WI0700277_GEO THERMAL_20120411

Permit Number
Program Category
Ground Water
Permit Type
WI0700277
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facili
Facility Name
The Buck Living Trust SFR
Location Address
116 Hazelton Rd
Gates
Owner
Owner Name
The Buck Living Trust
Dates/Events
NC 27937
Scheduled
Orig Issue
04/11/12
App Received Draft Initiated Issuance
03/30/12
Regulated Activities
, Heat Pump Injection
Ou.tfall NULL .
Central Files : APS_ SWP_
04/11/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Tina Stagg
Driller Well
PO Box 15482
Chesapeake
Major/Minor
Minor
VA
Region
Washington
County
Gates
Facility Contact Affiliation
Owner Type
Unknown
Owner Affiliation
Cynthia Buck
116 Hazelton Rd
Gates
Public Notice Issue
04/11/12
NC
Effective
04/11/12
233285482
27937
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NCDENR
North Carolina Department of Environment and
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
April 12, 2012
Cynthia Buck
1 l6 Haxelton Road
Gates, NC 27937
Natural Resources
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0700277
l t6 Nazelton Road, Gates, NC 27937
Dear Ms. Buck:
Dee Freeman
Secretary
On March 30, 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 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 Weil Construction Act and North Carolina
Administrative Code Title 1 SA Section 2C Subchapter .0211 (u)(2). Additionally, you should contact the Gates 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.Rogeryia ncdenr.goy if you have any questions.
Sinc
U
rel�, w
for Debra Watts
Supervisor
cc: Washington Regional Office - AP5
APS Central Files - Permit No. W10700277
Gates Couaty Health Dept.
Pinkston Pump and Well Co., Inc. (Tina Stagg)
AQUIFER PROTECTION SECTION
1636 Mall Service Canter, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phoney 919-807.64641 FAX: 91U07-6496
Internet: www.ncwaterquality-arst
An Equal OppuAurdly I Afrumavm Adn Employer
one
NorthCaxolina
urn!!

• fir} � } i K w � + • 1 . � �
NORTH CAROLINA DEPARTMENT OF ENVTRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 1 SA NCAC 42C .4200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of geothermal heating and cooling system.
These we#]s are "permitted by rule' aad do not require an individual permit when they are constructed in
accordance with the rules of ISA NCAC 02C.0200 and this Notice is submitted prior to construction.
Print or Type Information aced Mall to the Address on the Lasi Page -
DATE: r 1 it iC'.+[' •� 2011 PERMIT NO. W 1 (to be filled in by Dll'Q)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual residence Business/Organization
Government: State Municipal County Federal
B. 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:
l II
Mailing Address: i hs H cI t k r-
City: �r `, State:_VL Zip Code: I { - —County:--- 14L"
Day Tele No.: Cell No.: J
FMA1L Address: Fax No.:
C. -LOCATION OF WE, LL SITE — Where the injection wells are physically located:
(1) Parcel Identification ,Nuttther (PIN) of well site: County:
(2) Physical Address (if different than mailing address):
City: State: NC Zip Code: IIDR 3 0 7012
D. WELL DRILLER INFORMATION 41%r Protiectlon Section
Well Drilling Contractor's Name: - James Maupin
NC Well Drilling Contractor Certification No-: #3517A
Company Name: Pinkstan Pump and Well Co.. Inc. tla Pinkston 0cotherinal
i -
Contact Person: Tina S EMAIL Address: tinansta,+ enerrsv.com
Address: 636 Benefit Road
i
i City: Chesa rake _Tip Cede: 23322 State: VA County: Ch ffN 22ake
Office Tele No.: 757-438-9392 Cell No,: Fax No.:757421-21 Q8
GPUAJIC 5QW Notification (Revised. 3/1 WO 11) Pa¢e 1
i

rw409p" T* 4- #i"fee *Oft - • 1 • 1
E. H-EAT PUMP CONTRACTOR INlliORIWATION (if different than driller)
Company Name:
Contact Person.
Address:
City:
❑Mee TeleNo,:
EMAIL Address:
Zip Code: Slate: County:
. WELL CONSTRUCTION DATA
Cali No-
F
Fax No.:
(]) NurnbcT of borings to be constructed*: _ �? Depth of each boring (feet): � : �
* If existing water supply wells will be used then provide~ the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc):
(3) Well casing. Ifthe welI(s) will use casingthen provide the tyke (steel, PVC, etc_), diameter, depth.
and extent of casing appearing above ground: ►� i1;C� L a is
(4) Grout (ruater4l surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite** -�4— Other (specify)
"* Dy sdccting hentanite a vut, a variance is hereby requested to I5A NCAC 2C .02I3(d)i IXA). which rarires a cemem we, grout.
(b) Grout depth of tubing (reference to land surface): from 0 to _ (feet)
If well has casing„ indicate pout depth: from to (feet)
G. WELL LOCATIONS — Maps roust be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection ►vell(s). label all Features clear] and include a north arrow.
(1) Attach a site -specific map showing the locations of the fallowing:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation 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 -
.NOTE. In most cases, an aerial photograph ufthe property parcel showing property lines and structumx can he
obtained turd downloaded from the applicable county GIS wehsite. Typically, the property can he searched by
owner name or address. The Location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc, can theft be drawn in by hand Also, u 'layer' can be selected showing topographic contours or
elevation data.
GFUMC 5QW Ngtlflcation (iteyised 311812011) Yagc 2

