WI0400011_GEO THERMAL_20160419

PAT MCCRORY Governor DONALD-R. VAN DER VAART Secretary Water Resources ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN Mr. Robert Risen 3057 Lori Lane April 19, 2016 Yadkinville, North Carolina 27055 SUBJECT: Dear Mr. Risen: Laboratory Analytical Results Geothermal Underground Injection Control Well Heat Pump System Permit No. WI0400011 Yadkin County DirecJor On March 22, 2016, Jim Gonsiewski and Jeff Robinson of the Division of Water Resources (DWR) collected -groundwater samples from.the influent and effluent access points to your Geothermal Underground Injection Control_ Well Heat Pump System. The· samples were sent to· R&A Analytical Lab9ratories in Kernersville, -NC and the DWR Central Laboratory in Raleigh, NC for analysis. The samples were analyzed for fecal coliform, chloride, t<:,1;al dissolved solids, hardness, nitrate, nitrite, aluminum., arsenic, calcium, chromium, copper, iron, lead, magnesium, manganese; nickel, potassium, sodium, and zinc. Laboratory analytical results from the samples did not detect any constituents above ·the State of North Carolina 2L (NC2L)·groundwater standards. · We appreciate your cooperation in the collection of these samples.· If you have any questions, please contact me at [phone] or via email [e-mail]. Sincerely, ~~~ James. J. Gonsiewski, P.O. Hydrogeologist Water Quality Regional Operations Section Division of Water Resources, NCDEQ -WSRO enc.: Laboratory Analytical Reports cc: WSRO Files RECE\VEO/NCDEQ/OWR AUG O 1 2016 Water ouality Regional Operations Section 450 W. Hanes MIii Road, Suite 300, Winston-Salem, North Carolina 27105 Phone: [phone] \ FAX: [phone] \ Customer Service 1-877-623--6748 Internet www.ncdenr.gov -www.ncwater.org
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Chromium (Cr), Total pg/L
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Copper (Cu) Ng/L
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PAT MCCRORY
Govemor
DONALD R. VAN DER VAART
Water Resources
ENVIRONMENTAL QUALITY
May 9, 2016
Robert and .Linda Risen
3057 Lori Lane
Yadkinville, NC 27705
Re: Issuance of Injection Well Permit
Permit No. ·WI0400011
Geothermal Heating/Cooling Water Return Well
Yadkin.County ·
Dear Mr. and Mrs. Risen:
· Secretary
S. JAY ZIMMERMAN
Director
In accordance .with your permit renewal application received February 18, 2016, I am forwarding
Permit No. WI0400011 fotthe continued operation of geothermal heating/cooling water return well(s)
located at the above referenced address.· This permit shall be effective from date of issuance until April
30, 2021, and shall be subject to the conditions and limitations stated therein.
Please Note:
• Samples from the influent and effluent sampling ports of your geothermal well system
were collected on April 18, 2016. Please find the attached laboratory analytical results.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit art
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 Resources. If you have any questions regarding your permit or the Underground
Injection Control Program, please call me at [phone]~
Best Regards,
4~-
Shristi Shrestha
Underground· Injection Control (UIC) -Hydrogeologist
Division of Water Resources, NCDEQ ·
Water Quality Regional Operations Section
State ofNorth Carolina I Environmental Quality I Water Resources
1611 Mail service Center I Raleigh, North Carolina 27699-1611
919 707 9000
..
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
·RALEIGH, NORTH.CAROLINA
PERMIT FOR THE USE OFA 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
Robert and Linda Risen
FOR THE CONTINUED OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defined inTitle 15A North Carolina Administrative Code 02C .0224(a), which will be used
for the injection of heat pump effluent. The injection well(s) located at 3057 L_ori Lane, Yadkinville, Yadkin
County NC 27055 will be operated in accordan_ce with the application submitted February 2, 2016, and conformity
with the specifications and supporting data received, all of which are filed with the Department of Environmental
Quality and are considered a part of this permit. ·
This permit is for continued operation of an injection well. shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, an~ 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 April 30, 2.021, and shall be
subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 9th day of May 2016.
S. JayZimmerman, P.G.
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Permit #WI0400011 UIC/5A7
ver. 11/15/2015
Page 1 of 5
PART I -PERMIT GENERAL CONDITIONS
1. The Permittee shall 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). Noncomplia1we 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 is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data [15A NCAC 02C .021 l(a)].
3. 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 [15A NCAC 02C .0211(1)].
4. This permit is not transferable without prior notice and approval. 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, including any supporting materials as may be appropriate, at least 30 days prior to the date of
the change [15A NCAC 02C .021 l(q)].
5. 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. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met [15A NCAC 02C .0203].
PART II -WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed in accordance
with the requirements of rule 15A NCAC 02C .0107 except as required in Item #2 below.
2. Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC 02C .0107
except that the entire length of the casing shall be grouted in such a way that there is no interconnection of
aquifers or zones having differences in water quality that would result in degradation of any aquifer or zone.
For screened wells, grout shall be emplaced from the top of the gr~vel pack to the land surface. For open-
end wells, the casing shall be grouted from the bottom of the casing to the land surface [15A NCAC 02C
.0224(d)(2), (3)].
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing conditions.
[15A NCAC .0225(g)(8)].
4. The injection well system shall be constructed such that a sampling· tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [15A NCAC 02C .0224(d)(4)].
5. Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal as defined in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .01070)(2)].
Permit #WI0400011 UIC/5A7
ver. 11/15/2015
Page 2 of 5
7. A completed Well Construction Record· (Form GW-1) shall be submitted as described in Part V.5 of this
permit.
PART III -OPERATION AND USE CONDITIONS
1. The· Pennittee shall comply with the conditions of this permit and properly ·operate and maintain the
injection facility in compliance with the conditions of this permit and the rules of 15A NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [ISA NC_AC 02C .021 l(j)].
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface water
or groundwater resulting from the operation of this facility .. 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 inurtediate corrective actions ·that _may be required,
such as the repair, modification, or abandonment of the injection facility [rSA NCAC 02C .0206]. .
PART IV -INSPECTIONS [ISA NCAC 02C .021 l(k)]
1. Any duly authorizedofficer, employee, or representative of the Division ofWaterResources (DWR) 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. DWR 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 samples of the injection facility's activities.
PART V -MONITORING AND REPORTING REQU~MENTS
1. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained·on-site and available for inspection [15A NCAC
02C .0224(f)(2), ( 4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State and
compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
.0224(f)(l)]. . .
3. The Pemiittee shall report any monitoring or other information that indicates noncompliance with a specific
permit condition, that a contaminant may cause a violation of applicable groundwater quality standards; or
that. a malfunction of the injection system. may · cause the . injected fluids to migrate outside the approved
injection zone or area. As specified in rule 15A NCAC 02C .021 l(r), noncompliance notification shall be
as follows_: ·
(A) Oral notification shall · be given within 24 hours of the · occurrence, or first knowledge of the
occurrence, to the Whiston-Salem Office, telephone number 336-776~9800.
(B) Written notification shall be made within five days of the occurrence and submitted to the addresses
in Item #5 ·below.
Permit #WI0400011 UIC/5A7
ver. 11/15/2015
Page3of5
(C) The written notification shall contain a description of the noncompliance and its cause; the period of
noncompliance, including dates and times; if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and any steps taken or planned to reduce, elimi11ate, and
prevent reoccurrence of the noncompliance.
4. The Permittee shall record the number and location of the wells with the register of deeds in the county in
which the facility is located. [15A NCAC 02C .0224(f)(3)].
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
UIC Program Staff
Division of Water Resources
163 6 Mail Service Center
Raleigh, NC 27699-1636
and
Water Quality Regional Operations Section
DWR Winston-Salem Regional Office
450 West Hanes Mill Road
Winston-Salem, NC 27105
PART VI-PERMIT RENEWAL [15A NCAC 02C .0224(c)]
As required by rule an application for permit renewal shall be made at least 120 days prior to the expiration
date of the permit. This permit condition does not apply if the Permittee chooses to discontinue operation
of the well for injection of effluent from the geothermal heating and cooling system associated with this
permit.
PART VII-CHANGE OF WELL STATUS [15A NCAC 02C .0240]
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complying with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to rule
15A NCAC 02C .0l 13(b) in order to prevent the well from deteriorating and acting as a source or conduit
of contamination, which is prohibited by General Statute 87-88(c).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water.:.tight cap or well
seal that cannot be removed without the use of hand or power tools.
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall permanently abandon that injection well in accordance with the procedures specified in 15A
NCAC 02C .0113(b), which include, but are not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
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 in accordance with rule 15A
NCAC 02C .011 l(b)(l)(A), (B), and (C).
Pennit#WI0400011 UICi5A7
ver. l lilS/2015
Page 4 of 5
(D)
(E)
(F)
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.
In those cases when a subsurface cavity has been created as a result of the injection
operations, each well shall be abandoned in such a manner that will prevent the movement
of fluids into or between underground sources of drinking water.
The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .'0224(f)( 4) within 30 days of compl~tion of abandonment.
5. The written documentation required in Part VII (4)(F) shall be submitted to the addresses specified in Part
V.5 above.
Permit #WI0400011 UIC/5A7
ver. 11/15/2015
Page5 of.5
RC27380 North Carolina Division ofWater Resources Water Sciences Section Laboratory Results
Loc. DOM,' RISEN RESIDENCE
county: Yatdklrt
CaUactDr
] GONSEE"Ki
VISMD
Region: WSR[1
Report To
WISRO
Loc*mn )D:
4Pj)9VW104fkg011
Rivet Basin YI PQ1
collect Date:
f 6
Priority
ROUtl
Emergency
Collect -Dime:
10:37
Sample Matrix:
gdguNL7�rATER
Coo Yea/110
Sample Depth
N6
Lac. Type:
Walar Suoofv
Final Repo
Sample lP:
AC_ _2730
PC) Number 9
I wo78
Pate Received:
Q
Time Received'
wa
LabwoftL0gin1D
TANEMI
Delivery Method
N er
Ffnal Report Dater-
Qj3jj¢
Report Pdat Dot@:
9fi14Mj
If this report Is labeled prellmirrary report; the resWts have not been validated Dv not use for Regulatory purposes,
es,u
Method
Analysis
GAS # Analyze fame
Qualf er
units
ale n
Kale
Ys to
LAB
Sample temperature at receipt by lab
2.1
WMi6
RBYRD
NUT
nitrate as N in Ilquid
0.02
0.63
mglLas N
EPA 353.9 RE1/ 2
4/4115
CGPrEN
N tti[te as N Iri liquid
0.01
0.01 U
MWL as N
EPA 353.2 REV 2
3/W6
CGREEN
NO2+NO3 as N in liquid
0.32
0.63
mg/L as N
EPA 353.2 REIr2
3/ 06
CGREEN
W9T
Bromide
0.4
"U
M9fL
EPA 300.0 rad2. f
W29/18
CGREEN
Chloride
10
2A
MQ/L
EPA, 300.0 rev2.1
3129116
GGREEN
Pluoride
0.4
CA U
ft/L
EPA 300,0 MvZ,1
312911e
CGREEN
Sulfate
2:0
2.2
M2&
EPA 300,0 rav2. t
VM16
CGREEN
Total Dissolved Solids in liquid
12
116
mg1L
SM 2840 C.1997
V2WIe
CGREEN
7428-9"
Al by [CP
s0
MET
50 U
ug/L
EPA 200.7
3/30/f6
ESTAFFORD9
7440-30-2
AS by ICPMS
2D
2.0 Lt
uQL
EPA 200,8
3/30111D
ESTAFFORM
7440.70-2
Ca by 1CP
0.10
12
mg/L
EFA700.7
a/mif
E3TAFFORR1
7440-47-3
Cr by ICPMS
5.0
5.0 U
u91t_
EPA 200,8
3fM16
ESTAFFORDI
7440.5Q-£i
Cu by.FCPMs
2-0
ISO
4L
EPA 2 0.8
3130116
ESTAFFORDI
7439-as-s
Fe by 1GP
50
5Q U
ug/L
EPASBQ.r
a1WII@
ESTAPFCADI
Hardness by Calculation.
1.0
49
mgVL
SM2340SEPA200.7
41111115
GSTAFFORID1
7440.09-7
K by ICP
0.10
1.$
rng1L
EPA 200.7
3l2arle
ESTAFFOR01
7439.95.4
Mg by ICP
0.10
4,7
mg/L
EPA200.7
5128116
F-STAF50ROI
7439-96Z
Mri by ICP
10
IOU
ug/L
EPA2MI
3130118
ESTAFFORD1
744&23,5
Na by ICP
0.10
6.2
mg/L
EPA 200.7
aka„ a
ESTAPFORRO1
7440-02d1
N1 by ICPMS
.0
2.0 U
UQ&
EPA204.6
awls
ESTAFFDRD1
7439-92-1
Pb by ICPMS
2.0
2.0 U
u8/L.
EPA20b.8
3130116
ESTAFFORt)1
7440-6&6 Zn by iCPMS 10 10 U UA EPA20o.8 wflme ESTAFrORDI
WSS Chamintry Laboratary" 1623 Marl Serv[" Cantor, Radei9h, NC 2711W1823 (918} 1334908.
Not Detected" or'U' does not lndlcste the sample is one" free but that the aneyte is not detected at a above the POL
Pages 1 of 'I

-7s-
North Carolina Division of Water Resources
Central Laboratory (water Sciences SeCtt0n)
Water Sample Collection & Submittal
Form
19 n
10"1
AC27 380
o
Or on Desc ption,
k-S Ok
L ation CIT e.-I
1P 0 9
t,D,&t RIF =ird 2
- I ME 1
12 ! Mauk C3 0 V-� 6 t, �U s, r_ i
ElAmbient
utirie
ElCompliance
0 COC
[j Eme rgency
[:]CXA
rISAMA"O
ter
r Mat, OX:
1-1,
0 Sijrface
RGround
L]waste
E3111ank
05olution
Fp
F�Ai
- veffs[Fearn
Ofstua ry
ElMonitorinS Well
[:]Effluent
[31FIelciftok
E] Filter Blank
E]Other.
Ipe:WU
L aki�]
[]canal
EkaterSuppty
Lion6uent
Elyrtp Blank
jd
N -
M fij-6;16�-W
�$Diff,Negiogp. \A)
I
"I
(W-Y! 184.0
Mai w 0 P-I
.F 'd, -:�rm
e 'A
F 11 1;
- Ee.- L
LjSlate courier
[jHand Dowery
LjOther
-3-1
- MINIM
F� ChInnnaled FjOe-chlorinated in Fie -id
Sj,jTjfN' �Grate LComposite
- Other-
T.6 M era Uire
❑Piltered in Field Dissolved analysis. Enter "DIS'
in checK-boxes Tor par
-7
su a an
.
. . . . . . . .
A
Acidity, as CaCO3, to pH 4.5/8-3
mg/L
oil and Grease, HEM, Total Recoverable
mg/L
I
Aiuminurn (All
pg/L
Titanium (Ti) V&IL
Mallnity, as CaCO3, to pH 4,S/8.3
mg/L
Phenols, Total Recoverable
PgA
Antimony (Sb)
pp./L
Vanadium (V)i pg/L
800; glocherniml Oxygen Demand, 5-day
mg/L
Residue: Total (Total 5ol;ds)
mg/L
WArsenic tAs)
ktg/l.
V
Zinc (Zn) PEA
cUOD: Carbonaceous BOD, 5,day
mg/L
Residue: Valatife/Fixed, Total
mg/L
Barium (Ba)
pg/L
Catifcrm: fecal MF
/100MI
Residue: Suspended (Suspended Solids I
mg/LP
Beryllium (Bel
pg/L
Boron (A), Total lig/L
Conform: Total Mf
1100MI
Residue; Volatile/Fixed, Suspended
mg1L
Cadmium (Cd)
pp,/L
Mercury 1631, low-level rig/L
Cc liform: Tube fecal
/100ml
IDS- Total Dissolved Solids
mg1l,
LI
Calcium (Cal
rngIL
Cob form: Tub e To ta t
/100rn1
silfca
mg1L
t,-'
Chromium (Cr], Total
wgA
Spe ciric Conductance, at 2.5 "C
jimhos/cm
Sulfide
Mg/l.
Cobalt JCO)
PO/L
Acid Herbicides
TOC - Total Organic Carbon
mg/L
Tannin & Lignin
rnglt
Copper (Cu]
i4gAL
'Dr%anochlarine Pesticides
Turbidity
NTU
V-
Iron (Fe)
pg/L
Organunitragen Pesticides
Lead [Pb)
pg/L
Organophosphorus Pesticides
*'WK-
t F.0,
pH
s. U
Lithium Ii
}igJL
PCBs (polychlorinated biP env 5
84-amide
mg/L
%,-I
Hardness, Total as CaCO3 - by Ovation
mg/L
't?iagnesllurn [Mg)
rngIL
jochlofide
mg/L
Manganese(mn)
pg/L
Semi -Volatile Organics (SNA5)
Fluoride
mg/L
Mercury IHS)
$Jg/l.,
TP H Diesel Raose
Sulfate
MgIL
Molybdenum (Ma]
Ch - c, ro-Jq [I a
pg/L
Ammonia as N (NH3-N)
mg/L
te"
Nickel (Ni)
PgA
Va lati le 0 rga n Ics (VOA I
Colul; ADMI
C'u,
'N I tra le- Ni Ente as N (1403 * NO2- N)
mg/L
L--l'
Potassium (K)
malt
Color: Platinum Cobalt
C.Ul
Total Kjeldahl Nitrogen as N (TKIN)
mg/L
Selenium (Set
pg/L
TPH Gasoline Range
CQD: Chemical Oxygen Demand
mg/L
Total Phosphorus as P (TP)
mg/L
5�er[Agj
pg/L
Cyanide, Total
mg/L
Witri te as N I N 0 2- N)
mg/L
L—Sodium
(Na)
rnglL
IRW*49'ai-9.
...... ......
Formaldehyde
Mig/l.
Nitrate as N (NO3-N calculated)
mg/L
stwontLorn (Sr)
pg/L
phytoplanktoll / Afgae
Hexavalent Chromium (Cf5+)
mg/L
as P (P 04)
Mg/Lf—,
Thallium (Ti)
pg/L
I I
LAB COMMENTS :

AC273n North Carolina Division of Water Resources Water Sciences Section Laboratory Results
Lae. parlor.-
RISEN RESIDENCE
county:
Y_xeSkl Collector.
d GON5jtEW i1
VlsitlD
Region:
WSR4 Report To
WSRO
Location ID'
E�HMQENC�E
fiber Damn •
162L1 Cd7lett.aate:
03t3112E+1R
Priority
RpUjl�
Emergency
Eailect Time;
11�es
Sample Matrk
ORGU iLWATER
COG Ybs1No
Sample Depth
f&
Lae. Type:
WdIL-Rgoniv
Final Relport
Sample ID:
AC27379
PO Number d
16G0077
slate Remiyed;
3p 12=61a.
Time Removed:
011-1
Labwo is LogIND
TA5CEM01
Cefrvery Method
mc cowrier
Final Report Data:
01
Rapwt Print liars-
Q41i41201.6
ff this report is labeled preliminary report, the results have not been vaRtdated Do not use for Regulefory purposes.
CA$ #
,Pu 'tafvte MWrn
Sample temperature at receipt by tab
PQL
Resultl
ual r
LAS
2.1
- Lh
°G
Mg-thad
Reference
Analysis
Date
3122116
►rsilaatBa �y
RSYAn
Nitrate as N In liquid
0.02
NUT
0.65
rnWL as N
EPA 353.2 REV 2
41411E
CGREEN-
Nftrite a$ N irY liquid
0.01
0.01 U
mgrLas N
EPA 353.2 REV 2
31221i6
CGREEN
NO2+NO3 as N in Ifquid
0.02
0,65
mg7Las N
E:PA 363.2 REV 2
312W16
CGREEN
Bromide
GA
WIE T
0.4 U
mg1L
EPA 300.0 rav21
3728116
03REEN
Chloride
1.0
2.4
mg)L
1=PA306.0 rav2.l
3729118
CGREEN
Fluoride
0.4
0A U
rmg1L
EPA 3M.0 rev2.1
3/29/113
CGREEN
Sulfate
2.0
2.3
rng1L
EPA300:0 re 2J
3129f16
CGREEN
Total Dissolved Solids in liquid
12
86
mglt,
sal 2S41) C-1997
5123116
CGREEN
7422-90-5
Al by ICP
50
MET
so U
ug1L
EPA 200.7
3180116
E97APPORD1
7440.39-2
As by ICPMS
2.0
2.0 U
UWL
EPA 200A
3WI16
ESTAFFORDI
744D-70-2
Ca by ICP
0.10
12
mg1L
EPA 2001
=8110
ESTAFFORDI
7440147-5
Cr by ICPMS
5.0
&O U
ugft
EPA 200.8•
3130116
E-STAFFt7RD1
7440'50'8
GU by tCPMS
2.0
12
ug7L
EPA 200.8
3rW116
ESTAFFORDI
7439.894
Fe by lCP
50
$6 U
WL
EPA 200.7
3130tia
ESTAFFORDI
Hardness by Calculation
1.0
49
mg1L
SM2340BEPA 2001
4/11114
ESTAFFORDI
7440-9$-7
K by IGP
0.10
1.6
PnGVL
EPA 200.7
3126116
ESTAFFORDI
7439-95-4
Mg by ICP
0,10
4.7
mglL
£PA200.7
3 &V8
ESTAFFORDI
7439.96-5
Mn by ICP
10
IOU
UWL
EPA.200•7
31361i6
ESTAFFOR01
7440.234
Na by ICP
010
4.2
mg1L
EPA 200.7
31281113
ESWFORDI
7440,-0ZC
Ni by ICPMS
2.0
4.2
u91L
EPA240.8
3130118
ESTAFFORDI
7439.92.1 Pb by iCPMS 2.0 2.0 U u9d- EPA 200.8 3130116 ESTAFFORD1
7440.OM xn by (CPMS 10 IOU ug1L EPA 200.8 3730116 ESTAFFOR01
WSS Chemistry LebaMboryaa 1623 Mail Serulcr Cerxta►, Raleigh, NC 27699-1623 (9111) 731.3908.
'Nat Datected' or "LP does not Indicate lhasample Is analyte free but thar the anaiyta Is not detected at or above the POL
Page 1 of i

