WI0400034_GEO THERMAL_20120514

Beverly Eaves Perdue
Governor
A~A-.
~,~ .. ~lll!lla~-
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 14, 2012
American Hebrew Academy
4334 Hobbs Road
Greensboro, NC 27410
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
P.ermit Number: WI0400034
To Whom it May Concern:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carotina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http://portal.ncdenr.org/web/wq/aps.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
~~
Eric G. Smith, P.G.
Hydrogeologist
cc: UJC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
~one: 919-807-6464 \ FAX: [phone]
:Tiet: www.ncwaterguality.org
Equal Opportunity\ Affirmative Action Employer
Permit Number WI0400034
Program Category
Ground Water
Permit Type
• '1
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Permitted Flow
Facilit
Facmty Name
American Hebrew Academy
Location Address
4334 Hobbs Rd
Greensboro
Owner
Owner Name
NC
American Hebrew Academy
Dates/Events
27410
Orig Issue
04/04/03
App Received Draft Initiated
03/17/08
Scheduled
Issuance
Central Files: APS_ SWP_
09/17/08
Permit Tracking Slip
Status
Active
Project Type
Renewal
Version
2.00
Permit Classification
Individual
Permit Contact Affiliation
·Todd Kowalsky
4334 Hobbs Rd
Greensboro
Major/~inor
Minor
NC
Region
Winston-Salem
County
Guilford·
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Glen · Drew
4334 Hobbs Rd
Greensboro
Public Notice Issue
09/10/08
NC
Effective
09/10/08
27410
27410
Expiration
08/31/13
_R_e_g_u_la_t_e_d_A_c_t_iv_it_i_es ________________ R_e_g~u_e_st_e_d~/R~ec_e~i_v_e_d_E_v~e_n_t_s __________ _
Heat Pump Injection RO staff report requested
Outfall 1\!t.· . L
Waterbody Name
Additional information requested
RO staff report received
Additional information received
Stream Index Number Current Class
03/18/08
03/18/08
09/02/08
09/02/08
Subbasin
Michael F. Easley, Governor
(�j P William n Ross al esout ry
es
y North Garalina Department of Environment end Natural Resources
Coleen H. Sullins, director
Division of Water Quality
September 10, 2008
Glenn A. DreW, V. P.
American Hebrew Academy
4334 Hobbs Road
Greensboro, NC 27410
Re: Issuance of Injection Welt Permit
Permit No. W10400034
Issued to American Hebrew Academy
Dear Mr. Drew:
In accordance with your application received March 17, 2008, I area forwarding Permit No.
WI0400034 for the operation of a vertical closed -loop geothermal mixed-flaid heat pump
injection well system to be located 4334 Hobbs Road, Greensboro, Guilford County, NC 27410.
This permit shall be effective from the date of issuance until August. 31, 2013, and shall be
subject to the conditions and limitations stated therein.
Please pay special attention to the monitoring and reporting requirements in Part VI.
paragraphs 1 and 2 in this permit.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit
an application to renew the permit three 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 tindergzound Injection Control Program please call Mr. Qu Qi at [phone] or me at
[phone].
Best Regards,
Michael Rogers, Enviro ental Specialist
CC: Sherri Knight — Winston-Salem Regional Office
Central Office File — W10400034
Todd Kowalsky — American Hebrew Academy
Guilford County Health Dept.
Attachment(s)
Aquifer Protection Section 163614 a Service Center Raleigh. NC 27699-1636
Internet: hllwww.ncwaternuahty.or:- 2728 Capital Boulevard Raleigh, NC 27604
An Equal CpportunitylAflirmative Arlon Employer-50% Recycledl10% Post Consumer Paper
Op a Carolina
Naturally
Telephone: [phone]
Fax 1: [phone]
Fax 2: [phone]
Customer Service' [phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
American Hebrew Academy
FOR THE OPERATION OF A TYPE 5QM INJECTION WELLS), defined in Title 15A North
Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed -
loop geothermal -mixed -fluid heat pump system that will circulate water, sodium hypochlorite
and potassium ortho & polyphosphate. This system is located at 4334 Hobbs Road. Greensboro,
Guilford County, North Carolina 27410, and will be operated in accordance with the application
dated March. 17, 2008, 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 August 31,
2013, and shall be subject to the specified conditions and limitations set forth in Parts I through
X hereof.
Permit issued this the day of - .^c am , 2008.
Colee-n H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. W10400034 Pa'-e- 2

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with .all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditio1ts 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. TID:s .pennit shall become voidable unless the facility is con.structed in accordance with the
conditions.of this penilit, the approved plans and specifications,.and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface
cannot migrate into the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall .be afforded reasonable protection against damage during
construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate
according to 2C .0213(g).
PART II -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of ~aterialS' 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 maybe
appropriate, at least 30 days prior to the date ofthe 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.
Permit No. WI0400034 Page3
PART III -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater, which will render it unsatisfactory for normal use .. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be .
required by the Division of Water Quality such as the repair, modification, or abandonment ..
of th! injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART IV -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 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 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 VI -MONITORING AND REPORTING REQUIREMENTS
1. An· sample results shall be submitted to the Underground Injection Control Program,
Groundwater Section, NC DENR-Division of Water Quality, 1636 Mail Service Center,
Raleigh, NC 27699-1636 and to the Groundwater Section, Winston-Salem Regional
Permit No. WI0400034 Page4
Office, 585 Waughtown Street, Winston-Salem~ NC 27107; 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. Irrigation well BB-2 shall be sampled prior to the introduction of additives and once every
year in the month of August during injection .activities for the following parameters:
Volatile Organic Compounds (VOCs),
pH,
chloride,
Total Dissolved Solids (TDS),
sodium,
potassium,
orthophosphate
(A) The samples shall be prepared and analyzed for VOCs by EPA Method
6210D or 6230D
•
(B) Any laboratory selected to analyze parameters must be Division of Water
Quality (DWQ) certified for those parameters required.
3. 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 at the injection facility, which results iri 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.
4. 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.
5. 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 RENEW AL
The Permittee shall, at least 90 days prior to the expiration of this permit, request an
extension.
Permit No. WI0400034 Page 5
PART VIII-CHANGE OF WELL STATUS
1. The Pennittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe, which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids · into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion
of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Permit No. WI0400034
Aquifer Protection Section-DIC Staff
DENR-Division of Water Quality
Page 6
..
1636 Mail Service Center
Raleigh, NC 27699-1636
PART IX -OPERATION AND USE SPECIAL CONDITIONS
None .
Permit No. WI0400034 Page 7
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 08/27/2008
To: Aquifer Protection Central Office
Central Office Reviewer: Michael Ro gers
Regional Login No: __ _
County: Guilford
Permittee: American Hebrew Academy
Project Name: Am. Hebrew Academy
Application No.: WI0400034
L GENERAL INFORMATION
1. This application is (check all that apply): D New ~ 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 ~ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IZJ Yes or D No.
a. Date of site visit: 04/03/2008 & 06/03/2008
b. Person contacted and contact information: Todd Kowalsky. Facilities Manager [phone]
c. Site visit conducted by: Stephen Berry
d. Inspection Report Attached: D Yes or~ No.
2. Is the following information entered into the BIMS record for this application correct?
~ Yes or D No. lfno, please complete the following or indicate that it is correct on the current application.
a. Location(s): 4334 Hobbs Road, Greensboro
b. Driving Directions: From WSRO, 1-40 to exit 213. north on Guilford College Road: Right on New Garden
Road, right on Hobbs Road, Academy is on north side of street.
c. USGS Quadrangle Map name and number: UNKNOWN
d. Latitude: 36 06'45.58" Longitude: 79 52'13.47" (GoogleEarth)
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
D Heating/cooling water return flow (5A7)
~ Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes
3. Are there any potential pollution sources that may affect injection? D Yes
What is/are the pollution source(s)? n/a
FORM: WI0400034_ APSSRR
~No
~No
RECEIVED/ DENR / DWQ
Aquifer Protection Section
SEP O 2 2008
AQUIFER PROTECTION REGIONAL STAFF REPORT
What is the distance of the injection well(s) from the pollution source(s)? n/a
4. What is the minimum distance of proposed injection wells from the property boundary? Unkown
5. Quality of drainage at site: D Good ~ Adequate D Poor
6. Flooding potential of site: D Low t8J Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: n/a
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? D Yes or IZJ No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Iniection Well Permit Renewal And Modification Only:
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)?
0Yes ~ No. If yes, explain:
2. For renewal or modification of groundwater remediation permits (of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes ~ No. If yes, explain:
3. Drilling contractor: Name: NIA
Address:
Certification number:
4. Complete and attach Well Construction Data Sheet.
Please refer to the permit app lication for full size schematics
FORM: WI0400034 _ APSSRR 2
AQUIFER PROTECTION REGIONAL STAFF REPORT
V. EVALUATIONANDRECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application: Please see comments below.
2. Attach Well Construction Data Sheet -if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? IZI Yes D No. If yes, please explain
briefly. This facility has not met the conditions of the existing permit. Arid there is no proof that the facility
will follow the conditions of a renewed permit.
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:
I None
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
I None
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
Groundwater monitoring should continue to be T~is facHity failed to meet the requirements of
a condition of the permit. the existing permit (i.e., periodic sampling).
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information; IZI
Issue; D Deny. If deny, please state reasons: __
8. Signature ofreport preparer(s): _____::s_=---1 ---1~1----~-~6:::::.._"'1t" ___ f~("-•-----------
Signature of APS regional supervisor: "JI~ T. Ki:11
Date: ------=0-=6/'-=2---'--'7 /-=2-=--00=--=8=---------
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
This facility also failed to notify DWQ-APS in December 2005 that the system had ruptured and subsequently
was repaired (a violation under I SA NCAC 2C .021 l(s)).
Attached: Groundwater sample analysis results (11 pages total)
FORM: WI0400034 _ APSSRR 3
'Mr O`W[) Laboraton, .Section
County:
I�
Sample ID.
AB30853
River Basin
A �
PO Number#
8GO609
Report To
WSROAp�
RECEIVED
Date Received
O610412008
pt_ of eNh.
Time Received:
09:00
Callecter
S E3ERRY
Y
Labworks Loginl❑
DSAUNpERS
Regloh.
WSRO
r•
U N It �O`r
Y
hate Reported:
619108
Sample NlaVix.
GROUNDWATER
Salon:
Loc. Type:
TRIP BLANK
� RegionalWlaswn
Regional ice
Report Generated:
v61v9l2v08
Emergency Yes/No
COC Yes/No YES
VisiliD
f}
�5
Loc.
f3eser.: RMEfifCAN kEBRE1M11 ACADEh1Y
Location ID:
4P041WM400034
Collect Date:
06103=08
Collect Time:: 12-35
Sample Depth
Sample Qualifiers and Comments
Routine Qualifiers
For a more detailed description of these qualifier codes refer to www.dwglab.org under Staff Access
A -Value reported is the average of two or mom determinations
N3-Estimated concentration is < POL and?MDL
81-Countable membranes with <20 colonies; Estimated
NE -tip Bsiablished PaL
132- Counts from all fitters were zero.
03- Countable membranes with more than B0 or 80 colonies; Estimated P-Elevated POL due to matrix interference andfor sample dilution
B4-Filters have counts of both >50 or 80 and s 20; Estimated 41-Hold ing time exceeded prior to receipt at lab.
B5-Tao many colonies were present; too numerous to count (TNTC) 172- Holding time exceeded following receipt by lab
POL- Practical Ouamitation Llmit-subject to change due to instrument sensitivity
J2- RepoRed value sailed to meet OC criteria for either precision or aocxaracy; Estimated
J3-The sample matrix interfered wilh the ability to mane any accurate dayterminal-nn: Estimated U- Samples analyzed for this compound. but not detected
Js-The lab analysis was from an unpreserved or improperly chemically preserved sample; EaGmaled x1• Sample not analyzed for this compound
NI -The component has been tentatively identified based on mass spectral library search and has an estime led value
LAB
Laboratory Section— 1623 Mail Service Center, Raleigh, NC 27699.1623 [phone] Page 1 of 5

----
WC <DWQ La6oratory Section <R.§su[ts Sample ID AB30853
Location ID: 4P041Wl0400034 Collect Date: 06/03/2008
Loe. Descr.: AMERICAN HEBREW ACADEMY Collect Time:: 12:35
Visit ID ·
CAS# Analyte Name PQL Result Qualifier Units Analyst/Date Approved By /Date
Sample temperature at receipt by lab 1.0 ·c OSAUNDERS MMATHIS
Method Reference 6/4/08 6/4/08
VOL
VolaUle Organics In llquld _TITLE_ ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
75-78-1 Dlchlorodlftuoromethane 1.0 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
74-87-3 Chloromethane 0.50 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
75-01-4 Vinyl Chloride 0.50 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
74-83-9 Bromornethane 0.50 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
75-00-3 Olloroethane 0.50 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
75-69-4 Trk:hlorofluoromne 0.50 Not detected ug/L VANDREWS RKEl:.LING
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
75-35-4 1, 1-0lchloroethene 0 .25 Not detected ug/L VANDREWS RKELLING
. Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
75-09-2 Methylene Chloride 10 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 6/4,08 6/5/08
156-60-5 trans-1,2-0lchloroethene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
1634-04-4 Methyl Tert-Butyl Ether .0.25 Not detected lzyL VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
75-34-3 1, 1-0lchloroethane 0 .25 Not detected ug/L VANDREWS RKELUNG
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
156-59-4 ds-1,2-Dlchloroethene 0.25 Not detected ug/l VANDREWS RKELLING'
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
74-97-5 Bromochloromethane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 6/4/08 6/5/08
67-66-3 Chloroform 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624(8260 6/4/08 6/5/08
590-20-7 2,2-Dlchloropropane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 6/4/08 6/5/08
107-06-2 1,2-0lchloroethane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 6/4/08 6/5/08
Laboratory Section>-> 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone] Page 2 of 5
--------·--___ ._....,__ . -------·· -----♦--~-----
:JvC cJYWQ La6oratory Section <R.§su[ts Sample ID AB30853
Location ID: 4P041WI0400034 Collect Date: 06/03/2008
Loe. Descr.: AMERICAN HEBREW ACADEMY Collect Time:: 12:35
Visit ID
CAS# Analyte Name PQL Result Qualifier Units Analyst/Date Approved By /Date
71-55-6 1, 1, 1-Tr1chloroethane 0.25 Not detected uglL VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
563-58-6 1, 1-Dlchloropropene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 6/4/08 6/5/08
56-23-5 Carbon T etrachlortde 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
71-43-2 Benzene 0.25 Not detected ug/L VANDREWS RKELLING.
Method Reference EPASOJ0/624/8260 6/4/08 6/5108
74-95-3 Olbromomethane 1.0 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
78-87-5 1,2-Dlchloropropane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 6/4/08 615/08
79-01-6 Trtchloroethene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8i60 6/4/08 615/08
75-27-4 Bromodlchloromethane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 6/4/08 6/5!08
10061-01-5 ds-1,M>k:hloropropene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
10061-02-6 trans-1,3-Dlchloropropene 0.25 Not detected ug/l VANOREWS RKELLING
Method Reference EPA50301624/8260 6/4/08 6/5/08
79-00-5 1, 1,2-Trtchlaoethane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/62418260 614!08 6/5/08
108-88-3 Toluene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 614/08 6/5/08
142-26-9 1,3-Dlchloropropane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 614/08 615!08
124-46-1 Dlbromochloromethane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 6/4/08 615/08
106-93-4 (EDB)1,2-Dlbromoethane 0.25 Not detected ug/l VANOREWS RKELLING
Method Reference EPA5030/62418260 614/08 6/5/08
127-18-4 Tetrachloroethene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030!62418260 6/4/08 615/08
108-90-7 Chlorobenzene 0.25 Not detected ug/L VANDREWS RKELUNG
Method Reference EPA5030/624/8260 6/4/08 6/5/08
100-41-4 Ethylbenzene 0.25 Not detected ug/L VANDREWS RKELUNG
Method Reference EPA50301624/8260 614/08 6/5/08
Laboratory Section» 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone] Page 3 of 5
----------7-r•.._ .... .,.. -~---... -
:NC <D'WQ La6oratory Section <.R.§su(ts Sample ID AB30853
Location ID: 4P041WJ0400034 Collect Date: 0610312008
Loe. Oescr.: AMERICAN HEBREW ACADEMY Collect Time:: 12:35
Visit ID
CAS# Analyte Name PQL Result Qualifier Units AnalysVDate Approved By /Date
75-25-2 Bromofonn 1.0 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 6/4/08 6/5/08
108-38-3 m,J:>-Xylene 0.50 Not detected Ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 614/08 6/5/08
100-42-5 Styrene 0.25 0.30 ugfL VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
79-34-5 1, 1,2,2-T etrachloroethane 0.25 Not detected Ug/L VANDREWS RKELUNG
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
630-20-6 1, 1, 1.2-T etrachloroethane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 6/4/08 6/5/08
95-47-6 o-Xylene 0 .25 Not detected uglL VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
96-18-4 1,2,3-Trfchloropropane 0.25 Not detected Ug/L VANDREWS RKELUNG
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
98-82-8 lsopropylbenzene 0 .25 Not detected Ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 614/08 6/5/08
108-86-1 8romobenzene 0 .25 Not detected Ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
103-65-1 n-Propylbenzene 0 .25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 614/08 6/5/08
95-49-8 2-Chlorotoluene 0.25 Not detected ug/L VANOREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
106-43-4 4-Chlorotoluene 0.25 Not detected Ug/L VANDREWS RKELUNG
Method Reference EPA5030/624/8260 6/4/08 6/5/08
108-67-8 1,3,> Trtmethylbenzene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624l8260 6/4/08 6/5/08
98-06-6 tert-Butytbenfene 0 .25 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
95-63-6 1,2,4-Trfmethylbenzene 0.25 0.33 ug/L VANOREWS RKELUNG
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
"135-98-8 sec>Butylbenzene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 6/4/08 6/5/08
543-73-1 m-Olchlorobenzene (1,3) 0.25 Not detected ug/L VANOREWS RKELLING
Method. Reference EPA5030/624/8260 6/4/08 6/5/08
106-46-7 i>Olchlorobenzene (1,4) 0.25 Not detected ug/L VANDREWS RKELUNG
Method Reference EPA5030/624/8260 6/4/08 6/5/08
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page 4of 5
JYC WQ_ Laboratory Section Results Sarnple IU Atf3UUbJ
Location ID: 4PO4iwi0400034 Collect Date: 0610312000
Loc. Dew.: AMERICAN HEBREW ACADEMY ColleO Time:: 12:35
Visit I❑
+ CAS 2 Analyte Name
95.50.1 o-DIchlornbenzene (1.2)
Melhfld Referents 6PA50301fi2418260
99.87.8 p4sopropyltaluene
Method Reference EPAS030162418260
FOL Result Qualifier units Analyst/Dals Approved By 10ate
US Not de betted L /L VANDREWS RKELLING
614108 6f5f06
0.25 Nat detected Loft- VANDREWS RKELLING
614108 6/5f06
104.51.6
n-Butylbenzene
o.25
Not detected
UA
VANDREWS
RKELLING
Merhod Reference
EPA5030162416260
&14108
W-woa
96-12.8
1,2-Dlhmmo-3-C'. k opropane
2.0
Not detected
091L
VANDREWS
RKELLING
Method Reference
EPA50301624l8260
af4108
6f5f06
120.82-1
1,2.4-Tdrhiornbenzem
0.50
Nat detected
UwL
VANDREWS
RKELLING
Method Refererrw
EPAS0301634M260
BMW
6l5me
91-20-3
Naphthalene
0.50
Not deterred
uplL
VANDREWS
RKELLING
Method Reforarl a
EPAS030162418260
614108
6f5f06
97-66-3
Heavdttcrobutadiene
0,50
Not detrxted
0p1L
VANDREWS
RKELLING
Method Reference
EPA503"W418260
sfal06
am=
87.61-5
1,2,3-Trkhiorobenzere
1.6
Not detected
uglL
VANDREWS
RKELLING
Method Reference
EPASOM24f9760
GAM
amm
Laboratory Section57 1623 Mail Service Center, Raleigh, NC 27699.1623 [phone] Page 5 of 5

