WI0400010_GEO THERMAL_20160502

PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary Water Resources
ENVIRONMENTAL QUALITY
S. JAY ZIMMERMAN
Sharon Wyrick
8233 Walter Combs Way
Stokesdale, NC 27357
Subject:· Pennit Rescission
UIC Permit No. WI04000i0
May 2, 2016
Geothermal Heating/Cooling Water Return Well
Guilford County
Dear Ms. Wyrick:
Director
Reference _is made to your request for rescission of the subject _Geotherrrud Heating/Cooling Water Return
Well Permit located at 8233 Walter Combs Way Stokesdale, NC 2735.· Staff from the Winston-Salem
Regional Office has agreed that a permit is no longer required. Therefore, in ·accordance with your request,_ Underground Injection Control (UIC) Permit WI0400010 is rescinded, effective immediately.
If in.the future, you wish to operate a Geothermal Heating/Cooling Water Return Well injection system, you must first apply for and receive a new permit. Operating a geothermal heat pump injection system
without a valid permit may result in the assessment of civil penalties and/or the use of other enforcement mechanisms available to the state. · ·
If it would be helpful to discuss this matter further, please do not hesitate to-call Shristi Shrestha at
[phone].
Attachment( s)
cc: Winston-Salem Regional Office .. WQROS
Central Files -Permit No. WI0400010
Guilford County ·Environmental Health Dept.
Sincerely,
IMM~J-~
~~erman, P.G., Director
Division of Water Resources
State ofNorth Carolina I Environmental Quality I Water Resources
1611 Mail service Center I Raleigh, North Carolina 27699-1611
919 707 9000
PAT MCCRORY
Govemor
DONALD R. VAN DER VAART
·Secreta1:v
Water n.Csources
ENVIRONMENT AL QUALITY
S. JAY ZIMMERMAN
Sharon Wyrick
8233 Walter Combs Way
Summerfield, NC 27358
Subject: Permit Rescission
UIC Permit No. WI0400010
April 5, 2016
Geothermal Heating/Cooling Water Return Well
Guilford County
Dear Ms. Wyrick:
Director
Reference is made to your request for rescission of the subject Geothermal Heating/Cooling Water Return
Well Permit located at 5531 US 220 N, Summerfield NC 27358. Staff from the Winston-Salem Regional
Office has agreed that a permit is no longer required. Therefore, in accordance · with your request,
Underground Injection Control (UIC) Permit WI0400010 is rescinded, effective immediately.
If in the future, you wish to operate a Geothermal Heating/Cooling Water Return Well injection-system,
you must first apply for and receive a new permit. Operating a geothermal heat pump injection system
without a valid permit may result in the assessment of civil penalties and/or the use of other enforcement
mechanisms available to the state.
If it would be helpful to discuss fuis matter further, please do not hesitate to call Shristi Shrestha
at (919) 807-_6406.
Attachment( s)
cc: Winston-Salem Regional Office -WQROS
Central Files -Permit No. WI0400010
Guilford County Environmental Health Dept.
Sincerely,
Cfo..c,-~s ~
<l(\,-Jay Zimmerman, P .G., Director
1 Division of Water Resources
St.ate of North Carolina I Environmental Quality I Water Resources
1611 Mail service Center I Raleigh, NorthCarolina27699-1611
91-9 7079000
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: March 9, 241b
To: Sherri Knight
From: Shristi Shrestha, WQROS — Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Far. [phone] E-Mail. [e-mail]
Permit Number: WI4400445' OJ 10 `- Q G 0 10
A. Applicant: Sharon WyrickClt NC [?Apartment of
Env
ironmental vironmental quality
wlt
B. Facility Name: Received
MAR 2 4 2016 �; � MAR 14 2016
C. Application: s
y� Wfnstcn-Salem
Permit Type: Geothermal Heatin �1'eturn Well
Sack Li* Regional Office
Project Type: Renewal
E. Comments/Other Information:
I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a completed WOROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
ir
RO-WOROS Reviewer: Date: �- la
COMMENTS:
NOTES: Permit rescission form was sent by mistake by owner according to note
rescission form in staff report. 0. M5 , '�a r�
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FORM: WQROS-ARR ver. 092614 .
Page 1 of 1

Permit ·Rescission Form
Information to be ·filled out b y Central Office:
Facility N ~me: Sharon Wyrick
Permit Number: WI0400010
Regional Office: Winston-Salem
County: Guilford
Date Rescission Requested: 02/06/2016
Received Original Request: X I Central Office D Regional Office
Form of Received Request: D Letter ___ I Signed Annual Fee Invoice . .__I X _ ___.I Other (form)
Information to be filled out b y Region:
Please Check Appropriately:
D Site Visit Performed D Groundwater Concerns Addressed
Recommendations
D Rescind Permit Immediately
Reason for Approval ____________________________ _
D Require Renewal with Suspended Actions
Recommended Actions to be Taken ------------------------
□ Do Not Rescind/Recommend ·Renewal
Reason For Denial _____________________________ _
Signature of Certifier (WQROS Section):
Signature of Certifier: _________________ _
Date Certified: ______________________________ _
Return Completed and Signed Form to the WQROS Section
DIVISION OF WATER RESOURCES
WQROS
February 11, 2016
MEMORANDUM
To: Sherri Knight
Winston-Salem Regional Office
From: Shristi Shrestha s. c; .
WQROS
Re: Rescission Request
SA 7 Geothermal Heating/Cooling Water Return Well
Permit No; WI0400010
Sharon Wyrick
Guilford County
The WQROS Central Office has received a permit renewal form indicating the permit be
rescinded. A Permit Rescission Form is attached. Please determine if a rescission should be
issued for this permit and return the completed Permit Rescission Form to this office.
If you have any questions please contact me at [phone].
Thank you for your cooperation.
Attachment( s)
__ N~Mb"kl2fo~~~~g~ DEPARTMENT oF Er-NIRONMENT AND NA TURAL REsou~_c_'E_s __ _
APPLICATION FOR A PEAAIIT TO CONSTRUCT OR OPERAT~ INJECTION WELLS
FEBO 8 ZO!g Accordance With the Provisions of15A NCAC 02C -•~'
Water Quality
A§~-HEATING/COOLING WATER RE TURN WELL(S,
These well(s) inject groundwater directly into the subsurface as part of a geotheTIT! al heating and cooling system
CHECK ONE OF THE FOLLOWING: 1
__ New Application ___ Renewal* ___ Modification _X _Per mitRescission Request* I
*f or Pennit Renewals or Rescission Request, ..::omplete Pa!!es l and 4 ( i gnature page) only~
Print or Type Information and Mail to the Address on the Last Page. Illegible Applicatic:::::ms Will Be Returned As Jncmrplete.
DATE: __ ,20 /~ PERMIT NO.{,d:LQ l(Q·)dfc:::lleave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave blank "fNew Application)
1. C1JJ1JTJrielllHJ§,e of W en
a. Continue to use as __ Geothermal Well __ Drinking Wat~r Supply __ Other Water
Supply
b. Terminate Use: If the well is no longer being used_as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a C:::opy of the Well Abandonment
Record (GW-30).
[}Q Yes, I wish to rescind the permit
2. Current Own~irship Status
Has there been a change of ownership since permit last issued? D YES D NO
If yes, indicate new owner's contact jnformation:
Name(s) ________________________________ _
Mailing Address: __________________________________ _
City: ___________ State:_· __ Zip Code: __________ County:
------
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence Business/Organi zation
Government: State Municipal __ County Federal -
C. WELL OWNER(S)/PERMIT APPLICANT-For individual residences, li st owner(s) on property deed. For
all others, list name of entity and name of person delegated authority to sign: -------------
Mailing Address:-----------------------------------
City: ____________ State: __ Zip Code:. _______ County : _____ _
Day Tele No.: ________________ C_e_11~N~o_.: _____________ _
EMAIL Address : ______________ -",.F~ax~N~o_.: ______________ _
G eot h ermal Water Return Well Permit Application (Revised Jan 2015) Page 1
'VOTE. In most cases an aerial photograph oj'the property parcel showing property lines and sintemres can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched br
owner name or address_ The location of'the wells in relallon to property boundaries, houses, septic tanks, other
wells, etc_ can then be drawn In btu hand. Also, o 'layer' can be selected showing topographic conlours or
elevation data
M. CERTIICATiON (to be signed as required below or by that persons authorized agent)
l SA NCAC 02C .4211(e ) requires that ali permit applications shal l be signed as follows:
1. for a corporation: by a responsible corporate officer;
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 all the erstini si lhsted on the proper". deed,
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicani•that names and authorizes their agent to sign this application on their behalf.
"f hereby certify, under penalty of law, that I have personally examined and ani 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, 1 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 accordance with the approved specifications and conditions of
the Permit."
Signature of Property Owv " "/Applicant
Print Ur Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Naine -- -
Submit two copies of the completed application package to:
Divisions of Water Resources
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Weli Permit Appiication (Revised San 2015) Page 4

Permit Rescission Form
Information to be filled out by Central Office:
Facility Name: Sharon Wyrick
Permit Number: WI0400010
Regional Office: Winston-Salem
County: Guilford
Date Rescission Requested: 02/06/2016
Received Original Request:
U Central Office 0
Regional Office
Form of Received Request:
0
Letter
Signed Annual Fee Invoice L —J
Other form
Information to be filled out by Region:
Please Check Appropriately:
❑ Site Visit Performed
Recommendations
❑ Groundwater Concerns Addressed
p CEIVED[KNOMWR
❑ Rescind Permit Immediately MAR 01 Z016
WNW OU'VIny
Reason for Approval— "MCV t& sectkm
❑ Require Renewal with Suspended Actions
Recommended Actions to be Taken
XDo Not Rescind/Recommend Renewal
Reason For Denial S C7 C7 ' W I _ -4 rre Y t 1 <<. � �T _cam u4,—
�1 i'K _ ile_L.PYlIvSri a

Signature of Certifier (WQROS Section):
.,,,.. ""
Signature of Certifier: ~~~
Date Certified: ~} ~ / f {p
Return Completed and Signed Form to the WQROS Section
NORTHCAROLINA DEPART!¼ENT OF E:NVIRONlvIENT AI'ID NATURAL RESOURCES
---. -....:!:!.t;~OINCDEQm\lJR .
APPLICATION FOR A.PERMIT TO ·CONSTRUCT OR DPER.l\.TE INJECTION WELLS
FEB O· S ZOtg Accordance With the Provisions of 15A "NC.AC 02C .0224
1
Water QuaHty
R8~-HEATIN.G/COOLIN G -~'IV ATER RETURN WELL(S}
These well(s) inject groundwater directly into the ~ubsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application ___ Renewal* __ Modification ~Permit Rescission Request*
· *For Pennit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned ,1-s Incomplete .
DATE: .)._-, 20 / /p .PERMIT NO.{jl.LQ lf<})d/(1leave blank ifNew Application)
A. CURRENT "WELL USE AND OWNERSHIP STATUS {ieave blank if New Application)
1. Current Use of Well
a. Continue to use as Geothermal Well __ Drinking Water Supply __ Other Water
Supply
b. Terminate Use: If the well is no longer being used ~s a geothermal injection well and you wish to
rescind the permif, check the box below. If abandoned, attach? copy of the Well Abandonment
Record (GW-30). ·
~ Yes, I wish to rescind the permit ·
2. Current Ownership Status
Has there been a change of ownership since permit last issued? D YES D NO
If yes, indicate new owner-'s contact jnfonnation:
Name(s) ______________________________ _
Mailing Address: _____________________________ _
City: __________ State:_· __ Zip Code:._· ______ County: _____ _
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence Business/Organization __
Government: State Municipal __ County__ Federal
C. WELL OWNER(S)/PERMIT APPLICANT-For individual residences, list owner(s) on property deed. For
all others, list name of entity and name of person delegated authority to sign: ___________ _
Mailing Address: ______________________________ _
City: ____________ State: __ Zip Code:. _______ County: _____ _
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
Geothermal Water Return Well Permit Application (Revised Jan 20 I 5) Page 1
NOTE. _in most cases an aerial photograph of the i roperty parcel showing properly lines and ,structures can be
abtained and downloaded from the applicable county GIS websita Typkally, the property can he searched by
owner name or address. The location of the wells in relation to property boundaries, Douses, septic tanks, ather
wells, etc. can their be drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data
M. CERTIFICATION (to be signed as required below or by -that person's authorized agent)
15A NC:AC: 02C _0211 (e) 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 all the trer_sonLl listed on the tvooe , _deed.
If an authorized agent is signing on behalf a[ the applicant, then sapply a ietter signed by the
applicant that names aad authorizes their agent to sign this application on their behalf.
1 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, l 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 accordance with the approved specifications and conditions of
the Permit"
flKW1)1M"7!;NM
MAR 0 1 - ' 16
W, .
FECEM1NCDEUDWR
MAR 01 Z016
Water Qualky
itiowl open "i" Boman
Signature of Property Owi .rlApplicant
500106N /-fWyxrc-kl
Print or Type Full Name
Signature of Property Owner/Applicant
i'ruii or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Perrnir Application {Revised ]an 2015) Page 4

Permit Number WI0400010
Program Category
Ground Wa~r .
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael. rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
F. David and Sharon H. Wyrick SFR
Location Address
5531 US 220 N
Summerfield
Owner
Owner Name
F
Dates/Events
Orig Issue
10/30/1987
NC
David
App Received
8/26/2009
Re g ulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27358
Wyrick
Draft Initiated
Scheduled
Issuance
Central Files: APS SWP
11/3/2015
Permit Tracking Slip
Status
Active
Version
2.00
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Regi~n
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
F David Wyrick Sr.
Public Notice
5531 US 220 N
Summerfield
Issue
12/17/2010
Re q uested /Received Events
RO staff report received
RO staff report requested
Additional information requested
Additional information requested
Additional information received
Additional information received
Streamlndex Number Current Class
Effective
12/17/2010
NC 27358
Expiration
11/30/2015
12/9/10
9/4/09
5/5/10
9/4/09
5/5/10
12/9/10
Subbasin
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE QUEST FORM
Date: March 9, 2016 .
To: Sherri Knight
From: Shristi Shrestha, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: w-1-04-004"45 "'-' :r.. 04-o o o t D
A. Applicant: Sharon Wyrick
B. Facilitv Name:
C. · A pp lication:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
_I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a completed WOROS Staff
Report.
When you receive this · request form, please write your naine and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above. ·
RO-WOROS Reviewer: __________________ Date: _____ _
COMMENTS:
·NOTES: Permit rescission form was sent by mistake by owne~ according to note
rescission form in staff report.
FORM: WQROS-ARR ver. 092614 Page 1 of 1
PAT MCCRORY
Govemor
DONALD R. VAN DER VAART
Secretary
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
Sharon Wyrick
8233 Walter Combs Way
Stokesdale, NC 27357
March 9th 2016
RE: Acknowledgement of Application No. WI0400445
Geothermal Heating/Cooling Water Return -Well
Guilford County
Dear Mrs. Wyrick:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on .March 1 2016. Your application
package has been assigned the number listed above, and the primary reviewer is Shristi Shrestha
Central and Winston-Salem Regional Office staff will perform a detailed review of the
provided application, and may contact .you with a request for additional information. To ensure
maximum efficiency in processing permit applications, the Water Quality Regional Operations
Section. (WQROS) requests your assistance in providing a timely and complete response to any
additional information requests.
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. If you have -any questions, please contact Shristi
Shrestha-at 919-807-6406 or email at [e-mail].
Sincerely,
~-
,;~
r.J!"'\ Debra J. Watts, Supervisor
1"-Animal Feeding Operations & Groundwater
Protection Branch
cc: Winston-Salem Regional Office, WQROS
Permit File WI0400445
Division of Water-Resources
State of North Carolina I Environmental Quality I Water Resources
1611 Mail service Center I Raleigh, ·North Carolina 2 7 699-1611
919 707 9000
Director
PAT MCCRORY
Govemor
DONALD R. VAN DER VAART
water Resources
ENWRONMENTAL QUAL+TY
February 2, 2016
CERTIFIED MAIL # 7014 1200 0001 3432 8619
RETURN RECEIPT REQUESTED
Sharon Wyrick
8233 Waiter Combs Way
Stokesdaie, NC 27357
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. W10400010
Guilford County
Dear Mrs. W yri ck
Secrerory
S. JAY ZIMMERMAN
D[reelor
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on December 17, 2010, and expired on November 30, 2015. Per permit conditions and
requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior to expiration of the permit if you wish to continue operating the injection well
on your property. According to our records, the permit renewal application is now past due.
Please submit your renewal application (attached) as soon as possible if you wish to continue using
the well for injection.
If Your Geothermal Water Return Well is Stilt Currenfiv Beim Used for Iniection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you Faust submit the enclosed renewal
application (Application for a Permit to Construct or Operate injection Wells — Geothermal
Heating/Cooling Water Return Wells), The form is also available on-line at our website
http:llportal. ncdenr,org/web/wq/aps/gwpro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Beim Used far Injection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, inigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
State of North Carolina j Environmen[al Quality i Water Rewurm
1611 Mail service Center I Paleigh, North Carolina 27599.1611
919 707 9000

Page2 of2
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
If There has been a Change of Ownership of the Property:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email at [e-mail].
Regards,
~-
Shristi Shrestha
Hydro geologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Winston-Salem Regional Office -WQROS w/o enclosures
Central Files -Permit No. WI0400010 w/o enclosures
PAT MCCRQRY
Governor
DONALD R. VAN DER VAART
WaterResources
ENVIRONMENTAL MAU"
December 2, 2015
CERTIFIED MAIL # 7014 1200 0001 3432 8596
RETURN RECEIPT REQUESTED
F, David and Sharon Wyrick 0"
`V233 Walter Combs W . V
g> lu 1d, NC , 5 8 -i ��Dk.6� p,4U �
Subject: Notice of Expiration (NOE)
Geothermal Water ReturnlOpen-Loop Injection Well
Permit No. WI0400010
Guilford County
Dear Mr. and Mrs, Wyrick:
Secretary
S. JAY ZIMMERMAN
Dirceror
The Underground Injection Control (UIC)Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for
the geothermal injection well system located on your property at the above referenced address
was issued on December 17, 2010, and expired on November 30, 2015. Per permit conditions
and requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least
120 calendar days prior to expiration of the permit if you wish to continue operating the injection
well on your property. According to our records, the permit renewal application is now past
due. Please submit your renewal application (attached) as soon as possible if you wish to
continue using the well for injection.
If Your Geothermal Water Return Well is -Still CurrentlN Beira Used for Iniection:
In order to comply with the regulatory requirements. listed under North Carolina Administrative
Code (NCAC} Title 15A, Subchapter 2C, Section .02I 1, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells -- Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http://portaLncdenr.org/web/wq/aps/gwpro/per-mit-applications.
If Your Geothermal Water Return Well is NO LONGER Bein_t Used for Iniection:
If the well is no longer being used for injection, you do not have to renew your permit. Check
the box in Part A of the attached renewal application that you wish to rescind the permit and
indicate the current status of the well (i.e., used as water supply well, irrigation well, inactive,
plugged and abandoned, etc.). If it is no longer being used for any purpose, it must be
permanently abandoned according to the regulatory requirements listed- under NCAC Title 15A,
Staic nfNomb Carolina j Eawifonmeotal Quality j Water RnMacu
1611 Mail mxvice Center j Raleigh, NorIL Carolina 27699-1611
919 707 900

Subchapter 2C, Section .0240. ·When the well is plugged and abandoned, a well abandonment
record (Form GW-30) must be submitted to our office to certify that the abandonment was
properly conducted.
