 1(b) requires that all permitapplication4 shall be signed as rallows:
1. f'or a corporation! by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively.
3. for a municipality or a sLate, federal, or other public agency: by either a principal executive
officer- or ranking pubEiely elected official;
4. for all others- by the well owner [which means all t+ersoris listed tin the eed).
If un antho rized agent is signing on behalf of thr applicant, then qupply x letter signed by the
applicant that names end authorirtes their agent to sign this application on their befall[
N hereby certify, under penalty of law, that i have personally examined and am familiar with the information
subinitted in this; doctiment and ail attachments lhcreto and that Nsed on my inquiry of those individuals
ini-nediately responsible for obtaining said information. 1 believe that the information is true. accurate and
complete. i alrr aware that there are s'tgnifc8rtt penalties. including the possibility of tines and irttprisoiunent.
for submitting False information. I ap.rec to construct, operate. inainiain. re1jair. and it applicable. abandon the
itijection well and afl related appurtenances in accotdance with 11+e approved specifications and Conditions of
rlre Permit."
r
SSiiggnnMUre of Property Owner/Applicaort
Friitt nr �'ype 1•u11 iVamc
F_,
ign t re of 'irperty Qwt er/App Gant
Print or Type FuII Name
Siggnattrrc of A uthot•ized Agent. if any
Print or Type Ril I Name
Submit two copies of the coinpleted application package to:
DWQ - Aquifer Protection Section
1535 Mai] Service Center
Raleigh, NC 27699-I636
Telephone [phone]
RECEIVEDIDENR1DWQ
APR 16 2012
Aquifer Pmte ion Sedon
OPWO1r g 0 M remit A pti I i cp4fi m IRcvised 1/2412n1 Ir ppge 3

NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
William F. Morgan Il
Joan C. Morgan
2036 Martin's Point Road
Kitty Hawk, NC 27949
Dear Mr. and Mrs. Morgan:
Division of Water quality
Charles Wakild, P.B.
Director
April 17, 2012
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. W10700274
William & Joan Morgan 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 Apr -it 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 64 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
S' cerely,
4��
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 Banks Heating & Cooling, Inc.
Permit File W10700274
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, Nooh Carolina 27699.1636
Location: 512 N. Salisbury 5t., Raleigh, North Carolina 27604
Phone: 91"07-$4641 FAX: 919-W7.6496
Internet: www.nwatemualltv.om
An Equal Opportunity I AffirrnaGve AOon Employer
ne
TNO-oiihCarohna
�tumlly

Central Files: S Ps_ SwP_
04/05/12
Permit Number W10700274
Permit Tracking Slip
Program Category
Status Project Type -
Ground Water
Active New Project
VV' i:er of } i:�iil` v'tirr-i a�:.. i ���i�j
.......
Primary Reviewer
Permit Contact Affiliation
eric.g.srnith
Tina Stagg
Driller Well
Coastal 5W Rule
PO Box 15482
Chesapeake VA 233285482
Permitted Flow
Facili€y
Facility Name
William & Joan Morgan SFR
Location Address
203E Martin's Point Rd
Kitty Hawk NC 27949
Owner
Owner Name
William
F Morgan
Scheriulrtt
Orig Issue App Received Draft initiated Issuance
04/05/12 03/28/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Major/Minor Region
Minor Washington
County
Dare
Facility Contact Affiliation
Owner Type
individual
Owner Affiliation
William F. Morgan tl
2036 Martin's Point Rd
Kitty Hawk
Public Notice Issue
04/05/12
NC 27949
Effective Expiration
04/05/12
Waterbody Name Stream Index Number Current Class Subbasin

Ai
_
NCDENR
North Carolina Department of Environment and Natural Resources
Nvision of ► ater Otiality
4•Nvi s..� � 1
April 5, 2012
William F. Morgan 0
Joan C. Morgan
2036 Martin's Polrtt Road
Kitty Hawk, NC 21949
Subject Acknowledgement of Went to Construct Type 5QW Injection Well System
Permit No. WI0700274
7..036 Man in', Point Road, Kiwi Hawk, NC 27919
titer 1.vi.r, & ivirs. 1r orgiai:
On March 26, 2012, 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 geothemal 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 .4213, 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.