North Carolina D(vislon of Water Resources
Laborator [Water Sciences Secdo+r Water Saenple Collecdan &Submittal Forme
Y )
Nisi�46:Central
@,� tiljA
�r. ...
%3��
Receive
1
Cntativn.Descrlpfiar+:
1 Se Y1 ES i � L�
tacatlon C_ ode
' p6d
-county: �r 1,
CPate
allrctvr,
Priority:
Y
❑Ambient
Routine
Cam Irance
❑ p
❑COC
Emergency
[—](IA
WaterMatr►x.
❑ 5u1 Face
Ground
Kg
❑Watee
glank
❑Sa3utian
t'ocptiorr Fype:
❑Riverlstream Laue
Estua Canal
❑ rY ❑
❑5lormwater
❑IVlonitorin Well ®Water Suplsiv-
❑Effluent ❑InflUOnt
❑ Trip Blar xFvtl:
Fil[erBlank
❑Other.
Tree Rete7Ued:j
,� `R Q 1
QLVR Region: (�' !�
�esed,��ui,: 6� LJ
,,;•. t, __ 2
M97off!Fe"'�
{{orn e Ir,ome��
t 9i,,,, 1
14ecelved ey;
,State
��Rfuer.Bosih:
" I
Courier
Merhod: ❑Hand Delivery
� ❑Other
��cDepvery
ff,T,�rO .
❑Oe-chlorinated in Fieldntp1;
ZVLQJIM� GrabCOnVoSlteChlorinated
❑Other
Terrr�eraature;{ Cj ry r
°'-'Arrl,rul r
T "
Dissolved analysis. Enter"DiS'
ElFiltered in Field in check baxea Tor Parameters
{SgrnPL±epthr
eRarJs:Eamments; v '1f 'F �.� �. SO -7 9
.0 -Irem
tVA%rgtiiblogy'�P i�� rjr
MBAS isurfactantsJ mgll
i T#Mewls Pai_a_me_-i� l� -
Y.
Tin (SnJ ugji
Acidity, as CaCO3, to pH 4.5/8.3 mg/L
Oil and Grease, HEM, Total Recoverable mgjl
LAluminurn
(AI) pg/L
Titanium (Ti) pg/L
Alkafinity, as CaCO3, to pH 4-5/8.3 mg/L
Phenols, Total Recoverable pg/L
Antimony {Stijl pg/L
Xanadiurn (V) VS/L
BCD: 8lochemlcal Oxygen Demand, 5-day mg/L
Residue: Total (Toro►Solids) mg/L
V
Arsenic (As) pg/L
Zinc (Zn) µg/L
CB0O' Carbonaceous BOO, 5-day mg/L
Residue: Volatile/Fixed, Total mg/L
Barium (8a) pg/L
Coliform: Fecai MF /100m1
Residue• Suspended (SuspendedSollds) mg/L
Beryllium (Be) pg/L
Boron (B), Total VOL
Cclife rm: TotaI MF /100rnl
Residue: Volatile/Fixed, Suspended mgjL
Cadmium (Cd) pg/L
Mercury 1631, low-level ng/L
Caliform. Tube Fecal /100m1
TDS - Total Dissolved Solids mg/L
Calcium Ma) mglL
Coll Form: Tube Total 110orrll
silica mg/L
Chromium (Ce), Total pg/L
Oigaiilrs�pararn tars
Specific Conductance, at 25 °C vmhos/cm
Sulhde mg/L
Cobalt (Co) pg/L
Acid HeWddes
TOC- Total Organic Carbon mg/L
Tannin & Lignin mg/L
Copper (Cu) PEA
Organochlorine Pesticides
Turbidity NTLI
iron (Fe) pg/L
Organonitragen Pesticides
Other Parartie ik
Lead (Pb) pg/L
0rganophospharu5 Pesticides
H!WeslGfieFilsrParars%
rs:
pH s U.
Lithium (Li) pg/L
PCBs (polychlorinated biphenyls)
B amide mg/L
j
Wiardness, Total as CK03 - by titration mg/L
agneslum (Mg) mglt
Chloride mg/L
manganese (Mn) ug/L
Semr•Volatite Organics [BNAsj
Fluoride mg/L
Mercury (Hg) pg/L
TPH Diesel Range :
Sulfate mglL
Y (minis` P3 ase te[ i- } '.i
Molybdenum (MO) pgIL
Chlnrophyli a pg/L
Ammonia as N (NH3-N) mg/L
t4icket (M) pg/L
Volavie Organics (VOA)
C8l[+r '1DMI C.U.
Nitrate -Nitrite as N (NO3+NO2-N) mg/L
j"
Potassium (K) rng/L
Color. Platinum Cobalt C.U.
Total Kjeldahl Nitrogen as N (TKN) mR/L
Selenium (Se) pg/L
TPH Gasoline Range
COD: Chemical Oxygen, Oemane mg/L
Total phosphorus as P (I P) mg/L
ZlIver (Ag) PKA
Cyanide, Total mg/L
Nltrlte as N (NO2-N) mg/L
Sodium (Na) m IL
8lologleai: r _
Formaldahyde mg/L
Nitrate as N (NO3-N calculated) mg/L
Strontium (5r) pg/L
PhytopIan kton / Algae
Henavalent Chromium (Cr6+) mg/L
I
Orthophosphate as P (PO4) mg/L
Thallium (TI) pg/L
LAa COMMENTS :
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Report of, Analysis.
� 4 ORATOR ES INC*
3/221216
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450 W. Hanes Mlii Rai. Suite 300
Winston-Salem, NC 27105
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Attn: ,lames Gonsimski
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Cltent.Sample ID:. Risen Residence I5-1
Late Sample ID; 16515-M
Site; NC DEC
Collection Date; 31211241E 10:37
Water An_ alvals
Parameter MAMA idea 1 Unit ggz—cia-w &Ja Yet Data 7Tv e
E. Coll SUM238 CoHlert Absent MK 312U2016 ' 16 0
No Face) ConfaminWan Found a
Total Collform SM 9223 8-2004 Catilart Absent MK 312112016 1600
No Baiatertal Contamination Found
Client Sample ID: Risen Residence ES-1 Late Sample ID: 16515-02 :J
Stte: NC DEG Collection Date: 3/21/2016 11:06
F.
Drinking*
Wa r Analysis
Parameter Method ul $ Standard 6Lg y.¢g D to 'time
E. Coii 3 OMS Coillert Absent MK 3121/2016 1600
No Fecal Contamloa8on Found .
Total Conform SM 9223 B-20D4 Colllert Absent MK 3121/2016 1600
No Bacterial Contamination Found
■ Max1mum Allowable Limit Nei = not anoty2ed
trVL = milligrams per Liter = pads per million (ppm)
e d Less than or Below Detectlon Llmils
P.O. Box.73 1Q6 ShodStMeet KarnersviDa. North Carolina 272a4 T Tel'. U6-M-2841 Fax:336-9a"32® www.iandslabs.com ��-P%,?e 1
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Permit Number
Program Category
Ground Water
Permit Type
WI0400011
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Faclllty Name
Risen, Robert Alan -SFR
Location Address
3057 Lori Ln
Yadkinville
Owner.
Owner Name
Robert
Dates/Events
NC
Alan
Orig Issue
1/11/1989
App Received
2/18/2016
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27055
Risen
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP __
4/28/2016
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classificatlon
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Yadkin
Faclllty Contact Affiliation
Owner Type
Individual
Owner Afflllatlon
Robert Alan Risen
3057 Lori Ln
Yadkinville
Issue
NC
Effective
27055
Expiration
Requested /Received Events
RO staff report received
RO staff report requested
Streamlndex Number Current Class
4/22/16
2/19/16
Subbasln
AATER_QUALITY REGIONAL OPERATIQNS SECTION
APPLICATION REVIEN REQUEST FC�RI�I
)Bate: Febran 2016
Sherty Knight 3i C)9r
Shristi Shrestha, WQROS — Auimal Feeding Operations and GrQQndwator Protection Branch
7'eiephone.- 919-807-6406 Fax. [phone] F Mafi. [e-mail]
Permit Number: W10400011
A. Avylicant: Robert and Linda Risen,
B.. Facility Name:
C. AVRHEltio •.
Perm& Type: geothermal Heatb�wco ft watdr7-0" VV411:
Project Type. Renewal
F- CommentslUtW Informe.tiQ 3
I would like to accompany you on a site visit
MAY 0 6 NIS
Water Quality Regional
Operations -Season
Attached, you will find all' infortnation submitted in support of the above -referenced application for your
review, c omment; gnd/or aetio& Within ail calendar days, please rdum a conwketed WO R06 --Staff.
R
When you receive times request farm, please write your name and slates in the spaces below, ;rake a copy of
this sheet, and return it to the appropriate Cehtral Office Orounfdwater Protection Branch contact person
Iisted above,
COMMENTS.-,
oas Cam-?
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FORM: WQROS-ARR ver. 092614 P .1 bil

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P,OKM: WOS-AkK ver.4M 14 1"W140

WATER QUALITY REGIONAL OPERATIONS SECTION
r APPLICATION REVIEW REQUEST FORM
Date: February 19, 2016
/*611, _To: Sherry Knight
re) From- Shristi Shrestha, WQROS -- Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail. [e-mail]
Permit Number: WI0400011
A. Applicant: Robert and Linda Risen
B. Faeift Name:
C. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
RECEIUF-0tnlr,r ^�illNR
APR 21 Z016
VVater Quality Regional
pperau011s a �t�art
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 WQRDS 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.
RQ-WQRDS Reviewer: _ t► z-"�^—�� Date:S
COMMENTS:
NOTES:
n&-t •e� . Nc�
�andILn�i-CX,( slNQctis
FORM: WQRDS-ARR ver. 092614
t' NC Department of
Environmental Quality
Received
t FEB 2 5 2016 � =
. .
Winston-'Sa lem
Regional office
Page 1 of 1

WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: February 19, 2016
To: Sherry Knight
From: Shristi Shrestha, WQROS -- Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mall: [e-mail]
Permit Number: W10400011
A. Applicant: Robert and Linda Risen
B. Facilit! Name:
C. Application:
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 34 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.
RO-WOROS Reviewer:
COMMENTS:
NOTES: pIC a,0 v a't� -�c ems, �,�w►
Date:
,"'�V 7'�gp
FORM: WQROS-ARR ver. 092614 Page 1 of 1

PAT MCCRORY
Govemor
DONALD R. VAN DER VAART
Secreta,:v
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
February 19, 2016
Robert and Linda Risen
3057 Lori Lane
Yadkinville NC 27055
RE: Acknowledgement of Application No. WI0400011
Geothermal Heating/Cooling Water Return Well
Yadkin County
Dear Mr. and Mrs. Risen:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on February 18, 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
maximurtl 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].
cc: Winston-Salem Regional Office, WQROS
Permit File WI0400011
Sin:~•
DebraJ. Watts,Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
State of North Carolina I Environmental Quality I Water Resources
1611 Mail service Center I Raleigh, North Carolina 27699-1611
919 7079000
Director
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
· In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RE TURN WELL (S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application . / Renewal* __ Modification __ Permit Rescission Request*
*For Permit 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 As Incomplete.
DATE: .2 I 1fl 20 ,~ PERMIT NO. V'.J .1D~()00 I f(leave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave Blank if New Application)
1. Current Use of Well
a. Continue to use as . V . Geothermal Well ;,/Drinking Water 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 copy of the Well° Abandonment
Record ( GW-30). RECEIVED/NCDEQ/DWR
D Yes, I wish to rescind the permit FEB 18 2016
2. Current Ownership Status Water Quality
Has there been a change of ownership since permit last issued? D YES ~~I Operatlone Sectk>n
If.yes, indicate new owner's contact information:
Name(s) ___________________________ _
Mailing Address: ____________________________ _
City: __________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: ____________ _____,cE=ma=i=l-=-A=d'"""dr=e=s=s.'-'--: __________ _
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,.o4ters, list name of entity and name of E_e~son delegated authority to sign: __________ _
J.< vb -~r~ a. HJ h t fJ a'\.. tl. 5 -~ iJ
Mailing Address': ,f,tt \ 5 i? ,./ ' ?,t; .... 1 I f:-c.1~ la!] Lori, J...o ,.J l;.,.
"
City: Y ~cl )l: ,.., .; .-I \..e State: ·fvC Zip Code: ~ 1 c> s·Si-County: Y o.d /lt ,v
DayTeleNo.: 3]6;.>.9b l -<t,9'2 CellNo.:
EMAIL Address: r . t', 's -t' t-2 .i c:> °)•'""'a.~) , U'.:> ~~ Fax No.:
Geothermal Water Return-Well Permit Application (Revised Jan 2015) Page 1
D. WELL OPERATOR (if different from well owner) -For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the business
or agency: ______________________________ _
Mailing Address:----------------------------------
City: State: __ Zip Code: _______ County: _____ _
Day Tele No.: Email Address.:
E. LOCATION OF WELL SITE-Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: __________ County: _____ _
(2) Physical Address (if different than mailing address): ________________ _
City: _______________ State: NC Zip Code: ________ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: __________________________ _
NC Well Drilling Contractor Certification No.: _____________________ _
Company Name: _________________________________ _
Contact Person_: _______________ EMAIL Address: ___________ _
Address:------------------------------------
City: Zip Code: _____ State: __ County:
Office Tele No.: _________ Cell No.: Fax No.: ________ _
G. HVAC CONTRACTOR INFORMATION (if different than ~riller)
H.
HVAC Contractor's Name: ____________________________ _
NC HVAC Contractor License No.:
Company Name: ________________________________ _
Contact Person_: _______________ EMAIL Address: ___________ _
Address:------------------------------------
City: _________ Zip Code: ____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ------------------
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES __ _ NO ___ _
YES ___ _ NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS -As specified-in 15A NCAC 02C .0224 (d ):
(1)
(2)
The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page2
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface. ·
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(I) Specify the number and type of wells to be used for ·the geothermal heating/cooling system:
____ *EXISTING WELLS ____ PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall qemonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type,.thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited Jot sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107{0(8)
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well s9reen and d~!h below land surface
K. OPERATINGDATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ o F.
L. SITE MAP-As specified in ISA NCAC 02C .0224(b)(4). attach a site~specific map that is scaled or otherwise
accurately indicates distances and orientations . of the specified features from the injection well(s). The site map
shall include the following:
(I) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application_a,rea, and repair area located within 250 feet of the i~jection well(s).
(2) Any other potential ·sources of contamination listed in ISA NCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 3
NOTE: Inmost cases an aerial photograph of the propertr parcel shoving property -lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211te] 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 person(s) listed on the property deed,
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
PLTrnit."
Signature of Property Owner/Applicant -
1 �3 � Car'} ��, `� ii • � -
Print or Type Full Name
J'
Signature of Property Owner/Applicant
L, IN J. 4 W Zf Sell
Print or Type Pull 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]
GeothernlaI Watcr itcturn Well Permit AppIication (Reviaed Jan 2015) Pagc 4

PAT MCCRORY
rove „o,
DONALD R VAN DER VAART
Water Resources
ENVIRONMENTAL QUALITY
February 5, 2016
CERTIFIED MAIL # 7014 1200 0001 3432 9633
RETURN RECEIPT REQUESTED
Robert A. and Linda Risen
3057 Lori Lane
Yadkinville, NC 27705
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0400011
Yadkin County
Dear Mr. and Mrs. Risen:
seereaa"
S. JAY ZIMMERMAN
Areelnr
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 February 1, 2011, and expired on January 31, 2016. 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 Curren U1 , Being, Used for Injection:
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 Infection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http:llportal.nedenr.org/web/wq/aps/gwpro/pennit-applications.
If Your Geothermal Water Return Well is NO LONGE_R_Seinz Used for Inflection:
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, Subchapter 2C, Section
State of North Carolina I Environmental Quality I Water Resources
161 ] Mail service Center ! Raleigh, North Carolina 27699-1611
919 707 9000

Page 2 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 Ownershi p of the Pro perty :
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
163 6 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,
,/;1/·
7·1/
Shristi Shre.stha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Winston-Salem Regional Office -WQROS w/o enclosures
Central Files -Permit No. WI0400011 w/o enclosures
Postal Service,,,
¢[iomestic Mall Only; No Insurance Coverage Providec
Cc
dtil
Postage 5
rn
Certired Fee
M Retum Receipt Fee Postmark
CO (Endorsement Required) Here
C3
Resldcted Deovery Fee
r3 (Endorsement Required)
M
ru ToTalP08
Robert A. and Linda Risen
� sear a
rq �
3057 Lori Lane
r- a"PO&ox Yadkintville, NC 27770
rx
WN=`
4S Form 3800. August 2006
■ Complete Items 1, 2, and 3.
w PrInt your name and address on the reverse
so that we can return the card to you.
w Attach this card to the back of the mailplace,
or an the front If space permits.
t. Afflele A&Irpaaar� r,,,
Robert A. and Linda Risen
3057 Lori Lane
Yadkinvilie, NC 27770
Shristi Shrestha
1� �rletGre
13APM
H. Received by (Printed ►Yams) C. Gate of Dellvery
f r
D. Is delivery address dlffererit from Ibern 17 © yes
If YES, enter delivery address below: C3 No
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Ps Form 3811, Aprli 2015 PSN 7530-02-000-9053
Domestic Return Recalpt

Permit Number WI0400011
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
johri.mccray _ ·
· Coastal SW Rule
Permitted Flow
Fa c ili t v
Facility Name
Risen, Robert Alan -SFR
Location Address
3057 Lori Ln
Yadkinville
Owner
Owner Name
NC 27055
Robert Alan Risen
Dates/Events
Orig Issue
01/11/89
App Received
08/31/10
Re a ulated Activities
Heat Pump Injection
Outfall NULL
Draft Initiated·
Scheduled
'Issuance
Central Files: APS_ SWP_
01/31/.11
Permit Tracking Slip
Status
In review
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Yadkin
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Robert Alan Risen
3057 Lori Ln
Yadkinville NC
Public Notice Issue Effective
°'\'"' Re g u est8d/Rece ived Events
Additional information requested
Additional information received
27055
Expiration
tJ~lll/J
09/09/10
01/28/11
Waterbody Name Stream Index Number Current Class Subbasin
Air -A
MCDENR
North Carolina Department of Environment and Natura
Division of Water Ouality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
February 1, 2011
Robert Risen
3057 Lori Lane
Yodkinville, NC 27055
Re: Issuance of Injection Well Permit
Permit No. WI04010011
Issued to Robert Risen
Yadkin County
Dear Mr. and Ms, Risen:
Resources
Dee Freeman
Secretary
In accordance %pith your application received August 31, 2010, 1 am forwarding Permit No. W10400011 for the operation
of a SA7 geothermal underground injection control (UiC) well heat pump system located at 3057 Lori Lane, Yadkinville,
Yadkin County. This permit shall be effective from the date of issuance until January 31, 2016, 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
December 21, 2010. Laboratory analytical results of both the influent and effluent samples collected on December 21
indicate exceedances M. the maximum contamination level (MCL) or elevated levels for the following parameter(s):
Parameter I, units MCL I Resuits
Conger uRIIL 1 1000 1 1200 (effluent)
The source or cause of these exceedances is unknown. It is recommended before using water from this well for personal
consumption that yoU consult with the Yadkin County Environmental Health Department.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application to renew
the permit 120 months 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 Itxlection Control Program please call me at [phone].
Best Regards.
John McCray
Environmental Specialist
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location 2729 Capits I Boutevard, Raleigh, North Carolina 27604
Phone: 919-7a3221 l FAX 1! 919-715-0558; FAX 2: 919.715.6048 ) Customer Service: 1-677.623-6748
lntemet: www.ngwatercualitv.are
Aa Equal Opponunity I Afinatiye Acvor Employer
ne
n bCarolina
,Naturally

cc: Sherri Knight Regional Office
Central Office File -WI040001 l
Yadkin County Environmental Health Dept.
Attachment( s):
Permit
Sample Results
l'; , ~
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, ~hapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Robert Risen
FOR THE OPERATION OF 1. TYPE 5A7 INJECTI~ WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be 'used for the injection of heat pump ~ffluent. This
injection well is located at 3057 Lori Lane, Yadkinville, Yadkin County, NC 27055, and will be constructed and
operated in accordance with the _application Aug11st 31, 2010, 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 La~s, Rules, and Regulations
pertaining to well construction and use. ·
This permit shall be effective, unless revoked, from the date of its issuance until January 31., 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
Permit issued this the 1st day of February, 201 1.
J-{\ Coleen H. Sullins, Director t Division of Water Quality
By Authority of the· Environmental Management Commission.
Permit #WI0400011 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 (l SA 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 naJure~ 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 Pennittee 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. Furthermore, 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 #WI0400011 UIC/SA7 Page 2 of 5
ver. 03/2010
PART Ill-PERFORMANCE STANDARDS.~
1. The injec~ion 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 Pennittee 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 permit even if compliance
requires a reduction or elimination of ~e 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 Pennittee 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 representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on otrelated 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.C.G.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 #WI0400011 UIC/SA7 Page 3 of S
ver. 03/201·0
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:
(A) Any occurrence atthe 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 rel~vant 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 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 Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
PART VIII-CHANGE OF WELL STATUS
1. The Permihee shall provide written notification .within 15 days of any change of status of an injection
well. Such a change would include the discon~inued 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 #WI0400011 UIC/SA7 Page 4 of 5
ver. 03/2010
(E) ' In the case of gravel-packed wells in which the casing and screens have not been
temoved, 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.
(G) The Perinittee shall submit a Well Abandonment Record (Fonn GW-30) as specified in
15A NCAC 2C .02 l3(h)(l) within 30days ofconipletion of abandonment.
3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted .to:
Permit #WI0400011
Aquifer Protection Section-VIC Pr9gram
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/SA7
ver. 03/2010
Page 5 of 5
l.
MEMORANDUM 31-Jan-ll
To: Robert Risen
From: John McCray [phone]
Re: Groundwater Sampling Results from December 21, 2010
Influent Water Sam(!le Effluent Water Sam (!le
Parameter Standards Results Standards Results
Groundwater Drinking Groundwater Drinking
Colifonn, total 1 per 100ml zero <1 Coliform, total 1 per 100ml zero <1
Colifonn, fecal 1 per 100ml zero <1 Coliform, fecal 1 per 100ml zero <1
pH 6.5-8.5 7.0 -8.5 6.04 pH 6.5-8.5 7.0-8.5 6.39
Hardness no standard no standard 46.1 mg/L Hardness no standard no standard 46.1 mg/L
Chlori<le, Cl 250 mg/L nci standard 2.4 mg/L Chloride, Cl 250 mg/L no standard 2.4 mg/L
Flouride, F 2mg/L 4 mg/L <0.4 mg/L F_loride, F 2mg/L 4mg/L <0.4 mg/L
Sulfate, SO4 250 mg/L no standard <2.0 mg/L Sulfate, SO4 250 mg/L no standard <2.0 mg/L
Dissolved Solids 500mg/L no standard 80 mg/L Dissolved Solids 500 mg/L no standard 87 mg/L
NH3 as N in liquid 1,500 ug/L no standard mg/L NH3 as N in liquid 1,500 ug/L no standard mg/L
Total K,jeldahl N. 0.2mg/L . no standard mg/L Total Kjeldahl N · 0.2 mg/L no standard mg/L
asNinliquid as N in liquid
NO2· + NO3-as N 10 mg/L 10 mg/L 0.56 mg/L NO2· + NO3 " as N 10 mg/L 10 mg/L 0.54 mg/L
Phosphorus total .02 mg/L no standard mg/L Phosphorus total .02 ·mg/L no standard mg/L
as Pin liquid as P in liquid
Nitrate as N in liquid 10 mg/L 10mg/L mg/L Nitrate as Nin liquid 10 mg/L io mg/L mg/L
Nitrite as N in liquid 1 nig/L l mg/L mg/L Nitrite as Nin liquid lmg/-1. 1 mg/L mg/L
.Aluminum, Al SO ug/L no standard <50 ug/L Aluminum, Al SO ug/L no standard <SO ug/L
Arsenic, As ,SO ug/L 10 ug/L <2.0 ug/L Arsenic, As SO ug/L lO ·ug/L <2.0 ug/L
Barium, Ba 2.0 mg/L 2.0mg/L 18 ug/L Barium, Ba 2.0 mg/L 2.0 mg/L 18 ug/L
Cadmium, Cd 1.75 ug/L 5.0 ug/L <1.0 ug/L Cadmium.Cd 1.75 ug/L 5.0 ug/L <1.0 ug/L
Calcium, Ca 0:1 i'Tlg/L no ·standard 11 mg/L Calcium, Ca 0.1 mg/L no standard 11 mg/L
Chromium, Ci: ·10 ug/L 100 mg/L <10.0 ug/L Chromium., Cr 10 ug/L 1.00 mg/L <10.0 ug/L
Copper, Cu ·1 mg/L 1.3 mg/L 0.05 mg/L Copper, Cu lmg/L 1.3 mg/L 1.2 mg/L
Iron, Fe · 300 ug/L no standard <SO ug/L Iron, Fe 300 ug/L no standard <50 ug/L
Lead, Pb 15 ug/L 15 ug/L <10.0 ug/L Lead, Pb 15 ug/L 15 ug/L <10.0 ug/L
Magnesium, Mg 0.1 mg/L no standard 4.6 mg/L Magnesium, Mg 0.1 mg/L no standard 4.6 mg/L
Manganese, Mn SO ug/L no standard <10 ug/L Manganese, Mn SO ug/L no standard <10.0 ug/L
Nickel;Ni 100 ug/L no standard <10.0 ug/L Nickel, Ni 100 ug/L no standard <10.0 ug/L
Potassium., K 0.1 mg/L no standard 1.5 mg/L Potassium, K 0.1 mg/L no standard 1.5 mg/L
Seleniwn, Se 50 ug/L 50 ug/L <5.0 ug/L Selenium, Se SO ug/L SO ug/L <5.0. ug/L
Mccray, John
From: Knight, Sherri
Sent: Friday, January 28, 2011 4:08 PM
To:.
Subject:
Attachments:
Mccray, John ·
wi0400011 Sample results
DOC012811.pdf
Do you want to send the results to Mr. Risen along with the permit or do you want me to send?
Sherri Knight,· PE
NC D~NR Winston~salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
· Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail ~orrespondence to and from this address may be subject to the North Carolina P~blic
Records Law and may be disclosed to third parties.
-~---Original Message-----
F~om:.DENR Wiriston-Salem Office [mailto:[e-mail]]
Sent: Friday, January 28, 2011 4:05 PM
To: Knight, Sherri
Subj~ct~ Scanned from TOSHIBAUST 01/28/2011 16:04
Scanned from TOSHIBA~ST.
Date:·01/28/2011 16:04
Pages:6
Re$olution:200x200 DPI
---------------------------------------
1
Mccray, John
From:
Sent:
To:-
Subject:
Knight, Sherri
Friday, January 28, 2011 3:39 PM
Mccray, John
RE:·WI0400011 5A7 renewal .
I got the samples results back this week on this one. The only result of note is copper. The influent had a Cu of 47 ug/1.
the effluent had a value of 1200 ug/1 which is above 2L (1000). I would note that this sample w·as taken from the outside
faucet which was probably brass. Do we make. an issue of this? I don't know what type of plumbing is in the house.
Sherri Knight, PE
NC DENRWinston-Salem Regional Office
-Division _of Water Quality, Aquifer Protection Section
585 Waughtown Street .-·
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]&;,0 0 7" 13,.
~o ~3 4-' 38"'
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: Mccray, John
Sent: Friday, January 28, 20111:56 PM
To: Knight, Sherri
Subject: FW: WI0400011 SA7 renewal
Ms. Knight,
Debra wanted me to find out the status of this staff report arid was wondering if you had any issues with us proceeding
with the issuance of the renewed permit. Is it ok to proceed with renewal in your opinion?
Best Regards
-John McCray
From: Mccray, John
Sent: Tuesday, January 04, 201110:02 AM
To: Knight, Sherri
Subject: WI0400011 SA7 renewal
Ms. Knight,
I sent a staff report request by courier .on Septe_mber 9, 2010 for the permit WI0400011 SA7 renewal ?tpplication . If you
have any information on the status of this review, please have someone forward it to me.
Best Regards,
John McCray
1
jj
(Ari" 11).
Country.
YACKIN.
RECZIVE13
N.O. Dpp�. of ENR
-' : ' ' . .- - I
Sample V
AS66798
River Basin
r4 ..
PO Number 9
7
Report To
W$898
JAN 2.5 2011
L$
Date R6mlvad:
1712212010
Collector.
Time Rocarwad:
SMATHIS
Sample Matrk
GROUNDW64
Report Can arated:
-U21�11
Loc. Type;
WATEB AUPP
N.
Date Reported.,
0112112011
Emergency Ye4VNo
D
cor, YOSIND
Loc. Deacr., ROMT RISEN
1-ccatibr, ID!
4PD99RJSF-WNF
I ColladDift. 1=1=10
collect-71me: 10:30
Sample Depth
CAS #
LAS
AnalHa Me
Sample temperature at receipt by lab
C
4
L=
C
Method
Reference
Anajy§
Date
12122JI 0
SMATHIS
WET
Ion Chromatography
-TITLE-
rpgk
EPA 300.0
1110111
MO . VERMAN
Chloride
1 2A
rftgfL
EPA 300.0
111C111
MOVERMAN
Fluoride
0.4 U
mgA.
EPA 300,0
1hu'll
MOVERMAK
Sulfatd
2 2.0 U
rrtgtL
EPA 400,0
VIC111
MOVERMAN
Total Oissolved Sofidat in liquid
1z 80
mWL
APHA2640r—IOTH
IM211 G
CGREEN
NUT
N
-NO2+NO3 as In hquid
"'0.02
mgiL as N
LR010-107-04-1-r
12J22110
CGREEN
MET
7446-22-4
Ag by ICPMS
5 SA U
CIDA-
EPA 200.8
EESTAFFORD1
7420-90-5
At by ICP
50 60 U
qjL
EPA 200-7
12128/10
ESTAFFORD1
7440-38-2
As by-ICPMS
2 2.0 U
ugit
SPA, 200.0
Ira (i I
E,97AFFORDI
7440-38-3
Ela by ICP
10 111
uq&
EPA 2110-7
12n9110
ESTAFFORDI
7440-70-2
Ca by IGP
11
ma/L
EPA ZOO,7
12/29110
ESTAFFORDI
744043-9
Cd by ICPMS
1.0-u
u@&
5PA200.4
113111
9STAFFORDI
7440G&
,47-3
CrGr by ICPMS
11
;,10"llp"4:IOU
EPA 200.8
113111
ESTAFFORDI
7440-50-4
Co by ICPMS
-2 47
ug/L
EPA 200A
113111
ESTAFFORD1
7439-89-6
Fe by ICP
so r -60 v
4L
EPA 200.7
12n9f10
E5TAFFORDI
Hardness by CSICUIStOn
1. 46
MWL
SM2340BEPA 200.7
12129110
ESTAFrORDI
7440-09-7
K by ICP
0.1 1,5
mgIL
EPA 20D.7
12=10
ESTAFFORD1
7439-96-4
Mg by)CP
0.1 4.6
MUIL
EPA200.7
12MAC
ESTAFFORD1
7439-96-5
Mn by ICP
I ot.,..t 110 U
"I
aPA 200,7
12128/10
ESTAFFORD1
7440-2"
'Na by lCP k
t
9 5-0
mg1L
EPA 260.7
121213/10
ESTArFORF17
744"2-0
N1 by ICPMS
10 IOU
tig/L
EPA 20D.8
Vw1 I
ESTAFFORD1
70942-1 , PbbyICPMS 10 IOU uglL EPA200.6. I/wi f ESTAFFORD1
7782-49-2 Se by ICPMS 5 1. r 5.0 U Ljg& EPik200-8 113111 ESTAFFORD1
- . '7440-0" 7-n by ICP
—ot 10 - latj
Lrg1L EPA200.7 12J29110- FSTAFFORDI
Laboratory So cfl ow- 1623 Mall 5 orwIrA.Ganj4er, ti a(jgft,,,KC 2n#%-1 323 (019) 13 3-3 60 8
SDI I 41.OL. 1.4 4. "r1pN— of the q.hNft t cedes WIT to�
Page 1. of 1

