WI0400058_GEO THERMAL_20040504

May 4, 2004
MEMORANDUM
To: File
From: Thomas Slusser~
Hydrogeological Technician II
Underground Injection Control Program
Reference: UIC Permit # WI0400014
Issued to Mr. Millard J. Gold
Michael F. Easley, Governor
William G . Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
This permit number for construction and operation of a Type 5QW injection well was originally
issued in October 1995 and due to expire in October 1999. Effective February 1, 1997, this type of
injection well is deemed permitted by rule and no longer requires a permit.
On this date the record for this permit was removed from the tn:Cfile database, which keeps track of
injection wells that need permits, and added to the 5QWlist database, which keeps track ofinjection
wells that do not require permits. Likewise, the paper file was moved to a drawer that stores 5QW
injection well files.
N. C. Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, N.C . 27699-1636
Phone: [phone] Fax: (9 I 9) 715-0588 Internet: http://gw.ehnr.state.nc .us
Customer Service
1-877-623-67 48
J
Gold
C:\PFPRD\DATA\PFINDER\UIC,..SRC\COR\RQ31618B.COR Statistics Version 3.3
Recs Mean Std Dev Minimum Maximum
Latitude 216 36}�04'16.710"N 1.962 36'3404'1 14A 5"N 36%04'18.796"N
Longitude 216 793433'54.362"W 1.744 79%33'54:642'"W 79%33'S4.207"W
Altitude 216 184.026 1.523 181.114 189.890
No velocity records in file.
No DCP records in file.
Start GPS Week ##:792 on 03/16/95 at 18:38:01
End GPS Week #792 on 03/16/95 at 18:45:24
Datum WGS-84
Coordinate System Latitude/Longitude
Altitude Mode Height Above Ellipsoid
Altitude/Distance Units Meters
Velocity Units Meters/Second
I
Tw2

6, old -z w z 3a44.ct 4c
C:\PFPRO\DATA\PFINDER\UIC\WSRO\COR\RO31618C.COR
Recs Mean Std Dev Mi
Latitude 237 36%04118.628"N 1.346 36}�O
Longitude 237 79%33154.788"W 1.133 79;¢3
Altitude 237 176.338 2.393
No velocity records in file.
No DOP records in file.
Start GPS Week #792 on 03/16/95 at 18:46:10
End GPS Week #792 on 03/16/95 at 18:53:21
Datum : WGS-84
Coordinate System : Latitude/Longitude
Altitude Mode : Height Above Ellipsoid
Altitude/Distance Units : Meters
Velocity Units : Meters/Second
aAon
Statistics Version 3.3
'mum maximum
18.174"N 36%04118.756"N
54.98211W 79j�33'54.19811W
174.050 193.455

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State of North Caro11na
Department of Environment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor ·
Jonathan B. Howes, Secretary
A Preston Howard, Jr., P.E., Director
GROUNDWATER SECTION
October 27, 1995
MEMORANDUM
To:
From:
Chris Greene
Groundwater Section
Winston-Salem Regional Office
Karen Harmon ](at/-
UIC Group
Groundwater Section
Raleigh Central Office
Re: Issuance of injection well permit.
,NA
DEHNR
Permit No. WI0400014 to use a well for the injection of
heat-pump effluent has been issued to Mr. Millard J. Gold. This
permit is an amendment to existing Permit No. WI0400014. A copy
of the permit is enclosed for your files.
cc: UIC Files
W-SRO Files
Enclosures
P.O. Box 29535,.Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer so,. recycled/ 1 OIL post-consumer paper
State of North Can._. .. ,10
Department of Environment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
Mr. Millard J. Gold
722 HWY 61
Whitsett, NC 27377
Dear Mr. Gold,
GROUNDWATER SECTION
October 27, 1995
NA
DEHNR
In accordance with your application dated September 15, 1994,
and your amendment request dated September 29, 1995, we are
forwarding Permit No. WI0400014 for the construction and operation
of a well system consisting of one new injection well and two
existing injection wells, for the purpose of injecting heat pump
effluent, in Guilford County.
This pe~mit is an amendment of existing Permit No. WI0400014
and shall be effective from the date of issuance until October 31,
1999, and shall be subject to the conditions and limitations stated
therein, including the requirement to notify this office by
telephone 48 hours prior to initiation of operation of the
facility. This permit replaces and shall also'supersede existing
Permit No. WI0400014.
In order to continue uninterrupted legal use of this well for
the stated purpose, you should submit an application to renew the
permit six months prior to its expiration date.
If you have any questions regarding your permit please feel
free to contact me at (919) 715 -6166.
cc: UIC Files
W-SRO Files
Enclosures
Sincerely,_ 1<~a.~~
Karen A. Harmon
Underground Injection Control Program
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer WI, recycled/ 10,, post-consumer paper
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL SYSTEM _ 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
Millard J. Gold
FOR THE CONSTRUCTION AND OPERATION OF AN INJECTION WELL SYSTEM
consisting of one new injection well and two existing injection
wells for the purpose of injecting heat pump effluent. This well
system will be located at 722 HWY 61, Whitsett, North Carolina, in
Guilford County, and will be const,_ructed and operated in accordance
with the application dated September 15, . 1994, and with the
amendment request dated September 29, 1995, and in conformity with
the specifications and supporting data submitted, all of which are
filed with the Department of Environment, Health, and Natural
Resources and are considered a part of this permit.