(�iL:�S�, CGlltili:t'14�1:{Ct` l�.(!?,zr5:T1 ������ Rt77'�•70� i]1 !1'ire',�?;t;'�.1�['t:�..;/,a.7,�,t��..,i_..�,�.� 1F�'Cll�'1i'P Fiil�� rSti,n�411r;�^
Stu 'r tW'
for Debra
Supervisor
cc: Washington Regional Office - APS
APS Central Files - Permit No. W10700274
Dare County Health Dept
Pinkston Pump and Well Co., Inc. (Tina Stagg)
Outer Banks Heating & Cooling (Mark Burble)
AQUIFER PROTECTION SECTION
1636 Mail Servioe Center, Raleigh, North Cardirta 27699-1636
Location: 512 N- SaKaty SL, Raleigh, Nnnh Carolina 27604
Phone: 919M7-64641 FAX: 9IM7-6496
Internet, wuuNa.rtr wWmualltv.M
An Equal Opmrtunity 1 AiMnative AdDn EmMer
No e bCarolina
;aturall

Mar 26 1210:57a Pinkston Geothermal 757-421-2108 p,2
03/25/2812 21:49 125241410639 08HC PAGE 01
RECEIVED1DENRIDWO
NORTH (CARt7UNA DEPARTMENT Or ENVIRONMENT AND NATURAL RCSA6 10t�
NOTURCATIOM OF XKTENT TO CONSTRUCT OR OPERATE I NJEC'I �CiDn
[n Acrprdancc With titre Provisionr of 15A NICAC 02C . V00
CLUSED,LQO�I' W TLIt QNLY QE_0jHERMAL '_H,CTI�I WELLS
These wells cirtv late potable wator only its part of itgcothrrmal heating and cooling sysmm,
These wcfl% are "pertnittcd by rule" and do not require an individisa[ permit when they are constructed iif
aecardanee with die rules of 15A NCAC 02C .0200 and this Notice is subat lLied prism to can s tract I on.
Print or 7)rpy lgformorir?n oird Mail err 1I1e �Addrlr"i on nce Lost page,
DATE: _ _: ? __o 7 . 20 1a PERHMNU Vim- �� o [in 1,e Filled in by DWQ)
A. STATUS Of WELL OWNER (chaose one)
Non-Goverinrrent: Individual RcridenceRusinessldrganiration
Government: State __ Municipal County �edml
R. WELL OWN th — Fot individual residences, list gjKls owner Cn property deed. For all others. state name of
entity nd surne of person delegated authority to si&m on behalf of the bo%iness or agency:
-"�
rft
illfail;n� flddrtss- •srP City-, C State:G- t ip Gade: Cc+vnty:
Day Teie Nq_- Cell No.:
EMAIL Arldvess: Fax bra.: C. LOCrlTI[1+N:OVyVELL SITE — Where t1le iijjcrtion wrells see physicInliy located:
(l) PamAlldellttifica0onNumber (PIN)ofwell site: / County: ��
(2) Physic3l Address (if diffemntthan mailing addn:x7s):
City: State: Ng Zap Code:
D. WELL DAtLLER iNPOPUNATION
We[i 0ciIIing Cnntracwr 5 Name: JAMca Mnu4rin
WeII Ulyllin6 Contractor Ceitifcation N'n.: 43517A
C ornimay Maine: Pinkstart Pump and Well Co., tric. Va Pink%ton Geothermal
Contact Perwn: Tina 51agg EN[AH. Address: tirint^+tag�carr�.com
Address: 636 6enefrt 1td.
