WI0800183_GEO THERMAL_20100217

Permit Number
Program Category
Ground Water
Permit Type
WI0800183
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Thomas Hyatt SFR
Location Address
2221 Tattersalls Dr
Wilmington
Owner
Owner Name
Thomas
Dates/Events
NC 28403
Hyatt
Orig Issue
02/17/10
App Received Draft Initiated
02/03/10
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Scheduled
Issuance
Central Files : APS_ SWP_
02/17/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Jim Cornette
PO Box 882
Hampstead
Major/Minor
Minor
NC
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Thomas Hyatt
Owner
2221 Tattersalls Dr
Wilmington
Public Notice Issue
02/17/10
NC
Effective
02/17/10
28443
28403
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
47TTVIA
j... &
CDENIZ
North Carolina D.Qpartment of Environment and
Division o` Water Quality
Beverly Eaves Perdue Coleen H. SAirs
Governor Director
2/17/2010
Thomas Hyatt
Ante Hyatt
2221 Tattersalls Drive
Wilmington, NC 28403
Natural Resources
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0800183
2221 Tattersalls Drive
Wilmington. NC 28403
Dear Mr. & Mrs. Hyatt:
Dee Freeman
Secretartr
In accordance with the application submitted to the Underground Injection Control (UIC) Prou-mm that was received on
02/03/2010, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed -loop geothermal water-
o_>y injection well system for the operation of a ground -source heat pump located at 2-121 Tattersalls Drive, Wilmington,
New Hanover County, NC 28403. 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 trust 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]_
Sinc�ely, ��
for Micha ogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Wilmington Regional Office - APS
Z- PS Cc=raI Fiie% - NV.'L'10S00i $2
New Hanover County Health Dept.
Jim Corvette (Applied Resource Management, P.C., P.O. Box 882, Hampstead, NC 28443)
Nate Carr (O'Brien Heating and Air, 3308 Enterprise Drive, Wilmington, NC 28405)
AOUIFER PROTECTION SECTION
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTI-IERMAL
WATER-ON.LY INJECTION WELL SYSTEM:
TYPE 5-QW WELLS I
In Accordance with the provisions of NCAC Title 15A: 02C,0200, please
complete this notification and mail to address on the hack Page (please Print or Tie_ information).
DATE: December 23, 2009
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_
Mused-100 j?
Yes X Continue completing this form,
No Do Not compiete this form. 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 inhibitors).
A. PROPERTY OWNERS)/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 wlauthority for signature): Thomas and Anne Hvatt
(1)
(2)
Mailing Address: 2221 Tattersalis Drive
City: _ Wilmington State: NC Zip Code; 28403 County. New Hanover
Hnmc/Office Tele No.: 910- 520-3625 Cell No.:
Email Address: Website:
Physical Address of Well Site (if different than above):
City:
Home/Office Tele No.:
State: Zip Code:
Cell No.:
County -
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not awn the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person:
Address:
City:
Office Tele No-
State: Zip Code:
Address:
County:
W-3fi22rox
Website Address of Company, if any: kIV>r0 J 1]ENR f 171P+lC#
MquRel ion Secdorn
GPUIUIC 5QW Notification oP Intent Form {Revised 8,2008) FEB 0 3 2010 Page I

' .
C. WELL DRILLER INFORMA'flON
Company Name: A pp lied Resource Mana gement. P.C.
Well Driller Contractor's Name: ..... H-. M-.-ic-h=a~e•-s~a=g=e ________________ _
NC Contractor Certification No.: 2531-A
Contact Person~: =J=im~C~o~rn=e=tt=e __________ =E~M=A-1._L ... A....,..dd=r .... e=ss'"'":"""J'""'im=--"A'-=-R=M=®=b--=-e=lls=o'""u=th=.n=e=t __
Address: ___ P~.O~ ...... B ___ o=x ..... 8~8=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 lNFORMATION (if different than driller)
Company Name: O'Brien Heatin g and Air
Contact Person"-: -=-N-=a=te=-C=ar=r ________ -=E=MA=-==IL=--=--aA=d=d._re=ss __ : __ N __ a=te=®=o=br:..c.ie=n=s=erv'--'-'-'ic=e:..:..:.c=o=mc:,__ __
Address: 3308 Enterprise Drive
City: Wilmin gt on 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 geothennal system. Water onl y. Grouted alon g the loo p's entirety.
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: __ 2"'"'/1~0~/2"""0'""1-"-0 _____ Number of borings: __ 6~--
Approximate depth of each boring (feet): __ -=2~0~0-' _____ _
(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 2! (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 Other (specify) Thermex
(b) Grout placement: Pumping __ Pressure Other __
(c) Grout depth of tubing (reference to land surface): from 0 to 200 {feet)
If well has casing, indicate grout depth: from to (feet)
GPU/UIC 5QW Notilication oflntent Form (Revised 8/2008) Page 2
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the in_jectiort equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing. buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing wells) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Lahel all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference prainis such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by em
I person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, 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 injtcction well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit"
Si mature of Property Ow er/Applicant
�z�
Print or Type Full Nastae and titl;/-
L'__ -;P - J4 -
Signature of Property Owrterl4
plicant
pli, m L T I! �L Q.-- f 7
Print or Type Full Name • ,d title
Signature of Authorized Agent, if any
Print or Type Pull Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-LTIC Program
1636 Mail Service Center
Raleigh., NC 27699-.1636
Telephone [phone]
OPUASIC 5QW Notiticadon of intent Form (Revised 3n008) Nip 3