This permit is for Construction and 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 system 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 is an amendment of existing Permit No. WI0400014,
which was issued on October 21 , 1994, and shall be effective,
unless revoked, from the date of its issuance until October 31,
1999, and shall be subject to the specified conditions and
limitations set forth in Parts I through X hereof. This permit
replaces and shall also super~ede existing Permit No. WI0400014.
Permit issued this the ,,2~ ~ ___ _
Ted L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Environmental Management
By Authority of ~he Environmental Management Commission.
PERMIT NO. WI0400014
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 fo~ in N.C.G.S.
87-94.
2. This permit shall become voidable unless the facility is
constructed in accordance with the conditions of this permit,
the approved plans and specifications, and other supporting
data.
3. Each injection well shall not hydraulically connect separate
aquifers.
4. Each injection well shall be constructed in such a manner
that water from land surface cannot migrate into the gravel
pack or well screen.
5. Each injection well shall be secured to reasonably insure
against unauthorized access and use. Each well shall be
permanently labeled with a warning that it is for injection
purposes and the entrance to each well must be secured with a
lockable cap.
6. Each injection well shall be afforded rea,onable protection
against damage during construction and use.'
7. Each injection weil shall have permanently affixed an
identification plate.
8. A completed Well Construction Record (Form GW-1) must be
submitted for each injection well, to the Division of
Environmental Management (Division), within 30 days of
completion of well construction.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (48) hours prior to constructing each
injection well, the Permittee shall notify the Groundwater
Section -Underground Injection Control (UIC), Central Office
staff, telephone number [phone].
PAGE2 OF7
PART III -OPERATION -AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature,
volume of materials and rate of injection, as described in
the application and other supporting data.
2. This permit is not transferable without prior notice to, and
approval by, the Director of the Division of Environmental
Management (Director). In the event there is a desire for
the facility to change ownership, or there is a name change
of the P~rmittee, a formal permit amendment request must be
submitted to the Director, including ~ny supporting materials
as may be appropriate, at least 30 days prior to the date of
the change.
3. The issuance of this permit shall not relieve the Permittee
of the responsibility of complying with any and all statutes,
rules, regulations, or ordinances which may be imposed by
other local, state, and federal agencies which have
jurisdiction. Furthermore, the issuance of this permit does
not imply that all regulatory requirements have been met.
PART IV -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and
operated at all times so that there is no contamination of
groundwaters which will render them unsati-sfactory 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 th6se actions that may be required by the
Division of Environmental Management such as the ·repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to cqmply with the terms and
co~ditions of this permit even if compliance requires a
reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee
of the responsibility for damages to surface or groundwaters
resulting from the operation of this facility.
PAGE 3 OF7
PART V -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.
3. At least forty-eight (48) hours prior to the initiation of
the operation of the facility for injection, the Permittee
must notify by telephone the Groundwater Section -
Underground Injection Control (UIC), Central Office staff,
telephone number [phone]. Notification is required so
that Division staff can inspect or otherwise review the
injection facility and determine if it is in compliance with
permit conditions.
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of
the Division of Environmental Management may, upon
presentation of credentials, enter and inspect any property,
premises, or place on or related to the injection facility at
any reasonable time for the purpose of determining compliance
with this permit, may inspect or copy any~zecords 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 (see attached diagram).
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil
sampling) deemed necessary by the Division of Environmental
Management to insure surface and ground water protection,
will be established and an acceptable sampling reporting
schedule shall b~ followed.
PAGE4 OF7
2. The Permittee shall report by telephone, within 48 hours of
the occurrence or first knowledge of the occurrence, to the
Winston-Salem Regional Office, telephone number (910) 771-
4600, of 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 i~jection
operations, such as mechanical or electrical
failures.
3. Where the Permittee becomes aware of an omission of any
relevant facts in a permit application, or of any incorrect
information submitted in said application or in any report to
the Director, the relevant and correct facts or information
shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform
satisfactorily, the Permittee shall take such immediate
action as may be required by the Director.
PART VIII -PERMIT RENEWAL
The Permittee shall, at least six (6) months prior to the
expiration of this permit, request an extension.
PART IX -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 15 NCAC 2C .0113, 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 15 NCAC 2C .0214, including but not limited to
the following:
(A) All casing and materials may be removed prior to
initiation of abandonment procedures if the
Director finds such removal will not be
PAGES OF7
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)(1) within 30 days of completion of
abandonment.
3. The written documentation required in Part IX (1) and (2) (G)
shall be submitted to:
Groundwater Section -UIC Staff
DEHNR -Division of Environmental Management
P.O. Box 29578
Raleigh, NC 27626~0578
PART X -OPERATION AND USE SPECIAL CONDITIONS
NONE
PERMIT NO. WI040001.4
PAGE6 OF7
AU-rAU1LMMR1 I
PERMIT NO. W10400014
Sanitary well Seal
Min- 12 inches casing above
land. surface
: . TT"
-J
0
Sampling Tap
(Effluent) HEAT
_J PUMP
hig
fit 'v.,
V
i.
-171
h7...
V.