city, clocespe2ke 7.ip Code: 23322 State: VA
Office Tele No : 757439-9392 Cell No.: 757-4 9-93►12
County: Chuspooke
Fax No.' 757421-2108
Cir'i+JtIIC SOW Notifsolinl+ [ftevimd 311Rao 11)
Pt%c 1
RECEIVED 03-26-' 12 10:39 FRM- 7574212108 TO- NC DENT P&S Pt7l�2I0�4

Mar 26 12 10:57a Pinkston Geothermal 757-421-2108 p .3
PAGE 02 03/25/2012 21:49 12524410639 081-C
,.
RECENED/DENRIOWQ
HEA't POMP,CONJIUci'O.RINtrORMAUON (ifdiffercn,l than driller) MAR 2 6 20\2
Cornpru,y Name:~ B+Js. If~ b GK{! . ....,').,__-------::---
Con:act Person~ d u,?.t,lc. EMA IL Ad.dress; ~r ~ ~ • Q;_,..
Address: /U.lo_~GC...:;:;..._.;l,__'li~'lr'-----•----:..S~~~9C-~lj,Jl'i-'F!~----------
City: Q~ HI/II-IL. ZipCod~: ---aa::::...---State:UC...county: ___/>,t.-t,'-----
Office Tele No.! rfl-'r(/-l7't.() Cell No.: Fax ~-o.: di:T2. -trtf -(),Jf
WELL CONSTRUCTI.ON DATA
( I) Number of boring, to be constructed•: 7 Depth of each boring (fe~):i::._200 _ __,,.. __ _
• ~f exi.Jting wrdl!r .,apply wells wllJ be 11sed lhel7 prrwide the i11formolirm in it~ni (4) helm~,.
(2) Type of tubing to be used (steel. PVC . etc): ~IJPP.E _________ _
(3) Well C$ing. ff the we1l(s) will l1se c.'lsing then provide the~ (steel. r,vc, etc.),~~-~-
and ~~ of ,asing appearing above grouod: _ N(t casa,g-geathennal closed loop
(4) Gmut(mclterial surroundlllg wen ca..c;ing and/or piping): Closed laop-net a watcr's■pply
(a) Crout type: Cen,ent_ Bcntonitc0 V Other (~pecify)----:--:-:--~·---~.
~• Hr ,c:11:1:tlnl! ticntonitc izrr,ut ll v:1ri:r11cc ;., hcNhy requested co 1~/\C 2<: .n2 I .1(d)( 11(,\). wllii:h n:(l11irn II CE!ll(.nt LY, ~),",b_ ~
(b) Grout depth aftubing (rcfc:,cncc to land surface): frum ___ to ___ (fed)~
. If well has casing. indicate grout dc~th: fh,m ___ to ____ (fl:ct) u~
G. WELL LOCATIONS-Maps mu~t be scaled or othc1wise accurately Indicate distances and <1rientaLions of
feati,rcs localed within 1000 feet of the injection well(s). L;tbcl allJeatures clenrly m,d.jnclude a north arro_\Y, . .S, Je. ~
(I) A.tfKn "ii sitc-sp!tific:map showing the locations of.the following:
" Proposed injection wells
• Surface water bodie~
• Ouilclings • Prop~1ty bou11darics
"' Water supply wells
"' Septic tanks and associated spray irrigation sites. drain fields; or rcpaii-areas
-t E!."Cii-thiv or potential sources of grou1,dwatcr contamina.ti(ln
(2) A~ch a topographi~ map or lhc 1irea ~tending 1/4 mile from the injection well site that indicates thi;:
facility's location and the map !lame.