If There has been a Change of Ownership of the Property:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the
applicable forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for.
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email [e-mail].
Best Regards,
~ fJ;~
• Michael Rogers, P. G. (NC & FL)
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Winston-Salem-Regional Office -WQROS w/o enclosures
Central Files -Permit No. WI0400010 w/o enclosures
Guilford County GI5
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#wrier.
WYRiCK, F DAVE . SR
�it Address
$,233.WALT-EP.C'OMBS WAY
!Nail City
SUMKERFIF:Lb
Mail state
o
-Mail. ZIP
27358
rMperty
Address
8233 'ih A1TFR `C4 MWq WAY
UPI 3, .51'4C, 7 tB 67-142
-oft ription itSlllwFtVIRY
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http:llgis.co.guilford.ne.us/guilfordsl/ 121212015

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0147371 ALL ;w
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Current
Bill # Old Bill # Parcel # Name Location Bill Flags
Due
OQQ071.2695-2015-_201.5-
0147371
WYRICK, F DAVID
8233 WALTER COMBS SUMMERFIELD NC
0000-00
SR
27358-9250
0000712695-2014-2014-
147371
WYRICK, F DAVID
8233 WALTER COMBS SUMMERFIELD NC
0000-00
SR
27358-9250
0000712695-2013-2013-
147 71
WYRICK, F DAVID
5531 US 220 NORTH SUMMERFIELD NC
00_ 00-00
SR
27358-9250
0000712695-2012-2012-
. 0147371
WYRICK, F DAVID
5531 US 220 NORTH GUILFORD NC
0000-00
5R
4000712695-2011-20111-
0147371
WYRICK, F DAVID
5531 US 220 NORTH GUILFORD NC
0000-00
SR
0000712695-2010-2010-
0147371
WYRICK, F DAVID
5531 US 220 NORTH GUILFORD NC
0000-00
SR
0000712695-2009-2009-
20090229069 0147371
WYRICK, F DAVID
.5531 U5 220 N SUMMERFIELD,NC 27358-�
0000-00
SR
9250
QQ Q7i2F9.-2008-2008-
2008023I678 4147371
WYRICK, F DAVID
5531 US 220 N SUMMERFIELD,NC 27358-
00000
SR
9250
20070227451 0147371
$2,321.95
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
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Current
Bill 9
Old Sill #
Parcel 9
Name
Location
Bill Flags
Due
0000712695-2007-2007-
WYRICK, F DAVID
5531 US 220 N SUMMERFIELD,NC 27358-
0000-00
SR
9250
0000712695-2006-2006
-
2D060220$52
Oi4737i
WYRICK, F DAVID
5531 US 220 N SUMMERFIELD,NC 27358-
$D,04
00 00 00
SR
9250
0000712695-200-5-2DQ5-
20050217351
0147371
WYRICK, F DAVID
5531 US 220 N SUMMERFIELD,NC 27358-
$0.00
0000-00
SR
9250
0000712695-2004-2004-
20040214744
0147371
WYRICK, F DAVID
5531 US 220 N SUMMERFIELD,NC 2735$-
$0.00
0000-00
SR
9250
0000712695-2003-2003-
20030210547
0147371
WYRICK, F DAVID
5531 US 220 NORTH NC
$0.00
0000-00
SR
0000712695-2002-2002-
20020207712
0147371
WYRICK, F DAVID
5531 US 220 NORTH NC
$0.00
0000-00
SR
0000712695-2001-R001-
20010207369
0147371
WYRICK, F DAVID
5531 US 220 NORTH NC
$0.00
0000-00
SR
Total: $2,321.95
Ali information contained within this portion of the Guilford County website is Public Record and is maintained and provided in
accordance with North Carolina General Statute 132. View Statute
Location: 400 West Market St, Greensboro, North Carolina 27401 & 325 E. Russell Ave., Nigh Point, North Carolina 27260
Phone:[phone]
Email the Tax Director: [e-mail]
The Billing & Collections records provided herein represent information as it currently exists in the Guilford County tax system. This
data is subject to change daily. Guilford County makes no warranties, expressed or imptied, concerning the accuracy, completeness,
reliability, or suitability of this data, Furthermore, this office assumes no liability whatsoever associated with the use or misuse of
such data.
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-S1w'-w M 'S'e -
R # I C; F DAVIp S
NO fI Address
S33 WALTER : CON68 WAY,
magdty
SUMMEl��ELD
Mai State
Nc
Man zip
2,7358
Property
SWAY
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Guilford County GIS Page 2 of 2
http://gis.co.guilford.nc.us/guilfordsl/ 12/2/2 0 15
U.S. Postal ServicerM
CERTIFIED MAIL,,, RECEIPT
(Domestic Mail Oniy; No Insurance Coverage Provided)
For delivery into rmation visit our wehslte at www.USPSX0M
{j®ii��wu rvv Q05�8 fiC
Here
p (EndOrsameR Require 7
R FResidoed Dalwery Fee
1 [Endorsement Asqulred]
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Seer Q Sharon Wy
rick
a�A 8233 Walter Combs Way --------
wPoa Stokesdale, NC 27357
5hristi 5hre5tha
■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailplece,
or on the front 11 space permits.
1. Article Addressed to.
Sharon Wyrick
8233 Walter Combs Way
Stokesdale, NC 27357
111111111111111111111111111111111111111111111111
9590 9403 0730 5196 3153 73
� ArtIcIA NrvAhar 1Trarrsfea hptir. s4(vfCe_rtebef}
7014 1200 0001 3432 8619
Ps Force 3811, April 2o15 PSN 7630-02-aoae053
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�. Received bX(Pflrried j C. Date of Dellvery
D. Is delivery address dlfferertt from ftem 17 0 Yes k
If YES, enter da]lvery address below: ❑ No
3. Service Type
R Prior* Man Expree"
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Domestic Return Receipt

PAT MCCRORY
Grrrernor
DONALD R. VAN DER VAART
WaterResources
ENVIRONMENTAL QUALITY
December 2, 2015
CERTTFIED MAIL # 7014 1200 0001 3432 8596
RETURN RECEIPT REQUESTED
F. David and Sharon Wyrick
8233 Walter Combs Way
Summerfield, NC 27358
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0400010
Guilford County
Dear Mr. and Mrs. Wyrick:
Secretary
S. JAY ZIMMERMAN
Dimctor
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for
the geothermal injection well system located on your property at the above referenced address
was issued on December 17, 2010, and expired on November 30, 2015. Per permit conditions
and requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least
120 calendar days prior to expiration of the permit if you wish to continue operating the injection
well on your property. According to our records, the permit renewal application is now past
due. Please submit your renewal application (attached) as soon as possible if you wish to
continue using the well for injection.
If Your Geothermal Water Return Well is Still Cu.rrentIN Beine Used for Iniection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The fora is also available on-line at our website
http://portal.nedenr.org/web/wq/aps/gwpro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Being Used for Infection:
If the well is no longer being used for injection, you do not have to renew your permit. Check
the box in Part A of the attached renewal application that you wish to rescind the permit and
indicate the current status of the well (i.e., used as water supply well, irrigation well, inactive,
plugged and abandoned, etc.). if it is no longer being used for any purpose, it must be
permanently abandoned according to the regulatory requirements listed under NCAC Title 15A,
State o£Nostl Carolina I Environmental QaOtty I Water Resource,:
1611 Mail service Center j Raleigh, North Caroln t 27699-1611
9l9 707 9M

Subchapter 2C, Section .0240. ·When the well is plugged and abandoned, a well abandonment
record (Form GW-30) must be submitted to our office to certify that the abandonment was
proper! y conducted.
If There has been a Change of Ownership of the Pro p ertv :
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the
applicable forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email atMichael.Rogers(w,ncdenr.gov.
Best Regards,
~~~
• Michael Rogers, P.G. (NC & FL)
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Winston-Salem-Regional Office -WQROS w/o enclosures
Central Files -Permit No. WI0400010 w/o enclosures
El
(Domestic Mall Only; No Insurance Coverage Provldee
For delivery Information visit our wehsits at www.usps.coms
ru
M
"r Postage $
m
CenlRed Fee
0 Raw Receipt Fee Pasprark
1--3(Endorsernant Requited) Here
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C3 (Endorsement Required)
C3
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F. David and Sharon Wyrick
-r °Rr r° 8233 Waiter Combs Way
C3 srrsar,Ap'. n Summerfieid, NC 27358
rl-
or PO Box rdc
LYy s ":e `f
1
1741, August 200E
■ Complete Items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the ma1plece,
or on the front It space permits.
7 Article Addressed tm
F. David and Sharon Wyrick
8233 Walter Camps Way
Surnmerfieid, NC 27358
I l l l l l 1111111111111111 H 111111111111111111111
9590 MS 0730 5196 5152 67
7 AlrIkAft Numhar f1humw fizim son** la6a
7014 fail O001 3432 8596
Ps Form 3811, Apfil 2015 PSN 7830-02-gU6 90& l
A. Signature
x o Agent
Cl Addresses
a. R000lved by Printed Nurse) C. date of DO wry
D. Is dellvery address ditrerarrt from item 17 Q Yes
If YES, enter dellvery address below. ❑ No
3. Service type
D Priority Mall Fxprees®
El Adut Slgnawre
0 Registered Mall-
0 Adult Signature f leatrictad 6elNwy
Cr Reeggistered Mad Rstri ected
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❑ Signature Confrrnatlon
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Restrlcted Delivery
$500.
Domestic Retum Reaefpt

FA
CDE R
North Carolina Department of Environmental Quality
Pat McCrory
Governor
November 3, 2015
CERTIFIED MAIL# 7014 1200 0001 3432 8527
RETURN RECEIPT REQUESTED
F. David and Sharon Wyrick
5531 US 220 North
Summerfield, NC 27358
Subject: Notic.e of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
PermitNo. WI0400010
Guilford County
Dear Mr. and Mrs. Wyrick:
Donald R. van der Vaart
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above-referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on December 17, 2010, and expires on November 30, 2015. Per permit conditions and .
requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior .to expiration of the permit if you wish to continue operating the injection well
on your property. According to our records, the permit renewal application is now past due.
Please submit your renewal application (attached) as soon as possible if you wish to continue using
the well for injection.
If Your Geothermal Water Return Well is Still Currentlv Being Used for In iection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells -Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Bein g Used for In i ection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Phone: [phone]\ Internet: http://wvvw.ncwater.org
An Equal Opportunity\ Affirmative Action Employer -Made in part by recycled paper
Wyrick SFR Page2
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
If There has been a Chan g e of Ownership of the Pro pe rtv :
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for your
cooperation and timely response. If you have any questions, please contact me by phone at (919)
807-6406 or by email at Michael.Ro gers {@ncdenr.gov.
Best Regards,
~(4~
Michael Rogers, P.G. (NC & FL)
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Winston-Salem- Regional Office -WQROS w/o enclosures
Central Files -Pennit No. WI0400010 w/o enclosures
..FA
CDE R
North Carolina Department of Environmental ·Quality
Pat McCrory
Governor
November 3, 2015
CERTIFIED MAIL# 7014 1200 0001 3432 8-527
RETURN RECEIPT REQUESTED
F. David and Sharon Wyrick
5531 US 220North
Sunimerfield, NC 27358
Subject: Notic.e of Expiration (NOE)
Geothertnal Water Rettirn/Open-Loopinjection Well
PermitNo. WI0400010 ·
. .
Guilford County
Dear Mr. and Mrs.' Wyrick:
Denald R. van der Vaart
Secretary
The Underground Injection Control (UIC) Program of the North Carolina-Division of Water
Resources (DWR) is entrusted to protect the groundw~ter quality and re·sources of the S_tate of
North Carolina, and is responsible for the regulation of injection well construction arid operation
activities within-the state. Our records indicate that the above-referenced operating pe~it for.the
geothermal injection well system lo~ated on your property at_the above referenceda<:fdress was: ·
issued on December-17, 2010, and-expires onNovem.berJO,· 2015~ · Per permit conditions.and .
requirements per 15A NCAC 2C .0224(c), the· renewal application must be submitted at least 120
calendar days prior _to expiration of the permit if you wish to ·continue operating the injection well
on your property.· According to our records, the permit renewal application is now past due.
Please submit your renewal application(attached) as soon as possible if you wish to continue using
-the well for injection.
If Your Geothermal Water Return Well is Still Currently Being Used for 1.niection:-
. In order to ·comply with the regulatory requirements listed under North Carolina Adrtiinistrati ve
Code (NCAC) Title 15A, Subchapter 2C, Section :0211, yo~ must submit the enclosed renewal
application (Application for a Permit to_ Constructor Operate Injection Wells.._ Geothermal
Heating/Cooling Water Return Wells). The form is also .available on-line at our website
http://portal.ncdenr.org/web/wq/aps/gwpro/permit-app1ications.
If Your Geothermal Water Return Wellis NO LONGER Being Used for Iniec.tion:
If the well is no longer being used for injection,· you do· not have to renew your permit. Check the
b·ox in Part A of the attached renewai application that you.wish fo rescind the permit and indicate
the current status of tl1e well (i.e., used as water supply we11, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must.be permanent_ly abandoned
1636 Mail Service Center, Raleigh, North Carolina 27699-1636 ·
Phone: [phone]\ Internet: http://www.ncwater.org
An Equal Opportunity\ Affirmative Action Empioyer -Made in part by recycled paper
WyTick SFR Page2
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.0240. When the well is plugged and abandoned,·a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted'.
If There has been a Change of Ownership of the Property:
Ifthere has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclos~d but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for your
cooperation and timely response.· · If you have any questions, please contact me by phone at (919)
807-6406 or by email at [e-mail].
Best Regards,
~14~
Mfohael Rogers, P.G. (NC & FL)
Hydro geologist
Division of Water Resources
Water Quality .Regional Operations Section
Enclosures
cc: Winston-Salem-Regional Office -WQROS w/o enclosures
Central Files -Permit No. WI0400010 w/o enclosures
■ Complete items 1, 2, and 3_
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mall piece,
or on the front if space permits.
1. Article Addressed to:
F. David and Sharon Wyrick
5531 US 220 North
5ummerfleld, IBC 27358
A 09nature
x ❑ Agent
© Addressee
B. Received by jPfinted Name) C. Date of Delivery
D. is del Nary address ditferent from ftem 17 C1 Yee
it YES, enter delivery address below: Q No
s. Service rye
a y Mall eqxme
© Adult 3lgnsture
Q Registered MaIITM
Q AduR Signature RastdOW Delivery
❑ RReelpWered Mall Pm5Wcted
ary
9590 W3 0730 5196 3150 69
Q CadMed Mel! ResWcted Delivery
Q Rehnn ReIM for
Collect on Delivery
Merchandise
a AM^Lr Ali —d. ✓nn--. A......e., L— r..a. n
Q CAl1eCt on Dsllvery Restricted Dellvery 0 Signature CoMllmaVOrlTM
QsIRgeat
7014 },1200 0001 3432 8527
AMalReetrecWoOhwy
ateednature n i� yam°°
_ $500)
— -
PS Form 3811. Apol2D15 PSN T53D-02-000-9053
Domestic Return Recelpt

Perm:t Number WI0400010
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael. rogers.
Coastal SW Rule
Permitted Flow
Facilitu
Facility Name
F. David and Sharon H. Wyrick SFR
Location Address
5531 US 220 N
Summerfield
Owner
Owner Name
F
Dates/Events
NC 27358
David Wyrick
Orig Issue
10/30/87
App Received Draft Initiated
08/26/09
Scheduled
Issuance
Central Files: APS_ SWP_
12/20/10
Permit Tracking Slip
Status
Active
Version
2.00
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
.Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
F David Wyrick Sr.
5531 US 220 N
Summerfield NC 27~58
Public Notice Issue
12/17/10
Effective
12/17/10
Expiration
11/30/15
_R_e .... o_u_la_t_e_d_A_c_t_;v_it_ie_s ________________ =R=e=o=u=e=-st=e=d=/R'--"-=-ec=e=i:...:.v=e=d-=E=v:....::e::..:..n=-=-ts=• __________ _
Heat Pump Injection RO staff report requested
Outfall I
l • -...1.,_~
Waterbody Name
Additional information requested
Additional information requested
Additional information received
RO staff report received
Additional information received
Stream Index Number ·current Class
09/04/09
09/04/09
05/05/10
05/05/10
12/09/10
12/09/10
.Subbasin
Permit Number WI0400010
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
F. David and Sharon H. Wyrick SFR
Location Address
5531 US 220 N
Summerfield
Owner
Owner Name
F
Dates/Ev ents
NC 27358
David Wyrick
Scheduled
Orig Issue
10/30/87
App Received Draft Initiated Issuance
08/26/09
Re g ulated Activities
Heat Pump Injection
Outfall LJL _
Central Files: APS_ SWP_
12/13/10
Permit Tracking Slip
Status
In review
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
F David Wyrick Sr.
5531 US 220 N
Summerfield NC
Public Notice Issue Effective
Rea uested/Received Events
RO staff report requested
Additional information requested
Additional information requested
Additional information received
RO staff report received
Additional information received
27358
Expiration
09/04/09
09/04/09
05/05/10
05/05/10
12/09/10
12/09/1-0
Waterbody Name Stream Index Number Current Class Subbasin
RA
MCDEMR
North Carolina Department of Environment and Natu.ral Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
December 1 7, 2010
F. David and Sharon H. Wyrick, Sr.
5531 US Highway 220 North
S~erfield, NC 27358
Re: Issuance of Injection Well Permit
Permit No. WI0400010
Issued to F. David and Sharon H. Wyrick
Guilford County
Dear Mr. and Mrs. Wyrick:
Dee Freeman
Secretary
In accordance with your application received August 26, 2009, Iain forwarding Permit No. WI0400010 for
the operation of a 5A7 geothermal underground injection control (UIC) well heat pump system located at the
above referenced address. This permit sh&ll be effective from the date of issuance until November 30, 2015,
and shall be subject to the conditions and limitations stated therein.
Also attached is a summary of the laboratory sampling results from water samples collected_ from your
geothermal well on April 26, 2010.
In order to continue uninterrupted legal use of.this well for the ·stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this permit is
not transferable to any person without prior notice to, and approval by, the Director of the Division of Water
Quality. If you have any questions regarding your permit or the Underground Injection Control Program
please call me at [phone].
