WI0400065_GEO THERMAL_20160804

ermit Number
Program Category
Ground Water
Permit Type
WI0400065
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
P-.rmltted Flow
Facility
Facllity Name
Mark and Christel Oliphant SFR 5A7
Location Address
1259 Elon Pl
High Point NC
Owner
Owner Name
Mark L
Oates/Events
Orig Issue
8/1/2005
App Received
6/20/2016
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27263
Oliphant
Draft Initiated
Scheduled
Issuance Publlc Notice
Central Files: APS SWP
8/4/2016
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classlflcation
Individual
Permit Contact Affiliation
Major/Minor
Minor
Faclllty Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mark L. Oliphant
1259 Elon Pl
High Point
Region
Winston-Salem
County
Guilford
NC 2726.3
Issue Effective Expiration
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
6/24/16
8/1/16
Subbasin
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Water Re$ources
ENVIRONMEN·TAL· QUALITY
Mark arid· Christel Oliphant
1259 Elon Pl
High Point
NC 27263
Re: Issuance of Injection Well Permit
Permit No. WI040006S
August 8, 2016
Geothermal Heating/Cooling Water Return Well
Guilford County .
Dear Mr. and Mrs. Oliphant:
Secretary
S. Jf..Y ZIMMERMAN
Director
In accordance with your permit renew~l applica(ion _received June 20,, 2016, I am forwarding Permit
No. WI0400065 for the continued operation of geothermal heating/cooling water return well(s) located
at the above referenced address. This permit shall be effective from date of issuance, until July 31,
2021, 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 120 days prior to its expiration date. As indicated in the permit, this
permit is not transferable _to any person without prior notice to, and approval by, the Director of the
Division of Water Resources. If you· have any questions regarding your· permit or the Underground
Injection Control Program, please call me at [phone].
Best Regards,
Shristi Shrestha
Underground Injection Control (UIC)-Hydrogeologist
Division of Water Resources, NCDEQ
Water Quality Regional Operations Section
cc: Sherri Knight, Wilmington Regional Office
Central Office File, WI0400065
Guilford County Environmental Health Department
State ofNorth Carolina I Environmental Quality I Water Resources
1611 Mail scrvkc Ccutcr I Raleigh, North Cai:olina 27699-1611
919 707 9000
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENTCOMMISS_ION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
In accordance with the provisions ofArticle 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
· Mark and Christel Oliphant
FOR THE CONTINUED OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S); defined in Title 15A North Caroiina Administrative Code 02C .0224(a), which will be used
for the injection of heat pump effluent. The injection well(s) located at 1259 Elon Pl, High Point, Guilford county,
NC 27263 will be operated in accordanc~ with the application submitted June 20, 2016, and in conformity with
the specifications and ·supporting data all of which are filed with the Department of Environmental Quality and
are considered a part of this permit
This permit is for continued operation of an injection well shall be in compliance with Title . l SA North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and RegulatiO!}S pertaining to well
construction and ·use.
This permit shall be effective, unless revoked, from the date of its issuance until July 31, 2021, and shall be subject
to the specified conditio~s and limitations set forth in this permit.
Permitissued this the 4th day of August 2016.
~ S. Jay Zimmerman, P.G.
\ ' Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Permit#Vv10400065 lHC/5A7
ver. 11/15/2015
Page 1 of 5
PART I -PERMIT GENERAL CONDITIONS
1. The Permittee shall comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). 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 iri N.C.G.S. 87-94 ·
2. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data [15A NCAC 02C .021 l(a)].
3. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data [15A NCAC 02C .0211(1)].
4. This permit is not transferable without prior notice and approval. In the event there is a desire for the facility
to change ownership, or there is a name change of the Permittee, a formal permit amendment request must
be submitted, including any supporting materials as may be appropriate, at least 30 days prior to the date of
the change [15A NCAC 02C .021 l(q)].
5. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, · or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met [15A NCAC 02C .0203].
PART II -WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed in accordance
with the requirements of rule 15A NCAC 02C .0107 except as required in Item #2 below.
2. Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC 02C .0107
except that the entire length of the casing shall be grouted in such a way that there is no interconnection of
aquifers or zones having differences in water quality that would result in degradation of any aquifer or zone.
For screened wells, grout shall be emplaced from the top of the gravel pack to the land surface. For open-
end wells, the casing shall be grouted from the bottom of the casing to the land surface [15A NCAC 02C
.0224(d)(2),(3)].
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing conditions.
[15A NCAC .0225(g)(8)].
4. The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [15A NCAC 02C .0224(d)(4)].
5. Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal as defined in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .0107G)(2)].
Permit #WI0400065 UIC/5A7
ver. 11/15/2015
Page 2 of 5
7. A completed Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 ·of this
permit.