NOTE: /11 nunt c,ne,, •• aeflr,I f'l,m.og,,,pt, of lht pm~y p,,rctl .tflowi,rg propnty nna •"" strlldllrn cnn bt
ofJla.lntt a,r,d ~ow,,l11r,tlt.d from '11• ttpplia,641 ct1rrmO, GIS webiha. Tjpko.11..~, 0,e p,optrty can be 5t!Mdl.d ~JI
owner ""'"' or 11.ddn!,'-TM lot:atlon of ,r,e we/Ix in rftdion ttJ prnperl:J; bt,,mdarin. lunua, a,p,ic trmb, ""'er
we"s~ ~c. con then b~ drrz111n 11, ~ ban,I. A/111, a •r~er' ,rm be ~cted sl,r,wlltf tr,pogrt1ph.k ,rmttJUr, 11r
elnatio,, dottL ·
(.l'll/lllC !QW N"titic.1tio11 (R.cvisL'tl J/18121ll I)
RECEIVED 03-26-'12 10:39 FROM-7574212108 TO-NC DENR P&S P003/004
Mar 26 12 10:57a Pinkston Geothermal
03/25/2012 22:49 12524410639
OBHC
757421-2108
p.4
PAGE; 03
RECEIVEMENUM
[ . CER`I(WICATION (tn Ise signed as rctluised below or by that person's atuhorized age14AR 2 6 201Z
15A NCAC: 02C _0211(b) requires that all pmnit applications shelf be signed ws :i wiecti011 Section
1. for a crirporetion: by a. responsible corpumte officer:
2. for a partnership or sole proprietorship- by a general lsartaer or the praprickor. respectively;
ti, for a muoicipably or a state, -rederal, or other pttl)lle agency: by efthes• a principal executive
otl Iccr 0V NMI kittg publicly F.]W Cd Official.
4, for all ethers. by the well owner Lich tnc a 1w, a peraon$ fisted n ti ronerty deed),
If an authorized agent is signing on riehnif of the applicant, theft supply a letter Signed by the
applicent that alines Rad authorizes their algctat to sign this app)ication on their behalf.
"i tierchy ceitify. under penalty of law- that I {save persuna.11y examined and am familiar with the inforniation
qu5mittecf in tlii9 document and ail maehmenu; thereto and that. hosed can my iiiquiry of those htrlividualq
immediately resryonctble for obtaining said infnrinaticnt l bclicve that the information is true. arcuratc wd
complete. i am aware th:a there are siglsifrcaoi penettics. incivaig the RQgsibimy orftits mid imprisonment,
for sOsr Mirig false information. I agree to carnstrtsct. operate; inaimain. repair. and if applicable, abmtdor the
inieetimi well and all related appurtenances in aeccndance with ilie appttwed spc6fictiftnc and conditions of
the PeMIC
.r Ov%—
. L� >:t+re of Prttperly awn �Applicaiit
Apr9go
Print or Type Full Name
5 ignaturc of Authorized Agent, if My
Print or Type roil Nime
Submit the complete application package to:
AWQ - Aquifer Protection Section
16M Mail Service treater
Raleigh, NC 27699-1636
Telephone [phone]
0111uu1C 3QW NAi;rTOMiarr ERe Axj ?lyl &701 ty
vats 3
RECEIVED 03-26-' 12 10: 39 FROM- 7574212208 TO- N&%DENP P&S P004I004

Mar 2612 10;57a Pinkston Geothermal
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Mar26 12 11:05a Pinkston Geothermal 757-421-2108 P.1
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MAR 2 9 2012 -
'tat
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Mar 261211 i05a Pinkston Geothermal 757-421-2108 p.2
mit EAI za-Lz 21: a4 11524410ti39 i]BK FACE 01
RECEIVEDmENWM
MAR 2 6 2012
1,4011-U H C.: KQL44Ei DePA .,rMENTOF ENVI rONME,*4TA D NATVRAL ILESOURCES
€ NOT FICATIN OF WTENT TO CONSTMUCT r W _N WEUS
In Accordance With the Provision.% of 15A NCAC 02C .0200
CLOSED -LOOP WATER -ONLY GEMIERMAL INJEC'ION WELLS
These well, circulate potable water only as Part ofa geothermal heating and cool mg syslcm.
