WI0800159_GEO THERMAL_20081124

Permit Number
Pro gram Category
Ground Water
Permit Type
WI0800159 /
Injection Water Only GSHP Well System (SOW)
Primary Reviewer
michael.rogers
Permitted Flow
Facilit
Facility Name
DOT -Barbados Blvd
Location Address
5504 Barbados Blvd
Castle Hayne
Owner
Owner Name
NC 28429
NC DOT General Services Division
Dates/Events
Central Files : APS_ SWP_
11/24/08
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Mike Hadley
102 Middle St
Jacksonville NC
Major/Minor
Minor
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Cameron Lee, Jr, PE
1525 Mail Service Ctr
Raleigh NC
28546
276991525
Orig Issue
10/20/08
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
10/20/08
Effective
10/20/08
Expiration
10/20/08
Re g ulated Activities
Heat Pump Injection
Outfall ,•!i "L
Waterbody Name Stream Index Number Current Class Subbasin
Permit Number WI0800159
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Permitted Flow
Facilit
Facility Name
DOT -Barbados Blvd
Location Address
5504 Barbados Blvd
Castle Hayne
Owner
Owner Name
NC 28429
NC DOT General Services Division
Dates/Events
Central Files : APS_ SWP_
10/20/08
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Mike Hadley
102 Middle St
Jacksonville NC
Major/Minor
Minor
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Cameron Lee, Jr, PE
1525 Mail Service Ctr
Raleigh NC
28546
276991525
Orig Issue App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective Expiration
10/20/08
Re g ulated Activities
Outfall i,J ..,;;_l.
Waterbody Name Stream Index Number Current Class Subbasin
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins Director
Division of Water Quaiity
10/20/2008
Michael Shumsky, P.E.
NC DOT - General Services Division
€ 525 Mail Service Center
Raleigh, NC 27699
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0800159
5504 Barbados Blvd
Castle Rayne, NC 28429
Dear Mr. Shumsky:
In accordance with the application submitted to the Underground Injection Control (UIC) Program that
was received on 10/20/08, the Aquifer Protection Section (APS) acknowledges your intent to construct a
closed -loop geothermal water-onlN injection well system for the operation of a ground -source heat pump
located at 5504 Barbados Blvd, Castle Hayne, New Hanover County, NC 28429. This system is deemed
permitted by rule (North Carolina Administrative Code Title 15A, Subchapter 2C, Section .0211(u)(2)).
However, it is recommended that you contact the New Hanover County Health Department, as they may
have additional construction or permitting requirements for this type of system. If you modify your
system at any time, including the addition of antifreeze, corrosion inhibitors, or any other substances to
the circulating fluid, you must contact the APS to verify compliance with applicable rules.
Thank you for submitting this notification. If you have any questions please call me at [phone].
Sincerely,
D-k4k &f:'>Q�
Michael Rogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Wilmington Regional Office - APS
APS Central Files - Permit No. Wl0800159
New Hanover County Health Dept,
Mike Hadley (Coastal Geothermal - 102 Middle Street, Jacksonville, NC 28546)
PlnrtFrCarolina
,Naturally
Aquifer Protection Section 1636 Mail Service Center
Internet_ www.ncwaterquatftv.ore L.ocatian: 2728 Capital Boulevard
An Equal OpportunitylAirirmaWe Action Employer— 50% Reoyciei:1110% Post Consumer Paper
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

NORTH CAROLINA
OCT 2 0'OQ
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-0W WELLS)
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page {please PAW or TWe information},
DATE: - • f G - 2008
Well Type Confirmation: Does the proposed system circulate potable water oal• (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loov)?
Yes _x_ Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well o en -loop well injecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)IAFPLICANT(S)
List each. Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): State of North Carolina_ Michael J. Shumsk%,P.E.
- Actingg Director -for General Services Division D O T
(1) Mailing Address: 1525 Mail Service Center
City: Raleigh State: NC_ Zip Code: 27699-1525 County: Wake
Home/Office Tele No.: 919-715-0401 Cell No.:
Email Address: mshurnslcv_&ncdot.gov Website: www.ncdot.org
(2) Physical Address of Well Site (if different than above)_ 5504 Barhados_Blvd
City: Castle Hgme Star: ,NQ Zip Code: 28429 County: New Hanover
Home/Office Tele No.: Cell No--
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate U1C well)
Company Name: -
Contact Person:
Address:
City:
Office Tole No.:
State: Zip Code:
Website Address of Company, if any:
EMAIL Address:
County:
Cell No.:

C. WELL DRILLER INFORMATION
Company Name: Coastal Geothermal
Well Driller Contractor's Name: Sanford Sweeting
NC Contractor Certification No. :NC 2082
Contact Person: Mike Hadley EMAIL Address: mhadle y@ bizec.rr.com
Address: 102 Middle St.