PART III -OPERATION AND USE CONDITIONS
1. The Permittee shall comply with the conditions of this permit and properly operate and maintain the
irtjectiort facility in compliance with the conditions of this permit and the rules of ISA NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [15ANCAC 02C .021 l(j)].
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface water
or groundwater resulting from the operation of this facility. In the eventthat 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 that may be · required,
such as the repair, modification, or abandonment of the injection facility [ISA NCAC 02C ~0206].
PART IV-INSPECTIONS[15ANCAC 02C .02ll(k)]
1. Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation of credentials, enter and inspect any property, premises, or place on or related to the
injection facility at any reasonable time for the purpose of determining compliance with this permit, may
inspect or ·copy any records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwater, surface water, or injection fluids.
2. DWR representatives shall have reasonable access for purposes of inspection, observation, and sampling
associated with injection and any related facilities as provid~d for in N~C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary samples of the injection facility's activities.
PART V ~ MONITORING AND .REPORTING REQUIREMENTS
l. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on-site and available for inspection [ISA NCAC
02C .0224(t)(2), (4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State and
compliance · with the groundwater quality standards specified in ISA NCAC 02L [15A NCAC 02C
. 0224( t)( 1)].
3. The Permittee shall report any monitoring or ot~er information that indicates noncompliance with a specific
permit condition, that a contaminant may cause a violation of applicable groundwater quality standards, or
that a malfunction of the injection system may cause the injected fluids to migrate outside the approved
injection zone or area. As specified in rule 15A NCAC 02C .021 l(r), noncompliance notification shall be
as follows:
(A) Oral notification . shall be given within -24 hours • of the occurrence, or first knowledge of the
occurrence, ~o the Wilmington Regional Office; telephone number 910-796-7215.
(B) Written notificatio11 shall be made within five days of the occurrence and submitted to the addresses
in Item #5 below.
Pernut#WI0400065 UIC/5A7
ver. 11/15/2015
Page 3 of 5
(C) The written notification shall contain a description of the noncompliance and its cause; the period of
noncompliance, including dates and times; if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and any steps taken or planned to reduce, eliminate, and
prevent reoccurrence of the noncompliance.
4. The Permittee shall record the number and location of the wells with the register of deeds in the county in
which the facility is located. [15A NCAC 02C .0224(±)(3)].
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
UIC Program Staff
Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Water Quality Regional Operations Section
DWR Wilmington Regional Office
127 Cardinal Drive
Wilmington, NC 28405
PART VI-PERMIT RENEWAL [15ANCAC 02C .0224(c)]
As required by rule an application for permit renewal shall be made at least 120 days prior to the expiration
date of the permit. This permit condition does not apply if the Permittee chooses to discontinue operation
of the well for injection of effluent from the geothermal heating and cooling system associated with this
permit.
PART VII-CHANGE OF WELL STATUS [15A NCAC 02C .0240]
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complying with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to rule
15A NCAC 02C .0113(b) in order to prevent the well from deteriorating and acting as a source or conduit
of contamination, which is prohibited by General Statute 87-88( c ).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well
seal that cannot be removed without the use of hand or power tools.
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall permanently abandon that injection well in accordance with the procedures specified in 15A
NCAC 02C .0113(b), which include, but are not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.·
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected prior to sealing in accordance with rule 15A
NCAC 02C .011 l(b)(l)(A), (B), and (C).
Perm.it #WI0400065 UIC/5A7
ver. 11/15/2015
Page 4 of 5
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends fo the bottom of the well and is raised as the well is
filled.
(E) In those cases wllen a subsurface cavity has been created as .. a result of the injection
operations, each well shall be abandoned in such a manner that will prevent the movement
of fluids into or between underground sources of drinking water.
(F) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0224(f)(4) within 30 days of completion of abandonment.
5. The written documentation required in Part VII ( 4 )(F) shall be submitted to the addresses specified in Part
V.5 above.
Permit #WI0400065 UIC/5A7
ver. 11/15/2015
Fag~ 5 of 5
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM NC Department of
• Environmental Quality
Date: June 2,11, 2016 Receive
d
JUN282016
.1 SO r\S 1- S Winston-Salem
T-0 ' - Shristi Shrestha, WQROS — Animal Feeding Operations and Groundwater Protectionrintnielli' OfflCe
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0400065
A. Applicant: Mark and Christel Oliphant
B. Facility Name:
C. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment. and/or action. Within 30 calendar days, please return a completed WQROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WQROS Reviewer:
COMMENTS:
1 l
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AUG eI2016
Water Quality ReQ,onal
Operations Section
FORM: WQROS-ARR vcr. 092614 Page 1 of 1

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
HECK ONE OF THE FOLLOWING:
New Application Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Pr nt or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: F4 — f . ,20 1 k PERMIT NO. WM4 OWLS (leave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave Blank if New Application)
I. Current Use of Well
a. Continue to use as V Geothermal Well Drinking Water Supply Other Water
Supply
b. Terminate Use: lithe well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a cop
tikinstmn
Record (GW-30). �
❑ Yes, I wish to rescind the permit JUN 2 4 2016
Water Quality Regional
2. Current Ownership Status : rations Section
Has there been a change of ownership since permit last issued? 0 YES NO
If yes, indicate new owner's contact information:
Name(s)
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
r.