These well; are "permitted t}y rule le"and do not require an individua I permit when they are cnnmucted Iii
accardwKe with the nrW of 1 SA NCAC 02C .A200 and this Notice is submitted prior to constmOoan.
Print ar 7))I;e irIfnrmagic" and etdrad In rfre Addr#_-,is em the I ov loose.
DATE: _ ;1 [ ' , zo FEH14lIT NO. _ _- t(o be filled in by DWQ)
A. STATUS OFWJU L OWNER [choose nne]
Non -Government: Individual Residence Susines5A)rgan ration
Government: State Muutcipal County Federal
111. VMI, OWMl0 -- For individual residences, I ist c cl, owner en properly deed. ror all others, state nvm of
entity ald name ce(person detcgated authority to sign on behalf of the hwniness ar agency:
&c&lam - E • ftt,,I - --
Mailing Ad
City: --af
Ste; +GC_ zip Code: 7 Comit
Day Tele No-:
EMAIL Address:
C. LOCATIO1R630WML SOE -- Where the isrjection wells are lylv5icrdly located--
(1) Parcel IdentifleRtlon Number (PIN) of well site: / t"ourtty: �
(2) Physical Adds%% (fdifferent-tNin mailing atddres-,):
City; ` State: IM zip Code:
D. WELL DAI'LLM INFORMATION
Well Drilling Contractor's Name: James Maupar
Well Urill'ntg Contractor Cvti>'ication Nd.- #3517A
CcrrnvarryNalnc: Pixtksten Pump sod Well Co., tinr- tin PinkAon Geu4h-armal
Contact Perron: Tina Stagg EMAIL. Addrrss: tiurr�afsggciwergy.cona
Addmv�: 636 Benerit ]Rd.
C)ty; Citeaapeake ZipCdde: 23322 State: VA County: Chesapca&e
Office Telc No.: 757-439-9392 Cell No.: 757433-9392 Fax ?41D.: 757-4214108
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RECEIVED 03:26-:412 10:48 FROM- 7574212108 TO- NC DENH P&5
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Mar 26 12 11:05a Pinkston Geothermal
103/25/2012 21:413 12524410635
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757-421-2108 p.3
a3-c RECEIVEDIDENRINQ PACE 02
MAR 2 6 z kd
.j A;44 (if d i rferatst tisan di l l let
n _�. ;��rr% pqu#er'Protection Section
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. i0 w4L 1 (2 dAc . 4ir*,
City: W— Zip Code: 26i,
Stve4tCoum:
Offica Teie No.: �-" �—��i�� Cell tva.: Fax N;)— 5!Y, --a 1;
F. WUL CONSTRUC ION JDATA
(1) Number of borings to ticconstructed*: Depth of each boring (feet):_/__200 _
* !f exiving WggMjstg&w4h wig err then pr+wide the i+iTarmcrrinn in ilvm (heknv.
(2) Type of tubing to be used (steed. PVC. etc): _Y�IIPIVPg
(3) Well casing. If the well(s) will w9c casing that provide the b= ( [eel. PVC, ctc1, dUmeter_
arid W.M of casing appearing above gmvnd : _ No rasing - gaotherertal ckned loop
(4) Grrwtimatcrial surrounding well casing andfor pipingl: ClmI4 loop - not a water aapoy
(a) Grout type: Cement Bentrmifee Other (specify)
•• 1�p!x1[cting t+entenl[C grnuk n rv1,1,<e+C fs dCrd+y nequs�ard W 1 A A[ x[' .ill t �dlt } Hh;, +�tiiell rrgxirac x eornGnt lytsc t��
N Gmit depth of tubing (refercnee to land surface): Front td (feel)
lr wc11 has casing, indicate grout cicfstls: from to (feet)
Q WELL LOCATIONS -Mop tnusst be scaled or edictwise accurately Indicate distatsces and orientations of
feahires located within 1000 feet of the injcatian well(t), 1AW tl Pe e. i inc i W_ +%;_
(1) Ailkh a sns-sptfdifietiiap showing the locations of the following:
* Proposed irijection wells
' Surrace water bodies
" Duildings
" Water supply wel Is
It Property boundaries
" 5cptic tanks and associated spray irrigation sites, drain fields. or repair areas
* Existing or potential sources of gmund water =taminatitm
(2) Attach a topographic snap or the area emending ;14 mile from the in.iwicil wtr11 site that 'indicates. the
Fat ifity's 10011i'D11 and t>hc map name.