Best Regards,
~£u~ {2,)r
Michael Rogers, P .G. (NC & FL)
Environmental Specialist
cc: Sherri Knight-Winston-Salem Regional Office
Central Office File -WI0400010
Guilford County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevzrd, Raieigh, North Carolino 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-7'i5-6048 \ Customer Service: 1-877-623-6748
Internet www.ncwaterqualitv.org
An Equal Opprtuniiy I Affim1ative 1;_ct1or, Employer
.NOnethC-1· . or· . ~aro ·1.na
J\7aturn.lllf ""
NC DIVISION OF WATER QUALITY
LABORATORY ANALYTICAL RESULTS
5A7 GEOTHERMAL UNDERGROUND INJECTION CONTROL (UIC) WELL
PERMIT NO.: VVI0400010
PERMITTEE(S): F. Davirl and Sharon H. Wyrick
SAMPLE COLLECTION DATE: April 26. 2010
Paameter Fecal Coliform Total Coliform
units CFU/100ml CFUl100ml
NC MCL and/or EPA Standard NC MCL=< 1 NC MCL= 1
Influent Sample Results <1 <1
Effluent Sample Results <1 <1
Parameter Nitrate Nitrite
units mg/Las N mgflasN
NC MCL and/or EPA Standard NCMCL= 10-NCMCL= 1
EPAPDWS= 10 EPAPDWS= 1
Influent Sample Results 3.8 <.01
Effluent Sample Results 3.9 <.01
Parameter Barlum,Ba Calcium,Ca
units pg/L mg/L
NC MCL and/or EPA Standard NC MCL= 700 NS
EPA PDWS = 2000
Influent Sample Results NA 6.1
Effluent Sample Results NA 6
Parameter Potassium, K Magnesium, Mg
units mg/L mgfl
NC MCL and/or EPA Standard NS NS
Influent Sample Results 1.1 2.2
Effluent Sample Results 1.2 2.1
Parameter Selenlu·m, Se Zinc, Zn
units pgfl pgfl
NC MCL and/or EPA Standard NC MCL = 20 NC MCL= 1000
EPAPDWS=50 EPA SOWS = 5000
Influent Sample Results NA 27
Effluent Sample Results NA 88
NC MCL = North Carolina Mai<imum Contamination Lim~ per 15A NCAC 2L .0200
EPA PDWS = Environmental Protection Agency Pri'\Jary Drinking Water Standards
EPA SOWS = Environmental Protection Agency SeGQndary Drinking Water Standards
NS = No standard
NA = Not analyzed
Total Dissolved Solids Chlorlde,CI
mg/L mgfL
NCMCL=500 NC MCL=250
EPA SDWS = 500 EPA SDWS = 250
74 · 9.9
70 10
Nitrate + Nitrite Silver.Ag
mglLasN 1,1g/L
NC MCL= 10 NCMCL=20
EPAPDWS= 10 EPA SOWS = 100
3.8 ~ NA
3.9 NA
Cadmium.Cd Chromium, Cr
pg/L pg/L
NC MCL=2 NC MCL= 10
EPAPDWS=5 EPA PDWS = 100
< 1.0. < 10
< 1.0 < 10
Manganese, Mn Sodium, Na
pgfl mg{L
NC MCL=50 NS
EPASOWS=50
?O 7.6
24 8.1
pH(lield)
units
NC MCL = 6.5-8.5
EPA SOWS = 6.5 to 8.5
NA
NA
Fluoride, FL
mgfL
NC MCL= 2
EPA POWS = 4.0
<0.4
<0.4
Aluminum, Al
pg{L
NS
EPA SOWS = 50 to 200
< 50
< 50
Copper, Cu
pg/L
NC MCL = 1000
EPA SDWS = 1000; PDWS = 1300
200
220
Nickel, NI
pg{L
NC MCL= 100
14
<10
'-
Sulfate, S04
mg/L
NC MCL=250
EPA SOWS = 250
<2
<2
Arsenic,As
pglL
NCMCL= 10
EPAPDWS= ~O
NA
NA
Iron, Fe
pg/L
NC MCL=300
EPA SDWS = 300
< 50
<50
Lead,Pb
pg/L
NCMCL=15
EPAPDWS= 15
< 10
< 10
.
NORTH CAROLINA
. ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
F. David and Sharon H. Wyrick, Sr.
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 5531 US Highway 220 North, Summerfield, Guilford County, NC 27358, and will be
constructed and operated in accordance with the application received August 26; 2009, and in confonnity with
the specifications and supporting data submitted, all of which are filed with the Department of Environment and
Natural Resources and are considered a part of this perm.it.
This permit is for operation of an injection well shall be in compliance with T,itle l SA North Carolina
Administrative Code 2C ·.0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until November 30, 2015, and shall
be subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
~
Permitissued this the D day.of ])ec&:&r , 2010.
~"-~~ ~
~ Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0400010 UIC/SA7
ver. 03/2010
Page 1 of 5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
PART II -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least· 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthem10re, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
Permit #WI0400010 UIC/SA7 Page 2 of 5
ver. 03/2010
PART Ill-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the ·creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of W atei-Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be _required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART IV -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
PART V -INSPECTIONS
1. Any duly authorized officer, employee, or representativ.e of the Division of Water Quality may, upon
presentation.of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities -as provided for in N.CG.S. 87-:90.·
3. Provisions shall be made for .collecting any necessary and appropriate samples associated with the
injection facility activities.
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface · and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
Permit #WI0400010 UIC/SA7 Page 3 of 5
ver. 03/2010
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Winston-Salem Regional Office, telephone number (336) 771--5000, any of the
following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures .;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant a,nd
correct facts or information shall be promptly_submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VII-PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Pennittee shall
submit an application to renew the permit 120 days prior to its expiration date.
PART VIII-CHANGE OF WELL STATUS
, 1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well
· Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
Permit #WI0400010 UIC/SA7 Page 4 of 5
ver. 03/2010
(E)
(F)
(G)
In the case of gra~el-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with .the
terms .and conditions of the permit..
The Permittee shall submit a Well Abandonment Record (Form GW..;30) as specified in
15A NCAC 2C :0213(h)(l) within 30 days of completion of abandonment.
3-. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
Permit #WI0400010
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/5A7
ver. 03/2010
Page 5 of 5
Routing Slip for 5A7 Well
Laboratory Review
Date: J:l / ! '3 /4,/P
Permit No. i/.1-0 'flJl?(}/e,
Pennittee( s): ------------
I have reviewed the attached laboratory analytical
results and have made any comments below. w Initial
1-f/%/lfDate
71, ~ A.Lj?~ ~~(77.,,,
~ C ~-at/ ~ .&4 ~./4 a.k.. ~ CA~ Emn < \~
,I'-~ IA"".lJ:, ,v e,\ ,ix/,"'-'-#4--c.c,,.. ~ ...JU.
Rogers, Michael
From: Byrd, Roy
Sent:
To:
Friday, December 10, 2010 1:54 PM
Rogers, Michael
Cc: Knight; Sherri;. Watts, Debra
Subject:
Attachments:
RE: Reports for AB57559 & AB57560
AB57560.pdf; AB57559.pdf
Michael,
These samples were not COC, so that form is not available. However, I have attached the field sheets, but it appears the
field pH was not done. None of the parameters requested require a pH of the sarople ·.
Have a Great weekend,
Roy
from.: Rogers, Michael
Sent: Friday, December 10, 2010 12:53 PM
To: Byrd, Roy
Cc: Knight, Sherri; Watts, Debra
Subject: FW: Reports for ABS7559 & AB57560
Roy-Sherri-
Which of these results is influent and effluent? Can you forward me the chain of custody sheets with the field pH.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
. NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line (919) 715.-6166; Fax [phone] (put to my attn on cover letter
http://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications#geothermApps
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Knight, Sherri
Sent: Thursday, December 09, 201011:57 AM
To: Watts, Debra; Slusser, Thomas; Rogers, Michael
Subject: FW: Reports for ABS7559 & AB57560
Attached are the analytical results for Dave Wyrick residence. Coliform results were negative for both influent and
effluent. If you need those results, let me know and I will send. They were done by a contract lab.
Sherri Knight, PE
NC DENR \Ninston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: (336) 771--5280
FAX: (336) 771~4632
1
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Byrd, Roy
Sent: Thursday, December 09, 2010 11:12 AM
To: Knight, Sherri
Subject: Reports for AB57559 & AB57560
Hi Sherri,
Your reports should be attached. Let me know if you have any questions or concerns.
Happy Holidays,
Roy
Please note new emai l address --Ro y.B [e-mail]
Roy Byrd
Microbiology & Inorganic Chemistry Branch Manager
Laboratory Section
{919) 733--3908 x222
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
2
L IL -)
I
esurts
,
County:
GUILFORD
Sample ID;
AB57559
River Basin
t�~���
PO Number #
10G0217
�C
G
Report To
MR
��
Date Received:
04/2712010
jTime
Received:
07:60
Collector-
S KNJGHT
0.
r.-�
Labworks LoginlD
SMATHIS
Region:
W_ SIR
Report Generated:
5113110
Sample Matrix: GROUNDWATER
Date Reported:
121D912010
Loc- Type:
WATER SUPPLY
Emergency
YeslNo
ViaiVID
COC Yes/No
Lac. Deacr.: WYRICK DAVID RESIDENCE
Location ID. 4PO41MO400010
Collect Date 04/26/2010
Collect Time: 10:50
Sample Depth
Result/
Method
Analysis
CAS #
Analyte Name
59—L
Units
Validated by
Qualifier
Reference
Date
LAS
Sample temperature at receipt by lab
1.2 °C
4127110
SMATHIS
WET
Ion Chromatography
_TITLE_ mgll-
EPA 300-0
4129110
CGREEN
Chloride
1
9.9 mpIL
EPA 300-0
4129110
CGREEN
Fluoride
0-4
0.4 U mglL
EPA 300.0
4129110
CGREEN
Sulfate
2
2.0 U mak
EPA 300,0
4129110
CGREEN
Total Dissolved Solids in liquid
12
74 mglL
APHA2540C-18TH
4128110
MOVERMAN
NUT
NO2+NO3 as N ir1 liquid
002
3.8 mglL as N
Lac10-107-04-1-c
4127110
CGREEN
Nitrate as N in liquid
0A2
3.8 mg& as N
Lachat107-04.1-c
6112110
MOVERMAN
Nitrite as N in liquid
0-01
0,01 U mg1L as N
Lachatl07-04-1-c
4127110
CGREEN ,
MET
7429.90-5
Al by ICP
50
5o U uglL
EPA 200.7
513110
ESTAFFORDI
7440-70-2
Ca by ICP
0.1
6A mg1L
EPA 200.7
513110
ESTAFFORD1
7440.43-9
Cd by ICPMS
1
1.0 U uglL
EPA 200.8
4129110
ESTAFFORDI
7440-47-3
Cr by ICPMS
10
IOU ugll-
EPA 200.8
4129110
ESTAFFORDI
7440-50-8
Cu by ICPMS
2
200 uglL
EPA 200,8
4129110
ESTAFFORDI
7439-09-6
Fe by ICP
50
SOU uglL
EPA 200.7
5131io
ESTAFFORDI
7440-09-7
K by ICP
0-1
1.1 mg1L
EPA 200-7
513110
ESTAFFORDI
7439.95-4
Mg by ICP
0-1
2.2 mglL
EPA 200.7
513110
ESTAFFORDI
7439-95.5
Mn by ICP
10
20 uglL
EPA 2007
513110
ESTAFFORDI
7440-23-5
Na by ICP
0.1
7,6 m91L
EPA 200.7
513110
ESTAFFORDI
7440-02-0
Ni by ICPMS
10
14 ug1L
EPA 200.8
4129110
ESTAFFORDI
1439-92-1
Pb by ICPMS
10
1 O U uglL
EPA 200.8
4129110
ESTAFFORDI
744MB-6
Zn by ICPMS
10
27 ugll-
EPA 200.8
4129110
ESTAFFORDI
Laboratory Seetlun-1623 NBII Service Cantu, Raleigh, NC 27699-18Z3 [phone]
For a dataHed aeacnpuorn of the qunkMer cddaa refer td P tr.'llf oOm n -der- OrnrJ.eS^x.2n at'7._atfi�srncUass iat•: ,i� ar�.'cCr .. -hh� 10P.nnl nr-0011 9ra:wotrr rMTotsramnhxlrrnaaxis•+
Page 1 of 1

GROUNDWATER FIELD/LAB FORM
Location code: 4 PO L} 1 w 1.04 Mq I
County:: GIU.t LF017— 7
Quad No Serial No.
Lat.
Long.
Report To: ARO, FRO, MRO, RRO, WaRO, WtRO,
Water
❑ soil
❑ Other
❑ Chain of Custody
Department of Environment and Natural Resourees
MViSION OF WATER QUALITY -GROUNDWATER SEC
SAMPLE PRIORITY
E$ Routine Lab Number /J
❑• Emergency ZN F pate Received 7 - fl Time:
Ree'd By: From:Bus, ourier, I nd ❑el.,
Other.
Data Entry By:
Ck:
Kinston FO F Trust, Central Off., Other: Date Reported:
1pped toy_ Bus, Hand del., Other Purpose: Baseline, Complaint, tiance, UST, Pesticide Study, Federal Trust rorcleone), Other: groundwater
Collector(s): _ . '<G ; I•ti �� 5 he rvi Date oy 2-6 10 Time I d5 a Resource evaluation.
FIELD ANALYSES Owner: ►rrc It3 iDa u I d
pH 4w Spec_ Cond.w at 250C Location or Site: WV r('C'L i4 5i L"Le- - tk + � �y�a� �servrw�
Temp.to °C 00 mg[L: Description of sampung paint: � n � I+�� -I- - w i I R S
Appearance Sampling Method C r rr-b Sample Interval
Field Analysis By: Remarks�''°`'$'�_
LABORATORY ANALYSES (Pumpft f"ne• airWmp.. etal
BOD 31 a rng&
COD High 340 MWL
COD Low 335 mgrL
Coliromr: MF Fecal31616 floorfrl
COTrromi: MF Total 31504 1loornt
Toc 680 rrVL
Turbidity 76 NTU
Rseldue, ToW Suspended 530 mg1L
pH 403 units
Alkarinity to pH 4.5 41D rn911-
Alkalinity to pH a.3 415 mg1L
Carbonate 445 nxx
Bicarbonate 440 mot.
Carbon dio=le 405 m91L
Chloride 940 m91L
Chroneurn: Hex 1032 0glL
Color: True 80 Cu
Cyanide -120
Lab
Diss. Solids 703DO mgfL
Fluoride 951 mg1L
AgSilver 46556 u 1L
AI ASurNnum 40557 L
'
Hardness: Total 990 mglL
As -Arsenic 46551 LKVL
Hardness (non-carb) 902 mg/L
Ba-Barium 46558 u 1L
Phenols 32730 ugn
Ca -Calcium 46657 Tai
Specific Carrel 95 pblltwslem
Gd Cadmium 46559 uatL
Sulfate 945 mgIL
Cr-Chromium 46559 ugIL
Sulfide 746 mglL
><
Cu-Capper 48582
Fe -Iran 46663 u
PA
oN and Grease mg1L
HgMermrry 71900
I{-Potasslum 4B555 Tryl
Silica
><
Mg-Magnesiurn 46554
Mn-Manganese 46565
N% as N BIG m91L
No -Sodium 46656 MWL
TKN as N 625 ►r1grL
Ni-Nidrel !L
N% t N% as N 630 90911.
M-Lead 48564 UWL
P: Total as P 055 mgrL
Se-seler ium L
Nitrate (NO3 as N) 520 mglL
InZnc 46567 u gIL
Nitrite (NO2 as N) 615 n1gIL
OW-54 REV. 7103 Far [Dissolved Analysts-suhmIt filtered sample and wrft'DIS" in block.
Or anvchlonne Pesticides _
8 ono hos horns Pesticides
N' en Pesticides
Acid Herbicides
PCBs
Semlyotatile Or anim
TPH-Dleser Range
Volatile organ ks OA boUle
TPH-Casorne Range
TPH-BTEX Gasoline Range
LAB IJSE ONLY
Temperature on arrival (°C]: t

County:
GUILEORO
Sample ID:
ABS7560
River Basin
pF W 1r�+�
PO Number #
10G0218
Report To
WSROAP
�� �`�G
Date Received:
04127/2010
rry. ;P
? t�
Time Received:
07:60
Collector:
S KNIGHT
Labvorks LoginlD
Sl41ATHIS
Region:
WSRO
Report Generated:
5173110
Sample Matrix:
GROUNDWATER
Date Reported:
1210912010
Lac. Type:
WATER SUPPLY
Emergency YeslNo
VisR10
COC Yes/No
Lae. Dow.: WYRICK. DAVID RESIDENCE
1. Location ID: 4P041 WI0400010 Collect Date: 0412612010 Collect Time: 10:68 Sample Depth
CAS # Analvte Name
LAB
Result/ Units Method AnalysisPQL Validated by
Qualifier Reference mate
Sample temperature at receipt by lab
1.2
"c
4W110
SMATHIS
WET
Ion Chromatography
_TITLE_
mg1L EPA 300.0
4129110
CGREEN
Chloride 1
10
mg1L EPA 300.0
4/29110
CGREEN
Fluoride 0.4
0.4 U
mg1L EPA 300.0
4129110
CGREEN
Sulfate 2 2•0 U mgfL EPA 300.D 4/29110 CGREEN
Total Dissolved Soiids in liquid
12
70
mg1L
APHA254OC-18TH
4/28110
MOVERMAN
NUT
NO2+NO3 as N in liquid
0.02
3.9
mglL as N
Lsc10-107-04-1-0
4127110
CGREEN
Nitrate as N In liquid
0.02
3.9
mgfL as N
Lachat 107-04-1-c
5/12110
MOVERMAN
Nitrite as N in liquid
0.01
0.01 U
mgfL as N
Lachat 107-04.1-C
4127110
CGREEN
MET
7429-90-5
AI by ICP
50
so U
ug1L
EPA 200.7
513110
ESTAFFORDI
7440-70.2
Ca by ICP
0.1
6.0
mg1L
EPA 200.7
513110
ESTAFFORDI
7440-43.9
Cd by ICPMS
1
1.0 U
uglL
EPA 200.8
4129110
ESTAFFORDI
7440-47-3
Cr by ICPMS
10
IOU
ug1L
EPA 200.8
4129110
ESTAFFORDI
7440-50-8
Cu by ICPMS
2
220
ug1L
EPA 200.8
4129/10
ESTAFFORDI
7439.8"
Fe by ICP
50
so U
uglL
EPA 200.7
513110
ESTAFFORDI
7440-09-7
K by ICP
0.1
1.2
mgfL
EPA 200.7
513110
ESTAFFOR01
7439-96-4
Mg by lCP
0.1
2.1
mgfL
EPA 200.7
513110
ESTAFFORDI
7439-96-5
Mn by ICP
10
24
u91L
EPA 200.7
513110
ESTAFFORD1
7440-23-5
Na by ICP
0.1
8.1
mgfL
EPA 200.7
513110
ESTAFFORDI
7440-02-0
Ni by ICPMS
10
10 U
uglL
EPA 200.8
4129110
ESTAFFORDI
7439-92-1
Pb by ICPMS
10
10 U
uglL
EPA 200.8
4129110
ESTAFFOR01
7440-89-6
Zn by ICPMS
10
88
ug1L
EPA 200.6
4129/10
ESTAFFORDI
Laboratory SvMow-1623 Mall Service Center, Raleigh, NC 276994623 1919j.733-3908
Fin a (I"Itw dowipw or me glHNrler popes We, to nnn 'ir•urt:,{ nC�ST• Mb1.r bR�oR_+1�:glglnnrn�k-rndy9]9lttP n Gu+l!Fer_ Goar S'Rtiry.lioonPl nc Geer owwA �IAh� a(f jtL^[hAs9rYsr
Page 1 of 1

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources
W I DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Location code: SAMPL.F TYPE SAMPLE PRIORITY
��^^ t JD0� 1j. R�'i��0
County:: L� u- � �] Water � Routine Lab Number
ency ❑
Quad No Serial No. ❑ Soil Emerg
� f Date Received "d2 ' Id Time
Other
Lat. Lang. Rec'd By: From:Bu Courier, and Del.,
❑ Chain of Custody Other: fA
Report To: ARO, FRO, MRO, RHO, WaRO, WiRO,
cjogD Kinston FO, Fed. Trust, Central Off'., Other
Shipped by: Bus, Hand Del., Other.
