WI0800227_GEO THERMAL_20110118

Permit Number
Program Category
Ground Water
Permit Type
WI0800227 / }.
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Jeffery and Patricia Mayer SFR
Location Address
2492 Hillsborough Dr
Southport
Owner
Owner Name
Jeffery
Dates/Events
NC 28461
Mayer
Orig Issue
01/18/11
App Received Draft Initiated
01/06/11
Regulated Activities
Heat Pump In jection
Outfall J
Scheduled
Issuance
.. Central Files: AP$_ SWP_
01/18/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
James L. Cornette
PG
PO Box 882
Hampstead
Major/Minor
Minor
NC
Region
Wilmington
County
Brunswick
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Jeffery Mayer
2984 Mashie Way
Southport
Public Notice Issue
01/18/11
NC
Effective
01/18/11
28443
28461
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
�AXE
z.rr r
MENR
Nortfi Carolina 1Departrnent of Environment and Natural Resources
Division or Watei �Quahly
_R?veriy Eaves Perdue Coleen H. Suliinc
7UverlQr Director
111 Y�.'"'fl 11
Jcf cry Mayer
Patriam fvlave:
29Su hf�tshie L�'a;•
Southport NC 28461
Subject; Acknawledgement of intent to Construct Type 5QW Injection Wei System
Permit No. W10900227
?4921 Hillsbrough D,ivc. 5nuthpor' NC.' 2R46l
Dew Mr. & Mrs Mayer:
wee Freeman
J?';reia ry
On 11612011, 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. A.n
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 consmuctian 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 BniwoA4cfi 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 NCchael.'RoLrersta.ncdenr.,-o�- if you have any questions -
Sincerely,
cc: Wilmingwri Regional office - AP5
AP5 Central Files - Permit No, W10800227
WiIrningtan County 11ealth Dept.
Applied Resourc- Management (,iim C:ometm— PO 8n; 021. Ftamps[ea�. 1';i: 284A.3)
Fulford H.earin-, & Air (Justin Fulford —1461 Holden Beach Rd Mk, Supply. NC 29461 i
AQUIFER PROTtMIQN SECTION
1636 V0 Sonke Center. Raleigh, Nord} 1;.ar ina 77699.1 6�e
Location, 2728 Capitat BmIvied RaP60, Norb Garoiina 27604
Pifane: 919.73=1 l FAY,1: 919-7 iM5U, =F}.2^. 91$-715.048 l Custcame^ Serve 1•,77-623-674
Nrte-nat. M n• ncwateruali .or
An Equei OWrkin y i Af nTOve khor. Emdoyv
Om
Noath C al•[?l1 na

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 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 Tyne information).
DATE: January 4. 2011 va ❑ <j C)o
A.
B.
Well hype Confirmation: Does the proposed system circulate potable water only (n❑ 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 inieJ cting 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): JeffeEy & Patricia Mayer
(1) Mailing Address: 2984 Mashie Way
City: Southport State: NC Zip Code: 28461 County: Brunswick
Home/Office Tele No.: 608-952-5375 Cell No.:
Email Address: target.golf(i juno.corn Website:
(2) Physical Address of W ll�ite (if different than above): 2492 Hiilshorough Drive
5a..4�hpoti� .
City: St. James State: NC Zip Code: 28461 County: Brunswick
HomelOffice 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 UTC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
State: Zip Code:
County:
Office Tele No.: Cell No.:
Website Address of Company, if any.
GPUIUIC 5QW Notification of Intent Fann (Revised 8/2008) rage 1

C. WELL DRILLER INFORMATION
Company Name: A pp lied Resource Management, P.C.
Well Driller Contractor's Name: -'H=-=-. M=ic=h=a=el"""S=a=g=e ________________ _
NC Contractor Certification No.: -----""2-"-53"-1"--"""A"'----------------------
Contact Person.~: ~J=im~C~o=rn=e=tt=e __________ =E=MA=I=L~A~d=dr=e=ss=:~J=im=---A~RM~ ... l~.b~e_ll ~so __ u_th_._ne_t __
Address: --~P~.O"-.~B"-o~x"-8"-8=2~--------------------------
City: Ham pstead 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: ___ F"-u=l=fo=r~d~H=e=a=ti=ng---=an=d~A~ir~--------------------
Contact Person: Justin Fulford EMAIL Address:
Address: 3461 Holden Beach Road SW
City: Su pply Zip Code: 28461 County: ---=B=ru-==ns~w~i=ck~-------
Office Tele No.: 910-620-5577 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 s ystem. Water onl y. grouted along the loo p's entiretv .
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: Janua ry 24 , 2011 Number of borings: __ 5 __ _
Approximate depth of each boring (feet): ___ 2=5~0-' ______ _
(2) Type of tubing to be used (copper, PVC, etc): _HDPE ____________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes QI (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 Other (specify) __ T_h_e_rm_e_x __ _
Grout placement: Pumping__ Pressure X Other
Grout depth of tubing (reference to land surface): from O 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
H. INXECTZON-RELATED EOUTPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piphagtubing associated with the iniection owration. The manufacturer's brochure may provide supplementary
i n fntmatio rt.
I. LOCATION OF WELL(S)
Mach two copies of maps showing the following intbrmati4n:
(1) Include a Site Map (can l74- drawn) ghavving: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and dist� between the proposed well(s) and
any ex6stiag 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 l have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on soy inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and eomplete-
I am aware that there are significant penalties, including the possibility of fities and imprisonment, for submitting
Wse information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtersances in accordance with the approved specifications and conditions of the Permit"
Signature o perry 0wriex/A /leant
P75�
Ulf Namdar Mle
11
[
AX �
Si_ ore of Property a A, plicasr v
I
LTV-�t� +�1
Print or Type Full Name and title
5ignatme of Authorized Agent, ifany
Print or Type F uil Natne and line
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]
GPLVUIC 5QW Not6cmion orweur Farm (Hevimd 9?00$)
Page 3
-V-d dLC:g0 0L LL Oe❑