H. CERTIFICATION (to be signed as requu'ed below or by that person's authorized agent)
15A NCAC 02C _02.11(b) requires that all permit appticatio.ns shall be signed as follows:
I. for a corporation: by a responsible corporate officer;
2, for a partnership or sale proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal. or other public agency: by either a principal executive
officer or ranking publicly elected official;
4, for all others: by the well owner twhich means ail persons listed on the proberrz- 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,
"I hereby- certify, under penalty of law, that l have personally examined and am familiar with the information
submitted in this doctunent and all attachments thereto and that, based on my .inquiry of those individuals
immediately responsible for obtaining said information, 1. believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. l 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."
Sh.�ature of Property QwnerlAppplicant
Pri 'A or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GYUfU1C 5QW NoCifica tun (KerisW 31IY2011) Page 3

Page 1 of 1
Sharon G. Harrell
Register of Deeds, Gates County, NC
Consolidated Real Estate Index
Criteria -Given Name: cynthia Last Name: buck Grantlee/Grantor: Grantee Party Type: Either
Date: 04/12/2011 Doc No: 303215 Kind: DEED Book: 291 Page: 173 Desc: 121/633 (HOME LOT 34.6 AC) SR 1311(HAZEL TON RD) RIDDICK CARTER BUCK TRACT(91 1/2 AC) SR
1311 PARCEL 16A( 4.324 AC) SR 1311 1/50-6 GREEN AC Ref: DBK B121 P633Tax: $0 .00
Grantors
BUCK, EDWARD CARL
BUCK, CYNTHIA S
http:l/216.27.81.171/gatesncnw/realestatesearch.asp
Grantees
BUCK LMNG TRUST THE
BUCK, EDWARD CARL \TR
BUCK, CYNTHIA S \TR
4/10/2012
NONRESIDENT'IAL WELL CONSTRUCTION RECORD
a r North Carolina Department of Environment and Natural Resaieaes- Division of Water Quality
WELL CONTRACTOR CERTIFICATTON # NCWC 3517-A
1. WELL CONTRACTOR:
James Lee MauDin
Welt Contractor (individual) Name
Maunln's Wpil Drilling
Well Contractor Company Name
225 Tatem Road, _
Sheet Address
Kng=gland NC 27950
City or Tow State Zip Code
7t 57 > 621-0396
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(ir applicable)
SITE WELL ID #(if appilcaw)
d. TOP OF CASING Is A FT. Above Land Surface"
`Tap of casing terminated allof below land surface may require
a variance in accordance with 15A NCAC 2C .0116.
e. YIELD (gpmy: METHOD OF TEST—
f. DISINFECTION: Tvoe Amount
g. WATER ZONES (depth):
Top 31 Bottom
Tap
Bottom —
Top i3attom
Top
Bottom _
Top—_ _ Bottorn
Tap_
-- Bottom _
Thickness/
7. CASING: Depth Diameter
Weight Material
Top Bottom Ft.
: Top Bottom Ft.
= Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/PublicLi ti. GROUT: Depth Material
IndustriallCommercial o A&outtural o Recovery ❑ Injection D : Top surf Bottom 200 Ft. QuickGrout
Irrigationo Other© Mist use) Geo-thermal wells : Top Bottom Ft.
DATE DRILLED 1 1 ; Top Bottom Ft.
4. WELL LOCATION:
116 Hazelton Gate County 27937
(Streal Name. Numbers` Community, Subdivision, Lai No., Parcel, ZZp Coda)
CITY; Gates couNwGates _Court
TOPOGRAPHIC 1 LAND SETTING: (mark appropriate ban)
oSlope clVailey EJFlat C]Ridge pother
IATfTUOE 36 ° 31 •35.2000 " DM5 OR 3X.%XxXXXXXX DD
LONGITUDE 76 ° 42 1 21.1000 " DMS OR 7) xxXXXX)t7t7C DO
Latitudellomgitude source: BPS ©ropographic map
(locatfon of well must be shown on a USGS topo map andattached io
this form ifnot using GPS)
5. FACILITY (Name of the business where the well is located.)
Svnthiaht ick
Facility Name Facility ID# (if applicable]
116 Hazeltan
Street Address T
Gates L1LC27937
City or Town Slate Zip Code
Contact Name
Mailing Address
Cily or Town Slate
Zip Code
r 757438-9392 _
Anew wde Phone number
6. WELL DETAILS:
a. TOTAL DEPTH- So fin}' --
b. DOES WELL REPLACE EXISTING WELL? YES©
NO q/
c. WATER LEVEL Below Top of Casing:
FT.
(Use "+' t7 Above Top of Casing)
9. SCREEN_
Depth
Diameter
Top
Bottom
Ft. in.
: TOP.
Bottom
Ft. in.
Top
Bottom
Ft. in..
: 10. SANDIGRAVEL PACK:
Depth
size
Top
Bottom
FL
Tap
Bottom
Ft.
Top
t3otivm
Ft
11. DRILLING LOG
Method
Qum
Slot Sae Material
in.
in.
in.
Material
Top Bottom Formation Description
1 /2
_21 33
33 160
k1 130 ..,,
130 1 131
1
.- .
it =�
12. RIiMMKS:
H-i@6-28B'
I tx] H CE T" I8 LL WAS CONSTRI VM0 IN ACCORDANCE WITH
• 115A 2G, w C R T 7 L14RD5, AND THAT q COPY or THIS
Flq& REEK OED TH OWNER.
�. �Lt
� E OF CERTIFIED WELL N7RAG'i dR QA
PRINTED NAME OF PERSON CONSTRUCT THE WELL
Submit within 30 days of completion to: Division of Water QualiFormty Rev. 1{19
y P ty - Information Processing, Rev.21fl9
1617 Mail Service Center. Raleigh, NC 27699-161. Phone : [phone]