City: Jacksonville Zip Code: 28546 County: Onslow
Office Tele No.: 910-353-0926 Cell No.: 910-376-1100
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company NIA. _______ _
Contact Person . .,_: ----=E=MAIL===-=A-=d=dres=s=: _________ _
Address: _________ _
City: ___ Zip Code: __ County: ___________ _
Office Tele No.: Cell No.: ----------
E. STATIJS OF APPLICANT
Private: Federal: Commercial:
State:y_ Municipal: __ Native Ainerican Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loop Geothermal Heat Transfer Systems
This is for a test well and will be used in the final construction of the loop field
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: /Vo ( 2oar" Number of borings: __ I __ _
Approximate depth of each boring (feet): __ 250 _____ _
(2) Type of tubing to be used (copper, PVC, etc): _High Density Polyethylene, ______ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes Q! (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: ___galvanized steel __ black steel__plastic __ other (specify)
Casing depth: From ___ to __ _;feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No _x __
( 4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite _x_ Other (specify) _____ _
(b) Grout placement: Pumping_x_ Pressure__ Other __
(c) Grout depth of tubing (reference to land surface): from _o __ to _250_ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
H. INJECTION -RELATED EQUIPMENT
Attach a diagram shov-drtg the vrrLin►trio- layout or propoied nttralification of tirc injection equilmacatt w id vxttrior
plpiagnubing associated with the irtiecticart operation. the rnatulacturer's brochure may provide supg?cmenrary
infornr:ttiom
.L LOCATION OF WELLS)
Attach two copie> of maps shoving the following informal !on :
(1) Include: a Situ Map (can be drawn) showing: buildings. property lines. surface water bodies, potential
sources of groundwawr contamirial ion and the oricnttadmi oruaad list traces Ix:tween ilk: proposed wull(s) and
any existing well(s) or waste disposal facilities Such as septic tanks or drain fields lecaled within 200 feet of
the geothermal heat pump well System. I rebel all featwes clearly and include a north .irrow.
(2) The Site Map must tihatw the Subject proficrty in telatiwa to lbst surrounding area by using at least two ImW
reference points such as roads, streams, auVf r highway intersections.
J. CERTIFICATION
vfutel ThlS 1'ermit Application must tee signed hyeach persun appearing on the
recorded legal propertt deed.
" 1 herebv certify, under penalty of law. that I hove per sully esamirtexi and ant Familiar with the information
Suhmitted in this document and all attachments thereto and that, based on my intluiry of those individuals
immediately- responsi We ror obtaining --;aid infortuarion. i believe that the information is true, acr=urate and complete_
I am aware that there are significant penalties. including the pus3ibifily of fines and imprisonment. for subminint,
falsi: inibrin ation. 1 agree to construct. operate, maintain, repair, and if applicable. abandon the injection .yell and
all related appurtenances in accord.ince mete the ripprnved specifications and cumlitions of the Pei-n3it."
RECEIVED I of NR I DV40
jlQ,,rr;� PRnTr m gFr'T10M
CCT 2 0 Z009
Signature �74�pplk'aatt
Print or Type FulI Name and bible
S[�ytir��a �iv� SiAtin
signature ter Property OwnerfAppliraun
Print or'I'ype ElilI Nrinrc and title
Signature of Autheri%sd Agzent, if any
Print or Type F UII Nance and title
Pleatii rLttaraa hvi? cupies of the +:uraapleWd Application package to:
North Carehua DENR-liWQ
Aquifer -Protection Section -I i IC; Progrtni
1636 !Mail Service Center
Raleigh, -NC 27699-1636
7'elgihone [phone]
( P L o t K 3g2Vk iiWI fi"ti0ra t,l1maarr Pwsar+Rso,6ed T2(jL'8I PVC It

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28429
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NORTH CAROLINA
RECEiVEO I DENK ! OWQ
AQUIFFR'PRnTFrTlnN C:FCTION
OCT 2 O 2008
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLO SED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-0 W WELL{S)
In Accordance with the provisions ofNCAC Title ISA: 02C.0200, please
complete this notification and mail to address on the back page (please Print or~ information).
DATE: _ ___,O_c;__.t_· _C--'-7___,. 2008_
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loop)?
Yes_ x_ Continue completing this form.
No __ Do Not complete this form. Complete other UIC application forms for installing
either a 5A 7 well (open-loop well injecting potable water into the aquifer) or a 5QM well (closed-
loop well containing additives such as R-22. ethanol. or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): State of North Carolina . Michael J. Shums ky, P.E.