County-
River Basin
Report To
GUILFOR❑
WSROAP
Collector.
5 SERRY
Region:
WSRO
Sample Matrix:
GROUNDWATER
Loc. Type:
WATER SUPPLY
Emergency Yes/No
r4.C. D►ot M F"
JUG! t i M
r911nGL 04talrrkt
Sample ID:
PO Number 11
Date Received!
Time Received:
Labwarks LogrnlD
Date Reported
Report Generaled.
COC YesINO YES Vsitlp
Loc. Descr.: AMERICAN HEBREIN ACAOFMY - [
Location ID: 4PO41WI0400034 Collect Date: 0610312008 Coltect Time:: 17:35 Sample Depth
Sample Qualifiers and Comments
Routine Qualifiers
For a more detailed description of These qualifier codes refer to www.dwglab.org under Staff Access
A•Vaiue reported is the average of two or more determinations
91-Countable membranes with <20 Colonies; Estimated
92• Counts #bm all fillers were zero
B3- Countable membranes with more than 60 or 80 colonies; Eslimated
84-Filtem have counts of bolh a60 or 80 and < 20; Estimated
$5-Too many ooionies were present; too numerous to count (TNTC)
r2- Reported value Failed to meet 0C criteria for either precision or accuracy; Estimated
33-The sample matrix interfered with the ability to make any accurate determination; Estimated
J6-The lab analysis was from an unpreserved or improperly chemically preserved sample; Eslima"
N1-The component has been tentatively identified based on mass speclral library search and has an estimated value
LA E3
N3-Estimated concentration is < POL and >MDL
NE -No eslabilshed POL
P-Eievated POL due to matrix interference and/or sample dilation
01-Holding time exceeded prior to receipt at tab-
0 2 - Holding lime exceeded Following receipt by iab
POL- Practical Ouantltation Limit-sublect to change due to instrument sensitivity
U- $amples analyzed for this compound but not detected
X1- Sample not analyzed for this compound
AH30052
9GO608
06/04/2006
08.00
DSAUNDERS
U24108
0612412008
P.
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699.1623 [phone] Page 1 of 5

!NC ©WQ £a6oratory Section ~suits
Sample ID AB30852
Location ID: 4P041WI0400034 Collect Date: 06/03/2008
Loe. Descr.: AMERICAN HEBREW ACADEMY Collect Time:: 12:35
Visit ID
CAS# Analyte Name POL Result Qualifier Units AnalysUDate Approved By /Date
Sample temperature at receipt by lab 1.0 ·c DSAUNDERS MMATHIS
Method Reference 614/08 6/4/08
WET
Ion Chromatography _TITLE_ mg/L MIBRAHIM1 MOVERMAN
Method Reference EPA300.0 6117/08 6/23/08
Total Dissolved Sollds In liquid 12 284 mgll MBOGGS MOVERMAN
Method Reference APHA2540C-18TH 6110/08 6/23/08
Chloride ..,. 1.0 15 mglL MIBRAHIMl MOVERMAN
Method Reference EPA300.0 6117/08 6/23/08
Fluortde 0.4 2.0 U,P mg/L MIBRAHIM1 MOVERMAN
Method Reference EPA300.0 -~ 6117/08 · 6/23/08
Sulfate 2.0 24 mg/L MIBRAHIMl MOVERMAN
Method Reference EPA300.0 6117/08 6/23/08
MET
7440-09-7 KbylCP 0.10 0.87 mg/L DSTANLEY EST AFFORD
Method Reference EPA200.7 6/6/08 6it1/08 ".t:
7440-23,-4 NabylCP 0.10 32 mgll DSTANLEY ESTAFFORD
>
Method Reference EPA200.7 6/6/08 6/11/08
VOL
Volatile Organics In llquld _TITLE_ ug/L VANDREWS RKELLING l •
Method Reference EPA5030/624/8260 614/08 6/5/08
75-78-1 Dlchlorodlfluoromethane 1.0 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 6/4/08 6/5/08
74-87-3 Chloromethane 0.50 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 614/08 6/5/08
75◄1-4 Vinyl Chlortde 0.50 Not detected ugfl VANDREWS RKELLING
Method Reference EPA5030/624/8260 614/08 6/5/08
74-83-9 Bromomethane 0.50 Not detected ug/L VANDREWS RKELLING
~ Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
75-00-3 Chloroethane 0.50 Not detected ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 614/08 6/5/08
75-69-4 Tr1chlorofluoromethane 0.50 Not detected ugll VANDREWS RKELLING
-~ethod Reference EPAS0J0/624/8260 614/08 6/5/08
75-35-4 1, 1-0lchloroethene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference ~PAS0J0/624/8260 6/4/08 6/5/08
75-09-2 Methylene Chloride 10 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 614/08 6/5/08
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page 2 of 5
WC (l)WQ La6oratory Section ~sufts Sample ID AB30852
Location ID: 4P041 WI0400034 Collect Date: 06/03/2008
Loe. Descr.: AMERICAN HEBREW ACADEMY Collect Time:: 12:35
(
Visit ID
CAS# Analyte Name PQL Result Qualifier Units Analyst/Date Approved By /Date
156-60-5 trans-1,2-0lchloroethene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
1634-04-4 Methyl T ert-Butyl Ether 0.25 Notdetected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
75-34-3 1, 1-0lchloroethane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
156-59-4 ds-1,2-Dlchloroethene 0.25 Not detected ug/L .VANDREWS RKELLING
Method Reference EPASOJ0/824/8260 6/4/08 6/5/08
74-97-5 · Bromoc:hloromethane 0.25 Not detected ug/l VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
67-66-3 Chloroform 0.25.~ Not detected ug/L .VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
590-20-7 2,2-0lchloropropane 0.25 Not detected ug/l VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
107-06-2 1,2-0lchloroethane 0.25 Not detected ug/L VANDREWS RKELLING , .
. 'II':
Method Reference EPAS0J0/624/8260 614/08 615/08
71-55-6 1, 1, 1-Tr1chloroethane 0.25 Not detected ug/L VANDREWS RKELLING
.Method Reference EPAS0J0/624/8260 614/08 6/5/08
563-58-6 1, 1-Dlchloropropene 0.25 Not detected ug/L VANOREWS RKELLING
Method Reference EPASOJ0/624/8260 614/08 6/5/08 .I .,,
56-23-5 carbon Tetrachlortde 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 614/08 6/5/08
71-43-2 Benze~ 0.25 Not detected ug/l VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 614/08 6/5/08
74-95-3 Dlbromomethane 1.0 Not detected ug/l VANDREWS RKELLING
\ Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
78-87-5 1,2-Dlchloropropane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 614/08 · 6/5/08
79-01-6 Tr1chloroethene 0.25 Not detected ug/l VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
75-27-4 Bromocllchloromethane 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 614/08 6/5/08
10061-01-5 ds-1,3-0lchloropropene 0.25 Notdetected ug/l VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
10061-02-6 trans-1,3-0lchloropropene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 6/4/08 6/5/08
Laboratory Section» 1623 Mall Service Center, Ralelgh, NC 27699-1623 [phone] Page 3 of 5
WC (,DWQ Laboratory Section results Sample 1D A830852
ocation ID. 4P041WI0400034 Collect Date: 05103/2008
oc. Descr.' AMERICAN HEBREW ACADEMY Collect Time" 12:35
isit ID
CAS #
Analyte Name
PGL
Result Gualitier
Units
AnalysilDate
Approved By !Date
79-00-5
1.1,2 Trlctdaraettfaane
0.25
Not detected
OWL
VANDREWS
RKELLING
Method Reference
EPA5030162418260
614M
86"
108-88-3
Toluene
0.25
Not detected
u91L
VANDREWS
RKELLING
Method Reference
EPA503t11624r8260
614108
6151138
142-28-9
1,3-0Ichloropropane
0.25
hkA detected
- uglL
VANpREWS
RKELLING
Method Reference
EPA50301624/9260
514108
Er"
12448-1
(AbrDmocUoromethane
0.25
Not detected
uglL
VANRREM
RKELLING
Method Reference
EPA503aW418260
614108
&5108
106-93-4
(ED13)1,2-0Ihhorroethane
0.25
Not detected
u9fL
VANDREWS
RKELLING
Method Reference
EPA503M2418260
614r08
el`
127.184
Tetrad0orvethene
0.25!.
Not detected
u91L
VANDREWS
RKELLING
Method Reference
EPA5030162418260
614108
BMW
108-90-7
C 0orobenzene
0.25
Not detected
u91L
VANDREWS
RKELLING
Method Reference
EPIA5WWU418260
614108
615M
100-41-4
Ethylbtlrtzrene
0.25
Not deteded
U94-
VANDREWS
RKELLING
it
Method Reference
EPA503t1162418260
614f08
fi15fOB
75-25-2
Bromoform
1.0
Not detected
ug1L
VANpREWS
RKELLING
Method Reference
EPA5030162418250
G14168
tiwa
108-38-3
m,p-Xylene
0.50
NOE detected
ug1L
VANDREWS
RKELLING
Method Reference
EPA5030162418260
514108
Gr" f
$00-42.5
Styrene
0.25
Not detected
uglL
VANDREWS
RKELLING
Method Reference
EPA503MA11WO
614108
WW08
79-34-5
1,1,2,2-Tetrachloroethane
4.25
Not detected
UwL
VANDREWS
RKELLING
Method Reference
EPA503016241a260
614=
66M
630-20-6
1,1,1,2-Teuachlac a ne
0.25
Not detected
u9fL
VANDREWS
RKELLING
Method Reference
EPA503W2418260
fi4108
Usm
95-47-6
0 Xylwr a
0-25
Not detected
u911.
VANDREWS
RKELLING
t
Method Reference
EPA5030162418260
6MM
5fwa
96-18-4
1,2.3-Trk*4oroprmane
0.25
Not detected
uglL
VANDREWS
RKELLING
Method Reference
EPA5030162418260
614M
66"
95.82.8
I30propylherizenet
0.25
Not detected
u9rL
VANpREWS
RKELLING
Method Reference
EPA5030162418260
614108
615108
108-85-1
Brambenaene
0.25
Not detected
ug1L
VANDREWS
RKELLING
Method Reference
EPA5030162418260
614108
6l5108
103-65-1
a+-ropyrtbwzene
0.25
Not detected
u91L,
VANDREWS
RKELLING
Method Reference
EPA50301S24B250
GMM8
615ro8
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page 4 of 5

¾C <DWQ La6oratory Section ~sufts Sample ID AB30852
location ID: 4P041 WI0400034 Collect Date: 06/03/2008
Loe. D~scr.: AMERICAN HEBREW ACADEMY Collect Time:: 12:35
Visit 10
CAS# Analyte Name PQL Result Qualifier Units AnalysUDate Approved By /Date
95-49-8 2-Chlorotoluene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 614/08 6/5/08
106-43-4 4-Chlorotoluene 0.25 Not detected ug/l VANDREWS RKELLING
Method Reference EPA5030/624/8260 614/08 6/5/08
108-67-8 1,3,5-Trtmethytbenzene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 614/08 6/5/08
98-06-6 tert-Butylbenzene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 614/08 6/5/08
95-63-6 1,2,4-Trfmethytbenzene 0.25 Not detected ug/l VANDREWS RKELLING
Method Re.ference EPA5030J624/8260 ·614/08 6/5/08
135-98-8 seo-Butylbenz.ene 0.2S: Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 614/08 6/5/08
543-73-1 . m-Dlchlorobenzene (1,3) 0.25 Not detected ug/L VANDREWS RKELUNG
Method Reference EPA5030/624/8260 614/08 6/5/08
106-46-7 p-Olchlorobenzene (1,4) 0.25 Not detected ug/L VANDREWS RKELUNG I',;,
Method Reference EPAS0J0/624/8260 614/08 6/5/08
95-50-1 o-Ok:hlorobenzene (1,2) 0.25 Not detected ug/L VANDREWS RKELUNG
Method Reference EPAS0J0/624/8260 614/08 6/5/08
99-87-6 p-lsopmpyltoluene 0.25 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 614/08 6/5/08 /
104-51-8 n-Butytbenzene 0.25 Not detected ug/L VANDREWS RKELUNG
Method Reference EPA5030J624/8260 614/08 6/5/08
96-12-8 1,2-Dlbromo-3-Chloropropane 2.0 Not detected ug/L VANDREWS RKELUNG
Method Reference EPASOJ0/624/8260 6/4/08 6/5/08
120,82-1 1,2,4-Trtchlorobenzene 0.50 Not detected ug/L VANDREWS RKELLING
Method Reference EPASOJ0/624/8260 614/08 6/5/08
91-20-3 Naphthalene 0.50 Not detected l!g/L VANOREWS RKELLING
" Method Reference EPAS0J0/624/8260 614/08 6/5/08
87-68-3 Hexachlorobutadlene 0.50 Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 614/08 6/5/08
87-61-6 1,2,3-Tr1chlorobenzene 1.0 Not detected . ug/L VANDREWS RKELLING
Method Reference EPA5030/624/8260 614/08 6/5/08
voes BY GC/MS Not detected ug/L VANDREWS RKELLING
Method Reference EPAS0J0/624/8260 614/08 6/5/08
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page 5 of 5
07/02/2008 12:41 336-9960326 R & A LABORATORIES
RESEARCH &. ANAly1icAl
LAbORATORiEs, INC.
Analytical/Process Consultations
American Re:brew Acade·my
4334 Hobbs Road
Greensboro, NC 27410
Attn; Todd Kowalsky
Parameter
Phoe,Ortho
Storet #
(70507)
Clients Sample Source
Number
Time Collected (Hrs)
Date Sample Colleci:ea
Date Sample Received
Cate Sample Analyzed
.Date of Repo;rt
Analyses Per.formed
tab Sample Numher
Reaults
.:o.oso mg/1
WELL
0830
by
PAGE 03/04
06/10/08
I OS/10/08
06/10/08
s OS/15/0B
:ow
P.O. Box 473 • 106 Short Street• Kernersville, North C'-lrolina 27294 • 336·996-2841 • Fax 336~996•0326
INWW,randalabe.oom
·•
A QUIFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: March 18 . 2008
To: 0 Landon Davidson, ARO-APS
□ Art Barnhardt, FRO-APS
0 Andrew Pitner, MRO-APS
D Jay Zimmerman, RRO .. APS
0 David May, WaRO-APS
0 Charlie Stehman, WiRO-APS
~ Sherri Knight, W-SRO-APS
From: Michael Ro gers Groundwater Protection Unit
Telephone_: (919 ) 715-6166 Fax: [phone]
E-Mail: Michael.Rogers@ ncmail.net
A. Permit Number: WI 0400034
B. Owner: American Hebrew Academy
C. Facility/Operation: _· _._
D Proposed ~ Existing D Facility D Operation
D. Application:
1. Permit Type: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D I/E Lagoon D GW Remediation (ND)
~ UIC -(SQM) closed loop mixed fluid geothermal __
For Residuals: D Land App. D D&M D Surface Disposal
D 503 D 503 Exempt D Animal
2. Project Type: D New D M~jor Mod. D Minor Mod. ~ Renewal D Renewal w/ Mod.
E. Comments/Other Information: ~ I would like to accompany you on a site visit.
NOTE: I would like to go on-site when you ins pect-preferably between 11:00AM and 2:00PM.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 14 calendar days, please take the following actions:
1:8] Return a Completed APSARR Form.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a co:!nplete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below; make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: ------------------Date: ____ _
FORM: APSARR07/06 Page I of 1
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins Director
❑ivision of Water Duality
March 17, 2008
Glenn Drew
American Hebrew Academy
4334 Hobbs Road
Greensboro, NC 274 10
Subject.- Acknowledgement of Application No, W10400034
American Hebrew Academy
Injection Mixed Fluid GSHP Well System (5QM)
Guilford
Dear Mr. Drew;
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on March 17, 2008. This application package has been assigned the number
listed above and will be reviewed by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary.
To ensure the maximum efficiency in processing permit applications, the Division requests your assistance in
providing a timely and complete response to any additional information requests,
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final
action by the Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days
after receipt of a complete application.
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at
[e-mail]. If the reviewer is unavailable, you may leave a message, and they will respond
promptly. Also note that the Division has reorganized. To review our new organizational chart, go to
http:l/h2o.enr.state.nc.us/documcnWdwq orachart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS
PROJECT.
Sincerely,
far, Debra
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Permit Application File WI0400034
Aquifer Protection Section 1636 Mall Service Center
Internet: www.ncwater ualik .or Location: 2728 Capital Boulevard
An Equal Opportunity/Affirmative Action Ernployer— 50% Recycled110% Post Consumer Paoer
NOne Carolina
A171urrt!!ff
Raleigh, NC 27699.1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 5-0 M WELL {S)
____ New Permit Application OR __ xx ___ Renewal (check one)
DATE: March 13
PERMIT NO. WI0400034 (leave blank if NEW permit application) MAR 17 2008.
A. PROPERTY OWNER(S)/APPLIC~T(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entityandarepresentativew/authorityforsignature): Glenn A. Drew, Vice President
representative of owner, American Hebrew Academy
American Hebrew .Academy
(1) Mailing Address: _.4_3_3_4_H_o_b_b_s_R_o_a_d __________________ _
City: Gre.ensboro State: NC Zip Code: 2 7 410 County: Guilford
Home/Office Tele No.: 336/217-7100 Cell No.:
EMAIL Address: g drew@americanhebrewacademy .org
(2) Physical Address ·of Site (if different than above): _______________ _
City: _________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: ____________ C=elc.:..;1 N~o.;.:_: _________ _
EMAIL Address : _______________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:-------,--------------------------N/A-. -··· -·· . .-. · ·
Contact Person . .:_:-------'-'-'------------· :....:...,•>·-=E=M=AIL-=·=·c..:::·A=:·d=d=re=·~=s: __________ _
Address: _______________________________ _
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: ______________ _
GPU/UIC SQM Well Permit Application (Revised 9/2007) Page 1
C. WELL DRILLER-INFORMATION
Company Name: _______ M_i_ch_a_e_l_B_a_r_l_o_w_w_e1_·1_D_r_i_l_l_i_n_g_S_e_r_v_i_c_e_s_,_r_n_c_. __ _
Well Drilling Contractor's Name: ________________________ _
NC Contractor Certification No.: __ 2_0_6_2 _____________________ _
Contact Person ...... : --------------=EM=A=IL~A=d=d=re=s=s:'------------
Address: 522 Underwood Lane
City: Bel Air, 'MDzipCode: 21014 County: ____________ _
Office Tele No.: 410/838-6910 Cell No.: ----------
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyName: __ E_D_c_· __________________________ _
Contact Person: Raymond Hunt EMAIL Address: rbuur@edcweb cam
Address: 1660 Huguenot Road
City: Midlothian, VA Zip Code: 23113 County: ____________ _
Office Tele No.: 804/897-0900 Cell No.: 804/396-5578
Ext. 125 ----------
E. STATUS OF APPLICANT
Private: XX
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed system -geothermal heat pump condenser water loop.
G. WELL CONSTRUCTION DATA (Skip to Section H if this is a Permit RENEWAL} N/A
(1) Proposed date to be constructed: _______ Number of borings: ____ _
Approximate depth of each boring (feet): _______ _
(2) Chemical additives to be used in closed-loop system (only those chemicals indicated have been app.roved):
___ R-22 --~propylene glycol __ ethanol ________ other (other additives will
need prior approval by NCDENR before use)
(3) Type oftubing to be used· (copper, PVC, etc): ______________ _
(4) Well casing. Is the well(s) cased? (check either (a.) YES!! (b.) NO b~low)
(a) YES ___ if yes, then provide casing information • such as~ (steel, PVC, plastic, etc.), diameter,
depth, and extent of casing appearing above ground: ________________ _
(b) NO
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite . Other (specify) ______ _
(b) Grout depth of tubing (reference to land surface): from ___ to ___ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC SQM Well Permit Application (Revised 9/2007) Page2
H. IN.IECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF NVELL(S)
Attach two copies of maps showing the following information:
(1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothermal heat pump well system, label all features cieariy and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
1 hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, 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, rnainWn, repair, and if applicable, abandon the injection well and
a41 related appurtenances in accordance with the apprgved specifications and conditions of the Permit."
.� .-r I
gnature of Property OwnerlAppkcant
Glenn A. Drew
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
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UlC 5QM Well Permit Application (Revised 912007) Page 3