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence if Business/Organization
Government: State Municipal _ County Federal
C. WELL OWNER(S)IPERMIT APPLICANT — For individual residences, list owner(s) on property deed. 11 or
all others, list name of entity and flaw of person delegated authority to sign:
CA-.,54.a..1 I-.Dli r1 c,
Mailing Address: 15 E Y ; &1.0 l=
City: t (1 State: ip Code: ,)... R i3 . - County:yj`0. i�! 1 � ()
Day Tele No,. '�j 5��� - :?3.- 22 _ Cell No.: jlr�- 64,9 -6 3 1
EMAIL Address: Fax No.:
Geothermal Water Return Well PermitApplication (Revised ]an 2015) Page 1

D. WELL OPERATOR (if different from well owner) -For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the business
or agency:-----------:-----------------------
Mailing Address:--------------------------------
City: _____________ State: __ Zip Code: _______ County: _____ _
Day Tele No .: Email Address.:
E. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1)
(2)
Parcel Identification Number (PIN) of well site: __________ County: _____ _
Physical Address (if different than mailing address): ________________ _
City: _______________ State: NC Zip Code: ________ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.: _____________________ _
Company Name: ________________________________ _
Contact Person"---: _______________ EMAIL Address: ___________ _
Address:-----------------------------------
City: __________ Zip Code: _____ State: __ .County: _________ _
Office Tele No.: · _________ Cell No.: Fax No.: ________ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: ____________________________ _
NC HVAC Contractor License No.: _________________________ _
Company Name: ________________________________ _
Contact Person.c-: _______________ EMAIL Address: ___________ _
Address:-----------------------------------
City: __________ Zip Code: _____ State: . __ County: _________ _
Office Tele No.: Cell No.: __________ Fax No.: ______ _
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _
YES __ _
NO ___ _
NO ----
I. WELL CONSTRUCTION REQUIREMENTS -As specified in )15ANCAO02C .0224(d ):
(1)
(2)
The water supply well shall be constructed in accordance with the water -supply well requirements of
15ANCAC02C .0107.
If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page2
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom ·of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional ·source of water
during system operation for. the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
( 1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
____ *E.XISTING WELLS ____ PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a . schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specification~ as long as th~ _diagram clearly i_~entifies or distinguish(?s each_ well -fyom one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a min~mum, the following well construction _specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing · depth below land surface
( d) Casing height "stickup" above land surface
(e) Groutmaterial(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited/or sealing water-bearing zones with 1500
mg/L chloride or greaterper 15A NCAC 02C .0107(1)(8)
( t) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATINGDATA
(I) Injection Rate: Average (daily) gallons per minute ($Pm).
(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.
L. SITE ~-As specified in 15A NCAC 02C .0224(b){4). attach a site-specific map that is scaled or otherwise
accurately indicates .distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
( 1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
applicatiori ;atea, arid rep~ir area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located. · · ·
(4) An arrow orienting the site to one of the cardinal directions (north, _south, west, or east)
Geothermal Water Return Well Permit AppHcatiori (Revised Jan 2015) Page3
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
ISA NCAC 02C .0211(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the person( si listed on the uronerty deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf:
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
subtnitted 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 arc significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
/-7
Signature of Property cwnet1Applican
Print or Type Full Name
Signature of Property Owner/Applicant
Ptint or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 4

PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary·
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
Mark and Christel Oliphant
1259 Elon Pl
High Point
NC 27263
June 29, 2016
RE: Acknowledgement of Application No: WI0400065
Geothermal Heating/Cooling Water Return Well
Guilford County
Dear Mr. and Mrs~ Oliphant:
The Water Qualify Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting ·documentation received on June 20, 2016. Your application
package has been assigned the number listed above, and the primary reviewer is Shristi Shrestha
Central and Winston Salem R_egional Office staff will perform a detailed review of the
provided application, and may contact you .with a request for additional information. To ensure
maximum efficiency in processing permit applications, the Water Quality Regional Operations
Section (WQROS) requests your assistance in providing a timely and complete response to any
additional information requests.