Collectors]: fC vt i c�. h�, � hzrrr i
FIELD ANALYSES
Data Entry By: Ck:
Date Reported:
Purpose: Baseline, Cflmplaisst, nmplisnce, USi , Pesticide Study, Federal Trust (ardo om), Other: groundwater
Time 5 S, Resource evaluation.
Owner: Lr3yri �l4 l� da��
pH 4ao Spec. Cond.94 at 25°C Location or Site: VuY rcc-k �esrda n C 4 - �► G cn �a�tnarrrc •[
Temp.,n °C DO mg/L: Description of sampung point: C� i"`^�- yU,y, I}telt oft pu�sy'le sprc�� 1'
Appearance Sampling Method Ciro-h Sample Interval
Field Analysis By: Remarks
BOO 310
COD High 340
COD Low 335
Conform: MF Fecal 31616
Wiform: MF Total 31504
TOC 690
Turbidity 76
Restdue, Total Suspended 530
Date G4 2- 4P i o
mg1L
Dlss. Sollds 73300
mV1L
Fluodde 951
wKyL
><
Hardness: Total goo
110orni
Hardness (non-carb) 902
110orri
Phenols 32730
rngn-
i
Specihc Cond. 95
NTU
Sulfate 946
rnafL
Sulfide 745
Oil and Grease
mglL
AgSilv¢r4656B
Ai -Aluminum 46557
mglL
mV1L
As Arsenic 46551
rngk
83-Badum 46558
ugA
><
Ca-Cakdum 46552
aslcrn
Cd-Cadmium 46559
rngll
><
Cr-Chromium 46559
mg)L
Cu-Copper 40562
Fe -iron 46563
mglL
Hg-Mercury 71900
[Pumping time. all tomp., ems]
pH 403 unfls
>
K-Potassium 46555 L
Alkalinity to pH 4.5 410 mg1L
Silica
Mg -Magnesium 46564
Alkalinity to pH 8.3 415 MCI
Mn-Manganese 48565 r 1t
Carbonate 445 M91L
NH, as N 810 mg1L
Na-Sodium 45556 TgLl
Sirarbanate 440 malt.
TKN as N 625 mg1L
Ni-Nickel /L
Carbon dioxide 405 mg1L
NO,+ NO,,, as N 63a mW
Pb-Lead 46564
Chloride 940 M9A-
P. Total as P 665 mg1L
SeSeienium UgIL
Chromium: Hex 1032 uglL
Nitrate (NO3 as N) 620 mg&
2n-Zinc 46567 11-
Cater. True 80 Cu
Nitrite (NG2 as N) 615 m91L
Cyanide 720
Lab Comments
GW-54 REV, 7103 For ❑issolved Analysis -submit filtered sample and write'DIS' in block.
or anocNodne Pesticides
Organophosphorus Pestikdes
N" en Pesticides
Add Herbic}des
PCBs
Seml,olatile Organics
TPH•Diesel Rance
Volatile OrganIcs. _0IOAAbog6
TPH-Caso4ine Range _
TPH-BTE7( Gasoline Range
rSE ONLYerature on arrival (°C): y

Rogers, Michael
From: Knight, Sherri
Sent: Thursday, December 09, 2010 11 :57 AM
To:
Subject:
Attachments:
Watts, Debra; Slusser, Thomas; Rogers, Michael
FW: Reports for AB57559 & AB57560
ab57559.pdf; ab57560.pdf
Attached are the analytical results for Dave Wyrick residence. Coliform results were negative for both influent and ...-
effluent. If you need those results, let me know and I will send. They were done by a contract lab.
Sherri Knight, PE
NC DENR Winston.:salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Byrd, Roy
Sent: Thursday, December 09, 2010 11:12 AM
To: Knight, Sherri
Subject: Reports for AB57559 & ABS7560
.Hi Sherri,
Your reports should be attached. Let me know if you have any questions or concerns.
Happy Holidays,
Roy
Please note new email address -Ro y .B y rd@ncdenr.g ov
Roy Byrd
Microbiology & Inorganic Chemistry Branch Manager
Laboratory Section
[phone] x222
E-mail correspondence to and from .this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties .
1
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 04/27/10
To: Aquifer Protection Central Office
Central Office Reviewer: RoeerslSlusser
Regional Login No:
County: Guilford
Permittee: Wyrick, Dave
Project Name: Wyrick Residence, Dave
Application No.: W10400010
RE v L; , _,CAR i uvvu
L GENERAL INFORMATION Aquifer Proter oon Serbon
1. This application is tcheck alt that apply): ❑ New ® Renewal MAY 4 6 m Q
❑ Minor Modification ❑ Major Modification
Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 543 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation ® Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
a. Date of site visit: April 26. 2010
b. Person contacted and contact information: _Dave Wyrick (33! f 643-4286
c. Site visit conducted by: Sherri ght
d. Inspection Report Attached: ❑ Yes or ❑ No.
I. Is the following information entered into the BUNTS record for this aF
® Yes or ❑ No. If no, please complete the following or indicate
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude; Longitude:
?lication.
e. Regulated Activities 1 Type of Wastes (e.g., subdivision, food processing, municipal wastewater): None
For Disposal and In"ection Sites:
{If multiple sites either indicate which sites the information applies to, cogv and paste a new section into the
document for each site. or attach additional pages for each site)
a. Locations): 6136 Burlington Road, Gibsonville, NC
b. Driving Directions, From Winston-Salem take Hwy 52 north approximately 1.3 miles to exit
#109A/Kemersville onto US 158 East. Go --- 2 miles to Exit #8 WalkertownlReidsville— 0.5 mile.
Continue on US 158 — 20 miles until the ramp toward Greensboro/US 22201Madison. Go — .12 mile. Turn
right on US 220 N. 5531 is — 1 mile on the right.
c, USGS Quadrangle Map name and number:
d. Latitude: 36 1 Y 12" Longitude: 79 54' 30"
R. NEW AND AILVOR MODIFICATIONAPPLICATIONS (this section not needed for renewals or minor
modifications, Alp to next sectiont
Description Of Waste(S) And Facilities
FORM: staff report - Wyrick uic.doc 1

AQUIFER PROTECTION REGIONAL STAFF REPORT
1. Please attach completed rating sheet. Facility Classification: __
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No D N/A. Ifno, please explain: __
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No D N/ A. If no, please explain: __ Does the
application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D Yes D No
D N/ A. If no, please explain: __ Is the proposed residuals management plan adequate and/or acceptable to
the Division. D Yes D No D N/ A. If no, please explain: __
4. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D N/ A. If no~ please explain: __
5. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No D N/ A. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
6. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit: __
7. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
m<?nitoring parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
8. For residuals, will seasonal or other restrictions be required? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or maior modification
systems)
Description Of Waste(S) And Facilities
1. Are there appropriately certified ORCs forthefacilities? D Yes or D No.
Operator in Charge: __ . Certificate #: __
Backup-Operator in Charge: __ Certificate #: __
2. Is the design, maintenance and operation ( e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D No.
If no, please explain: __
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? D Yes or D No. Ifno, please explain: __
FORM: staff report-Wyrick uic.doc 2
AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Has the· site changed in any way that may affect permit ( drainage added, new wells· inside the compliance
boundary, new development, etc.)? If yes, please explain: __
5. Is the residuals managementplan for the facility adequate and/or acceptable to the Division?
D Yes or D No. If no, please ~xplain: __
6. Are the existing application rates (hydraulic or nutrient) still acceptable? D Yes or D No. If no, please
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Will seasonal or other restrictions be required for added sites? D Yes D No D N/ A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, please attach a
map showing .conflict areas or attach any new maps you have received from the applicant to be incorporated
into the permit: __ -
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? D
Yes or D No. Ifno, please explain: ____ _
11. Were monitoring wells properly constructed and located? D Yes or D No D N/ A. If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? D Yes or
D No D N/ A. Please summarize any findings resulting from this review: __ _
13. Check all that apply: D No compliance issues; D Notice(s) of violation within the last permit cycle; D
Current enforcement action(s) D <;µrrently under SOC; D Currently under JOC; D Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc): ____ _
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? D Yes
D No D Not Determined D N/ A.. If no, please explain: -__
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit?
D Yes or D No D N/ A. If yes, please explain: __
FORM: staff report-Wyrick uic.doc 3
AQUIFER PROTECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS(Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
D Heating/cooling water return flow (5A7)
~ Closed-loop heat pump system (5QM/5QW)
D In situ remediation (5I)
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
D Other (Specify: __________________ _
2. Does system use same well for water source and injection? ~ Yes D No
3. Are there any potential pollution sources that may affect injection? D Yes ~ No
What is/are the pollution source(s)? None known. What is the distance of the injection well(s) from the
pollution source(s)?
4. What is the minimum distance of proposed injection wells from the property boundary? _> 100 ft.
5. Quality of drainage at site: ~Good D Adequate D Poor
6. Flooding potential of site: ~ Low D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes or D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program:
8. Does the map presented represent the actual site (property lines, wells, surface drainage)?~ Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal And Modification Onlv:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation ( e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
~ Yes D No. If yes . explain: All of the water is not reinjected; a portion is discharged beside of the
house.
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes, explain:
3. For renewal or modification of groundwater remediation permits (of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes D No. If yes , explain:
FORM: staff report -Wyrick uic.doc 4
AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Drilling contractor: Name: Bainbridge Well Drilling
Address: __ G=r=een~sb~o~ro~. ~N~C
Certification number:
5. Complete and attach Well Construction Data Sheet.
FORM: staff report• Wyrick uic.doc 5
AQUIFER PROTECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application. Samples taken. Results will be
forwarded when received. Samples negative for total and fecal coliform. New furnace was installed 2004.
2. Attach Well Construction Data Sheet -if needed information is available
3. Do you foresee any problems with issuance/renewal ofthis permit? D Yes IZ! No. If yes, please explain
briefly.-----'-
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information;
8. IZ! Issue; D Deny. If deny, please state reasons:
9. Signature ofreport preparer(s): ________________________ _
Signature of APS regional supervisor: _____________________ _
Date: _______ _
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: staff report-Wyrick uic.doc 6
Ro gers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Knight, Sherri
Wednesday, May 05, 201 0 11 :52 AM
Slusser, Thomas; Rogers, Michael
Watts, Debra
Wi0400010
staff report -Wyrick uic.doc
Staff report attached. Sorry this one is so old. This is one that Stephen Berry had before he left and it fell through the
cracks. I sampled it. Coliform samples are OK. Metals and nutrients are not back yet.
Sherri Knight, PE
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
1
AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: September 4 . 2009
To: 0 Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS
0 Andrew Pitner, MRO-APS
0 Jay Zimmerman, RRO~APS
0 David May, WaRO-APS
□ Charlie Stehman, WiRO-APS
~ Sherri Knight, W-SRO-APS
From: Michael Rogers Groundwater Protection Unit
Telephone: [phone] Fax: (919 ) 715-0588
E-Mail: Michael.Ro [e-mail]
A. Permit Number: WI 0400010
B. Owner: F. David and Sharon W vrick
C. 1.f11cility/Operation: ___.;
D Proposed ~ Existing D Facility D Operation
D. Application:
1. Pernut Type: D Animal D SFR-Surface Irrigation□ Reuse D H-R Infiltration
D Recycle D I/E Lagoon D GW Remediation (ND)
~ UIC -SA 7 Geothermal well
For Residuals: □ Land App. 0 D&M
· D 503 D 503 Exempt
D Surface Disposal
0 Animal
2. PrtJjectType: D New D MajorMod. D MinorMod. ~ Renewal D Renewalw/Mod.
E. Comments/Other Information: ~ I would like to accompany you on a site visit. I NOTE:
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within, please take the following actions:
~ Return a Completed APSARR Form and attach laboratory analytical results, if applicable.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: ------------------Date: ____ _
FORM: APSARR 07/06 Page I of I
Beverly Eaves Perdue
Governor
4.rA MCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
August 31, 2009
F. David Wyrick, Sr.
Sharon H. Wyrick
5531 US 220 North
Summerfield, NC 27358
Subject: Acknowledgement of Application No. WI0400010
Injection Heating/Cooling Water Return Well (5A7)
Wyrick, M.L. -SFR
Guilford
Dear Mr. & Mrs. Wyrick:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on August 26, 2009. This application package has been assigned the number listed above·and will be reviewed by
Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 -90 days after receipt of a complete
application. ·
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at [e-mail]. If the
reviewer is unavailable, you may leave a message, and they will re~pond promptly. Also note that the Division has reorganized. To
review our new organizational chart, go to http://h2o.enr.state.nc.-us/documents/dwg orn:chart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
O~A-~
for Debra J. Watts
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Permit Application File WI0400010
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-STT--623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity \ Affirmative Action Employer
N%rthCarolina
J(Jaturattu
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMMT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR,
TYPE 5-A7 WELL($)
New Permit Application OR Renewal (check one)
DATE: Aug. 25, 2009, 20_
PERMIT NO. W 104000 10 . (leave blank if NEW permit application)
A.
iI
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 far signature); F. David W y r i c kS a rid
Sharon H. Wyr ick
(1) Mailing Address; 5531 US 220 North
City: _S-umme r_ _f_ i e i d State: N C zip Code: County: 6-LL. I Lf3:aQ
Home/Office Tele No.: _ 36 643 4226 Cell No.:
EMAIL Address:
(2) Physical Address of Site (if different than above):
City:
State: Zip Code:
Home/Office Tele No.: Cell No.:
EMAIL Address:
County.
AUTHORIZED AGENT OF OWNER, YF ANY (if the Permit Applicant does not own the subject property,
attach a ietter 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:
RECEIVED f ( ENR t 0WQ
GPISUIC 5A7 We]I Permit Application (Revised 9/2007) A0U1FFR'PPnTFf T1nN fiP(,TION PW t
AUG 2 6 2009

C. WELL DRILLER INFORMATION
Company Name: UN KN OWN
Well Drilling Contractor's Name: _______________________ _
NC Contractor Certification No.: ________________________ _
Contact Person._: --------------=EM==-AIL=· =-:a.A=d=d=re=ss==-----------
Address: ---------------------------------
City: _________ Zip Code: ____ County: ____________ _
Office Tele No.: _________ Cell No.: _________ _
D. HEAT PUMP CONTRACTOR INFORMATION (ff different than driller)
Company Name: Do n B e n nett -$ e e At tac h e d
Contact Person-'--: --------------------'E=M~A=IL=-:;..A=d=d=re=ss=: __________ _
Address:---------------------------------
City: _________ Zip Code: ____ County: ____________ _
Office·Tele No.: Cell No.: _________ _
E. STATUS .OF APPLICANT
P . 'X nvate: __
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be U$ed)
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection op·eration?,
Personal consumption?
YES_....._X __
YES_ ..... X __
NO __ _
NO __ _
R WELL CONSTRUCTION DATA (Skip to Section I if this is a Permit RENEW AL)
PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1)
through (7) below as PROPOSED construction specifications. Submit Form GW-1 after
construction.
EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through
(7) below to the best of your lrnowledge. Attach a copy of Form GW-1 (Well Construction
Record) if available.
(1) Date to be constructed: _______ Number of borings: ___ _
Approximate depth of each boring (feet): _______ _
(2) Well casing. Is the well(s) cased? (check either (a.) YES m: (b.) NO below)
(a) YES ___ If yes, then provide the casing ·information below.
Type: Galvanized steel __ Black steel __ Plastic __ Other (specify) ______ _
Casing thickness: __ diameter (inches): ___ depth: from ___ to ___ ft. (reference to land surface)
Casing extends above ground ____ inches
GPU/UIC 5A7 Well Permit Application (Revised 9/2007) Page 2
(b) NO
(3) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
__ Around closed-loop piping; from ___ to __ (feet).
___ Around well casing; from ___ to ___ (feet).
(4) Well(s) Screen lnfonnation
Depth of Screen: From ____ to ____ feet below land surface
(5) N.C. State Regulations (Title ISA NCAC 2C .0200) require the Pennittee to make provisions for
monitoring wellhead water quality and processes. A faucet on both Influent (groundwater entering heat
pump) and Effluent (water being injected back into the well) lines is required. Will there be a faucet on:
(a) Influent line? Yes __ No__ (b) Effluent line? Yes __ No __
(6) Source Well Construction Information (if the water source well is a different well than the injection well)
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available, provide the
following data:
Groundwater Source. From what depth, formation, and type of rock/sediment units will the groundwater
be withdrawn? (e.g. granite, limestone, sand, etc.)
Depth: _______ Formation: ______ Rock/sediment unit: _______ _
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR PROPOSED WELLS IF
THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
I. OPERATING DATA
(1) Injection rate:
(2) Injection Volume:
(3)
(4)
Injection Pressure:
Injection Temperature:
J. INJECTION-RELATED EQUIPMENT
Average (daily) 7 gallons per minute (gpm).
Average ( daily) __ gallons per day (gpd).
Average ( daily) __ pounds/square inch (psi).
Average (January)~° F, Average (July)_§_§_° F.
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.
K. 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 1000 feet of the
geothermal ·heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the.facility's location and the map name.
GPU/UIC 5A7 Well Permit Application (Revised 9/2007) Page 3
L. 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 relieve 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 accordance with the approved specifications and conditions of the Permit."
Signature of Property OwnerlAppiicant
F. adv id Wvrjck_ Sr.
Print or Type Full Name
L�
Signature of Property Owner/Cant
Sharon H. Wvrick
Print or Type Full Name
Signature of Authorized Agent, W any
Print or Type.Fuh Name
Please return two copies of the completed Application package toy
North Carolina DENR-DWQ
Aquifer Protection Section
T_]IC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEW i DEW DWQ
GPUfU]C 5A7 Well Permit Application (Revised 912007) RQUJFFR PPnT1-r-TON SFCTT()N Pie 4
AUG s 6 2049

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: W 10 4 0 0 010
Permittee Name: F P j, v; d 61 y; ; r.k ; r
Address: 5531 US 220 North, Summerf iPtrl, NC 27458
Please check the selection which most closely describes the current status of your injection well system:
1) x ( Well(s) still used for injection activities, or may be in the future.
2) ( Well(s) not used for injection but is/are used for water supply or other purposes.
3) { Injection discontinued and; a) ( Well(s) temporarily abandoned
b) (Well(s) permanently abandoned
c) ( Well(s) not abandoned
4) ( Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description of how the well
was sealed and the type of material used to fill the well ffpermanently abandoned);
Permit Rescission:
If you checked (2),(3), or (4) and will not use a well for injection on this site in the future, you should request rescission of the
permit, Do you wish to rescind the permit?
( Yes kNo
Certification:
"I hereby Certify. under penalty of law, that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
Signature Date
Revised 5/05 GWIUIC-68
RECI±IvEu- d )EHR 10WQ
AQUIpFR PRMt f 71NJ gF—"ON

t artily the an KU of thin d►awing, 1 Bar-
reyed the property thdown on this pMr that the
properly linos andklocaiien of all structures are
aoeureteiy shorn hereens thet no structure lo-
coted on fhir property encroach" an coy adja•
cent rtreet or preperyl and that no structure en
adjacent property encreoehes ew preMlses
gvrwoyw
This prapwty is .pot iaeated in
a soeeiel. fiend faeu►d eras as
deternnxed by **. Deperfetenl of
Housing and U4mn Devaiopmenf.
