WI0800213_GEO THERMAL_20120403

NON REsI DEN TIAL WELL coNsTRucrmN REcoRD
North Carolina Department ofEnvironment and Natural Resource~ Division of Water Qualiij ECEfVEO/DENR/OWQ
WELLCONTRACTORCERTIDCATION# 2082 APR O 3 2012
1. WELL CONTRACTOR:
Sanford Sweeting
Well Contractor ~ndividual) Name
Coastal Geothermal
Well Contractor Company Name
102 Middle St.
Street Address
Jacksonville
City or Town
< 910 l 353-0926
Area code Phone number
2. WELLINFORMATION:
NC 28645
State Zip Code
WELL CONSTRUCTION PERMIT# WIQ80Q21 3 --=--':....:.;::;..:.;::e.==--:.-=--------
OTHER ASSOCIATED PERMIT#(if applicalfo) ________ _
SITE WELL ID #(if applicalie.__ __________ _
3. WELL USE (Check One Box) Monitoring D Municipal/Pu~ic D
Industrial/Commercial □ Agricultural □ Recovery □ Injection □
Irri gation □ Other IVQist use) Geothermal Looc
DATE DRILLED Feb/Mar-2012
4. WELL LOCATION:
BLDG 235/245
(Street Name, Numbers, Community, Subdivision , Lot No., Parca, Zip Code)
c1TY: Came Leieune couNTY Onslow
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
□Slope □Valley lifRat □Ridge □Other ______ _
LAllTUDE 36 ___ " OMS OR 3x.xxxxxxxxx DD
LONGITUDE~ ____ • OMS OR 7x .xxxxxxxx x DD
LalitudeAongitude source : [J3PS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this fonn if not using GPS)
5. FAQUTY (Name of the business where the well is located.)
BEO
Faclity Name
"D" Street Bid □ 235/245
Street Address
Camp I aiauoe
City or Town
Carl H Baker
Contact Name
Bid □ 1005 Michael Rd
Mailing Address
Came I eieu

