WI0800262_GEO THERMAL_20111025

Permit Numb e r
Program Category
Ground Water
Permit Type
WI0800262 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Orton Rd . SE 5QW
Location Address
9174 Orton Rd Se
Winnabow
Owner
Owner Name
Lawrence
Dates/Events
NC 28479
M Noe
Scheduled
Orig Issue
10/25/11
App Received Draft Initiated Issuance
10/14/11
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files : APS_ SWP_
10/25/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Lawrence M. Noe
President
2299N Sea Rd
Southampton
Major/Minor
Minor
NY
Region
Wilmington
County
Brunswick
Facility Contact Affiliati on
Owner Type
Individual
Owner Affiliation
Lawrence M. Noe
President
2299 N Sea Rd
Southampton
Public Notice Issue
10/25/11
NY
Effective
10/25/11
11968
11968
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
i..~A a ,,~~
MC DE~N~R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Lawrence M. Noe -President
Belvedere Property Management, LLC
2299 North Sea Rd.
Southampton, NY 11968
Coleen H. Sullins
Director
10/25/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0800262
9174 Orton Rd. SE
Winnabow, NC 28479
Dear Mr. Noe:
Dee Freeman
Secretary
On 10/14/2011, 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:
l. The injection well system contains only potable water,
2. The iitjection 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 Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the Brunswick 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.
s i cerely, _/ ·
Please contact Mike Rogers at [phone] or Michael.Ro e ers @ncdenr4e:ov if ou have any questions.
~ 1_t,Jlt\..->
cc: Wilmington Regional Office -APS
APS Central Files -Permit Ne , V. l0800:!62
Brunswick County Health Dept.
forD atts
Supe.
Diana Helias (ARM's Waterworks, P.O. Box 882, Hampstead, NC 28443)
John Powers (Green Dot Heating and Air, 1227 S. 3rd St., Wilmington, NC 28401)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-71fi-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterauality.org
An Equal qpportuniiy \ Affirmative Action Employer
NOnithe C 1· o. -_· aroma
r/Vaturall!I
\ A ff D ?:[x)d-ocf"', REC.EIYED I DENR I DWQ Y V.J..J _ _Aquifer Protection Section ---OCT .14 .2011.
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED-LOOP WATER-ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on the Last Page.
DATE: October 6 20 11 PERMIT NO. ________ (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non-Government: Individual Residence X Business/Organization __
Government: State Municipal __ County__ Federal
B. WELL OWNER -For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
Belvedere Property Management, LLC -Lawrence M. Noe, President
Mailing Address: 2299 North Sea Road
City: Southampton State: NY Zip Code:_1_1_9_68 ____ County: _____ _
Day Tele No.: 646-465-0602 Cell No.:
EMAIL Address: _____________ ~F~a=x~N~o~.:_2_1_2_-4_0_3_-0_9_4_0 _______ _
C. LOCATION OF WELL SITE-Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 311100749747 County: Brunswick
(2) Physical Address (if different than mailing address): _9_1_74_O_rt_o_n_R_o_a_d_S _E ________ _
City: Winnabow State: NC Zip Code: _2_8_4_7_9 ______ _
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: _H_._M_i_ch_a_e_l_S_a_g_e ___________________ _
NC Well Drilling Contractor Certification No.: _2_5_3_1A __________________ _
Company Name: ARM's Waterworks
Contact Person: Diana Helias
Address: PO Box 882
EMAIL Address: [e-mail]
City: Hampstead Zip Code: 28443 State: NC County: _P_e_n_d_e_r ______ _
Office Tele No.: 910-270-2919 Cell No.: Fax No.: 910-270-2988 -------~
GPU/UIC SQW Notification (Revised 3/18/2011) Page I
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Green Dot Heating and Air
Contact Person: John Powers EMAIL Address: -----------------------------------
Address: 1227 S 3rd Street
City: Wilmington Zip Code: _2_84_0_1___ State: NC County: New Hanover
Office Tele No.: 910-791-0480 Cell No.: Fax No.: "-="'--"--'-='----------
F. WELL CONSTRUCTION DATA
( 1) Number of borings to be constructed*: 20 Depth of each boring ( feet):_2_5_0_' _____ _
* If existing water supply wells will be used then provide the information in item (4) below .
(2) Type of tubing to be used (steel, PVC, etc): _H_D_P_E _______ _
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: _N_/_A _________________ _
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** Other (specify) _T_h_e_r_m_-_e_x ___ _
** By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)( I )(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from O to 250 (feet) ----
Ifwell has casing, indicate grout depth: from ____ to ____ (feet)
G. WELL LOCATIONS-Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GJS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5QW Notification (Revised 3/18/2011) Page2
08CSVED I DENP 1 Dft
Aquifer Prat"M Seclyon
OCT 14 2411.
IL CCRTMICATIQN (to be signed as required below or by that person's authorized agent)
I SA NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all twfsons listed on the Luoix ttv deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"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 accordan with the approved specifications and conditions of
the Permit."
Si nature of Property Owner/Applicant
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUIUIC 5QW NoSifi=cation (Revised 3/1812011) Page 3

Print Preview RECEIVED 1 DENR l DWG!
Aquifer PmWcWn Serlion
OCT 14 20H
Pagel of Z
n
W212i
Brunswick County, NC
Parcel Number 14400001
Account Number 30820120
PIN 311100749747
Owner ❑RTON PLANTATION HOLDINGS LLC
Owner Address 1 %LAWRENCE NOE 17TH FLOOR
- - T
Owner Address 2 1251 AVE OF THE AMERICAS
city
state
Zip
Legal Description
Parcel Street
Number
Parcel Street
Street Type
Street Dir
Subdivision
Deed Book
Deed Page
Deed Date
Plat Book
Plat Page
NEW YORK
NY
10020
381.00 ACRES ORTON PLANTATION
231396&231149
9140
FaUqUOIN
RD
SE
3104
0552
11/10/2010
0023
0396
Plat Date
Land Value
Building Value
Other Value
fVe'
erred Value
otal Taxable
alue
Heated Sq Ft
-f Year Built
Bedrooms
Full Baths
Stories
Ext. Wall
Ext. Wall 2
Neighborhood
Municipality
Fire Tax District
Township
Acreage
Sale Price
$1,608,230
$733,470
$100,630
$115,040
$2,442,330
1,290
1875
2 BEDROOMS
CEDAR 1 REDW
SIDIN
3004
SMITHVILLE
381
$3,000,000
http://gis.brunsco.net/printPreview.aspx?PrintOptData=Brunswick County, NCj0�0jtruejfa... 10/12/2011

Print Preview
Disclaimer: Map and parcel data are believed to be accurate, but accuracy is not
guaranteed. This is not a legal document and should not be substituted for a title search,
appraisal, survey, or for zoning verification.
Page 2 of2
Ma p Scale
1 inch = 1533 feet
.RECEIVED/ D.ENR I D'{VQ
Aquifer ProtectiOn SectiOn
OCT 1 f .20.tt
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