NOTE lrr mace resat, ors cerJ f rA1Af g1WPh Of 16C PMPedy Pam shrvw&sg pr#PP" rMes and s& a nra can be
ad tcsd nud dawraloaded} rn the lk+ofile scrrrtr� wcJ�xftG Ty►pica UF, the preperrp cart he swrAed by
atr,Aw rrww a► Awermm The lacorion of tlba wd& in re+hm*ff so j"RWrV 10uplawles, koAm, sgmk rmrltr, other
wcHr, arc cart Warr be d ntrrr by by band Abo, a "layer" cart be aelerted Aawbig topogrgok contours or
elerafien dare
GlIU91IC Saw hletifieation (kevised 348nol 11
PUfC 2
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Mar 2512 11:45a Pinkston Geothermal
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Fir -MA
757-421-21 08
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PAGE 93
RECE1VEa1DENRICWQ
C,&A j IfICA il'ION (to be signed as rcqui+-ed below or by that p"IfitU06d agent)
Ajuifer Protection Section
i 5A NCAC 02C .0211(b) requires iltat all pennit appfioation shall be signed as r0riows;
1, fix- a corporation: by a responsible corporm officer:
2. fai a partnersltipor Role prolnietemhip: by a gencral partner or the pmprietor. respectively;
:. for a municipality yr a state, fiedcral, or other public agency: by cither a principal exceritive
vffiecr or ranking pub -Hein clectrA official;
4. for all athes-s: by the %yell owmrer twhich means gIl�eraens tisW on the vii4a erty de
If an atlthorind ageal is sigtling an bebralf of the applicant, then sappty s leWr signed by the
applicant that names and autba' rim their meat to sign this application on their behalf,
"1 11etthy certify, under penalty of law, that i have personally catamined and am familiar with the informetioa
submitted in this document and all attachm iLS th£ret0 and that. halted on my inquiry of those imlividualq
immediately responsible for nbtaining said infarma'tiprt! T believe that the infonnation is truS, accurate and
complete. i am aware that there ar4 sign ficant penalties. Including the possibility of fino and imprisonment,
for submitting false information. l agree to eonstrueL uperate, inafntain, repair. and if a.pplica}rter abandon the
injretion well and all related appurtenances in acewdence with the apprtwed v> cifcstians and conditions of
-tile Nmil",
Pr *rty Dwner/A *154d:knt
Prim or-ryoe Full -Name
0.r'—
�m ►are of ProNrty Qwn IAVplicaiit
vrz pryQa? __ _
Print or Typo Full Name
Signatute or Authorized Agent. if any
Print or Type cull Name
Submit the corapicle application package to:
DWQ - Agdiiler Protection Section
1636 MaR Service Center
Raleigb, KC 276"-16M
Telephone [phone]
ortt,�rc �w T�rotPffcallosr trt�+�r 3nit�rir ry
i `1ge 3
RECEIVED_ 03-26.7' 12 10:48 . FROM- 7574212108 TO- NC DENR P&S P0041005

Mar 261211:05a Pinkston Gootherrml
83/25/2012 21.49 12524410689
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757-421-2108
PAGE 87
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- 7574212108 TO- NC DENR PAS
RECEIVEDIDENR/DWQ
MAR 2 6 2012
Aquifer Protection Sewn
P005/005

03/25/2012 21:49 12524410639 (38HC
09"JL
WORTH CAROLINA DEPARTMENT OF EN VIR ON MENT A ND NATURAL RESOURCE-5
PAGE 01
NOIVICA71ON OIL 1«TENT TO CONSTRUCT OR OPERATE FN'TECTION WELLS
In Accordance With die Provisions of" 15A NCAC 02C .0200
CLQSED-LOOP WATER-ONLYGEOTHERMAL INJECTION WELLS
Theae well,- circulate potable water only as part of a gcothermal heating and carding systern.
