WI0800267_GEO THERMAL_20111122

Permit Number
Program Category
Ground Water
Permit Type
WI0800267
Central Files: APS_ SWP_
11/22/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (SQW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Jeffrey & Virginia Langley SFR
Location Address
1173 Royal Oak Rd
Supply
Owner
Owner Name
Jeffrey
Dates/Events
NC 28462
Langley
Orig Issue
11/22/11
App Received Draft Initiated
10/28/11
Regulated Activities
Heat Pump Injection
Outfall NU'...-
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Diana Helias
PO Box 882
Hampstead
Major/Minor
Minor
NC
Region
Wilmington
County
Brunswick
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Jeffrey Langley
1173 Royal Oak Rd
Supply
Public Notice Issue
11/22/11
NC
Effective
11/22/11
28443
28462
Expiration
Stream Index Number Current Class Subbasin
P L-A
j
CDEN
North Carolina Department of Environment and Natural Resources
Division of Water Quaiity
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
i lr??!2011
Jeffrey Langley
Virginia Langley
l l73 Royal Oak Road NLI'
Supply, NC 28426
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well Systern
Permit No. WI0800267
1173 Royal Gals Road, Supply, NC 28462
Dear Mr. & Mrs. Langley:
Dee Freeman
Secretary
On October 28, 2011, 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:
I . 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 I5A 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 .4211(uj(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.
Please contact Mike Rogers at [phone] or Michael,Ro¢ers:&ncdenr.eay if you have any questions.
Sincerely,
A6jor Deb
Surervisor
cc: WilmineWnRegionalOffce -APS
APS Central Files - Permit No. WfO800267
Brunswick County Health Dept,
Diana Helias (ARM's Waterworks)
Justin Fulford (Fulford Heating & Airy
AMIFr R PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carallm 27699-1636
Location: 2728 CapkaI Roulevard, Releigb. North Carolina 27604
Phone; 919-73,'r-322t 1 FAX 1:9tS-715-0588; FAX Z.319-715-ZD48) Customer Service' 1.8r � -623.674E
Internet www,na atemualitv.a.^
One
No]rth{Czarohm,
An Equal fspponuN1y 1 A(nrmF6n Anon=mpbyer

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: Octber 13 . 20__!!_ PERMIT NO. ~t}O;l.to3: (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non~Govemrnent: 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:
Jeffrey & Virginia Langley
Mailing Address: 1173 Royal Oak Road NW
City: Supply State: NC Zip Code:_2_8_4 _26 ____ County: Brunswick
Day Tele No.: 919-548-4519 Cell No.:
EMAIL Address: [e-mail] Fax No.:
C. LOCATION OF WELL SITE-Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 15100002 County: Brunswick
(2) Physical Address (if different than mailing address): _1_1_7_3_R_o .... y_a_l O_a_k _R_o_a_d ________ _
City: Supply State: NC Zip Code: ~ .2&':J WLI
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 EMAIL Address: [e-mail] ,:..._--------------===-'====--___;;;; _______ _
Address: PO Box 882
City: Hampstead
Office Tele No.: 910-270-2919
GPU/UIC 5QW Notification (Revised 3/18/2011)
Zip Code: 28443 State: NC County: _P_e_n_de_r ______ _
Cell No.: _______ Fax No.: 910-270-2988
RECEiVED / DENR / DWQ
Aquifer Proter,tion Section
OCT 28 2011
Page 1
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Fulford Heating and Air
Contact Person: Justin Fulford
Address: 3461 Holden Beach Road
EMAIL Address:
City: Supply Zip Code: 28462 State: NC County: _B_r_un_s_w_ic_k _____ _
Office Tele No.: 910-842-6589 Cell No.: Fax No.: 910-846-3414 ----------
F. WELL CONSTRUCTION DATA
(I) Number of borings to be constructed*: 6 Depth of each boring (feet):_20_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) Therm-ex
•• By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(A)-, w-h,..,.ic_h_r-eq-u1,---·re_s _a _ce-m-en_t_ty_pe grout.
(b) Grout depth of tubing (reference to land surface): from _O ___ to 200 (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 GIS 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) Page 2
10/17/2011 12:25 3199 ENPSECURITV PAGE 03103
Its. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be.signed as follows:
i. for a corporation: by a responsible corporate officer;
2.. for a partnership or sole proprietorship, by a generalpartner 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 Mgms all persons listed on the -proyMdeed).
If an autborixed agent is signing on behalf of the applicant, then supply a letter signet] by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hcrcby certify, under penalty of law, that I have Personally examined and am familiar with the irxt'ormation
submitted in this dmument and all attachments thereto and tbat, based on toy inquiry of those individuals
immediately responsible for obtaining said information, l believe that the information is ttve, accurate and
complete. I am aware that theic arc sign i-ficarkt peaalties, including the possibility of fates and irnpnsonment,
for subimittng false information. I agree ro construct, operate, maintain, repair, and if applicable, abandon the
injectionwell and all related appurtenances in acaordarnce with the roved speedcations and conditions of
the Permit" i J � /-Y' I? /'Y /
i
;5t-c P
Si a of Pro--
� Pert]' DwtnerlApplicgwt
print ar ype Pall Name
Signature of Authorized Agent, if any
Print or Type Full Flame
Submit the complete applicatiou package to:
DWQ - Aquifer protection Section
1636 Maid Service Center
Raleigh, NC 27699-1636
Telephone (91.9) 733,3221
REU-tVED I DEN rD-NG
►Aglrifer Prolpslio[t Seth]
ou 28 2011
CPU/UFC sQw Nobfir3nop (Rcviea v1 s12011) PW1