� Tap [Effluent)
-1-
2.
r
V TICAL "CLOSED LOOP.-
ER
,..INJECTION WELL, USING
CASED WATER WELL
The Injection facility design Incorporates three wells, each one
a closed loop within a water well. The Injection wells are
connected to each other and to the 2 heat pumps via a common
Influent line and a common effluent line.

PERMIT APPROVAL REQUEST
IN [ 5'.
Plea jr'init ial ands s e` ! !
return to Karen
for processing.
Ted Bush•-
Bob Cheek
Mark Milligan
Karen Harmon �j �" d I `1 2� ��

Ms. A. Elizabeth Morey
Manager
Millard J. · Gold
722Hwy61
Whitsett, NC 27377
September 29, 1995
Dept. of Environmental Management
P.O. Box 29535
Raleigh, NC 27626-0535
Dear A. Elizabeth,
I am writing you to request a modification-to the well injection permit which I
received last year. I would like to increase the capacity of the system I have in place by
adding a third well and a second heat pump.
Included with this cover letter is a copy of the original permit, a plat of the site with.
the additional well draw in, and a drawing of the proposed mechanical layout. If you need
additional information or have any questions please give me a call at 910-279-4121.
enclosures: Copy of Original Permit
Marked up Plat
Mechanical Drawing
Very truly yours,
r,v/4JJ~
Millard J. Gold
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Action code: Apply00006 Facility ID Number: NCS000000139
APPLICANT Name: Gold, Mr. Millard J. Address: 722 Hwy 61 City: Whitsett
State and Zip: NC 27377 County: Guilford
FACILITY Name: Address:
State and Zip: County:
Permit Number: WI0400014 Application (new or renew): new
Renew Not. Sent: 2nd Renew Not. Sent:
Appl. Rec-Incomplete: Appl. Return:
Appl. Acknowledge: 9/19/94
RO REQUESTED TO: Review Appl: 9/20/94 Inspect: 9/20/94
Telephone#: [phone] Fax#:
w.lt-q 10 ~, q -'4-1 1. I
City:
Telephone#: Fax#:
Permit Type (co-hp): co-op
Analytical Report Recd: 9/19/~4
Sample (renewal):
RO Sends Appl. Review to CO: RO Inspects_: \ O / /'-f( 'If RO Samples: ~ I Pr Lab Report:
PERMIT: to Manager: 9/20/94 to Supervisor: 9/21/94
to Permittee: c,c,/1"1{1'( Copy Filed: 10/7..v/ei'(
to ACGW: 10/20/94 Approved: fo/-Z.,f /"1'{
Copy to RO: lo/1.'{ I q<-t Entered Uicfile: J.o/z'I/ 'i\
Permittee Informs, Ready to Operate: RO Requested to Inspect: RO Inspects:
Analytical Report (New Source): GW-1 Received:
Permit Process Completed:
State of North Ca1 . ...;lina
Department of Environment,
Health ahd Natural Resources
Division of Environmentol Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
MEMORANDUM
To:
From:
Chris Greene
GROUNDWATER SECTION
October 24, 1994
Groundwater Section
Winston-Salem Regional Office
Karen Harmon
UIC Group
Groundwater Section
Raleigh Central Office
Re: Issuance of injection well permit.
AVA
DEHNR
Permit ·No. WI0400014 to use two wells for injection has been
issued to Mr. Millard J. Gold; a copy of the permit is enclosed
for your files.
cc: UIC Files
W-SRO Files
Enclosures
P.O. Box 29536, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ l 0% post-consumer paper
Stote of North O olina
Department of Environment,
Health and Natural Resources
Division of Environmental Management AVA
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
DEHNR
Mr. Millard J. Gold
722 Hwy 61
Whitsett, NC 27377
Dear Mr. Gold,
GROUNDWATER SECTION
October 21, 1994
In accordance with your application dated September is, 1994,
we are forwarding Permit No. WI0400014 for the Construction and
Operation of two wells, for the purpose of injecting heat pump
effluent, in Guilford County.
This permit shall be effective from the date of issuance
until October 31, 1999, and shall be subject to the conditions and
limitations stated therein, including the requirement to notify
this office by telephone 48 hours prior to ·initiation of operation
of the facility.
In order to continue uninterrupted legal use of this well for
the stated purpose, you should submit an application to renew the
permit six months prior to its expiration date.
If you have any questions regarding your permit please feel
free to contact me at (919) 733 -3221, ext. 407.
cc: UIC Files
W-SRO Files
Enclosures
Sinc4.2r:sq t/_~ o/
A. Elizabeth Morey
Manager
Underground Injection Control Program
P.O. Box 29536, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post-consumer paper
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OP ENVIRONMENT, HEALTH, ARD NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND .OPERATION OF TWO WELLS 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
Millard J. Gold
FOR THE CONSTRUCTION AND OPERATION OF TWO INJECTION WELL~ for the
purpose of injecting heat pump effluent. These wells will be
located at · 722 Hwy 61, Whitsett, North Carolina, in Guilford
County, and will be constructed and operated in accordance with the
application dated September 15, 1994, and in conformity with the
specifications and supporting data submitted, . all of which are
filed wi_th the Department of .Environment, Health, and Natural
Resources and are considered a part of this permit.