NORIB CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CWSED-LOOP WATER-ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "pennitted 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 lriformation and Mail to the Address on the Last Page.
DATE: 11aa,AcJ. a q , 20 I J-PERMIT No\J\St-0 ') oo~ 7 J (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non-Government: Individual Residence ./' Business/Organization __
Government: State Municipal __ County__ Federal
B. 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:
Cl.,10:\-\-) ,·Q blA c.k
Mailing Address: -----=--l ....... l ...... l o~H._.__..c ..... \ .... 2..,,,,,e__,__( -h---'--"-o"'-'-. r_:)L-~ .............. ..,,__0.:...,c.J_._i.\d........,._,~----~---
City: gut T{: S State: £zip Code: fi 1 q 31 County: ga_+e.._s
Day Tele No.: _____________ __,,,C,..ell"""N~o.:.:...: ____________ _
EMAIL Address: ____________ __,F~ax=N=o=-=~------------
C. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: _________ County: ____ _
(2) Physical Address (if different than mailing address): ______________ _
· t:§OmE a.c; csbc,ie .
City: ______________ State: NC Zip Code: _______ _
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: ---=J=am=es"-'M=au~p=in~----------------
NC Well Drilling Contractor Certification No.: ... N@...=.c'--C.=---"""#=3=51""'7..:..cA=--------------
Company Name: Pinkston Pump and Well Co., Inc. t/a Pinkston Geothermal
Contact Person: Tina Stagg EMAIL Address: tina@staggenergy .com
Address: __ ~6=3~6 =B_en=efit==R=oad~-----------------------
City: Chesapeake Zip Code: 23322 State: VA County: ~C=h=esapeak==e~----
Office Tele No.: 757-438-9392 Cell No.: Fax No.:757-421-2108 -------
O.PU/UIC 5QW Notification (Revised 3/ISf201 l) RECEIVED/DENR/D W~e 1
APR 2 5 ZOL~
Aquifer Protection Section
E. HEAT PUMP coNTRAcrOR INFORMATION (if different than driller)
Company Name: Geo R ctf ,.. Co 01-p kft-,1/
Contact Person: EMAILf ddress:
Address: l O <;;7 ~ f A-«..~~
City: £.J-• "t~r.3~ ~Zip Code: ai~JPl State:N C..county: _______ _
Office Tele No.~ Sa_)-'3,.3$-~,9\{i:ell No.: ________ "'-'Fax"""-'N_,,o...,.:'------
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: _____ Depth of each boring (feet): 2.o 0
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): ______________ _
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: t-..\ \ f\ c LQSe D Lob P
<
(4) Grout (material surrounding well casing and/or piping):
(a) Grouttype: Cement__ Bentonite** L Other(speci:ty) ______ _
'"By selecting bentonite grout, a variance is hereby requested to ISA NCAC 2C .0213(d)(I)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from O to 2.,.0C) (feet)
Ifwell has casing, indicate grout depth: from ___ to ____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation 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.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer• can be selected showing topographic contours or
elevation data.
GPU/UIC SQW NotifiC1J.tion (Revised 3/18/2011) Page2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021 l(b) requires that all permit applications shall be signed as follows:
1. for 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 state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons list.ed on the propertv deed).
H an authorized agent is signing on behalf of the applicant, then supply a Jetter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty oflaw, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
thePennit ...
fltl.,~.J>-fuJ:.. ✓
Si ture of Property Own~r/Applicant
~xn+hia s, -:R(A r~k
Pri or Type Full'Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ -Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED/OENR/DWQ
APR 2 5 LLiil'.
Aquifer Protection Section
GPU/UIC 5QW Notification (Revised 3/18/2011) Page3
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