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Brunswick County, NC
Parcel Number 16100002 Plat Date
Account Number 53283530 Land Value $88,180
PIN 210000130555 Building Value , $119,860
Owner LANGLEY JEFFREY C & VIRGINIA C Other Value $8,005
Owner Address 7 Deferred Value $0
Owner Address 2 1173 ROYAL OAK RD NW Total Taxable Value $216,045
city SUPPLY Heated Sq Ft 3,182
State NC Year Builf 1948
Zip 28482 1 Bedrooms 3 BEDROOMS
Legal Description L-362.89X320 2.66 ACRES SR 1345 Full Baths
Parcel Street Number 11173 Stories
Parcel Street ROYAL CAK Ext. Wall T CEDAR ! REQW SID[N
Street Type I RD Ext. Wall
Street Dir NW Neighborhood 5010
SubdMsion Municipality
Deed Book 3052 Fire Tax District SUPPLY
Deed Page 0696 Township LOCKWOOD FOLLY
Deed Date 6/7/2010 Acreage 2,66
Plat Book Sale Price $0
Plat Page
Disclaimer., Map and parcel data are believed to be accurate, but accuracy is not Mar, Scale
guaranteed. This is not a legal document and should not be substituted for a title search, 1 inch = 131 feet
appraisal, survey, ❑r for zoning verification.
hrttp://gis.brunsco.net/printPreview.aspx?PrintOptData--Brunswick County, NC10101truelfa... 10/13/2011

Approximate Closed Loop locations, spaced 20' apart
Notes:
1. Subject property serviced by private septic and well water.
2. Adapted from Google Earth and Brunswick County GiS Map, October 2011.
TITLE; SITE MAP FIGURE;
3plied Rosource Manar�ement "C, 1 173 ROYAL OAK ROAD NW
0. Box 882, Hampstead, NC 28443 JOB: SCALE; DATE; DRAWN BY;
[phone]FAX [phone] Langley As Shown 10/13/1 1 ❑NH

Subject Property
�r Man-made Pond
N
Private Well And Septic System
Notes:
i . Subject property and surrounding properties serviced by private septic systems and well water.
2. Adapted from Google Earth and Brunswick County G!S Map, October 2011.
TITLE; SURROUNDING SITE MAP FIGURE;
:lied Keoource Mana Bement PC 1173 ROYAL OAK ROAD NW
P.O. Box 882, Hampstead, N 443 Job: SCALE; DATE; ❑RAWN BY:2
(910j 270-2919 FAX [phone] Langley : A5 ShoWrl 1 ��1 ��� ❑IVH

F- 7ti.
1 'ir
Note: Adapted from USGS Supply, NC Topographic Quadrangle (1990),
TITLE: SITE VICINITY MAP FIGURE:
Applied Rewurce
Management,3
l? C. GCB: SCALE: DATE: DRAWN BY!
hempsr , NC 28443 1 "= rye 000r 1 0/24/ ! ! KLC