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IF
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Approximate Property Lines
Approximate Building Perimeter f
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
2. Well locations are approximate and will be a minimum of 20' apart and 25' from the building.
3. Adapted from Google Earth and New Hanover County GIS Map, November 2009.
TITLE: SITE MAR FIGURE:
7� jcd Kcoource Mana�: ement f C 2221 TATTERSALLS DRIVE
am JOB: SCALE: DATE: DRAWN BY:
[phone] FAX [phone] Hyatt I" = --100' 12/23/09 DNH

kol
O
N
Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
2. Well locations are approximate and will be a minimum of 20' apart and 25' trom the building.
3. Adapted from Google Earth and New Hanover County GIS Map, November 2009.
TITLE: SITE MAP FIGURE:
At
:lied Keaource Mana ement FIC 2221 TATfERSALLS DRIVE
Box ampsteod. NC 28443 JOB: SCALE: DATE: DRAWN BY:
410} 27�-2919 FAX [phone] Hyatt 1 " - 100' 12/23/09 DNH

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Approximate Property Lines
Note: Adapted from Goggle Earth and New Hanover County GiS Map, November 2009.
TITLE: SITE VICINITY MAP FIGURE:
.lied ize5aurce Marra. etnent PC 2221 TATTERSALLS DRIVE
BOX 862, HOMPSTea JOS: SCALE: DATE: DRAWN BY:
k
7�,
910) 270-2919 FAX [phone] Hyatt 1 " -•400' 12/23/09 DNH 2
ail

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Approximate Property Lines
1.d
W.,
Note: Adapted from Google Earth and New Hanover County GI5 Map, November 2009.
TITLE: SITE VICINITY MAP FIGJRE:
.lied Ke aurce Mana zemenC f G 2221 TATTERSALLS DRIVE
am S . Hampstead, 4 Job; SCALE: DATE: DRAWN BY:
At.ia� 2�o z4i9 Fax z�a z�sa Hyatt 1 " = --400' 12/23/09 DNH
IF #I
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL(S)
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~ information).
DATE: December 23. 2009
Well Type Confirmation: Does the proposed system circulate potable water onl y (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loo p)?
Yes X Continue completing this form.
No ___ Do Not complete this form. Complete other UIC application forms for installing
either a SA 7 well ( open-loop well injecting potable water into the aquifer) or a SQM 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): Thomas and Anne H yatt
(1) Mailing Address: --~2=22=1~T~att~e=r~sa=ll=s~D~r~iv~e ____________ _
City: Wilmin gt on State: ___NQ__ Zip Code: 28403 County: New Hanover
Home/Office Tele No.: 910-620-3625 Cell No.:
Email Address: _________ -'W""--""eb"""s=it=e'-: _____________ _
(2) Physical Address of Well Site (if different than above): _______________ _
City: __________ State: __ Zip Code: ______ County: _____ _
Home/Office Tele No.: ----------------=C"---'e=ll'---"N'--'-o=.-'---: __________ _
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_MA __ IL_A_d_dr_e_ss~: ___________ _
Address:----------------------------------
City: _________ State: __ Zip Code: ______ County: ________ _
Office Tele No.: Cell No.:
website Address of Company, if any: RECEIVED I DENR I DWQ Aquifer Protection Section
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) FEB O 3 2010 Page 1
C. WELL DRILLER INFORMATION
Company Name: A pplied Resource Management. P.C.
Well Driller Contractor's Name: --'H~. M=i=ch=a=e-=-l=S=ag_,_e~-----------------
NC Contractor Certification No.: 2531-A
Contact Person,_: --"'J=im=--.::C"-'o~m=e=-.,tt::c::e=--------------=E=MA'-=-'=IL=-=-A=d=d=re=s"-"s.,_: --"'J=im~A=RM==,b=e=ll=so=u=t=h.=n=et-"--------
Address: __ ___:a..P..:..:.O=•c..:B=o=x:...;8=8=2=-----------------------------
City: Hampstead Zip Code: 28443 County: ---=P-=e=n=de=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 Heating and Air
Contact Person,_: -=N_,_,a=te=-----=C=arr=-------------=E=MA'-="=IL=-=-A=d=d=re=s=s-=-: N=-=a=te""@ ... o=b=r""ie=n=s=erv~ic=e~.c~o=m~--
Address: -----=3-=-3-=-0=8 -=E=n=te=r .. p=ri=se=-D==ri""'"v-"-e ________________________ _
City: Wilmington Zip Code: 28405 County: ___ N_e_w_H_an_o_v_e_r ______ _
Office Tele No.: _ ___,....91~0--7~9~9~-6_6_1 _1 _____ 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 Loop g eothermal s ystem. Water only. Grouted along the loop's entiretv .
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: __ 2~/1~0~/2~0-=l~0 _____ Number of borings: __ 6 __ _
Approximate depth of each boring (feet): ___ 2_0_0' ______ _
(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 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 Other (specify) Thermex
(b) Grout placement: Pumping __ Pressure Other
(c) Grout depth of tubing (reference to land surface): from 0 to 200 (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/UIC 5QW Notification oflntent Form (Revised 8/2008) Page 2
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WEL"S)
Attach two copies of maps showing the following information_
(1) include a Site Map (can be. drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed wed(s) and
any existing wells) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Maly must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"1 hereby certify, ender penalty- of law, that i have personally examined and am familiar with the information
submittal 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 the Permit."
St_ nature of Property Ow erlApplicant
/n'Y -r-- '-5" Ae01 /-�� -
Print or Type Full Name and tit/
x-L-' 1#
Signature of Property Ownerlpplicant
Print or Type Full Name Ad 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 DENR DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/WC 3QW NatiCieanon of Intent Form (Revised 9/2009) Page 3