These wells are "permitted by rule -'and do rive 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 wnsirmt ion.
Print or i)+pe lnformaliarr and Mail in ripe d dclres.c nn the LOSE Page.
DATE: .201a PERMIT NO. (robe filled in by DWQ)
A. STATUS GIF WELL OWNER (choose one)
Non-Caoverninent: Individual Re4idence _x Business/QTganiration
Government, State Municipal County Federal
B. WELL OWN -- For individual residences. I ist caclt owner on property deed. For all others. ,-tee nasne of
entity ind name (if person delegated authority to sign on behalf of the business or agency:
"Mm-0 G. M4440 ,
Mailing Address: _
City: 14n,74 State: Vc_zip Code: County:_&AQ
Day Tele No_: Cell No.:
EMAIL Address: Fax Na.: _
C. L0C,ATI01%rb* WtI,L SITE — Where the injection wells are physically located
(1) Parcel Identification Number (PIN) of well site: -17 / county.- 4011�4i
(2) Physical Address (if different,than +nailing address):
City: ____ State: NC Zip Cade:
M WELL DRt LJLF R INFORMATION
Well Otilling Cnntractvr's Name: JAMes Martpin
Well Drilling Contractor Ceatfication No.: #3517A
Company Narne: Finkstva Pump end Well Co., lnC. t/aPinlotonGecOcirmal
Contact Remy rl: Tim Stagg EMAIL Address: [e-mail]
Address: 636ftenrtit Rd.
City: Chesapeake 7ip Code: 23322 Stnte: VA County: Chestpeake
Office Telc Nrr.: 757-03-9392 Cell No.: 757-438-9392 Fax No.: 757-421-2108
GI'i.MIC 5OW NMirieatinn (Revimcd Y, V201 I) I'nr�c l
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03/25/2012 21:49 12524410639 OBHC PAGE 02
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RECEIVED!DENR/DWQ
MAR 2 8 2D12 8EA1' l"OMP.CON'ilUCTO.R INFORM.A TJ.ON (if different than driller)
Company Name:~ 8+.J.f, /leJJ"J b CtM_(r ') Aquifer Protect ion Section
Contact Person: ~ d~c:.. EMAI L A_ddrc ss: /UJek ·"w..l>1er G,.c/;J.c · '»,.,
Addre~s: ,.,.,~ /t.//,1 ~
City: AIJ;f.1 !/8'hl-ZipCod~: .i,i,: State:Uc..county: ~'-------
Office Tele No.: Js:{J,--w/-l7'tf/ Cell No.: _______ Fa.'< ~o.: m-W -(J'.Jf
WELL CONSTRUCTION DATA
(I) Nu111ber of borinas to be constructed*: 7 Depth of each boring (fet.t):~200 ____ _
• If exi.Jting waur ppplv wells wUI k ged then pml'ide the iltformatinn in item (4) below .