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a
TRANE"
UNITARY PRODUCTS GROUP
EQUIPMENT OWNER
154
DAVIT} WYRICK
5531 US 220 NORTH
SUMMERFIELD, NC 27358
USA
PH# [phone]
Model No TAYWARD255
Agreement No 2403851
170070 04-219
SERVICES
BENNETT, DON SERVICE COMPANY
7601 PEACEFUL LANE
SUMMERFIELD, NC 27358
USA
PH# [phone]
American Standard Warranty Company/National Product Care Company
} (during the Perm of this Agreement) will,
j through a servicer, make necessary adjustments. repairs, and/or
} replacements on the equipment covered.
# American Standard Warranty Company/National Product Care Company
j will pay for all replacement parts and/or labor subject to the
product coverage lasted and subject to the Terms and Conditions
listed on the reverse side.
MODEL A71POER SERIAL NUMBER
GSUJ0481BB2LOOO W04A02409
RQUI PWNT LOCATION
WYRICK, DAVID
5531 US 220 NORTH
SUMMERFIELD, NC 27358
USA
Date Equipment Installed: 02-13-2004 Data Coverage Begins: 02-13-2004
Warranty Sales Price: $425.00 Date Coverage Ends: 02-13-2024
A+,hAAAAF►IAi/ARffAWAAA/A PRODUCT COVERAGE AAAA1.1/.AAA#.AR.,►�rAA+A.AA
DURING THE COVERAGE PERIOD SPECIFIED ABOVE, TO REPAIR OR REPLACE
THE EQUIPMENT OR ANY INTERNAL COMPONENT IN THE EQUIPMENT
LISTED ABOVE AND IDENTIFIED BY MODEL AND SERIAL NUMBER.
THIS COVERAGE IS SUPPLM4ENTAL TO THE MANUFACTURER'S LIMITED WARRANTY
PLEASE KEEP THIS AGREEMENT IN A SAFE PLACE
EXTENDED WARRANTY
Pub. No. 26-1026-02
., r •A..'19'6-A%%r-V 'M1 'iFR , f sn°W ART' y.. ,' G-'S�F' �!. n:•'Cm: "u4• •r •41G" in8".�• + Er. a!a IM' M

A.VA.
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
August 20, 2009
F. David Wyrick, Sr.
5531 US 220 N
Summerfield, NC 27358
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WI0400010
Guilford County
Dear Mr. Wyrick:
Dee Freeman
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water Quality (DWQ) is
entrusted to protect the groundwater quality and resources of the State of North Carolina, and is responsible for
the regulation of injection well construction and operation activities within the state. Our records indicate that
the above-referenced operating permit for the underground injection well system, which was issued to you on
October 15, 2004, and expires on October 20, 2009, has not been renewed. If you wish to keep this permit and
operate the injection well system, the permit must be renewed and issued in your.name. Our records do not
indicate that the well system has been plugged and abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative Code (NCAC)
Title 15A, Subchapter 2C, Section .0211, you must submit one of the following forms:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for Injection with Geothermal Heat
Pump System for Type 5A7 Well(s) ifthe injection well system on your property is still active.
-OR-
B. Status of Injection Well System if the injection well system is inactive or has been temporarily or
permanently abandoned.
If there has been a change·of ownership of the property, an Injection Well Permit Name/Ownership Change
Form must also be submitted.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capitai Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity I Affirmative Action Employ~r
_ ..One C .. North arolina
Jvaturallll
If the injection well system is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requi;ements listed unded'.~CAC Title 1 SA, Subchapter 2C, Section .0214. When
each well is plugged and abandoned, the well abandonment record (Form GW-30) must be submitted to our
office to certify that the abandonment was properly conducted. If the injection well system is still active and
you wish to renew your permit, the renewal application must be submitted within 30 calendar days of the
receipt of this letter to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties in accordance
with North Carolina General Statute 87-94. For your convenience, a renewal application and a UIC well system
status form are attached along with a self-addressed envelope. The above referenced forms are also available
on-line at the DWQ website at http ://h2o.enr.state.nc.us/ap s/gp u/forms.htm.
Thank you in advance for your cooperation and timely response. If you have any questions, please call me at
[phone].
Attachments
Sincerely,
r2~t27---
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
cc: Winston-Salem Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0400010 w/o enclosures
2
j►]ti '�Ili:]<�t�]�fi��
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, arid*
other applicable Laws, Rules, and Regulations
PERNUSSION IS HEREBY GRANTED TO
DAVID WYRICK
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent.
This injection well will be located at 5531 US 220 North, Summerfield, in Guilford County, and will
be operated in accordance with the application submitted May 14, 2004 and in conformity with the
specifications and supporting data submitted, all of which are filed with the Department of
Environment and Natural Resources and are considered a part of this permit.
This permit is for Operation only, and does not waive any provisions of the Water Use Act or any
other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be in
compliance with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and any other
Laws, Rules, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date ofits issuance until October 20, 2009,
and shall be subject to the specified conditions and limitations set forth in Parts I through VIE
hereof.
Permit issued this the _1 S____ day of c . 2004.
.Ted L. Bush, Jr., Chief
Aquifer Protection Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No, WI0400010 PAGE 1 OF 5
GW/UIC-5 ver, 7/04

PART I -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change. ·· 1
-=·· ..... , ..
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances that may be imposed
by other local, state, and federal agencies that have jurisdiction. Furthermore, the issuance
of this permit does not imply that all regulatory requirements have been met.
PART II-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater, which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this pennit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART III -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
Permit No. WI0400010
GW/UIC-5 ver. 7/04
PAGE 2 OF 5
PART IV -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fl~ids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART V -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary
by the Division of Water Quality to insure surface and ground water protection, will be
established and an acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Winston-Salem Regional Office, telephone number
[phone], any of the following:
3.
4.
(A) Any occurrence at the injection facility that results in any unusual
operating circumstances
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
Where the Permittee becomes aware of an omission of any relevant facts in a permit (~
application, or of any incorrect information submitted in said application or in any report-!d~
the Director, the relevant and correct facts or information shall be-promptly submitted td 11
the Director by the Permittee.
In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
Permit No. WI0400010
GW/UIC-5 ver. 7/04
PAGE3 OF 5
PART VI-PERMIT RENEWAL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
PART VII -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinuation of use of a well fo.(_:,
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(l ), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe that extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have
not been removed, the casing shall be perforated.opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the ·
perforations. -
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner·
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
Permit No. WI0400010
GW/UIC-5 ver. 7/04
PAGE 4 OF 5
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion of
abandonment.
3. The written documentation required in Part VII (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC · 27699-1636 ·
PART VIII -OPERATION AND USE SPECIAL CONDITIONS
None
Permit No. WI0400010
GW/UIC-5 ver. 7/04
..... .
PAGES OF 5
UIC Permit for David Wyrick
1 of 1
Subject: UIC Permit for David Wyrick
From: Thomas Slusser <[e-mail]>
Date: Tue, 12 Oct 2004 11 :33:31 -0400
To: "[e-mail]" <[e-mail]>, Evan Kane <[e-mail]>
Greetings Chris,
Thank you for your telephone message the other day. Since you folks do not have any issues with David Wyrick's application for permit
renewal or with anything that came out of your inspection on August 5, 2004, I am sending the permit up for review and signature. I am still
anticipating receipt of your Form B inspection report for this permit renewal. Thank you for all of your help!
-Thomas Slusser
UICProgam
Thomas Slusser <Thomas.Slusser~ncmail.net>
Hydrogeological Technician II
NCDENR,DWQ
Aquifer Protection Section, UIC Program
10/14/2004 11:48 AM
COUNTY. GUILFORD
QUAD NO:
REPORT TO : CENTRAL OFFICE
COLLFCTOR(S) : C GREENE
DATE: 8/5/2004
TIME:
PURPOSti:
LABORATORY ANALYSIS
Regional Office
BOD 310 mWL
COD High 340 m
COD Luw 335 mg1L
Colirorrn! MF Feca131616 110W
Colirorm: MF Total31504 fioomI
TOC mg/1
Turbitity NTU
Residue., Suspended 530 mg11.
"Total Suspended solids mg/L
pH [�. ,�-7 units
Alkalinity to pH 4.5 m911,
Alkalinity to pH 8.3 rriglL
Qubanate mg1L
!Bicarbonate n101
Carbon dioxide mg/L
X
Chloride 5 Q2 mg/L
Chromium: Hex 1032 ug/L
Color. True 80 C.L.
Cyanide 720 mglL
COMMENTS
Owner.
Location or Site:
Description of sampiing point
Sampling Method:
Remarks:
DIVISION OF WATER QUALITY
Chemistry Laboratory Report 1 Ground Water Quality
SAMPLE PRIORITY
RIROLrr NE EMERGENCY
CHAIN OF CUSTODY
El SAMPLE TYPE
DAVID WYRIZK
X
Diss_ Solids 70300
130
mg/L
Fluoride 951
mg/L
X
Hardness: total 900
fib
mg/L
Hardness: (non-carb) 902
mg/L
Phenols 32730
ug/L
Specific Cond. 95
umhoslem2
Sulfate
m L
Sulfide 745
mg1L
M BAS
mglL
Oil and Grease
m
Silica
mg/L
Boron
Formaldehyde
ntg/L
NH3 as N 610
mg/L
TKN as N 625
MWI.
NO2 +NO3 as n 630
2.3
mg/L
P: Total as P 665
mg1L
PO4
mg1L
X
Nitrate (NO3 as N) 620
2.3
mWL
X
Nitrite (NO2 as N) 615
0.01U
mpjl.
Ag-Silver 46566
ug/L
Al -Aluminum 46557
u L
As -Arsenic 46551
ug/L
Ba-Barium 46558
ugfL
X
Ca -Calcium 46552
20 mg1L,
Cd-Cadium 46559
uglL
X
Cr-Chrom um 46560
25U ug/L
X
Cu- Copper 1042
28 ug/L
X
Fe- Iron 1045
5OU ug1L
Hg- Mercury 71900
ug/L
X
K-Potassium 46555
1.7 mglL
X
Mg- Magnesium 927
3.9 mg/L
X
Mn-Manganese 1055
1 OU ug/L
*
Na- Sodium 929
7.3 mg[L
X
Ni-Nickel
101J ug/L
X
Pb-Lead 46564
SOU ug1L
Se Selenium
ug/L
X
Zn Zinc 46567
SOU ug/L
Lab Number
4G1208
Date Received :
$11612004
Time Received :
8:40 AM
Received By
DS
Reieascd By
!C
Date rtportcd :
9/30/2004
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
l I Acid Herbicides I
Gasoline

COUNTY :
GUILFORD
QUAD NO:
REPORT TO .
CENTRAL OFFICE
COLLECTOR(S)
: C GREENE
DATE:
8/5/2004
TDAE:
PURPOSE:
LABORATORY ANALYSIS
DIVISION OF WATER QUALITY
Chemistry Laboratory Report 1 Ground Wale Quality
SAMPLE PRIORITY
E]ROUTINE EMERGENCY
Regional Office CHAIN OF CUSTODY
W❑ SAMPLE TYPi~ /V?n f
BOD 310 mg/L
COD High 340 man -
COD Law 335 m L
Coliform: MF 1"31616 1100m1
Colifotm: MF'rotal31504 I100mi
TOC mg/l
Turbitity NTU
Residue., Suspended 530 m 1.
Total Sunded solids mgll.
pit .: 3 units
Alkalinity to pH 4.5 mg/L.
Allufinily to pH. 8.3 mglL
Carbonate MO —
Bicarbonate no,
Carbon dioxide m gLL
X
Chloride 10 mglL
Chromium: Hex 1032 ugll_
Color. True 80 c.u.
Cyanide 720 mg/L
COMMENTS
Ownor.
Location or Site:
Description of sampling point
Sampling Method:
Remarks:
DAV11) WYRLZK
X
Diss, Solids 70300
160
mg/L
Fluoride 951
mglL
X
Hardness: tota1900
71
mgli.
Hardness: (non�arb) 902
mg/L
Phenols 32730
uglL
S wific Cond. 95
umhoslcm2
Sulfate
mg/L
Sulfide 745
mg/L
MBAS
nWjL
Oil and Grease
mg[L
Silica
mg1L
Baron
Fortnaldehyde
mg1L
NH3 as N 610
mg1L
TKN as N 625
mg/L
NO2 +NO3 as n 630
2.2
mg/L
P: i'otal as P 665
mgl[.
mglL
IPO4
Nitrate (NO: as N) 620
22
mg/L
X
Nitrite (NO2 as N) 6l5
0.01 U
mg1L
Ag-Silvcr 46556
u93 -
AI -A luminum 46557
uglL
As-Amcnk; 46551
ug11.
Ba-Barium 46558
ug1L
X
Ca -Calcium 46552
21 mg11.
Cd-Cadium 46559
VWL
X
Cr-Chromium 46560
25U ug1L
X
Cu- Copper 1042
3.7 ug1L
X
Fe- Iron 1045
50U ug/L
i{g- Mercury 71900
ug/i.
X
K-Potassium 46555
1.9 mg/L
X
Mg- Magnesium 927
4.4 mglL
X
Mn-Manganese 1055
10U ug/I_
X
Na- Sodium 929
7.9 mg/L
X
Ni-Nickei
1DU ugiL
X
Pb-Lead 46564
10U ug/L
Se -Selenium
uglL
X
Zn Zinc 46567
—
16 ugll.
F
Lab Number
4G 1209
Date Received
91612ON
Time Received :
8:40 AM
Received By
DS
Released By :
JC
Date reported :
9130I2004
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
Sernivo:atiles
TPH-Diesel Range
Volatile Organics (VOA bottle
TPH-Gasoline Range
T'PH-BTEX Gasoline Range

Wyrick UIC sampling -Influent vrs. effluent
1 of 1
Subject: Wyrick UIC sampling -Influent vrs. effluent
Date: Fri, 13 Aug 2004 16:04:59 -0400
From: Chris Greene <[e-mail]>
Organization: NC DENR -Division of Water Quality, Ground Water Section
To: evan kane <[e-mail]>, Thomas Slusser <[e-mail]>
Hello. Please note that the designations for ""influent" and "effluent"
should be reversed from the designations "indicated on the GW-54's
submitted to the State Lab for samples collected 8/5/04. The ""influent"
sample labeled as that leading from the climate control system should
"instead be labeled as "effluent"-. The GW-54 submitted to the Lab
labeled as "effluent" is "instead the ""influent" sample, as it was
sampled from the hose bibb at the wellhead. The samples are valid; just
mark out and replace the appropriate "description of sampling point".
Thanks for your attention.
Chris Greene
NC DENR Winston-Salem Regional Office
Division of Water Quality, Ground Water Section
585 Waughtown Street
Winston-Salem, NC 27107
Vo"ite: [phone] ext 324
FAX: [phone]
8/16/2004 1:29 PM
MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
May 18, 2004
To: Sherri Knight, Groundwater Supervisor
Groundwater Section
Winston~Salem Regional Office
From:-Thomas Slusse11S5
Central Office
Re: Renewal of Permit #WI0400010 issued to F. David Wyrick. Request for inspection and
routine sampling of Mr. Wyrick's injection wells in Summerfield, North Carolina.
1. Please review the application and submit any comments to CO-UIC group. Retain the
application for your UIC file.
2. Please inspect the injection well site to verify that the location and construction plans
submitted in the application are accurate and that the NCAC Title 15A 2C.0200 standards
are being. complied with, using the enclosed Injection Facility Inspection Report (Form
B) as appropriate.
3. Collect samples from the influent and effluent sampling ports and submit the results
to the CO-UIC.
You are requested to return the completed Injection Facility Inspection Report (Form BJ to the
CO-UIC by June 9, 2004. If the inspection and review cannot be accomplished by this date,
please let me know.
The UIC group appreciates your assistance with this review. If you have any questions regarding
this review or the UIC program~ please contact me at [phone].
cc: CO-UIC Files
Enclosures
y
North Carolina Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B,
INJECTION WELL PERMIT NO. WT D �r flora 10
NAME OF OWNER (-7,1-1 "�> �
DATE I.l Y 0 �
ADDRESS OF OWNER 5
(Streeff road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable)
{Street) road or lot and subdivision , county, town, i(different than owner's address, plus description of location on site)
Potential pollution source Distance from well
Potential pollution source �.���- : �.a-- Distance from well
s- r
Potential pollution source e- v Distance from well -- 7o -�iz
Minimum distance of well from property boundary vl as a�
—sC]
A nic"
Quality of drainage at site(:S , Flooding potential of site M.
{good,adeguate poor) (high,moderate.low) `-=}
GPS Data:
►f
Latitude: 112 {, Longitude: 7y ��f r3 9
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and
north arrow.)
y)Y-v'�
L � i
V J4 J `
DESCRIBE INJECTION SYSTEM (vertical closed loop, uncased borehole or cased water well: separare source well and
injection well,- combination source and injection well; or other description as applicable)
ll�t� e•� do-S / 14, "e -
Ver.3101 GWIMC-2

i
INJECTION rACILITY INSPECTION REPORT -FORM B (CONTR'UED)
wrELL CONSTRUCTION
Date constructed 9�`)
Drilling contractor: Name ,,,�jyro�O� rt,s•�i��-'" r� �n�'° 6� s�xcss tiy�ry}
Address
Certification number 37
f 7
Total depth of well D D Total depth of source well
(f applicable)
Inspection point Measurement Meets minimum standards Comments
Yes No
Casing
�
37
Depth
Diameter
&
Height (A.L.S.)
%
Grout
Depth
Screens
Depth(s)
l`l
Length(s)
I.D. Plate
Static water level
0 1,0
Well yield
2—
Enclosure.
Enclosure floor
(concrete)
Sampling port
(labeled)
Water tight pipe entry
Well enclosure entry
Vent
Functioning P� heat pumpe
NO _ rro
INSPECTOR Co rP.�►y
Vv7INESS
(Determine from the owner if heat pump functions properly.)
Office
Address
WITNESS
V er_3101
Address
GWICT%C-2

NORTH CAROLINA
DEPARTl\IBNT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RENEW AL APPLICATION FOR PERMIT'TO USE WELL{S) FOR INJECTION WITH A
HEAT PUMP SYSTEM
Type 5A7 and SQM Wells
In accordance with the provisions ofNCAC Title 15A: 02C.0200
complete application and mail to address on the back page.
TO: DIRECTOR, NORTII CAROLINA DMSION OF WATER QUALITY
DATE: May 14 20 04 ----
A. PER!vllT APPLICANT
C) .r:.-
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Permit Number: W 1 04 Q Q O J 0
Name: F • D a v i d W yr i ck
(WI0######, listed at the bottom of each page of your permit)
Address: 5 5 3 l U S 2 2 0 N o r t h
City: Summerfield State: NC Zip code: _2 _7 _3 _5 _8 ___ _
County: G u i 1 f o r d Telephone: 3 3 6 6 4 3 - 4 2 8 6
B. PROPERTY. OWNER (if different from applicant)
Name: _____________________________ _
Address: ____________________________ _
City: ______________ State: __ _ Zip code: ______ _
County: Telephone: ______________ _
C. STATUS OF APPLICANT
Private: X Federal: Commercial: State: Public: -----------------
Native American Lands: __ _
D . FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Public or Commercial).