• - MOM "arvlma
G ROU NDWATEIR FIELD/LAB FORM Department of Environment and Natural Rasources
' DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Lveation code �� ►1� SAMPLETYPE SAMPLE PRIORITY !'1(}+ _
County fQtL 1fd N ; Water Rouilne Lab Number dcQ
El Sail © Emergency
Quad N❑ Serial No. Date Received ! Time•
Lat Long_ EJ Other Redd By: From:Bus, Duller, and Del.,
Cl Chain of custody Other. _ _
Re rt To: ARO, FRO, MRQ, RRO, WaRO, WiRO, - Data Entry Sy: Ck:
Kinston FO, F Trust, Central Off., Other. - Date Reported:
Shipped by: Sus, l d Dal. Other: Purpose:
Collector(s): Date MIZVIPTimew] 30 Baseline, Cam lai C is UST, Pesticide Study, Federal Trust, Other:
-FIE ANALYSES owner is m (d der el
pt{ 4w . Un Spec. Cond.& at 25% Location or Site i MCL,
Ternp.=o °C Odor Description ofsampling.point
Appearance Sampling Method Sample Interval
Field Analysis By: Remarks wmm siapiar."
Pn ! W14, 9if lam '.M 1
k ARC1i2 A-i-C7RY O1UA1 YCPC f �"P a4 P.. }
9CD 310 mgh-
Disa. Sofida 70300 rttglt�
COD Hlgh 340 mg1L
Fluarkle 951 M91L
Coo Low 335 mgA.
WZ
Hardness: Tarel 900 mg1L
CoYform: MF Feral 31616 1100m1
Hardness (noncorb) S02 mgn-
Caiiform: MF Total 31504 1100w
Phenols 32730 ugA
TOC Sao mgA-
Specift Oond. 95 jimhoslam
Turbidity 76 N FL1
Sulfate 945 m9A_
Racidue, Total Suspended 430 mg1L
Sulfide 745 mg&
Oil and Grease mg1L
pH 403 unEts
Alkalinity to pH 4.5 410 mglL
Alkalinity to pH 8A 415 -Pt
Carbonate 445 mg1L
NH3 as N 610 mOAL
Bicarbonate 440 mg1L
TKN as N 625 mg[L
Carbon Rode 405 ma&
NO,+ NO, as N 630 rn 1k
ChWde 940 mg1L
P: Told as P 665 mgfl
M1ral6 (N%as N) 620 mg1L
Chromium: i-iex 1032 ugi
Color. True So CU
I i1r to {N% as N) 615 m91L
Cyanide 720 mg1L
Lab Comments — ane octd'--yrf 6041k S- �q&-A •-
CAW-54 REV.4106 For Oi"vad Analysls-subroil flitemd sample and write •DIS' In black.
Ag-&Iwer46566 u L
Al -Aluminum 46557
As Rrsenic 46551 u L
Ba-Barium 48558 e
Ca-Caldum 46552
Cd-cadmium 46.659 u 1L
Cr-Chromium 46559
Cu-Copper46562 u &
Fe -Iron 46563 u gJL
Hg-MerciJry 7190a u L
K Polassi0m45555 m
ling -Magnesium 46554 m 1L
Mn-Mahganass 46565 u
Na-Sodium 46556
Ni-Niakel u L
Pb-Lead 45664 u
Se -Selenium u
Zn iinc 46567 ug1L
forge nochlarine PaslicidZs
Organophosphorkis Pesticides
Nitro en Paslicides
T Add Herbicides —
PCBs
SemrvolalSa• Organics
TPH-Qlesel Range
VN_edle Or anics OA batlic
TPH-Gasoline Ran e
TPH-BTEX Gasoline Ran a
LAB USE ONLY
Temperature on arrlvW (°C). r

. County: YA616H-
RiverBasli
Rt:CEIVEs7 +
N.C. Dept. of ENR
rtiillAj4a
Report To., Muhl!
'
Co]lectur- KNI[3H
44pp
JAN 5 7011
4D. 4
,2
,
Reglon: W$Ro
W1natpn.8aIam
Sample Metric: l3ROLINgMTER
Reglchw office
- -}yF•y "► " •.aNr„
Loc- Type: WATER SUPPLY
;�;!
Emerpenoy Ye81Np.�Iptl4.;!
'y
(:0C Yeamo
�dj:JO.Y,
t,.oa. arse.: Jl�eeftr �� .
LoCalion [O: 4P099ii1SEHEFF
Coileet QISie' "+ 12127120T0
P-611 Ar;alyi& 1Name�
Ilk
R
LAB
4. -
Sample temperet&a at receipt by lab
;;;.:.k`a ' • ;" ::. 1A.:
Sample 10:.
PO NLimber #
Date Received;
Time RecelvW:
Labwof" LoginlD
Raporl Goinerated:
Date Reported:
A066797
19t10984
1212212010
9s;itf
SMATHiS
1/21111
0112112011
Collet! Time: 10;45 Semple 6apth
Method Analysls • Validated b�
Reference bate
'C T2122110 SMATHIS
WET
fen Chromatography
TI'CLE
mg1L
EPA309.0
1110111
MOVERMAN
Chloride
1 _
„ .2.4
mg1L
EPA300.0
ill 01i1
MOVERMAN
Nuorlde
0;4
` 0AU -
mgfL
EPA SOS. 0
1110M1
MOVERMAN
Sulfate
2
2A U
mWL
EPA•309-0
1110111
MOVERMAN
Total Dissolved Solids in liquid
12
67
mg1L
APHA254OC-ISTH
17woo
CGREEN
NUT:;;;: F ..
NO2+NO3 as N in- liquid 0.02>i: ; 0,54 . mglLalsN Lac10-107-04-1-c 12122/19 CAREEN
MET
7440.22.4
_
Ag by ICPMS
-5
-5,0 U
uglL
EPA200-8
* 118111
E5TAFF0RD1
7429-90-5
Al by lCP
50
sou
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12/29/10
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113111
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9 7440.70-2
i
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1, R# •: 1.0 U
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i 7440-415
i
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18 tJ
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V301
ESTAFFORDi
7440-5078
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2
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120D
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113111
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- Fe by ICP
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}
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12/29/10
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Labdmtm Beetlasraa 1823 M9Tf'Srrvls*:Centar, RAW Igh, NC Z7699.1023 [910) 733.3908
Far. tld�urf 4 �A1Snn of IM Gu'z1Mf�[ e+06K rMr to tdm:nrsrlaFS�d�y.ty�rt�P+ns��nronarnn,j�low !Lanett cones ihtlarrc�Tmie.�r amr,.nnr,aerJ�i y�J,(fj(OR�+�°�'�'�
. Jeage 1 of 1 ;

GROUNDWATER FIELD/LAB FORM
Location code 24:F044 KisenSAMPLE TYPE SAMPLE PRIORITY
County Y.0LiK; Y7 _ i� Water 9 Roviine
Quad NO Setial No. ❑ Soil ❑ Emergency
Lat.— Lang. ❑ Other
❑ Chain of Custody
Re oA To: ARO, FRO, MRO, RRO, WaRO, WIRiO, =
SR Kinston F Trust, Central Off„ Other.
pped by: Bus curl and Del., Other. Purpose:
Coltectar(s}: V%It ti k} Date Time 1Q1!
FIELD ANALYSES Owner
Department of Environment and Natural Resources
DIVISION OF WATER 4UALrY-GROUNDWATER SECTION
1b&D1104
Lab Number
y IeTT Date Received � 119 Time-
Reed By: From:Bus ourier Hand Del.,
other,
Data Entry By: Cic:
Date Reported:
:om Ila ,_LIST_ Pesticide Study, Federal. Trust, Other.
PH 40g 4 Spec. Cond.94 at 25°C Location or Site -29
Temp.iu °C Odor Description of sampftng paint i
Appearance Sampling Method Sample Interval
Field Analysis By: Remarks "' ` _
♦�
I ARC}RATCTRY ANAL T SF.q f"wg Gyre• Or 1amp•. OC-i k
1300 310 mg/L
COD High 340. my1L
COD LOW 335' rrtglL
CaVorm: MF Fecal 31816 1100ml
Caliform: MF 1ata13i594 11170ml
TOC 600 mg/L
Turbldity 76 NTU
Rasidue, Total Suspended $30 mglL
pH 403 urirls
Alkaffnity 10 pH 4,5 410 mg1L
Alkal{nity to pH 8.3 415 m91L
Carbonale 445 mg/L
flic arbonate 44D mg?L
Carbon doldde 405 mg/L
jj<Ch1Cdde
940 mg1L
Chromium: Hex 1032 ugf'l
Odor. True 80 CU el I
Cyanide 720 mgfl-
Lab Comments
Dims. Shcda 70300 rng1L
Ag-Sher 46566 U V&
FluOrida 951 MOIL
PkAlurnfnum 46557 u L
Hardness: Total 900 nti9iL
Hardness {non-carn} 902 mgfL
Aa-Arseric 46557 u L
Ra-Barium 46556 ' uglL
Phenols 32730 ugA
Ca -Calcium 46552 rulL
Specific Cand.96 uMhoskm
Cd-Cadmium 4a559 uy�
Cr-Chromfum 46559 u
Sulfate 945 mg1L
50fide 745 mg/L
Cu-Copper 46562 ARL
-•
Fe4m 46563 ugtL
Oil and Greasa M41-
F; Mercury 71900 uglL
K-Polassturn 45555 my
nesium 46554 m L
genese 46565 _ L
Nti, as N 610 mg7Lum
46556
TKN as N $25 mMael
upk
12i.
NO.2 + NO, as N 630 maiLd
46564 � u A-
P: Total as P 666 rmVLrdurn
u21L
Nitrate [NOS as N] 520 mg1L46567
} u
NIMIs (NO2 as N) 616 mA
GW-64 REV, 4106 For Dissolved :Ana[ygs-suhmit fOlered sample and wdta'DIS' In block,
r&
O anoalvane Fes6ddes
n ano"hos rue Pesticides
11hrogen Pesticides
Acid Herbiddes
PCBs
Semt rolatrle Organics
TM-FDlesO Ran
VOWHe Org gnics VOA bottle
TPH•GaWfne Range
TPH-STEX Gasoline Ranoe
LAB USE ONLY
Temperature on anival (IC):
ti

• o Page 1 of 1
TROOTEST
Laboratory Report
znb Lacalian 'f?' — - �I, Cab CAcatran 'C` LO lwobon 'W
NCM1111 Cart,#: 067 NCIDW Cart.#: 37731 ? NCIWW Cert.#: I W NC111W Cert,* 17111 NC111W CM,* I]75 NCIDIV Cart,#: 37111
6701 Conference Dr. Raleigh, NC 27607 6300 Remade €}r, Suite C2, Clemmons, NO 27012 6624 Gordon Rd, Unit G, Wilmington, NO 28411
Ph: [phone] Fax:. [phone] Ph: [phone] Fax [phone] Ph: [phone] Fax: (910) 343-a688
Project No.:
Project ID: RISEN RESIDENCE; SHERRI KNIGHT
-- Prepared for --
MELISSA ROSEBROCK
DWO
585 WAUGHTOWN ST.
WINSTON-SALEM, NC 27107
Report Date: 12129/2010
Date Received: 12121/2010
Work Order #: 1012-01 04
Cuat. Code: 800993
oust. P.O.#:
No, Sample ID Data Sampled Time Sampled Matrix Sample Type Condition
001 WELL INFLUENT 12/21/2010 10:30 GW Grab 4 +1- 2 deg C
Test Performed Method Results Lab Loc tW8' Tune Qualifier
Feral CollformsOF SM 9272D 0 CFU/100mL C 12121110 12:30
No. Sample ID Date Sampled Time Sampled Matrix Sample Type Condition
002 WELL EFFLUENT 12121/2010 10,45 GW Grub 4 +1- 2 deg C
Test Performed
Method
Results
Leh Loc "aaadTrma Qualifier
Fecal Collform8lMF
SM 9222D
=1 CFU 100mL
C 12/21110 12:30
RECEiVEO
kc, Dept, of FNR
i
1 !"Stow-salem
L» __ Raglonal Offlee
Reviewed by:
for Tritest, Inc.

Jan 07 11 12:2la Tritest Clemroon3 3367662314
T R TE ST Chain of Custody
't71 Conlerence Drive. Raleigh. NC 276C7
4, (919) 834.49M. lax: [phone]
NCWW Cer1#67, NGDW Ca"37731
._t 6674 Gordon Redo, Unit G. Witminglon, NC 28411
ph:[phone].tax: (910)343-968$
NCWW Cert475, NCDW Coo#37721
J 5300 Ramada Dr.. Suite C2, Clemmons, NC 27012
ph- (SM) 766.7846. iax: [phone]
NCWW Carta#703. NCOW CarW37733
Report Pies ultsTo:
Company: 4 c flw
Address: StS
Attr1: + -
Phone:-33 L. -771! ZI 4
Fax:— B� U Zi 1 - 4(131
Sampled by signature):
Tritest W.a. #4 — L s r
Bill To: ;�
f C)LA) �} Project Reference: ti I it 4; Le,
� le 3 IN16� r t_SeryCt� .rr l�
e. j_5L 7)5 (C99 Project Number:
Purchase Order #;
S?dtandard Report Delivery
❑ Rush Report Delivery 1wisomharge)
" Hush projects are aublect to prior approval by
the laboralory
Requested Due Date:
Sample Descrlption QM-P k.a
6tart pate
End Date
Matrix
oiv�su�
Analyses Requested
Treed
StprtTire
End Time
WC1 �
6W
r4er4A C01;6v
a� 4
ae
z v
�Y
�fca.� C'vi fir t
'111. lshedby(5ignalure)
ii eve by., ure)
J'- =
Date
Tirna
Relinquished by {signature!
IWeoeived try (stgnature)
hate
Time
Relinquished by (5ignalure)
Recaivad by (signature)
Date
Time
Receipt Conditions (Lan Only)
M 412°C - Temp: IC
Res. Chlorine:
CIMEisenl 0 pmaenl 'D Na
Acid p,eserv. 127
qkJFs l r] Wa
Odin prasam 3�727
Cl Yes i- No

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: September 9. 2010
To: ❑
Landon Davidson, ARO APS
❑
Art Barnhardt, FRO-APS
❑
Andrew Pitner, MRO-APS
❑
Jay Zimmerman, RRO-APS
❑ David May, WaRO-APS
❑ Charlie Stehman, wao-APS
® Sherri Knight, WSRO-AP5
From: John McCrav , Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E Mail: i ohn.mccrava+ncdenr. zov
A. Permit Number. W10400011
B. Owner: Robert and Linda Risen
C. Faeillm/Operation: Robert and Linda Risen 5A7 SFR
❑ Proposed ® Existing ❑ Facility ❑ Operation
D. Application:
I. Permit Type: ❑
Animal
❑ Surface Irrigation. ❑ Reti<se
❑ H-R Infiltration
❑
Recycle
❑ I/E Lagoon ❑ OW Remediatiou (ND)
®
UIC - (5A7) open loop geothermal
For Residuals:
❑
Land App. ❑ D&M
❑ Surface Disposal
❑
503 ❑ 503 Exempt
❑ Animal
2, Project Type: ❑
New ❑
Major Mod. ❑ Minor Mod. ® Renewal
❑ Renewal w/ Mod,
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 take the following actions:
® Return a Completed Form APSARR.
❑ Attach Wall Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO*.
* Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS representatives in Order to prepare a complete Attachment 13 for
certification. Refer to the RPP SOP for additional detail.
When you receive this request farm, 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 02/06 Page 1 of 1

HCDEHR
North Carolina Department of Environment and
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
September 7.2010
Robert Risen
3057 Lori Lane
Yadkinviile, NC 27055
Subject: Acknowledgement of Application No. WI0400011
Risen, Roberti Alan - SFR
Injection Heating/Coaling Water Return Well (5A7)
Yadkin
Dear Mr. Risen:
Natural Resources
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 31, 2010. This application package has been assigned the number listed above and will be reviewed by
John McCray.
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 John McCray at 919-715-6169. or via e-mail at [e-mail]. If the reviewer is
unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To review our
new organizational chart, go to htto://Uo.enr.stateene.us/documents/dwo orggharjIg
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROTECT,
Srncrrtl�'.
to— I
far Debra J. Watts
Supervisor
cc: Winston-Salem Regional office; Aquifer Protection Section
Permit Application File WI0400011
AQUIFER PROTECTION SECTION
1636 Mail Servioe Center, Raleigh, North Carolina 27693-1636
Lo ation: 2728 Capital Bouievard, Raleigh, North Carolina 27664
Phone: [phone] � FAX 1: 919.715.0588; FAX 2, 919-715-60481 Customer Service: 1.877-623-6748
Intemet www.nmateraualrtv.aru
An Equal Opponumity I Afirmallva Action Employer
One
North Carolina
Nawrally

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A GEOTHERMAL HEAT PUMP SYSTEM
TYPE 5A7 "OPEN LOOP" INJECTION WELLS
(check one) New Permit Application _Renewal _y Modification
DATE: 20_1
PERMIT NO.: WI_ U t bg o j i _ (leave blank if NEW permit application)
A- PROPERTY OWNER/PERMIT APPLICANT
Name of each owner listed on property deed. For a business or government agency, state name of entity and
name of person delegated authority to sign application on behalf of the business/agency;
(1) Mailing Address: �a 0 Loa 1 i-,i #j e
City: � c_ J 1< : jo J, i 1pstate: t-k Zip Code: 17 o S 5, County.. `L Z- �k v
Home/Office Tele No.: 334-1, G /- (v 7 Z- Cell No.:
Fax Na. 16 _6_-3 2 1 _ to ti 45 Email Address: 4j, SIP., :k ear- ,�__ ,� - e f
(2) Physical Address of Well Site (if different than above):
City.
Home/Office Tele No.:
State: Zip Code:
Email Address:
B. PROPERTY OV*WERSHIP DOCUMENTATION
Cell No..
County:
Provide legal documentation of property ownership, such as a contract: deed, article of incorporation, etc. and
a PLAT map showing the property. This information may be obtained from county Register of Deeds or GIS
website.
C. AUTHORIZED AGENT, IF ANY
If the property owner/permit applicant wants to authorize someone else to sign the permit on their behalf, then
attach a signed letter from the property owner/permit applicant specifying and authorizing their agent (well
driller, heat pump contractor, or other type of contractor/agent) to sign this application on their behalf.
Company Name:
Contact Person: Email Address:
Address:
City: State: Zip Code: County:.
Office Tele No.: Fax No. Cell No.:
Website Address of Company, if any:
RECEIVED � DERR 1 [)rN
ilayFR'DR0TF0T1% C'FC710t4
Type 5A7Injection Well Permit Application (Rev, August 2009) AUG 31 2U16 Page i of