Approximate Property Lines
Approximate New Residence Envelope
Approximate Closed Loop Locations
Notes:
1, Subject property and surrounding area are served by public sewer and water.
2. Geothermal well locations are approximate and will be ❑ minimum of 20' apart.
Adapted from Google Earth and Brunswick County GIS Map, December 2010.
TITLE: SITE MAP FIGURE:
Fed Ke5ouree Mana:,ement PG 2492 Hillsborough Drive
At��
o. Box Hampstead, N na JOB: SCALE; DATE: DRAWN BY:
270.2919 FAX 27� 2988 Mayer NTS 114111 DNH

Approximate Property Lines
Approximate New Residence Envelope
Approximate Closed Loop Locations
N
i
Notes:
1. Subject property and surrounding area are served by public sewer and water.
2. Geothermal well locations are approximate and will be a minimum of 20' apart.
Adapted from Google Earth and Brunswick County GIS Map, December 2010.
TITLE: SITE MAP FIGURE;
ryrlfod resource Mar34cment f C 2492 Hillsborough Drive
Box 882, Hampstead, NC 28443JGB: SCALE: DATE: DRAWN By,,
(91 p) 270-2919 FAX [phone] Mayer NTS 114111 ❑NH 2

Approximate Property Lines
Approximate New Residence Envelope
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are served by public sewer and water.
2. Geothermal well locations are approximate and will be a minimum of 20' apart.
Adapted from Google Earth and Brunswick County GIS Map, December 2010.
TITLE: SITE MAP FIGURE:
lied Keeource Mara,+anent PC 2492 Hillsborough Drive
BOX U64 Hampst a JOB: SCALE: DATE: DRAWN BY: I
[phone] FAX [phone] Mayer NTS 114111 1 DNH

Approximate Property Lines
Approximate New Residence Envelope
Approximate Closed Loop Locations
Notes:
1, Subject property and surrounding area are served by public sewer and water.
2. Geothermal well locations ❑re approximate ❑nd will be ❑ minimum of 20' apart.
Adapted from Google Earth and Brunswick County GIS Map, December 2010.
TITLE: SITE MAP FIGURE:
2
Alp-�
esource Manaoerrierrt f C2492 Hillsborough Drive
. Box 8 2, Hampstead, N 26443 JOB: SCALE: DATE; DR�AAWN BY:
�oj 270 2919 FAX [phone] Mayer NTS 11411 1 DNH

1/3/2D11
Print Preview
Brunswick Ca unty, NC
Parcel Number
2190GO04
Plat Date
4/6/2010
Account Number
Land Value
PIN
205704909156
Building Value
❑wirer
MAY ER JEFFREY S ETUX PATRICIA KAY
Other Value
Deferred Value
Owner Address 7
Ow7er Addrass 2
6759 RAMSEY ROA❑
Total Taxable Value
city
MIDDLETON
Heated Sq Ft
State
WI
Year Built
Zip
53562
Bedrooms
Legal Description
Full Baths
Parcel Street Number
2492
Stories
Parcel Street
HILLSBOROUGH
Ext. Wall T
Street Type
DR
Ext. Wall 2
Street Dir
Neighborhood
Subdivision
WILLOW WALK
Municipality
Deed Book
3065
Fire Tax District
Deed Page
0369
Township
LOCKWOOD FOLLY
Deed Date
7/20/2010
Acreage
0.37
Plat Book
0065
Sale Price
Plat Page
0008
Disclaimer.- Map and parcel data are believed to be accurate, but accuracy is not
gis.brunsco.net/printPreview.aspx?Print... 1/2