State of North Carolina
Department of Environment and Natural Resources
Divisions of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: WI0400034
PermitteeName: American Hebrew Acad
Address:
4334 Hobbs Road, Greensboro, NC 27410
Please check the selection which most closely describes the current status of your injection well system:
1) 6 Well(s) still used for injection activities, or may be in the future.
2) ❑ Well(s) not used for injection but is/are used for water supply or other purposes.
3) ❑ injection discontinued and: a) ❑ Well(s) temporarily abandoned
b) ❑ Well(s) permanently abandoned
c) ❑ We11(s) not abandoned
4) ❑ Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
.relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description ofhow the well
was sealed and the type of material used to , fill the well if permanently 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:
9 hereby certify, under penalty of law, #hat I have personally examined and am familiar with the infbnnation submitted
in this document, and that to the best of my krr6wledge thfc in ation is true, accurate, and complete."
3/13/08
nature (Glenn A. Drew) Date
Revised 5105 GWll1lC-58

CERTIFIED MAIL #70071490 0003 7399 7103
RETURN RECEIPT REQUESTED
Glenn A. Drew, Vice -President
American Hebrew Academy
4334 Hobbs Road
Greensboro, North Carolina 27410
RE: Notice of Violation of Permit #W[0400034
Mr. Drew,
Michael F, Easley, Governor
Witham G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quahty
AQUIFER PROTECTION SECTION
May 21, 2008
RECEIVED I DEER 1 DWO
AOUIFGa PRnTF( -nnN SF_CTI0N
MAY $ 7 2008
The Aquifer Protection Section (APS) of the Division of Water Quality (DWQ) mandate is to protect the State of
North Carolina's groundwater resource. This includes oversight of underground injection well activities.
As you know, Stephen Berry of the Winston-Salem Regional Office (WSROAPS) and Michael Rogers of the
Central Office APS recently reviewed your existing permit for a Closed -Loop Geothermal Mixed Fluid Injection
Well in anticipation of issuing a renewal of the aforementioned permit. This review found the American
Hebrew Academy to be in violation of Permit #W10400034.
Specifically, Part Vi of your permit dated April 7, 2003 states:
"All sample results shall be submitted to the underground Injection Control Program (UIC)...and to the
Winston-Salem regional Office. ..Any monitoring deemed necessary... will be established and an
acceptable sampling reporting schedule shall be followed." And that,
"Irrigation well 88-2 shall be sampled prior to the introduction of additives and once every year in the
month of August during injection activities for the following parameters: VOCS,pH, Chloride, TDS,
sodium, potassium, orthophosphate..,"
During a facility inspection on April 3, 2008 the Facilities Superintendent, Todd Kowalsky, acknowledged that
neither he nor his staff had prior knowledge of the permit or of the permit's requirements. And neither the UIC
program in Raleigh or the Winston-Salem Regional Office has sample records as required by your permit.
Moreover, Mr. Kowalsky confirmed that no samples from the irrigation well of groundwater have been collected
during his tenure. This negligence to sample prior to injection and annually thereafter (a total of six
separate events) constitutes six (S) violations of the said permit.
NC General Statute 87-94 prescribes enforcement action such that violations shall be assessed a civil
penalty of $1,000.00 per each violation. Each day of a continuing violation shall be considered a
separate offense.
Mr. Kowalsky has been notified by voice mail, email, and in person that DWQ requires a sample (of local
groundwater from irrigation well BB-2) be taken and analysis rendered prior to the renewal of Permit
#W[0400034. To date, no correspondence has been received from Mr. Kowalsky.
INLoithcarolina
Division of Water quality 1 Aquifer Protection Section Natund"J
585 Waughtown Street Winston-Salem, NC 27107 Customer Service
Phone: (33$)77f-5o6Q Fax: (338} 7714$32 Internet: http:flncwateroualltv.om 1-$00$23-7748

American Hebrew Academy -Notice of Violation
Page 2 of 2
Please contact Stephen Berry at [phone] within ten (10) calendar days of receiving this
notification to schedule a day and time when a sample_ can be collected from the BB-2 irrigation well.
Failure to follow-up will be considered further violati'on, and may carry a civil penalty for continued non-
compliance with the permit.
If you believe there were events or circumstances beyond your control that caused these violations, you should
include any such justification in writing to the letterhead address, ATTN: Stephen Berry.
Cc: WSRO
Central Office -APS
Todd Kowalsky
American Hebrew Academy
4334 Hobbs Road
Greensboro, NC 27410
Sincerely,
~"ri~
Sherri V. Knight
Aquifer Protection Regional Supervisor
N.?~carolina
-------------Di-vls-io_n_o_fW-a-te_r_Q_ua-lity-/A_q_u_ife-r-Pro-t-ect-io_n_S_ect_i_on--------;va/tlfOfl!I
585 Waughtown Street Winston-Salem, NC 27107 Customer Service
Phone: [phone] Fax: [phone] Internet: http://ncwaterguality.org 1-800-623-7748
ViIA rEyQ�
�OF
Michael F. Easley, Governor
.7
Willtarn G. Ross Jr., Secretary
r
North Carolina Department of Environment and Natural Resources
Q -(
Coleen H. Sullins, Director
Division of Water Quality
February 29, 2008
American Hebrew Academy
4300 Hobbs Road
Greensboro, NC 27410
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7006 2150 0003 5466 5673
Subject: Notice of Ehpiratiou (NOE)
5QM Mixed. -Fluid Geothermal Injection Well
Permit No. W10400034
American Hebrew Academy
4334 Hobbs Road, Greensboro, NC
Guilford County
To Whom it May Concern:
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Quality (DWQ) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for
the underground injection well system, which was issued on April 4, 2003, and expires on April
30, 2008, has not been renewed. In addition, 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 5QM Well(s)
OR
B, Status of Injection Well System
If there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form must also be submitted.
I?" e Caro i a
ratura
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone: [phone]
Internet: www riewaterquality.nre Location: 2728 Capital Boulevard Raleigh, NC 27604 Fax is [phone]
Fax 2: [phone]
An Equal 0pporWriity lAffrmOve Action Employer- 50°% Regded110% Post Consumer Paper Customer Service: [phone]

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 wellis plugged and aban.doned, the well abandonment record
(Fonn 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 submittedwithin 30 calendar days of the receipt of this letter to:
Aquifer Protection Section
Groundwater Protection· Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil ·penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at . the DWQ website at
http://h2o.enr.state.nc.us/ap s/gp u/fonns.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call me at [phone]
Sincerely,
~:7 ~~
• Environmental Specialist
Attachments
cc: Winston-Salem Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0400034 w/o enclosures
Page 2
Permit Number W10400034
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
evan. kane
Permitted Flow
Facility !dame
American Hebrew Academy
Location Address
4334 Hobbs Rd
Greensboro NC 27410
Owner
Owner Name
American 'Hebrew Academy
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance
04/04/03 11 /06/02
Regulated Activities
Unknown 00
❑utfall NULL
Central Files. AP5 SYUP
02/29/08
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
MajorlMlnor Region
Minor Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Non -Government
Owner Affiliation
W �F �,•=
4334 Hobbs Rd
Greensboro NC 27410
Public Notice Issue
04/04/03
Effective
04/04/03
Expiration
04/30/08
Waterbody Name Stream Index Number Current Class Subbasin

Guilford County Property Card
Page 1 of 4
Guilford County Property Record Card
Parcel ID: 00-03-0177-0-0831-00-003 Data Upload Date: 4/1/2007
Property Address: 4300 HOBBS R❑ Inquiry Date: 2/29/2008
_ _ � _, —ram r•- � -- �
0
Ir�:rre� 2 . i 'w Ira
Disclaimer: While is to keep
T
ALT W.mr
Q% ' i � �
_ . Q �f7� {;�
S,�,b • ":ram"
every effort made
information
r r - . �-:r 1` w
`1� • •- '� .yam +q ,rR #,
4
provided over the inlemet accurate
nd up-to-date, Guilford County does not certfy
information.
* taw I&S
•.,.ieb�
authenticity or accuracy of such
No warranties, express or implied, are provided
for
,T Y E;
of
GY
;P _
or the records andior mapping data herein, or
heir use or Interpretation by the User.
Owner
Name: AMERICAN HEBREW ACADEMY INC
Address: PO BOX 700
City State Zip: BURLINGTON, NC 27216
Property Information
Description: 100.01AC 2 PB 130-19 JEFFERSON VIL Parcel Sire: 100.01 Acres
Address: 4300 HOBBS RD Area as Mapped: 97.62
Use: Tax District. 01
Zoning: Contact the City of Greensboro for zoning
Sales History
Book -Page Sale Date Price Type Qualification Improved
4746-419 9/16/1998 $8,341,000 Warranty Deed Unqualified No
Total Appraisal Values
Assessed Building Out Building Land Deferred
$15,959,400 $7,295,900 $88,500 $8,575,000 $0
http:llgcgis.co.guilford.nc.uslguitford_newlpropertyCard.aspx?PIN=000301770083l00003 2/29/2008

. G~ilford County Property Card
Appraisal Building Information (Card 1 of 3)
Code
BAS
UBM
FOP
24
• .. -
N =
10 -
N
QI
K
Description
Base -Main Floor
Unfinished Basement
Finished Open Porch
24
Is 24 r
BM
•
Is 1~ 24
Building Area Totals
Improvements
1612
....
UI
• ~
N =
1D -
....
LIi
u
Is
Square Feet
4,760
2,206
880
Page 2 of 4
Use: Private School, College Heating Fuel: Gas I
Foundation: Continuous Ft Heating Type: Forced Air(ducted)
Floor System: Slab On Grade Air Conditioner Type: Central
Exterior Wall: Stone Heated Sq Ft: 4,760
Roof Structure: Steel Frame Or Truss Market Factor: 3
Roof Cover: Cedar Shakes Quality Factor: Above Average Custom
Interior Wall: Drywall Year Built: 2001
, Interior Floor Cover: Quarried/Hard Tile, Cork/Vinyl Tile Effective Year Built: 2001
; Structural Frame:
: Ceiling & Insulation:
Fixtures:
Commercial Improvements
Steel
Ceiling and Wall Insulated
27
Units:
Ceiling Height:
N/A
N/A
http://gcgis.co.guilford.nc.us/guilford_new/propertyCard.aspx?PIN=000301770083100003... 2/29/2008
Guilford County Property Card Page 3 of 4
Appr~isal Building Information (Card 2 of 3)
@1]
Building Area Totals
Code Description Square Feet
BAS Base -Main Floor 36,281
Improvements
Use:. Private School, College Heating Fuel: Gas
Foundation: Spread Footing Heating Type: Forced Air(ducted)
Floor System: Slab On Grade Air Conditioner Type: Central
· Exterior Wall: Stone Heated Sq Ft: 36,281
Roof Structure: Steel Frame Or Truss Market Factor: 3
Roof Cover: Metal Quality Factor: Above Average Custom
Interior Wall: Drywall Year Built: 2001
Interior Floor Cover: Carpet, CorkNinyl Tile Effective Year Built: 2001
Commercial Improvements
Structural Frame: Steel Units: N/A
Ceiling & Insulation: Ceiling and Wall Insulated Ceiling Height: N/A
: Fixtures: 76
http://gcgis.co.guilford.nc.us/guilford_new/propertyCard.aspx?PIN=000301770083100003 ... 2/29/2008
:
Guilford County Property Card
Code
BAS
PTO
Use:
Foundation:
Floor System:
Exterior Wall:
Roof Structure:
Appraisal Building Information (Card 3 of 3)
CJ> ~
Description
Base -Main Floor
Patio
57
•
63
m = N
57
BU
• ...... a C
1 ..II,
C ·
~ 'lt Cl
...... 41 0 0
Building Area Totals
Improvements
Private School, College Heating Fuel:
Spread Footing Heating Type:
~
(./,)
Square Feet
19,297
2,655
Slab On Grade
Stone
Air Conditioner Type:
Electric
Heat Pump
Central
19,297 Heated Sq Ft:
Market Factor: 3
Page 4 of 4
Roof Cover:
Interior Wall:
Steel Frame Or Truss
Cedar Shakes
Drywall
Quarried/Hard Tile
Quality Factor:
Year Built:
Above Average Custom
2001
Interior Floor Cover:
Structural Frame:
Ceiling & Insulation:
Fixtures:
Effective Year Built:
Commercial Improvements
Steel
Ceiling and Wall Insulated
65
2001
Units:
Celling Height:
N/A
N/A
http://gcgis.co.guilford.nc.us/guilford_new/propertyCard.aspx?PIN=000301770083100003 ... 2/29/2008
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
April 7, 2003
MEMORANDUM
To: Sherri Knight, P.E., Regional Groundwater Supervisor
Groundwater Section
Winston-Salem Regional Office
From: Mark Pritzl 14P- [e-mail]
Hydrogeological Technician II
[.TIC Group
Groundwater Section.
Raleigh Central Office
Re: Issuance of a Closed -Loop Geothermal -Mixed -Fluid Injection Well System (Type
SQM.):
PermiE Number WI0400034 to operate wells for the injection of an closed -loop
ground -source heat pump system has been issued to American Hebrew Academy at 4334 Hobbs
Road, Greensboro, North Carolina. This is a new permit and the Undergound Injection Control
Group appreciates your assistance with the inspection and review tasks. Please retain the
application and paper work for the WSRO-UIC files. If you have any questions regarding this
permit or the MC program, please contact me at [phone] or Evan Kane at (919) 715-
6166.
CC' CD-UIC Files
Enclosures

w A rFR
Q�
y
Glenn A. Drew, Vice -President
American Hebrew Academy
4334 Hobbs Road
Greensboro, NC 27410
Dear Mr. Drew:
Mlchaei F. Easley, Governor
Wiliiarn G. Ross Jr., Secretary
North Carolina' artment of Environment and Natural Resources
April 7. 2003
Alad W. Klimek, P.E, Director
Division of Water Quality
In accordance with your application submitted on November 6, 2002, we are forwarding
Permit Number WI0400034 for the operation of a vertical closed -loop geothermal mixed -
fluid heat pump injection well system at 4334 Hobbs Road, Greensboro, North Carolina.
This permit shalt be effective from the date ofissuance until April 30, 2008, 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 application to renew the permit three
months prior to its expiration slate,
If you have any questions regarding your permit please feel free to contact me at (919) 715-
6166 or Evan Kane at [phone].
Sincerely,
Mark Pritzl
Hydrogeological Technician
UIC Program
trc; CO-UIC Files
WSR0-CT1C Files
Enclosures
AM
Fj M UN -A
Customer Service Division of Water Quality I Groundwater Section
1 800 623-7748 1636 Mail Service Center Raleigh, NO 27699-1636
Phone: [phone] Fax: [phone] Internet: http://gw.ehnr.state.nc.us

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAND 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 applic8:~le Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
American Hebrew Academy
FOR THE OPERATION OF A TYPE 5QM INJECTION WELL(S), defined in Title ISA North
Carolina Administrative Code 2C .0209( e )(3)(F), for the purpose of operating a vertical closed;.
loop geothermal mixed-fluid heat pump system that will circulate water, sodium hypochlorite
and potassium ortho & polyphosphate. This system is located at 4334 Hobbs Road, Greensboro,
North.Carolina, and will be operated in accordance with the application received on November 6,
2002, 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 ISA 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 April 30, 2008,
and shall be subject to the specified conditions and limitations set forth in Parts I through IX
hereof.
Permit issued this the 4 +-day of i&\;>r~ l , 2003.
l~ ~ ~. LAJ..~.
\JI\. Ted L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0400034
ver.3/01 GW/UIC-5
PAGE 1 OF 6
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.-
2. This permit shall become voidable unless the facility is constructed in accordance with the
cpnditions 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 ot 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 injection well shall have permanently affixed an identification plate.
PART II -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
irij ection, 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 Pennittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances which inay 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.
Permit No. Wi0400034
ver.3/01 GW/UIC-5
PAGE20F6
PART III -PERFORMANCE STANDARDS
1. The injection facility shall be.effectively maintained and operated at all times so that there
is no contamination of groundwater which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure oft4e injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the· injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART IV -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 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
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 hav~ 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.
Permit No. WI0400034
ver.3/01 GW/UIC-5
PAGE3 OF 6
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. All sample results shall be submitted to the Underground Injection Control Program,
Groundwater Section, NC DENR-Division of Water Quality, 1636 Mail Service Center,
Raleigh, NC 27699-1636 and to the Groundwater Section, Winston-Salem Regional
Office, 585 Waughtown Street, Winston-Sale~, NC 27107. Any monitoring (including
groundwater, surface water, or soil sampling) deemed necessary by th~ Division of Water
Quality to insure surface and ground water protection, will be established and an acceptable
sampling reporting schedule shall be followed. .
2·; Irrigation well BB-2 shall be sampled prior to .the introduction of additives and once every
year in the month of August during injection activities for the following parameters:
Volatile Organic Compounds (VOCs),
pH,
chloride,
Total Dissolved Solids (TDS),
sodium,
potassium,
orthophosphate
(A) The samples shall be prepared and analyzed for VOCs by EPAMethod
6210D or 6230D
(B) Any laboratory selected to analyze parameters must be Division of Water
Quality (DWQ) certified for those parameters required.
3. 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 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.
4. 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.
Permit No. WI0400034
ver.3/01 GW/UIC-5
PAGE40F6
5. In the event that the permitted facility fails to perform satisfactorily, the Pennittee shall
take such immediate action as may be required by the Director.
PART VII -PERMIT RENEW AL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
PART VIII-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to. be used for any purpose that well must be
permanently abandoned according to. I SA 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 ISA NCAC 2.C .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) Drilled wells 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, neat-cement shall be injected into the well completely
filling it from the bottom of the casing to the top.
Permit No. WI0400034 PAGE 5 OF 6
ver.3/01 GW/UIC-5
(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 Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion of
abandonment.
3. The written documentation required in Parts VIII (1) and (2) (G) shall be submitted to:
Groundwater Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART IX -SPECIAL CONDITIONS
None
Permit No. WI0400034
ver.3/01 GW/UIC-5
PAGE 60F 6
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
RALEIGH, NC 27699-1636
2728 CAPITAL BLVD, RALEIGH, NC 27604
FAX: [phone]
PHONE: [phone]
WEB ADDRESS: http://GW.EHNR.STATE.NC.US
TELECOPY TO: _Chris Roth, Construction Manager
COMPANY NAME: EDC --
FAX #:[phone] TELE#:[phone] DATE: _April 7, 2003 _
NO. OF PAGES INCLUDING THIS SHEET: _8 ____ _
FROM: _Mark Pritzl (UIC Program)_ TELE#: _(919) 715-6166 __ _
COMMENTS: Chris, it has been a pleasure working with you, take care!
1 of 1
Subject: American Hebrew Academy
From: Mark Pritzl <[e-mail]>
Date: Wed, 02 Apr 2003 13:31:22 -0500 ·
To: Sherri Knight <[e-mail]>
Sherri;
mailbox:///CI/Document~%20and%20Settings/UIC%20Tech/ Applicat. ..
This is to confirm our phone conversation on Tuesday that irrigation well B82 is
appropriate to monitor groundwater at this site. Samples must be taken _by the owner
once a year in the month of August to determine if this ·1a:r;ge geothermal system has
impacted groundwater at this site. Thanks Sherri for all your help!
Mark Pritzl
UIC Program
Groundwater Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Q = -K(dh/dl)A
Voice: [phone] Fax: [phone]
4/2/2003 2:17 PM
TopoZone -The Web's Topographic Map http://www.topozonP,com/print.asp?z=17&n=3996548&e=601228...
Toqozenc�om
Target is UTM 17 601228E 3996548N - GUILFORD quad [Quad Ind
meters
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The TopoZone is produced by Maps a is carte, Inc. - © 2000 Maps a la carte, Inc. - All rights reserved. Use of this site is governed
by our Condltions and Terms of Us,:: We care about your privacy - please consult ourPrivacy Statement for details.
1 of 1 3/31/2003 9:26 AM

DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
RALEIGH, NC 27699-1636
2728 CAPITAL BLVD, RALEIGH, NC 27604
FAX:· [phone]
PHONE: [phone]
WEB ADDRESS: http://GW.EHNR.STATE.NC.US
TELECOPY TO: _Sherri Knight, P.E.
COMPANY NAME:_ Winston-Salem Regional Office_
FAX #:[phone] TELE#:[phone] DATE: _March 28, 2003 _
NO. OF PAGES INCLUDING THIS SHEET: 2 ____ _
FROM: __ Mark Pritzl (UIC Program)__ TELE#: _(919) 715-6166 __ _
:COMMENTS: Sherri, this map shows the proposed monit()r well's location, BB2.
Please call me and. let me know if this is the well you believe is
appropriate for monitoring this system.
� Rig
` 'r�:�': r .w •� •' � r. � ter^ � .• -
OP 0
io
.•�. ++•!\yam• �. . r.-J `•'•h+-.r ' �^•^ � �..... IF
f' :ti:. y.v • ;�; ' j f�'' �' , --i Field
-Z LAW
;;•,:';�;`Y:�:;;:.+ter;'` •- '1 .. - '. • , t •; ,.•�,�` . _ � i � {_
f ^ :, .�r " :., .• i� • •rr • • � r s �f �1 - � � :�' +(/� • •f rr' I� ..ram—. r....,..
tip.: ;;�,•,;, ; ,. � � �. �, ` •;, ''',`I. F �i4
•,,-ter :�:'�•. •���� Vas*- • � ti .ry.. �� � •� •.. 'r � .` v
r ' Fw I� r
Pf
IT
• 4�'j - ,' r:r• • rt• ono �T'� �►11`j�;

• ''!i' a •x.' _
MAR-T-2083 THU 14 ; 34. AM FROG, PAX:'336856' 8 ?X�i 1' '
Pax"..,
�'�x �'v;ar'� �ri�•
ONR Groundwater Section
Fz? � 19-733-M i
�, 'Chrls Roth
Mafch 28, 2003
Well 1-sedan at to American Hebrew Academy
::ear iiiark,
Aiached-is the site map shoWng the location of the imigatl©h-vvi4'Ws vAl -us.& to conduct tz.
water quality tests. It is well B.I.
l: you have any questions, plgmm give me a call at 336-451-4 156.
�3nceral�c,
�fffr �+r
Chris FWh
ConstrLdon. Manager
s9
_ n
� d
ECC OREENBBGRO PROJECT OFFICE - 4&U RCSS$ iRO;-Z
GREENSBGRo, NC 27410. PHONE 33 46&2ne1- FA;; n�V- /

0
A9IINDERSUH $ ASSOCIATES, INC.
Pmi®ssivnal paagn SerAms
arvfaes
Osn*.q HC, -F7J09
V;runFa VWh CaMlon - rermSgee aws, omv
DRAWN SCALE bww— [][iCf.A&N T w-.,
CAP I 1:400 2S mAR 03L17371-678

1 of2
imap://[e-mail]: 143/fetch%3EUID%3E/IN ...
Subject: Re: American.Hebrew Academy
From: Betty Wilcox <Betty. [e-mail]>
Date: Tue, 11 Mar.2003 15:12:56 -0500
To: Mark Pritzl <[e-mail]>
Request voe constituents by Standard Method 6210D or 6230D.
Mark Pritzl wrote:
Betty:
VOC(s), pH, Chloride, TDS, Sodium, Potassium and Orthophosphate are the
parameters that you recommend to monitor in Groundwater with t.he use of
Sodium Hypochlorite (biocide) and Potassium Ortho-& Polyphosphate
(corrosion inhibitor) in American Hebrew Academy's closed-loop
geothermal ~ystem.
The only question I have is do you want a specific EPA method for the
voes or do_you want specific voes to be monitored? Thanks!
Betty Wilcox wrote:
Mark,
I have reviewed the information you forwarded regarding a proposal to
use, as a biocide, Sodium Hypochlorite maintained at a concentration of
0.5 to 1.0 PPM free chlorine in a closed loop geothermal system at
American Hebrew Academy.
Sodium Hypochlorite is a hazardous ingredient, however it has been
approved by EPA for the disinfection of potable water as long as EPA
established drinking water standards, i.e., _maximum concentrations of
chlorine and disinfection by-products are not exceeded.
Based on EPA criteria, use of concentrations of Sodium Hypochlorite to
treat water used in the closed loop geothermal system to drinking water
standards would comply with the requirements in 15A NCAC .0209(e) (3) and
would not potentially render the waters of the state unsuitable for
their intended best usage.
It is recommended that if Sodium Hypochlorite· is used to treat water
used in the system, the concentrations of chlorine and disinfection
by-products in the treated water should not exceed dr{nking water
standards.
Recommended groundwater constituents to monitor if this product is
used: voe, pH, Chloride, TDS, Sodium.
Betty
Formula 4515: (Corrosion Inhibitor) Potassium Ortho-& Polyphosphate
This product contains no reported hazardous .ingredients~
Recommended groundwater constituents to monitor if product used:
Potassium, Orthophosphate, TDS, pH.
Mark P:dtzl
UIC Program
3/12/2003 8:05 AM
ALDERSON ENGINEERING, INC.
CONSULTING ENGINEERS
Ca
February 27, 2003
w
i -
North Carolina
w
Dept. of Environment and Natural Resources
UIC Program
s _
1536 Mall Service Center
Raleigh, NC 27699-1636
C -
att: Mr. Martz Pritzl
re: American Hebrew Academy 1 00-100 1 Geothermal System Water Treatment
Dear Mark;
As requested, attached is the MSDS sheet for the Sodium Hypochlorite we intend to inject into the closed
loop geothermal system at the American Hebrew Academy. The chemical will serve as a biocide and we
will maintain a concentration of between 0.5 and 1.0 PPM of free chlorine in the loop.
Please contact us if any additional information is required to approve our permit. Thanks.
Sincerely,
Paul Chiappardi
Alderson Engineering, Inc.
M. Mr. Glenn Drew - AHA
Mr. Chris Roth - EDC��i7
r Ill 490.3
CARq
-``• t�FESS�D l
a 6EAL -
"022367 -
�o�
407 LAKESIDE DRIVE ■ SOUTHAMPTON, PA. 18966 ■ [phone]

FROM ALDERSON ENGINEERING, INP
(7HU) FEB 27 2003 7';VST, 7.541HO. 6305299105 P 1 .
ALDERSON ENGINEERING, INC.
(215) 3644635
[phone] FAX Dates 2/2710 3
Frans Paul _Chiamardi No. of Nges P Z
(Inxi. Coves Sheet)
To; North Carolina DNR
Att: Mark-Pritzl 9to �. ZAN Nou
Americans Hebrew A m 919— 715-0588
Peoject Nsma� No : �'e .. �r��.Pc .. Y.
s*act; Letters: Water Treatment Chem Cancentratian
massap : As requested
QIIQInfl to follow
bymmv:
;ayes
cc:
Glenn Drew
Chris Rath
o,7 x 6A ksu&L.-
g�t"3>
vtA� US�

FROM ALDERSON ENGINEERING, I N.r (THU)FEB 27 2003 7' WST. 7;5410,E3O52991O5 P 2
ALDERSON ENGINEERING, INC.
CONSULTING ENGINEERS
February 27, 2003
North Carolina
Dept. of Environment and Natural Resources
UIC Program
1538 Mail Service Center
Raleigh, NC 27699-1836
att: Mr. Meek Prit d
re: American Hebrew Academy 1 00.100 1 Geothermal System Water Treatment
Dear Mark;
As requested, attached is the MSDS sheet for the Sodium Hypochlorite we intend to inject into the closed
loop geothermal system at the American Hebrew Academy. The chemical will serve as a biocide and we
will maintain a concentration of between 0.5 and 1.0 PPM of free chlorine in the loop.
Please contact us if any additional information is required to approve our permit. Thanks.
Sincerely,
�Z--
Paul Chiappardi
Alderson Engineering, Inc.
cc: Mr. Glenn grew - AHA
Mr. Chris Roth - EDC
+��+ysti�}�r�►►h
++04% �A CAt? p�''fr.
SEAL
■ 02267 -
4 fill t ��
407 LAKESIDE DRIVE • SOUTHAMPTON, PA. 18966 1, (215) 364-S636

Q4allCbemInc.
W814w rmoftnent and SpecAf141 Chemical Alanutactudog
SODIUM HYPOCHLORITE 12.5%
OXIDIZING DISPERSANT
DESCRIPTION AND USE
SODIUM HYPOCHLORITE 12.5% is a solution of sodium hypochlorite (Minimum 12.5% as
NaOCI) for use in the treatment of various water systems. It is used for controlling organics which can
contaminate systems and as an oxidizer for iron prior to filtration. It can be used for the treatment of
potable water as long as EPA guidelines with respect to the maximum amount of chlorine are met.
EPA Product Reg. #01 T-44-2 EPA Est. #54359-VA-001
NSF Cert. #151199MH18026
CHEMICAL FEEDING, AND CONTROL
SODIUM HYPOCHLORITE 12.5% is normally fed continuously to the system being treated when
utilized in potable or once through water treatment. When used in cooling towers or other recirculating
water systems, the product is normally shack fed with the amount and frequency dependant upon the
observed conditions in the system.
The concentration of SODIUM HYPOCHLORITE 12.5% can be checked utilizing a Chlorine test.
The best available test is the DP❑ test which can be used to check Both free and combined chlorine.
TYPICAL PROPERTIES
Appearance .........................................................Pale Yellow Liquid
Odor....................................................................Typical mild chlorine
Specific Gravity..................................................1.225-1.235
pH(undiluted) ......................................................> 12
Freeze Point........................................................<-5°C(20°F)
SAFETY AND HANDLING
SODIUM HYPOCHLORITE 12.5% may be harmful or fatal if swallowed, ❑O NOT TAKE
INTERNALLY. If ingested, drink several glasses of milk, gelatin solution or water. GET IMMEDIATE
MEDICAL ATTENTION. Contact with eyes causes severe irritation or burns. If eyes are contacted,
immediately flush with clear water for 15 minutes and then get medical attention. If skin is contacted,
immediately wash with soap and water. Change and launder contaminated clothing before reuse. Wear
safety goggles and rubber gloves when handling this product. For more information, consult the Material
Safety Data Sheet provided with this product.
PAC KAG I N G
SODIUM HYPOCHLORITE 12.5% is packaged in 55, 30 and 15 gallon, non -returnable plastic
drums. Other packaging available by request.
QuallChem, Inc. • 2003 Salem Industrial Drive ■ Salem, VA 24153 • Phone [phone] • Fax {540] 375-3880 a www.qualichem.com

MATERIAL
SAFETY NFPA Designation 704
DATA 4EGREE OF EJCTREM EAZAR6
SHEET 3 = HIGH 1
z = MODERATE SPECIAL HAZARD
1 = SLIGHT
0 = INSIGNIFICANT
SODIUM HYPOCHLORITE 12.5%
SECTION ==IDENTIFICATION ================ ============
Effective Date: 5/1/97 Revised: 8/1/01
Name and Address: Phone: [phone]
QualiChem, INC. Emergency Phone: CHEM--TEL [phone]
P.O. sox 926
SALEM, VA 241.53
Chemical Name: SODIUM HYPOCHLORITE SOLUTION Formula: SEE SECTION II
Synonyms: N.A. Chemical Family: AQUEOUS CHLORINE CMPD.
Shipping Name. CORROSIVE LIQUID, BASIC, INORGANIC, N.D.S.
D.O.T. Hazard Cade: 8, UN3266, PG III NAERG #154
SECTION II:==--_____----------===INGREDIENTS
A. Hazardous Ingredients % TLV
SODIUM HYPOCHLORITE (as NaOC1) Minimum 12.5 NONE ESTAB.
CAS NO. 7681-52--9
B. Other ingredients %* TLV
WATER Bal. NONE ESTAB.
SECTION III:==== --=======_-=====PHYSICAL PROPERTIES==========-_==_ ==_ =_====
Boiling Paint: >200 Specific Gravity: 1.225-1.235
Percent Volatile (volume): 100 pH (undiluted): >12
Vapor Pressure (mm H ): N.A. Solubility in Water: COMPLETE
Vapor Density (air=l): C12: >1 Evaporation Rate (water=l): -1.0
Appearance and Odor: PALE STRAW LIQUI❑ WITH CHLORINE ODOR
SECTION IV: ---======------=FIRE AND EXPLOSION HAZARD DATA============= _======
Flash Point (method used): NONE, WATER SOLUTION
Flammable Limits in Air (lower): N.A. (upper): N.A.
Extinguishing Media: FLOOD WITH WATER TO COOL AND DILUTE PRODUCT. HEAVY WATER
]ET ADVANTAGEOUS.
Special Fire Fighting
Procedures: USE NIOSH APPROVED POSITIVE PRESSURE, SELF-CONTAINED
BREATHING APPARATUS WHEN ANY MATERIAL IS INVOLVED IN
A FIRE.
Unusual Fire or
Explos.ivn Hazards: HEAT DECOMPOSES PRODUCT CAUSING EVOLUTION OF CHLORINE GAS.
SECTION V:-r-===--=-----=--- HEALTH HAZARD DATA===
A. TLV and Source: NONE ESTABLISHED FOR PRODUCT OR INGREDIENTS
B. Effects of a single overexposure by
1. Ingestion: MAY BE TOXIC OR FATAL BY .INGESTION. CAUSES BURNS OF MOUTH
AND TISSUES OF THE GASTROINTESTINAL TRACT.
2. Inhalation: IRRITATING TO MUCOUS MEMBRANES AND RESPIRATORY TRACT.
INHALATION OF CHLORINE GAS MAY BE FATAL.
3-skin Contact: CONTACT CAUSES IRRITATION OR BURNS.
4. Eye Contact: CAUSES SEVERE IRRITATION OR BURNS.
February 19, 2003 1

MATERIAL
SAFETY NFPA Designation 704 i
DEGREE OF HAZARD 1
DATA 4 = EXTREME 1
SHEET 3 HIGH
Z = MODERATE SPECIAL HAZARD
I = SLIGHT
0 = INSIGNIFICANT
SODIUM HYPOCHLORITL 1 Z.5%
C. Effects of Repeated Overexposures: OTHER THAN ACUTE EFFECTS NONE KNOWN.
D. Emergency and First Aid Procedures for
1. Ingestion: FEED GRUEL OR COOKED CEREAL FOLLOWED BY BREAD SOAKED IN
MILK. GET IMMEDIATE ATTENTION. DO NOT INDUCE VOMITING.
2. Inhalation: REMOVE VICTIM TO FRESH AIR. IF VICTIM NOT BREATHING, GIVE
MOUTH--TO-MOUTH RESUSCITATION. WHEN BREATHING DIFFICULT,
OXYGEN MAY BE USED. GET IMMEDIATE MEDICAL ATTENTION.
3.Skin Contact: WASH THOROUGHLY WITH WATER FOLLOWED BY SOAP AND WATER. IF
IRRITATION OR REDNESS PERSISTS, GET MEDICAL ATTENTION.
4. Eye Contact: FLUSH WITH WATER FOR 15 MINUTES AND GET MEDICAL ATTENTION.
SECTION VI: --=---=====--=--=PERSONNEL PROTECTION DATA=====__---_----=----_=
Respiratory Protection: NOT NORMALLY REQUIRED
Ventilation: NORMAL VENTILATION SATISFACTORY
Protective Gloves: RUBBER OR PLASTIC Eye Protection: GOGGLES OR FACE SHIELD
Other Protective Equipment: EYEWASH STATION AND SAFETY SHOWER IN AREA OF USE.
SECTION VII:—_—=====----====_======REACTIVITY DATA============================
A. Product stability: UNSTABLE Conditions
to Avoid: HEAT, EXPOSURE TO SUNLIGHT
B. Incompatibility: HAZARDOUS REACTIONS CAN OCCUR WITH ACIDS, AMMONIUM
COMPOUNDS, GASES, UREA, CATALYTIC METALS Cnickel, Copper
iron, cobalt, magnesium), EXCESS ALKALINITY, REDUCING
AGENTS OR READILY OXIDIZABLE MATERIALS.
C. Hazardous Combustion or
Decomposition Products: CHLORINE GAS
D. Hazardous Conditions
Polymerization: WILL NOT OCCUR to Avoid: NONE:
SECTION VIII:=--=========---===ENVIRONMENTAL DATA===================W=====__
A. spill or Leak
Procedures: IF POSSIBLE, DIKE AND CONTAIN SPILL. CHLORINE AND CHLORINE
COMPOUNDS ARE TOXIC TO FISH AND DIRECT RUNOFF INTO STREAMS 0
WATERWAYS SHOULD BE PREVENTED. PUMP AS MUCH OF THE CONTAINED
MATERIAL INTO PLASTIC OR SUITABLY LINED CONTAINERS FOR
DISPOSAL. CONTAINERS MUST BE VENTED TO PREVENT PRESSURE
BUILDUP. FLUSH REMAINING MATERIAL WITH COPIOUS QUANTITIES OF
WATER, PREFERABLY TO A SANITARY SEWER IF ALLOWED.
B: Waste ❑isposal: DISPOSE OF CONTAMINATED PRODUCT, EMPTY CONTAINERS AND
MATERIALS USED IN CLEANING UP SPILLS IN A MANNER APPROVED
FOR THIS MATERIAL. CONSULT APPROPRIATE FEDERAL, STATE AND
LOCAL AUTHORITIES TO ASCERTAIN PROPER DISPOSAL PROCEDURES.
C. other Environmental Data: THIS PRODUCT IS TOXIC TO FISH. DO NOT DISCHARGE
INTO LAKES, STREAMS, PONDS OR OTHER PUBLIC WATERS UNLESS I
ACCORDANCE WITH AN NPDES PERMIT. FOR GUIDANCE, CONTACT YOU
REGIONAL OFFICE OF THE ENVIRONMENTAL PROTECTION AGENCY.
February 19, 2003 2