D. WELL DRILLER INFORMATION
Company Name: "'( adJ(: ~ l>Je.ll
Well Drilling Contractor's Name: -------~:,__-_____________________ _
NC Contractor Certification No.: ----=V~t'-~"----_____ C=-o=n=t=ac=t=--=P:._;e=r =so=n=: ___________ _
Company Website-'--: ---'W---'---'W-'--W-'-'-'-. ______________ E_m_ai_l_A_d_dr_e_s_s _: ________ _
Address: I '1 ~, \io~p~r' u;\\a. (W?.
City: µ c. ,-e4 ,'J ; I t e State: ,->-, Zip Code: ______ County: Ye-ot ~; r'
Office Tele No.: j:l <.-tf(,1--Lf 'i lf::O Fax No.: Cell No.: _______ _
E. HEAT PUMP CONTRACTOR INFORMATION (if different than Driller)
Company Name: U~ )l.. Contact Person:
Company Website: WWW. Email Address:
Address:-----------------------------------
City: _________ State: __ Zip Code: ______ County:
Office Tele No.: Fax No. Cell No. ________ _
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
"k-~ vJ :\\ ~<2 vs.e.,f ~r Q__ ~:-it--:\:? a..; r-!,.. e<"\k--pu tA p
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES ✓ NO ___ _
(2) Personal consumption? YES _,,.,,,--NO ___ _
H. WELL CONSTRUCTION DATA
(1)
PROPOSED Well(s) to be constructed fonise 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 knowledge. Attach a copy of the Well Construction Record (Form
GW-1) if available.
Well Construction Date: 4J '1 '1 Number ofborings: __ I __
Depth of each boring (feet):_ ....... uc.J.1'\J~t, _____ _
(2) Well casing. Is the well(s) cased?
(3)
(a) YES ✓ If yes, then provide the casing information below.
Type: Galvanized steel __ Black steel __ Plastic __ Other (specify) __ L) __ rJ_)l._, __
Casing thickness: __ diameter (inches): ___ depth: from ___ to ___ feet (relative to land surface)
Casing extends above ground ____ inches
(b) NO
Grout material surrounding well casing: v,.>\C .
(a) Grout type: Cement__ Bentonite* Other (specify) ______ _
"'By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Depth of.grout around well casing (relative to land surface): from ___ to ___ feet
Type 5A7 Injection Well Permit Application (Rev. August 2009) Page 2 of 4
I.
J.
(4)
vr>t.
Well Screen or Open Borehole depth (relative to land surface): from ____ to ___ feet
(5) N.C. · State Regulations (Title lSA NCAC 2C .0200) require the Pennittee to make prov1S1ons for
monitoring wellhead 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 the well construction record (Form GW-1). If Form GW-1 is not available, provide
the following data:
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 OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHER\VISE UNAVAILABLE.
OPERATING DATA u ~[. t
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi) ..
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
(
INJECTION-RELATEDEQUIPMENT~:s· .~l ,s ?.J 'O·a.~J. olol., 7. ,J..:,,;l }'\,~ . . -1-k ~ s ; r-J l-4.,.. ~.:· 0 eJ
Attach a schematic diagram or cross-section of the well construction that shows the total depth, length of casing,
extent of grout, stickup, location of influent/effluent sampling ports, etc. . If this is a modification, show the
engineering layout or proposed modification of the injection equipment and exterior piping/tub1ng associated with
the injection operation. The manufacturer's brochure may provide supplementary information if needed.
K. LOCATION OF WELL(S)
(1) Attach a site map (can be drawn) showing: houses and other structures, property lines, surface water bodies,
potential sources of groundwater contamination, and. the orientation of and distances between the proposed
_ injection well(s) and any other 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) Attach a scaled topographic map of the area extending 1/4 mile from the property boundary that indicates
the facility's location, a north arrow, and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing proper'ly lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the proper'ly can be sltarched by owner
name or address. The location of the wells in relation to proper'ly boundaries, houses, septic tanks, other wells, etc.
can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or elevation data.
Type 5A7-Injection Well Permit Application (Rev. August 2009) Page 3 of 4
L. CERTIFICATION (to be signed as required below or by that person's authorized agent)
NCAC 15A 2C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship; by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official,
4. for all others: by the well owner.
If an authorized agent is signing on behalf of the applicant, then submit a letter signed by the
applicant that names and authorizes their agent as specified in Part C of this permit application.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted in
this document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible for
obtaining said information, I believe that the information is true, accurate and complete. I am aware that there are significant
penalties, including the possibility of fines and imprisonment, for submitting false information. I agree to construct, operate,
maintain, repair, and if applicable, abandon the injection well and all related appurtenances in accordance with the approved
specifications and conditions of the Pen -nit."
24-,-J 11 Lex--el_
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit TWO signed copies of the completed application package and all attachments to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636 RECENED J DENR I BWQ
AQ1iIF" p PgrITFi`. sm' RFOON
Telephone [phone] AUG 312010
"Type SA7 Injection Well Permit Application (Rev. August 2009) Page 4 of4

ID
W
W-.O'Z
1;
3 as7 tsar J,AJF-
�" C vjjlfe . NL

Yadkin County
t NORTH LWA ■ t
r
Bomb,.
r L 7
iL
i
f �
r r . + it + .•�1y I �•. �a r �
t[j4 ft
Map created by Yadkin County & Northwest Piedmont Yadkin County Assumes no legal responsibility for the data on
COG. this map. Please check with original source to verify data.

62E2
0703
783
r)
SrA19 OF Rani Fs1-,.
L(L+s3 1,%
rN w
lA-03217)
ki
141 IL— 4A
F �€ PUP
Nxcias Tax : Recording Time, Book s Page
................................................... .... ........
ibis instrument was prepared by Shore, Hudspeth and'Bardinq
Attorneys
WORTH CARCLINA
YADKIN 0004M WARRANTY DEED
This deed made and entered into this the a—Ij day of
1988, by and between CLYDE DINXINS and wife, MYRTLE
IQ. IbiKIbIS, of Yadkinville, Yadkin County, North Carolina,
hereinafter called Grantors,
and
RGBERT ALAN RISEN and wife, LINDA B. RISEN, of Yadkin County,
Borth Carolina, whose mailing address is P. 0. Sox 313
Yadkinville, NC 27055, hereinafter called Grantees.
WITHESSETR:
Grantors, for and in consideration of the sum of ten dollars
and other good and valuable considerations in hand paid by
Grantees, the receipt of which is hereby acknowledged, do hereby
sell and convey unto Grantees, their heirs and assigns, promises
described as follGw[
IA-03217) Forbush Township, Yadkin County, North Carolina;
BEING Lot No. 7 of Plat D, Section 5 of Forbush Forest as
shown on plot of survey of Forbush Forest Plat p, Section 5,
which is duly recorded in Plat Boole 6, page 2214 Yadkin
County Registry. Reference to said plat is made for a more
complete
SUBJECT, to Restrictive Cov description.
rs pas recm-ded in took 182, at page 322.
For reference purposes for source of title see: deeds
recorded in Hook 106, page 672 and Book 106, page 6BS,
Yadkin County Registry.
To have and to hold the above described plemiaes, with all
the appurtenances therounto belonging, or in any wise
appertaining, unto Grantees, their heirs and assigns forever.
Grantors covenant that they are seised of said premise6 in
fee, and have the right to convey the same in tee simpler that
said promises are free from encumbrances except as stated above,
if aryl and that they will warrant and defend the said title to
the same Against the lawkul claims of all persons whomsoever.
Ise witness whereof, GcaAtora have hereuato ast their hand
and seals, the day and year first above written.
v a_- a/ (SEAL)
iold
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State of North Carolina RECvvED IDFNR / UWQ
Department of Environment and Natural Resources AQUIFFR'PPnrrr nAiv RFCT14S
Division of Water Quality AUG 25 2010
STATUS OF INJECTION WELL SYSTEM
Permit Number: UU T D 'r 00,�I It
Permittee Name: 1 -3 b e -
Address: 3 J r7 Last j,) , C �-r.-d r i l J u ]
Please check the selection which most closely describes the current status of your injection well system:
i) Weil(s) still used for injection activities, or may be in the future.
2) L Well(s) not used for injection but is/are used for water supply or other purpnses.
3) ❑ injection discontinued and: a) ❑ Well(s) temporarily abandoned
b) ❑ Well(s) permanently abandoned
c) ❑ Well(s) not abandoned
4) CI Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, iirrigation, 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 ofhow the weld
was sealed and the type of material used to fill the well if permanenl4i, 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 ❑ No
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."
iL�,F-�,o.s,..i-
Signature Date
Revised 5/05 GWIUIC-68

Jr-A
CDE R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Robert Risen
3057 Lori Lane
Yadkinville, NC 27055
Coleen H. Sullins
Director
August 2, 2010
Subject: Notice of Expiration (NOE)
SA 7 Geothermal Injection Well
Permit No. WI0400011
Yadkin County
Dear Mr. Risen:
Dee F reernan
Secretary
The UndergroU:11d 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 January 6, 2006, and expires
on January 31, 2011, 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 SA 7 Well(s) if the 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 Mall 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: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity I Affirmative Action Employer
NOnehC ·1• · ort aro 1na
/Vaturallll
If the injection well system 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 .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/aps/gpu/forms.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call me at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydro geologist
Attachments
cc: Winston-Salem Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0400011 w/o enclosures
2
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
February 15, 2006
Robert Risen
3057 Lori Lane
Yadkinville, NC 27055
Ref: Receipt of Disinfection Information
Injection Permit # WI0400011
Dear Mr. Risen:
On February 10, 2006 the Underground Injection Control Program received documentation
regarding the disinfection of your injection well system. This information satisfies the
requirement in Part VIII of injection permit # W10400011 issued to you on January 6, 2006.
Thank you for submitting this required information. Please contact me at 919-715-6166 if you
have any questions about injection wells or the Underground injection Control Program of North
Carolina.
Best Regards,
Thomas Slusser
Hydrogeological Technician II
Underground Injection Control Program
cc: Sherri Knight, Winston-Salem Regional Office
CO-UIC Files
Aquifer Protection Section 1636 Mall Service Center Raleigh, NC 27699-1636
Internet: http:1lh2o.enr.state.nc.us 2728 Capital Boulevard Raleigh, NC 27604
An Equal OppoftnitylAfRrmallve Action Employer— 50% Recycfedll0% Post Consumer Paper
Telephone: [phone]
Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Dear Sirs:
RECEIVED/ DENR / DWQ
AQUIFER PROTECTION SECTION
FEB 1 O 2006
On February 1, 2006, Yadkin Well Company disinfected my well and heat pump system. The
following is the information you requested I provide:
a) 68% Super Shock-It calcium hypochlorite with a ~um of 64% available chlorine.
b) 6" well casing.
c) 350 gallons of water in the well.
d) Estimate of 55 gallons of water in heat pump and household plumbing.
e) One pound of calciwn hypchlorite used.
f) Solution remained in well and heat pump for 24 homs.
Sincerely,
Robert A. Risen
Michael F. Easley, Governor
William G. Ross Jr., See retary
Nortli Carolina Department of En v iron men t a n d Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
January 9, 2006
Robert Risen
3057 Lori Lane
Yadkinville, NC 27055
Ref: Issuance of Injection Permit # W10400011
Dear Mr. Risen:
On November 29, 2005 the Underground li-rjection Control (UIC) Program conducted an inspection and
sampling event as part of the injection well permit renewal process. Enclosed for your records is a copy of the
water quality results of your water supply well (influent) and injection well (effluent). Test results exceed the
groundwater quality standards for total coliforn-t in the effluent water sample. It is the well owner's
responsibility to take corrective action if sample results exceed groundwater quality standards, as stated in the
North Carolina Administrative Code, Title 15A, Subchapter 2C, Section 0.0206.
hi accordance with your application dated June 16, 2005 the UIC Program is renewing and reissuing permit #
W10400011, which shall be effective unless revolted until January 31, 2011. You must disinfect your well
and heat pump system as a condition of your perrnit. as stated in Part VIII._and submit notification of
disinfection within 60 days of receiving-, vour pen -nit. A pamphlet on well disinfection is enclosed for
reference. Please note that you must reapply for renewal at least 3 months before the expiration date in order
to maintain uninterrupted legal operation of your injection well.
Please contact me at 919-715-6166 or Evan Kane at 919-715-6182 if you have any questions regarding this
letter, disinfection procedures, or the UIC Program.
Best Regards,
Thomas Slusser
Hydrogeological Technician 11
UIC Program
Enclosures
cc: CO-UIC Files
Sherri Knight, Winston-Salem Regional Office
None hCarolina
,Nrrtrrrrtll11
Aqui ter Protection S.SediOYI 1636 Mail Service Center Raleigh, NC 27699-1636 Phone [phone] Customer Service
Internet: littp:/lh2o.enr.state.nc.us 2728 Capital Boulevard Raleigh, NC 27604 Fax [phone]
Fax [phone]
A Equal Opportunity/Affirmative Action Employer— 50°% Recycled/10% Post Cons umerPape i

MEMORANDUM 27 December 2005
To: Robert Risen
From: Thomas Slusser [phone]
Re: Groundwater Sampling Results from 29 November 2005
Influent Water Sam ple Effluent Water Sam ple
Colifo1111, total <1/lO0mL Coliform, total 4/l00mL
Co lifonn, fecal <1/l00mL Coliform,· fecal <1/l00mL
pH 11S pH ns
Chloride, Cl 6mg/L Chloride, Cl <5 mg/L
Dissolved Solids 86 mg/L Dissolved Solids 86 mg/L
NO2· + NO3-: as N 0.49 mg/L NO2· + NO3~ as N 0.55 mg/L
Aluminum, Al <50 ug/L Aluminum, Al <50 ug/L
Calcium, Ca 9.5 mg/L Calcium, Ca 9.6 mg/L
Cadmium, Cd ns Cadmium, Cd ns
Chromium; Cr <25 ug/L Chromium, Cr <25 ug/L
Copper, Cu 110 ug/L Copper, Cu 68 \lg/L
Iron, Fe <50 ug/L Iron, Fe <50 ug/L
Mercury, Hg ns Mercury,Hg 11S
Potassium, K 1.4 mg/L Potassium, K 1.4 mg/L
Magnesium, Mg 4.6 mg/L Magnesium, Mg 4.6 mg/L
Manganese,Mn <10 ug/L Manganese, Mn <10 ug/L
Sodium, Na 6.1 mg/L Sodium, Na 6.0 mg/L
Nickel, Ni <10 ug/L Nickel, Ni <10 ug/L
Lead, Pb <10 ug/L Lead, Pb <10 ug/L
Selenium, Se <5 ug/L Selenium, Se <5 ug/L
Zinc, ·zn <10 ug/L Zinc, Zn <10 ug/L
State Groundwater Quality Standa_rds:
Classifications and Water Quality Standards Applicable To The Groundwaters of North Carolina
(North Carolina Administrative Code Title 15A: 02L.200)
Coliforn1, total <1/100 ml
Coliform, fecal <1/100 ml
Chloride <250 mg/L
Total Dissolved Solids <500 ing/L
NO2· + NO3-as N <11 mg/L
Cadmium <1.75 ug/L
Chromium, Cr <50 ug/L
Copper, Cu <1,000 ug/L
Iron,Fe <300 ug/L
Manganese,Mn <50ug/L
Nickel, Ni <100 ug/L
Lead, Pb <15 ug/L
Zinc, Zn <1,050 ug/L
Arsenic, As <50 ·ug/L
Mercury, Hg <1.05 ug/L
Barium, Ba <2,000 ug/L
mg/L = milligrams per liter= parts per million
ug/L = micrograms per liter =. parts per billion
1,000 ug/L = 1 ing/L
ns = not sampled
( 1 gram/ l ,000grams )/ l ,000grams
(lgram/l,000,000gran1s)/l,000grams
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT 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
ROBERT RISEN
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title I5A 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 3057 Lori Lane in Yadkinvi Ile, Yadkin County, North Carolina, and
will be operated in accordance with the application submitted June 23, 2005 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 of its issuance until January 31, 2006
and shall be subject to the specified conditions and limitations set forth in Parts I through X hereof.
Permit issued this the day of , 2006.
�A cc- a �� t11- Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. W10400011 PAGE 1 OF 4 T
GWILTIC-5 ver. 7/05

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.
3. The issuance of this permit shall not relieve the Permittee of the responsibility ofcomplying
with any and all statutes, rules, regulati_ons, or ordinances which may be imposed by other
local, state, and federal agencies which 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 norm.al 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 thqse actions that m_ay 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 permit eve1,1. if
compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsi~ility 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 mainta~ned and operated at all times.
2. The Permitte.e mustnotify 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.
3. At least forty-eight (48) hours prior to the initiation of the ~peration of the facility for
injection, the Permittee must notify by telephone the Aquifer.Protection Section-Underground
Injection Control (UIC), Central Office staff, telephone number 919-715-6166. Notification is
required so that Division staff can inspect or otherwise review the injection facility and
determine if it is irt compliance with permit conditions.
Permit No. WI0400011
GW/UIC-5 ver. 7/05
PAGE20FIS'
PART 1111-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 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.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 336-771-4600,
any of the following:
(A) Any occurrence at the injection facility which 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 Pennittee. 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 i?ennittee.
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 VI -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an
extension.
Permit No. WI0400011
GW/UIC-5 ver. 7/05
PAGE30F IS
PART VII -CHANGE.OF WELL STATUS
1. The Perrnittee 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 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 ISA 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 inj~ction 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.
(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 conditio~s of the permit. ·
(G) The Permittee shall submit a Well Abandonment Reco·rd (f onn GW-30) as ·
specified in ISA NCAC 2C .oi13(h)(l) within 30 days of completion.of
abandonment.
3. The written documentation required in Part.VII (1) and(~) (G) shall be submitted to:
Permit No. WI0400011
GW/UIC-5
. Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
ver. 7/05
PAGE40FOG
PART VIII-OPERATION AND USE SPECIAL CONDITIONS
1. The pennitee shall disinfect the well and heat pump system in accordance with the North
Carolina Administrative Code Ti~le 15A, Subchapter 2C, Section .0111 within 60 days of
receiving this permit.
2. The permitee shall submit within 15 days of completion a detailed notification of all activities
taken to conduct this disinfection process. If chlorination is used this notification shall include,
but not be limited to, the following: .
a. Sourc·e of high test calcium hypochlorite (such as the trade names HTH, Chlor-tabs) and
the product's amount of available chlorine
b. Thickness of water column in the well
c. Volume of water in the well
d. Estimate of water amount in heat pump system and household plumbing
e. AmolJ.llt of calcium hypochlorite product used ·
f. Amount of time the chlorine solution remained in the well and heat pump system prior to
flushing
Other methods of disinfection that are at least as -effective as chlorination may be used upon
prior approval of the Director. If such a procedure was used, describe in detail the materials,
methods, and procedures used.
3~ The written documentation required in Part vm shall be submitted to:
Permit No. WI0400011
GW/UIC-5
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
ver. 7/05
PAGE50Ff5
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
January 6, 2006
MEMORANDUM
TO: Debra Watts
THROUGH: Evan Kane ~ /)1p
FROM:
RE:
Thomas Slusser-,S
Injection Permit Issuance
I recommend that Injection Permit# WI0400011 be issued to Robert Risen ofYadkinville in Yadkin
County, NC for the operation of a Type 5A 7 injection well system. The inspection was performed on
November 29, 2005 and water quality results were received on December '27, 2005. Laboratory test
results indicate that the only water quality violation is for total coliform, which was detected at 4
colonies per 100 mL; the 2L standard is 1/100 mL. Part Vill of the attached permit instructs the
permittee to disinfect the injection well system and submit documentation of the procedures used for
disinfection. Peter Pozzo and Sherri Knight of the Winston-Salem Regional Office do not have any
reservations about issuing this permit. Please let me know if you have any questions regarding this
submittal.
DIVISION OF WATER
AQUIFER PROTECTION SECTION
January 6, 2006
MEMORANDUM
TO: Geothermal Injection Well Permit Files
-,7j~ ' FROM: ~homas Slusser, Underground Injection Control Program
RE: Chlorine Disinfection of Type SA7 Geothermal Heat Pump Systems
The issuance of injedion permits to construct and operate Type SA7 ''open loop" injection wells
associated with geothermal heating and cooling systems is accompanied by the sampling of
influent and effluent water samples. Sometimes test results indicate the presence of coliform
bacteria, which must be removed via disinfection of the well and ·plumbing associated with the
heat pump system.
The Underground Injection Control Program has recommendedthat disinfection procedures using
chlorine should follow the guidance given for water supply wells found in 15A NCAC 2C .0111.
There had been some concern about the effects of a 100 mg/L chlorine solution on the .heat
exchanger coil, which is made of approximately 10% nickel and 90% copper. Chlo'rine is a
corrosive element and copper is highly susceptible to chlorine corrosion. Was the UIC Program
inadvertently recommending a disinfection procedure that would be harmful to the heat
exchanger?
Some information from the pool industry suggested that copper-nickel heat excha~gers, which
are the industry standard, could be damaged by solutions with'.:chlorihe in excess of 2-3 times the
normal safe swimming level, which is reportedly 1-10 mg/L. Several heat pump manufacturers
were _ contacted in order to obtain guidance for disinfection · of heat pump _ systems.
Representatives from two manufacturers, Florida Heat Pump and from Water Furnace, said that
they do not consider a solution of 100-mg/L chlorine to be detrimental to the heat exchanger coil
as long as it is used for episodic, short-term disinfection and not long-term circulation.
Based on this information the Underground Injection Control Program will continue
recommending 100 mg/L solution of chlorine for well and heat pump disinfection unless additional
information is received that suggests that this procedure should not be followed.
COUNTY: YADKIN
QUAD NO:
DIVISION OF WATER QUALITY
Chemistry Laboratory Report/ Ground Water Quality
SAMPLE PRIORITY
(!]ROUTINE □EMERGENCY
REPORT TO _W_S_R_O ________ Regional Office □ CHAIN OF CUSTODY
~ SAMPLE TYPE
I I
COLLECTOR($) :_P_P_o_zzo ______ _
DA TE: 11/29/200S
TIME: 9 :55
EFFLUENT
I I
PURPOSE: UIC INSPECTION Owner: ROBERT RISEN
Location or Site:
Description of sampling point ____________________ _
Sampling Method:
Remarks:
LABORATORY ANALYSIS
BOD310 mg/L X Diss. Solids 70300 86 mg/L Ag-Silver 46566
CODHigh340 mg/L Fluoride 951 mg/L X Al-Aluminum 46557
CODLow335 mg/L X Hardness: total 900 mg/L As-Arsenic 46551
X Coliform: MF Fecal 31616 1 82 /lO0ml Hardness: (non-carb) 902 mg/L Ba-Barium 46558
X Coliform: MF Total 31504 4 /l0Oml Phenols 32730 ug/L X Ca-Calcium 46552
TOC mg/I Specific Cond. 95 umhos/cm2 Cd-Cadmium 46559
Turbidity NTU Sulfate mg/L X Cr-Chromium 46560
Residue., Suspended 530 mg/L Sulfide 745 mg/L X Cu-Copper 1042
Total Suspended solids mg/L MBAS mg/L X Fe-Iron 1045
Oil and Grease mg/L Hg-Mercury 71900
pH units Silica mg/L X K-Potassium 46555
Alkalinity to pH 4.5 mg/L Boron X Mg-Magnesium 927
Alkalinity to pH 8.3 mg/L Formaldehyde mg/L X Mn-Manganese 1055
Carbonate mg/L NH3 asN610 mg/L X Na-Sodium 929
Bicarbonate mg/L TKNasN625 mg/L X Ni-Nickel
Carbon dioxide mg/L X NO2 +N03 as n 630 0.55 mg/L X Pb-Lead46564
X Chloride SU mg/L P: Total as P 665 mg/L Se-Selenium
Chromium: Hex 1032 ug/L P04 mg/L X Zn-Zinc 46567
Color: True 80 c.u. Nitrate (NO3 as N) 620 mg/L
Cyanide720 mg/L Nitrite (NO2 as N) 615 mg/L
COMMENTS:
Lab Number : 5G2827
Date Received : 11/29/200S
Time Received : 1:05 PM
R~eivedBy : HMW
Released By : JSW
Date reported : 12/19/200S
ug/L Organochlorine Pesticides
SOU ug/L Organophosphorus Pesticides
ug/L Nitrogen Pesticides
ug(L
9.6 mg/L Acid Herbicides
ug/L
25U ug/L Semi volatiles
68 ug/L TPH-Diesel Range
SOU ug/L
ug/L Volatile Organics (VOA bottle)
1.4 mg/L
4.6 mg/L TPH-Gasoline Range
t
10U ug/L TPH-BTEX Gasoline Range
6.0 mg/L
10U ug/L
10U ug/L
5.0U ug/L
10U ug/L
5G2827.x1s
COUNTY: YADKIN
QUADNO:
DIVISION OF WATER QUALITY
Chemistry Laborat_ory Report/ Ground Water Quality
SAMPLE PRIORITY
(!]ROUTINE □EMERGENCY
REPORT TO _W_S_R_O ________ Regional Office □ CHAIN OF CUSTODY
~ SAMPLE TYPE
I I
COLLECTOR(S) :_P_P_O_zzo ______ _
DA TE: 11/29/200S
TIME: 10:05
INFLUENT
I I
PURPOSE: UIC INSPECTION Owner: ROBERT RISEN
Location or Site:
Description of sampling point ____________________ _
Sampling Method:
Remarks:
LABORATORY ANALYSIS
BOD310 mg/L X Diss. Solids 70300 86 mg/L Ag-Silver 46566
CODHigh340 mg/L Fluoride 951 mg/L X Al-Aluminum 46557
CODLow335 mg/L X Hardness: total 900 mg/L As-Arsenic 46551
X Coliform: MF Fecal 31616 1 B2 1100ml Hardness: (non-carb) 902 mg/L Ba-Barium 46558
X Coliform: MF Total 31504 1 B2 /lOOml Phenols 32730 ug/L X Ca-Calcium 46552
TOC mg/I Specific Cond. 95 umhos/cm2 Cd-Cadmium 46559
Turbidity NTU Sulfate mg/L X Cr-Chromium 46560
Residue., Suspended 530 mg/L Sulfide 745 mg/L X Cu-Copper 1042
Total Suspended solids mg/L MBAS mg/L X Fe-Iron 1045
Oil and Grease mg/L Hg-Mercury 71900
pH units SiUca mg/L X K-Potassium 46555
Alkalinity to pH 4.5 mg/L Boron X Mg-Magnesium 927
Alkalinity to pH 8.3 mg/L Formaldehyde mg/L X Mn-Manganese 1055
Carbonate mg/L NH3 asN610 mg/L X Na-Sodium 929
Bicarbonate mg/L TKNasN625 mg/L X Ni-Nickel
Carbon dioxide mg/L X NO2 +NO3 as n 630 0.49 mg/L X Pb-Lead 46564
X Chloride 6.0 mg/L P: Total as P 665 mg/L Se-Selenium
Chromium: Hex 1032 ug/L P04 mg/L X Zn-Zinc 46567
Color: Troe 80 c.u. Nitrate (NO3 as N) 620 mg/L
Cyanide720 mg/L Nitrite (NO2 as N) 615 mg/L
COMMENTS:
LabNumber : 5G2828
Date Received : 11/29/200S
Time Received : 1:05PM
Received By : HMW
Released By : JSW
Date reported : 12/19/200S
ug/L Organochlorine Pesticides
SOU ug/L Organophosphorus Pesticides
ug/L Nitrogen Pesticides
ug/L
9.5 mg/L Acid Herbicides
ug/L
2SU ug/L Semivolatiles
110 ug/L TPH-Diesel Range
SOU ug/L
ug/L Volatile Organics (VOA bottle)
1.4 mg/L
4.6 mg/L TPH-Gasoline Range
10U ug/L TPH-BTEX Gasoline Range
6.1 mg/L
10U ug/L
10U ug/L
5.0U ug/L
10U ug/L
5G2828.xls
· AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 11/29/2005 , County: Yadkin
To: A quifer Protection Central Office
Central Office Reviewer: Thomas Slusser
Regional Login No: __ _
Permittee: Robert Alan Risen
Project Name: Risen Re.sidence
Application No.: WI0400011
L GENERAL INFORMATION
1. This application is (check all that apply): D New X Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation X Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? X Yes or D No.
a. Date of site visit: 11/29/2005
b. Person contacted and contact information: Robert Alan Risen
c. Site visit conducted by: Peter Pozzo
d. Inspection Report Attached: D Yes or X No.
RECEIVED/ DENR/ DWQ
AQUIFER PROTECTION SECTION
DEC 12 2005
2. Is the following information entered into the BIMS record for this application correct?
X Yes· or D No. Ifno, please complete the following or indicate that it is correct on the c~;~t appii~~ti~n.
For Treatment Facilities:
a. Location:
b. Driving Directions: __
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Dis posal and Io iection Sites: ·
(If multiple sites either indicate which sites the information app lies to , co py and paste a new section into the
document for each site , or attach additional pa ges for each site )
a. Location(s): 3057 Lori Lane , Yadkinville , NC 27055 ·
b. Driving Directions: 42 L to Speerbrid ge rt.from ram p, It on Old 421 . 2.1 miles It on Boulder. Lt on Lori
c. USGS Quadrangle Map name and number: East Bend 36080-B5-TF-024
d. Latitude: 36° 07' 12.394" Longitude: 80° 34' 38.265
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed fo r renewals or minor
modifications. skip to next section )
Descri ption OfWaste(S) And Facilities
I. Please attach completed rating sheet. Facility Classification: __ _
2. Are the new treatment facilities adequate for the type of waste and disposal system?
FORM: Risen inspection report
AQUIFER PROTECTION REGIONAL STAFF REPORT
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. Ifno, please explain: __
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes D No ON/A. Ifno, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No0
NI A. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D NI A. If no, please explain: __
7. 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: __
8. 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: ___ _
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.)· adequate? D Yes D No D NIA. 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: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D NIA If yes, attach list of sites
with restrictions (Certification B?)
Ill 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 for the facilities? 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: Risen inspection report 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 management plan for the facility adequate and/or acceptable to the Division?
D Yes or D No. If no, please explain: __
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. lfno, please explain: ____ _
11. Were monitoring wells properly constructed and located? D Yes or D No D N/A. Ifno, 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: 0 · No compliance issues; D Notice(s) of violation within the last permit cycle; D
Current enforcement action(s) D Currently 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: Risen inspection report 3
AQUIFER PROTECTION REGIONAL STAFF REPORT
IY. INJECTIdN 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:
X Heating/cooling water return flow (5A7)
❑ Closed -loop heat pump system (5QN 4/5QW)
❑ In situ remediation (5I)
❑ Closed -loop groundwater remediation effluent injection (5LP'Non-Discharge")
❑ Other (Specify:
I Does system use same well for water source and injection? ❑ Yes _ X�N ,.�� � 4 �� t•'�
3. Are there any potential pollution sources that may affect injecti X Yeses
What is/are the pollution source(s)? Supply well. What is the distance of the injection well(s) from the
pollution sourcesV 20-30 ft.
4. What is the minimum distance of proposed injection wells from the property boundary? ft.
5. Quality of drainage at site: X Good ❑ Adequate ❑ Poor
6. Flooding potential of site: X Low ❑ Moderate ❑ 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? ❑ Yes ❑ No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program.-
S. Does the map presented represent the actual site (property lines, wells, surface drainage)? ❑ Yes or X No. If
no or nomap, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow. (The map in the September 13, 1999 App is very good)
Iniection Well Permit Renewal And Modification Onl►•;
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 X No. If yes, explain:
2. For closed -loop beat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? ❑ Yes ❑ 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? ❑ Yes X No. If yes, explain:
A. Drilling contractor: Name:
FORM: Risen inspection report 4

