WI0800204_GEO THERMAL_20100722

I
Permit Numbe r WI0800204
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (50W)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
William Ferris Kelly SFR
Location Address
107 Webb St
Swansboro
Owner
Owner Name
William
Dates/Events
NC 28584
Ferris Kelly
Orig Issue
07/22/10
App Received Draft Initiated
07/21/10
Re gulated Activities
Heat Pump Inj ection
Private res idence, sing le family
Outfall NULL
Scheduled
Issuance
Central Files : APS_ SWP_
07/22/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
William Ferris Kelly
Owner
107 Webb St
Swansboro NC
Major/Minor
Minor
Region
Wilmington
County
Onslow
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
William Ferris Kelly
Owner
107 Webb St
Swansboro NC
Public Notice Issue
07/22/10
Effective
07/22/10
28584
28584
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
CDEN
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Govemor Director
7/22/2010
William Ferris Kelly
107 Webb St.
Swansboro, NC 29584
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10800204
101 Webb St.
Swansboro, NC 28584
Dear Mr. Kelly:
Dee Freeman
Secretary
On 07/21/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a Closed -loop water -aril■
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 Well Construction Act and North Carolina
Administrative Code Titic 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Cnsiow 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 Michaei.Rogersfa nedenr;gov if you have any questions.
Sinefely,
for Debra
Supervisor
cc: Wilmignton Regional Office - APS
APS Central File: - Permit No_ WI08002041
anslow County Health Dept.
Mike Smith (Climate Control Heating & Cooling Co., Inc., 102 Middle St., Jacksonville, NC 28546)
AQUIFER PROTECTION SECTION
1636 Mail Senrlce Center. Raleigh, North Carolina 27699-1635
Localinn; 2726 Capital Boulevard, Raleigh, North Carolina 27604
Phone. [phone] FAX 1 9i9 71a-05$E; FAX 1 919.71M048 I Customer Selvlcs: 1.877-623.6748 NorthCaroUa
Internet www.ncwatemuatitr-vrg ry���R� r��
Ain Equal Opponunlo ti Aihrmalive Action Emoloye N

VJDOZM:;�
AQU mn� nN N TION
NORTH CAROLINA JUL I I mo
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INT NT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLN
In Accordance with the provisions of NCAC Title I5A: 42C.0200, please
complete this notification and mail to address on the back page (please Print or 1W information).
DATE: July. 19 , 2010
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 5A7 well ❑ n-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): William Ferris Kelly
IL
(2)
Mailing Address: 147 Webb St_
City: Swansboro State: NC Zip Code: 28584 County: Onslow
Horne/Office Tele No.: 910-577-2652 Cell No.:
Email Address: Website:
Physical Address of Well Site (if different than above);
City: State: Zip Code:
Home/Wice Tele No.: Cell No.:
County:
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 1AC well)
Company Name:
Contact Person: _. EMAIL Address:
Address:
City:
State; Zip Code:
County:
Office Tele No.: Cell No.:
Website Address of Company, if any:
GPUtWC 5QW Notification of mien Farm (Revised 9/2008) Page t

C. WELL DRILLER INFORMATION
Company Name: ___ C=oa""s"'tal=-"G"--'e:'.-"o'-"'th~e~rm=al,__ ____________________ _
Well Driller Contractor's Name: -'=S""an""'fi""o:.e.:rd=S_,_,w--"'ee"'"'t=in.!l:a,__ __________________ _
NC Contractor Certification No.: NC 2082 ______________________ _
Contact Person . ..:..: -=-M'-"'1o:;.k,.::ce...::S=m=i=th_,__ ______ _____:E=MA.:.=..:=IL=A=d=d=re=s=s:'--------=m=sm=1=·th=®=b-=iz=e=c.=rr=.c=o=m~---
Address: 102 Middle St.. ___________________________ _
City: Jacksonville Zip Code: 28546 _____ County: __ _,O""'ne.::s~lo"-w:.,:__ __ _
Office Tele No.: 910-353-9040 _______ Cell No.: 910-376-1101 ________ _
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Climate Control Heatin e: and Cooling Com pany Inc.
Contact Person: Mike Smith EMAIL Address: [e-mail]
Address: 102 Middle St. ___________________________ _
City: Jacksonville Zip Code: 28546 County: __ _,O=ns=lo'-'-w.,____ ____ _
Office Tele No.: 910-353-9040 _____ Cell No.: 910-376-1101 ________ _
E. STATUS OF APPLICANT
Private: X
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p Geothermal
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _______ Number of borings: 4
Approximate depth of each boring (feet): ____ 200_
(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 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) 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 _0 __ to __ 200 __ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Fonn (Revised 8/2008) Page2
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.
1. 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 well(s) 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 Map 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.
"I hereby certify, under penalty of law, that I have personally examined and am familiar wdth 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 spe 's ' ti is and conditions of the Permit"
Signature ojf'Pr vrtv erlApplicant
RECEIVED IDEHR I DWQ !! �.',�r�'1
1'�1.IIFFR'aRnTFMn 4Fi.MN
JUL g I Print or Type Full Name and title
Signature of Property OwnerlAppticant
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 DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephrine [phone]
GPU/UIC 5QW Notification of Inient Form (Revised WON) Page 3