□
e
City or Town
1 910-'i 451-2213
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:_2_5-5~' -----
FaciitylD# (if ap~ica~e)
NC 28547
State Zip Code
NC 28547
State Zip Code
b. DOES WELL REPLACE ElCISllNG WELL? YES □ NO c:."
c. WATER LEVEL Below Top of Casing: n/a FT.
(Use·+· if Above Top of Casing)
: d. TOP OF CASING IS n/a FT. ~~.'!§c ~~'l't §.4.rfa~• •
: *Top of casing terminated at/or belovll\ijl;i l~W~lll rSeCtlOO
a variance in accordance with 15A NCAC 2C .0118.
: e. llELD (gpm}: n/a METHOD OF TEST _____ _
: t DISINFECTION: Type n/a Amount ____ _
: g. WATER ZONES (depth):
; TOP, n/Q. Bottom TOP. ___ Bottom ___ _
: ToP, Bottom ToP, ___ Bottom ___ _
: TOP. Bottom TOP, ___ Bottom~---
Thickness/
: 7. CASING: Depth Diameter
! Top.....!lliL_ Bottom ___ Ft __ _
: TOP, ___ Bottom ___ Ft __ _
: TOP, ___ Bottom~--Ft __ _
: 8. GROUT: Depth Material
\ Top_Q__ Bottom 255 Ft. Bentonite
Weigh_t Material
Method
Pump
: ToP, ___ Bottom ___ Ft _____ _
: TOP. Bottom ___ Ft _____ _
: 9. SCREEN: Depth Diameter Slot Size Material
! Top__o.lg____ Bottom ___ Ft __ in. in.-----
: ToP, ___ Bottom ___ Ft __ in. in ____ _
: ToP, ___ Bottom ___ Ft __ in in ____ _
: 10. SAND/GRAVEL PACK:
Depth Size Material
: TOP. n/a Bottom ___ Ft. ___________ _
: ToP, ___ Bottom,__ __ Ft ___________ _
: ToP, ___ Bottom ___ Ft ___________ _
: 11. DRILLING LOG
Top Bottom Formation Description
0 '~6~□~--Clay some Sand
60 ,_1 ... 2 ... 0 __ Sandy Silt
120 /.....,2 .... 0 .... 0 __ Soft to Medium Limestone
200 /_.2 .... 5..,.5 __ Sandy Silt
---·'-------'-------·'----'-------, ___ _
---·'-------'-----
: 12. REMARKS:
: Installed 97-250' x 1" geothermal loops
: I DO HEREBY CERll FY THAT lH S WELL WAS CONSTRUCTED IN ACCORDAN CE WITH
• 15 ARDS ,ANOTHATACOPYOFTHS
: R ....,..,.,_,,.,.,.., L OWNER
3/22/12
DATE
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone: [phone]
Form GW-1b
Rev. 2/09
' • RECEIVED / DENR / o~a
Aquifer Protection Section
AUG 19 201'
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-0 W 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 .D:'.ru< information).
DATE: August 17 , 2011
Well Type Confirmation: Does the proposed system circ1.1late potable water only (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 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 signatures ;
MCB Camp Lejeune
ATTN: Carl H. Baker, Deputy Public Works Officer
(1)
(2)
Mailing Address: Building 1005 Michael Road
City: MCB Camp Lejeune_ State: NC_ Zip Code:~2=8~5~47 ___ County: Onslow
Home/Office Tele No.: 910-451-2213 Cell No.:
Email Address: [e-mail]
1is f-IA.J.e l I .P'1,-r1-/r JI= w I l> eo o 2. I 3
Physical Address of Well Site (if different than above): Building HP-245
City: MCB Cam p Le jeune State: NC Zip Code: 28547 _J;_ounty: Onslow
Home/Office Tele No.: 910-451-221 .
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: __________________ _
ContactPerson~=-----------~E=MAIL=-==-A==ddr=e=ss~=-----------
Address: __________________ _
City: _________ State: ___ ZipCode: _____ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: _______________ _
GPU/UIC 5QW Notification of Intent Form (Revised 7/2008) Page 1
C. WELL DRILLER INFORMATION
Company Name: Coastal Geothermal
Well Driller Contractor's Name: Sanford Sweetinir
NC Contractor Certification No.: NC 2082
Contact Person: Mike Hadley EMAIL Address: [e-mail]
Address: 102 Middle St.
City: Jacksonville Zip Code: 28546 County: Onslow
Office TeleNo.: __ 910-353-0926 Cell No.: 910-376-1100
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company: North State Mechanical, Inc.
Contact Person: Larry Brown EMAIL Address:
Address: 225 Ellis Blvd.
City: Jacksonville State: NC Zip Code: 28540 County: Onslow
Office Tele No.: 910-355-9332 Cell No.:
E. STATUS OF APPLICANT
Private:
State:
Federal: X
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loop Geothermal Heat Transfer Systems
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: Oct to Dec/ 2011 __ Number of borings: 47
Approximate depth of each boring (feet): 255'
(2) Type of tubing to be used (copper, PVC, etc): _High Density Polyethylene_X
(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 ___ 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 _255_ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 7/2008) Page2
REC;O'f,�Lj IARAI
r uvwr
;Gat a1�
H. INJECTION -RELATED EQU PMWN
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacture?N- btochure may provide supplementary
information.
L LOCATION OF WELLS)
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 weil(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 taw, that 1 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, Aiaintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with th a roved specific ns a d—condditions of the Permit."
� �R •Y
Signature of Property Owner/Applicant
_Carl Baker, Deputy Public Works Officer
Print or Type Full Name and title
Signature of Property Owner/Applicant
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
Telephone [phone]
GPUMIC 5QW Notification of Intent Form (revised 7/2008) Page 3