-Actin g Director for General Services Division
(1) Mailing Address: 1525 Mai l Service Center
City: Ralei gh State: _NC_Zip Code: 27699-1525 County:.....,.W-ak1=-e __ _
Home/Office Tele No.: 919-715-0401 Cell No.:
Email Address: [e-mail] Website: www.ncdot.org
(2) Physical Address of Well Site (if different than above): 5504 Barbados Blvd
City: Castle HAYPe State: NC Zip Code: 28429 County: New Hanover
Home/Office Tele No.: Cell No.:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: ___________________________ _
Contact Person,_: _____________ E=MAIL===A=ddr=es=s.,__: _________ _
Address: ______________________________ _
City: ________ State: __ ZipCode: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: ______________ _
C. WELL DRILLER INFORMATION
Company Natne: Coastal Geothermru
Well Driller Contractor's Name: Sanford Sweeting
NC Contractor Certification No. :NC 2082
Contact Person: Mike Hadley EMAIL Address: mhadley@ bi zec .rr.com
Address: 102 Middle St.
City: Jacksonville Zip Code: 28546 County: Onslow
Office Tele No.: 910-353-0926 Cell No.: 910-376-1100
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company N/A. _______ _
Contact Person"-: ----=E=MAIL===-=-A=d=dre=ss..,_: _________ _
Address: ________ _
City: ___ Zip Code: __ County: __________ _
Office Tele No.: ____ Cell No.: _________ _
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State:_x_ Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loop Geothermal Heat Transfer Systems
This is for a test well and will be used in the final construction of the lOOJ> field
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: No iJ ., -ioo ( Number of borings: __ l __ _
Approximate depth of each boring (feet):_250 _____ _
(2) Type of tubing to be used (copper, PVC, etc): _High Density Polyethylene ______ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes .m: (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: __galvanized steel __ black steel_plastic __ other (specify)
Casing depth: From ___ t.o __ ....;feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No _x __
( 4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite _x_ Other (specify) ______ _
(b) Grout placement: Pumping_x_ Pressure__ Other
(c) Grout depth of tubing (reference to land surface): from _o __ to _250_ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
H. INJECTION-REIATED EQUIPMENT
Attach a dikimun showing the Gnginuct-iiig, layout or proposed nitWi[iewiuii of the irijectiun eyuipirreiit urid exizrior
piping/tubing associated with the injection operation. 'Ihr manufacturer's brochure may provide supplementary
infminalitut.
1. LOCATION M WELIAS)
Mach two copies of maps showing the follo►Hing information:
(1) hicludu a Sitc Map (gait bar drawn) shuwine: buildings. property lines, surface water bodies, potential
sources of groundwater containinal ion and ilk- urivi-oa ion of alit] distances between the prop sad weI1(s) and
tiny eNisting ►rc1I1;) or Kastc disposal ftciiitics such as septic tanks or drain ficlds lucawd wilhin 200 feet of
the geothermal heat put top «411 srslem I -ube! all ivatuies clearly and include a north arrow.
(2) The Site Map must show lhc: ti(ihjetet proptrir• in whititm to tlzc suiruwadiiig area by using, at least two fixed
retercnce voints such as roads, streams. and/or highway intersections.
J. CERTIFICAUON
Note: 'flats J'ermit Application must he signet) lk rarh person altlwaring on the
rerurdLd It -Cut pruperty deed.
1 hereby ccnit}. tinder penalty of law, that 1 have pvtsuilaliy examined and wu ftunibW with the inli71"lllatit.a1
stihnt'ittcd in this docunient t:nd all attachnients thereto and that. based on my inquiry of !host: individuals
iinmediatety respon;ihle for obisining ;aid inrwmatinn, l believe that the infurinanon is true, accurate and complete.
I ani aware !fiat there are significant penalties, inciuding the possibility of !tn►s and irnpri5mnment. for sub! -hitting.
Wsv information. I agree to construct. operate. maintain. repair, and if applicable. abandon the injection well and
all related appurteminces in aecordancr ►%itir 11ic approved specilications and conditions of the Permit
RECEIVED / DENR i DWQ
AQUIFPP'PPnTFrnnN SFrTIO
OCT 2 0 2008
Signature of Prop:. ► wra rlAPlslicant
Print or Type full Name Hod Iide.
Ct��� L,,r tnr �a+^ istY",tra
Sigrimurc: of Proper! Owner/Applicant
Print or )pe fulI Nainc and title
Signuture ol'Autherized Agent. if any
Print car'rypc Ful I Name and title
1'ic::tw reliirn 1%t o cople-i of the completed Application package to -
North Carolina DENit-DWQ
Agniier Protection Sectitrn-tliti: Program
1636Alai! Service Center
Raleigh, NC 27699-1636
Telq)hune [phone]
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Barbados Blvd, Castle Hayne, NC
28429
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http://maps.live-comlprint.aspx?mkt--en-us&z--14&s=r&cp=pqq4mngh9374&poi=Barba-.- 10/17/2008