This permit is for Construction and 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 these
injection wells shall be in compliance with Title 15 North Carolina
Administrative Code 2C, .0100 and .0200, and any other Laws, Rules,
and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date
of its issuance until October 31, 1999, and shall be subject to the
specified conditions and limitations set forth in Parts I through
X hereof.
Permit issued this the di* day of October, 1994.
<Li±:d-i·
\£::::,Jr., Assistant Chief
Groundwater Section
Divisio·n of Environmental Management
By Authority of the Environmental Management Commiss.ion.
PERMIT NO. WI0400014
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 (15 NCAC 2C .0200).
Any noncompliance with conditions of this permit constitutes
a violation of the North Carolina Well Construction Act and
is grounds for enforcement action as provided for in N.C.G.S.
87-91.
2. This permit shall become voidable unless the facility is
constructed in accordance·with the conditions of this permit,
the approved plans and specifications, and other supporting
data~
3. Each injection well shall not hydraulically connect separate
aquifers.
-4. Each injection well shall be constructed in such a manner
that water from land surface cannot migrate into the gravel
pack or well screen.
5. Each injection well shall be secured to reasonably insure
against unauthorized access and use. Each well shall be
permanently labeled with a warning that it is for injection
purposes and the entrance to each well must be secured with a
lockable 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.
8. A completed Well Construction Record (Form GW-1) must be
submitted for each injection well, to the Division of
Environmental Management (Division), within 30 days of
completion of well construction.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (48) hours prior to constructing each
injection well, the Permittee shall notify the Groundwater
Section -Underground Injection Control (UIC), Central Office
staff, telephone number [phone].
PAGE 2 OF 7
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature,
volume of materials and rate of injection, as described in
the application and other supporting data.
2. This permit is not transferable without prior notice to, and
approval by, the Director of the Division of Environmental
Management (Director). In the event there is a desire for
the facility to change ownership, or there is a ·name change
of the Permittee, a formal permit amendment request must be
submitted to the Director, including any supporting materials
as may be appropriate, at least 30 days prior to the date of
the change.
3. The issuance of this permit shall not relieve the Permittee
of the responsibility of complying with any and all statutes,
rules, regulations, or ordinances which may Qe imposed by
other local, state, and federal agencies which have
jurisdiction. Furthermore, the issuance of this permit does
not imply that all regulatory requirements have been met.
PART IV -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and
operated at all times so· that there is no contamination of
groundwaters which will render them unsatisfactory for normal
use. In the event that the facility fails to perform
satisfactorily, including the creation of nuisance conditions
or failure of the injection zone to adequately assimilate the
injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the
Division of Environmental Management such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and
conditions. of this permit even if compliance requires a
reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee
of the responsibility for damages to surface or groundwaters
resulting from th~ operation of this facility.
PAGE 3 OF 7
PART V -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.
3. At lea·st forty-eight ( 48) hours prior to the initiation of
the operation of the facility for injection, the Permittee
must notify by telephone the Groundwater Section -
Underground Injection Control (UIC), Central Office staff,
telephone number [phone]. Notification is required so
that Division staff can inspect or otherwise review the
injection facility and determine if it is in compliance with
permit conditions.
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of
the Division of Environmental Management may, upon
presentation of cred~ntials, enter and inspect any property,
premises, .or place on or related to .the injection facility at
any reasonable time for the purpose of det.ermining 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 (see attached diagram).
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil
sampling) deemed necessary by the Division of Environmental
Management to insure surface and ground water protection,
will be established and an acceptable sampling reporting
schedule sqall be followed.
PAGE 4 OF 7
2. The Permittee shall report by telephone, within 48 hours of
the occurrence or first knowledge of the occurrence to the
Winston-Salem Regional Office, telephone number (910) _896-
7005, of any of the following:.
(A) Any occurrence at the injection facility which
results.in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons, that
renders the facility incapable of proper injection
operations, such as mechanical or electrical·
failures.
3. Where the Permittee becomes aware of an omission of any
relevant facts in .a permit application, or of any incorrect
information submitted in said application or in any report to
the Director, the relevant and correct facts or information
shall be promptly submitted to the Director by the Permittee.
4. In the event that the pe:qnitted facility faiis to pe~form
satisfactorily, the Permittee shall take such immediate
action as may be required by the ~irector.
PART VIII -PERMIT RENEWAL
The Permittee shall, at least six (6) months prior to the
expiration of this permit, request an extension.
PART .IX -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 15 NCAC 2C ~011.3, 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 15 NCAC 2C .0214, including but not limited to
the following:
(A) All casing and materials may be removed prior to
initiation of abandonment procedures if the
_Director finds such removal will not be
PAGE 5 OF 7
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)(1) within 30 days of completion of
abandonment.
3. The written documentation required in Part IX (1) and (2) (G}
shall be submitted to:
Groundwater Section -UIC Staff
DEHNR -Division of Environmental Management
P.O. Box 29535
Raleigh, NC 27626-0535
PART X -OPERATION AND USE SPECIAL CONDITIONS
NONE
PERMIT NO. WI0400014
PAGE 6 OF 7
Sanitary Well Sea]
Min. 12 inches casing above
land surface
M4
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ATTACHKFRU 1
PERMIT NO. W10400014
Sampling Tap
{Effluent] _J HEAT
Pump
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PC, M. Xf•
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'77
kk
VERTICAL "CLOSED LOOP
INJECTION WELL, USING
CASED WATER WELL
The injection facility design incorporates two wells, each one a
closed loop within a water well. The injection wells are
connected toeachother and to the heat pump via a common
influent: line and a common effluent line. A single sampling tap
is provided on the effluent line.

