WI0800181_GEO THERMAL_20100113

Permit Number
Program Category
Ground Water
Permit Type
WI0800181 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastaf SW Rule
Permitted Flow
Facilitv
Facility Name
Adrian Sanders SFR
Location Address
1106 Pine Gate Ct
Leland
Owner
Owner Name
Adrian
Dates/Events
NC 28451
Sanders
Orig Issue
01/13/10
App Received Draft Initiated
01/11/10
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Scheduled
Issuance
Central Files : APS_ SWP_
01/13/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Afflllatlon
Adrian Sanders
Owner
1106 Pine Gate Ct
Leland
Major/Minor
Minor
NC
Region
Wilmington
County
Brunswick
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Adrian Sanders
Owner
1106 Pine Gate Ct
Leland
Public Notice Issue
01/13/10
NC
Effective
01/13/10
28451
28451
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
•~A •• ,.~
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Adrian Sanders
Karen Sanders
1106 Pine Gate Court
Leland, NC 28451
Coleen H. Sullins
Director
1/13/2010
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0800181
1106 Pine Gate Court
Leland, NC 28451
Dear Mr. & Mrs. Sanders:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (IBC) Program that was received on
01/11/2010, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed-loop geothermalwater-
only injection well system for the operation of a ground-source heat pump located at 1106 P_ine Gate Court, Leland,
Brunswick County, NC 28451. This system is deemed permitted by rule (North Carolina Administrative Code Title 15A,
Subchapter 2C, Section .021 l(u)(2)).
However, it is recommended that you contact the Brunswick 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].
3/1· ~&_~
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI0800181
Brunswick County Health Dept.
for Mic:tt-Rogers
Environmental Specialist
GPU-Aquifer Protection Section
Jim Cornette (Applied Resource Management, P.C., P.O. Box 882, Hampstead, NC 28443)
Jimmy Williams (O'Brien Heating and Air, 3308 Enterprise Dr., Wilmington, NC 28405)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Caoital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] i FAX 1: 919-715-0588: FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity I Affirmative Action Employer
NirthCarolina
Naturally
wT-DW3« I
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTEIIERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-OW WELL(5)
In Accordance with the provisions ofNCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Type information)_
DATE: November 19. 2009
Well Tyne 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 forma Complete other UIC application forms for installing
either a 5A7 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 hdiibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List gK Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauth❑rity for signature): Adrian and Karen Sanders
(1) Mai ling Address: 1106 Pine Gate Court
City: Leland State: NQ Zip Coder28451 County: Brunswick
Ho►nelOffiee Tele No.: 910-722-0010 Cell No.:
ErnaiI Address: Website:
(2) Physical Address of Well Site (if di&rent than above):
City- slate: Zip Code: County:
Home/Office Tele No.: Cell No.:
S. AUTHORIZED AGENT OF OWNER, IF ANY (if the Pennit 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: EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Cell No__
Website Address of Company, if any:
]RECE1vED 1 DENR 19M
GPU/U1G 5QW Noti£cat on of Intent Form (Rcvised 912008) AqLNw Pr*dVA ti KOW Fags I
JAN I 1 M0

