WI0800280_GEO THERMAL_20120202

Permit Number
Program Category
Ground Water
Permit Type
WI0800280
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
William & Jennifer de Bruin
Location Address
6425 Shinnwood Dr
Wilmington
Owner
Owner Name
William
Dates/Events
NC 28409
De Bruin
Scheduled
Orig Issue
02/02/12
App Received Draft Initiated Issuance
12/29/11
Regulated Activities
Heat Pump Injection
Outfall NULL
l ·•
Central Files: APS_ SWP_
02/02/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Diana Helias
PO Box 882
Hampstead NC
Major/Minor
Minor
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
William De Bruin
6425 Shinnwood Dr
Wilmington NC
28443
28409
Public Notice Issue Effective
02/02/12
Expiration
02/02/12
Waterbody Name Stream Index Number Current Class Subbasin
A�A
�rti►
NCDEER
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Waltild, P.E.
Governor Director
February 2, 2012
W ill iam de Bruin III
Jennifer Chelle de Bruin
6425 Shinnwood Drive
Wilmington, NC 28409
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10800280
6425 Sbinnwuod Drive, Wilmingtorh_ NC 28409
Dear Mr. & Mrs. de Bruin:
Dee Freeman
Secretary
On 12/29/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl
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:
The injection well system contains only potable water,
1 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
1 '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 I (u)(2). Additionally, you should contact the New Hanover 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 1Michael.Roeer8d)ncdenr. Lov if you have any questions.
Y�i/
fur Debra acts
Supervisor
cc: Wilmington Regional Office -APS
APS Central Files - Permit No. W10800280
New flanovcr County Health Dept.
ARM's WaterWorks (Diana; lehas)
Fulf'ord Cleating & Air (Justin Fulford)
1636 Mail Service Center, Ralegh, Nartlh Carolina 27699-1636
l xall= 512 N. Saiisbury St, Rafe K North Carolina 27604
Phone; 91 M07-64641 FAX! 919-80U496
Internet: www.nuwaterqualitv.oe�
One
N'46rtbCarolina
An Equal Qpporluafty t AliirmaUve Ac.dLD Ernp'uyer

0
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOUIZCFS
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance Willi the Provisions of 15A NCAC 02C .0206
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable Neater only as part of a geothermal heating and cooling system,
These wells are "pennitted by rule" and do not requitz an individual permit when they are constructed in
accordance with the rifles of 15A NCAC 02C ,0200 and this Notice is submitted prior to construction.
Pr lnt m- Type Iri formation and Mail to the Adds est on the Last Page.
DATE: _ December 13 , 20 11 PERMIT NO. _(to be f Iled in by DWQ)
A. STATUS OF 1NVELL OWNER (choose one)
Non -Government: individual Residence BusinessfOrgaiiixation
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:
William do Bruin III and Jonntfer Chelle de Bruin
Mailing Address:.6425 Shinnwood Drive
City: Wilmington State. NC Zip Code: 28409 County:- New Hanover
Day Tele No.: 910-620-2763 Cell No.:
EMAIL Address: bill.debruin0stiamesplantation.com FaxN❑.:
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Pavcol Identification Number (PIN) of well site: R06216-010-005-000 Coautty: New Han.
(2) Physical Address (if different than mailing address):
D.
City:
WELL DRILLER INFORMATION
Well Drilling Contractor's Name: H. Michael Sage
NC Well Diiffitig Contractor Certification No.: 2531A
Company Name; ARM's WaterWorks
State: NC Zip Code: . -
Contact Person: Plana Hellas EMAIL Address: [e-mail]
Address: PO Sox 882
City: Hampstead lip Code: 28443
OtI`iee Tele No.: 910-270.2919 Cell No.:
OPUIUIC 5QW Notification (devised 3/18/2011)
State: NC County: Ponder
fax No.: 910-270-298S
RECEIVED) D&Jh: , uft
Aqu&r PrMmllon-13w,6011
Page t
I'.G+. -� 2011