(2) Type of tubing to be used (steel. PVC. etc): ~IUJP.E _________ _
{3) Well casing, If the well(~) will we ca..c;ing then provide the~ (steel. PVC, etc.), rua1.11eter. ~-
and ~~!!! of casing appearing above ground: _ No caSilJg • geothermal do9ed loop
(4) Grout(material surrounding well casing and/or piping): Closed loo p -not a w•tersupply
(a) Grout type: Ceinent_ Bcntonite•• .V Other (i-pecify) -------
•• tJ!' ~1ct:li11J tN;nt(lnltc ~t ii llllrinru:e is hcrcliy rcquC'!ted 10 l~J\C Zt: .n2t;l(d){INAJ. 1o1--hich n:quirC!' 11 cement typn smul
(b) Grout depth of tubing (reference to 1,mt surface): from ___ to ___ (feet)
lf well has casing. indicate grout depth: from ___ to ____ (feet)
G. WELL LOCA TlONS -Maps mu$t be scaled or othcl'wise accurately indicate distances and c,rientations of
features located within 1000 feet of the injection well(s). Label al I features cJearly ancljnclude a north arro_w.
(1) A:lfi~li ·a sitc-spetific:map showing the locations of_the following:
• Proposed if\iection well$ • Buildings • Pror,erty boundaries
• Surface water bodicii • Water supply wells
"' Stptic tanks and associated spray irrigation sites, drain fields. or repair areas
• Exi~ting or potential soun;cs of groundwater contaminatfon
(2) Attach a topographic map of the area e.~ending 1/4 mile from 1he injection well site that it1dicatc.i; the
facility's location and the map name.
NOTE: In mosi cmo, 1111 IIUltll photograph of tit~ pmpmy JHIICd showing plO~ lines and str11~11m can be
o""'1Md atul dowl1loadd /rf,m the wuca6#.e cormty GIS wmittt. Typktllq, the propmy au, be &mrclltd by
t1wner name or tultlfEJ:r. Tht! loct1li'111 of the wt!ll.f in l'f!lation to propBfy bor,ntlarle$, ht1uses, sq,tk tanb, other
wt1lls, ere. can then bt ,1,.,,,,,,. b, lzy lland. Also, a 'IIIJler_. cnn be :relb:ted 1l1owtng top11grqphft: contalltl ,,,
tlnatfo11 dot& .
Gl'U/UIC SQW N1;1tificathm (Rc111~d 3/IBf.lOl ll
03I2512012 21.49 12524410639 OBHG PAGE
03
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H. CERTII ICATION (to be, signed ae required below or by that persons authorized agent)
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15A NCAC: 02C .O2 l 1(b) requires that all pennit applications shall be signed as fultows;
ac
ey
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1, fora corporation: by a responsible corporate officer:
a
2. for a partnership or Role proprietorship: t]y a genctal partner or the proprietor-,
3. for fcdcral,
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a municipality or a state, or other public agency: by either a principal caecut
officer or rankiitg pubiicl,v elected official;
Ia
4. for all othem: by the well owner Wjiq means all DerjpA listed on the pr9pprty de ).
If an authorized agent is signing ort behalf of the applicant, then supply a letter Rigued by the
2pplic811t that lnagnts and authorim their agent to sign this application on their behalf.
"I lierchy certify, under penalty of law. that: i have personally examined and am familiar with the information
submitted in this document and all anadime}rts thereto and that ba.Red on my inquiry of diuso individuals
immediately responsible for obtaining Said itifnrtnatton, l believe that the information is true. accurate and
complete. i am aware that there are significant penalties. inctudhig the Possibility of -Fne,% and imprisonment,
for submitting False inlonvation. I agree to construct_ operate, maintain. repair. and if applicable, abandon the
infection well and ail related appurtenances in accordance with the approved spWfications and conditions of
the Permit."
$igni"XTUm f PCppelty (7vrmerttim
I"e
Print or �.�m Full -Name
AP*--
gn tune of Property Own, 1Appltcant
OL _xolr!9 AZ E
Print or Type Fall Name Ij
Sigmaturc of Authorized Agent, if any
Print or Type Full dame
Subirrit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1.636
Telephone [phone]
Gt IMIC 50W Nntigwtion (Revkml 31i SM 11) 3

03/25/2012 21.49 12524410633
PAGE 07
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