Kk
HCDENR
North Carolina Department of Environment and Natura
Division of Water Quality
Beverly E-aves Perdue Coieen H. Sullins
Govemor Director
10/28/2010
Carl H. Baiter
Deputy Public Works Officer
Building 1005
Michael Rd.
MCB, Camp Lejeune, NC 28547
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10800213
Building HP-235/245
MCB Camp Lejeune, NC 28547
Dear Mr. Baker.
Resources
Ne Freeman
Secretary
On 10/22/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-ordy
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is toot required for the construction and operation of this type of geothermal injection well system a& long as the
following conditions arc 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 Wcll Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(uj(2]. Additionally, you should Contact the Onslow 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.RoQerz,runcdenneov if you h any questions.
Si
for Debra
Supervisor
cc: Wilmington Regional Office - APS
APS Central Files - Permit No. W10800213
Onslow County Health Dept.
Mike Hadley (Coastal Geothermal, 102 Middle St.. Jacksonville, NC 28546)
AQUIFER FRO ECTION SEC iION'
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NOR1H CAROLINA
RECEIVED/ DENR I DWO
Aquifer Protection Sffclion
tAUG 19 2011
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: A ugu st 17 , 2011
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 IBC 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 signatures;
MCB Camp Lejeune
ATIN: Carl H. Baker, Deputy Public Works Officer
(1)
(2)
Mailing Address: Building 1005 Michael Road
City: MCB Camp Lejeune_ State: NC_ Zip Code:-'2=8=5~47-'--__ County: Onslow
Home/Office Tele No.: 910-451-2213 Cell No.:
Email Address: [e-mail] te-Jrw~t, .J~r-t,=t--tt-bl I 0~002-13
Physical Address of Well Site (if different than above): Building HP-235
City: MCB Cam p Lejeune State: NC Zip Code: 28547 ~ounty: Onslow
Home/Office Tele No.: 910-451-221
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: _______________ _
GPU/UIC 5QWNotification of Intent Form (Revised 7/2008) Page I
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: [e-mail]
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: Ramsey Air Conditioning
Contact Person: Kurne y Ramsey EMAIL Address:
Address: 2731 Commerce Rd.
City: Jacksonville State: NC Zip Code: 28546 County: Onslow
Office Tele No.: _910-455-0414 ____ Cell No.: 910-358-2200
E. STATUS OF APPLICANT
Private:
State:
Federal: X
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loop Geothermal Heat Transfer Systems
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: Oct to Dec/ 2011 __ Number of borings: 48
Approximate depth of each boring (feet): 255'
(2) Type of tubing to be used (copper, PVC, etc): _High Density Polyethylene_X
(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 ___ 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 _x_ Other (specify) ______ _
Grout placement: Pumping_ X_ Pressure__ Other
Grout depth of tubing (reference to land surface): :from_0 ___ to _255_ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 7/2008) Page2
RECEKO ► DENR r i7 M
,A;pp #er Froler im Seftn
IL INJECTION -RELATED EQU PMEPI i AUG 19 2011
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 WELLS)
Attach two copies of maps showing the following information:
(I) 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 21DO 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 eacb 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 injection well and
all related appurtenances in accordance with the sroved sperm ati s and conditions of the Permit."
Sign ure of roperty Owner/Applicant
Carl Baker, Deputy Public Works Officer
Print or Type Full Name and title
Signature of Property Owner/Applicant
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
Telephone [phone]
CPUIUIC 5QW Notification of Intent Form (Rovised 712008) Page 3

