WI0800222_GEO THERMAL_20110110

Permit Number
Program Category
Ground Water
Permit Type
WI0800222
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
David Hasket SFR
Location Address
1109 Hedrick Blvd
Morehead City
Owner
Owner Name
David
Dates/Events
NC 28557
Hasket
Central Files: APS_ SWP_
01/10/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Mike Hadley
Driller Well
102 Middle St
Jacksonville
Major/Minor
Minor
NC
Region
Wilmington
County
Carteret
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David Hasket
1109 Hedrick Blvd
Morehead City NC
28546
28557
Orig Issue
01/10/11
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
01/10/11
Expiration
12/08/10 01/10/11
Re g ulated Activities
He at Pump Injection
Outfall N~Jl,l
Waterbody Name Stream Index Number Current Class Subbasin
CDENR
North �� Carolina Depement of Environment and Natural Resources
Division of Water Quaky
Beverly Eavev Perdue Colsen H. Sullins
Governor Director
1 / 1. t1'2011
David Hasket
1 IOQ Hedrick Blvd
Moreh-.ad City. NC 285,57
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Permit No. W1080022 I
1 109 Hedrick- Blvd_ Morehead Citv. NC 2855'_7
Dear Mr. Haskell
Dee Freeman
.Secretary
On 121g/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -
only 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 iniection 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 naps 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
Carteret 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 Micliael.RoaersLs�cdenr.&!otir if you have any questions.
Sincerely,
fin- Debra 1� att
supervis«r
cc: WiIiningimRegionalOffice -APS
APS Central Files - Permit No. W10800222
Carteret County Health Dept.
Cup:wrs'. ueotherma"' C iirnat: Comras Hcatina & C.00linr (Mile Hallay- - 102 Middit Street..lacksonville, NC _"t� I
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A.
B.
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-OW WELL(S)
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Type information).
Well Type Confrrmalion: 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).
PROPERTY OWNER(S)lAPPLICANT(S)
Gist 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; David Hasket
(1)
(2)
Mailing Address: 1109 Hedrick Blvd.
City: Morehead Ciro State: NC Zip Code: 28557 County: Carteret
Home/Office Tele No.: 252-726-3982 Cell No.:
Email Address:
Physical Address of Well Site (if different than above):
City:
Rome/Office Tele No.:
State: Zip Code: 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 [JIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
State: Zip Code:
Website Address of Company, if any:
County:
GPUNiC 5QW 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:_ Climate Control Heating & Cooling Co ____________ _
Contact Person"--: -=Mik=·=e=--=H=ad=l=e.,_y ___ --=E=MA=-==IL=A=-=-=ddr=e=ss"'-: =mh=ad=l=ey,._.@=b=iz=ec=·=rr=.c=o=m'------
Address: 102 Middle St
City: Jacksonville State: NC Zip Code: _28546 __ County:_On~s_lo_w ___ _
Office Tele No.: 910-353-9040 ______ Cell No.:910-376-1100 _____ _
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 Heat Transfer Svstems
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _Dec/2010 ____ Number of borings 3
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!!! (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) Grouttype: NeatCement__ 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 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
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 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 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.
1 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 specif tions and c tditions of the Permit."
Sikrr 'P ogerty O +wner/Applicant
Print or Typtr Full Nance and title
Signature of Property Owner/Appl icant
Print or Type Full Name and titir
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/EAC 5QW Noti6cabion of Intent Farm (Revised 7/2008) Page 3

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910-353-0926
102 Middle Street Fax: [phone]
Jackwnville. NC 28546 mhadloy§bizec.tr corn

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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEO'i`Iri♦i?MAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLS)
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Type information) -
DATE:
Well Type Confwmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-lootr 0
Yes _x Continue completing this form.
No Do Not complete this form. Complete other UIC application forts for installing
either a 5A7 well (�aen-loop well iniecting 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 OWNER(S)lAPPLICANT(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; David Hasket
(1) Mailing Address: 1109 Hedrick Blvd.
City: Morehead City State: NC Zip Code: 28557 County: Carteret
Home/Office Tele No.. 252-726-3982 Cell No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County:
Home/Office Tele No.: Cell No.:
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: EMAIL Address:
Address:
City: _ State: Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company, if any:
GPUIMC 5Qw Natlfication of lucent Foam (Revised 7/2008) Page t

• I
C. WELL DRILLER INFORMATION
Company Name: Coastal Geothennal
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:_ Climate Control Heating & Cooling Co ____________ _
Contact Person: Mike Hadley EMAIL Address: mhadle y@ bizec.rr.com
Address: 102 Middle St
City: Jacksonville State: NC Zip Code: _ 28546 __ County:~Ons~=lo~w-'----
Office Tele No.: 910-353-9040 Cell No.:910-376-1100 -------------
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 Geothennal Heat Transfer Systems
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _Dec/2010 ____ Number of borings 3
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!!! (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) Grouttype: NeatCement__ Bentonite_x_ Other(specify) ______ _
(b) Grout placement: Pumping_ 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 5QW Notification of Intent Fonn (Revised 7/2008) Page2
H. INJECTION -RELATED EQCiHMEN
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-
(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 tunics 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 rued
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 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 flues and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, an if applicable, abandon the injection well and
all related appurtenances in accordance vs ill; ti prove catins and cartd' 'sons of the Permit."
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 CaroUma DENR-DWQ
Aquifer Protection Section-U1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/MC SQW Notification of Intent Form (Revised 712008) Page 3

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Mike Hadley, CGD
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t[ $ kEW& 91 o-a76-1100
910-353-0926
102 Middle Street Fax: sio-353.1060
jac"onville. NC 2&W [e-mail]

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