WS REGIONRL OFFICE
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Fax:[phone] Oct 19 '94 11:27 P.01104
North Carolina De.artment of
Environment, Health, and Natural
Resources
Division of Environmental Management
Groundwater Section
Winston-Satern - regional- Office
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OCT 19 1994 Fax
AT&T Winston-Salem Cover
Advanced Technology systems Regional Office
PO Box 26124 Sh e e t
Greensboro, NO 27420
Date: !o f /S `71
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Ph -CONSTRUCTION INJECTION FACILITY INSPECTION REPORT -- PORM A
INJECTION WELL PERMIT NO. WI �i D �Ot �? DATES
NAME OF OWNER-j � r _• j�'7r ��.� �� � � �- - — - - -- �
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WS RE61UNRL OFFICE
Fax:1-91U-896-?005 Oct 14 '94 14:03 P.01/03
Borth Carolina Cie, .irtment of
Environment, Health, and Natural
Resources
Division of Environmental Management
Groundwater Section
Winston-Salem Regional- Office
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W; Kl=UIUNHL UN F 1(,E Fax : -91U- 9b-?005 [Dct 14 ' 94 14 : 04 P. 02/03
State of North Ca:.Ana
Department of Environment, -
Health and Natural Resources ' . •
Wfnston-Salem i7egionol Office
,.roes B. Hunt, it.. Governor NESM
Jonathan B. Howes, Se-c-(etary ID
Leesno Fu0er, Reganal Manager
DMSION OF E! YMRONMENTAL
MANAGEMENT
GROUNDWATER SECTION
October 14, 1994
Mr. Mille rd gold
7 i `! :i tate Highway 61
' hitsett, NC 27.�77
Suhj%ct: �Axbandoned Well, Millard Gold Residence, 722 State Highway 61,
■V hitsett, Guilford County
iD Sir:
On Ortoher 13 1994, during the course of my inspection of the subject property
for a prospective Injection Well permit, an abandoned well (24 inch diameter) was
discovered in proximity to the old barn (see diagram attachment).
I hRve enclosed nand a copy of the definition, of "abandoned weld" from the
F,nvironmental Laws of North Carolina, and an excerpt from 15A NCAC 2C Well
Conitructiop Standards addressing the proper method of abandonment of a water
s=Ypply well.
Other items in need of clarification are;
1_ The location of the septic system on the premises, including
precise drain line delineation.
2. What is the source of water for the faucet in the front yard?
3 The function of the PVC (4") pipe, oriented vertically, buried
beneath square -shaped cement covers, southwest of the carport.
4. The protruding PVC pipe (4") located on the west side of the
prrperty.
PM5 North Point Boulevard, Suite IDD, Winston-Salem, North Caolina 27106-320.3
Telephone 91C�896-7007 FAX 91MM-7005
An En-_tril Opprxtu,ity Affvmatio* Action Employer 5M recycled/ 10% post•consxner pow

WS REGIONAL OFFICE
Gold Residence
Page2
Fax:[phone] Oct 14 '94 14:04 P.O31O3
A ground absorption system is considered a potential pollution source. It is
unc~rtain where such systems may be located on your premises. It may be necessary
to meet at the sub,ier.t ~ite., ·Please cont.act me at. the address or telephone number on
th~ letterhead in ordet' to resolve these questions in preparation for an injection well
perrn.itl or for any questions you may have concerning well abandonment.
Sincerely,
~-J--
Christohper Greene
Hydrogeological Technician II
State of North Cai'-,jna
Department of Environment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A Preston Howard, Jr., P.E., Director
.NA
DEHNR
GROUNDWATER SECTION
September 20, 1994
MEMORANDUM
To:
From:
Ch~is Greene
Groundwater Section
Winston-Salem Regional Office
UIC Group 1<,Q/}l.
Groundwater Section
Raleigh Central Office
Re: Request for review of new injection well permit application
for construction and operation and for pre-construction
inspection.
An application by Mr. Millard J. Gold for a new permit for
construction and operation of an injection facility has been
received by RCO-UIC. A copy of the application is enclosed.
1. Please review the application and submit any comments to
RCO-UIC. Retain the application for your UIC file.
2. Please inspect the proposed injection well site to verify
that the location and construction plans submitted in the
application are being followed and that the NCAC T15A:02C.0200
standards are being complied with, using the enclosed
Preconstruction Injection Facility Inspection Report (form A).
Return any application review comments and the completed
Preconstruction Injection Facility Inspection Report (form A) to
the RCO-UIC by September 29, 1994, as discussed by telephone. If
the inspection cannot be accomplished by this dat~, please inform
RCO-UIC.
After the permit has been issued and the facility has.been
constructed and when operation is about to commence, the RCO-UIC
will request the RO to inspect the facility in operation.
cc: UIC Files
W-SRO Files
Enclosures
P.O. Box 29535, Raleigh, North Carollha 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post-consumer paper
State of North Carv,1na
Department of Environment,
Health and Natural Resources r~-~ Division of Environmental Management
,1-'] ....