R A
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Govemm
Carl H. Baker
Deputy Public Works Officer
Building 1005
Michael Rd.
MCB, Camp Lejeune, NC 28547
Coleen H. Sullins
Director
10/28/2010
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0800213
Building HP-235/245
MCB Camp Lejeune, NC 28547
Dear Mr. Baker:
Dee Freeman
Secretary
On 10/22/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
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 wi~h weil 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 Title 15A Section 2C Subchapter .02ll(u)(2). Additionally, you should contact the Onslow 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.Roe ersc@ncdenr.!!OV if you hn an~ que~tions.
~ -Jc;J>w~
forDeb~1S
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI0800213
Onslow County Health Dept.
Supervisor
Mike Hadley (Coastal Geothermal, 102 Middle St., Jacksonville, NC 28546)
AQUIFER PROTECTION SECTION
1636 Mail Service Genier. Raleigh , North Carol,na 27699-1536
Locailon: 2728 Capital Boulevard. Raieigt. North Caro!eia 27604
?none: 919-733-3221 ', FAX 1: 919-715-0588: r'AX 2. 919-715-6048 i Customer Service: 1-877-623-6748
internet· www.ncwatergualitv.org .
Arc =a,:a1 0pp-Jfiunity l Affirmative ActiGn Employe~
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142 Middle St, Jacksonville, NC 28546 to D St, Jacksonville, NC 28547 - Google Maps
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http://maps-google.comlmaps?i=d&source=s d&saddr=102+Middle+St,+JacksonviUe,+NC&daddr=D+Street+Camp+Lejeune,+NC&.hl=ern&geocode=FT5... 8/1812011

Permit Number W10800213
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW )
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit-
Facility Name
MCB Building HP-2351245
Location Address
Building Hp-2351245
Camp Lejeune NC 28547
Owner
Owner Name
McB Camp Lejeune
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance
10/28/10 10/22/10
Re: -elated Activities
Heat Pump Iniection
Outfall J.
Central Files: APS 5WP
1012$110
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
Permit Classification
1,00
Individual
Permit Contact Affiliation
Mike Hartley
Driller Well
102 Middle St
Jacksonville
NC 28546
MajortMinor Region
Minor Wilmington
County
Onslow
Facility Contact Affiliation
Owner Type
Government - Federal
Owner Affiliation
Carl H. Baker
Building 1005
Camp Leieune
Public Notice Issue
10/28/10
NC 28547
Effective Expiration
10/28/10
Waterbody Name Stream Index Number Current Class 5ubbasin

A7A ;;-;;-.1~ ....... MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Carl H. Baker
Deputy Public Works Officer
Building 1005
Michael Rd.
MCB, Camp Lejeune, NC 28547
Coleen H. Sullins
Director
10/28/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0800213
Building HP-235/245
MCB Camp Lejeune, NC 28547
Dear Mr. Baker:
Dee Freeman
Secretary
On 10/22/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
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 wit.h weil 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 Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Onslow 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.Ro l!erst@ ncdenr.!l ov if you h any questions.
~t JocOW"R)
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI0800213
Onslow County Health Dept.
forDebr~
Supervisor
Mike Hadley (Coastal Geothermal, 102 Middle St., Jacksonville, NC 28546)
AQUIFER PROTECTION SECTION
1636 Mail Service Cenier, Raleigh, North Carolina 27699-1636
Location: 2728 Caoital Bouleva;d, Raieigh. North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588: FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Oppori~ni:f \ ,l\ffirmative Action Employer
NOnehC r ort . . aro~1na /vaturally
�ooa� 3
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTTON WELL SYSTEM:
TYPE S-QW WELLS)
In Accordance with the provisions of NCAC Title 15A: 02C.0204, please
complete this notification and mail to address on the back page (please Print or Tie information).
DATE: Oct. 07.2010
Well Type Conf tnWion: 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 17
Yes x Continue completing this form.
No Do Not complete this form. Complete other [TIC application forms for installing
either a 5A7 well (open -loop well in'ei ctin 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)IAPPLICANF(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 signatures; MCB Camp Lejeune ATTN: Carl H. Baker, Deputy
Public Works Officer
(1) Mailing Address: Building 1005 Michael Road
City: MCB Camp Lejeune State: NC Zip Code: 28547 County: Onslow
Home/Office Tele No.: 910-451-2213 Cell No.:
Email Address: carLh.bakera)usmc.mil Website:
(2) Physical Address of Well Site (if different than above): _Building HP-235/245
City: MCB Camp Lejeune State: NC_ Zip Code: 28547 County: Onslow
Home/Office Tele No.: 910-451 2213
B. AUTHORIZED AGENT OF OWNER,, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter Gorr the property owner authorizing Agent to install and operate UIC weII)
Company Name:
Contact Person: EMAIL Address:
Address:
City: _ State: Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company, if any:
GPUXIC 5QW Notification of Intent Fonn (Revised 7/2008) Page 1