AQUIFER PROTECTION REGIONAL STAFF REPORT
Address:
Certification number: __
5. Complete and attach Well Construction Data Sheet.
FORM: Risen inspection report 5
,AQUIFER PROTECTION REGIONAL STAFF REPORT
V. EVALUATIONAND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes X 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
None
S. 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
None
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
None
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information; X
Issue; ❑ Deny. If deny, please state reasons:
S, Signature of report preparer(s):
Signature of APS regional supervisor: '•
Date: a V 0 5
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: Risen inspection report 6

'<10
�' AOUIFER PROTECTION SECTION �-�``�
APPLICATION REVIEW REQUEST FORM _j: r'+ `� ;��4�i
Date: June 29. 2005
❑ Landon Davidson, ARO-APS
❑ Art Barnhardt, FRO-APS
❑ Andrew Pitner. MRO-APS
❑ ]ay Zimmerman, RRO-APS
F m: Thomas Slusser. . Groundwater Protection Unit
Telephone: [phone] TS Fitc. 19l.91 715-0588
E-Marl: thomas.slusser(@ncmaiI.net
A� Permit Number: WI040001 1 AQUIF>~F P90TECTION SE+:+7IN
JUL 1 8 2005
B. Owner: ROBERT RISEN
❑ David May. Wand-jabCt��I�.
❑ Charlie Stehman. WiRO-iPS
® Sherri Knight. WSRO-APS
C. Facility/Operation: RESIDENCE
❑ Proposed Existing ❑Facility [ Operation
D. Aollication:
1. Permit Type: ❑ Animal ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ UE Lagoon ❑ GW Remedianon (ND)
Z UIC - (5A7) open loop geothermal
For Residuals: ❑ Land App. ❑ D&t'vl ❑ Surface Disposal
❑ 503 ❑ 5,03 Exempt ❑ Animal
? Project Type: ❑ New ❑ Major Mod, ❑ Minor Mod. ® Renewai ❑ Renewal w/ Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site Visit.
Attached. you wi11 find ail information submitted in support of the above -referenced application for your
review, comment. and/or action. Within 30 calendar days, please take the following actions:
® Return a Completed Form APSSRR.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment S Certification from the RO*.
* Remember that you will be responsible for coordinating site visits. reviews. as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachnicnt B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request Dorm, 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: -V} -� 1� Lc� _ _ - Date: '] U,
FORM: APSARR 09/04
Page IofI

a�a� � a rE,
.pc
17 F
> —i
D �c
June 29, 2005
Robert Alan Risen
3057 Lori Lane
YadlcinvilIe, NC 27055
Dear Mr. Risen:
Michael F. Easley. Governor
WiIIiam G. Ross Jr., $ecretary
Noah Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
Your renewal application for a permit to use a well for. the injection of geothermal heat pump
effluent has been received and is under review. A nieni.ber of the Aquifer Protection Section's
Winston-Salem Regional Office staff will be contacting you to arrange an inspection of the
injection well and collect water samples as part of the review.
Please contact me at 919-715-6166 or Evan Kane at 919-715-6182 if you have any questions
regarding the Underground Injection Control Program or injection well rules and regulations.
Best Regards,
Thomas Slusser
Hydrogeological Tecl nician 11
UIG Program
Cc: Sherri Knight, Winston-Salem Regional Office
CO-UIG Files
N91YhCaro
,Jvafim
Aquifer Pivection Section 1636 Mail service Center Raleigh, NC 27G99-I636 Phone [phone]i
Customer service
Intcnieu h1rpWh2o.enr.sta1e.nc.tts 2728 Capital Boulevard Raleigh, NC 27664 Fax [phone] l -
877-G23-G748
Fax (919)715-"
An Equal OpportunitylAffirmative Actim Employer — 50% Recycledll0% Post Consumer Paper

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY, AQUIFER PROTECTION SECTION
STATUS OF INJECTION WELL SYSTEM,
Permit Number: tJ JaLt t)oo it
Permittee Name:
Address: :7 S7 wry{ +-�ra� a� x ��; llk W-
Please check the selection which most closely describes the current status of your injection well.
In addition, please provide the requested information.
1 } Well is still used for injection activities.
�} _ Well is not used for injection but is used for water supply or other purposes. 4���
3) _ Injection discontinued and: a} Weil temporarily abandoned ft,
b} Well permanently abandoned
c} Well not abandoned
4} _ Injection well never constructed
ff you checked (2), describe the well use (potable water supply, irrigation, etc), including pumping rate and other relevant
information.
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 if permanently abandoned):
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 Date
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."
jR,l r�� a IR V'.e�_ 0 1 b . s�
Signature Date
ver. 7l04 GMLJ I G58

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RENEWAL APPLICATION FOR PERMIT To USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM
Type 5A7-and 5QM Wells
In accordance with the provisions of NCAC "Title 15A: 02C.0200
complete application and mail to address on the hack page.
CEI
TO: DIRECTOR, NORTH CARQLINA DIVISION OF WATER QUALITY AQ'EPValDip
A. PERMIT APPLICANT
Permit Number; 1►1 131000 (WI04##ff##, listed at the hottorn of each page of your permit)
Name: Robed-F xjG.r, _ oil; j1W
Address: ,0 S] L81CL1 A_Aoj_
City: q*'j]r, '+j; )IL& State: &A—� Zip code: 27
County: Y+'A jL r� Telephone:3 gL 1— 62 �--
B. PROPERTY OWNER (if different from applicant)
Name:
Address:
City: State: Zip code:
County: Telephone:
C. STATUS OF APPLICANT
Private: 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 conunercial facility
ven 7104 GWMC-57 HPR Page ] of 3

E. INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
,-JI A
F. WELL USE ls(are) the injection well(s) also used as the supply well(s) for either of the following?
(1) The injection operation? YES ✓ NO __
(2) Your personal consumption? YES 7 NO __
G. CONSTRUCTION DATA
H.
( 1) Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection permit.
,J1A
(2) NC. State Regulations (1 SA 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 __
(b)· on the effluent line? YES~ NO __
CURRENT OPERATING DATA
(1) Injection rate: Average ( daily) JtJ1'-gallons per minute (gpm)
(2) Injection volume: Average (daily) v rJI~ gallons per day (gpd)
(3) Injection pressure: Average (daily) .J~~ potmds per square inch (psi)
(4) Injection temperature: Annual Average J .,J "-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.
/J)R.
ver. 7/04 GW/UIC-57 HPR Page 2 of 3
M. CERTIFICATION
"l 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. 1 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 die Permit.-
�20A� 2 �
(Signature of Well Owner or Authorized Agent)
Ij autharized agent is acting on beha f of the well owner,
please supply a fetter signed by the owner
awhoruing 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 outer 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 .020f1)
(Signature of Property Owner if Different From Applicant)
Please return the completed Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
per. 7104 GWMC-57 HPR Page 3 of 3

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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of 1=rivironment and Natural Resources
Alan W. Klimek, P.E. Directer
Division of Water Quality
June 27, 2005
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7002 2410 0003 0273 6885
Robert Risen
3057 Lori Lane
Yadkinville, NC 27055
Ref: Notice of Regulatory Requirement
North Carolina Well Construction Standards
Applicable to Injection Wells - Subchapter 2C
UIC Permit No. W1040001I issued to Robert A. Risen
Dear Mr. Risen:
The Underground Injection Control CUIC) Program of the Division of Water Quality is responsible for the
regulation of injection well construction and operation activities within the state of North Carolina. The
purpose of this letter is to inform you, as the current property owner. of your responsibilities pertaining to
infection well rules.
The permit referenced above for the construction and operation of an injection well will expire on August 31,
2005. This office attempted to bring your injection well into compliance by sending you a notification of
expiration, a blank application for permit renewal, and an injection well status form in May of 2005. To date the
UIC Program has not received either the renewal application or the status form.
In order to comply with the regulatory requirements listed under North Carolina Administrative Code (NCAC)
Title 15A, Subchapter 2C, Section .0211, you must take one of the following actions:
1. Submit the fornl RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INFECTION WITH A HEAT
PuNe SYSTEM (form GWIUIC-57 HPR) if the injection well on your property is still active;
2. Submit the form STATUS of INJECTION WELL SYSTEM (form GWIUIC-68) if the injection well is
inactive or has been temporarily or permanently abandoned,
If the well 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 .0214. If the injection well is to
be permanently abandoned, a well abandonment record must be submitted to our office to certify that the
abandonment was properly conducted.
No Carolina
,A atiirally
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699.1636 Phone [phone] Customer Service
Internet: http:1lh2c.enr.state.nc.us 2728 Capital Boulevard Raleigh, NC 27604 Fax [phone] I-877-623-6748
Fax [phone]
An Equal Oppartun4lAffirrmative AcBen Employer— 50%Recydedl10% Post Consumer Paper

Mr. Robert Risen
June 27, 2005
Page 2 of2
Again, we have provided you with the appropriate materials to update your UIC permit. You must respond
within_ 15 days of the receipt of this notice, or a Notice of Violation will be issued tofu, which carries the
possibility for an assessment of fines or cessation of operation of the injection well system. Please contact
Thomas Slusser at [phone] or myself at [phone] if you have any questions about this
correspondence, the UIC Program, or the enclosed forms.
Sincerely,
Evan 0. Kane, L.G.
UIC Program Manager
cc: DWQ - Winston-Salem Regional Office
CO-LJIC Files
Enclosures

Michael F, EaSiey, Governor
William G. Ross Jr., secretary
North Carolina Department of EnVirOnment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
May 23, 2005
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7002 2410 0003 0273 7028
Mr. Robert Alan Risen
3057 Lori Lane
Yadkinville, NC 2705.5
Ref: Notification of Expiration
North Carolina Well Construction Standards
Applicable to Injection Wells - Subchapter 2C
UIC Permit No. W10400011 Issued to Robert A. Risen
Dear Mr. Risen:
The Underground Injection Control (UIC) Program of the Division of Water Quality 1s responsible for the
regulation of injection well construction and operation activities within the state of North Carolina. Our records
show that the operating permit referenced above for the injection well on your property will expire on August
31, 2005. In addition, our records do not indicate that the well has been abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative Code (NCAC)
Title 15A, Subchapter 2C, Section .0211, you must take one of the following actions:
1 . Submit the form RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A HEAT
PUMP SYSTEM (form GWIUIC-57 HPR) if the injection well on your property is still active;
2. Submit the form STATUS OF INJECTION WELL SYSTEM (form GWIUIC-68) if the injection well is
inactive or has been temporarily or permanently abandoned.
If the well 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 .0214. If the injection well is to
he permanently abandoned, a well abandonment record must be submitted to our office to certify that the
abandonment was properly conducted. The appropriate form(s) should be forwarded to us within 30 days of the
receipt of this notice, to allow adequate time for well water sampling and analysis.
I���`1tCaroli a
Natufally
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Phone [phone] Customer Service
Internet: http://h2o.enr.state.nc.us 2728 Capital Boulevard Raleigh, NC 27604 Fax [phone]
Fax [phone]

Mr. Robert Alan Risen
May 23, 2005
Page 2 of2
Please submit the appropriate form within 30 days of the date of this letter. If you have any questions regarding
the permit and injection well rules or would like assistance completing these forms please contact Thomas
Slusser at [phone] or myself at (919) 715 .-6179.
cc: WSRO-UIC Files
CO-UIC Files
Enclosures
Sincerely,
fon<_~
Jesse Wiseman
Processing Assistant
UIC Program
■ Complete iterr 2, and 3. Also complete
Item 4 if RestriL.-J Delivery 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 on the front if space permits.
1. Article Addressed to:
RCBERT RISEN
3057 LDRI LANE
YADKINVILLE NC 27055
A. Received by (P j Prt�ylearly} B. pate of Delivery
U Vl {Le, r'+- I ►►j
C, Signature
x "0 Agent
❑ Addressee
.. is d livery address c!Mf NIt fro ' em 1? ❑Yes
If YES, eater delivery address below.' ❑ No
3, Service Type
❑ Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail 0 C.O.D.
4. Restricted Delivery? (Extra Fee) © Yes
2. Article Number (Copy from 70112 2 410 0003 0274 ❑ 318
Ps Farm 3811, July 1999 Domestic Return Receipt 102595.00-M•0952
■ Complete items 1, 2, and 3. Also complete
Item 4 if Restricted Delivery is desired.
N Print your name and address on the reverse
so that we can return the card to you.
M Attach this card to the back of tha mailpie ce,
or on the front if space permits.
1. Article Addressed to -
NIT. Robert Alan Risen
3057 Lori Lane
Yadkinville, NC 27055
A.
❑ Agent
B. Received by (FWated Name) C. Date of Delivery
IRo-'e'�' Z : 3;-" 1 S/2s1 e S-
D. Is delWry address different from item t? E3 Yes
If YES, enter delivery address below: ❑ No
3. Service Type
YX Certified MaA ❑ Express Mall
❑ Registered 0 Ratum Receipt for Merchandise
❑ insured Me ❑ C.O.D.
4. Restricted Dellvery? (Extra Fee) ❑ Yes
2 7002 2410 0003 0273 7028
PS Form 3811, August 2001 Domesllc Retum Receipt 2ACPal-03-x-905

DIVISION OF WATER QUALITY
GROUNDWATER _SECTION
July 31, 2000
MEMORANDUM
To: Sherri Knight, E.I.T.
Groundwater Section
Winston-Salem Regional Office
From: Mark Pritz! . fl.(! [e-mail]
Hydr~geological Technician II
UICGroup
Groundwater Section
Raleigh Central Office
Re: Issuance of injection well permit type 5A7 Geothermal Heat Pump:
Permit Number Wl0400011 to operate a well for the injection of ground-source
heat pump effluent has been issued to Mr. Robert Alan Risen, in Yadkinville, North Carolina.
This is a renewal permit and the Underground Injection Control Group appreciates the Winston-
Salem Regional Office's assistance with the injection well inspection & sampling tasks. Please
retain the application and.paper work for the WSRO-UIC files. If you have any questions
regarding this permit or the.DIC program, please contact me at [phone] or Amy Axon at
[phone].
cc: CO-UIC Files
Enclosures
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
.: :::-.:::/;\:'.
JAM~$ B~ 1-'.i~JlfT JR/:·
July 31, 2000
. . . ·• . ~:
GOVERNOR : . ..
. ~.... ) ~
· sr1.:i:-'HoLMAN
.$,~C(tatTARY
Mr. Robert Alan Risen
. . 3057 Lori Lane
··.::?t yadkinville, NC 27055
Dear Mr. Risen:
In·accordance with your renewal application dated September 13, 1999, we are
· forwarding Permit No. WI0400011 for the operation of a geothermal heat pump
injection well at 3057 Lori Lane, Yadkinville, NC, in Yadkin County. A copy of the
'laboratory test results of water samples collected on October 28, 1999 and June 29,
2000 ate also enclosed.
This permit shall be effective from the date of issuance until August 31, 2005, 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 submit an
applkation to renew the permit three months pri~r to its expiration date on August
31, 2005.
If you have any questions regarding your permit please contact me at [phone]
or Amy Axon at [phone]. ·
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
CO-UIC Files
WSRO-UIC Files .,
Enclosures
GROUNDWATER SECTION
1636 MAIL SERVICE CENTER, RALEIGH, NC 27699-1636 -2728 CAPITAL, BLVD,, RALEIGW, NC 27604
PHONE 919-733•3221 FAX 91 g.7 I S-0588
AN E9UAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER • 50% RECYCLED/1 0o/o POST•CONSUMER PAPER
I
MEMORANDUM July 26, 2000
To: Mr. Robert Alan Risen
From: Mark Pritzl tel. [phone]
Re: Groundwater Sampling Results from October 28, 1999
Infl uent Wat er Samp le Effl uent Water S amp le
Coliform, total <1/l00ml Coliform, total <1/l00ml
Coliform, fecal <1/lO0ml Coliform, fecal <1/l00ml
pH 6.5 pH 6.6
Chloride 2mg/L Chloride <1 mg/L
Total Dissolved Solids 87 mg/L Total Dissolved Solids 57 mg/L
Total Hardness 42 mg/L Total Hardness 38 mg/L
NO2-+ NO3-as N <0.01 mg/L NO2-+ NO3-as N <0.01 mg/L
TKN 4.7 mg/L TKN 0.5 mg/L
NH3 0.01 mg/L NH3 0.01 mg/L
Aluminum, Al 84 ug/L Aluminum, Al <50 mg/L
Calcium, Ca 9.2 ug/L Calcium, Ca 9.0 ug/L
Silver, Ag <5.0 ug/L Silver, Ag <5.0 ug/L
Chromium, Cr <25 ug/L Chromium, Cr <25 ug/L
Copper, Cu 200 ug/L Copper, Cu 160 ug/L
Iron, Fe <50 ug/L Iron, Fe <50 ug/L
Potassium, K 1.2 mg/L Potassium, K 1.1 mg/L
Magnesium, Mg 4.1 mg/L Magnesium, Mg 4.0 mg/L
Manganese,Mn <10 ug/L Manganese, Mn <10 ug/L
Sodium, Na 5.0 mg/L Sodium, Na 4.7 mg/L
Nickel, Ni <10 ug/L Nickel, Ni 120 ug/L
Lead, Pb <10 ug/L Lead,Pb <10 ug/L
Zinc, Zn 22 ug/L Zinc, Zn 51 ug/L
July 26, 2000
MEMORANDUM
To; Mr. Robert Alan Risen
From: Mark Pritzi tel. [phone]
Re: Groundwater Sample Results of Nickel from October 28, 1999 compared with
Groundwater Sample Results of Nickel taken June 29, 2000.
Effluent ater
Sample # 1 10/2811999
Effluent Water Sa
ale # 2 6/29/200Il
Nickel, Ni
120 ug/L
Nickel, Ni
<10 ug/L
cc CO-UIC Ines
WSRO-UIC files