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. If you have any questions, please contact Shristi
Shrestha at 919-807-6406 or e11:13-il at [e-mail].
cc: Winston Salem Regional Office, WQROS
Permit File WI0400065
S_incerely,
For Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch Division of Water
Resources
State ofNorth Carolina I Environmental Quality I Water Resources
1611 Mail service Center I Raleigh, No1th Caroliua 27699-161 l
919707 9000
Director
WATER Q UALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: June 2j, 2016
To: Sherri Knight
From: Shristi-Shrestha, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0400065
A. A pplicant: Mark and Christel .Oliphant
B~ Facilitv Naine:
C. A pplication:
E.
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
Comments/Other Information:
_I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comme~t, and/or action. Within 30 calendar days, please return a completed WO ROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: _________________ Date: ____ _
COMMENTS:
NOTES:
FORM: WQROS-ARR ver; 092614 Page 1 of l
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE QUEST FORM
Date: June 29, 2016
To: Sherri Knight
From: Shristi· Shrestha, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephtme: 919-807-6406 Fax: [phone] E-Mail: [e-mail]
PermitNumber:WI0400065
A. Applicant: Mark and Christel Oliphant
B. Facility Naine:
C. App lication:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
£. Comments/Other Information:
_I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for . your
review, comment, and/or action. Within 30 calendar days, please return a completed WOROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces.below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: _________________ Date: ____ _
COMMENTS:
NOTES:
FORM: WQROS-ARR ver~ 092614 Page 1 of 1
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
June 29, 2016
Mark and Christel Oliphant
1259 Elon Pl
High Point
NC 27263 ·
RE: Acknowledgement of Application No. WI0400065
Geothermal Heating/Cooling Water Return Well
Guilford County .
Dear Mr. and Mrs. Oliphant:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt ofyour
permit application and supporting documentation received on June 20, 2016. Your application
package has been assigned the number listed above, and the primary reviewer ~s Shristi Shrestha
Central and Winston Salem . Regional Office staff will perform a detaij.ed review of the
provided application, and may contact you with a request for additional information. To ensure
maximum efficiency in processing permit applications, the Water Quality Regional· Operations
Section (WQROS) requests your assistance in providing a timely and complete response · to any
additional information requests.
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. If you have any questions, please contact Shristi
Shrestha at 919-807-6406 or e~l at [e-mail].
cc: Winston Salem Regional Office, WQROS
Permit File WI0400065
Sincerely,
For Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch Division of Water
Resources
State of North Carolina I EnvironmentalQuality I Water Resources
161 l Mail service Center I Raleigh, No1th Carolina 27699-1611
919707 9000
Director
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
HECK ONE OF THE FOLLOWING:
New Application Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Panes 1 and 4 (signature page) only
Pr nt or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
r
DATE: ; ' �- ,2O I PERMIT NO. WIN OWLS (leave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave Blank if New Application)
1. Current Use of Well
a. Continue to use as \if Geothermal Well Drinking Water Supply Other Water
Supply
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a cop,I{p�
Record (GW-30). 1[[CC
❑ Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES
If yes, indicate new owner's contact information:
Name(s)
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
JUN 242O8
Water Quality Regional
eralions Section
NO
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence V Business/Organization
Government:
State Municipal County Federal
C. WELL OWNER(S)IPERMIT APPLICANT — For individual residences, list owner(s) on property deed. +For
all others, list name of entity and naF}w of person delegated authority to sign: ri r.
Mailing Address: c f
!! t' pzA.11D.1p`) County: to 1 PO x� 1 City: State: t ip Code:
Day Tele No.: 12J h '' _ .�
EMAIL Address: Fax No.:
Geothermal Water Return Well Perndt Application (Revised Jan 2015) Page 1

D. WELL OPERATOR (if different from well owner) -For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the business
or agency: _____________________________ _
Mailing Address:--------------------------------
City: _____________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: Email Address.:
E. LOCATION OF WELL SITE-Where the injection wells are physically located:
(1)
(2)
Parcel Identification Number (PIN) of well site: __________ County: _____ _
Physical Address (if different than mailing address): ________________ _
City: _______________ State: NC Zip Code: ________ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name: ________________________________ _
Contact Person-'--: _______________ EMAIL Address: ___________ _
Address:-----------------------------------
City: __________ Zip Code: _____ State: __ County:
Office Tele No.:· Cell No.: Fax No.: ________ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: ____________________________ _
NC HVAC Contractor License No.: _________________________ _
Company Name: ________________________________ _
Contact Person-'--: _______________ EMAIL Address: ___________ _
Address:-----------------------------------
City: _________ Zip Code: ___ _ State: . __ County: _________ _
Office Tele No.: Cell No.: __________ Fax No.: ______ _
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES __ _ NO ___ _
YES ___ _ NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS -As specified in :15A NCAO 02C .0224 (d):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page2
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
( 1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
____ *EXISTING WELLS ____ PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system; A single diagram can be used for wells having the same construction
spe~ification~ as l_ong as th~ diagram clearly identifies or distinguish~s each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(()(8 )
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATINGDATA
(1) Injection Rate: Average (daily) gallons per minute (~m).