E. HEAT PUMP CONTRACTOR INFORMATION (ifdifforent than drille1)
Company Name: Fulford Heating and Air
Contact Person: Justin Fulford
Address: 3461 Holden Beach Road
City: Supply Zip Code: 28462
EMAIL Address:, .:[e-mail]
State: NC County: _B_ru_n_s_w_lc_k _____ _
Office Tele No.: 910-842-6589 Cell No.: Fax No.: ----------~~~~-------
F. WELL CONSTRUCTION DATA
(I) Number of borings to be constructed"': 5 Depth of each boring (feet):_2_5_0_' _____ _
* If existing waler supply wells will be used then provide the i1ifom1ation in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): _H_D_P_E _____________ _
(3) Well casing. If the weU(s) will use casing then provide the~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: _N_!_A ________________ _
(4) Grout (matet'ial sunounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** __ Other (specify) Therm-ex *• By selecting bentonite grout, a variance is hereby requested to I SA NCAC 2C .0213( d)(I )(A)-, ~-:vl-tic-h-re-qu-i~-es_a_c_em_ei_1t-ty-pe grout.
(b) Grout depth of tubing (reference to land surface): from _O ___ to 250' (feet)
If well 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 clearl y and include a 1101th atl"OW.
(I) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply we11s
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contaminatio11
(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: 111 most cases, a11 lle1·ial plwtognq,/1 of tlte prope,·ty pa,-ce/ slwwi11g JJl'opel"ty lines ,md stmctt11·es ctt11 be
obtained amt tlow11lottded fl'om the flpp/lc(lb{e co1111tJ• GIS website, Typi.cally, tlte propel'IJ' ca,, be sem·clted by
owner 1um1e 01· ftdtlress. The /ocatio11 of the we.lls i11 1•elfltio11 to prope,-tJ• bowularies, houses, septic tm1ks, otlte,·
wells, etc. cm, the11 be drawn In by lumd, Also, n 'Jaye,·' cart be selecte,l showl11g topogmphlc co11to111·s 01·
ele1•at/011 dat11.
GPU/UlC jQWNotification (Revised 3/18/2011) Page2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .Q2I I(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer,
2. for a partne ship or sole proprietorship: by a general partner or the proprietor, respectively;
3, for a 1nutlicipality 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 owtner fti_vhich means all persons listed on the - perry deed},
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that narues and allthorizes their agent to sigh (leis application oil their behalf.
"I hereby cer(ify, under penalty of lain, that I have personally exaunined and anti familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
imtnediately responsible for obtaining snid information, I believe that the information is tnic, accurate and
cornplete. I am aware that there are significant penalties, including die 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 Pennit."
Signet re of Propel ty Owner/Applicant
Print orType Full Name
i r tom, I3• ��
sit
NA e- &4f,6
Print or Type Dull Nellie
Signature ofAuthorized Agent, if any
Print or Type Fill Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Set -vice Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED I gENR I UAt)
AgQfer Plolerlrrn Ser on
LE1-- 49 20it
UPL1ftAC SQW Notification (Revised 3118/2011) Psae3

0
Z
-"'� - - -i 9, -�y
a
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N
Adapted from USGS Topographic
"Wrightsville Beach, N-C,,' 1970
Contour Interval = 5 Feet
TITLE: SITE VICINITY MAP I FIGURE:
applied Resource 642.5 SHINNWOOD DRIVE j
Management, P. C. JOB: SCALE: DATE: DRAWN BY: 1
r,--mp*tevANG26443 DeBruin 1"=2,000' ! 12/23/11 KLC

Or
" r �4& -r x
,,,' •� '.� • ti
A;

o )SIe earth 16e 100
111"CLICItol 50 N
Approximate Subject Property Lines
C Approximate Closed Loop Locations
Approximate Irrigation Well Location
Notes:
1. Subject property serviced by public water and sewer.
Adapted from Google Earth and New Hanover County GiS Map, December 2011.
TITLE: SITE MAP FIGURE:
7 p��lied Resource Manac ement i'C 1 — 6425 SHINNWQDD ROAD
Box OMPStead NU z ea IJOB: SCALE: DATE: DRAWN BY,
(9101 270-2919 FAX [phone] i DeBruln As Shown } 2122/} } DNH