New Hanover County
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New Hanover County
Profile
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Land
Values
Agricullural
Sketch
Full Legal
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Sub -Pa "I(s) Info
Original Parcel Info
Parcel Map
PARYD: ROGOIS-002-036-000
HYATT TH014A5 E ANNE P
I CONTACT US j iiELP
HHC Tax Home a Register or Peeds riomi:
Home Property Records
Owner Address Parcel ID Advanced
Last G1S Data Update: 1-Oct-2008
2221 TATTERSALLS OR CURREW RECORD
N If 7 0f 18 Y N
Data Copyright New Hanover County [Dlsdalmer] [Privacy Policy] Last updated: 28 Dec 2009
7 Site Design Copyright 1999-2006 Akanda Group LLC. All rights reserved.
http://elax.nhcgov.com/Forms/MapDatalet.aspx?slndex=O&idx=7&LMparent=20 1II 1/2010

. New Hanover County
PARID: R06015-002-036-000
HYATT THOMAS E ANNE P
Parcel
Alt ID
Address
Unit
City
Zip Code
Neighborhood
Class
Land Use Code
Living Units
Acres
Zoning
Legal
Legal Description
Tax District
Owners
Owner
City
State
Country
Zip
312611.65 .7765.000
2221 TATTERSALLS DR
WILMINGTON
1440
RES-Residential
958-Unused Land
1
.5051
R-15-RESIDENTIAL DISTRICT
LOT 21 PH 2 GLEN MEADE EXTENSION
WM
HYATT THOMAS E ANNE P
WILMINGTON
NC
28403
THE DATA IS FROM 2009
Page 1 of 1
2221 TATTERSALLS DR
http:/ /etax.nhcgov.com/F orms/PrintDatalet.aspx?pin= R06015-002-036-000&gsp= PRO FIL... 1 /11/2010
it
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4( 3W.,
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Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
2. Well locations are approximate and will be ❑ minimum of 20' apart and 25' from the building.
3. Adapted from Googie Earth and New Hanover County G!S Map, November 2009.
TITLE: SITE MAP FIGURE:
-lied Ke5ource Management FG 2221 TATTERSALLS DRIVE
7 P-PO. eox 8132, Hampstead, .]CB: SCALE: DATE: DRAWN BY:
1910) 270-2919 FAX [phone] Hyatt 1 N = _ 1 00' 1 2/23/09 DNH

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Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
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Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
2. Well locations are approximate and will be a minimum of 20' apart and 25' from the building.
3. Adapted from Google Earth and New Hanover County GlS Map, November 2009,
TITLE: SITE MAP FIGURE:
r-lied Rdoource Mara. emer+t PC 2221 TATTERSALLS DRIVE
x bkS2. HOMPSWCO,JOB; SCALE: DATE: DRAWN BY:
At410] 270 29�9 FAX [phone] Hyatt 1 " = ---1 pp' 12/23/09 DNH

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Approximate Property Lines
Note: Adapted from Google Earth and New Hanover County Gfs Map, November 2009.
TITLE: SITE VICINITY MAP FIGURE:
}lied Re5aurce Marra ement PC 2221 TATTERSALLS DRIVE
ar UU4 HOMPSIeW,JOB: SCALE; DATE; DRAWN BY:2
(910} 270 2914 FAX 27Q 2988 Hyatt I" _ — 400` 1 2/23/09 DNH
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Approximate Property Lines
Note: Adapted from Google Earth and New Hanover County GIS Map, November 2009.
i
TITLE: SITE VICINITY MAP FIGURE:
,ied I�ei5ource Mar�aiemernt FC - _ 2221 TATTERSALLS DRIVE
7kzp,
. I
ox Hc�-n 44 JOB: SCALE: f]ATE: DRAWN BY:
0)270-2919 FAX [phone] Hyatt 1 " =---400' 12/23/09 DNH 2
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