(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.
L. SITE MAP -As specified in 15A NCAC 02C .0224(b )(4 ). attach a site-specific map that is scaled or otherwise
accurately.indicates distances and orientations of the specified features from.the injection well(s). The site map
shall include the following:
(1) All water supply-wells, surface water bodies, and septic systems including drainfield, waste
application area, arid repair area located within 250 feet of the injection well(s).
(2) Any other potentiai' sources of contamination listed in 15A NCAC 02C .0107(a )(2 ) located within 250
feet ofthe proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed-injection well(s) are
to be located. ·
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page3
/
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a `layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the personts1 listed on the propertv deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
LI
rl J��J
Signature of Property [ wnerlApplicani
1
Print or Type Full Name
„,47
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 4

Water Resources
ENVIRONMENTAL QUALITY
RECE[VEDINCDEQP'
JUN 202616
Water Quality Re9l0i181
Operations Section
March 16, 2016
CERTIFIED MAIL # 7014 1200 0001 3432 8695
RETURN RECEIPT REQUESTED
Mark and Christel Oliphant
1259 Elon Pi
High Point
NC 27263
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0400065
Guilford County
Dear Mr. and Mrs. Oliphant:
secretary
S. JAY ZIMMERMAN
Director
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on April 18, 2011, and expires on March 31, 2016. Per permit conditions and requirements
per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120 calendar days
prior to expiration of the permit if you wish to continue operating the injection well on your
property.
If Your Geothermal Water Return Well is Still Currently Being Used for Injection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http://portal.ne.denr.org/web/wq/aps/gwpro/permit- applications.
If Your Geothermal Water Return Well is NO LONGER Being Used for Infection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.0240. When the well is plugged and abandoned. a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
State of North Carolina j Environmental Quality Water Resources
1611 Mail service Center , Raleigh, North Carolina 27699-161 I
919 707 9000

Page 2 of 2
If There has been a Chaim of Ownership of the Property:
If there has been a change of ownership of the property. an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above_ Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1 636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner rnay result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email at [e-mail].
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Winston-Salem Regional Office — WQROS w/o enclosures
Central Files - Permit No. WI0400065 w/o enclosures

PAT MCCRORY
Governer
DONALD R. VAN DER VAART
Water Resources
ENVIRgNMENTAL QUALITY
March 16, 2016
CERTIFIED MAIL # 7014 1200 0001 3432 8695
RETURN RECEIPT REQUESTED
Mark and Christel Oliphant
1259 Elon PI
High Point
NC 27263
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open- oop injection Well
Permit No, WI0400065
Guilford County
Dear Mr. and Mrs. Oliphant:
Secretary
S. JAY ZIMMERMAN
Director
The Underground Injection Control (VIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on April 18, 2011, and expires on March 31, 2016. Per permit conditions and requirements
per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120 calendar days
prior to expiration of the permit if you wish to continue operating the injection well on your
property.
If Your Geothermal Water Return Well is Still Currently Being Used for Injection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http:llportal.ncdenr.orglweblwglapslgwprolpermit-applications.
If Your Geothermal Water Return Well is NO LONGER Beim Used for Injection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
State of North Carolina I Environmental Quality I Water Resources
1611 Maii service Censer j Raleigh, North Carolina 27699-1611
919 707 9000

Page2 of2
If There has been a Change of Ownership of the Property :
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] orby email at [e-mail].
=~-
Shristi Shrestha
Hydro geologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Winston-Salem Regional Office -WQROS w/o enclosures
Central Files -Permit No. WI0400065 w/o enclosures
3432 8695
U.S. Postal Service
CERTIFIED MAIL, RECEIPT
(Domestic Mail Only; No insurance Coverage Provided)
For delivery information visit our website at www.usps-comp;
Return Receipt Fee
(Endorsement Required)
tiiestricted Delivery Fee
(Endorsement Required)
Tot
San! rc
drPO
Mark and Christel Oliphant
1259 E1on P1
High Point NC 27263
Postmark
Here
SENDER: COMPLETE THIS SECTION
• Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
• Attach thls card to the back of the mailpiece.
or an the front If space permits.