Name of Business or Facility: ______________________ _
Address: ____________________________ _
City: ______________ State: __ _ Zip code: ______ _
County: ___________ Telephone: ______________ _
Contact Person: __________________________ _
Standard Industrial Code(s) which describe commercial facility: ____________ _
ver. 10/03 OW/UIC-57 HPR Page 1 of3
E. INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
F. WELL USE Is(are) the injection well(s) also used as the supplywell(s) for either of the following?
(1) The injection operation? YESJL_ NO __
(2) Your personal consumption? YES_x_ NO __
G. CONSTRUCTION DATA
H.
(1)
(2)
Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection permit.
NC. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes. A faucet on both influent (groundwater entering heat pump) and
effluent (water being injected into the well) lines is required. Is there a faucet on:
(a) the influent line? YES_ NO_x__
(b) on the effluent line? YES_ NO _J(_
CURRENT OPERATING DATA NO CHANGE
(1) Injection rate: Average ( daily) gallons per minute (gpm)
(2) Injection volume: Average ( daily) gallons per day (gpd)
(3) Injection pressure: Average ( daily) pounds per square inch (psi)
(4) Injection temperature: Annual Average degrees Fahrenheit (°F)
I. INJECTION-RELATED EQUIPMENT
Attach a diagram showing any modifications to injection equipment since the issuance of the previous injection
permit including the engineering layout of the (1) injection equipment, and (2) exterior piping/tubing
associated with the injection operation. The manufacturer's brochure, if detailed, should satisfy (1 ).
J. LOCATION OF WELL(S) Attach a map
Include a site map (can be drawn) showing: the orientation of and distances between the injection well(s) and
any existing well( s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of
the ground-source heat pump well system; include buildings, property lines, surface water bodies, any other
potential sources of groundwater contamination. Label all features clearly and include a north arrow to indicate
orientation.
K. PERMIT LIST: Attach a list of all permits or construction approvals, received or applied for by the applicant
that are related to the site. Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
L. OTHER MODIFICATIONS: Indicate any other modifications to the injection well system (equipment, fluid,
operation, etc.) that have occurred since the issuance of the previous injection permit and have not been noted
elsewhere on this application.
ver. 10/03 GW/UIC-57 HPR Page 2 of3
M. CERTIFICATION
"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 operate, maintain, repair, and if applicable, abandon the injection
well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit.,,
r1-1-14
(Signature of Well 6wner uthoci7ed Agent)
If authorized agent is acting on behalrof the ,vell owner,
please supply a letter signed by the oumer
authorizing the above agent.
N. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property rights in
the well(s). A well is real property and its construction on land rests ownership in the land owner in the absence
of contrary agreement in writing.)
if the property is owned by someone other than the applicant, the property owner hereby consents to allow the
applicant to operate an injection well(s) as outlined in this application and that it shall be the responsibility of
the applicant to ensure that the injection well(s) conform to the Well Construction Standards (Title 15A NCAC
Subchapter 2C .0200)
(Signature of Property Owner if Different From Applicant)
Please return the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
(Telephone: [phone])
❑er. 10103 GWIUIC-57 HPR Page 3 of 3

■ Cor. to items 1, 2, and 3. Also complete
item 4 if Restricted ❑efivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or an the front If space permits.
1 Article Addressed to:
Mr. F. David Wyrick
5531 U.S. 220 North
Summerfield, NC 27358
A. Received by (Please Print Clearly) I M Date of Delivery
C. Signature
El Agent
0 Adore
D. Is delivery address dWerdht from item 17 ❑ Yes
If YES, enter del wary address below: ❑ No
3. Service Type
M Certified Mail ❑ Express Mail
❑ Registered ❑ Return Recelpt far Merchandlse
❑ insured Mail 0 C.0.4.
4. Restricted Delivery? (Extra Fee) ❑ Y&s
,2.
7003 1010 B001 2611 4391
P5 Form 3811, .July 1999 Domestic Return Receipt 102595.00-M•0952

OF W A TF
Michael F. Essley, Governor
Q
[
William G. Ross Jr„ Secretary
North Carolina Department of Environment and Natural Resources
_Q
Alan W. Klimek, P. E. Director
3
�{
Division of Water Quality
v Y
Coleen Fl. Sullins, Deputy Director
Division of Water Quality
May 10, 2004
CERTIFIED MAYL
RETURN RECEIPT REQUESTED
Mr. F. David Wyrick
5531 U.S. 220 North
Surnmerfleld, NC 27358
Ref.: Expired UIC Permit # W10400010
Dear Mr. Wyrick:
The Underground Injection Control (UIC) Program of the North Carolina Division of Water Quality
is responsible for the regulation of injection well construction and operation activities in the state.
Our records show that a geothermal heat pump system with an associated injection well was
constructed and permitted on your property under the name of F. David Wyrick. The permit for
this injection well expired on April 30, 1999; therefore, your well may be in violation of North
Carolina General Statute Section 88-870) and other state regulations.
The UIC Program would like to help you resolve this situation by completing one of the fallowing
procedures:
1.) If a geothermal heat pump system is operating on your property and. you Dave an injection
well as part of this system, please complete and sign the enclosed form "APPLICATION
FOR PEPAUT RENEWAL To USE A WELLS) FOP, INJECTION WITH A HEAT PUMP SYSTEM."
2.) If an injection well is not operating on your property, please complete and sign the
enclosed form "STATUS OF INJECTION WELL SYSTEM" indicating that an injection
well is not in operation on your property.
3.) If you are unsure whether you have an injection well, please contact us at the phone
number below so that we can help you make that determination.
NCIDENIR
N. C. Division of Water Quality 1 Groundwater Section
1636 MaiI Service Center Raleigh, N.C. 27699-1636 Pi�-
tomer SePhone: [phone] Far: [phone] Internet: hnp:llgw.ehnr.slate,nc.us 877Z3-67 8

Mr. F. David Wyrick
Expired UIC Permit # WI0400010
May 10, 2004
Page 2 of 2.
The UIC Pro gram is sendin g this letter in ex pectation that you res pond regardless of whether or not
you currently have an injection well as part of your heating and cooling system. Please note that if
you do not respond to this letter within 30 days an inspection of your property may be forthcoming
to determine if an injection well is operating on your property.
If you would like assistance completing any of the forms, or if you have any questions regarding the
UIC Program or injection well rules, please contact me at [phone] or Evan Kane at (919)
715-6165.
cc: CO-UIC Files
Enclosures
Best regards,
~~ -J/4<-Mf!,c
Thomas Slusser
Hydrogeological Technician II
UIC Program
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY, GROUNDWATER SECTION
STATUS OF INJECTION WELL SYSTEM
Date: 10/24/01 Permit Number:
Name: F, David Wl rick, Sr.
v
C
W i.
_�
—J
Address: 5531 U5 220 North Summerfieid NC 2735 .:bw
0
Please check the selection which most closely describes the current status of your injection wed.
In addition, please provide the requested information.
c�
--i
1 } X Well is still used for injection activities.
(-n
2) _X___ Well is used for water supply.
3) injection discontinued;
a} _-__ Well temporarily abandoned b) Well permanently abandoned
Describe the method used to properly abandon the injection well. (Include a description of how the well
was sealed and the type of material used to fill the well if permanently abandoned): If you checked two
{2}, report the pumping rate and what the water is used for.
Certification: (For well abandonment)
"I hereby certify, under penalty of law, that i am personally responsible for the proper abandonment
of any injection well as required in Title 15A NCAC 2C .0214 Criteria and Standards Applicable to Injection
Wells."
(Signature)
Certification: (For information verification)
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
Information submitted in this document, and that to the best of my knowledge the information is true,
accurate, and complete."
s
(Signatu e)
ver.3101 GW/LJIC-88

I
C:\PFPRO\DATA\PFINDER\UIC\A052420A.COR Statistics Version 2.13
Recs Mea1/ Std Dev
Latitude 400 36 14'01.323"N 3.363
Longitude 400 79 55'06.506"W 6.175
Altitude 400 239.382 16.917
East Vel 400 0.189 0.361
North Vel 400 -0.124 0.334
Up Vel 400 -0.277 1.124
Velocity 400 0.358 1.226
No DOP records in file.
Start GPS Week £750 on 05/24/94 at 20:16:43
End GPS Week £750 on 05/24/94 at 20:27:00
Datum WGS-84
Coordinate System Latitude/Longitude
Altitude Mode Height Above Ellipsoid
Altitude/Distance Units Meters
Velocity Units Meters/Second
Minimum Maximum
36 14 1 01.035 11 N 36 14'01.567"N
79 55'07.435"W 79 55'05.979"W
203.402 291.831
-0.524 0.923
-0.798 0.458
-2.606 1.009
2.775 1.443
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State of North Car·,_ .. na
Department of Environment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A Preston Howard, Jr., P.E., Director
.R'A
DEHNR
GROUNDWATER SECTION
April 25, 1994
Mr. P. David Wyrick
5531 US Hwy 220 North
Summerfield, NC 27358
Dear Mr. Wyrick,
In accordance with your application dated April 6, 1994, we
are forwarding a permit for the Operation .and Use of a well, for
the purpose of injecting heat pump effluent, in Guilford County.
This permit is a renewal of existing Permit No. 40 -0178 WO
-0006 which was issued on October 30, 1987, and shall.be effective
from the date of issuance until April 30, 1999, and shall. be
subject to the conditions and limitations as specified herein.
This permit replaces and shall also supercede existing Permit No·.
40 -0778 WO -0006. Please note that the permit numbering system
has been revised_ so that your permit has a new number.
In order-to continue uninterrupted legal use of this well for
the stated purpose, you should submit an application to renew the
permit six months prior to its expiration date.
If you have any questions regarding your permit please feel
free to contact me at (919) 7~3 -3221, ext. 407.
cc: UIC Files
W-SRO Files
Enclosures
I /' Sin;rely,. ~i
A. Eliz~ Morey 1 'i
Manager
Underground Injection Control Program
Groundwater Section
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX 919-715~0588
An Equal Opportunity Affirmative Action Employer 50% recycled/ l 0% post-consumer paper
NORTH CAROLINA
ENVIRONMENTAL-MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87;
Articl~ 21 , Chapter 1 43, and other applicable Laws, Rules and
Regulations.
PERMISSION IS HEREBY GRANTED TO
F. David Wyrick
FOR THE OPERATION OF AN INJECTION WELL for the purpose of injecting
heat pump effluent. This well is located at 5531 US Hwy. 220
North, Summerfield, North Carolina, in Guilford County, and will be
operated in accordance with the application dated April 6, 1994,
and in conformity with the specifications and supporting data
submitted, all of which are filed with the Department of
Environment, Health, and Natural Resources and are considered a
part of this permit.
This permit is for Operation only, and does not waive .any
provisions of the Water Use Act or any other applicable Laws, Rules
or Regulations. Operation and use of an injection well· shall be in
compliance with Title 15 North Carolina Administrative Code 2C,
.0100 and .0200 and any other Laws, Rules, and Regulations
pertaining to well construction and use.
This permit is a renewal of existing Permit No. 40 -0778 -WO
-0006 which was issued on October 30, 1987, and shall be effective
from the date of issuance until April 30, 1999, and shall be
subject to the conditions and limitations as specified in Parts I
through VIII herein. This permit replaces and shall also supercede
existing Permit No. 40 -0778 -WO -0006.
Permit issued this the 25th day of April, 1994.
T L. Bush, Jr., Assistant Chief
Groundwater Section
Division of. Environmental Management
By Authority of the Environmental Management Commission.
PERMIT NO. WI0400010
NORTH CAROLINA
ENVIRONMENTAL-MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87;
Article 21 , Chapter 143, and other applicable Laws, Rules and
Regulations.
PERMISSION IS HEREBY GRANTED TO
F. David Wyrick
FOR THE OPERATION OF AN INJECTION WELL for the purpose of injecting
heat pump effluent. This well is located at 5531 US Hwy. 220
North, Summerfield, North Carolina, in Guilford County, and will be
operated in accordance with the application dated April 6, 1994;
and in conformity with the specifications and supporting data
submitted, all of which are filed with the Department of
Environment, Health, and Natural Resources and are considered a
part of this permit.
This permit is for Operation only, and does not waive any
provisions of the Water Use Act or any other applicable Laws, Rules
or Regulations. Operation and use of an injection well shall be in
compliance with Title 15 ·North Carolina Administrative Code 2C,
. 01 00 and . 0200 and any other Laws, Rules, and Regulations
pertaining to well construction and use.
This permit is a renewal of existing Permit No. WI0400010
which was issued on October 30, 1987, and shall be effective from
the date of issuance until April 30, 1999, and shall be subject to
the conditions and limitations as specified in Parts I through VIII
herein. This permit replaces and shall also supercede existing
Permit No. -W±O 400016 ·+-1k_
olo ~~ :r
Permit issued this the 25th day of April, 1994.
Ted L. Bush, Jr.i Assistant Chief
Groundwater Section
Division of Environmental Management
By Authority of the Environmental Management Commission.
PERMIT NO. WI0400010
PART I -GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this pe~it
and with the standards and ciiteria. specified in Criteria and
Standards Applicable to Injection Wells (15 NCAC 2C .0200) .
. Any noncompliance with conditions -of this permit constitutes
a violation of the North Carolina Well Construction Act and
is grounds for enforcement action as provided for in N.C.G.S.
87-91.
2. This permit is effective only with respect to the nature,
volume of materials, and rate of injection described in the
application and other supporting data.
3. This permit is not transferable without prior notic~ to, and
approval by, the Director of the Division of Environmental
Management (Director). In the event there is a desire for
the facilities to change ownership, or there is a name change
of the Permittee, a formal permit am.endment req_uest must be
submitted to the Director, including any suppo~ting materials
as may be appropriate, at least 30 days prior to the date of
the change.
4. The issuance of this permit does not preclude the Permittee
from complying with any and all statutes, rules; regulations,
or ordinances which may be imposed by other local, state, and
federal agencies which have jurisdiction.
PART II -PERFORMANCE STANDARDS
1. The injection facilities shall be effectively maintained and
operated at all times so that there is no contamination of
groundwaters which will render then unsatisfactory for normal
use. In the event that the facilities fail to perform
satisfactorily, including the creation of nuisance conditions
or failure of the injection zone to adequately assimilate the
injected fluid, the Permittee shall take immediate
corrective actions including those actions that may be
required by the Division of Environmental Management
(Division) such as the repair, modification, or abandonment
of the injection-facility.
2. The Permittee shall be required_ to comply with the terms and
conditions of this permit even if compliance requires a
reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee
of the responsibility for damages to surface or groundwaters
resulting from the operation of this ·facility.
PAGE 2 OF 6
PART III -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facilities shall be properly maintained and
operated at all times·.
2. The Permittee must notify the Division and receive prior
written approval from the Director of any planned physical
alterations ·pr additions in the permitted-facility or
activity not specifically authorized by the permit.
PART IV -INSPECTIONS
1. Any duly authorized officer, employee, or representative of
the Division of Environmental Management may, upon
presentation of credentials, enter and inspect any property,
premises, or place on or related to the injection facility at
any reasonable time for the purpose of determining compliance
with this permit, may inspect or copy any records that must
be maintained under the terms and con~:Utions of this permit,
and may obtain samples of groundwater, surface water, or
injection fluids.
2. Department representatives shal_l have reasonable access for
purposes of inspection, observation, and sampling associated
with injection and any related facilities as provided for in
N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and
appropriate samples associated with the injection facility
activities (see attached diagram).
PART V -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil
sampling) deemed necessary by the Division of Environmental
Management to insure surface and ground water protection,
will be established and an acceptable sampling reporting
schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of
the occurrence or first knowledge 6£ the occurrence to the
Winston-Salem Regional Office, telephone number (910) 896-
7007 of any of the following:
(A) Any occurrence at the injection facility which
results in any unusual operating circumstances;
PAGE 3 OF 6
(B) Any failure due to known or unknown reasons, that
renders th~ facility incapable of proper injection
operations, such as mechanical or electrical ·
failures.
3. Where the Permittee becomes aware of an omission of any
relevant facts in a permit application, or of any incorrect
information submitted in said application or in any report to
the Director, the relevant and correct facts or information
shall ~be promptly submitted. to the Director ·by the Permittee.
4. In.the;event that the permitted facilities fail to perform
satisfactorily, the Permittee shall take such immediate
action as may be required by the Director.
PART VI .:.. PERMIT RENEWAL
The Permittee shall, at least· six (6) months prior to the
expiration of this permit, request an extension.
PART VII CHANGE OF WELL STATUS
1. The Permittee shall notify the Winston-Salem Regional Office
within 15 days of any change of status of the injection
well(s). Such a change would include the discontinued use of
the well(s) for injection. If the· well(s) is taken
completely out of service temporarily, the Permittee must
install a sanitary seal(s). If the well(s) is not to be used
for any purpose it must be permanently abandoned according to
15 NCAC 2C .0113, Well Construction Standards.
2. When operations have ceased at the facility and the well(s)
will no longer be used for any purpose, the Permittee shall
abandon the irijection well(s) in accordance with the
procedures specified in 15 NCAC 2C .0214, including but not
limited to the following:
(A) All casing and materials may be removed prior to
initiation of abandonment procedures if the Director
finds such removal will not be responsible for, or
contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of the well(s) shall be sounded before
it is sealed to insure freedom from obstructions that
may interfere with sealing operations.
PAGE 40F 6
(C) The well(s) shall be thoroughly disinfected~ prior to
sealing, if the Director determines-that failure to do
so could lead to the contamination of an undergrou~d
source of drinking water.
(D) The well(s) shall be completely filled with cement
grout, which shall be introduced in~o the·well(s)
through a pipe which extends to the bottom of the
well(s) and is raised as the well(s) is filled.
(E) In the · .. case of gravel-packed wells in which the casing
and screens have not been removed, the casing shall be
perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the
perforations.
(F) In those cases when, as a result of the injection
operations, a subsurface cavity has been created, the
well(s) shall be abandoned in such a matter that will
prevent the movement of fluids into or between
underground sources of drinking water and in accordance
with the terms and conditions o.f the permit.
PART VIII -SPECIAL CONDITIONS
NONE
PERMIT NO. WI0400010
PAGE 5 OF 6
AWACIMENT 1
PERMIT NO. W10400010
Sanitary Well Seal
Casing must extend min.
of 12 inches above
land surface
lVI
16 :20.
ro
0
M
40M
HEAT
PUMP
x Sampling Tap
x (Effluent) Z V F 4-71,
" L,47 W., i -.i 1! - " 1` ..
-W�x -, ! q � 11 1 ., ..,2 -i-j
- %Mli
Y,
V)
4*rIL.6 Mint
, P
COMBINATION SOURCE
AND INJECTION WELL..
Sampling Tap
(Influent)

J�
Wr sou ray
flF wn{N. ►Ajl Nwy 15$
I
J-j4CL�L
boWk1 OVER WW.L
4c4t
/ A) � L u G Aj-r :51+M PG 4zE `ram 4 e7v
�w y
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w/S53 i 'r
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6]0p-S
44E:;qr Pvrn10 w- ]R + 12 � 7-,*Al k "NpeR fiou56 rN 16145EM �rT
{3lsae,446-L- FUr►j flr5}r ;sPL1r � rw-.E 'Te-79 sonl a�
-r# C-7 �(E:�4R r C 'T�r6 5 Oe-47710 0 F rV A TAR A ► S G+,�a4 ,p E E� 7a
9u-t3 Dr-- AW wATC)e / tiJ 6'0- FD $4-Ck /A/rD
S� ri � Ezi -3 � ► r

GROUNDWATER FIELD/LAB FORM
County du , (_ F0
Quad NoSerial No.