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
a an
DEHNR
A. Preston Howard, Jr., P.E., Director
Mr. Millard J. Gold
722 Hwy. 61
Whitsett, NC 27377
Dear Mr. Gold,
GROUNDWATER SECTION
Septemb~r 19, 1994
Your application for a permit to construct and/or use a well
for injection has been received and is under review. Final
action on the permit will be taken within 60 days.
If you have any questions regarding the permit please feel
free to contact me at (919) 733 -3221, ext. 431.
cc: UIC Files
Sincerely, x~c.~
Karen A. Harmon
Hydrogeological Technician II
Underground Injection Control Program
Groundwater Section
P.O. Box 29535, Raleigh, North Carolina 27626-o.s35 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post-consumer paper
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A HEAT PUMP SYSTEM
Class 5 Wells a
to m
TO: DIRECTOR, NORTH CAROLJNA DIVISION OF ENVIRONMENTAL MANAGEMENT
M Ar*i
DATE:_MM J� 5 , 19 _ �rn
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and regulations
pursuant thereto, APPLICATION is hereby made for a PERMIT to construct and/or use a well or well at 1P!m
system as described below and in any accompanying data submitted as part of this APPLICATION.
Please type or print clearly. ram► rnn
cs
A. OWNER DATA
Name: --r. 6-Old
Business: r
Address:
City: Zip code: ot 7 :3 7 7
County: 61u; Ifer-a
Telephone: J9-1i;l 44-?- 764,6
Ownership
Federal State Private
Public Commercial Other (specify)
Native American Lands
B. FACILITY DATA {Fill out ONLY if the injection well(s) is (are) for the purpose of serving a
business or industry.)
Name:
Business:
Address:
City:
County:
Telephone:
C. HEATING CONTRACTOR DATA
Zip code:
Name: ,fin a Ss L[U &C _
Address: _
City:
County: -
Telephone:
Contact Person:
D. INJECTION PROCEDURE
Zip code:
describe how the injection well(s) will be used)
GW-57 HP (June 1993) Page 1 of 4

E. WELL USE Will the injection well(s) also be used as the supply well(s) for either of the
following?
(a) The injection operation? YES __
YES \/
NO ✓
NO~ (b) Your personal consumption?
~
F. CONSTRUCTIONDATA (CHECKONE)
EXISTING WELL being proposed for use as an injection well. Attach a copy of Form
GW-1 (Well Construction Record) and furnish (7 & 8) below. If Form GW-1 is not
available, furnish the data in (1) through (8) below to the best of your knowledge.
-✓----· __ PROPOSED WELL to be constructed for use as an injection well. Furnish
the data in (1) through (8) below as PROPOSED construction
specifications.
Well Drilling Contractor's Name: ------"V __,,e~· "'~().,=b -'-'le=--__.S""-'-ra__,ll)'---"-"'f.d'---'• _____________ _
NC Driller Registration number: 4 $7
(2) Date to be constructed: _A_S~A~f ____ Approximate depth: i welts 3 5() '
(3) Well casing:
(a) Type: Galvanized st~I __ Black steel __ Plastic_L___Other(specify) ____ _
(b) Inside diameter: 4 it inches; Wall thickness__A__inches or schedule# ~5
(c) Casing depth: From ___ to :J,o ft. (reference to land surface)
Casing extends above ground 1,111 inches (must be at least 12 inches)
(4) Cement grout:
(a) Around inner or "primary" casing: From 6"~ to a,o ft.
(b) Around outer (pit) casing, if present: From ___ to ___ ft.
(5) Screens (if applicable): WA
(a) Type:______ Inner diameter: ______ inches
(b) Depth: From ___ to ___ feet below land surface
(6) Gravel (if applicable): From ___ to ___ feet below land surface N" IA
(7) N.C. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make
provisions for monitoring well head processes. A faucet on both influent (groundwater
entering heat pump) and effluent (water being injected into the well) lines is required. Will
there be a faucet on: /
(a) the influent line?-yes ~ no -J (b) the effluent line? yes_, __ no_L
(8) Attach a diagram showing the location of the injection well and sampling faucets relative to
primary building on property.
G. PROPOSED OPERATING DATA
(a) i~h~m -ate: . Average (daily) IO gallons per minute (gpm J / . ,
(b) Injection volume: 1c,fo/ h g (I ·:;) I 00 gallons f 1 J (g; 1) C oS ed
(c) Injection pressure: Average (daily) I 8 pounds/square inch (psi)
( d) Injection temperature: Winter Average sa., tJ degrees F
Summer Average~degrees F
GW-57 HP (June 1993) Page 2of 4
H. INJECTION FLU@ DATA
(1) Fluid Source. If underground, from what depth and what type of rock/sediment does the fluid
to be injecL.:d derive (e.g., granite, limestone, sand).
(2) Chemical Analysis of Source Water. The following chemical characteristics MUST
accompany this application:
PH 6.3 ; Total hardness 9 i ppm (parts per million or mg/1);
Iron �� _ ppm; Chloride ? t ppm; Nitrate . - _ J)ptn;
Coliform bacteria _ - — counwloomi
NOTE. Assistance in determining these values may be obtained by contacting (a) your
local or county health offical, (b) a commercial water -testing laboratory, (c) your
well drilling contractor, or (d) the regional Hydrogeologist, North Carolina Dept.
of Environment, Health, and Natural Resources.
I. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the (1) injection equipment, and
(2) exterior piping/tubing associated with the injection operation. The manufacturer's brochure,
if detailed, should satisfy (1) above
1. LOCATION OF WELL(S)
Attach a detailed map showing the orientation of and distances between the proposed weil(s),
any existing well(s) that will in any way be involved in the injection operation, and at least two
(2) nearby reference points such as roads, road intersections, streams, etc. The roads should be
identified by US, NC or SR (county secondary roads) numbers, and streams should be named,
In addition, the diagram should show the direction and approximate distance to any existing
water -supply and/or injection wells within 1,000 feet of the proposed injection well.
K. CERTIFICATION
"I hereby certify, under penalty of law, that i have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my
inquiry of those individuals immediately responsible for obtaining said information, I believe
that the information is true, accurate and complete. I am aware that there are significant
penalties, including the possibility of fumes and imprisonment, for submitting false information.
I agree to operate and use the injection well and all related appurtenances in accordance with the
approved specifications and conditions of the Permit."
(Signature of wrier or Authorized Agent)
Please supply a letter signed by the owner
authorizing the above agent, if authorized agent is signer.
GW-57 HP (June 1991) Page 3 of 4

Please return the completed Application package to:
GW-57 HP (June 1993)
UICProgram
Groundwater Section
North Carolina DEHNR-DEM
P.O. Box 29535
Raleigh, NC 27626-0535
(telephone: [phone])
Page 4 of 4
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JOHN it. ALLEN
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AS OM-KVI.EC
ME141 or AND UREt��
0E ELOPMztr-
I certIfy that on I Surveyed the
property shorn on this plat : that the Property lines and the
location of all structures are accurately shorn hereon : that no
structure located on this property encroaches an any adjacent
property or street, and that no structure an the adjacent propert
encroaches an the preariees surveyed, except as shown hereon.
This Is all of tat No.
plat of which is recorded In Plat soak
pays in the Cffice of the Register of Deeds
for �I I�o�d_ County. lkarth Carolina .
Registered Land Surr or L-
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PROPERTY OF
MILLARD J. GOLD
ig WIFE
TANYA - HOWARD GOLD
ROCK CREEK TOWNSHIP
GUILFORD COUNTY • NORTH CAROLINA
QA'M THOMPSON SURVEYORS
12E E. ELM STREET
GRkW •NORTH CAROLINA 27253
SCALE- Sin.- 100 ft. DATE- NOVEll9ER 20.1994
SURVEY BY- JE QMWN BY- 48 1 APPRDVEO BY-
ORIENTEC TO NAG.ND TH PRECISION-i MART IN 12000
AREA - 5.19 1 FILF NPh.- 841139 1 DIS^ No.- iii

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The type of pi; ;ed has very little relation to the amount of heat
transfer that takes Vsace within the earth. The earth, not the pipe, is
the controlling factor. For this reason, it is not practical to use copper
or other metal piping that actually has better heat transfer capabil-
ities. Plastic pipe was chosen because of a combination of cost effec-
tiveness, availability, versatility and extremely long life.
Due to the water tem pe rature extremes of our earth coupling de-
signs, 300F to 100017, PVC piping is unacceptable. The stresses caus-
ed by these temperature fluctuations will weaken and eventually de-
stroy even high quality FVC.
When installing pipe horizontally, all piping should be 2 feet
apart. multiple pipes in one trench are the only application where this
requirement is relevant since trenching machines require approxi-
mately S feet of working space between trenches.
As the pipe goes through seasonal changes, the expansion and
contraction does not create an air gap around the pipe. Some old
experimental systems tried by other companies circulated refrigerant
through copper lines in the ground. These operated at much higher
temperatures and did cause air gaps resulting in system failure.
These systems can be solar assisted in several ways. Each specific
application must be evaluated on its own merits, then engineered to
assure optimum utilization of the entire system.
Geothermal Wells
GEOsystems recommends high quality plastic pipe be used in
earth couplings. We use the plastic pipe because it is flexible, lig
weight and has a thin wail for good heat transfer. The pipe is easy
handle and install, and has a long useful life in our type of insta
tions.

CCCL AIR
...........
........�._COMPRESSOR
Refrigerant to
■lilt.■t■
Ri■l■.■�■ Air ■ i
rator
Coil
DISCHARGE
WATER
900 F
Refrigerant
to Water
Condenser Coil
SUPPLY
44 WATER
80° F
Illustrating the AIR CONDITIONING REFRIGERATION CYCLE OF THE FHP ENERGY MISER WATER SOURCE
HEAT PUMP. The heat absorbed from the space being air conditioned is discharged to the condenser water .. .
With this design the FHP unit provides energy savings of 20 to 30 percent while cooling and over 50 percent (as
compared to electric strip heaters) while heating. (For clarity, the reversing valve is omitted.)

r
Aqua Tech Environmental Laboratories Inc.