MATERIAL
SAFETY NFPA Designation 704
DEGREE OF HAZARD
DATA 4 = EXTREME
SHEET s = HIGH
2 = MODERATE SPECIAL HAZARD
I = SLIGHT
a = INSIGNIFICANT
SODIUM HYPOCHLORITE 12.5%
SECTION IX:== --_===--------=====SPECIAL PRECAUTIONS================-- =======
A. Handling and
Storage: STORE IN A COOL DRY PLACE. KEEP CONTAINERS TIGHTLY CLOSED WHE
NOT IN USE. STORE AWAY FROM ACIDS AND OTHER INCOMPATIBLE
MATERIALS.
B. Other Precautions: THIS PRODUCT HAS BEEN DESIGNED FOR USE AS AN OXIDIZING
AGENT IN WATER SYSTEMS. IT IS MANUFACTURED TO NSF
STANDARDS FOR POTABLE WATER TREATMENT. CONSULT YOUR
TECHNICAL REPRESENTATIVE OR LITERATURE PROVIDE❑ FOR
APPROPRIATE USE GUIDELINES.
SECTION X:-__-_--_—_ ======REGULATORY INFORMATION=== __=_ _====___---_==
The following regulations are known to ap ly to the use and disp❑sal of this
product. Additional Federal, State and Loca regulations may also be applicable.
CERCLA (Comprehensive Environmental Response, Compensation and Liability Act):
unless listed below, this product does not contain greater than 0.1.% of
any listed hazardous substance(s) - 40 CFR 302.4.
SUBSTANCE AMOUNT (Lbs/Gal)
SODIUM HYPOCHLORITE (RQ=100 Lbs.) Maximum 1.505 L s.
SARA (Superfund Amendments and Reauthorization Act):
unless listed below, this product does not contain greater than the reportable
amounts of toxic chemicals as defined under the Various regulations under SARA.
section 302: Extremely F-lazardous Substances List-40 CFR 355 Appendix A
SUBSTANCE AMOUNT (ubs/Gaff)
NONE
Section 311/312 : This product falls in the following categories.
CATEGORY HAZARD
IMMEDIATE HEALTH, FIRE EYE, SKIN CORROSIVE, OXIDIZER
section 313: Toxic Chemicals List - 40 CFR 372.65
SUBSTANCE AMOUNT (Lbs/Gal)
NONE
RCRA (Resource Conservation and Recovery Act):
unless shown below, all components of this product listed as a hazardous was
under 40 CFR 261 are listed elsewhere in this MSDS. However, prior to disposal
the neat product, applicable regulatory agencies should be consulted.
SUBSTANCE AMOUNT (Lbs/Gal)
NONE
CWA (Clean Water Act):
Unless shown below, all components
which are listed under 40 CFR 401.15,
SUBSTANCE
NONE
in this product at greater than 0.
are listed elsewhere in this MSDS.
AMOUNT Lbs Gal
February 19, 2003

MATERIAL
SAFETY NFPA Designation 704 i
DEGREE OF HAZARD
DATA 4 EXTREME
SHEET 3 = 2 = MODERATE SPECIAL HAZARD
1 = SLIGHT
0 = INSIGNIFICANT
SODIUM HYPOCHLORITE 12.5%
OSHA (Hazard communication standard):
All components listed under this standard 29 CFR 1910.1200 are listed
section 11 of this MSDS .
TSCA (Toxic substances control Act):
All ingredients in this product are listed in the TSCA inventory.
STATE REGULATIONS
CALIFORNIA (Safe Drinking water and Toxic Enforcement Act - Proposition 65):
The following chemicals and associated hazard are listed:
SUBSTANCE HAZARD
NONE
OTHER STATES: Certain states maintain their own ingredients lists which diff
slightly from the Federal standards. States listed below have regulations
ingredients contained in this product. However, unless shown below, other sectio
of this MSDS contain the required reporting information.
STATE ADDITIONAL INGREDIENTS AMOUNT (Lbs/Gal)
NONE
Prepared By: Harry S. Weaver
The data contained in this Material safety ❑ata Sheet has been prepared based up
an evaluation of the ingredients in the product, their concentration in t
product and potential interactions. The information is offered in good faith a
i is believed to be accurate. It is furnished to the customer who s urged to st.0
it carefully to become aware of hazards, if any, in the storage, handling, use a
disposal of the product; and to insure his employees are properly informed a
advised of all safety precautions required. The i nformati on i s furnished f
compliance with the 'Occupational Safety and Health Act" of 1970, the "Nazar
Communication Act" of 1983 as well as various other Federal, state and Loc
regulations. use or dissemination of all or part of this -information for any oth
purpose is prohibited by law.
February 19, 2003 4

DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
RALEIGH;NC 27699-1636
2728 CAPITAL BLVD, RALEIGH, NC 27604
FAX: [phone]
PHONE: [phone]
WEB ADDRESS: http://GW.EHNR.STATE.NC.US
TELECOPY TO: _Chris Roth
COMPANY NAME: _EDC_
FAX #:[phone] TELE#:[phone] DATE: _February 27, 2003_
NO. OF PAGES INCLUDING TIDS SHEET: 2 -----
FROM: _:Mark Pritzl (UIC Program)_ TELE#: _(919) 715~6166 __ _
COMMENTS: Letter to American Hebrew Academy
Mlctmel F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Uepartment of Environment and Natural Resources
M -4
r `C
February 26, 2003
Glenn A. Drew, Vice -President
American Hebrew Academy
4334 Hobbs Road
Greensboro, NC 27410
Dear Mr. Drew:
Alan W. Klimek, P.E. Director
Division of Water Quality
The Groundwater Section has reviewed your request to add a biocide and two different corrosion
inhibitors to your closed -loop water -only geothermal heat pump system at American Hebrew
Academy. Two of the three proposed additives are classified as hazardous substances and
therefore cannot be allowed under the current regulations. However, the Groundwater Section
has determined that the corrosion inhibitor potassium ortho- & polyphosphate is permissible and
that you will be allowed to introduce this inhibitor once a monitor schedule is finalized and a
permit is given,
The Groundwater Section's Chemist, Ms. Betty Wilcox, has reviewed all three proposed
additives and has determined that sodium bromo-chloride and molybdate are considered a
pesticide and a hazardous substance, respectively. According to 15A NCAC 2C .0209(3)(e), the
Groundwater Section cannot approve operation of a system that utilizes any substance that, if
discharged to the land or waters of the state, would create a threat to human health or would
otherwise render those waters unsuitable for their intended best usage. Since there is potential
for this system to leak and to allow the release of these additives to the environment, we suggest
that you provide in writing either a proposal to use an alternative biocide compound that is not a
hazardous substance or a proposal to operate the system using only the potassium orthophosphate
and/or potassium polyphosphate solutions. If you propose to use alternative biocide compounds,
please provide a characterization of the chemical characteristics of each additive and its
concentration in the heat exchange fluid.
Tf you have any questions regarding your permit application or this letter, please contact me at
[phone] or Mark Pritzl at [phone].
Sincerely,
`7
Evan Q. Kane, L.G.
UIC Program Manager
cc: WSRa-Sherri Knight. PE
Co -Betty Wilcox
ANcMRAF
Customer Servloe Division of Water Quality 1 Groundwater Section
1 800 623-7748 1536 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: http:lfgw.ehnr.state.nc.us

1 of 1
mailbox:// /CI/Documents%20and%20Settings/UIC%20Tech/ Applicat. ..
·subject: RE: American Hebrew Academy
From: "Evan Kane" <[e-mail]>
Date: Wed, _26 Feb 2003 15:07:50 -0500
To: "Mark Pritzl" <[e-mail]>
Here is HEbrew Academy's letter. Sorry for any mix-up or delay on this.
Let's go ahead and fax this one soon.
Evan
-----Original Message-----
From: Mark Pritzl [mailto:[e-mail]]
Sent: Wednesday, February 19, 2003 1:23 PM
To: evan kane
Subject: American Hebrew Academy
Evan:
Here is the letter you requested, please bounce
back with your revised draft. Thanks.
Incoming mail is certified Virus Free.
Checked by AVG anti-virus system (http://www.grisoft.com).
Version: .6.0.454 / Virus Database: 253 -Release Date: 2/10/03
Outgoing mail is certified Virus Free.
Checked by AVG.anti-virus system (http://www.grisoft.com).
Version: 6.0.459 / Virus Database: 258 -Release Date: 2/25/03
3/12/2003 8:39 AM
mailbox:lllCllDocuments°/o20and°/a2OSet#ings/UIC°/Q20Tech/Applicat.,.
Subject: American Hebrew Academy
From: Mark Pritzl <[e-mail]>
Date: Wed, 19 Feb 2003 13:22:34 -0500
To: evan kane <[e-mail]>
Evan:
Here is the letter you requested, please bounce
back with your revised draft. Thanks.
Mark Pritzl <Mark.Pritzl rncmail.net>
UIC Program ^
Groundwater Section 1
I of 1 3/12/2003 8:41 AM

l of3
about: blank
If this were a remediation site proposing to inject into an area of free product, we'd send them a letter
asking them to revise their injection plan to avoid injecting into free product. I think we can handle this site
in a similar fashion by sending them a letter telling them that one/two of the additives they have proposed
do not comply with 2C .0209(e)(3) and ask them to revise their additive solution.
Evan
-----Original Message-----
From: Debra Watts [mailto:[e-mail]]
Sent: Friday, February 07, 2003 2:06 PM
To: Mark Pritzl; evan kane
Cc: Betty Wilcox
Subject: Re: UIC review
Mark/Evan,
Rather than get into a potentially heated discussion, do you think it would be better ifwe wrote up
our concerns first~ make sure we agree, and send the letter to them? I think then we (both the
consultant and us) would be better prepared to discuss. But I think we do need to find out if we
have approved before, before we draft anythlng up. djw ·
Sherri Knight wrote:
I have not talked with the consultant except to let him know that I was sending up my
comments and that I was going to recommend monitoring of the irrigation well. I did not
indicate that there might be problems with the additivies since it was my understanding that we
had approved them before .. I definitely think that they should be contacted and asked if they
want to consider other products. The on-site contact is Chris Roth at [phone]. Sherri
Mark Pritzl wrote:
Sherri and Evan:
Looking at Betty's email obviously has implications on how we go forward with this me
permit application. I do not think the applicant will be to surprised since they had implied
doubts about Biocide and it's approval. At this point I do believe we (I) need to call the
applicant and explain what our concerns are, especially since there are drinking water wells
in the neighborhood or close by. This system has over 600 wells at 500 feet bls and if these
wells were to leak this could cause a real mess.
Sherri, if you have already informed them please let me know. I will not contact them until I
talk to both you and Evan on exactly how to go forward with this application. We (I) will
probably write a draft letter explaining our decision pertaining the use of Biocide and
Molybdate. Thanks all, especially Betty on her very thorough review of this application.
3/12/2003 8:22 AM
2 of3
Betty Wilcox wrote:
Mark,
I have reviewed the American Hebrew Academy file as requested. My comments and
recommendations follow:
Formula 4629: (Biocide) Sodium Bromo-Chloride
This product is classified as a pesticide and is subject to pesticide disposal regulations.
Sodium Bromo-Chloride is listed as a hazardous ingredient.
Groundwater constituents to monitor if product used: Chloride, Bromide, VOC, TDS, pH.
In accordance with 15A NCAC 2C .0209(3), I do not recommend using this product as an
additive to the 656_ proposed wells.
Formula 4515: (Corrosion Inhibitor) Potassium Ortho-& Polyphosphate
This product contains no reported hazardous ingredients.
Recommended groundwater constituents to monitor if product used: Potassium,
Orthophosphate, TDS, pH.
Fortnula 4420: (Alternate Corrosion Inhibitor) Molybdate
This product contains hazardous substances: Sodium Hydroxide, Sodium Nitrite, and
Sodium Molybdate. In addition, the listed possible concentrations of Sodium Nitrite may
increase the risk of Nitrite and Nitrate contamination in groundwater.
Groundwater constituents to monitor if product used: Nitrate, Nitrite, Boron, Sodium,
Molybdenum, TDS, pH.
In accordance with 15A NCAC 2C .0209(3), I do not recommend using this product as an
additive to the 656 proposed wells.
Let me know if you need additional information.
Betty
Mark Pritzl wrote:
Betty:
I have another UIC application file Sherri Knight
and myself would ask you to review and give us
some recommendations on what constituents to
monitor in groundwater or if the additives should
be used at all. American Hebrew Academy is·
proposing to use a mixed-fluid closed loop
geothermal system, type SQM injection well, and
the additives they propose. are:
about: blank
3/12/2003 8:22 AM
I of3
BIOCIDE-SODIUM BROMO-CHLORIDE Na(BrC112)
CORROSION INHIBITOR.-POTASSIUM ORTHO &
POLYPHOSPHATE
ALTERNATE CORROSION INHIBITOR-MOL YBDATE
I will leave the file on your desk and again I ask
that you give your recommendation through email or
a Memo. THANKS AGAIN BETTY, your help is greatly
appreciated and if you have any questions ple·ase
feel free to come by!
Sherri V. Knight
Groundwater Section Supervisor
NC Department of Environment and Natural Resources
Winston-Salem Regional Office
Voice: [phone] ext. 322 Fax: [phone]
about: blank
3/12/2003 8:22 AM
North Caroli,..t Department of Environment and N':...ral Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO.
DATE
NAME OF OWNER ----
ADDRESS OF OWNER
(Streell road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable)
�� yu_Nv��1 s�.��s sularr►� l�r� w���,�', cam, .�
(Street road or lot and subdivisio x , county, town, if different than owner's address, plus description of location on sate)
Potential pollution source Distance from well ag w6.o 60oi.,)
Potential pollution source Distance from well �wt�c4
Potential pollution source
Distance from well
a
ca
c
Minimum distance of well from property boundary v J oo 4-'CA-
e
z
Quality of drainage at site cA
Flooding potential of site
(good,adequatepoor)
(high,moderate;low)
GPS Data: ..0 « rLr� y)fL r
L4} ►+� n UG�v/1 V ac.��rc{ �-c z , , �[n i - r i�S
��
Latitude:
Longitude:
4
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and
north arrow)
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)
Ver.3141 GW/MC '2 '

INJECTION _ _XILITY INSPECTION REPORT -FORM L CONTINUED)
WELL CONSTRUCTION
Date constructed 'I r flol la'-j-
Drilling contractor: Name L,j = r&' 8�+L
Address ']
Certification number -;Z 0(e - 3o s Z
Total depth of well IJ y- 5 0 Total depth of source well k /(v YU ct vd,o -,I„r
(if applicable)
Inspection point
Casing
Depth
Diameter
Height (A.L.S.)
Grout
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
Measurement Meets minimum standards Comments ISY Ic
Yes No
CW1 U"
Functioning of heat pump system (Determine from the owner (heat pump functions properly.)
INSPECTOR 40- Office UO E
WITNESS
Address
Ver.3101 GW/UIC-2

j& Raol ul +Jc�
wQ�L-k *c4a4 6n AAai-L) CL-ii,, j-u- Y'A_jl
5 C�
L --rrLIS
A�V_Jtj_ cy- • sc :�' c cJ1Qti K- . ^ �" . . $° Lv, e.��X SL,\ ` 3 L C, %� r J C(v lVJ' �11

Subject: American Hebrew Academy & ORC at Sunoco
Date: Tue, 21 Jan 2003 11 :34:41 -0500
From: Mark Pritzl <[e-mail]>
Organization: Groundwater Section
To: Sherri Knight <[e-mail]>
CC: evan kane <[e-mail]>
Sherri:
I have two UIC permit applications that involve the Winston-Salem regional office and both need to have
closure.
• The first UIC application, type 51, was submitted by Sunoco utilizing a Geoprobe for ORC
injection at 920 North Church Street. Sherri you sent me this email below and I was wondering if
Guilford County had sent you comments.
"I have looked at the information submitted and do not have any objections to allowing
further' injection of ORC. The initial injection appears to have knocked the levels down
fairly significantly, however they are still above the target Gross Contaminant Levels for
UST closure. I have requested comments from Guilford Coun~y who has incident
management oversight but have not received any. This is a small vacant lot with no obvious
signs of activity on site. I will forward GPS data when I get it downloaded. Do you know if
the project is still proposed? I think IT Corp declared banlcrupcy and closed some of their
offices."
1. If they have sent you comments can you forward those comments. If they have not
sent you comments, do you want me to contact Guilford County? Do you have their
number and whom should I talk to?
• The second UIC application, type SQM, belongs to American Hebrew Academy and at this time I
am waiting on Winton-Salem's review comments and suggestions. I know we have talked about
several aspects pertaining to their application, like taking groundwater samples from irrigation
wells on site to determine if this system impacts groundwater. If you have sent your comments
then I apologize, but at this time I do not have any comments for this site.
I appreciate your help with these reviews and look forward in closing out both UIC applications.
Mark Pritzl <[e-mail]>
VIC Program
Groundwater Section
MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
November 7, 2002
To: Sherri Knight, Groundwater Supervisor
Winston-Salem Regional Office
From: Evan Kane4J-
Manager, Underground Injection Control (UIC) Program
Central Office
Re: Request for review of an injection well permit application, type SQM injection well
(mixed fluid geothermal injection well), submitted by American Hebrew Academy.
American Hebrew Academy has submitted the attached injection well permit application in order
to convert their existing closed-loop, water-only geothermal injection well system to a closed-. .
loop, mixed fluid geothermal injection well system.
1. Please review the attached application and submit any comments to CO-UIC group.
Retain the application for your UIC file.
2. Please inspect the injection well site to verify that the location and construction plans
submitted in the application are accurate and that the NCAC Title 15A 2C.0200 standards
are being complied with, using the enclosed Post-construction Injection Facility
Inspection Report (Form BJ a~ appropriate.
3. You are requested to return The Review Comments and the completed Post-construction
lniection Facility Inspection Report (Form BJ to the CO-UIC by November 21. If the
inspection and review can not be accomplished by this date, please inform the CO-UIC.
The UIC group greatly appreciates your assistance with this review. If you have any questions
regarding this review or the UIC program, please contact Mark Pritzl at [phone] or
[e-mail].
cc: CO-UIC Files
Enclosures
Michael F. Easley. Governor
WiNlam G. Ross Jr., Secretary
North Carolina artment of Environment and Natural Resources
November 7, 2002
Mr, Glenn A. Drew
American Hebrew Academy
P,O. Box 700
Burlington, NC 27216
Dear Mr. Drew:
Alan W. Klimek, P.E. Director
Aivislon of Water Quality
American Hebrew Academy's application for a permit to operate a closed -loop mixed -fluid
injection well system has been received and is currently under review. A member of the
Groundwater Section'9 Winston-Salem Regional Office staff may be contacting you to arrange
an inspection of the injection well site as part of the review.
If you have any questions regarding your permit application or the Underground Injection
Control program please contact Mark Pritzl at [phone] or me at [phone].
Sincerely,
Evan O. Kane, LG.
Underground Injection Control Program Manager
cc: Winston-Salem Regional Office
CO-UIC files
NnFNR-
Groundwater Section 1536 Mail Service Center Raleigh, NC 27699.1636 [phone] Customer Service
1 800 623-7748