LaL
SAMPLE PRIORITY
XrROUTINE EMERGENCY
Repart To: ARO, FRO, MRO, RRO WiRO, �r ❑CHAIN OF CUSTODY
SR inston FO, Fed. Trust Central Off., Cher: �
Shipped by: Bus, Courier, Hand Del., Cher �� N rL
Purpose:
Collector(s): Data z Time Baseline, Complaint.
Owner _ Y Y I :M CS r
PHA Spec. Cond.at 250 C
Temp. oC or
Appearance
Field Analysis
North Carolina
Department of Environment, Health, and Natural Resources
DIVISION OF ENVIRONMENTAL MANAGEMENT- GROUNDWATER SECTION
Lang.
Location or site �x
Description of sampling point
Sampling Method
Remarks 4,_Acpk' (7
Lab Number'
Date Received C'- Time
Rec'd by: + From: Buqt=i5iand De .'
Other:
Data Entry By: Ck.
Date Reported:
Pesticide Study, Federal Trust, Other: (2/ el
P"� -.9 :�
amp. ING
Interval
AB R BY ANALYSE5-
BOD 314 MCO
Diss. Solids 70300 MWI
A - Silver 46566 u I
Or anochlorine Pesticides
COD High 340 mg/1
Flouride 951 I
Al - Aluminum 46%7 u I
Organophosphorus Pesticides
_
COD Low 335 I
Hardnes: Total 900 /I _ mcA
As - Arsenic 4fi551 uco
Nitrogen Pesticides
Colilorm: MF Fecal 31616 r100ml
Hardness non -cart 902 gig#
Ba . Barium 46558 uqA_
Coliform: MF Total 31504 /100ml
Phenols 32730 uco
Ca - Calcium 46552 MC0
Acid Herbicides
TOG 680 n19A
S is Cond. 95 umho&0
Cd - Cadmium 46559 u I
L'.
Turbidity 76 NTU
Sulfate 945 m I
Cr - Chromium 46560�'�?T uqA
Semivolaute Or arwca -a
Residue., Suspended 530 nw
Sulfide 745 rr/l
— — -- -
Cu - Copper 46562',FG 0 uqA
Fe - Iran 46563 c Sv—
_
H - Mercury 71900 u I
Volatile Organics A bdtt]
pH 403 unit
K - Potassium 46555 rngiI
_
Alkalinity to H .5 410 mgli
M - Magnesium 46554 I
TPH - Gasoline R n -�
Alkalinity to pH 8.3 415 mglt
Mn - Manganese 46%5 UO
TPH - BTEX Gasolim Rani '
Carbonate 445 mgll
NH as N 610 d, 1
Na - Sodium 46656 m 1
r1] r.' i
Bicarbonate 440
el r /0 u I
Carbon dioxide 49,6 rw
NQQ +NOS as N s30 �� W no
Pb - Lead 465G4 u I
Chloride 940 9194
P: Total as P 665 m I
Se - Selenium u
Chromium: Hex 1032 UgA
Zn - Zinc 46567 u
Color: True 80 Pt -Co
Cyanide 720 mg11
Lab Comments: F��-� _c�r�ii'-c❑f����.���.171 _ n . 7� . , I —,�i —
4 . , . cd
For DisWved Analysis - submit filtered sample and write "DIS" in I,....� -
f;W 5d AFV. Y � - �

GROUNDWATER FIELD/LAB FORM
County L , f)
Quad Na Serial No.
Lat.
Long
Rborni To: ARO, FRO, MRO, RRO, WaRO, WiRO,
Kinston FO OtherS by: Bus. Courier, ther.
Collector(s): L
A
PH 400
Temp. 1 a
Appearance
Field A is By:
OR Date 5
94
Taste
ROUTINE EMERGENCY
North Carolina
Department of Environment, Health, and Natural Resources
DIVISION OF ENVIRONMENTAL MANAGEMENT - GROUNDWATER SECTION
Lab Number 8
Date Receved 'ram J - -1 -1 Time ` "
SDA
by —^ From: Bu air raj
`�
EntryBy- 4 Ck.
Date Reported: er 17P 3P`5_
Time Purpose: Baseline, Complain,. Compliance LUST, Other —
Owner _ �( �.:� �i. (.Aj j� 1 C_ `C .55-31US 4w Y 2 ?_ 0 Al _
at 250 C Location or site
Description of sampling point _
Sampling Method R _ Sample Interval
Remarks
°iI `
k;.- -r �0= ac-IIU
LABQftATQBY ANALY i" C/ • - - - -
BODS 310 m A Diss. Solids 70300 : - (o mg/1 A - Silver 1077 NA- Or anochlorine Pesticides
COD High 340 mgA Flouride 961 mgA Al - Aluminum 1105 urn Organophosphorus Pesticides
COD Law 335 mgA
><
Hardness: Total 90015 mQ4
Ba - Barium 1007 ugA
Nitrogen Pesticides
Coliform: MF Fecal 31616 1100ml
Hardness non-carb 902 mqA
Ca - Calcium 916 mg/1
Coliform. MF Total 31504<1100m1
Phenols 32730 u A�
Cd - Cadmium 1027 u A
Acid Herbicides
TOC 680 m A
Specific Cond. 95 uMhoslcm2
Chromium:: Total 1034 u 11
Turbidity 76 NTU
945 mqA
><_Cu
• Capper 1042 ..2(, ugll_
Base/Neutral Extractable Or an"
_Sulfate
Sulfide 745 mgA
T
Fe - Iron 1045 u A
Acid Extractable Organics
H - Mercury 71900 u A
PH 403 7 units
K - Potassium 937 mqA
Purgeable Organics (VOA bottle)
Alkalinity to pH 4.5 410 mgA
M - Magnesium 927 mgA
_
Alkalinity to pH 8.3 415 mgA
Mn - Manganese 1055 u /l
1,2 - Dibromoethane (EDB)
Carbonate 445 mqA
Na - Sodium 929 m Act
Bicarbonate 440 m A
NH3 as N 610 < U' pL m_gA
Ni - Nickel 1067 <'In u 11
Arsenic: Total 1002 u A
TKN-a-s tV 625 mgA
Pb -Lead 1051 </( u A
Carbon dioxide 405 mqA
NO + NO3 as N 630 ( m 11
Se - Selenium 1147 u A
T
Chloride 940 tk mgA
P: Total as P 665 mqA
zn - Zinc 1092 . ` "
Chromium: Hex 1032 u4A
Color: True 80 Pt -Co
Cyanide 720 mgA
_
Lab Comments: - `e' i1 C J f�
GW-54 FIEV. 3192 For Dissolved Analysis - submil filtered sample and write 'DIS' in block
White Copy - Groundwater Central Office Yellow Copy - Fteolnnal Office Pink Copy - Central Files Goldenrod Copy - Lab

State of North Cai .na
Department of Environment,
Health and Natural Resources
Division.of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
GROUNDWATER SECTION
April 18, 1994
MEMORANDUM
To: Chris Greene
Groundwater Section
Winston-Salem Regional Office
From: UIC Group
Groundwater Section
Raleigh Central Office
Re: Inspection and sampling of injection well facility
operated/owned by David Wyrick.
A copy of the application for the renewal of a permit to
use a well for injection with a heat pump system is enclosed. The
permit has been issued; a copy of the permit is also enclosed.
Please inspect and sample the facility in operation. _Complete the
Well and Pump Inspection form Band send the form to RCO-UIC;
also complete the sampling report (Groundwater Field/Lab) form,
collect al-1 necessary samples of both source and effluent waters,
and send the samples and sampling report form (pre-addressed to
both RCO-UIC and the regional office) to the DEM laboratory for
analysis.
Your assistance is greatly appreciated. If you have any
questions, please feel free to contact me at (919) 733 -3221,
ext. 431.
cc: UIC Files
W-SRO Files
Enclosures
Sincerely,
~w,v\a.~
Karen A. Harmon
Hydrogeological Technician II
Underground Injection Control Program
P.O. Box 29535, Raleigh, North Caolina 27626-0535
An Equal Opportunity Affirmative Action Employer
Telephone [phone] FAX [phone]
50% recycled/ 1 O'I. post-consumer paper
NORTH CAROLINA M V 15 /2TINR
ENVIRONMENTAL MANAGEMENT CO T - k r _ SEC,
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NA UR �� c`
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INjgendN
WITH A HEAT PUMP SYSTEM
Class 5 Wells
TO: DIRECTOR, NORTH CAROLINA DIVISION OF ENVIRONMENTAL MANAGEMENT
DATE: 4/6 /94 .19
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and regulations
pursuant thereto, APPLICATION is hereby made for a PERMIT to construct and/or use a well or well
system as described below and in any accompanying data submitted as part of this APPLICATION.
A. OWNER DATA
Ownership
Please type or prim clearly,
Name:
Business:
Address:
City:
County:
Telephone:
Federal State private still in u s e
Public Commercial. Other (specify)
Native American Lands
B. FACII.TTY DATA (Fill out ONLY if the injection well(s) is (are) for the purpose of serving a
business or industry.)
Name:
Business:
Address,
City:
County:
Telephone:
C. HSATiTiG CONTRACTOR DATA
Name: Maness Heating
Zip code:
1i11.. e}i'Zimm
. .. . .d
County:. .
Telephone: 910 ., 66,
ContactPemn: Gil Manpsq
D. DOEC'110N PROCEDURE (Briefly describe, bow the injection well($) will be
F+-
GW-57 HP (June 1993) Page l of 4

E. WELL USE Will the injection well(s) also be used as the supply well(s) for either of the
following?
(a) The injection operation? YES NO
(b) Your personal consumption? YES`X NO
F. CONSTRUC 1ON DATA (CHECK ONE)
✓ EXISTING WELL being proposed for use as an injection well. Attach a copy of Form
OW-1 (Well Construction Record) and furnish (7 & 8) below. If Form GW-1 is not
available, furnish the data in (1) through (8) below to the best of your knowledge.
PROPOSED WELL to he constructed for use as an injection well. Furnish
the data in (1) through (8) below as PROPOSED construction
specifications.
(1) Well Drilling Contractor's Name: Bai nhri rinp R, Oanrp (414) Z49 - ►,f33I
NC Driller Registration number: Al
(2) Date4a4w constructed: -Sr-ht - 15 Approximate depth-
(3) Well casing:
(a) Type: Gaivanixed steel Black steel Plastic C Ottter(specify)
(b) Inside diameter: Lo inches, Wall thickness inches or schedule #
(c) Casing depth: From D to—Y7 ft. (reference to land surface)
Casing extends above ground l � inches (must be at :east 12 inches)
(d) Cement grout:
(a) Around inner or "primary" casing: From to ft.
(b) ground ❑uter (pit) casing, if present_ From to ft_
(5) Screens (if applicable):
(a) Type:
(b) Depth: From to
Inner diameter.
feet below land surface
inch&.%
(6) Gravel (if applicable): From to €eer below land surface
(7) N.C. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make
provisions for monitoring well head processes. A faucet on both influent (groundwater
entering heat pump) and effluent (water being injected into the well) lines is required. Will
there be a faucet on:
(a) the influent line? yesno (b) the effluent line? yes �% n❑
(8) Attach a diagram showing the location of the injection well and sampling faucets relative to
primary building on property.
G. PROPOSED OPERATING DATA
(a)
Injection rate:
Average (daily) 2 -3 allons per minute (gpm)
(b)
Injection volume:
Average (daily)gallons per day (gpd)
(c)
Injection pressure:
Average (daily)—pounds/square. inch (psi)
(d)
Injection temperature:
Winter Average degrees F
Summer Average degrees F
GW-57 HP (June 1993) Page 2 (A 4

H. INJECTION FLUID DATA
(1) Fluid Source. If underground, from what depth and what type of rock/sediment does the fluid
to be injected derive (e.g., granite, limestone, sand).
(2) Chemical Analysis of Source Water. The following chemical characteristics MUST
accompany this application: .,,.,/./
/
pH · Total hardness ____ ppm-(parts per million or mg/I);
Iron ____ ppm; Chloride ,/ppm; Nitrate _____ ppm;
Coliform bacteria _____ coun!Sfl{)0ml
f\)c:A
·\ ?-
NOTE: Assistance in determining these values may be obtained by contacting (a) your
local or county health offical, (b) a commercial water-testing laborcltory, (c) your
well drilling contractor, or (d) the regional Hydrogeologist, North Carolina Dept.
of Environment, Health, and Natural Resources.
I. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the .engineering layout of the (1) injection equipment, and
(2) exterior piping/tubing associated with the injection operation. The manufacturer's brochure,
if detailed, should satisfy ( 1) above
J. LOCATION OF WELL{S)
Attach a detailed map showing the orientation of and distances between the proposed well(s),
any existing well(s) that will in any way be involved in the injection operation, and at least two
(2) nearby reference points such as roads, road intersections, streams, etc. The roads should be
identified by US, NC or SR (county secondary roads) numbers, and streams should be named.
In addition, the diagram should show the direction and approximate distance to any existing
water-supply and/or injection wells within 1,000 feet of the proposed injection well.
K. CERTIFICATION
"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 operate and use the injection well and all related appurtenances in accordance with the
approved specifications and conditions of the Permit."
GW-57 HP (June 1993)
~ ~ tJ-/U~/4-w-
(Signature of ow?er or Authorized. Agent)
Please supply a letter signed by the owner
authorizing the above agent, if authorized agen_t is signer.
Page 3 of 4
Please return the completed Application package to:
GW-57 HP (June 1993)
UIC Program
Groundwater Section
North Carolina DEHNR-DEM
P.O. Box 29S3S
Raleigh, NC 27626-0S3S
(telephone: [phone])
Page 4of4
North Carolina rr,;; i�vi` ' I ER C c.
Environmental Management Commzss on
Department of Environment, Health &fifF". :ga¢l iIRppogces
Groundwater Section '
STATUS OF INJECTION WELL SYSTEM
Date: 416194 Permit # : - --WO-
Name:;.�Cl-a-vid W4rirk
Address:_ 55 1 ��s �20 iVnrfih
—Su=PT'fiPlrl, 1V{' 2TI�R
Please check the selection which most closely describes the
current status of your injection well. In addition, please
answer the appropriate questions in the space provided.
1) X Well is still used to inject heat pump return flow.
2J. Injection discontinued; well temporarily not being
used.
Why?:
How long out of service?:
Is the well sealed shut?:
Intended use:
Projected date of re -use:
3] Injection discontinued; well used as water supply
well.
Why?:
4] Injection discontinued; well permanently abandoned.
Why?:
How long out of service?:
Is the well filled or open?:
Who performed abandonment?:
Certification:
"I hereby certify, under penalty of law, that I have
personally examined and am familiar with the information
submitted in this document, and that to the best of my
knowledge the information is true, accurate and complete."
(Signature)
GW-BB

State of North Cai viina
Department of Environment,
Health and Natural Resources
Division of Environmental Management ,
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary D E HNR
A. Preston Howard, Jr., P.E., Director
GROUNDWATER SECTION
March 23, 1994
.. ,.
Mr. F. David Wyrick
5531 Hwy 220 N.
Summerfield, NC 27358
<:~ ;1 •
(.1"1' (.~ ,.n r,:.1
·P
Dear Mr. Wyrick,
Our records show that the operating permit for the heat pump
injection well on your property expired on October 15, 1992. In
addition, our records do not indicate that the well has been
abandoned. In order to comply with the regulatory requirements
for permitted injection facilities (15 NCAC 2C .0211), it is
imperative that you either submit the enclosed application for
permit renewal or submit the enclosed Status of Injection Well
System form that certifies that the injection faciliti is no
longer in use. If the well is no longer to be used for any
purpose, it must be permanently abandoned according to the
regulatory requirements (15A NCAC 02C .0113), and you must submit
the enclosed Well Abandonment Record form. The appropriate
form(s) should be forwarded to us by April 18, 1994. A copy of
the previous application is also enclosed for your reference.
If you have any questions regarding your Permit please feel
free to contact me at (919) 733 -3221, ext. 431.
cc: UIC Files
W-SRO Files
Enclosures
Sincerely,
~~a.~
Karen A. Harmon
Hydrogeolbgical Technician II
Underground Injection Control Program
Groundwater Section
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ l QII.. post-consumer paper
Please check the boxes below that apply:
— ❑ Please send me a copy of -the regulations applicable to injection wells.
❑ Please send me an application for a permit to use a well for injection., purposes.
1- can identify the location of. a well used to inject fluids to the subsurface.
{Mer requeststremarks: We'use one well for al-1 household needs and Heat Pum .
We return =max_' 2 to 3 .g.ai s,. per minute back to the same we11 -some- of the .time.
R,eason: -Not to heat''or caul' the- water in'the well I.
Name F..Dayid- Wyrick Telephone [phone] or 643-4286
affiliation - . .
Address- 5531 IJS 220- North
City Su6perfieId State NC dip Code 27358

North Carolina
Environmental Management Commission �� ++CC4
Department of Environment, Health & Natural Resources
Groundwater Section
Arts oN
STATUS OF INJECTION WELL SYSTEM
Date: 1119192 Permit #: cannot find _WO_
Name: — E. David Wrick
Address:
�-t i mmprf i p_l d _, -PIE- 2 7 3 f, R
Please check the selection which most closely describes the
current status of your injection well. In addition, please
answer the appropriate questions in the space provided.
1j X
2)
0]
Well is still used to inject heat pump return flow.
Injection discontinued;
used.
Why?:
well temporarily not being
How long out of service?:
Is the well sealed shut?:
Intended use:
Projected date of re -use:
Injection discontinued;
well.
Why?:
well used as water supply
4) Injection discontinued; well permanently abandoned.
Why?:
How long out of service?:
Is the well filled or open?:
Who performed abandonment?:
Certification:
"I hereby certify, under penalty of law, that I have
personally examined and am familiar with the information
submitted in this document, and that to the best of my
knowledge the information is true, accurate and complete."
(Signature)
GW-g8

State of North Carolina
Department of Natural Resources and Community Development
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor
S. Thomas Rhodes, Secretary
Mr. F. David Wyrick
5531 Hwy 220 N.
Summerfield, NC 27358
Dear Mr. Wyrick:
November 2, 1987
R. Paul Wilms
Director
In accordance with your application dated August 3, 1987
we are forwarding herewith Permit No. 40-0778-WO-0006 for the
operation and Use of a well, for the purpose of injecting heat
pump effluent, in Guilford County.
This Permit shall be effective from the date of issuance
until October 15, 1992 and shall be subject to the conditions
and limitations stated therein.
In order to continue uninterrupted legal use of this well
for the stated purpose, you should make application for permit
renewal at least two (2) months prior to ·its expiration date.
