WI0800207_GEO THERMAL_20101006

Permit Number
Program Category
Ground Water
Permit Type
WI0800207 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Judith P. Wilson SFR
Location Address
6632 River Rd
Wilmington
Owner
Owner Name
Judith
Dates/Events
NC 28412
p Wilson
Orig Issue
10/06/10
App Received Draft Initiated
09/27/10
Reaulated Activities
Heat Pump Inje ction
Private re sidence, single family
Outfall NULL
Scheduled
Issuance
Central Files : APS_ SWP_
10/06/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Judith P. Wilson
Owner
6632 River Rd
Wilmington
Major/Minor
Minor
NC
Reg ion
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Judith P. Wilson
Owner
6632 River Rd
Wilmington
Public Notice Issue
10/06/10
NC
Effective
10/06/10
28412
28412
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
MCDGNR
North Carolina Department of Environment and Natural Resources
Division} of Water Qualify
Beverly Eaves Perdue Coleen H, Sullins
Governor Director
10/06/2010
Judith P. Wilson
6632 River Rd.
Wilmington, NC 2ii412
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10800207
6632 River Rd.
Wilmington, NC 28412
Dear Ms. Wilson:
Dee Freeman
Secretary
On 09/2712010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -on),
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:
The injection well system contains only potable water,
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
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 Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the New Hanover 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.Rogersgncdenr.cov if you have any questions.
Sinc rely,
for Debra tjAU
Supervisor
cc-. WiImington Regional Office - APS
APS Central Files - Permit No. WI0800207
New Hanover County Health Dept.
Jim Comette (Applied Resource Management, P.C., P.O. Box 882, Hampstead, NC 28443)
Chris Maurice (Emmet's Heating and Air, 120 Circle Dr., Hampstead, NC 28443)
AQUIFER PROTECTION SUMON
1636 Mail "Service Center, Raleigh, Norttr Carolina 27699.1636
Location: 2726 Capital Boulevard, Raleigh. North Gamlina 27604 ��
Phone [phone] EAV 915-715-0586: FAX 2; 919.715-6648 l Custorner S wics:1-877.5.3-6746 N06A 3 Carol [na
intamet, www.amateroualih.om A
An EGuJ OppcoijMy 4Afflrmahv� AtIm EMptyer (iiC�i��kL�W

RECEIVED I ❑ENR I DV M
AQW(er Pr*v:tion 5erhon
NORTH CAROLINA P 2 7 2010
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDE
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5_-4W WELL(S)
1n 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: Sevtember 23. 2010
A.
B.
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 -loon)?
Yes X Continue completing this form.
No Do Not complete this form. Complete other LTIC application forms for installing
either a 5A7 well (gpen-loop well in 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).
PROPERTY OWNER(S)IAPPLICANT(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): Judith P. Wilson
(2)
Mailing Address:
6532 River Road
City: Wilminyion State: NC Zip Code:28412 County: New Hanover
Home/Office Tele No.: 910-791-6799 Cell No.: 910-599-4397
Email Address: iwilson4�ivcharter.net Websi(e:
Physical Address of Well Site (if different than above):
City:
State: Zip Code: County:
Home/Office Tele No.: Cell No.:
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 LTIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
State
Website Address of Company, if any:
Zip Code:
County:
GPU/LnC 5Qw Notification of Intent Fortn (Revised 9/2008) Page 1