State Groundwater Quality Standards:
Classifications and Water Quality Standards Applicable To The Groundwater's of North Carolina
(North Carolina Administrative Code Title ISA: 02L.200)
Coliform, total <1/100 ml
Coliform, fecal <1/100 ml
Chloride <250 mg/L
Total Dissolved Solids <500 mg/L
NO£+ NO3-as N <lOmg/L
Cadium < 5.0 ug/L
Chromium, Cr <50 ug/L
Copper, Cu <1,000 ug/L
Iron, Fe <300 ug/L
Manganese,Mn <50 ug/L
Nickel, Ni <100 ug/L
Lead, Pb <15 ug/L
Zinc, Zn <2,100 ug/L
1 Liter of water= 1,000 grams at 20° C
mg/L = milligrams per liter= parts per million
ug/L.= micrograms per liter= parts per-billion
1,000 ug/L = 1 mg/L
ns = not sampled
( 1 gram/1,000grams )/1,000grams
( 1 gram/1,000,000grams )/ 1,000grams
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7f Chapter 87; Article 21, Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Robert A. Risen
FOR THE OPERATION OF ·AN INJECTION WELL for the purpose of injecting heat pump
effluent. This well is located at 3057 Lori Lane, Yadkinville, North Carolina, in Yadkin County,
and will be operated in accordance with the application dated September 13, 1999, 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, No. WI0400011, is a renewal and renumbering of Permit No. 98-0080-WO-0001,
which was issued on June 17, 1994, and shall be effective, unless revoked, from the date of its
issuance until August 31, 2005, and shall be subject to the conditions and limitations specified in
Parts I through VIII herein. This permit replaces and shall also supersede Permit No. 98-0080-WO-
OOO l.
Permit issued this the ~ cg#, day of---=3~~-+-. -----~ ___ ,_2_0_00_. ___ _
1 -,L g_<>L, ;:;t->
Ted L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0400011 PAGE 1 OF 5
PART I-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 (ISA 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 is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
3. 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 ..
4. 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. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
PARTII-PERFORMANCESTANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwaters which will render them unsatisfactory for normal use.
In the event that the facility fails to perform-satisfactorily, inclucling 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 (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.
Permit No. WI0400011 PAGE20F S
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.
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 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.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activit_ies (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 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 Groundwater Section Staff, Winston-Salem Regional
Office, telephone number [phone]~ any of the following:
(A) Any occurrence at the injection facility which 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.
Permit No. WI0400011 PAGE 3 OF 5
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 facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
PART VI -PERMIT RENEW AL
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 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, 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 fo 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 No. WI0400011 PAGE4 OF 5
(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
move~ent of fluids into or between underground sources of drinking water and in
accordance with the terms and conditions of the permit.
(G) The Pennittee shall submit a Well Abandonment Record (Form GW-30) as
specified in 15A NCAC 2C .0213(h)( 1) within 30 days of completion of
abandonment.
3. The written documentation required in Part VII (1) and (2) (G) shall be submitted to~
DENR -Division of Water Quality
Groundwater Section ·-UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
PART VIII -SPECIAL CONDITIONS
NONE
Permit No. WI040001 l PAGES OF 5
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LABORATORY ANALYSIS
DIVISION OF WATER QUALITY
CMrwirlry La6a�alw-r Nepail lGru.rd ►VF{erQrdil�
$AMPLE PR IO R P Y
E]RourlNE ❑BORGENCY
RegVorul G1fke 0 CFiAlt<7 S]F CUSiUI]Y
0 S"iPLE I WYE
Own , fl9HSRlr A I&rlrA
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Sampllag Ivlerhod:
Rmwrls
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WD Hi s, i40 L
C W L*w 335 L
C31flfevn: MF Few 3%16 RD-1
cGkl*=... m FTe W 31501 wmml .
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Ab.Y.der w [14 c 'L
Alkm!nft fo ]I5° m L
Grborwlc M L
1!i[al8anatc n� L
CAxbmdiioxWe wWL
Cbkwgde n L
Ch�ki� W- 1A32 uryL
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11-idm -*r Wal9M
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Tiardnealc naP 992
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Phena4371J0
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Suuww 745
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MH3=N610
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Al•Aluurfeum 465y7
A& Aownk M561
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ft-Valium 4658
Ca�klum 46552 -
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Cid-Cadinm 4656q
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Date reparled: 77xWIM
Peaivria! Office

DWATER FIELD/LAB FORM -0 V TOD1
Q y ti - -
d tin Serfet Nv. ater auUrte
mot. Long. Shc Ell=megency
ri,�� ❑ other
le Ta. ADO, FRO, MRO, ARO, WaRO, W€RO, "in of Cuslod;
11
VSRO lnston _ . Trust, Central Off., Other. u+ � —
r .hipped by: Bus, Caurie , Hand Del., other
r" Purpos
:ollector(s): �— Date �� �� Time 3 " ISaselIr
It
o =4ELDANALYSES Owner �� e►
-H� fo, Q Spec. Cond. al 260 C Location or site 3as 7
"' "emp.Iu oC Odor 1)7� r-e Description of sam ling pc
n kppearance Sampling Methaf_ 1p; j
-field Analysis By: Remarks v
ABORATOAY ANALYSES
North Carolina
Department of Environment and Nalurel Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
t_ab Number
Date Rece 1p�
Other:
Data Entry By:
Cate Reported:
/4fe -C : I{111Gz PM,F.rr.
_Time ` I--Lk7=1�— .
Bu ,, C uue Hand DEC,
Ck:
Pestk:lde Study, Federal Trost, Dih :�
nterval
BOD ma rn
l
_ SWOF 45W Uw
Organochlorine Pesliddes
COD High 340 nw
Flourld�e 951 m
AI - Alunvinum 4M67
Organophosphorus PegoMs
COD Low 335
As- Ar5eNC 46561
Nit+ Pesticides.
Colllorm: MF Fecal mie 1100m1
Hardness nDn-Cara gat
Ba- Swlurn 4655E .
Add Herbicides
Co46orm: W Total31504 1100MI
Ca - Calcium 46652
13CW9
TOC 680 rn
d - Cadrniurn 465199 u
r`
r-
T'urbidlty 76 NTI.I
Stillate 045
V
Qr - Chromium 4658o u
-0
Residue., Suspended 53o mgR
Sultkie 745
Cu - copper 46562 u AW
rn
-
Fe - Iran 46663 UgA.
Serni+Adagte Organics
ra
oil end Grams rn l
Hq-morwryllaoo u l
TPH - Diesel Range
PH 403 w11t
Potassium 465W nxjlI
Alkalinhy to pH 41.5 410 MgA
- MagneSIUM 46654 rmA
AlkallnHy to pH 8.3 415 mgfl
Irmrl
- M0293nB38 46M UQA
Carbonate 445 m
NFI as N 610 m
a - Sodium 45556 rncjl
Volatile Organles (VOA Willa)
CD
Blcarbonate 440
v
TPH =Gaaaltrte Ran a
Carbon doxlde 405
NO + NO as N 630
Pb - Lead 46W4 U -
TPH - BTEX oasollm Range
Co.Chloride
so nrgrl
P: Total as P ew rr1
s -Selenium u 4
z
Chromium: Hex 1032 u
Zn - Zirtc 465BT v
Color. T rue 80 Gil
Lit
a
Cyanide 720 Z
Lab Cnmrnents:
� i J For Dissolved Analyst's - sutlmil iiltemd sample and write "DIS" In 6.