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type 5A7 and SQM Wells
In Accordance with the provisions of NCAC Title 15A: 02CO200
Complete application and mail to address on the back page.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: October 31 2002
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1) _ Type 5A7 wells inject water used to provide heating or cooling for structures.
(2) X Type 5QM wells contain a subsurface system of continuous piping, that is
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifareezes and/or corrosion
inhibitors. (NOTE: PERNUT IS TO ADD BIOCIDE & CORROSION
INffiBITORS. TO AN EXISTING WELLFIELD NO ANTIFREEZE
WILL BE ADDED. SEE GW-57CL DATED 12/07/00)
(3) _ Type 5QW wells contain a subsurface system of continuous piping, that is
isolated from the environment and only circulates potable water. If you selected
this well type, then complete form GW-57 CL, Nadfiicadon of Intent To
Construct A Closer -Loop Geothermal Water Only Injection Well System.
B. PERMIT APPLICANT (SITE ADDRESS)
Name: AMERICAN HEBREW ACADEMY
Address: 4334 HOBBS ROAD _--
City: GREENSBORO State: NC Zip Code: 27410 County: GUILFORD
Telephone: [phone]
C. PROPERTY OWNER (if different from applicant)
Name: AMERICAN HEBREW ACADEMY
Address: P.O, BOX 700
City: BURLINGTON Sate: NC Zip Code: 27216 County: GUILFORD
Telephone: [phone] —
D. STATUS OF APPLICANT
Private: X Federal. Commercial:
State: Municipal: Native American Lands:

E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: _________________ _
Address: ________________________ _
City: ________ Zip Code: ____ County: ______ _
Telephone: _________ Contact Person: ________ _
F. HEATPUMPCONTRACTORDATA
Name: WELLFIELD IS EXISTING. SEVERAL MECH CONTRACTORS ARE ON SITE
Address: CONSTRUCTION MANAGER IS EDC-1001 BOULDERS PKWY -SUITE 100
City: RICHMOND , VA Zip Code: 23225 County: ______ _
Telephone: [phone] Contact Person: RAYMOND HUNT
G. INJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.)
CLOSED SYSTEM -GEOTHERMAL HEAT PUMP CONDENSER WATER LOOP
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(I) The injection operation? YES ___ NO -=X'---_
(2) Personal consumption? YES ___ NO __ X __
I. CONSTRUCTION DATA (check one)
X EXISTING WELL 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 Form GW-
1 (Well Construction Record) if available.
PROPOSED WELL to be constructed for use as an injection well. Provide the
data in ( 1) through (7) below as PROPOSED construction specifications. Submit
Form GW-1 after construction.
(1) Well Drilling Contractor's Name: CW BING , INC. C/0 MICHAEL BARLOW
NC Contractor Certification number: __ 206_2~--------
(2) Date to be constructed: EXISTING Number of borings: 656
Approximate depth of each boring (feet):_~4_5_0 __
(3) Well casing: Is the well(s) cased?
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel __ Black steel __ Plastic __ Other (specify) ______ _
Casing depth: From ___ to ___ ft. (reference to land surface)
Casing extends above ground ____ inches
(b) NO _K_
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite _x_ Other (specify) PEA GRAVEL
(b) Grouted surface and grout depth (reference to land surface):
_x_ around closed loop piping; from _o_ to_!!!_ (feet).
__ around well casing; from __ to __ (feet).
(5) Screens (for Type 5A7 wells)
(a) Depth: From __ to __ feet below ground surface.
(6) N.C. State Regulations (Title 15A NCAC 2C .0200) require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent (fluid being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? Yes _x_ no__ (b) the effluent line? yes_x_ no __
(7) SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well).
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available,
provide the data in part K (1) of this application form to the best of your knowledge.
NOTE: Tim WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
J. PROPOSED OPERATING DATA (for Type 5A7 wells)
(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.
K. INJECTION FLUID DATA
(1) Fluid source (for Type 5A7 wells) If underground, from what depth, formation and type of
rock/sediment unit will the fluid be drawn (e.g., granite, limestone, sand, etc.).
Depth: _____ Formation: _____ Rock/sediment unit: ____ _
(2) Chemical Analysis of Source Fluid (for Type SQM wells)
Provide a complete listing of all chemicals added to the circulating heat transfer fluid:
·-BIOCIDE-SODIUM BROMO-CHLORIDE Na(BrCl2)-0.05 PPM
-,. CORROSION INIIlBITOR-POTASSIUM ORTHO & POLYPHOSPHATE -10.0 PPM
-ALTERNATE CORROSION INHIBITOR-MOLYBDATE-40.0 PPM
(NOTE: SEE ATTACHED MSDS SHEETS)
L. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
M. LOCATION OF WELL(S) Attach two maps. (SEE MAPS FLLED WITH 5QW FORM DATED
1217/2000 )
(1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks or
drain fields located within 1000 feet of the geothermal heat pump well system. Label all
features clearly and include a north arrow,
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include,
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge pemiks
(3) Sewage Treatment and Disposal Permits
O. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally ermined 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, agate 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:�ci. all related appurtenances in accordance with
the approved specifications and conditions of the P r,nit",
r
(Sic'vature of Well Owner or Authorized Agent)
Glenn A. Drew, Vice President
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner authorizing the above agent.
P. 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 landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the injection well(g) conforms to the Well
Construction Standards (Title 15A NCAC 2C .0200)
(Signature Of Property Owner If Different From Applicant)

Please return two copies of the completed Application package to:
UICProgram
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
mar ub ue untlaup
Uuat L VIC.
SEECO, Inc.
I
336- 5-2ROD p.3
13to c I L)E
2 104 Woy Court
Riall Polill, NC 17265
FORMULA 48V PhothVFux. (3.10) N$i-22�0'
SrAWJ&D LJOU10 CHLOPANWIRMW
FORMULA 4W Is dk AWiNzw WXY lnoA* krine for the tootmayt at OPon. rvdin-WWric
ugmWV*mwws. ovoporm*v**orodwww% air vp*mwa, dcoormdvofbutw—. owtmnponftwid omor
viubw w/akwm 7ho Imm" Is uoWled as a -cow vimooily. @@Wly pumped lqtid. When odded to
wwAw, the puluct fomw viobihmd hypobrc moos wo hypoolomw (HOlk and H00i) add..
Howwor, wal*dkrino. ft PORMULA46Z mnirO sins fill ooWtyst the vide ph mrVolpewwradly
wmuftred In 000firio wdw ayubwm
EPARMOVOW(Pr► Na. 58016-1-SWU
FOWLILA 4M Is ramo0y fed =*.vjmm y to tho symm being WaAW Ww ublmd to
xWe or onw VvvjM wadw "obneM Vft n ule 111% cooling bwam or o0w redrWidrig vAKdr
Wd0fft�**pVdWdI*FKNFl lY ohm* fed wth tht. wriourit and ftequerwydepen0rd won
xaorvad oardrtiom In the oy*ai .
Tho =ww000n of FMMULA 4WO ew be dxKked tiflixino a stwaSwd chlodro or
"nino twat. The best "l@W&tWiw the DPP teal . Vhm towku ffsoro. rmAely the ruadt by
3.25 to 00WIn VM onw0no ooncar&xbm
ry"CAL mgff"S
Appowwwo ..... . ...............................................Br aM qCw Ntbd
odor............. . . . ... I ................ —.1 . ..... . I.............TYoGW ligilogco
upwaft wovily................ . *I,, ............ : .. ....... _.-.1.264=
Doolty ................................... ....... .......... laS IbLtgw-
"4ftk&KV) ............................... ........ ............ >13
POIRMULA 4&0 awry be hwmkA or f " If w400vad. Do NOT TAKE INTERNALLY. If
I Vodwl. ddr* wmrW gNoom of Nk uWal-n sWi nion or wow. GILT IMMEDIATE M03CAL
)%TTINnON. CwAndWth wo o*A= mvem ipftd vcrham If sane wv=ftcted,IhvrodmWY
f uM Wth claw Wkw for 1S mirrulas wW get viadoi Mw*m If aWn Is tAx 'I ad. IMM&Mwely
%olh i" sow and "mdw- Ohm" mid INOW(-r oonlzrinided doting bek"Teow ~ 9d4rty
SoWmand nA*wowm ws Wdmmviw vrArip tNe Product. For momh ft OW&A
t -m MoWal Sofety Doft Shout pnowkind with Vd* prc duot
FORMULA 4M I$ PbAmVW in W30 and 1 S-Won "on-ftrmblo Phmdc drum CXher
rodwaing avoiloble by request.
tAll
Ndustrual iYatei Mannomew

Mar u5 Ue U41�:kdp
MATERIAL
S"ETY
DA':'A
SHIEET
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Efbdbe Dmiai IV 1101 Rimed: MODE
NomedadAtides ' Pbat CMSW2280
P%Dmt CHM 7&0 0y 25 24
SEA GC, INC.
21C-4IAIDY00W
HIC-1 POINT, NNC27
Cleamk* Mew+ . SEESECIION M 1 "ola: Na(Brcb)
SyI1DlIyM bil(RAICIDE cbm kal Fwwr MO[im
SliMft Meet *WtOSW LgMW if K. MtCilH+ CS, N.O.S.
D.O.T. rf(Iris:8,111N13MPG11 HA W-*1-4
AEMN ll:z:w-w.R...mm—mo-mmm—=.wlNy"EN�SwAuwwrws..�.
k Howdaa:: Io pw5ems % 7LY
SOi UU 9itL1tdO4XL0XK
CAS NNO.1PROPWARY M NONE ESTA9.
L Odder r0,6dmb %* nv
WAM Im. NONIEIESTAR.
`Lqet L-43k M-3-30%; i1-2,30%
SECWNI 01 Pp'7$IM PROREPTIH u-cme-......n.m=
NO%rd.t 2 t4 OW F. sperdlle WNW,1.37
peeae*MoM+ile (IlOieeee0� 142 ph (pmmm: 327
vawpmom ;IIR■ 1411: 19 WOW IRWalor. MWIRLE
paper dealt o" 1 onvolmdoa Rita Nall 1},1
Appmmm;:arl Odor; CLEAR YQ W TO CUM DRAMGE UQU ID
SECWX W. AND EMSlall HAiARC DATAm■■r¢=m••••Ma-, -wo=rr.
Pmb Palatlr10 rod AMM: NNE
Flamri{qgM! N.A.
E]dlr4"11 NLaw HOW RMWRM
Spedal 1m F10.ON RWOmm USE IAIOSH A"ROVED POSI I VE FSESSURE, SELF-
CONTAIMED imEAYHING APPARAIM WHFIN AWMATERIAL IS LYWOUIW IN AFIRE
tMum Nile or Emfoslae HAIR: NNE
SEEN Y:• H4URp]AiA•=arw...��s+wwas.�..Mr�.��ar�e�
A. iLV amd So rlte: N81"iE MIAB19M FOR PRODUCT OR L40MIElL,15
a
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336-- i-2280 P.5
MAi ERUkL
SAFETY
QA'i4
WEFT
FORMULA 4629
IF lxb"llra6■l I"
ONAMOF gAkARC
3 ON
2 ■ No46[Alt
3 - #uClll
0 a l�Si4il� iCAiT
rPW�ALZ1)XLD
IL Elk= Life Sift" Ommgnmby
I. I"wJo,r. U&9ET0= Is1lWG29TK)A.
2. Mkoleftt llilllTATING'M MUCM MB4Bkm4BAND RE5P4rtAT0ffnRACr.
3-Skim Q.i*rt CALM 9I1RA5 TO SbN
4. Ike oost i* CAN CAM BUI MS.
C Bbft c f 110PNA d Pnwft OTHER THM ACUTE EFFECINONE IWO'YI .
0. E�r�gTR�d Rr�AldAecedlll*i frx
L IaB MMr DlllKK SEVEItILL MASSES OF WA'I>~R AND Grr ii9lM DIATE MSMX
A'rmmwN.ISO "oTINDUCT=VOMfTwa
2 loWsUo.,cREWWVWnUTOFRMAM.IFNOTMEAIMINGGWAPMFWA RESRIRArM THEN GE r IMMcDiATE
MEDICALAMPMN.
3Skii Co nh tit WASH THOROtKKY WITH WATER FDLLDWFB BTS'W AND WATER FOR iS MINtM. IF WJrTAllQN OR
FEWNESS VEISISM GET MFRICAL ATMMON. CHANGE Mb LAUD OM CONTAltiRWATM CLOTHING B"E
RRJSI:
4. Eo Opftt IMMEDIAMYFLJISH WRH CLEAit WATER FDR 15 i4!lrWfTES AND
GET I4fDW^ATlEhTKK
SECTM K I;;•a EL PRQTE{.'Ti N BATAspa le=---amwo-m:��-n�aRw+y�■.�
rtmo p m Plt*x ON NJL
Vedle m N[RMAL WO ILATMOII SATISfX-M
Ptiaw"C.lai ei: RUBBU ON P ABIMC *& : GCOtM UR FACE WELD
OHW Pmb *e Eqoi~ EYEWASH nATOON AND sAEt Y SHOWER IN AREA OF USE
SIL MOM V l: :-wmmw=wumww—wmm==m=wREACTF f7 DATA—w a m1 = MlII�tiY�R7a
A.Pl' ouct f uiow. SSE commeA5 to Amokt KAT
L l omweta lip KAMOM NEWHO M CAN OCQJK tiWTIH ACIDS, AMMONIUM
CChMI*UPN)S,GASK WWA, WffWJU d SAL75, 110440MRC SURFACE
ACIWEAGENIS, CEUM COM USTOMAND ORCAMX$ AND
DMMV"tk a' f�NGt1 RMR41GM DROMIDE, BROMINE, HVDROGEN IDE,
Cif=MI L
�= F
D. Ha®lt im PWywertmbw. WILWrOCCHR Chnado■■to ate: NONE
SECM14 Vilb .ow—ft.■■— mmomENIIIROWENTAL DATA..--m-m—mmamw lo—ftw.z�=-
A. Spit ar tft* Tmmhnw. IIQrI MALL 50URCE5 OF 16WnON. SWAP UP SPILLS AND
RACESWE04KS W AC" C AINIM AND ISOLATENECOWfAINER OUiSIDEIN AWELLVF?RIIATED
ARGL DO NO!<SEA TWCi5WAlIi 0E
FIM THE AREA W M COPIOUS QU TIM OF WATER, PIIEFERABLYTp A S WI'iAW SEINER OR WASTE
TREATMO(T FA LITY.

mar un ue u4t'4"P L 'ue Ir1a. 3db- 'I-e-r-bu fo•b
MATERIAL
SA Fi=TY
DATA
SHEET
FORMULA 4629
IRA Dwtl(1 v*m 744
Dow of blAmb
s 's caailml
3 .. INN
10 MCDCRAI
3 • SLXHT
o - i9walr ACM
j I VGl be
tOA6, G
7&1-
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l V*6 Digr*M N PUBE DP CWAIWHAIT® M)DW, rWn COWAIMM AID
IWAIGUALS US® N CLUNI (` UP 8PtLLi3 IN A WARR AMOWFD
F)R MIDONG YA'lW&U& CONWTAPPRMIAIE FIDE1AL., STATE
A -VD LOMMAIlp IMTOASCItT N PROF">3t CISPOS&
C.OtherEnwpia-P-1 DmlWACiWAQ llcTOO=F►DRTAP1tWiCf
1# t11p01QM W1T Ca1159cm TO W H O L "all"
GRE MUST BE TAM TO PREVVEW !t[INW INTO KAYURAL
WATERWPM.
gECnom IA:a .CIS.■S,PEMPBRAt1Elomsm Sam
.��swA�ssl��a�wwwwslw�r.•
A. Haug mg and S%MW 9=9 IM A aaor. DRYPLACL KEL? CO tT]AIIIt71S TICH TLYGLOSED
WfIIEPI NOT IN USE MW AWAY FROM ACIDS AND OYN8I INWMPAnBLE IMATHiM,
s OUM PIMVIJOW TIi<S PRODIIC[ MS BLM 1 WGM FOR USd IN SPECIFIC MM
OF ;(O WATHE CMUM AND 5140UW EE WED ONLYtM
A0l*RDAW:EWM THE Ei;S'iRUC 0N6 PRIG SHE
1 SCHO L WMEWATrK GERWM AI0 THE FiApUM.
I
5EMN x. INFOR IATION—co+wwwwzarrwsss+w.wr:Mw•Fw
IM fci* Mag PW*6M On ko w*iQ W*lothe at Afd &%PD sl dthk Pled Gt. Additio ■W Fe i, St 0 aAd Loral M9dAl0fiS
melt also be aP ppl w*&
CtRCIA Mm"VeMMMM ElwirvaMEW 1Ig0RICL CWp MWMoa Mad llsdllly ACV:
Uoleu &W bOw, ft puled doe3 not onW ■ IO'ea*tk m 0.1%of any K tad ham otn sr ""s) - 40 Ct 302.4.
sWWM &W-N-Ttllb�Lw
TIIFS Pi1OD=1$ CIAMM AS A PE5TI E
AND IS SL BJWF70 PESTIME DISPOSAL ItSWI AT10M.
SARA PwerkW Awm6onis&W Red1E>luW&s•Ac*
Unkst§Mdbdm,tMhp1 OWdtlosw tmgtmn "6d1'tf1$n3:iF6rq)D[s111dRobOfIDdCCbwi[&3ad*+4Wde'�!!6
SAetit+Il 311 : L rr Haeeradoas S temez List - 4Q CFR 355, x.ppe rak A
NONE
3s0Ii� t 311 j3 !�: T1�la prt,�7rot�in t� 1b11ofrla5 �grxles.
HAND
IMMEDIATE HEALTH E r., SKIN COMO$iVE
Solert 313.,T000c CA wkaks U$t- 40CM37'Z45

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MATERIAL
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DATd%
SHEtT
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FORMMA 4629
WC
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own nF i.gmig
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ilRleaaaaynw6owrON(q- 00 oftftpWud ftW as a WorWomito:#dff4OCFWHime m!dd;C'~ioftWW.
Htr*"w. oft'b drip" of tt Rddt prod mct mWp o * mgai W f a0mes shotid be GdrlsWW&
Mamma ►wMiff 4W1w
HONE
CWA [Ciem n 1 tabar Ac*
Hls m - sbaarrl below, ail mmoftWill 08 p W§d at mooW thorn 0.1% wwlcil are RAW Nader 40 CFR 401.15. are Wood
aiaww,wn to twv AKSDf.
MOVE
OSHA tllepltud Co m o6caom .
M of 19 oneella N1 W v■dei tick stw t iJ 29 CR 2910- 22 DO am Now iw 5ewo R ai if tki s mm.
'I= (To* Scbflrl= CcwW AM:
IW err$ mdten� IN uia prodadt aro gybed ilI m01'SCJ1 In1►e�arx.
JTATW R17Bt1U1P" S
CALIFORNIA 9''aft DrtoWme Woo aid io* E1om rn m Act � AlopoWWo B9k e.
TM btu0 tdlalrlil~a4OW *Lvd Dd am fisted: , f�
OYl�R a*A�'�,: CeriRitl stHdlt ij■i11ERii riAk Dwn is lhtswt�lo11l1Af�rsAglltIYlM4rrit11e tea. gEaksl�dl�
kW RW1099 Oa I0908ft MUNed 111 ft pmdaet- ND" ftw, WASU $bwl bdW, DtbOt SECOOIS 5f U5 USDS CMW A tFA
sk1r; ltDDMONAL INGRaSIIMS AAMMAYM
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Pmpme d Br. Hi rry & W6mx