C. WELL DRILLER INFORMATION
Company Name: A pp lied Resource Management. P.C.
Well Driller Contractor's Name: """'H='-'. M"'-=ic=h=a=e=--1 S=a=g=e ________________ _
NC Contractor Certification No.: --~2=5=3=1-~A~--------------------
Contact Person~: ~J=im~C~o=m=e~tt~e __________ =E=MA=I=L_A~dd~r~e~ss~:~J_im_A_RM_._G~,b_e_ll~so_u_th_._ne_t __
Address: ___ P_.O~._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: __ ~E~m~m=e~t'~s =H=e=a~tin=g,._· =an=d~A~ir _____ _
Contact Person: Chris Maurice EMAIL Address:
Address: ------=-1=20=----=C=ir=c=le'--"D""r=iv"'""e'--________________________ _
City: Hampstead Zip Code: 28443 County: ---=P~e=n=de=r ______ _
Office Tele No.: 910-228-1108 Cell No.:
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 e.eothermal sy stem. Water only, grouted alon g the loo p 's entiretv.
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _______ 9"""'/3'""'0"'""/l""'0'-------Number of borings: __ 4 __ _
Approximate depth of each boring (feet):_-----"2~5~0-' _____ _
(2) Type of tubing to be used (copper, PVC, etc): __ HD_P_E _____________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes!!! (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)
(c)
Grout type: Neat Cement __ Bentonite
Grout placement: Pumping__ Pressure X
Other (specify) --"T~h=e=rm=e=x...__ __
Other
Grout depth of tubing (reference to land surface): from 0 to --"2~5~0_' __ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page2
03/26/2008 02:34 9107916799 JUDVWILS□NlZZILS PAGE 03/03
H. JNJECTION-RELA TEO EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment aod exterior
piping/tubing llSSOciated 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 infonnation:
(1) Include a Site Map (can be draw1;1) 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: Thi5 Perodt Application must be signed. by~ person appearing on the
recofded 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, maintajn, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
. /DENR/DWCl
Aooifr--·· ;:,,,,t~r.tion Sectiort
SC:P 2 7 2016.
~ /. u.J;t--
ig~ of Property Owner/ Applicant
$J,f h f. IA/2 fr lb • OwYJlf'
7 Print or Type Full Name and title
Signature of Property Owner/Applicant
Pdnt or Type Full Name and title::
Signatu(e 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
Aquife.-Protection Section-VIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification oflntent Form (Rllvised 8/2008)
New Hanover County
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PARID: R07800-005-004-001
WILSON IUDITH P 6632 RIVER RD CURRENT RECG'R0
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Last GIS Data Update: 4Jan-2016
Data Copyright New Hanover County [Disclaimer] [Privacy Policy] Last Updated: 20 Sep 2010
7 Site Design Copyright 1999-2006 Akanda Group I-C. All rights reserved.
Aqu fer P pt ra sedon
SEP 2 7 ZM
http://etax.nhegov.wua/Forms/MapDataletLaspx?sIndex=a&idx=1 &LMparent=20 9/23/2010

Approximate Property Lines
Approximate Structure Location
RECEIVED I DENR r DV40
`y.. Approximate 250' Deep Closed Loop Locations Aquifer Prpterti°n Sedon
SEP 2 7 zo10
Notes:
1, Subject property and surrounding area are currently serviced by private septic,
2. Geothermal well locations are approximate and will be ❑ minimum of 20' apart.
Adapted from New Hanover County GIS Map and Google Earth, September 2010
TITLE: SITE MAP FIGURE;
7 P,,.O. piim Keoouroe Mara?ement PC 6632 River Road
Box 882, Hampstead,JOB, SCALE: DATE: DRAWN BY:
�910) 270-2919 FAX [phone] Wilson As Shown 9/23/10 DNH

Approximate Property Lines
Approximate Structure Location
Approximate 250' Deep Closed Loop Locations RECEIVED i DENR / DWQ
Aquifer Protection Section
SEP 2 7 Zola
Notes:
1. Subject property and surrounding area are currently serviced by private septic.
2. Geothermal well locations are approximate and will be ❑ minimum of 20' ❑part.
Adapted from New Hanover County GIS Map and Google Earth, September 2010
TITLE: SITE MAP FIGURE:
r' -]ied Resource Mana. ement f C 6632 River Road
P.O. sox 882r Hampstead, NC 28443JOB: 'SCALE: DATE: ;DRAWN BY:
(910) 2702919 FAX [phone] Wilson AS Shown 9/23/1 n I DNH

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