/bhl
Attachment
cc: UIC Files
WSRO Files
Sincerely,
~,().~
Larry Coble
Regional Supervisor
Pollution Prevention Pays
P.O. Box 27687, Raleigh, North Carolina 27611-7687 Telephone [phone]
An Equal Opportunity Affirmative Action Employer
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
RALEIGH, NORTH CAROLINA
PERMIT FOR THE ❑PERATION NSE OF A WELL OR WELL SYSTEM FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87;
Article 21, Chapter 143, and other applicable Laws, Rules and Regula-
tions
PERMISSION IS HERESY GRANTED TO
F. David Wyrick
FOR THE OPERATION AND USE OF AN INJECTION WELL/WELL SYSTEM located
at 5531 Hwy. 220 North in Summerfield, North Carolina in Guilford
County, in accordance with the application dated August 3,
1987 and in conformity with the specifications and supporting data
submitted, all of which are filed with the Department of Natural
Resources and Community Development and are considered a part of this
Permit.
This Permit is for Operation and Use only, and does not waive
any provisions or requirements of the Water Use Act or any other
applicable Laws, Rules or Regulations. Operation and use of a well
or well system shall be in compliance with Title 15 North Carolina
Administrative Code 2C, and any other Laws, Rules and Regulations
pertaining to well construction and use.
This Permit shall be effective, unless revoked, from the date of
its issuance until October 15, 1992 and shall be subject to the
specified conditions and limitations set forth in Parts I and II
hereof.
Permit issued this the 3 0 tay of 1987.
La y Coble
Regional. Supervisor
By Authority of the Environmental Management Commission.
PERMIT NO. 40-0778--WO-0006

PERMIT NO. 40-0778-WO-0006
PART I
A. GENERAL CONDITIONS
1. The Permittee must comply with all conditions of
this Permit and with the staridards and criteria
specified in 15 NCAC 2C .0200. Any Permit
non-compliance constitutes a violation of the
appropriate Act and is grounds for enforcement
actio_n; for Permit termination, revocation and
reissu~nce or modification; or for denial of a
Permit renewal application.
2. It shall not be a defense for a Permittee in an
enforcement action that it would have been
necessary to halt or reduce the permitted
activity in order to maintain compliance with the
conditions of this Permit.
3. The Permittee shall take all reasonable steps to
minimize or correct any adverse impact on the
environment resulting from noncompliance with
this Permit.
4. The Permittee shall give advance notice to the
Director of any planned changes in the permittee
facility or activity which may result in
noncompliance with the Permit.
5. The Permittee shall report all instances of
noncompliance, not reported under condition 1. of
this Pai~, at the time monitoring reports are
submitted.
6. Where the Permittee becomes aware of a failure to
submit any relevant facts in a permit.
application~ or of any incorrect information
submitted.in said application or in any report to
the Director, the relevant and correct facts or
information shall be promptly submitted by the
Permittee.
7. The Permittee shall give notice to the Director
as soon as possible of any planned physical
alterations or additions to the permitted
facility.
8. In the event that the permitted facilities fail
to perform satisfactorily, the Permittee shall
take such immediate action as may be required by
the Director.
PART I (continued) PERMIT NO. 40-0778-WO-0006
PART II
9. The injection system shall be effectively
maintained and operated at all times so that
there is no contamination of groundwaters, or
other actions or occurrences which renders them
unsatisfactory .for normal use. In the event the
facilities fail to perform satisfactorily,
including the creation of nuisance conditions,
the i?ermittee shall take such immediate
corrective action as may be required by the
Director.
10. Department representatives shall have reasonable
access for purposes of inspection, observation
and sampling associated with injection and
related f~bility. · · · · ·
11. This Permit is not transferrable without prior
notice to, and approval by, the Director.
12. An application ·for modification,-· renewal or
transfer of _this Permit shall be ·filed .with the
Department at least 30 days prior to the
~xpirati~n date 6f this Permit~
A. SPECIFIC CONDITIONS
-NONE
Po—
N= CAROLINA
7
E `VIRJ)NM4TAL MANACI3T COMMISSION ^ ...•
DEPARTMEW OF NATURAL RESS AND � �.�
APPLICATION FOR PER41T TO CONSTRICT AND/OR USE A Wit E)R INJECTION
CLASS 5 WELLS
TO: DIRECTOR, NORTH CAROLINA DIVISION OF ENVIRONM]WAL MANAGEMENT
DATE: Auiiust 3 , 1987
In accordance with the provisions of Article 7, Chapter, 87; Article
21, Chapter 143, anZ regtlati.ors p=rsl?ant thereto, APPLICATION is hereby
made for a PERIIT to construct and/or use a well or well system as described
belaw and in any accompanying data submtted as a part of this APPLICATICN.
A. 04dM DATA: Nam.. F. David W y r i c k
Address: 5531 220 North
Summerf i el d, NC ZIp: 27358
County: Guilford Telephone: [phone]
Ownership Status: Federal State 0 Private
Public Cosmmrcial Q
Other (Specify)
B. FACILITY DATA (Fill out ONLY if the injection well(s) is (are) for
the purpose of serving a business or industry]:
Sussness/0arporate Name:
Address:
County:
ZIP:
Telephone:
C. HEATING CON TRACT+CR DATA (For heat pump systems only. Please give
info=ation for the contractor that
installed or will install your system) :
Names Maness Heatinc
Addx'egs: 3 3-10 S.D r i n� Gard -en St.
Greensboro. NC
ZIP: 2 Z4 0 3 Telephone: [phone]

MEMO.
,O: Ui 6 FLU.
DATE: L/
SUBJECT:
North Carolina Department of Natural
•�= Resources &community Development

~D ...... ,,~ION PR:CEDURE: • .Ll'iv~•
Briefly de~ribe how the injection well(s) will be used.
lf k{:.t,tt' e~r
E. WELL USE: Will the injection well(s) also be used as the supply \\1ell(s)
for either of the following?:
(a} 'llle injection operation?· YES G] . NO D
(b) Your personal consunption? YES LI] NO □
F. CCNSTROCTICN DATA: (check one)
bl] EXISTI?G WELL being proposed for use as an injection \\1ell. Attach a
copy of Fbnn GR-1 (Well Construction Pecord) and furnish (7 & 8)
below. If Fann GW-1 is not available, fumish the data in (1)
through (8) below to the best 2.f ~ knowledge.
D POOPOSED WELL to be constructed for use as an injection well.
Furnish the data in (1) through (8) below as PROPC\SED construction
specifications.
OOl'E: THE WELL DRII..LDG CCNrPACroR CAN SUPPLY THE DATA FOR EITHER
-EXISTIR; OR PRO]?(l;ED WELLS IF THIS INFO™ATICN IS UNAVAILABLE BY
OTHER MEANS.
(1) Well Drilling Contractor's Naioo: Ba; n brid g e & Dance
(2) I.ate (to be) constructed Se p t e mber 1985; Approx. Depth 300 ft.
(3) Well casID;J:
(a) Type: Galvanized Steel O Black Steel 0
Plastic O other (Spec...:·_i_fy~)=-====----
(b) Inside Dianeter: inches; Wall thickness (inches) ------
(c} casing Depth: Fran
( 4) Cement Grout:
to
.or schedule# ----
ft. (referenced to land .surface)
(a) Arcnmd inner or "primaJ:y" casing: Fran to ft. ------
(b) Around outer (pit) casing, if present: Fran to ft. --- ---
(5) Screen(s): (if applicable)
(a) Type: ; Inner Diameter: inches
(b) Depth: From to feet below land surface
(6) Gravel: (if applicable)
Frain: to feet below land surface
(7) N.C. State Regulations ons (15, 2, 2C, Section .0200) require the
permittee to make provisions for monitoring well head processes. A
faucet on both the influent (TAoter from well) and effluent (water
into well) lines is required. Is there a faucet on (a) the influent
line YES ❑ No ❑ , or (b) the effluent line YES ❑ NO ❑ ?
(8) Attach a diagram showing the details of construction of the existing
and/or proposed well(s).
G. PROPOSED DPERATIW3 DATA: (The manufacturer's brochure should include
this information.)
H.
(a) Injection Rate: Average (Daily) gallons per minute (qpm)
(b) Injection Volume: Average (Daily) gallons per day (gpd)
(c) Injection Pressure: Average (Daily) pounds/square inch (psi)
1NJ2C.TED FLUID DATA:
(1) Fluid Source (From what depth and what type of rock/sediment unit
does the fluid to be injected derive, i.e. granite,
Limestone, sand, etc . )
Depth:
RoWsediment unit:
(2) Chemical Analysis of Source Water: The following chemical
characteristics IJST many this application;
pH Tbtal hardness ppm (parts per million or mg/ 1)
iron L .03 ' ppm; Chloride ppm; Nitrate pprn
Colifoxm bacteria --�— I counts/100 m1.
NOTE: Assistance in obtaining ng these values may be facilitated by
contacting (a) your Local or county health official, (b) a
commercial water —testing Laboratory, (c) your well drilling
contractor, or (d) the Regional Hydrogeologist, North Carolina Dept.
of Natural Resources & Ccuuunity Development.
NOTE: If injection system is not for a heat pump, then a detailed
analysis of both the source water and the injection fluid may be
required.

Attach a diagram showing the engineering layout of the (1)
injection equipment, and (2) exterior piping/tubing associated
with the injection operation.
NOTE: The manufacturer's brochure, if detailed, should satisfy III above
if the system is a heat pump.
J. LCCATICN OF WELL (S )
Attach a detailed map showing the orientation of and distances
between the proposed well (s) , ary existing well (s) that will in
any way be involved in the injection operation, and at least two
(2) nearby reference points such as roads, road intersections,
streams, etc. The roads stx%ad be identified by U.S., N.C. or SR
(colony secondary road) numbers, and streams should be named. in
addition, the diagram should show the direction and approximate
distance to any existing water -supply and/or injection wells
within 1,000 feet of the proposed injection well.
"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 i V ry of
those individuals immediately responsible for obtaining said
information, z--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 operate and use the injection well and all
related appurtenances in accordance with the approved ,specifications and
conditions of the Permit," -
(Signature of er or Authorized Agent)
L. FOR CMCE USE ONLY:
1. Initial Application: Complete Tnomplete
If INCONK=, Date of Notification and Resubmittal
2. Standard Industrial Code(s) which best reflect the principal products
or services provided by this facility - if applicable.
(a) (b) (c) (d)
3. APPLICATION NO.
This well was installed 1985 and put in operation December
1985. The well and system have been inspected May 1987 by
Stephen Williams.

Dc P►' -MVq F XATtSL1L 1XSOURC S AND f tRMI DEVEL WMENT
' , V I S IGM O1 M IMOMMRi'AL HaAACKhtjfr
7307
ws11 location
Y`' T� �s Cosm., Subdivision and Lot No
Owner
Add rem
STRUMON
trilling Coatssttor Lia'
Nam .Add Tess
Distance fum
i�nX Yt�oi1 Spurce
Other Iacatioa 'stQadar+ds'
To to 1 D egth
-.-Casing
Depth
Diameter
Weight./thickness
Grout:
Type. .
Thickness
Depth
Date 3111
Area
County _rgutI - -
Road/Street -US 220
Quad No. 51
Let. L0Qt+
Heats Hin, StW,+grds
Mossure lu Ag lMrkg.
rr
�N ✓
w
Nam.
•Wei
c.r ns
'-
ne"o nt'
I. D. PZate
Abe oemset (tem o�ravxj_t"jw�t)`
Veil
,Shlorin oa
fir.:..,..

WELL HEAD COWLETLEW
Vu"- installer
Monte Address Reg. i
tieeta MLn. Staad4j
Measure Ims f - Reeks
EM losu 11 N/►G
Enclosurl floor PJ/i4
Casim height ►•
Access Dort
+�
V ■ via flow
AMA
Wa UTt LR ht DiDt enr
✓
will eatm(
►�
V ent
✓
Bose bib
Tel (let)
5uctiyb lin:
MA_._
ChIgrination
TSM2raEX Abaad.
A/Af
Date Well Coastrmeted 10 14 8<
Date Pumip Installed
F t s igus lu re
Witness
Name Address Type
Name Address _ Type
� 2
W[ X) o

COUNTY _�WL EQP—fl
QUAD NO, F5LI SERIAL NO.
LAT
LONG,
Report to: ARO, FRO, MRO, RRO, WaRO, WiRO,
WSR Kinston FO Other
Shipped by: Sus Courier Other
COLLECTOR(S]:40" DATE 3 4
FIELD ANALYSES
PH4dp Spec_ Cond.g4 at 250C
Temp.ta oC Odor �k&
Appearance l , Taste
Field Analysis By:,1f1f1��1Q�3
LABORATORY ANALYSES
BOD5 $10 moll
COD High 340 moll
COD Low 335 moll
0011larm:MF Focal 31616 ►10oml
Cailform:MF Twill 31504 � 1100ml
TOC 680 mg/1
Turbidity 76 NTV
PH 403 unita
Alkalinity to pH 4.5 410 migh
Alkalinity to pH a.3 415 mg/1
Carbonate 445 mg/1
BlcarLonste 440 moll
Arsenic;Totel 1002 ugli
coition dioxide 40S moll
Chloride 940 mu►I
Chromium:Hex 1032 ugll
Color.Trus 80 Pt -Co
Cyanide 720 mg11
Lab Comments:
MAIN bf tvsib-
N.C. 0ARTMENT OF NATURAL RESOUR.._a LAB NUMBER 8 DY +
& COMMUNITY DEVELOPMENT DATE RECEIVED —ro 1� Time �- ---�-
DEM Rec'd by: From: Bus ourier
GROUNDWATER FIELD/LAB FORM Other
SAMPLE PRIORITY DATA ENTRY BY: CI[:,1.X
ROUTINE ❑ EMERGENCY DATE REPORTED:
3 el TIME 112k>— PURPOSE: BASELINE, COMPLAINT, COMPLIANCE, LUST, O HER
(circle one)
Owner 1 lay A \J lU y1 k'
Location or site
Description of sampling point
� 1
Samplinq Method oL( Sample Interval s �lLLe.S�
r Tpu p, bailer, etc:]
Remarks �`7 �vtl L� QEl iinaO
Digs. solids 70300 taplt
Fluoride 951 glt
'meg►I
Hardnees:Total 90074
Hardness [non-carb] 902 moll
Phenols 327$0 ugll
So"llio Cood. 95 uMhoslCm7
Sutiala 945 m911
Sultide 745 mgll
NH3 an N 010 1 moll
TKX as N 626 mg►1
NO2 t NO3 as N 630 moll
P:Tatal as P 665 moll
Ag Silver 1077
U01
Al - Aluminum 1106
ug►1
60 - Barium'1007
00N
Ca - calcium BIG
MUM
Cd - Cadmium 1027
ugll
Chromium:Talel 1034
ugll
Cu - Copper 1042
10
uo11
Fe - Iron 1045
.r[
ug1}
Hg - Mercury 71900
ugll
K - Potaaslum 937
moll
Mg - Magnesium 927
moll
Mh - manganese 10S5
ug11
No - Sodium 929
mg/1
NI - Nickel 1067
.+[
uo11
Pb - Load 1051
C
ugli
Se - Saleniµm 1147
ugll
Zn - Zinc 1042
"410
ugli
❑roanochlo►Ine Pesticides
Organophespherus Pesticides
Acid Hardicides
Base I Neuiral Extraclabie Organics
Acid Exirsclable Organics
Purgearlie Droanice (VOA 110t116)
1,2 - Dltifomoolhans (EDO)
GW-54 Revised 7185 For Dissolved Analysis - submit filtered sample and write "DIS' in block
White copy - Headquarters Pi4 copy - Region Yellow copy - Lab

North Carolina Department of Human Resources
Division of Health Services
P~O. Box 2091 • Raleigh, North Carolina 27602-2091
James G. Martin, Governor
David T. Flaherty, Secretary
Ronald H. Levine, M.D., M.P.H.
State Health Director
October 21, 1987
Mr. Nathaniel C. Wilson
Permits Issuance Group
Groundwater Section
Division of Environmental Management
North Carolina Department of Natural Resources &
Community Development
P.O. Box 27687
Raleigh, North Carolina 27611-7687
Dear Mr • Wilson:
Re: Application for an Injection
Well Permit
F. David Wyrick
5531 Hwy. 220 North
Summerfield, North carolina
Guilford County
Permit No. 40-0778-W0-0006
Reference is made to the above subject.
Considering the legal matter of endorsing this proposal, we do not
believe there is sufficient information to deny the request based on a threat
to the groundwater or the public's health. However, our recommendation that
an assessment be made of the effects these systems might have on groundwater
remains.
If we can be of further assistance, please let us know.
JFS/Rf!C/ar
Sincerely,
4--1-~ "'~
James F. Stamey, Chief
Environmental Health Section
State of North Carolina
Department of Natural Resources and Community Development
Division: of Environmental Management
512 North Salisbury Street + Raleigh, North Carolina 27611
James G. Martin, Governor R. Paul Wilms
S. Thomas Rhodes, Secretary October 9, 1987 Director
Mr. ,Tames Stamey, Chief
Environmental Health Section
Department of Human Resources
Bath Building
Raleigh, NC
Dear Mr. Stamey:
This office has received application.sfor Permit to operate s
Use a well or well system for injection, as listed below. In
accordance with Article 7, Chapter 87-88(j), General Statutes of
North Carolina, we submit the fallowing application, in addition to a
draft copy of the proposed Permit, to DHR for review and
recommendation:
oper.
Renewal
APPLICANT
Permit
Permit
INJECTION SOURCE
William M. Bair
x
heat pump effluent
F. David Wyrick
x
"
Mark Peters
x
"
Larry J. Vickery
X
"
Richard L. Wright
x
"
William N. Rigsbee
x
"
Please note that the application complies with the specified
requirements as prescribed by 15 NCAC 2C .0200.
If we have not received any comments or recommendations within
ten (10) working days of the above date, we will assume that DHR has
no objection to the project as proposed. Please do not hesitate to
contact me at 733--3221 if you have any questions.
NCW/Is
Enclosures
Sincerely yours,
-�' A/Z07,
Nathaniel C.
Permits and
Groundwater
Pollution F�vwmnorr Pays
Wilson
Compliance Group
Section
P-0, Box 27687• Rak4h, North Carolina 27611.7687 Telephone [phone]
An Equal Opportunity Affirmame Action 1 mpkrjer

Stateof North Carolina
Department of Natural Resources and Community Development
Winston-Salem Regional Office
James G. Martin, Governor
DIVISION OF ENVIRONMENTAL MANAGEMENT
GROUNDWATER SECTION
Mr. David Wyrick
5531 US 220 N.
Summerfield, NC 27358
Dear Mr. Wyrick:
July 23, 1987
S. Thomas Rhodes, Secretary
Enclosed please find the application for the permit for
the use of a well for injection. Fill out the form as
completely as possible and mail to:
Mr. Nat Wilson
Department of Natural Resources
and Community Development
Groundwater Section
P. o. Box 27687
Raleigh, NC 27611
Also enclosed is the laboratory results for the
groundwater samples collected from your water supply well.
As an environmental agency,.we are not authorized to provide
guidance concerning the safe consumption levels of metals
present in a water sample. Please contact the Guilford
County Health Department ~t [phone] for this
inf orm~ion. llllffllml--\
SW/dh
Enclosure
cc: WSRO, GW files
Nat Wilson
Sincerely,
5~/J~
Stephen Williams
Hydrogeological Technician
8025 North Point Boulevard, Suite 100, Winston-Salem, N.C. 27106-3295 • Telephone [phone]
An Equal Oppommity Affirmative Action Employer