RI-" CElVEO / OENR
DWQ mfou:mwATER SECTION
COUNlY : YADKIN OOJ IO ~ IQ: 32
QUADNO:
REPORT TO _c_o __________ RegionalOffice
COLLECTOR(S) : _P_R_IT_Z_L _______ _
DA TE: JJ1m!l1222
TIME:
PURPOSE: Owtll'r:
Location or Site:
DIVISION OJ? WATER QUALITY
Chemistry Laboratory Report/ Ground Wafer Qualify
SAMPLE PRIORITY
(R]ROUTINE
□ CHAIN OF CUSTODY
~ SAMPLE 1YPE
MR RISEN
□EMERGENCY
G
Description of sampling point _______________________ _
Sampling Method:
Remarks:
LABORATORY ANALYSIS
B0D310 m g/L X Diss. Solids 70300 87 m r,/L X A J?-Silver 46566
COOHigh340 m g/L Fluoride 951 m g/L X Al-Aluminum 46557
COOLow335 m R/L X Hardness: total 900 42 * m g/L As-Arsenic 46551
X Coliform: MF Fecal 31616 <1 iiooml Ha rdness: (.non-carb) 902 m r,/L Ba-Barium 46558
X Coliform: MF Total 31504 <l /lOOml Phenols 32730 u g/i. X Ca-Calcium 46552
TOC m g/I S pecific Cond. 95 umhos/cm2 Cd-Cadium 46559
Turbitity NTU Sulfate m g/L X Cr-Chromium 46560
Residue., Suspended 530 m g/L Sulfide745 m g/L X Cu-Coooer 1042
Total Suspended solids m g/L MBAS m g/L X Fe-Iron 1045
Oil and Grease m g/L H r.-Mercu ry 71900
X IP H 6.5 units Silica m 2/L X K-Potassium 46555
Allcalinilv to p H 4.5 m g/L Boron X Mr,-Magnesium 927
Alblinilv to pH 8.3 m J?/L Formalrlehvde m r./L X Mn-Manr.ancse 1055
Carbonate m g/L X NH3asN610 0.01 m r,/L X Na-Sodium 929
Bicarbonate m g /L X TKNasN625 4.7 m g/L X Ni-Nickel
Carbon dioxide m g /L X N02 +N03 as n 630 <0.01 m g/L X Pb-Lead 46564
X C],Joride 2 m g/L P:Totalas P665 m F./L Se-Selenium
Chromium: Hex 1032 u r./L P04 m g/L X Zn Zinc 46567
Color: True 80 c.u.
C yanide720 m g/L
COM.MENTS: *IIARDNESS SAMPLE RECEIVED UNPRESERVED; PRESERVE WITH SULFURIC ACID TO pll<2
<5.0 u p,./L
84 u g/L
u g/L
UR/L
9.2 m r./L
u rt./L
<25 u g/L
200 u g/L
<50 u g/L
u r./L
1.2 m p,./L
4.1 m g/L
<10 u p,./L
5.0 m r./L
<10 u g/L
<10 u p,./L
u g /L
22 u g /L
LabNumber :
Dale Received :
Time Received :
Rel.--eivedBy
9Gl969
I0/28/1999
1:25PM
HMW
Released By : OS
Date reported: 12/30/1999
Orv.anochlorine Pesticides
Organophosphorus Pesticide~
Nitrogen Pesticides
Acid Herbicides
Semivolaliles
TPH-Diesel Range
Volatile Orp,anics (VOA bolllE")
TPH-Gasoline Range
'f PH-BTEX Gasoline Range
9 01969 .'ICls
GROUNDWATER FIELD/LAB FORM
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
( /".,.· //" '·--. </--\) :ounty_---+-y '~ci_._1 _.__..lb._.., ........ -"-l \,__________ SAMPLE TYPE SAMPLE PRIORITY
Quad No _____ Serial No. ~·-I~~N~F_·___ fl9 Water ral Routine § D Soil D Emergency
Lat Long.--------D Other
~~~::::::::::~ 1~f R T FRO D Chain of Custody eport o: ARO, , MAO, ARO, WaRO, WiRO, . -···--;:,----. ,;._ __
WSRO, Kinston FO, Fed. Trnst,~~_t_r~_,9_!90ther: ________ _
Lab Number /( -~' / {. / (=·-_--:_• _____________ _
Date Rece\Vrd I/ <·) . -;J.....~=6 Time , ' :_
Rec'd by: / /////I / From: Bus, Courier~~~~ .~~l-~
Other: __ " _____________ _
Data Entry By: ______ Ck: ______ _
Date Reported: _____________ _
Shipped by: Bus, Courier, Hand Del., Other·~ __________ _ · -V -1 l .., oc Purpose:
Collector(s): i ( -~ ·rz,, Date /Cl-') .. b -f 'I Time _·_t_c_·l_i~_;-_, __ -"T Baseline, Complaint, Compliance,!,LUST, Pesticide Study, Federal Trust, Other: -1 ,circle one) -------FIELD ANALYSES Owner ~ ,~2.('\
Location or site \k1d l;,v, \i. Ile
Description of sampling point ------6-=<==lY .... 4::=---......... + ______________________ _ pH400 _____ Spec. Cond.94 ___ at 25° C
Temp.10 55° ~ _ Odor _____ _
Sampling Method -------~-----------Sample Interval ______ _
~bailer, ele.)
Remarks _____________ -,-(pu_mp1--:-.ng-:-t,:-.m-e,-:-alr-=-1e_q> __ -:-elc-:-.,-----------------
Appearance ______________ _
Field Analysis By: ___________ _
LABORATORY ANALYSES
BOD. 310 mg/I X Diss. Solids 70300 ma/I )( Aq -Silver 46566 uq/1 Organochlorine Pesticides
COD High 340 mg/I Flouride 951 ma/I -;( Al -Aluminum 46557 ug/1 Organophosphorus Pesticides
COD Low335 mg/I ·)( Hardness: Total 900 ma/I As -Arsenic 46551 ua/1 Nitrogen Pesticides
)( Coliform: MF Fecal 31616 1100ml Hardness (non-carbJ 902 ma/I Ba -Barium 46558 ug/1 Acid Herbicides
X Coliform: MF Total 31504 -1100ml Phenols 32730 ua/1 )( Ca -Calcium 46552 · ma/I PCB's
TOC680 mg/I SnP.dfic Cnnd. 95 uMhos/cm2 Cd -Cadmium 46559 UQ/1
Turbidity 76 NTU Sulfate 945 ma/I X Cr -Chromium 46560 ug/1
Residue., Suspended 530 mg/I Sulfide 745 mall x Cu -Copper 46562 ug/1
X Fe -Iron 46563 ug/1 Semivolatile Organics
011 and Grease mQ/1 Hg -Mercury 71900 ug/1 TPH -Diesel Range
X pH 403 units X. K -Potassium 46555 mg/I
Alkalinity to pH 4.5 410 mg/I )< Mg -Magnesium 46554 mg/I
Alkalinity to pH 8.3 415 mg/I )( Mn -Manaanese 46565 UQ/1
Carbonate 445 mg/I X NH. as N 610 ma/I y... Na -Sodium 46556 mg/I Volatile Organics (VOA bottle)
Bicarbonate 440 mq/1 "X TKN ~c: N 6?5 mn/1 ')( Ni -NirkAI uo/1 TPH -Gasoline Ran_ge
Carbon dioxide 405 mg/I
X Chloride 940 mg/I
~ NO_ + NO. as N 630 ma/I _x_ Pb -Lead 46564 ug/1 TPH -BTEX Gasollre Range
P: Total as P 665 ma/I Se -Selenium ug/1
Chromium: Hex 1032 ug/1 '')( Zn -Zinc 46567 ua/1
Color: True 80 cu
Cyanide 720 mg/I
. .,..
Lab Comments:--------------------------------------------------------
GW-54 REV. 12/£ For Dissolved Analysis -submit filtered sample and write "DIS" in bl
nrrp a 6"V V4Q o � �
Troh
COUIM : VADKIN
�Q FEB - 7 PpI
QUAD NO
3: 04
REPORTTO Co
Regional Office
CQ[.i,FCTOR(S) : PRITZL
DATE: N1999
TIME
PURPOSE:
Owner.
L.acu tion a r Si le;
Description of sampling point
Sampling Method.
Vemarks:
LABORATORY ANALYS[S
501) 310
mp/ L
COD I li is N10
m L
COD Low 33S
m L
X
Coliforrrt: MF Fecal 31616
tl
/100mI
X
Califormw MF ToUl31504
t1
/100m1
TOC
m I
Turiahv
NTIS
Residur..Sus •ndcd 5.10
m /L
Total SLarwnded solids
m /L
%
1,H
6.6
unite
Alkalinity so •H 4.5
nr /L
Alkalinity to •H 83
m /L
Carbonate
m L
Bicarbonate
m L
Carlxrndioxide
m /L
X
Chloride
cl
m /L
1032
u jL
q�-:Iu—Hex
oTrue 8ilr.u.
yane T20
m L
COMMENTS:
DIVISION OF WATER QUALITY
Chemistry Laboratory Rep on! CrouM Wait Qu alily
sAMPLs m-0RTtir
®ROIff M ElEMERCENCY
CHAIN OF CUSMDY
�t•r.
5AmnETYPE
AULEMA
1f
Diss. souls 70300
57
m /L
Fluoride 951
rn /L
X
Hardness: tota1900
38
L
Hardness nanrarb 902
m L
Phmob 32730
u L
5 m ilic Cond. 95
umhoa co%2
Sulfate
m L
Sulfde745
m /L
MBAS
m L
Oil and Grease
m L
Silica
m L
Bomn
Fom=Meh%de
m /L
X
NH3 as N 610
0.01
m L
X
TKN m N 625
0.5
ur /L
R
NO2+NO3 u n 630
c0.01
m /L
P; Total as P 665
m /L
PO4
m /L
X
A Silver 46566
e5.0
ugll,
R
Ai -Aluminum 46557
r50
u L
As-Ammmak 46551
u&j L
Ba-Barium 465W
u L
X
Ca-Cakiam 4k%Z
9.0
m L
Cd-Cadium 46559
us/L
Cr-C3tr mium 46SW
<25
u , L
X
Cu-Cn erls>•I2
160
u /L
IX
*IX
Fe- iron ID45
<50
u /L
fi • Mercury 71900
u L
7L
K-Potmetmum 46555
1.1
m L
X
M -M.r nesium927
4.0
m /L
X
A4n-lYIart •anese 1055
<10
u L
2f
Na-Sadlum 929
4.7
m L
X
Ni-Nickel
120
u L
X
Pb Lead 46W
e10
u L
Se Sekxtium
u /L
X
ZrLZuw 46567
51
n L
Lab Number : 9G 1'J70
Daie It mhmd : 101na119F9
rune Received ; 13;25
Received By HMW
Relea5ed By ' U5
Date repofied : 2f2n000
Or anoclrlorine Pea4c-sdes
Or esro has hprruy Pesticklea
Nitroven Pesticides
I I Add Herbicides I
9GI970 -cis

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
Vdnty ' h SAMELE TYPE EAMPLE PRIORITY
F_ ® Water ® Routine
No Serial No.
- ❑ soil ❑ Emergency
Lat. Long. ❑ Other
Report To: ARO, FRO, MRO, PRO, WaRO, WiRO, i`
WSRO, Kinston FO, Fed. Trust Central Off. Other:
Shipped by: Bus, Courier and Del., [her•
Collector(s): ; +z L Date -~R�
FIELD ANALYSES,
pH4DO Spec. Con&94
Temp.44 o of Odor
Appearance
Field Analysis By:
LABORAIQBY ANALYSES
❑ Char of Custody
EFF
Lab Number 1
Date Received
Redd by:4L
Other:
Data Entry By: -
Date Reported:
From: Bus, Courier, and []
Ck:
Purpose:
Time /0- 5_54"_l Baseline Complaint Compliance LUST Pesticide Study Federal Trust Other:
at 250 C
Owner i i G.Y1
Location or site ZIP
Description of sampling point
Sampling Method Sample Interval
Remarks t ' liar.*C')
W-Onp 9—. w iwfip. *a.l
BOD 3 1 o m 11
X,
piss. Solids 70300 m II
A - Silver 46566 u I
Or anochlorine Pesticides
COD High 340 mgA
Flourlde 951 m 11
AI - Aluminum 46557 u 11
Organophosphorus Pesticides
COD Low 335 rr!I
XHardness'.
Total 9D0 mu/1
As - Arsenic 46551 u qn
Nitrogen Pesticides
Coliform: MF Fecal 31616 /100ml
Hardness non -carp 902 m 11
Ba- Barium 46568 u II
Acid Herbicides
Coliform: MF Total 31504 1100ml
Phenols 327 u I
Ca - Calcium 46552 mqjI
PCB's
TOG 680 m A
Specific Cond. 95 wMhoLQm,1
Cd - Cadmium 46559 u
Turbfdity 76 NTU
Sulfate 945 m 4
Cr - Chromium 4%W uco
Residue., Suspended 530 mgll
Sulfide 745 MqA
Cu - Copper 46562 u !I
Fe -iron 48563 u 1
Semivolatile Organics
PH 403
Alkalinity to pH 4.5 410
Alkalinity to pH 8.3 415
Carbonate 445
Carbon dioxide 405
Chloride 940
Chromium: Hex 1032
Color: True 80
Cyanide 720
Lab Comments:
Oil and Grease micall
NH as N 610 m A
NO + NO as N 630 m I1
P. Total as P 665 m
H - Mercury 7190D ugA
K - Potassium 46555 mg/1
M - Magnesium 46554 m I
Mn - Man anew 46565 u /l
Na - Sodium 46556 moll,
Pb - Lead 4{i564 u I
Se - Selenium ugA
Zn - ZInC 46567 uqA
TPH - Diesel
Volatile Organics (M
TPH - Gasoline Rang
TPH - BTEX Gasoline
GW-54 REV.IM
For Dissolved Analysis - submit filtered sample and write "DIS" In bl'
.J

North Carob__ Department of Environment and N�...:ral Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WI0400011' DATE 10/28/1999
NAME OF OWNER Robert Alan Risen
ADDRESS OF OWNER 3057 Lori Lane, Yadkinville, NC 27055
(Streetl road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source wells), if applicable) Both the injection and recovery wells
are located in the front yard.
(Street) road or lot and subdivision , county, town, if dierent than owner's address, plus description of location on site)
Potential pollution source
Potential pollution source
Potential pollution source
recovery well Distance from well _20-30 feet
Distance from well
Distance from well
Minimum distance of well from property boundary _100 feet
Quality of drainage at site _good_ Flooding potential of site _very dow
(good,adequatepoor) (high,moderate,low)
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and
north arrow.)
Property bomdory
...........................
supply well
... .........
North
InjectionMCAr
x
b
supply well
Property boundary
Injection Well -
DESCRIBE INJECTION SYSTEM (vertical closed loop, uncased borehole or cased water well, • separate source well and
injection well; combination source and injection well, or other description as applicable)
separate source well and injection well
System is very clean and well maintained.

INJECTION FACILr··~y INSPECTION REPOr 1-FORM B (CONTINUE]))
WELL CONSTRUCTION
Date constructed 12/1988 -----
Drilling contractor: Name _____ Yadkin Well _____________ _
Address ----------------------
Registration number _________ _
Total depth of well _40 feet_ Total depth of source well __ 260 feet __ _
Inspection point
Casing
Grout
Depth
Diameter
Height (A.L.S.)
Depth
Screens
Depth(s)
Length(s)
I.D. Plate
Static water level
Well yield
Enclosure
Enclosure floor
(concrete)
Sampling port
(labeled)
Water tight pipe entry
Well enclosure entry
Vent
(if applicable;
Measurement Meets minimum standards
0-40 feet
6 inches
_@12 inches_
0-20 feet
None ----
Yes No
X
X
X
X
X
X
X
X
X
X
X
Comments
Functioning of heat pump system (Determine from the owner if heat pump functions properly.)
INSPECTOR Mark Pritzl Office CO-UIC ---------------------
WITNESS Address --------------------------
WITNESS Address March 1998 --------------------------
GROUNDWATER SECTION
September 20, 1999
MEMORANDU
To: Sherri Knight, E.I.T.
Groundwater Section
Winston-Salem Regional Office
From: Mark Pritz] W ?tiark.pritzl@nc?riail.net
Hydrogeological Technician 11
UIC Group
Central Office
Re: Request for inspection and routine sampling of Robert Risen's injection well system.
This system is located at 3057 Lori Lane, Yadkinville, NC 27055.
1. Please review the injection Nvell permit renewal and submit any comments to the Central
Office -Underground Injection Control Group (CO-UIC). Retain the application for your
UIC files.
2. Inspect the injection well site to verify that the location and construction plans submitted in
the application are accurate and 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 B) to
the CO-UIC by October IS, 1999. If the inspection can not be accomplished by this date,
please inform the CO-UIC. The UIC group greatly appreciates Chris Greene's assistance
with this review, If you have any questions regarding this review or the UIC program, please
contact me at (919) 715-6I66 or Amy Axon at (9 t9) 715-6165.
cc: UIC Files
Enclosures

Name Date · T ~~ ~mit/Comments
~ f-1Ieat PumV Remediation Other
Mark Pritz! 1,--1-&"
-
1/i~/r» Heat Pump Remediation Other ·
Amy Axon -Ji+b
Ted Bush
JAMES 8 . HUNT JR;
GOVERNOR
WAY.NE MCDEVITT
· SECRETARY
KE~R T. STEVENS
cu~.ECTOR.
Robert Alan Risen
3057 Lori Lane
Yadkinville, NC 27055
Dear Mr. Risen,
NORTH ..... AROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
September 20, 1999
Your application for the renewal of a permit to use a well for the injection of
geothermal heat pump effluent has been received and is under review. A member of
the Groundwater Section's Winston-Salem Regional Office staff will be contacting
.you to arrange an inspection of the injection well and collect water samples as part of
the review.
If you have any questions regarding the permit or injection well rules please
. contact me at [phone] or Amy Axon at [phone].
cc: UIC Files
WSRO
Mark Pritzl
Underground Injection Control
GROUNDWATER SECTION
1638 MAIL SERVICE Cl!NTIR, RALEIGH, NC 27899•1836 • 2728 CAPITAL, BLVD,, RALEIGH, NC 27604
PHONE 919•733·3221 FAX [phone]
AN EQUAL OPPORTUNITY I AFFIRMATIVE ACTION EMPLOYER • SOo/o RECYCLED/10o/o POST-CONSUMER PAPER
NORTH CAROLINA
DEPARTKLrNT OF ENVIRONMENT, HEALTIL AND NArJRAL RESOURCES
APPLICATION FOR PERMIT RENEWAL TO USE A WELL(S) FOR XNJFCTION WITH
A HEAT PUMP SYSTEM
Type 5A7 and SQM Wells
In accordance with the provisions of NCAC Title 15A: 02C,0200
complete application and xnail to address an the back page.
Ta: DIRW70k NORTH CAROLNA DIVIS70N OF WATER QUALITY �
DATE; S 19 5 g
IL
A. S"YST210 CLASSIFICATION- Does the syirem re-cirvulate only patahb watei without aay aftdv" such as
corrosion inhibitors or antVioezes in continuous piping which isolates the fluid from the euvuonment?
YES If ym do not wrtiplete this farm, A j*w GW-5 7 CL, (Notification Of Inteat To Czmst ct A
Closes -Loop Gcothemal-Water-dolly injection Well System), should be completed.
NO If no, them coutmuc completing this form.
Name 17 .. ► - ; s r-.,j _
Addmas; 3,o_� o{z t ►., A �q t
City: ` Q- 1-4 State: N L Zap code: ` 10 j
County., � `i Telephone: 5 t. i - is 5 '] 2
C. PROPERTY OWNER (if different from applicant)
Name:
E.
Address:
City: W
County;
STATUS OF APPLICANT
State;
Telephone-,
Zip code:
Privata: I- k'edew: Corimrie mi: state: Public:
Native Americim bands:
FACUZY (SITE) DATA (Fill out ONLY if tho Stnma of Owner is F.daal, State. Public or Gommemw),
Name of BusWin or Facility:
Address;
City Star Zip code --
County. Telephone: Contact Persorc
Standard IndusbiAl Code(s) which describe commercial facility!
Ow-57 HPR (May 1998) Pop 1 of 3

F. INJECIiON PROCEDMM (specify any modificadons to the injection prQZCdurc since the issuance of die
previous injection permit)
Po j r--
G, RILL USE Wm) the injection well(a) also used as the supply well(s) for either of the following?
(1) The injectiop operation? YES NO s•
(2) Your penoxtal consumption? YES_NO f
H. CQNS'l'RUCTXDN DATA
(1) Spmify any and all modificotiom to the well casing, gmttt or semis sitter the issum of the previous
injection permit.
---- 4o N- -
(2) W. State Regulations (1 SA NCAC, 2C, Sc&fion .0200) require the permiuee to mare p7roviaiew for
mowtoring well head ptooesaes. A faucet on both, ionfluetu (groundwater entering best pump) and
effluent (waver being Wected into the well) lines n requffed. Is there a Faucet on:
(a) the htfluent line? yes aq!
(b) on the effluent lint? yea ,% no
I. CJRRENT OFERA'1'NG DATA
(1) lnjo=ou rate: Average (daily)9 _ gallons per minute (gpm)
(2) injection volume. Average (daily)a o gallons per clay (gpd)
(3) Inlet tioa FrDsmm: Average (daily) d pounds per square inch (psi)
J
(4) Injection temperature: Annual Average L- _ degrees Fahrenheit (° F)
1. MEMON-RELATED EQUIPMEIV'i'
Attach at diagram showwu any modif=tiom to injection equipment since the muawe of the pmviws injection
pert[ n Including the en2ineerkg layout of the (1) mjec m equipment, end (2) exterior plph*hubing associated
with the injection operation. Tht manufa tuir&n brochure, if deuakd, should satisfy (l).
K. LOCATION OF WELL(S) Attach a map
Include a site map (cart be drawn) showing- the orientation of and distances between the kdection well(s) and
any existing wrll(s) or waste disposal facilities such as septic tanks or drain fields located Within 1000 feet of the
ground -source hest pump well systemi inclwk buildings, property lines, surface water bodies, any otber
potential sources of groundwater aontambmtiart- LAW aU features clearly and include a north arrow to indicate
orientation.
GW57 F1.FIt (May 199s) Page 2 of 3

L PERMrr UST: Attach a list of all periuits or consuum m approvals, received or applied fbT by @te applicant
that are related to the site.
Fxunples include:
(1) Hazardous Waste Mawwment pmgrxm parroits undor Cttp.A
(2) NC Division of Water Quality Non -Discharge permit+
(3) Sewage Tmunent and DiWoaal Permits
M. OTHER MODIFICATIONS: Indimte any other aw di.4ications to the injection well sywk=
(equigrn=4 fluid, operation, etc.) that baave occurred simee the issuance of the
previous injection permit and knave not been noted elsewhere on this application,
too,sG
N. CER7MCATION
'I hereby cer fy, wider penalty of law, that I kher ve personally examined and am familiar with the in€nrmation
sub=#ed irk this document and all attachmrrrts thereto and that, based on xoty inquiry of &use individnals
inwwdiately responsible four obtaining said iPfo=ation, I b8ieve that the iafornaation is true, accurate and
complete. 1 am aware ftt there are sigruficant penalties, including the possibility of fiats and auptisoa mmt for
submitting hlsc infornuttion. I agree to opesat+e, mHiat m repair, and if appiicabla, abandon the miectiou well
and all related appulrteD ens i* accordance with the approved specifications wA Conditions of die keaWl."
(Signatum of Well Owner or Authorized Agent)
If auMor&ed agent is uefirtg on bcha'f of &v well opmer,
please supply a lenw signed by the owner
autharfstng the above agent
D. CONSENT OF PROPERTY OWNER (Owner rmans any person who hells the fee or other property rights in
tare welt(s). A well is real property and its construction on Sand rea4 owners hip in the iazrd owner in the absence
of cocttaty RgrCCtt m in wriftg-)
It the property is owned by someone other than the applicant, the property owner frtreby comserb to allow the
applicant to operate an injection wells) sb rnulincd in this appUg-.at ion and that it aball be *e responsibMY Of the
applicant to ensure that the mjecboo wells) conform to the Well Construction Standards (Title 15A NCAC
Subchapter X .0200)
(Signature of Properry Owner if Different From Applicant)
Please return the completed Application package to.
Underground Injection Control Program
Groundwater Section
North Carolina DEHNR-DWQ
IPO, Box 29578
RaMgh, NC 27626-0578
(T elep h one e: 919-715-6165)
GW-57 HPR (M•y 1998) Paac s ot3

POWER
POLE
Co
ERAL '
OWER
1NE
LOT 8
PB 6 Pg. 221-
S
W
z
EOSTiNG
GRANrrE
r MONUMENT-
0
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i
4tr�`fr•,.►
DB 282-0783
r
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r v
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NP
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ARC .17.35' ROBERT
A. RISEN
7 it o�. E�
a C� DB 2$2 Pg. 7B3
JIMII/1Y L. PINNIX
PB 6 Pg.
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DB 214 Pg. 583
50• ry
Ole
s"s4-
' R /W
J
LOT
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OF
PB 6 Pg. 221
��
TO W"OM IT MAY CONCERN -
THE SU&JECT PAdPERTY IS NOT LOCATED WITHLN
A SPECIAL FLOOD HAZARD AREA A$ DETERMIMED
WY FLOOD ww r
LABELED CURVE DATA
�HUID/FIA
�`{•�-L r_-L x! [. f
.�.
p
R
CHORD BRG.
DIST.
I HERESY CERTIFY THAT THE ATTACHED PLAT
OF SURVEY IS A TRUE AND CORRECT REPRESENTATION
C7
29939'52-
232,03•
N07°11'56••E -
OF LAND SURVEYED UNDER MY SUPERVISION..C14
48•I1'23••
25.00'
N31143'4rw -
20.41'
ire •�. � :-� -� r - .�
Cis
13.52.44••
50.00*
N45.53'01"W -
17.26•
DATE + 1 h (-
PLAT OF SURVEY FOR
ROBERT ALAN •RISEN
7
e�l�Yi11�1/�Ir..
BEING AL'_ OF LCT 7 AS SHOW
ON PLAT BOCK G AT PAGE 22;

_.
TilEcrid
W r&LA-
5+t.*LG
14 L AT
pr�.P
p�U�
14611
prn.p
j0d roe-
►. C1 l

NOT& MAP RAC11M ONLY 57ATE MAIHTARIED ROAD$
❑R 1IISPORFANF NONdYSTEAI ROADS.
IA LLAGE NOT SHOWN ON FRONTAGE ROADS.
ROADS SHOWN AS OF IAN, 1, 1990,
YADKIN
LEGEND
PRlµlf{YE OR UNIMPROVEa ROAD
CRADID AND DRALNEO ROAD
SOIL, GRAYD, ON STONE SURFACRD ROAD
.��
HARD SURFACED ROAD
r+•AR'P•P.
A LANE UHDW IDEo HIGHW AT
ON DED HGH W AY
_
HIGHWAY WITH PRONIAGE ROAD$
J i A
FULLCONTROL ACCESS
JAI
FEOFRII AID 04iliS7ATE ROAD
_J46..
FOULAL Ala PRARY EQAo
AAS
FEDERAL AD SIMECONOART ROAD
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Recs
Mean
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Latitude 518
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Longitude 518
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Altitude 518
213.499
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204.856 222.831
No velocity records in file.
No DOP records in file.
Start GPS Week #793 on 03/20/95 at 19:51:24
End GPS Week 4793 on 03/20/95 at 19:58:28
Datum WGS-84
Coordinate System Latitude/Longitude
Altitude Mode Height Above Ellipsoid
Altitude/Distance Units : Meters
Velocity Units : Meters/Second

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TO WHOM IT MAY CONCERN
THE SUBJECT PROPERTY IS HOT LOCATED WITHIX
A SFECIAL FLOOD HAZAAD AREA AS DETERMINED
BY HUD/ttFIA FLOOD WAR
LABELED CURVE DATA
❑ R CHORD BRG. DIST. 1
II
I HERESY CERTIFY THAT THE ATTACKED PLAT
OF SURVEY IS A TRUE AND CORRECT REPRESENTATION C7 29139'52" 232.03' N07011'56"E - 116.80'
OF LAND SURVEYED UNDER MY SUPERVISION.:
� C14 480II'23" 25.00' N31°43'41"W - 20.41'
�'�� =•!� -, 7—; CI8 19.52'44" 50.00' N45°53'01'W - 17.26'
DATE f f Nkq- CS
�yrr><alrr�rii�`
� k Cr�Rol 'POO..
PLAT OF SURVEY FOR
.. ROBERT ALAN RISEN
BEING ALL OF LOT 7 AS SHOWN
ON PLAT BOCK 6 AT PAGE 221
TOWNSH 7 °' - _ 11, 17-.1
CCUhiT" ; , r , ,, ST. AT N . C. 1

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GROUNDWATER FIELD/LAB FORK!
County YJ I"C. V1,
Quad NoG 5A?_ �__ Serial No. _ SAMPLE PRIORITY
Lat. 3el a �3Q'- Long. 1D �sf-'5V9RO NINE []EMERGENCY
To: ARO, FRO, MRO, RRO, WaRO, WiRO, L�"�❑CHAIN OF CUSTODY
� Vi1SR0 Kinston FO F Trust, Central Off., Other: Lid--
4S ped by: Bus, Courier and Del., Other
Purpose:
Collectortsj: �t^-� Date b Time MK Baseline, Cc
FIELD NA ES Ownerb
pH ' Spec. Cond.s4 at 25o C Location or site �4 s` T �a
Jrio °C Odor _ Description of sampling poin�L
Appearan a ''r Sampling Method
Field Analysis By: '�- � _ Remarks 5j-_14 - C-6 b
North Carolina
Departrnent of Environment, Health, and Natural Resources
DIVISION OF ENVIRONMENTAL MANAGEMENT- GROUNDWATER SECTION
Lab number
Date Received
ReC'd by:
Time
From: B s, vul7er and Dei.,
OM5,
Other:Data
Entry By:
Ck-
Date Reported:
.01/zo f
Yp-7
it, am LUST, Pesticide Study, Federal Trust, Other. �- i C_
{ 0r0)
Lu,- .. Y,, a ' k-, V% V:
_t.
w r r.M k-"v-
SOD 310 m /I Diss. Solids 70300 R b m I A -Silver 46%6 C UCO Or anochlorine Pesticides
COD High 34o m911 Flo ' e 951 m A1- Aluminum 46557 C 106 u i Organophosphorus Pesticides
COD Low 335 nW a ness. Total oo 313 mW L,T As - Arsenic 46551 uco Nitrogen Pesticides
liform: MF Fecal 31616 1100ml
Hardness non -carp 9o2 m /l
LlbBa
- Barium 46558 4 u
Coliform: MF Total 31504 /104m1
Phenols 32730 Ugll
a - Calcium 465M2 m I
Acid Herbicides
TOG 680 m9A
_. _
Specific Cond, 95 uM o cmP
d -Cadmium 465594 Q , f) u
Turbidity 76 NTU
Sulfate 945 m
r - Chromium 46560u n
Semivolatile Organics
Residue., Suspended 53o mg/1
Sulfide 745 mol
t,
lu - Copper 46662 Z/'7 u /1
Fe - Iron 46563 _14 /Od u9A—
H - Mercury 71900 ugA
Volatile Organics (VOA bottle]
pH 403 -7,7 unit
K - Potassium 46555.
Alkalinity to pH 4.5 410 mgA
M - Magnesium 46554 MQ4
TPH - Gasoline Flange I
q"Nkalinity
to pH 8.3 41,5 / mgA
Mn - Manganese 46565Z u 1
TPH - BTEX Gasoline Range
bgnate 445 .4 / mgA
NH as N 610 rn
Na -Sodium 46556 3.T_ mgA
Bicarbonate 440 S mg/1
- Nickol -c f ugo_
,jDarbon. dioxide 405 m94
V
+ NO as N 630 �� / m
Pb - Lead 46564< 1 USO
Chloride 940 mgll
P: Total as P 66s o] 0& m
-Selenium u
Chromium: Hex I= u
Zn - Zinc 46%7 -c:-u
Color: True 80 Pt -Co
Cyanide 720 mg/1
. Lab Comments:
GW-54 Rev. 61?q For Dissolved Analysis - submit filtered sample and write "DIS" in block.

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment, Health, and Natural Resources
DIVISION OF ENVIRONMENTAL MANAGEMENT -GROUNDWATER SECTION
County �c;� `Z' V,_
Quad No2-01 Serial No. SAMPLE PRIORITY
Lat.36 �07'3o �� � Lang. � 7r- -
246UTINE []EMERGENCY
Re o: ARO, FRO, MRO, RRO, WaRO, W' [:]CHAIN OF CUSTODY
WSRinston Fr) FPLH Trust, Central Off. th t�- R cL l e,;y k
Shipped by: Bus, CouHer Del., Other
Collector{s): C Date 4. a. 1. Time
FIELD ANALYSES
oH40n Spec. Cond'94
-amp.10 °C Odor
Appearance
Field Analysis By: �—
at 2-5o C
'off yo
Owner
Location or site
Description of sar
Sampling Method
Remarks 54h f: t
Lab Number
Date Received Time
YKIR YPr� t Reed b : From: Bu ourier, nd Del.,
y3a Other:
Data Entry By: Ck:
►Rtf7 Date Reported: _ r_� T Ic)1_
Purpose:
Baseline ornpiainc
�M + ., V_,,
Pesticide Study, Federal Trust, Other: u 'C
o S 7 G- r: t,1 , . Yad (r, ►�, r.i 1
IKA;
Sample
Ll
S
LABORATORY ANALYSES "
Bad 310 Dies. Solids 70300 F ❑ mg/Img/l V I Silver 46566 - u1 Or anochlorine Pesticides
COD High 340 m94
F nde 951 m
Al - Aluminum 46557.E /,00 u /i
Organophosphorus Pesticides
C09 Low 335
Hardness: Total goo �2 m /I
s - Arsenic 46%1 .0 uq4
Nitrogen Pesticides
iform: MF Fecal 31616 Moomi
Hardness non -carp 902 m Il
a - Barium 46559 u 4
Coliform: MF Total 315044 r 1100ml
Phenols 32730 u
a - Calcium 46552 rnaA
Acid Herbicides
TOG 680 nV4
Specift Cond. 95 uM os/Cmr
d - Cadmium 46559 Ugd
Turbidity 76 NTU
Sulfate 945 m
Cr - Chromium 46560� 50 u
Serrivolatile Organics
Residue., Suspended 530 mgll
Sulfide 745 m 4
u - Copeer 46M UgA
Fe - Iron 46563 u 4
'H - Mercury 71900 ugA
Volatile Organics (VOAtoWa)
403 fJ unit
K - Potassium 46555 mgA
Ikalin to pH 4.5 410 rngtl
- Ma nesium 46554 1.0 mgA
TPH - Gasoline Range '
Af linty to pH 8.3 415 ,C / m9A
Mn -Manganese 46565.0 u N
TPH - BTEX Gasoline Range
rhanate 445 mgll
NH as N 610 c3. n mall
Na - Sodium 46556 mqA
Bicarbonate 440 mgl
i - Nkkel 10
Carbon dioxide 405 mgA
g_lz
ENO, as N 630to-0 mgll
Pb - Lead 46564-4 f u li
Chloride No mg/I:
Total as P 665 6, D m
Ss - Selenium u
Chromium: Hex 1032 UgA
Zn - Zinc 46567- u 1
Color: True 80 Pt -Co
—T
Cyanide 7zo m91i
Lab Comments: ] -I to
GW_54 REV. G'01 For Dissolved Analysis - submit filtered sample and write "DIS" in block. 2 Af V

State of North Car\-.. f1a
Department of Environment,
He,alth ond Natural Resources
Division of Environmental ·Management
James B. Hunt, Jr., Governor
r~-~A
v= -~~ a a a
Jonathan B.·Howes, Secretary DEHNR
A. Preston Howard, Jr;i P.E., Director
Mr. Robert Alan Risen
3057 Lori Lane
Yadkinville, NC 27055
Dear Mr. Risen,
GROUNDWATER SECTION
June 17, 1994
In accordance with your application dated June 2, 1994, we are
forwarding a permit for the Operation and Use of a well, for the
purpose of injecting heat pump effluent, in Yadkin County.
This permit is a renewal of Permit No. 98 -0080 -WO -0001,
which was issued on January 11, 1989, and shall be effective from
the date of issuanqe until June 30, 1999, and shall be subject to
the conditions and limitations as specified herein. This permit,
Permit No. WI0400011, replaces and shall also supersede Permit No.
98 -0080 -WO -0001 . 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 ~tated 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 (91.9) 733 -3221, ext. 407.
cc: UIC Files
W-SRO Files
Enclosures
Sincere~:• ( t
{I, 2(~ a ~4/ w?
A. Elizabeth Morey
Manager
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/ 10% post-consumer paper
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
DALEIGH, 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
Robert Alan Risen
FOR THE OPERATION OF AN INJECTION WELL for the purpose of injecting
heat pump effluent. This well is located at 3057 Lori Lane,
Yadkinville, North Carolina, in Yadkin County, and will be operated
in accordance with the application dated June 2, 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 Permit No. 98 - 0080 - WO - 0001
which was issued on January 11, 1989, and shall be effective,
unless revoked, from the date of its issuance until June 30, 1999
and shall be subject to the conditions and limitations specified in
Parts I through VIII herein. This permit replaces and shall also
supersede Permit No. 98 - 0080 - WO - 0001.
Permit issued this the j l day of June. 1994 — - ---
ed L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Environmental Management