· New Hanover County
PARID:R06216-010-005-0DO
DE BRUI N WILL IAM E III JE.NIUFU C
Pa rc el
Alt ID
Address
Unit
City
Zip Code
Neighbortlood
Class
Land Use Code
Living Un~•
Acres
Zoning
Leg al
Legal Description
Tax District
Owne rs
Owner
City
State
Country
Zip
Sales
Sale Date
18-NOV-11
31-0CT-01
10-AUG-95
07-SEP-94
21-MAY-93
14-AUG-92
Sale Details
Sale Date
Sale Key
Sale Price
Grantee
Grantor
Sale Source
Book
Page
Sale Validity
Sale Type
Sale Flag
STEB
Instrument#
Instrument Type
Adj. Reason
Adj. Price
Adj .Amount
Residential
Card
Stories
Class
Physical Condition
Grade
CDU
Exterior Wall
Styte
Year Built
Effective Year Built
Remodeled Year
Living Area
Total Rooms
Bedrooms
Family Rooms
Attic
Basement
Full Ball1s
Half Baths
Additional Fixtures
Total Fixtures
Heat
Heating System
Heating Fuel Type
Pre Fab Fireplace
Sale Price
$310,000
$0
$257 ,000
$60,000
$0
$231,500
Grantee
DE BRUIN WILLIAM E Ill JENNIFER C
NEUWIRTH HOWARD B KAREN C
NEUWIRTH HOWARD B
HILL BROADUS E Ill KATHERINE R
MAYNARD MARK LANNA U
MAYNARD RUSSELL M MARK L
315614.34.4677 .000
6425 SHINNWOOD RD
WILMINGTON
5021
RES-Residential
10-1 Fam Res
1
0
R-20-RESIDENTIAL DISTRICT
(0.46AC) LT 2R SEC 2 SHINNWOOD ESTATES
WM
NEUWIRTH HOWARD B KAREN C
WILMINGTON
NC
28409
THE DATA IS FROM 2011
18-NOV-11
467101
$310,000.00
Grantor
NEUWIRTH HOWARD 8 KAREN C
NEUWIRTH HOWARD 8 KAREN C
HILL BROADUS E Ill KATHERINE R
MAYNARD MARK LANNA U
MAYNARD RUSSELL M
CARR MADELINE HOLMES
DE BRUIN WILLIAM E Ill JENNIFER C
NEUWIRTH HOWARD B KAREN C
M-Verified via MLS
5599
1102
Q.Qualltled
IMPROVED
Warranty Deed
310000
B-GOOD QUALITY
GD-GOOD
05-WOOD SHINGLE
CC-CAPE COD
1995
3,336
4
0-0
16
CENTRAL WITH A/C
Heat Pump
Electlic
1
Page 1 of2
6425 SHINN WOOD RO
Book Page Sale Key
5599 1102 467101
3091 OTI9 243235
1913 0720 243234
1809 0086 243233
1668 0019 243232
1615 0385 243231
~
http://etax.nhcgov.com/F orms/PrintDatalet.aspx?pin=R06216-010-005-000&gsp=PROFL_ 12/13/2011
New Hanover County
Masonry Fireplaces
Additions
Card
Addition Details
Card
Addition Number
Lower
First
Second
Third
Year Built
Area
Grade
CDU
Values
Year
Total Land
Total Buildings
Appraised Total
Addition Number
0
1
2
3
1996
1,668
THE DATA IS FROM 2011
Description
WOK
GAR
POR
MARKET VALUE SHOWN· EXEMPTIONS TO BE REFLECTED IN AUG BILLS
THE DATA IS FROM 2011
Area
1,668
504
504
228
Page 2 of2
CI:213)
2011
$195,000
$337,289
$532,289
http://etax.nhcgov.com/F orms/PrintDatalet.aspx?pin=R06216-010-005-000&gsp=PROFI... 12/13/2011
Page 1 of 1
~ .
J15E
http://etax:.nhcgov.com/images/maps/49 5 863 3 290 l 7 4 M .jpg 12/13/2011
._~A
B.1r._ti-~.».-
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality ·
Beverly Eaves Perdue
Governor
William de Bruin ill
Jennifer Chelle de Bruin
6425 Shinnwood Drive
Wilmington, NC 28409
Charles Wakild, P.E .
Director
February 2, 2012
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
PermitNo. WI0800280
6425 Shinnwood Drive, Wilmington, NC 28409
Dear Mr. & Mrs. de Bruin:
Dee Freeman
Secretary
On 12/29/20U, 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 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 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 New Hanover 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 gers @ncdenr.gov if you have any questions.
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI0800280
New Hanover County Health Dept.
ARM's Water Works (Diana Helias)
Fulford Heating & Air (Justin Fulford)
f,~UlFL :J~. FROTEGTI C/'J ;i~CT\Oi~
1636 Mall Service Center, Raleigh, North Ca rolina 27699 -1636
Location : 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: 919-807~464 I FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity I Affirmative Action Employer
Sa~ ~. dtJotv
for~atts
Supervisor
·.N~· ~e . Carolina . . . . ·1;··· .. ·t;~·. · · · '/1 'tlt"/1 · w· · · u :1 n1,u4 · · : . · :: .. : .......... :
��A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Glades Wakild, P.F.
Governor Director
February 2, 2012
William. de Bruin III
.lemiifer Chelle de Bruin
6425 Shintiwood Drive
Wilmington, NC'. 28409
Subject: Acknowledgement of intent to Construct Type 5QW Injection Well System
Permit No. W10300280
6425 Shinnwood Drive, Wilmington, NC 28409
Dear Mr. & Mrs. de Bruin:
Dee Freeman
Secretary
On I2/29/2011, 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:
1. 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 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have beencompletely 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 I(u)(2). Additionally, you should contact the New Hanover 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 (919) $07-6406 or Michael.Ro ors ncdenr. ov if you have any questions.
5' erel d` II���
'Y
%t Debra atts
SuperVisoT
cc: Wilmington RegionalOffce -APS
APS Central Files - Permit No. W10800280
New Hanover County Health Dept,
ARM's WaterWorlcs (Diana I Iclias)
Fulford Heating &. Air (Justin Fulford)
A; )UIFL� riRWr.L:Tk lid SEL.i Q;
1636 Mail.Servbe Center, Raleigh, North Carolina 27693-163S
Locafcn: 512 N. Sailsbury R, Raleigh, North Carolina 21604
Rhone: 919-807-64641 FAX [phone]
Internet www,mvatesaualitv.om
An E.qug Opportunity t Afrma6ve Action Employer
No7 ehCarolina
NaftifL al1il
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