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tlteiri�Daoe atr 7ilwr IslMc piadre#and O�bngai lllbera�6a�ls.'�c isli�rrr�vxo [sdfierred i■ i�t� ate iROr�icweeln Ocacwabc, R�
fw*M d #.} ttie custnaw who Is WWto sb* it MdWIY to bmww a+m at M wds, if sNY, Is tM 1P i >sefmgmg umaW
dMONal a! #1e prndat and tO hM n WS eMOUPM SO pMpo&Y iftMm5d and adrlsad of all sdW tnahftrs mod. TMe
i OWmadof, is the "OoaepolO@4 Sakty& d Heaft Apt" of MO. tale "11MZVOi Coerlwnic Mn aVd:' at
1983 asweaes rslbw aMw kdm , Slam asp 4W mgmWiom use orcMuenlfWWOO of ail or pedof this inmMMOOn foranyomer
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00
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DATA
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Ukd= D&M 8jl/09 Redsdd; 9/ i/Q1
NW s§d A ddMW Pbwe (33M 91 W28d
Emogocy PWoc CIIF*M (800) 2rk5-3924
See GC, WC.
2114IAWYC CURT
NOR FOINT, NC 27985
Cli wkw N;x r. NOTAPPUCARE F ormtft S£E S Il ON N
$Wuo"=11A. Cbes" FWdhr. ti11GWRE
Siipoft Nsnls_ COMPOU1Sf WATS TREAMME FT UQUID, N.O.S.
D.O.T. Him d I loss- NW • Oode IIv.1 ONE
SECTION I1 x�fR1.■R..�.r.t�si�....Nj(;��/���=�wasrrrwww...mnrY:=s>~a��^==
& llarwMvs lii % TLV
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Ilr OtwInoldleb
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P0TA8WN I'lOLVPN0$lm A1'£S
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*Lggm& L``■ si %; M,;I.10%; H-BYO%
SECTION Ilj.w.www=Mwwww.wxoaammom-WMICAL PROpIERM+rraG� �:a��ww...waRwRwr.Mw
I oligPWN D22" SppirMGrdw.IM-L36
POMIV* dir116dMIW. II3 PH Wnadn* 6-7
VWw Pwu n 0= H& NA Schift In WI1dr; C>MIIPLEM
1+Wna pwdt r tsir-fk ri P l pasaliag Rab t&U 2■ 1.0
Pppe=■m a d Odor. W►R7E3 W14RE UQl1ID WnW NO AMECIAIILE ODOR
SlLr4WK N;= — ---- rr=..FME ACID E PLOS10111 HAZARD DATAw•i•- •so
PW1 Pdidlmcbad WK
PbmmMe IjrHh ttl Alrpuwc*-. 1I.IL {ilpp%t. NJL
Ww"ll Ii "t MY FI 04A SUITABLE FOR THESURROUNDIHG FIRE
Spocld rim F%NNr
Prated Mier RR900M SHOULD WEAR NORMAL PRt3iEC' W EQUIPMENT.
!a r-CDNTAINED OREATHINQ APPARIITLIS SMI D BE IJSEO IN
C'OfFIN 0 AN EAS.
unnow RN or

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MATERIAL
SAFETY
RFPA 0464Wise 764
DATA
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SHEET
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FORMULA
NO.4515
"Nofft MMI
336-
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8PBC1A1.HAT.ARD
SECT10N Y.==.-W-ALLTH HAZARD DA1iA�N.ueaapifYl l�.ai=^J l3N�Nrar.RRiilNNlNa
A. TI.Yaad S S ce'. W)NE AUMMINFD FOR PRODUCT OR INii NiS
a. EAadb of a `-Jqk Onnocomby
L ImV5Sm9 MAYSETWCM OpCENIR11TM FORM. DO NOT TA1i{irINTSMAMY.
2. IaMaiMow 1I0TA LIXELYNO=OFDM'OSURE
3.5Ido Cm Iar O PROLONGED CONW MAY CAUSE IRRTTA17F )N.
4. Ele CwNr wt CAILiIiES INKITAT1001.
C` Bbesaf? Romobd Oo pomm 03IIE71 TNA<Mi ACITTE In ACTS, MOIIE WOWN.
o. Emwrper. rd FInitAiid Ppmmft t;1br
1, I ng diut DRRII(SRUAL Gf ASSO OF WATER AND OT I WAE NM MEDICAL
AT) EhTIOn.
2. InkWatkir, ROADVE VCW 10 FRW AIR. IF WTUREATtimG, I
AR' IS CIAL RENAMA10L GET WIMMA17 MMCAL AI TFJIR N.
3-*Ao Comb WASH WAH SOAP A NDWATM OR PAIN WA IX
A. k)% CuOad: IItM E MT®YR IM 11r17Ri CLEAR WATER FDR 15 MINIM AND IF
N111 i31ON ! RNM W IIIEOICALATrQRIOFI.
SECTION UI:a■ soomm-= i PFASONn1:1 PROTECTIOII uATAiN .�g.�i=������,_-r�=���
R*MhW arf f m zc1Iomc Wr Ir NIRIA LLY RED
►Ir<glMbM NOILMALVEN WITS? SA73FACM
PraCxfty$IMwe GI-2w 44: DPTKfti Ede Pm1 cdowr: avOcil.SS 09 FACE 3NMW
Doer• PMie IW EgalpawI t EYFWAwS119ATIQN IN A QE A OF LM E
SAG'1'ION X1I:im --�-mm•--wmw1ft*=kmm=#IEACIIYRY dA71N�i1:¢CilwRiiwixii�N�N��I���niafa�ar
AL PMd0K5IaD §Ir. SLWE CoN SOM
ID hookk BONE
IL tx*mpwwhis4r. ww IQiItlIII11
C. Hazomms ot-wrtboom or
Drcospmbimi hva wmL 0130I6 of PRO PIIDROLIS MAY 81 R'IBEASm IF WATER IS
04VO ATmerYHE"EATOFAFRE.
D. Hammos Co+rd11{ OM
Pgt►medz9vr WILL NOT 4CCA In AmK HONE
SEC IION 11II1.-===-a—mmmmiaNNNNNENWRONMUMTAL DAIIAImaami.rNN� d=r��i���aiaev-�lC.aN
A.Worl. k
Poodwwres, SMALL SPILLS MXYRERUMIEDWAIL Cam' tK QUWTIIESOF WAT IL
PRO ER MXY70 A SAAIRARYSI NER OR WASTETRI:AITf IEW FACILITY.
LARGER SP110 MAY REABSORBED IN SAWDUb-I OR OTHI t A RI;M

Mar US D2 04233P
MATERIAL
SAPEN
s[ Ds IMo.
*"A ftwo li6m 704
DATA
bbou BF Dime
;: UnME
SHEET
: - WIN
_ . molman
I. SLINK
10 ImAnSw1GAr
FORMULA
NO.4515
335-F -2280 P.
cop-i, 46-0 ox !
i N Q tbo-t' rz- fA&F [g
MiMEH-3
SMIAL HAZARD
MD'SMI NO D"MM OF M AM APPRIM LOD1all..
& Wtsw DUpo s* SmAm QuLvn= mw K DILUM WnM WATER AM FWS IED TO A
sAvnmrsom umm oummm IrwKau tm II« m
AP 2*)VED UK*I L WAIEM. 0WALL1BBtAL, STATI:OR
LWA _ RISGULAll S.
I- 01;W lEwi ro i InraNFal Dd& C.ALCRATFD AQUATIC 70Mf M M ME PROOua
tap PPM BASM 01111E MWI TOM INGRU IENT KNOW
IR THE PR00M.
BEt'MN Ll atsara+waa:samasaArsa wa1wSPECL4L PKCAUT1014sam aa mmmam0 wszsR. Cacwasw
A. lmudl��INc
SbXW. OWE wAMMDfffi'L1IMXMP00F47MMM FIGMYCLOSIMWHEN
MDTVW-
B. Otbw Pm ar &m THIS PRODUCT HAS KM DIMMED FOR USE N SPET± M TYPES
a- C 3"G WADI CMCUffS AND SHORIID SE USM ORLYIN
ACV >1dK" W TH INE IM$TiI11MVft PROWWW WT1F
TEMN" REPRMCt"UTW39RW AGTILEPApl.iii.Al L
11110 EDISFIS ARE NSF APMOVM FOR TMTMENt OF POTABIF
WATER$ HP TDA MAXIMUM . ANI;WTRATIOII (IF lO ppm
SEMML-elmonaasamaasaa=tmsa=°rREGUIATORYwfwm+nomw-maaammum oomarrma-aa.to
lie 1pIl0Wog Fl1pI-m am bon lofl*to the 11wa%d d1ill" 0bit prvdaci AddfllooAl Foft nob and Loaid mm "tions
may al * be Fa IIm I&
ClIMCIJI Pm ro okmo r Eo&vmwpw Rwvofme, covemdot1 wo Lmbft P4: '
Urft:s I ftd below, tMS pmdoct does W CDOWN pw tm tke ■ O.1%dMq listed ItsrAr[iD as sa6s#An*sj - 40 lit 301.4.
GAIIA gopm-Nmd Andsc> w t# &W Romotbw1midoR Aco:
UWasL skd betcrw, tMspmdod dDft out 0pMOBgvd `wtMo to ropo(W* am uas of W* dwwkWasdRAilPfi MI ftC
■wi& is, Mulations >lo6w SAM
$Md m 302! EWW* HUMID n S MSMGM List- 40 CFP SIM, AMnW A
Nape:
Seedeo 311/3 M TWs pm6ud%us lathe hawing csm@Mw
HAZARD

MATERIAL
SAFETY
11FPA G.s19"102 TIM.
OATA
man es uzAtb
SHEET
4■FltIm
1-mom
A r Y8MArt
I ■ Wow
m • ■srcrosx AIR
FORMULA
NO.4515
IIWIfil umflum D]EIRRITANT
sectiom 313:Tads DerAm sUd- 40 CFR372.66
NNE
C�r�r�a�� arl
4Ps91.uL M�RD �J, .
RCRA iRm wts I'. omw mliae jknd Fromm, Ac*
Udf953bMbd=,00CgWD*8ltidtfbprailowswaft render4OCFR261arei36dddst�iatkn
W DS. Knomow, polm dvoW of the rW pmdmtlt, 4be roliiiy arm*& sQMd be coftdWa
%Lmm ANFBmw&T4
NME
CWA (CIW W seer ACtk
iimiesB shmm brlw, mil I im tAi%pM0vd r. Ps"how 0.1%wb" are listed ender 40 CFO 4OL 15, are listed
ales vlo wel ■ tires AtSQS.
WINE
OSHA Oko d i Xemwkafios Starrdm*.
All o omppmemb bead ■Wwtkk llAndlyd 29 CFR 1910.1200 am It" le ,8adloo II oltfris WKSDDS.
79CA (rWo.id 00mW AdI:
All kordemb In tw predmct am Mild to tee iSCA lm erx.
'r
'MATE RUili.A N9 - !.
CAUFORNIA (Sale Ddddlr W9W erdTakE*MM+k Ad - PmMsftlom RS):
Tbo f A m4cg cbeerlwm and m m odmd Aeimyd aM Wg-.xC , j*
sAm
NONE: �
N
OTHER STATES: Carta s sufts States kd@d bekw
ham o fgo .rw: os ingmdkft onr l bm in Ws pmdmci Hoover, tmmw sw n oeiw*, Qti[ir wcUoasof tbit, MSN CO"R the
rmgdred ftWrd K it ftW mNftL
or; mai��RS AMQtlffj&b*tGm j
Has,

Mar 05 QF 04: fap :Co, I na.
MATERIAL
SAF•E N
:FFA lwijW i0■ 164
DATA
a&xK OF O WD
4 - aft xt
SHEET
, - wil
:y>mm"
i - sus"r
0 ■ muoursk.M7
FORMULA
NO.4515
PnVP0F0d By- Kl" S. Wesw
036, 5-2260 p.13
C-o9- ►J {j��
i m H k &t rc> rz. FXr E �J7 SWAL KAZARD
f {�
ti1R B 401�t OEd kR1 I,Isidka6i l ieli4l i?� SAgOt bead p �l00 Mum W prodod;
tkklrOQaarlrri$ ioo ii#d QIyhe ,�[1t ed po��lal k� iheiol0��be � a�ered 1a�4�I� R�d,,'�i �CMAid m�d�y��i�. iLTr
fWSi3bW 10 � "y� th Is a" IS � it CarEi� tD bomft Sme of II�uMb, N off, In a kai*mCW *d
dksosM of the prodwt sad 10 Imum W elope ere prep" loon and adrised of ad Sbdt p waubom req@kW, Tk %
kr wrsk3onIiRrN�bsdroroa+�prsanor+•itlrtre *000UP016mW SafWaW Hooft AID" d ISMAG ""NWMWnft*dsa4XAd" oc
19M8swe* as nftusodwFer%W,SUM and local nm MS60as. Useordm01Wrd not akiorpertufthisl4ormatfowlors*~
00 iG prpk died tqF kiN►r. i

mar UE U?- i:=utda
:k:U, 1 no.
3ze 5-2280 p.13
!LIM SEECO? Inc.
L '"w.-
FOR HULL. "20
COOLING S` 'STV tl IN Hlsl•rOR
tra►.1��1"�
Prnduct BLS
�44 LuJoy Vow
Ash Poirtt, NC- 21265 ,
` PhUnr/l�ex: (:*.psi 885-22110 '
FORMULA 4420 wataim a sy clislic ble d a4' ni riLa � ]ybdAd G=isitm irrllibilars with bay Y1e
amd si we buffos acid art x11,tts, TIM pt-oducL amp srya; th : ttt0ll t s )rc of whibitor blend for cAvitmt of
oorro�pts>nciolu�dttystt+mx.In a[1tlltiW�, thtiprodlrrL � afUa 1kWwd quickly {�tin�w•�t,an syKt��ai�rr w•t,aa
stew er srLgckxni�.8a� a]yn tla a r»IiAo trerx wa.L tc ty: W prior w. shulduw l Of* eyxton'L w11r+ it :r to
be out of strvLae ror s psi iod of Lime.
F%MULA 4420 ]s normal ly OlTa L''04 to
Par doaed:yahoos, eilhar a strut or bypwt feeda is t
ai my cvnvealem point wber4 mixing will Cox
Tfm meat ainuni may 0", emple Ow
pia pisn[. 7 masmratl o0nt[a] �sgal rrxy idLnl
sachttirJtl weclalisl u vic q the radlily.
A ryti -adh Lo ► sMUsh !ha dNs r,ra treaur"" sgwaronration.
ual]y t ie& Fk)rqVo systems, :Ile Lreaunent MaY b: added
iiri+a i r m4iyrbdrLs Vr i_ for
apou i w ry,um ftaA veAded .wid will be spwifial N Sifa
Apg4trw=........................
W_... ... ............ -.....Pdlc ftmw I,quid
Oft............. out,,,. �......
.............�r.. �.....,.n .,.,.,...........".PraCkirxllly uy,1!
PitRtt �OdPI.................n..n...u.,...u....._.,...u....e..,,r..,...i�1t
Speei[lc gr�lrlty. .�..�............._...
-w,..,, ... w_...� .....1.i'r
Pt3(us7dli 114.. .; ,.,..•.._.........,
W �..,,....» ..,.,.�.._.......cl
Frti}0000pair1L. ....._...._......... ......•...............�„.."_i..",��J'l'�
ra 20 airy be toxic by inwia i. Da r bt late imetnaliv. [Y injuisuA drb'!k at laaatt t mi t ?,1
lid of WOW and dte pariWr 1A UQrtst IOU, iddUO Vomit rig. TM 96t iftlaWhi1v a 1edit;W a[letllln4 (::elamat
' with Cyr{ qA1y1M Il on. If ayes en vontwmxe mnt�i tally flush with clear xxter for 15 minuw Awd if
j trrilatiou p=40, l t odiitlti atasL ou. For skin talmL at, Wa:t with **P xrg L water. Vasr vd4baw i kDmnatiurt.
Aft tba '. sSafaty Data 9lseet previtll:d Wink 4h , tCl.
r.
DRMULA 4421) is WK4ed in 55 IM 1( gallon A140, S gd (m lwj16
yuwlity b) Ire ttvaiiatalc.
�rV
trldLariLr+.ex� T�'e1:G+r M�r�erfl �'atl
r

Mar U;� UU i 1 : uba 1 Cp, InG.
02/22, 2E 87 09! 19 T 5a83193880 out' _7CHEM
MA71:R1AL
++VA 04912n414n '44
SA,ITY
DAU 4DMEI�
2 • rooiaw�
,sire"
o , Uucwxf -wT
FORMULA 4420 Serf ev
336- s-Eze❑ F•
PAbL
"SPr.(3Af,XA?-ALWAD Qx C ti i &-��i
+i 13 T DD�
FFA,C-A G
SFCTXON ) i Gail.-r
Effectivi Date: 5/1/33 Revised: 7/1/0
NaMe and Address: Phone: 336 B
IRwo- roer+cy Phone: 7SEFCO, INC.
2104 LA)OY OMW
HI Gh PoTwr . NC 2A�65
5-8816
EL [phone]
CheMiW N$Ae: NOT APPLICABLE, Fp1"Nj�a' SEF SEGTT[]tr xI
S DAp w N.A. Ch. micri 1 Fiel mxxru;tE
D�0- �4ataard C'laaS: 5.11 u1313i,�pG�i�1 1996 G #140 ,
S.C�'rloH tt:•..:�-s---�= .�....��Ii#GeE DIEATS� �__ :,��..--��..�,.....�p�
A. NahaAms Ingredients x TLV
Sdoxlara HY'!]iEQJ X09 CA& Nato]) CAS NO. 13 L0»7 -2 c1.0 2mg/w'/1Sm
S00i11N NITRITE CAS ND. 7612-00-0 c20-0 NCNE ESTAB.
SODiIP4 MOLYBOATE CAS NA. 7631-95-0 tS.O 5mg[Ma]I
5. Other CngredlerltS %* TLV
SMIUM BORATE m NWI: FSTAB .
SODIUM SILICATE M NONE rt5TAS,
'SODIUM TOLYLTiRIAMLE L NONE E S TAS .
*Leg*nd : I .w<1%; mwl-10X t W"20%
SEMON -11.2 r •+4•�!r�.P SICAL 4t0P �RTx11S�+� =-�} er�.osd.
So'ilin P(�int: >2120P Specific Gravityp: �.lfis-1.185
Parc■ n val ati 1 e (vol ww) : a 70 pH (un4i 1 utez : <2.2.5
Vapor Pr ei.sure (mm ��{lgg) : N.A. solubility in Water: COMPLETE s
Vapor De n� i ty (ai r�3 j all Evap,, rmt-$ on Rate (waEterml) • 1.0
AppealranCE; And bder:- CLEAR R RED L'IQUXV WIMI PRACTICALLY NO ODoft
SfCTION IV: IRE AHD EXPLO' .10N Hi"AiW DATA a.m..
'Plash it t (mtthcd us i�IDlti
FlaMMAIC LiMi-ES in All IbMIB!" X.A. �u�p er): N.A.
Extinguishing MMia: F WITH WATER. HI AVY WATER 3C1 NTAGSMS,
Soceial Fi re Fi.ghti rocedures:' If WATIA Z`.• EVAPORATM, THE DRY NITRITE CAN
OCAdN AT TCMPER; TUR1 S ABOVE 6100F To RELEASE TOKiC
TRCGYrN OXXDE GASSES WEJ R NIOSH APPROVED SELF -CONTAIN®
BRFATUM APPARATUS.
unusual ri re or E onion Hazards: IF WA•r 7-2 x i EVAPORATED, THE ' WRY NITRITi. I5 AN s
OXIDIAMT AND (AH s!1¢PLY poGEN 1Q STimm-A'Tt oR
ACCELERATE THE CONMIi{ TIM OF OTHER COMBUSTXALES . ; �1
s eioN +ram+=m�� REALT14 HAZARD C A I A•����ei e�-�a ��-m 4
A. TLV said source: CALCULATED s10000M BAS ® CM Na;o CONCEwrRATlorr a
Februsry 4, : 002 i
i