To: GOLD, MILLARD
722 HIGHWAY 61
WHITSETT NC 27377
Attn:
Client #[ : S0001
Your Sample ID: KITCHEN SINK
Sample Matrix : LIQUID
PO # : PAIL]
Date/Time/By:
Location
Lab # 10-94-109233
(4290) Login Date 04/08/94
Date Reported- 04/1.8/94
Date Printed : 04/18/94
COLLECTION INFORMATION
04/05/94 10:30 GOLD
Peter J. Youll
Report Approved By:
Analysis Result Units Analyst EPA Date of Run
Method No. Analysis Number
-----------------------------------------------------------------------------------------
10-94-109233
NITRATE + NITRITE N 2.16 MG/L JAM 353.2/9200 04/08/94 04000212
SPLIT SAMPLE FROM --
SANFORD LAB
181 S. MAIN ST. - P.O. BOX 436 - MARION, OH 43301-0436
PHONE [phone] - FAX [phone]

Aqua Tech Environmental Laboratorees Inc.
P.O. Box 76, Melmore, Ohio 44845, 419-397-2669 or 397-2222
P.O. Box 436, 181 South Main Street, Marion, Ohio 43302, 614-382.5991
P.O. Box 488, 936 North Horner Blvd., Sanford, North Carolina 27330, 1-800-522-2832
LABORATORY ANALYSIS REPORT
04-0 7-1994 40-4290-94
DATE REC'D. 04-28-1594 PD CH LAB NO. 50001
DATE REP'D. P.O. # CLIENT NO.
KITHCEN SINK 01 04-05-1994
SAMPLE LOCATION t„� GOLD DATE SAMPLED 10.30
SAMPLED BY TIME SAMPLED
MILLA-:D GOLD
COMMENTS:
722 HIGHWAY 61
WHITSETT NC 27377
S70RET
ANXLYSIS
RESULT
UNITS
DATE OF ANALYSIS
20940
CHLORIDE,C1
16
MG/L
04-08-1994
20900
HARDNESS,Tota1,CaCo3
81
MG/L
04--11-1994
21045
IRON,To tal,Fe
120
UG/L
04-15-1994
20005
INORGANICS TO MARION
--
--
04-20-1994
20403
pH,Lab
6.3
S.U.
04-07-1994
SIGNED_ . _ r�I—�
COPY DISTRIBUTION'WHITE - CLIENT YELLOW - FILE PINK - FILE

Bate Received: G- w 44�
Time Received: L U'
Received By: c.
How Received:
Logged In By:
Date to State:
Date to Client:
Aqua Tech Environmental Laboratories Inc. Client #: 4s
BACTERIOLOGICAL ANALYSIS - PUBLIC WATER SYSTEM
Laboratory I.D# 3 7 7 4 2
Water System I D# � - — - — — —
Cou nty: 6Lit,/ � (-e
Name of System: M 4i 11 ci Kd Gold
Sample Type: f 0G Routine; 2=Repeat; 3=Replacement; 4=Plan Approval; 5=Other)
Collected on: DATE 0 � 1 Q 1 131 (MMIDDNY) TIME: J t : LC. &M (HH:MM AM or PM)
Location Where Collected: +C� en s-.) �_
Location Type: ( 1=Entry Tap; 2=General Tap; 3=End
Tap; 4=Source/intake; 5=Other)
Location Code: L� Collected By:
- 1 4vel
FOR REPEAT SAMPLE: FOR REPLACEMENT SAMPLE:
Previous Positive Location Code: _
¢ ���
A.
Original Sample Type: ❑ (1=Routine; 2=Repeat;
3-Plan Approval; 4=Other}
Positive Collection Date: I 1
-- -- —
4-
Time: — — — — M
riginal Collection Date: —
Proximity: ❑ (t -Same; 2-Upstream;
Time: — M
3=Downstream)
—
Mail Results To:
Type of Supply: ❑ Community ❑ NTNC
��QrG� Gold
El Non -Community ❑ Adjacent
91"Private
7 ZZ )--h' � w ct v
Type of Treatment: E� Chlorinated
Why f$ e f G Z 7 Y 7 7
- . - - -
El Non -Chlorinated
Free Chlorine Residual:
Telephone No. 9 o 4-49 - 7 4 6
Co biped Chlorine Residual:
V/ rra v, I,,
RESULT
CONTAMINANT METHOD PRESENT ABS5EW INVALID
Total Coliform 31Z ❑ ❑
Fecal E Coli 3 L jQ ❑ Imo" ❑
Heterotrophic P.C. —�� /ml)
(number)
❑ Repeat Samples Required
Date Analysis Begun: 1 D Z 1 __9
Date Analysis Completed: D 1 1
Laboratory Log* 1U11�
COMMENTS:
INVALID CODES
t) Confluent Growt VNo coliform found
2) TNTCINo Coliform Found
3) Turbid Culture/No Coliform Found
4) Over 48 Hours Old
5) Improper Sample or Analysis
❑ Replacement Sample Required
Time Analysis Begun: _L : U _ pM
Time Analysis Completed: / :2- • 0 ;2 �2_M
Certified By: 1 w k,04W F
ATE-L-87 936 N. HORNER BLVD, • P.O. BOX 488 • SANFORD. NC 27331-0488
1.21.93 PHONE [phone] • 1-800.522-2832 • FAX [phone]