1. Article Addressed to;
COMPLETE THIS SECTION ON DELIVERY
A. Signature
B. -ecelved by (Printed Name)
ire
ii 2fr. -
Q. Data of Delivery
Mark and Christel Oliphant
1259 Elan P1
High Point NC 27263
111111111111111111111111111111111111111111
9590 9403 0730 5196 3154 41
D. Is delivery address different front Keen V © Yes
if YES, enter delivery address below: No
3. Service Type
0 Adult Signature
❑ Adult Signature Restricted Delivery
0 Certified Mail
Certified Mail Restricted Delivery
0 Collect on Delivery
+r• •� . fftens(er fri7m servlt,e (al*
7014 1200 0001 3432 8695
PS Form 3811, April 2015 PSN 753ti 2 - — - —
Collect on Delivery Restricted Delivery
Insured Mall
'�•rcd Mail Restricted Delivery
$ Qi
O Priority WI Expueea'
ID Registered Moll^"
0 Registered NW Restricted
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Domestic Return Receipt

Permit Number WI0400065
Program Category
Ground Water
Permit Type
.... ·.f
Injection Heating/Cooling Water Return Well {5A7)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Mark and Christel Oliphant SFR 5A7
Location Address
1259 Elon Pl
High Point
Owner .
Owner Name
Mark
Dates/Events
Orig Issue
08/01/05
NC 27263
L Oliphant
App Received Draft lnitiate_d
08/24/10 04/18/11
Scheduled
Issuance
Central Files : APS _ SWP_
04/25/11
Permit Tracking Slip
Status
Active
Version
2.00
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mark L. Oliphant
1259 Elon Pl
High Point NC 27263
Public Notice Issue
04/18/11
Effective
04/18/11
Expiration
03/31/16
_R_e....._g_u_la_te_d_A_c_ti_v_it_ie_s _______________ ----'R=e-=g-=-ue=-s"""'t=e-=d"""/R--"-e"-'c""""e'"""iv-"--e"'""'d'-'-=E-'-ve=n=t=s __________ _
Heat Pump Injection Additional information received
Additional information requested 08/31/10
Outfall N~J: ... L
Waterbody Name Stream Index Number Current Class Subbasln
Permit Number WI0400065
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow·
Facilit ,
Facility Name
Mark and Christel Oliphant SFR 5A7
Location Address
1259 Elon Pl
High Point
Owner
Owner Name
Mark
Dates/Events
NC 27263
L Oliphant
Orig Issue
08/01/05
App Received Draft Initiated
08/24/10 04/18/11
Scheduled
Issuance
Central Files: APS_ SWP_
04/18/11
Permit Tracking Slip ·
Status
In draft
Versi·on
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minot
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mark L .Oliphant
1259 Elon Pl
High Point NC 27263
Public Notice Issue Effective Expiration
Re a ulated Activities Re a uested/Received Events --------------------------
Heat Pump Inj ection Additional information received
Additional information requested 08/31/10
Outfall FUU
Waterbody Name Stream Index Number Current Class Subbasin
•~A ,,._1,~I'.
HCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Mark and Christel Oliphant:
1259 Elon Place
High Point, NC 27263
Re: Issuance oflnjection Well Permit
Permit No. WI0400065
Issued to Mark and Christel Oliphant
Gu.ilford County
Dear Mr. and Ms. Oliphant:
Coleen H. Suliins
Director
April 18, 201
Dee Freeman
Secretary
In accordance .with your application received August 24, 2010, I am forwarding Permit No. WI0400065 for the operation
of a SA 7 geothermal underground injection control (UIC) well heat pump system located at the above referenced address.
This permit shall be effective from the date of issuance until March 31, 2016, and shall be subject to the conditions and
limitations stated therein.
Please be aware of permit conditions Il.1 and Il.2 that require you to .schedule a site inspection with the regional
office within 30 days of permit issuance and that continued operation of the injection system is contingent upon
effluent quality. Groundwater samples will be collected from your geothermal well by Regional Office staff and
laboratory analytical results are forthcoming. An evaluation of the results will be made, including whether or not your
system ·is in compliance with North Carolina. Groundwater and Drinking Standargs.If contaminants exceed regulatory
levels, the Regional Office Staff will provide further guidance.
In order-to continue uninterrupted-legal use-of this well for the stated purpose, you should submit an application to renew
the permit four 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 thelinderground Injection Control Program please call me at [phone].
Best Regards,
l/--£A~
.C McCray
Environmental Specialist
cc: Sherri Knight..:. Winston.-Salem. Regional Office
Central Office File -WI0400065
.Guilford County Environmental Health Dept.
Attachment(s)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Caroline. 27699-1635
Location: 2728 Caoital Boulevard. Raieiah. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715:058B: FAX 2: 919-715-6048 \ Customei Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Eqw:I Opponunity I Affirmative Action E:rnoloye;
NOne_l c, 1 · °" ort1 aro.mc:..
;Ji1afurall!l
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Mark and Christel Oliphant
FOR THE OPERATION OF 1 TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 1259 Elon Place, High Point, Guilford County, NC 27263, and will be constructed
and operated in accordance with the application August 24, 2010, and in conformity with the specifications and
supporting data submitted, all of which are filed with the Department of Environment and Natural Resources
and are considered a part of this permit.