C. WELL DRILLER INFORMATION
Company Name: A pp lied Resource Management. P.C.
Well Driller Contractor's Name: ~H~. ~M=i~ch=a~e-1 ~Sa._.g ___ e~-----------------
NC Contractor Certification No.: -----=2=5-=-3~1--=-A-=-----------------------
Contact Person-: -=-J=im~C=o=rn=e=tt=e __________ --=E=M.a.=...aA=IL=-a..A=-=d=d=re=s=s:"'---""Ji=ma:_a.A=RM=a..®-",b=e=ll=s-=-ou=t=h=.n=et.,__ __
Address: __ .... P...,.=O_._. =B....,o ......_88=2.._ ________________________ _
City: Ham pstead Zip Code: 28443 -County: ---=-P-=-e=nd=e~r ________ _
Office Tele No.: 910-270-2919 Cell No.: 910-512-4890
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: O'Brien Heatinll and Air
Contact Person: Jimmy Williams EMAIL Address: Jimm y<@.obrienservice.com
Address: 3308 Ente mrise Drive
City: Wilmin gton Zip Code: 28405 County: ----'-N_,_,e=w-'--"-'H=a=no-=-v'""'e..,_r ______ _
Office Tele No.: 910-799-6611 Cell No.: __________ _
E. STATUS OF APPLICANT
Private: _X_ Federal: Commercial:
State: Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p geothermal s ystem. Water onl v. Grouted alon g, the loo p's entirety.
G. WELL CONSTRUCTION DATA
(]) Proposed date to be constructed: 1/15/2010 Number of borings: 5
Approximate depth of each boring (feet): __ .=2=-50"-'------
(2) Type of tubing to be used (copper, PVC, etc): ___ H_D_P_E ___________ _
(3) Well casing. Is the well(s) cased? (check either {a.) Yes or (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)
(b)
Grout type: Neat Cement__ Bentonite Other (specify) ~T ... h=e=1m=e....,.x __
Grout placement: Pumping__ Pressure__ Other __
(c) Grout depth of tubing (reference to land surface): from O to 250 (feet)
ff well has casing, indicate grout depth: from ___ to ____ (feet)
1.-t.,N1J. \ HYl3'J \ tdVl3:jJ:-i
GPU/UJC 5Q)\~NeHfid atihii·bf i~t~lit ~·onn (Revised 8/2008) Page2
H. INSLCx ION-R,ELATEA EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injcctiots cquil)merit and exterior
piping/t�blng Mwiated with the 1hjeail6n operation. The manufacturer's brochure m2y provide suppiementaty
information.
L LOCATION OF WEL VS)
Attach two copies of reaps showing the foi lowing inf<am=ion,
(1) include a Site Map (can be drawn) showing: buildings, property line s, sur]i" wine. br dies, potential,
sprees of groundwater contamiriaaion and the orientation of and distances betwuun thu pmposcd wells) and
any existing well(s)or waste disposal facilities such as septic tanks or drain r1c1ds locatcd within 240 fett of
the geothermal heat ptarip well syst=n.- Label all featu= clearly and include a north,.arrow.
(2) The Site Map racist show the subject p!operty in relation to cite surrounding erect by uyim•, at least iwv fixed
refemce points such as roads, streams, and/or highway intersections,
J, CERTIFICATION
Note: This Permit Application mast be slgned by each person appearing on the
recorded legal property deed.
"I hereby certify, colder penalty of law, That I have personally examined and am fandliar wiih the information
submilted in this documetit and all attachments thereto wd lhat, based on my inquiry of those individuals
immediately responsible for obtaining said information. I believe that the information is true, accurate and vompleta.
I am aware that there are significant peinaltaes, includine the possibility of fines and itnprisnnment, leer WbmittiTtg
false information. I agree to construct, operate, -maintain, repair, and if applicable, ahmion fFw injection well and
all related appurtenances In accordance with, the approved sp~cifications and condition;: o[*the Permit-"
Signature of Property Dwner/Applicant _.
Ti/407 Jrto�s"S
Print or Type Fult Name and title
Signature ofPropcM Owner/Applicant
Gd°4n V_ Sa-iAri
} Print or Type Full Name and title
Signature Of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina D NR QWQ RECEIVED r DENR I DWQ
Aquifer Protection Sectiork-UIC Progra rn Aqu*r ftf djon SWJon
1636 Mai! Service [ enter JAN I 1 2D1�
Raleigh, NC 21699-1636
Teleplwne (91.9) 715-6935
C.P111UIC 5QW Nhtiir►;IalVA csi Intent Munn [RLviyal sf2v s) 11:kcc
bet WJM:Ze OWE zl •uef oral 3NOHd etc{P.,tU dIn no?oy� ; biMid

Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public sewer and water.
2. Well locations are approximate and will be ❑ minimum of 20' ❑part and 25' from the building,
3. Adapted from Google Earth and Brunswick County GIS Map, January 2010.
TITLE; SITE MAP FIGURE:
7 r-ulied Kcoource Management PC .__ 1 1 Db-Pine Gate Court
Po. Box 882, Hampstead, NC 28443 JOB: SCALE: 1DATE: �IDRAWN BY:
[phone] FAX [phone] i Sanders 1 "' _--+135' . 117]09 DNH

1/11/2010
Print Preview
Brunswick County, NC
HA61340N P�11+iSS C�'lJR7. 097JH01C�
Q37JFlg03 �i
437JH017
037 JH021 PE ER%tN D WE
¢ 037JkS?2$ ,
t337JH01� _- --
' I 037JH022
4 !
{i ea
i
1 `037JH025
'a37KCO75
D37K4014
Parcel Number
037JH023
Plat Date 18/21/2007
Account Number
23595070
Land Value 1$152,400
PIN
1219709150769
Building Value i $o
Owner SANDERS ADRIAN ET KAREN
Other Value
$0
Ow Ter Address I
Deferred Value i $0
Ow 7erAddress 2
106 S LAKESHORE ❑R
Total Taxable Value
$152,000
City
WHISPERING PINES
Heated Sq Ft
State
NC
28327
Year Built
Bedrooms
Zip
Legal Description
Full Baths
Parcel Street Number
stories
Parcel Street
Ext. Wall I
Ext. Wall 2
Neighborhood
AAvnicipafJty
! 201A
LELAND
Street Type
Street Dir
{
Subdivision
HAMPTON PINES @ MAGNOLIA GREENS
2056
0358
12/9/2004
Deed Book
Fire Tax District
LELAN❑
Deed Page
Township TOWN CREEK
Deed Date
Acreage
Plat Book
0042
Sale Price I $0
Plat Page
0097
1
Disclaimer Map and parcel data are believed to be accurate, but accuracy is not
AA7n Cnalep
http://gis.brunsco.net]printPreview.as... 112

Ro gers, Michael
From:
Sent:
To:
Diana Helias [[e-mail]]
Monday, January 11, 2010 12:48 PM
Rogers, Michael
Subject:
Attachments:
NOi Pine Gate Court -Sanders Property
NOi Pine Gate Court.pdf
Michael,
Please find attached to this message, an NOi for the Sanders Property at 1106 Pine Gate Court in Brunswick County. A
, hard copy will follow via USPS.
Please let me know if any additional information is needed.
Thank you,
Diana Helias
Project Coordinator
Applied Resource Management, P.C .
www.ARM-PC.com
ARM's Waterworks
www.WaterWorksWells.com
910.270.2919
910.270.2988 Fax
P.O. Box 882 4 .,
Hampstead, North Carolina 28443
1