Map of 107 S Webb St, Swansboiro, NC 28584-9668
Page I of I
Map of 107 S Webb St, Swansboro, NC 28584-9668
When using any driving directlons or map, it's a good idea to do a reality check and snake sure the mad still exists,
watch out Far construction, and follow all traffic safety precautions. Tbis is only to he used as an aid in planning.
http:llmaps.yahoo.comlptint?mvt=m&ioride--vs&'tp=1 &stx=&fcai=&fat�&clat=34.689Q 1... 7/20/2014

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RECEIVED/ DENR / DWQ
AQUIFl=R"PROTFrTION SF.CTION
NORTH CAROLINA JUL ! 1 2010
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENII) .
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-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: __ __,,_Ju=l'-'-'y,......,1=9--~· 2010
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the enviromnent (i.e.
closed-loop)?
Yes _X _ Continue completing this fonn.
No ___ Do Not complete this fonn. Complete other UIC application forms for installing
either a 5A7 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): __ W--'-'-"i=lli=a=m~F'""'e=rr=is~K=el __ ly.__ ________ _
(1) Mailing Address: 107 Webb St. ____________________ _
City: Swansboro State: NC Zip Code: 28584 County:~O~n=s=lo~w __ _
Home/Office Tele No.: 910-577-2652 Cell No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above): ______________ _
City: _________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: --------------'C=e=ll,._,N=o=·c:....: __________ _
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=s=s~: __________ _
Address: ________________________________ _
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: _______________ _
GPU/UIC 5QW Notification of Intent Fonn (Revised 8/2008) Page I
C. WELL DRILLER INFORMATION
Company Name:. ___ ~C~o~as~ta~l~G~e~o~th"'e~rm=a!....l _____________________ _
Well Driller Contractor's Name: __,,,S~an:fi=o,.__,rd~Sw=ee~t""in~g,.__ __________________ _
NC Contractor Certification No.: NC 2082. ______________________ _
Contact Person._,_: ...:.;M!.!ci~k~e2,,S~m,!.!i~th~------~E~MA~~IL~A~d~dr~e~s~s:'-------_ ___Jm=sm"'--"'ith~@~b:!.,!iz""e""-c.'""rr'--'-'.c"'o""m~---
Address: 102 Middle St. ___________________________ _
City: Jacksonville Zip Code: 28546 _____ County: ------=O=n=s=lo::..:w..,__ __ _
Otlice Tele No.: 910-353-9040 _______ Cell No.: 910-376-1101 ________ _
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Climate Control Heating and Cooling Company Inc.
Contact Person: Mike Smith EMAIL Address: msmith@ bizec.rr.com
Address: 102 Middle St. ___________________________ _
City: Jacksonville Zip Code: 28546 County: __ ...::O::..o.n!"'s=lo'-"w'-------
Office Tele No.: __ 910-353-9040 ______ Cell No.: _910-376-1101 ________ _
E. STATUS OF APPLICANT
Private: X
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p Geothermal
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _______ Number of borings: 4
Approximate depth of each boring (feet): ____ 200
(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 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) 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 __ 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 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 well(s) 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 Map must show the subject property in relation to the surrounding area by using at least two fixed
reference paints such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signer/ by each 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. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved spec' " ati is and conditions of the Permit"
Signature of pr nerlApplicant
t
all�
'W®11EDFDOR IDWa Print or Type Fui 1 Name and title
JUL It 2019
Signature of Property Owner/Applicant
Print or Type Full Name and 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-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification of Intent Form (Revised 812008) Page 3

Map of 107 S Webb St, Swansboro, NC 28584-9668
Page 1 of 1
Map of 107 S Webb St, Swansboro, NC 28584-9668
When using any driving directions or map, it's a good idea to do a reality check and make sure the mad stilt exists,
watch out For construction, and Follow all traffic safety precautions. This is only to be used as an aid in planning.
http://maps.yahoo.comlp&Vmvi m&ioride=us&tp=l&stc--8cfcat=&frat=&c1at--34.68901... 7/20/2010

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