This permit is for operation only, and does not waive any provisions of the Water Use Act or any other
applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be•in compliance with
Title 15A North Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations
pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until March 31, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
Permit issued this the 18th day of April, 2011,
Ljc
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #W40400055
UIC/5A7
ver. 03/2010
Page 1 of 5

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically conp.ect 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.
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 -WELL CONSTRUCTION SPECIAL CONDITIONS
1. Within 30 days of permit issuance, the Permittee must contact the Winston-Salem Regional Office APS Staff in
order to have samples collected at the source well and injection well.
2. Continued operation of the injection system is contingent upon the effluent not impacting groundwater quality. The
water quality of the effluent cannot be that of a lower quality than the influent, which results in a degrading of water
quality of the aquifer.
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
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit #WI0400065 UIC/SA7 Page 2 of 5
ver. 03/2010
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality.· The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
PARTIV-PERFORMANCESTAN:DARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform. satisfactorily, including · the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions jncluding 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 perm.it even if compliance
requires a reduction or elimination of the permitted activity.·
3. The issuance of this perm.it shall not relieve the Penn.ittee of the responsibility for damages to surface or
groundwater resulting from the operation of thi_s facility.
PART V -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility, shall.be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive .prior.·written approval from the Director of any
planned physical alteratiqns or additions in the permitted facility or activity not· specifically authorized by
tp.e permit. · ·
PART VI -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 perm.it, 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 VII -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
Permit #WI0400065 UIC/SA7 Page 3 of 5
ver. 03/2010
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Winston-Saiem Regional Office, telephone number [phone], any of the
following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application .or in any report to the Director, the relevant 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 RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
PART IX-CHANGE OF WELL STATUS
'
1. The Permittee shall provide written notification within 15 days of an.y 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 JSA NCAC.2C .0213(h)(l), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled. .
Permit #WI0400065 UIC/5A7 Page 4 of 5
ver. 03/2010
(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 iri 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
l SA 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 #WI0400065
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/SA7
ver. 03/2010
Page 5 of 5
Mccray, John
From:
Sent:
To:
Cc:
Subject:
Knight, Sherri
Friday, April 15, 2011 4:1"8 PM
Watts, Debra
Mccray, John
RE: W 10400065 5A 7 Renewal
No go ahead and issue and I'll sample when I can reschedule. I have scheduled multiple times and had to cancel -last
time I was out with a sick kid. Have to work around his work schedule and can't sample for nitrate Thursday or Friday.
Sherri Knight, PE
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aauifer Protection Section
585 Waughto~n Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be-subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Watts, Debra
Sent: Friday, April 15, 2011 3:28 PM
To: Knight, Sherri
Cc: Mccray, John; Watts, Debra
Subject: RE: WI0400065 SA7 Renewal
Hi Sherri
Crazy times!
I asked John to send the note below -WI0400065 -since we have had this renewa~ r·equest since last August. ,Sheu.Id
we go ahead and issue and you schedule the sampling when you can? Let me know if you have concerns if we did this.
Thanks! djw
Debra J. Watts, Supervisor
Groundwater Protection Unit
Aquifer Protection Section
919-715-6699
DISCLAIMER: Per Executive Order No. 150,all e-mails sent to and from this account are subject
to the North Carolina Public Records Law and may be disclosed to third parties.
From: Mccray, John
Sent: Thursday, April 14, 2011 3:22 PM
To: Knight, Sherri
Cc: Watts, Debra
Subject: RE: WI0400065 SA7 Renewal
Ms. Knight,
Have you been able to conduct the site visit for this application? I hav_e not yet received a Staff Report for this facility
and am hoping to get it issued as soon as possible.
1
Best Regards,
John McCray
From: Knight, Sherri
Sent: Monday, March 14, 2011 3:34 PM
To: Mccray, John
Subject: RE: WI0400065 SA7 Renewal
I am scheduled to· go out there on Wednesday or Thursday of next week. This is the one I have had trouble scheduling (
scheduled-then cancelled, unable to reach homeowner, etc. Owner is unavailable at times, but said he would be able to
meet me next week.
Sherri Knight, PE
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquifer Prntection Section
585 Waughtown Street
Winston-Salem, NC 2.7107
Voice: {336) 771-5280
FAX: {336) 771-4632
E-mail correspondence to and from this address may be subject to the North Carolina Public Records law and may be
disclosed to third parties.
From: Mccray, John
Sent: Monday, March 14, 2011 3:02 PM
To: Knight, Sherri
Subject: fW:.WI0400065 SA7 Renewal
Ms. Knight,
Do you have a Staff Report for this permit application? I am preparing to issue this permit without the Sample Results in
accordance with the new 5A7 procedures and was hoping that you have completed a site inspection.