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: [e-mail]
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=MA==IL=A=d=dr=e=ss==----------
Address: ________________ _
City: ---------=S~ta=te~=--Zip Code: _____ County:. ______ _
Office Tele No.: Cell No.:
E. STATUS OF APPLICANT
Private:
State:
Federal: X
Municipal: __
------------
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p Geothermal Heat Transfer Systems
For testing purposes
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: __ Oct/2010. ____ Nwnber ofborings: _1 __ _
Approximate depth of each boring (feet):_250' _____ _
(2) Type of tubing to be used (copper, PVC, etc): _High Density Polyethylene_X
(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: Pwnping_ X_ Pressure Other
(c) Grout depth of tubing (reference to land surface): from_0 ___ to _250_ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC SQW Notification of Intent Form (Revised 7/2008) Page2
H. INJECTION -RELATED EQUIPMEN
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipiugltubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
L 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.
.1. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"1 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, irwintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance witLthhe- y+ved spec' atiop and conditions of the Permit."
Property DwnerlAppiicant
Carl Baker, Deputy Public Works Officer
Print or Type Full Name and title
Signature of Property OwnerlApplicant
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
Telephone [phone]
GPUMC 5QW Notifi"tion of Intent Fonn (Revised 7/2008) Page 3

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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 5-0 W 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: Oct.07.2010
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 (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 signatures; MCB Camp Lejeune ATIN: Carl H. Baker, Deputy
Public Works Officer
(I) Mailing Address: Building 1005 Michael Road __ _
City: MCB Camp Lejeune_ State: NC_Zip Code:-'2=8=5~47,__ __ County: Onslow
Home/Office Tele No.: 910-451-2213 Cell No.:
Email Address: [e-mail] Website:
(2) Physical Address of Well Site (if different than above): _Building HP-235/245
City: MCB Cam p Le jeune State: _NC_ Zip Code: 2854 7 _____Qounty: Onslow
Home/Office Tele No.: 910-451-2213
B. AUmORIZED 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=--: ------------E=MA~=IL~A=d=dr,~e=ss~=----------r-
C) .:::,r\
~ -a f1' " n
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Address: __________________ _
City: _________ State: ___ ZipCode: _____ County: ______ _
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0
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Office Tele No.: Cell No.: r;y ~ .....
S;?c.,; ....._,_.,
w l/1;.
Website Address of Company, if any: _______________ _ .:;::-... , .
(")
GPU/UIC SQW Notification of Intent Form (Revised 7/2008) Page 1
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: mhadley@ 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 _____________________ _
ContactPerson~=----------'E=MA==IL==A=d=dr=e=ss=: _________ _
Address: ________________ _
City: ---------=S=ta=te~: __ Zip Code: _____ County: ______ _
Office Tele No.: Cell No.: ___________ _
E. STATUS OF APPLICANT
Private:
State:
Federal: X
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loop Geothermal Heat Transfer S ystems
For testing purposes
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: __ Oct/2010 ____ Number of borings: _l __ _
Approximate depth of each boring (feet):_250' _____ _
(2) Type of tubing to be used ( copper, PVC, etc): _ High Density Polyethylene_ X
(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 ___ 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)
GPU/UIC 5QW Notification of Intent Form (Revised 7/2008) Page 2
H. INJECTION -RELATED EQUIPMEN
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
Mote: 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 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, l 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, opera4,, maintain, re RR �'r, and if applicable, abandon the injection well and
all related appurtenances in accordance with tfie approved sptici lca inns and conditions of the Permit."
ature of Property Owner/Applicant
Carl Baker, Deputy Public Works Officer
Print or Type Full Name and title
Signature of Property Owner/Applicant
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
Telephone [phone]
GPi.fMC 5QW Natification of Intent Form (Revised 712009) Page 3

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