mar uC Uc i s t uds UU, Lne . 336 P • 10
BT142F:?E J2 B9' 19 15AB3753B6$ DUA _I0_EM PAGE 82
MATERIAL MFFA veaig►ra Am' oA ALTUL3Ar6,,
'�pS►
RG1151 of NA tOb
4 is i:1 REMIE
SiIcET F
x rox-
0 - DISMI rAlff
FORMULA 4420 5erxe$
IZ. Effects Of a Single over
sure by
IEStian: M�+�IY fiE 7�. Ou1: TC KxaF ppH, MAY cAuSk 5T'VE14E; .IeRxTArxnx TO
INTERNAL TISSUES . LAUGE Ad�l11NTS CAN RESULT Iry . ACNE" Toxic
EFFECTS WWXCH MAY SE FATE L .
�. rmhalAtian: NOR A LIKELY IROIITE bi MOSURE. INHALATrON,Of- NX57
IRRITATING TO NESPIW TORN TRACT.
3 . SIC i n CDntac t : PROLONGED CONTACT mm CaSE IRRITATION . /
4. Ere Contact: CAVSES SEVERE IRRITAI XON DR BURR.
C. Effe: is of Repeated Overaxposures : HER THAN ACUTE. B/FEc­rS, WJ NE' icrNcytrr.
0. VAergency and First Aid Procedures T r f
1. ingeStiDnr DRINK 5EVERl11. Q ASSE; OF WATER AND,4ET IM40XATE MEDICAL
ATTf.NTION'- DOULT V(* rTih G BY S*rTgk XNG F 1,NQLR THROAT
AND C0M1TXXUEc UNTIL VCMIT IS CLE . IF CYAPJOSIS blue skin)
OVELOPS ADMINISTE3R OXYGEMI.
Z. 'r galation: MOVE IfCTIM TO FRES4 AIR. I I= BREATHING, GIVE
AMFX�IAL RLSU5CXTA'1 X0N. GE IWei)IATE WDICA►L ATTENTION.
3 . Sir•i n Contact: WAsm WITH soA AND wA TER DR LAIN WATER.
4 _ t?�►e Contact : IM+IEOIATELv F1_115N WIT,f CL ►jjATER FaQR 1S NIt4UTE5 AND I F
I!lE:.ITi1TIpfi1 PERSI5T5 . ;k"r E"" ATTQJY IO?I . "
SECTION v C : �-- �-mmm • PEA$QWEL PR jr C rJON aAT14-=���-rt��••- �+ •••+�
RRspi rwx y Pro�[i ian: NOT NOMLLY 1RE Q 'RE:I
Vanei1Ati,Mr NORML wwr%AmN was FA wy
Prat#ct• wa Gloves: OPTIONAL ja Frotectian: GOGGLES OR FACE SKIELD
othgr Pr o-mctire Ewipel nt : EYVNASM S I [ON tN AREA OF USE. ,
SECTION V":Y: Moslems=
A. Pr0d1IC'_ StAbility. STABLE
B . tncosipati bi 1 i ty: HAZAgOMS
COMPWNDS
AWD 'TRIOS
C. Haza►doul; Combusrion or
Iv CfY 7ATA---_-�.m..m�. �-� -
C�oEadi Ciyon Z
to A /eid : SEE" sccrION TV.
RF. eriaMS AN OCCUR tillTEl ACIDty ANMY[iM1
ETUCING 4GENfS, CYANIDES, THIOCYANATFS
F►�TES, CIE eTA i COMBU] TJOLES AND ORGANICS.
DecOelpigs t Ori Products: IDES of CAR ION .WD NXTROCEN MAY BE RELEASeD IF
TIA IS EVA1xjRA'i1x BY THE HEAT OF A FIRE. SEE
5 EC.TION IV.
D. Haz&rd(,us Candi--:ion--t
POI YU eO xsti an : VXL NOT OCCUR to A - aid d w)wEe
SECTION V7x3.z;m� ..sMws..ENVIR0N1W:NTA1- DATAso- =�•s ['1�'4
A. Spi 11 C r i.eak
Pr edures: MALL. SPILLS 0Y BE FLl1:.HED WITH COir OUS 4UANTMES OF WATER i
TO A SANITARY SEWER OR FASTT; 'MEA7%1iNT rACILM. LARGER SPIT.L$ ;
SHOULD SE DIKF.d TO PREYS NT FUR OFF AND PUMPED WO A SUITABLF
MWTAYNER FOR DXSPOSAL . j'.
8 : waste G i SpoSal : SMALL QUAWrrTIES MAY E E D] LUTE D WITH WA1 CR ANU FLUSHED TO A
SAN-rrA1tY SIRWER . LAX019 0;-J- TITIES MAY BE SIM ECT TO FEDERAL,
, �
STATE OX LOCAL REGULA, ION; CONSULT AppRoPRrATE: RECAILarrNG
AGE w_XES BEFORE DISFV. ING OF WASTE MATE"RTAL.

P.
..-• __ %06 L A . VUi
E212'2 P2M n.It
WTEMAL
$AFM
DATA
f3HM.T
- Y / ■ T - v -
15493753BBB 6UJ MCWN
oo.?A cKaigni tion- 704
ot0ss of 1u uRo
i - OMME
2 MORPATI
I - sUtelr•►
0 • IN514Gwxl MAW
FORMLIA 4420 Serie:i
'sow o-r-ctfu
S7'1 L%L H•ttAt�
PAN- 102
C. athi•r Envir'onmentlll Data: 04LCULATM AOUATIC TDXrCTTY rQR L' pROrx►eY
'APPROXIMAT Ly 100 pp�mIn BASED ON TuM I�TRI r£
COI�ITEN'T OF 'THE PRODUCT.
A. Handling and Stara: STORE IN A COOL DRY PLACE. KEEP
WHEN NOT rN USE-. S- DRE AWAY Fl
INCOMPATIRLE Mt-TER;'ALS.
s. ether Precautions: THIS PRODUCT HAS I.EF.N DESIGNED +
OF COOLING WATER t xRCI TTS AND $H+
ACCORDANCE WITH Ti ' E It,STRUCTI S
YECMNICAL REPRES& TA'n VE SE ICI!
SECY i+ : - =��REGULATO tY I YF
the foI•1'CW R�p reUu'latiOng, ara known to + Iy
product. AOpitivital Federal, state and L-ical r
Ct N[LA {{ [ amp. thensi► a Environmental Res one
Un T� s listed below Mi S - Dro�duct cj)es
li st:f d hazardous suLtancq(s) - 40 CFf
S*)1 FIDE (RRQw5�, DOQ rLbs • )
SWIM NITRITE ("100 LbS , )
SARA (slip•3rf'und Ama is and Rath
Unless M gted below this pro dl�ct
amounts 4. - tbx i c chimi Cal s as efi n
Set- t,l on 302s Extremely Nazar !
NQF E
CoQQ�.,i phi
FA4E5.
TATNEAS TIGHTLY CLDSED
ACIDS AND UTHE R
R' USE IN SP+ECTFIC TYPES
UM BE USEd ONLY IN
PROVIDED BY THE
G THE FACILITY.
the use And disposal of W S
ulations may also be applicable.
compensation and Li alai i i t ►►tt)
t contain greater than 0.of any
2.4.
o•��l
Maxi-mmu 1.768 Lbs
/rirati)n Act):
s tot i Aontai n greater than tha reportable
Unier the various r gulat pt� s under SARA.
U oStalCes Li St - 4V CFR 300
sett -on iIl/312: This prod t falls in the following categories.
cAiLraDW1-=,IAT EALTIM. FIRE FYIE ::RRIT� 0XIMER ,
section 313 : TOXIC chain Gel S List - 4Q +:Flt 372.65
SURSTANCE �LJDIiI�Isi hs
NON41��'�+.
RCRA (Rescurce onservati n and ReCover Act",
unless skwn baloir, �71 omponents of this p-oduct listed as hazardous waste
under 4o Crrt tas are 4s ed ellre in :hid MSDS. r4arlever. p or to d4posal of i
the neat product, appl i able regulatory : 9enc i es should be consulted.
�T� gM�l�u3•slgsf�l)
AtpFi'�i
CWA (Cl-W Mtater Act 1
Unl+ess shown be ow, all components in -his product at greater than 0.1%
zebrufty 2�, :-002
3•

Mar■ 02 02 1 1 = []Ba
336 .5-2?90
ilmu i- M
P.12
92t=i M2 09.19
bUiT EI AL
SA R FTY
DATA
SH Ei-T
154037535100 DLL%LICHW
NFFA a+signt tion 704
oLLCAft of N, iApa
Z • naDHAri
x SLYCAT
6 T K%6nti ICANT
17ORMULA 4420 Serie:
whi =h are 1 i sted under 40- CFR 401. Y5, are listed elsewhere
SU ANOW _ C I - b_JLG_
OSHA (Hazard Comunitation standard):
CTE
�0M
L A kI(NTo(Z.
thi s NOS.
Al l ;o00non s 19 sted under this staan lard 29 GFR 1010.12C are listed in
slicC of n ix orthis Msus.
TSCA C( t7 c SubstanC4s Control ACt) :
Al1 fngredilRts to this product airs listed in the T Cn inventory.
STATE �Td � �4NS �
CALIFW4h1[A,{saf Dtinkipg water and Talk enibreemeere
Act - Proposition 65)
The foTtow in Chemicals and astoci xted hazard listed:
WINIrd TA ►LRR
DINER "+TOTES. Certain slates maint in heir in red�ants lists which differ
l i t_ Y f ran the Federel standard$ . i tact i i ste below have r•e l at id116 on
1 r i er #s cantai need # n rhi s prskissCt. Fk ra4 ml es s shown Wow , other %actions
of- thi (tea contain th6 regUI red repor tinq/ frvformati on .
9AX a AIW= C�l)
MA, na u+OL�►aear:.re. N , c as ) +pax i mum 6�LDS .
Preparf4 By, Harry S. Weavar
The - dam � contained in this Neteri al fw y of to sheet has been prepared based upon
an eva uation of the ingredients n t to rodum their concentration in the
produci and potential i naraction The i nf�r r ion is offered in good faith
iY believed to he accurate. Tt is iiurnisned to tN cusromr who is urged ro stInd
it carefill to become awy►re of arils,if' arty, in the storage, handlin , use
disposal of the prp��ui~t; and insure his enlayeea are properly infarnwd and
advisac �)f all $afMV, precau ions regti i reo . The informatti n i a fern► shed For
Compliance with t1Ie 4Ccnp at ' anal safety and Health r�ct" of 1970, the "ifazards
Corwnunic:ition Act' of 1983 well as various other r-eder'al, state and Local
regulations_ Use or disserni t on of all or part of. this Information for any other
purpose is prohibited' liy tr.
PWruary 12 2002
4
;I
e

DwiSION OF WATER QUALITY
GROUNDWATER SECTION
January 18, 2001
To: Sherri Knight, E.I.T., Groundwater Supervisor
Groundwater Section
Winston-Salem Regional Office
From: Mark Pritzl J0. mark pritz1 ncmaiLnet
Hydrogeological Technician II
[.TIC Group
Groundwater Section
Raleigh Central Office
Re: Receipt of Notification for a Closed -Loop Geothermal Water -Only Injection Well
System.
Notification to constrict and operate a well for a closed -loop geothermal heat pump system has
been filed by American Hebrew Academy of Burlington, North Carolina and a copy of the
Notification is enclosed for your files. This injection well system is deemed permitted by rule
(NCAC T 15A: 2C.211(u)2) and no regulatory action is necessary. If you have any questions,
please contact me at [phone] or Meliktu Fanuel at [phone].
Ae 4ew,&,&�'
Gh Pe
CC.' CO-UIC Files
Enclosures

f{fCEIVEO / DENR owa GROUNDWATER SECTION
01 FEB -2 PM 2: 33
Mr. Mark Pritzl
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
January 31, 2001
RE: Closed Loop Water Only Geot:hermal System for The American Hebrew Academy Campus
4334 Hobbs Road
Greensboro, North Carolina, 1'1 '/ I 0
Dear Mr. Pritzl:
Per your request, I am pleased to enclose a Master Plan of the American Hebrew Academy
Campus. Please note that the well fields presently under construction on the campus will be located
in those areas highlighted in yellow on the Master Plan.
A vicinity map, as you requested, is also shown in the upper left comer of the Master Plan.
Directions to the site area are as follows:
1-40 to Guilford College Exit. Right off of Guilford College Road onto New Garden Road.
Continue on New Garden Road and tum right onto Hobbs Road to reach the site. The construction
entrance and job site trailer are located on the Jefferson Road side of the property.
Should you need· any further information concerning this project, please do not hesitate to contact
the undersigned.
Very truly yours,
Vice President
GAD/ssf
Enclosure
AMERICAN HEBREW Aco\DEMY
5509-C WEST FRIENDLY AVENUE • GREENSBORO, NORTH CAROLINA 27410
MAILING ADDRESS: POST OFFICE Box 19849 • GREENSBORO, NORTH CAROLINA 27419
TEL: [phone] • FAx·: 336.854.9064 • WEB ADDRESS: www.AMERICANHEBREWACADEMY.EDU • E-MAIL: [e-mail]
W A rF�i
Glenn Drew
American Hebrew Academy
P.O. Box 700
Burlington, NC 27216
Bear Mr. Drew:
Michael F. Easley
Governor
Sherri Evans -Stanton, Acting Secretary
Department of Environment and Natural Resources
January 18, 2001
Kerr T. Stevens
Division of Water Quality
In accordance with the notification submitted on January 9, 2001; the Groundwater Section
acknowledges your intention to construct a closed -loon geothermal water -only injection well
system for the operation of a ground -source heat pump. The system as described in your
notification will not require an injection well permit and is deemed permitted by rule (North
Carolina Administrative Code Title 15A: 2C.0211(u)2). The Underground Injection Control
Group has added your site to our inventory. If you modify your system, please contact the
Groundwater Section to verify compliance. Thank you for submitting this notification.
If you have any questions regarding geothermal heat pump wells please feel free to contact me
at [phone] or Mel iktu Fanuel at [phone].
cc:
�'A
NDi NR
Customer Service
1 800 523-7748
Sincerely,
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
CO-UIC Files
WSRO-UIC Files
Division of Water Quality 1 Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: httpJ/www.gw.ehnr,state.nc.us

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTHERMAL WATER-ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type SQW Wells
In Accordance with the provisions ofNCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
This is !!!!!_the proper form to be used for injection wells in an o pen~loo p geothermal system.
Do not use this form for systems that circulate anv substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: December 7th 20.QQ_
A. SYSTEM CLASSIFICATION Does the proposed system circ.ulate potable water in continuous
piping that completely isolates the fluid from the environment?·
YES _x_ If yes, then continue completing this form.
NO lfno, do not complete this form. Form GW-57 HP,Application For
Permit To Construct And/Or Use A Wel/(s) For Injection With A Heat
Pump System, should be completed.
B. SYSTEM FLUID Will any additives be introduced to the system's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES If yes, do notcomplete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Injection With A Heat
Pump S)lstem, should be completed.
NO X If no, then continue completing this form.
C. PROPERTY OWNER
Name: American Hebrew Academy
Address: P. 0. Box 7 00
City: Burliniton
County: Guilford
State: _NC_ Zip Code: __ 2 ..... 7..-2....-1 ...... 6 ______ _
Telephone: [phone]
D. STATUS OF PROPERTY OWNER
Private: _i._
State: __
GW-57 CL (Jan, 2000)
Federal: __
Municipal: __
Commercial: __
Native American Lands: __
Page I of 4
.,
E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: ______________________ _
Address: _____________________________ _
City: _________ State: __ Zip Code: _____ County: ____ _
Telephone: __________ Contact Person:
Standard Industrial Code(s), SIC, which describes commercial facility: ________ _
F. HEAT PUMP CONTRACTOR DATA
Name: __ N_o_t_S_e_l_e_c_t_e_d_A_t_T_h_i_· s_,1:_i_· m_e ________________ _
Address: ____________________________ _
City: _________ State: __ Zip Code: _____ County: ____ _
Telephone: Contact Person: ____________ _
G. CONSTRUCTION DATA (check one)
(1)
(2)
x
EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (4) below to the best of your
knowledge. Attach a copy of Form GW-1' (Well Construction Record) if available.
PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump
well(s) . Provide the information in (1) through (4) below as PROPOSED
cons1ruction specifications. Submit Form GW-1 after construction.
WellDrillingContractor'sName: C. W. Bing, Inc. c/o Michael Barlow
Drilling Service Inc.
NC Contractor Certification number: N. C. Contractor's License No. 1544/Well Drilling
. Certification No. 2062
Date to be constructed: 12 /00 -6 /0l Numberofborings: __ 6_5_6 ____ _
Approximate depth of each boring (feet): ___ 4 _5o_F_t_. __________ _
Well casing: Is the weU(s) cased?
(a) YES If yes, then provide the casing infonnation below.
Type: Galvanized steel_·_ Black steel_ Plastic __ Other (specify) ____ _
Casing depth: From ___ to ___ ft. (referenc-e to land surface)
Casing extends above ground ____ inches
(b) NO _X_
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.):
NOTE:
(a) Grouttype: Cement__ Bentonite_. _ Other(specify)Pea Gravel & Bentonite
(b) Grouted surface and grout depth (reference to land surface):
Elev. '84 7 around closed loop piping; from O to 10 (feet).
__ around well casing; from __ to __ (feet).
THE WELL DRILLING-CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNA V All.ABLE BY OlllER MEANS.
GW-57 CL (Jan, 2000) Page 2 of 4
H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
infonnation.
I. LOCATION OF WELL(S) Attach two maps.
( 1) Include a site map ( can be drawn) showing: buildings, property lines surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks
or drain fields located within 200 feet of the ground-coupled heat pump well system. Label all
features clearly and include a north arrow. __ .
(2) location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections).
J. PERMIT LIST: Attach a list of all permits or construction approvals 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
K. CERTIFICATION
"I hereby certify, under penalty oflaw, that I have personally examined and am familiar with the
infonnation 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 info 1 n. I agree to construct, operate, maintain,
repair, and if applicable, abandon the ground-sourc e pum em an all related appurtenances in
accordance with the approved specifications and c 1tions th ermit."
GW-57 CL (Jan, 2000)
Signature ofWel
Glenn A. Drew, Vice President
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
Page 3 of 4
L. 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 landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the ground-source heat pump system's weU(s)
conforms to the Well Construction Standards (Title 15A NCAC 2C .0200)
GW-57 CL (Jan, 2000)
(Signature Of Property Owner If Different From Applicant)
..
Please return two copies of the completed Application package to:
UICProgram
Groundwater Section
~orth Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Page 4 of 4
CITY OF GREENSBORO
STORM WATER SERVICES DIVISION
EROSION CONTROL SECTION
...............ur
Utinty or
cu-
@ 373-2302
This certifies that a grading permit has been issued tom
for the grading of
Located at 4& 1��111111111111
■r
&516
'Number
1 a01

e 4 Z'1 • Oa by
r ff
Erosion Control lnspecbr
s nonce must be posted in a conspicuous lace on the job.
E GREED s%)pi}
REQUIRED INSPEC
27'Inv iier r
G ���I�L•fG4Ci9 i•LI'7?!r r.n _ -'-
colliact
ire land-disturbing-
remporary
erosion control measure
Storm
drainage installation and protection
tAaintenance of erosion control measure _
Permanent stabilization
_,_ _