WI0800217_GEO THERMAL_20101124

Permit Number
Program Category
Ground Water
Permit Type
WI0800217 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
John & Vivian Westbrook SFR
Location Address
126 Leslie Dr
Hubert
Owner
Owner Name
John
Dates/Events
NC 28539
Westbrook
Orig Issue
11/24/10
App Received Draft Initiated
11/15/10
Re !:l ulated Activities
Heat Pump Inject ion
Outfall
Scheduled
Issuance
Central Files: APS_ SWP_
11/24/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Bruce Brazill
102 Middle St
Jacksonville NC
Major/Minor
Minor
Region
Wilmington
County
Onslow
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
John Westbrook
289 Creedmoor Rd
Jacksonville NC
Public Notice Issue
11/24/10
Effective
11/24/10
28546
28546
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
A;7A
NCQENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
1112-4/20 3 0
John Westbrooic
Vivian Westbrook
289 Creedmoor Road
Jacksonville. NC 28546
Subject: Acknowledgement of Intent to Construct Type 5QW injection Well System
Permit -No. WIOSD0117
126 Leslie Drive; Huber, NC 25539
Dear Dr. & Mrs, Westbrook:
Dee Freeman
Secretary
On 11/15/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-lonl•
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 injectiob well system contains only,potabie 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 Onsiow 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.Rosersimnedenr.vvv if you have any questions.
Sincerely,
Uukk-
1hr Debra Watts
sultery isur
cc: Wilmington Regional Office - APS
APS Cant ral Files - Permit No. W10800217
Onslow County Health Dept.
Climate Conrnvl Beating & Cooling Co., inc. r Coastal Geothennal 1144iku Smith)
AQUIFER PROTECTION SECTION
1636 Mail SeMce Center. Raleigh, booth Carolina 27599-1636
Lacafi= 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: 919-75?3221 l FAX 1: 919.715-058$; FAX 2: 919-715-66481 Custarner ^aervime 1.877-623.6748
Internet wwwxmteg1uaI4y.p
Hn Equal Opawunq 1ATfirmative ACN6n Empin±asr
One
N ortb Carolina
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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 WELLISS}
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 Tme information).
DATE: November 11 2010 010 f 0 <� L_j r1 i
G�
8,
Well Type Confarnwion: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -lop)?
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 in'el cting potable water into the aquifer) or a 5QM well (closed -
loop weli containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
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); Dr. John_& Vivian Westbrook
(1) Mailing Address: 289 Creedmoor Road
City: Jacksonville State: NC Zip Code: 28546 County: Onslow
Home/Office Teie No.: 9� 1 o) 353-7848 _ Cell No.: 9f l 01--389-1 I32
Email Address: Website;
(2) Physical Address of Well Site (if different than above): 125 Leslie Drive
City: Hubert State: NC Zip Code: 28539 County: Onslow
Home/Office TeleNo.: [phone] _ Cell No.: (9I0)-389-1132
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: EMAIL Address:
Address:
City:
State: Zip Code: _
County:
Office Tele No.; CelI No.:
Website Address of Company, if any:
GPUIUIC 5QW Notification of Intent Form (Revised 812008) NOV 16 7010 Pap I

C. WELL DRILLER INFORMATION
CompanyName: ___ ~C-=-oas=ta=l~G""'e=-=o=th=e=rrn=al~---------------------
Well Driller Contractor's Name: ~S=an=fo=r=d ~S~w~e~et=in-g _____________________ _
NC Contractor Certification No.: ;..;N=C,....,2=0"-"8=2'------------------------
Contact Person-=-: =M=i=k=e -=S=m=it=h,__ ______ ---=E=MA=-==IL=---.,..,.:A=d=dr=-=e=ss=: __ ______=cms=m=i=th=®=b =iz=ec=·=rr=.c=-=o=m"'-----
Address: 102 Middle St. ___________________________ _
City: Jacksonville Zip Code: 28546 _____ County: --~Ons~=lo~w~---
Office Tele No.: ~9=10~-=35""'3~-~90~4~0'--------Cell No.: ______________ _
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=-ns=l=o'-'-'w'--------
Office Tele No.: (=9-=-10=--)c..::3=5-=-3-...:;.9-=--0---'--'40=--------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 Geothermal
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: November 2010 Number of borings: ill
Approximate depth of each boring (feet): 200 feet
(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 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)
(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 O to _____ 2=00.;a.___ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (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.
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 waxer 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.
"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 far 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"
a1w of Property Owner/Applicant
r -
�, �1L�,
Print or'ry Full Name and title
Signature of Propert Qwner/Applicant
lV 1l esflbmold.
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]
GPUf[]IC 5QW Notification of Intent Form (Revised 8/2008) Page 3

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