By Authority of the Environmental Management Commission.
PERMIT NO. W10400011

PART I -GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit
and with the standards -and criteria specified in Criteria and
Standards ·Appl·icable to Injection Wells ( 15 NCAC 2C . 0200).
Any noncompliance with conditions of this permit'constitutes
a violation of the North Carolina Weli 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 notice 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 amendment request must be
submitted to the Director, iriclu~ing any supporting materials
as may be appropriate, at least 30 days prior tq the date of
the change.
4. The issuance of this permit does not preclude the Permittee
from complying with any and all statutes, rules, regulatidns,
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 them 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 Permi ttee 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 inj~ct~on ;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 or 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
pres~ntation 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.C.G.S. 87-90. .
3. Pro~isions shall be made for collecting any necessary and
appropriate samples associated with the injection t'acility
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
Mana~ement 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
Groundwater Section Staff, Winston-Salem Regional Office,
telephone number [phone], 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 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 and correct facts or information
shall be pro~ptly 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 provide written notification 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 accoiding 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 injection 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.
PAGE40F6
(C) The well(s) shall be thoroughly disinfected, prior
to sealing, if the Director determines that
£allure to do so could lead to the contamination
of .an underground source of dri~king water.
(D) The well(s) shall be complet~ly filled with cement
grout, which shall be introduced into the well(·s)
through a pipe which extends to the bottom of the
well(~) 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 b~ 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 of the
permit.
(G) The Permittee shall submit a Well Abandonment
Record (Form GW-30) as specified in 15A NCAC 2C
.0213(h)(1) within 30 days of completion of
abandonment.
3. The written documentation required in Part VII (1) and (2)
(G) shall be submitted to:
Groundwater Section -UIC Staff
DEHNR -Division of Environmental Management
P.O. Box 29535
Raleigh, N.C. 27626-0535
PART VIII -SPECIAL CONDITIONS
NONE
PERMIT NO. WI0400011
PAGE 5 OF 6
ATTACIDGKNT l
Sanitary Well Seal
Casing must extend
min. of 12 inches above
land surface —�� m
.j
r•
•�w1 �i:,•lrV. r
' _
a
E
PERMIT NO. WI0400011
Sampling Tap
[Influent]
o+
SOURCE
WELL
HEAT
PUMP
Sampling Tap
(Effluent)
.1W.!• •Nf. Jr• •I S..
;: : L'+ :1° • • •� �';+.� •reji;r,':M;:••i S y'r is :•,• ;�:': ;•+•'• •0
fir•' • _ .. •', �•�;• :'`.I• • y„r�.s •�, •+, .
— Sanitary Well Seal
min, of 12 inches above
land Surface
Casing must extend
t
INJECTION
WELL

State of North Carl. ,,a ·
Department of Environment,
Health and Natural Resources
Division of EnvlrorimentalManagement
James B. Hunt, Jr., Governor
Jonathan B. Howes. Secretary
A Preston Howard, Jr., P.E., Director
RA
D E HNR
GROUNDWATER SECTION
June 8, 1994
MEMORANDUM
To:
From:
Chris Greene
Groundwater Section
Winston-Salem Regional Office
UIC Group
Groundwater Section
Raleigh Central Office
Re: Request for review of injection well permit application and
for routine sampling/inspection of the facility.
An application for the renewal of injection well Permit No.
WI0400011 by Mr. Risen has been received by the UIC Group.
Please review the application and submit any comments to the UIC
Group by June 24, 1994. Retain the application for your UIC
files.
Please sample and inspect the injection well facility as soon as
possible, the priority of this sampling being the same as that of
the Tomberlin and Rocamora samplings. Send a copy of the
completed Well and Pump Inspection Report form GW-36 to UIC-RCO
an~ request the DEM lab to send a copy of Groundwater Field/ Lab
form GW-54 to UIC-RCO.
cc: UIC Files
W-SRO Files
Enclosures
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post-consumer paper
State of North Care is
Department of Environment, IAr
Health and Natural Resources At,*Divislon of Environmental Management
James B. Hunt, Jr., Governor C
Jonathan B, Howes, Secretary [D C H
A. Preston Howard, Jr., P.E., Director
GROUNDWATER SECTION
June 8, 1994
Mr. Robert Alan Risen
3057 Lori Lane
Yadkinvi.11e, N.C. 27055
Lear Mr. Risen,
Your application for the renewal of a permit to use a well
for injection with a heat pump system has been received and is
under review. Your injection well facility will be inspected and
sampled as part of the review.
If you have any questions regarding the permit please feel
free to contact me at (919) 733 - 3221, ext. 431.
Sincerely,
Karen A. Harmon
Hydrogeological Technician II
Underground Injection Control. Program
Groundwater Section
cc: UIC Files
RO. Box 29535, Rdeigh. Nofth Carolina 27626-0635 Telephone [phone] FAX [phone]
An Equal Opportunity Affrmotive Action Employer 50% recycled/ 10% post -consumer paper

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTNIENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT ANDIOR USE A WELL FOR INJECTION
WITH A HEAT PUMP SYSTEM
Class S Wells
TO: DIRECTOR, NORTH CAROLINA DIVISION OF ENVIRONMENTAL MANAGEMENT
DATE:- z , 1924
1n 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.
35m
Please type or print clearly. ri
� x4
A- PERMIT APPLICANT
Name:
Address:
City:
County:
Telephone:
150�7 46ri Ld^J-O C N&u I
dad I ;Qvf x- Zip,cade:
VoAk,n .a
n w
l 7 ( - 'r� �' r"
B. STATUS OF APPLICANT
Federal
Public
Native American Lands
State Private-.
Commercial Other
C, FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Public or Commercial.
Name of Business or Facility:
Address:
City:
County:
Telephone:
Contact Person:
D. HEATING CONTRACTOR DATA
Name:
Address:
City:
County:
Telephone:
Contact Pw-
E. INJECTION PROCEDURE {Briefly describe how the injection well(sl will be used).
%l. gJ'zi 4y"` L ILLS
tl
--r —,
F. 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 NOX
(b) Your personal consumption? YES NQ
GW-57 HP (April 1994) page 1 of 4

G. CONSTRUCTION DATA (CHECK (?NE)
EXISTING WELL being proposed for use as an injection welLAttach a. copy of Form GW-1
(Well Construction Record) and furnish (7 & 8) below. If Form GW-1 is not avaifable, furnish the data in
(1) through (8) below to the best of your knowledge.
X PROPOSED WELLt0 be 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: -~-a--'-",{,L.....a.'1<1__;,·.:....·Y'-..:..........,\A....,l ..... e ..... LL~------------
NC Driller _Registration numb~~: _ I 1/\'P:YlbW>'\ -
(2) Date~constructed: ,;.. /gtJ Approximatedepth:._4-{J_fe_··_eL ______ _
(3) Well casing: . . .. . . . . . . .
(a) Type: G.alvanizedsteel. . Black steel_· __ Plastic~Othyr(specify) ______ _
(b) Inside diameter: . ~~hes; Wall thickness f \f;u inches or schedule# __ ....,.,......_
(c} Casing depth: · From O ·to 40 ft. (reference to land surface)
Casing extends above ground I V inches (must be at least 12 inches)
(4) Cement grout:
(a) Around inner or "primary" casing: From ___ to_-----,--!.ft. Al/ Pr
(b) · Around outer (pit) casing, if present: From O to )-.t) ft.
(5) Screens (if applicable):N -~
(a) Type:._~ ____ ; Inner diameter: ______ inches
(b) Depth: From ___ to · feet below land ·surface
(6) Gravel (if applicable): From ef[J to 40 feet below land surface
(7) N.C. State Reg~iations (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?. yes~no __ . __ (b) the effluent line? yes )(..... no __ .
(8) Attach a diagram showing the location of the injection well. and sampling faucets relative to primary
building on property. .
H; PROPOSED OPERATING DATA
(a) Injection rate: · Average (daily) £ gallons per minute .(gpnt)
(b) Injection volume: Average (daily);)1QAI} ·gallons per day (gpd)
(c) Injection pressure: Average (daily) 0 pounds/square inch (psi)
(d) Injection temperature: Annual Average {d7° degrees F
I. INJECTION FLUID DATA
(l) Fluid Source. If underground, from what depth .and what type of rock/sediment does the fluid to be
inj~ derive ( e.g., gnmite, limestone, sand). ·
if,,~fjNJ,,v,r,, .
(2) Chemical Analysis of Source Water. The following chemical ·characteristics MUST accompany this
application:
pH 1,,.1 ; Tomi hardness l/0~~ tt m (parts per million or mg{I); Iron /.oc,,g/ I ppm;
Chloride 6 f'.h~ I / ppm; Nitrate c. ppm; Coliform bacteria · kk' j counts/lO0ml
NOTE: Assistance in determining these values may be obtained by contacting (a) your local or county
health offical, (b) a commercial water-testing laboratory, (c) your well drilling contractor, or
(d) the regional Hydrogeologist, North Carolina Dept. of,Enviro~merit, Health, and ·
GW-57 HP (April 1994) Page 2 of 4
Natural Resources.
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
K. 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.
L. 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 aril 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 Owner or Authorized Agent)
Please supply a letter signed by the owner
authorizing the above agent, if authorized agent is signer.
M. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property rights
in the well being constructed. 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 theapplicant to construct an injection weIl(s) as oulined 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 (Tide 15A NCAC Subchapter 2C .0200)
Name of Property Owner (Print):
Mailing Address.•
(Signature of Property Owner if Different
From Applicant)
OW-57 HP (AprA 1994) Page 3 of 4

GW-57 HP (April 1994)
;:,....:........
Please return the completed Application package to:
UICProgram
Groundwater Section
North Carolina DEHNR-DEM
P.O. Box 29S35
Raleigh, NC 27626-0535
(telephone: [phone])
Page 4 of4
North Carolina
Environmental Management Commission
Department of Environment, Health & Natural Resources
Groundwater Section
STATUS OF INJECTION WELL SYSTEM
Date: "--2--'l "1 ---=---=-------Permit#: -wo---------
Name: 'K.obec \o-A . '2 rst,.,J
Address: 3oJJ Lo ~, bANE
-J o..ct ((: J 11: \ l~ N '-~J os:1
Please check the selection which most closely describes the
current status of your injection well .. In addition; please
answer the appropriate que~tions in the space provided.
1) / Well is still used to inject heat pump return flow.
2) Injection discontinued; well _ temporarily not being
used.
Why?: ------------------------
How long out of servic·e?: ____________ _
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."
'i2 o-b-J 0.. 72 ~
(Signature)
GW-68
3
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M
.
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POWER
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PB 6 Pg. 221
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DB 282-0783
LOT 7
POWER POLE
ARC . T7.36' ROBERT A. RISEN
vi
7 G� 18, °DDTP DB 282 Pg. 783
1 PB 6 Pg, 22!
1 50' ��s�3Os.
` R i W �sg„
I (-)T
EIP D.
PB 6 Pg. 221 1�
TO WHOM IT MAY CONCERN =
THE SUBJECT PROPERTY IS NOT LOCATED WITHIN
A SPECIAL FLOOD HAZARD AREA AS DETERMINED LABELED CURVE DATA
BY HUD/FiA FLOOD MAR
r f ❑ R CHORD BRG. DIS7.
Wo
EXISTING
GRANITE
MONUMENT
O „r
of ti -
JIMMY L. PINNIX
DB 214 Pg. 583
1 HERESY CERTIFY THAT THE ATTACKEO PLAT
OF SURVEY IS A TRUE AND CORRECT REPRESENTATION C f 29°39 5z 232.03' N0T°11'S6" 118.8Q'
OF LAND SURVEYED UNDER MY SUPERVISION,
C14 489II'23" 25.00' N3I°43'41"W - 20.41'
C18 19052'44" 50.00' N45°53'01"W - 17.26'
0ATE I f Nev. f2;
PLAT OF SURVEY FOR
R48ERT ALAN R15EN
iyaavr<rerArrr►rr
BEING ALL OF I-OT 7 AS SHOWN
ON FLAT BOCK 6 AT PAGE 221
TOWNSHIP.' UNTY: vnr ,I-w
STATE: N. C.

0-4
'ri-Is .Ta,7 d —
,SOJrte-
L. 4LI t

State of North ci~ollna
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
May 19, 1994
Mr. Robert A. Risen
Route 2
P.O. Box 211 CC7
Yadkinville, N.C. 27055
Dear Mr. Risen,
Our records show that the operating permit for the heat pump
injection well on your property expired on January 1, 1994. In
addition, ou;r 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 facility 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 June 6, 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,
Karen A. Harmon
Hydrogeological Technician II
Underground Injection Control Program
Groundwater Section
P.O. Box 29535, Raleigh, North CaroHna 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ l 0% post-consumer paper
SENDER: I also wish to receive the
Complete items t and/or 2 for additional ses ccs
• Complete items 3, and 4a & b. following services [far an extra
• Print your name and address on the reverse of this form so feel:
that we can return this card to you. 1. ❑ Addressee's Ad(
• Attach this form to the front of the mailpiece, or an the
back if space does not permit.
■ Write "Return Receipt Requested" on the mailpiece next to 2• ❑ Restricted Deiivt
the article number. Consult_postmaster for fe
Article Addressed to:
MR ROBER'I' A RISEN
RT #2
PO BOX 211 CC7
LADKINVI= NC 27055
01 -C Wd • Y AN �G
6. Signature {Agent/
4a. Article Number
067 737 196
4b. Service Type
❑ Registered
U Certified
Express Mail
❑ Insured
❑ COD
❑ Return Recei
■ A--4......i:....
7. ❑ate of Del'v y
S. Addressees Address (Only if re
and fee is paid/
PS Form 3011. October 1990 *u.s. cpo: 1eea--27MO1 DOMESTIC RETURN RECEIPT

State of North Carolina
Department of Environment,
Health and Natural Resources
Division of Environmental Management
w-s~
r~-~ e uwwws i-. a a a James B. Hunt. Jr., Governor ·
Jonathan B. Howes, Secretary D E HNA.
A Preston Howard, Jr., P.E., Director
Mr. Robert A. Risen
P.O. Box 313
Yadkinville, NC 27055
Dear Mr. Risen,
GROUNDWATER SECTION
March 23, 1994
Our records show that the operating permit for the heat pump
injection well on your property expired on January 1, 1994. 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 facility 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,
XU,Wy\_CL ~
Karen A. Harmon
Hydrogeological 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 0% post-consumer paper
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. Raul Wilms
S. Thomas Rhodes, Secretary Director
January 6, 1989
Mr. Robert A. Risen
P.O. Box 313
Yadkinville, NC 27055
Dear Mr. Risen:
In accordance with your application dated December 12,
1988 we are forwarding herewith Permit No. 98-0080-111-0014 for
the construction of a well and Permit No. 98-0o8rl-wo-000I for
the Operation and Use of a well for the purpose of injecting
heat pump effluent, in Yadkin County.
This Permit shall be effective from the date of issuance
until January 1, 1994 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.
Sincerely,
P
Larry Cohle
Regional Supervisor
Ite7
Attachment
cc: UIC Files��t:�� ''••'��
WSRO Files
Pollution Prevrnlian PaVS
P.fl. Box �76V, Ralcht, Norm Carolina 27611-7687 1elc honc 919-733.713i5
An Equal opportuniry Affirmative Acoan EmPIOM

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
RALEIGH, NORTH CAROLINA
PERMIT !QS THE -CONSTRUCTION OF~ WELL OR WELL SYSTEM FOR INJECTION
!n accordance with the provisions of Article 7, Chapter 877
Article 21, Chapter 143, and other applicable Laws, Rules and
Regulations
PERMISSION IS HEREBY GRANTED TO
Mr. Robert A. Risen
FOR THE CONSTRUCTION OF A WELL/WELL SYSTEM located at Lot #7, SR
1753 in Yadkinville, North Carolina in Yadkin County, in
accordance with the application dated December 12, 1988 and in
conformity with the specifications and.supporting data, 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 Construction only, and does not waive any
provisions or requirements of the Water Use Act, requirements for
operation, or any other applicable Laws, Rules or Regulations.
Construction of any well or well system under this Permit shall be
in compliance with Title 15 North Carolina Administrative Code 2C,
and any other Laws, Rules and Regulations pertaining to well
construction.
This Permit shall be effective, unless revoked, from the date
of its issuance until January 1, 1994 and shall be subject to the
sp~cified conditions and ·limitations set forth in Parts I and II
hereof.
Permit issued this the //~ day of Cfa~/ (/ J
, 1989.
~~ ;Q . ~-Lari-yCoble
Regional Supervisor
By Authority o_f the Environmental Management Commission
Permit No. 98-0080-WI-0014
., -
PERMIT NO. 98-0080-WI-0014
PART I
A. GENERAL CONDITIONS
1. The Permittee must comply with all conditio•ns of this
Permit and with the standards and criteria specified in 15 NCAC 2C
• 0200. Any Permit noncompliance· constitutes a violation o ·f the
appropriate Act·and is grounds for enforcement action; for Permit
termination, revocation and reissuance or modification; or for
denial of a Permit renewal application.
2. It shall not be a defense for a Permittee in an enforce-
ment 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 sha-11 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 permitted facility or activity which
may result in noncompliance with this Permit.
5. The Permittee shall report all instances of noncompliance,
not reported under condition 1. of this Part, at the time monitor-
ing reports are submitted.
6. Where the Permittee becomes aware of a failure to submit
any relevant facts in a permit ap~lication, or of any incorrect
information submitted in said· a·pplication or in ·any report to the
Director, the relevant and correct fadts or information shall be
promptly submitted by the_ Permittee.
7. The Permittee shall gi~e notice · to the Director of any
planned physical -alterations or additions to the injection well(s)
after the initial construction/completion forms have been
submitted as required.
8. Department repres~ntatives shall have reasonable access
for purposes of inspection,· observation and sampling associated
with injection systems and ·related facilities.
9. This Permit is not transferrable without prior notice to,
and approved by, the Director.
10. An application for modification, renewal or transfer of
this Permit shall be filed with the Department at least 30 days
prior to the expiration date of this Permit.
PERMIT NO. 98-0080-WI-0014
PART I (continued)
A. GENERAL CONDITIONS (continued)
11. Provisions ·shall be made for collecting samples of
facility effluent, both prior to its entrance to treatment devices
and subsequent to leaving the treatment devices but before enter-
ing the injection well.
PART II
A. SPECIFIC CONDITIONS
- N O N E -
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION/USE 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 HEREBY GRANTED TO
Mr. Robert A. Risen
FOR THE OPERATION AND USE OF AN INJECTION WELL/WELL SYSTEM located
at Lot #7, SR 1753 in Yadkinville, North Carolina in Yadkin County,
in accordance with the application dated December 12, 1988 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 January 1, 1994 and shall be subject to the speci-
fied conditions and limitations set forth in Parts I and II hereof.
Permit issued this the �'`�` day of J. 1989.
z � ��LL
Lay Coble
Regional Supervisor
By Authority of the Environmental Management Commission.
PERMIT NO. 98-0080-WO-0001

►
PERMIT NO. 98-008.0-WO-0001
PART I
A. GENERAL CONDITIONS
1. The Permittee must comply with all conditions of
this Permit and with the·standards and criteria
specified in 15 NCAC 2C .0200. Any Permit
non-compliance constitutes a violation of the
appropriate Act and is grounds for en·forcement
action; for Permit termination, revocation and
reissuance 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 sha11·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 Part, 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 applic_ation 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 (con.tinued) PERMIT NO~ 98-0080-WO-0001
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 Permittee 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 facility.
11. This Permit is not trarisferable 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
expiration date of:this Permit.
13. Provisions shall be made for collecting samples of
facility effluent, both prior to its entrance to
treatment devices and subsequent to leaving the
treatment devices but before entering the
injection well.
A. SPECIFIC CONDITIONS
- N O N E -
NORTH CAROLINA
ENVIRONM]WAL MANAGEMENT COMMISSION
�AT ER SECT1O N
DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DE EtGK. WC
APPLICATION FOR PEWIT TO CONSTRUCT AND/OR USE A WELL FOR DUECTION
CLASS 5 Ta7 T S
TO: DIRECTOR, NORM CARO= DIVISION OF ENVIRONMENTAL MANAGEMENT
DATE : , 19 'rS
In accordance with the provisions of Article 7, Chapter, 67; 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 a part of this APPLICATION.
A. OWNER DATA: Nam: _ = : r �- 1 '� 1 a,a 5 e ..}
Address: ox ti3
y4k,-kV;I�4 , M1�G ZIP: 9.7as5
County: Telephone: �i� • �,� °� -r{7d
omership Status: Federal State ❑ Private 12
PublicEl Commercial F1
Other (Specify)
B. FACILITY DATA (Fill out ONLY if the injection rve11(s) is (are) for
the purpose of serving a business or industry)-
Business/Corporate Name:
Address:
ZIP:
County: Telephone:
C. HEAT1W. CCNTRACTC?R DATA (For heat pump systems only. Please give
information for the contractor that
installed or will install your system:
i� � �� ►11F-4•�.
Address:? a-� llZat
ZIP: Telephone:

D. INJECTION PRDCEDURE:
Briefly describe how the injection well(s) will be used.. -1-1
E. WELL USE: Will the injection well also be used as the supply Well(s)
for either of the following?:
(a) The injection operation? YES[] NO E]
(b) Your personal consumption? YES nNO
F. CONSTRi]C"TION DATA: (check one)
EXISTING WELL being proposed for use as an injection well. Attach a
copy of Fbrm chi-1 (Well Construction Record) and furnish (7 & 8)
below. If Form GnT--1 is not available, furnish the data in (1)
through (8) below to the best of your knowledue.
© PRDPOSED WELL to be constructed for use as an injection well.
Furnish the: data in (1) through (8) below as PROPOSED construction
specifications.
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER
EXISTING OR PROPOSED WEM IF THIS INFORMATION IS UNAVAILABLE BY
OTHER N EANS .
(1) Well Drilling Contractor's Name: a :.s e_ �
(2) Date (to be) Constructed a, -., ; Approx. Depth -Vo ft.
(3) Well Casing:
(a) Type: Galvanized Steel
Plastic
Black Steel
Other (Specify)
(b) Inside Diarrter:` inches; Wall thickness (inches)
or schedule #
(c) Casing Depth: From Q to J1 D ft. ( referenced to land surface)
(4) cement Grout:
(a) Around inner or "priu ary" casing: From to ft. � J A
(b) Around outer (pit) casing, if present: From 0 to = ft.

.(5) Screen(s): (if applicable) ,J o,JE.
(a) 'fype: ; Inner Diameter: inches --------------
(b) Depth: From to feet below land surface ------
(6) Gravel: (if applicable)
Fran: -'J.;O to 40 feet below land surface
(7) N.C. state Regulations (15, 2, 2C, Section .0200) require the
penni ttee to make provisj_ons for nonitoring -well . head processes. A
faucet on both the influent (water fran well) and effluent (water
~to wellLl.ines is required. Is there a faue;et on (a) the influent
line YES D9 NO □ . , or (b) the effluent line YES ~ ~o □ ?
(8) Attach a diagram showing the details of construction of the existing
and/or proposed -well (s) •
G. POOPOSED OPERATDG DATA: (The manufacturer's brochure should include
this infonnation. )
(a) Injection Rate: Average (Daily) __ g __ gallons per minute (gpn)
(b) Injection Volume: Average -(Daily) , .. 0 00 gallons per day (gpd)
(c) Injection Pressure: ·Average (Daily) o pounds/square :i:nch (psi) -~-
(d) Injection Tenperature: Win~r Average (Daily)
SUimer Average (Daily)
H. INJECTED FLUID DATA:
"'I S degrees F
'i O degrees F
(1) Fluid Source (Fran what depth and what type of rock/sediment unit
does the fluid to be injected derive, i.e. granite,
limestone, sand, etc .. )
Depth: ;2,~o'
Rock/ sediment unit: _<: ___ 1
\ ...... ~--)--, --'-S\-°'-~------------
(2) Chemical Analy sis of Source Water: The following chemical
characteristics MUST acconpany thi_s application;
pH · l ~I ; 'lbtal Hardness lfo at,/ I ppm (parts per million 9r ~/1)
Iron 1 .. 0 "'~ ) 1 ppn; Chloride..( ( f'I\ 'lb ppn; Nitrate ~ I ~ ~) I pµn
Colifonn mcteria N½ cmmts/100 ml
NOTE: Assistance in obtaining these values may be facilitated by
contacting (a) your local or county health official, (b) a
canmercial wate~testing · laborato:r:y, (c) __ your -well drilling
contractor, or (d) the Iegional Hydrogeologist, North Carolina Dept.
of Natural Resources & Conmmity .Developnent. -
NOrE: If injection _system is not for a heat pump, then a detailed
anafysis of both the source water and the injection fluid may be
required.
I. IN=ICN-RELATED EQUIPMENT:
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 (1) above
if the system is a heat pump.
J. LOCATICN 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 twu
(2) nearby reference points such as roads, road intersections,
streams, etc. The roads should be identified by U.S., N.C. or SR
(county 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.
K. CERTTFTCATION:
"I hereby certify, under penalty of law, that I have personally
e.,omined and am familiar with the information suhmitted in this
docLurent and. -all attachments thereto and that, based on my iirq iiry of
those individuals inuediately 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."
LJ
(Signature of Owner or Authorized Agent)
L. FOR OFFICE USE ONLY:
1. Initial Application: Complete Incomplete
If INOC711PLETE, Date of Notification and Resubndttal
2. Standard Industrial Cade(s) which best reflect the principal products
or services provided by this facility - if applicable.
(a) (b) (c) (d)
3. APPLICATION NO.

ELM
I
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DS 282-0783
a
EX SITING '
3 GRANITE. '
(MONUMENT
rti
10111WA
91Jw
ARC 214w
e7I9" Oil.; Elp
,.POWER POLE ,
e-ARC = 17.3W ROBERT A. RISEN
r1OW CUD. EIP DB 282 .Pg..783
PS 6 Pg. •221
R /W•
1 ■
\ �I LOT 6
P8 6 Pg, 221
woom -Ir :rur CDkcERK+
THE- UGAIRCT PMPK RT,Y IS *0T LOCATED 1K{;HIft'•
A BPEGlAL, FLow HAZaQ AREA -AS' pET6RA1J�1 0
BY HUDfFJA FLOGS MAR
11
JIMMY L. PIN- NI,X
DB 214 Pg.: 583.
1.
LABELED CURVE DATA
d :.R CHORD -BRG. DIST. .
I HEREBY CERTIFY- THAT THE ATTACHED PLAT- C7 29'39'52'� 232.03'
,OF SURVEY 1S. A TRUE AND CORRECT REPRESENTATION,
OF LAND SURVEYED UNDER MY SUPERMION•'
C14 48.1r23" 25.00,
CI8 19'5244" 50.00'
oars 11 044, Ba
��rullpYr■r
N07*11'56*'E . 118.8Q'
r
N31.43'41'W - 20.4I'
N45.53'01"W 17.26'
PLAT OF SURVEY FOR
ROBERT ALAN RISEN
SEWO ALL OF LOT 7 AS SHOWN
ON PLAT BOOK 6 AT PAGE 221 ..
P: FORBUSH COUNTY: YADKIN' STATE: ^N..C.
MOW

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Imo-
ry

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.
January 17, 1989
Mr. Nathaniel C. Wilson
Permits and Compliance Group
Groundwater Section
Division of Environmental Management
N. ·c. Department of Natural Resources &
Community Development
P. 0. Box 27687
Raleigh, North Carolina 27611-7687
Dear Mr·. Wilson
Re: Application for an Injection
Well Permit Mr. Robert A. Risen
Lot #17, SR 1753
Yadkinville, NC
Yadkin County
Permit No. 98-0080-W0-0001
State Health Director
We have reviewed the material submitted to this office concerning the
above referenced subject.
Considering the legal matter of endo~sing this proposal, we believe we
do not have sufficient information to deny the request due to a threat to
the ground water source or to·the public health.
Our recommendation that an assessment be made to the effects these systems
might have on groundwater remains.
If we can be of further assistance, please let us know.
LCS/RWC/ar
Sincerely,
Linda C. Sewall, Acting Chief
Environmental Health Section
State of North Carolina
Department of Natural Resources and Community Development
Division of EmAronmental Management
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor
S. Thomas R es, Secret} [
Mr. Jam" Stamey, pChie f
Environmental Health Section ,DV.
Department of Human Resources
December 21, 1988
JW Jk C,.-*, 0, 44.
Ma Bath Sul-lding ?.O.Nok .26,71 7k-z r��J1
s Raleigh, NC
• Dear Mr. Stamey:
R. Paul Wilds
Director
50 f. This office has received applications for Permit to Operate &
Use aT 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 following application, in addition to a
draft copy of the proposed Permit, to DHR for review and
recommendation:
Oper. Renewal Const
APPLICANT Permit Permit Permit INJECTION SOURCE
'Fed And Pat
Arrington
x
Heat Pump Return
Mr. Robert Risen x x Heat Pu-np Return
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/bhl
Enclosures
Sincerely yours,
� /e�? � elall
Nathaniel C. Wilson
Permits and Compliance Group
Groundwater Section
Pollution Prev n6on Pioyl
PC, Box 27697, Raleigh, Nomlf Carolina 27611.7697 Telephone [phone]
An Equal (]ppomniry Affirmative Action Empbycr