Best Regards,
John McCray
From: Knight, Sherri
Sent: Friday, January 28, 2011 3:44 PM
To: Mccray, John
Subject: RE: WI0400065 SA7 Renewal
i had an appointment when them which turned out to be one of the days that it snowed. I have left a message to try to
rescheduie for next week. He works and can only m~et me either at lunch on certain days or after 6:00 pm.
Sherri Knight, PE
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 271.07
2
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Mccray, John
Sent: Friday, January 28, 2011 3:18 PM
To: Knight, Sherri
Subject: WI0400065 5A7 Renewal
Ms. Knight,
Debra wanted me to also inquire on the status of the review on this renewal application as well. Can we proceed with
the renewal of this permit or is the review nearly complete?
Best Regards
John McCray
3
Print Preview
http: //gcgi s. co.gui l ford.nc. uslguil ford_LnewlprintPrev iew .aspx?Pri ntOp...
Guilford County, NC
Old Parcel Number
9554704301007E 009
Condo Book
Parcel. Number
0161538
Condo Page
PIN
7810914564
Total Assessed Value
$389,800
Owner Name
OLIPHANT, MARK LEWIS ; OLIPHANT,
CHRISTEL A
Total Building Value
$281,600
Mailing Address 1
1259 ELON PL
Total Out Building
Value
$0
Mailing Address
City
HIGH PO I NT
Total Land Value
$106,200
Mailing Address
State
NC
Total Deferred Value
$0
Mailing Address
Zip
27263
Building Count
1
Property Address
1259 ELON PL
Building Number
1
Legal Desc 1
Lot # 37.19 AC KERSEY & 4636-434
Year Built
2004
Land Units
37.1900
Heated Area
2791
Deed Book
004636
Bedrooms
3
Deed Page
00434
Bathrooms
FULL:3 HALF:
0
.949zf N
79.94(930 w
3t i 5 ex47Dj
EK;,cI4P. +� �PI
43.4
I of 2
3/14/2011 4:19 PM

Print Preview http://gcgis.co.guilford.nc.us/guilford_new/printPreview.aspx?PrintOp ...
2 of2
Plat Book Use Code RESIDENTIAL
Plat Page Appraisal Model Code SFR
Map Scale
Disclaimer: While every effort is made to keep information provided over the internet
accurate and up-to-date, Guilford County does not :certify the authenticity or accuracy of
such information. No warranties, express or implied, are provided for the records and/or
mapping data herein, or for their use or interpretation by the User.
1 inch = 881 feet
3/14/2011 4: 19 PM
Mccray, John
From:
Sant:-
To:
Knight, -Sherri
Monday, March .14, 201'1 3:34 PM
Mccray, John
Subject: RE: WI0400065 5A7 Renewal
I am scheduled to go out there on Wednesday or Thursday of next week. This is the one I have had trouble scheduling (
scheduled-then cancelled, unable to reach homeowner, etc. Owner is unavailable at times, but said he· would be able to
me~t me next week.
Sherri Knight, PE _
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquife·r Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: {336) 771-4632
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third.parties.
From: Mccray, John
Sent: Monday, March 14, 2011 3:'02 PM
To: Knight, Sherri
Subject: FW: ·wI0400065 SA7 Renewal
Ms. Knight,
Do you have a Staff Report for this permit application? I am preparing to issue this permit without the Sample Results in
accordance with the new SA7 procedures and was hoping that you have completed a site inspection.
Best Regards,
'John McCray
From: Knight, Sherri
Sent: Friday, January 28, 2011 3:44 PM
To: Mccray, John
Subject: RE: WI0400065 SA7 Renewal
I had an appointment when them which turned out to be one of the days that it snowed. I have left a message to try to
reschedule for next week. He works and can only meet me either at lunch on certain days or ·after 6:00 pm.
Sherri Knight, ·PE .
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
1
FAX: {336) 771-4632
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Mccray, John
Sent: Friday, January 28, 2011 3:18 PM
To: Knight, Sherri
Subject: WI0400065 5A7 Renewal
Ms. Knight,
Debra wanted me to also inquire on the status of the review on this renewal application as wen. Can we proceed with
the renewal of this permit or is the review nearly complete?
Best Regards
John McCray
2
Mccray, John
From:
Sent:
To:
Subject:
Attachments:
Ms. Knight,
Mccray, John
Tuesday, January 04, 2011 9:53 AM
Knight, Sherri
FW: WI0400065 -SA7 permit renewal
SKMBT _60010083112260.pdf; WI0400065app_rev_request100831.doc
Do you have any information on the Permit Review for this facility? If you do, could you please have someone send it.
-
Best Regards,
John McCray
From: Mccray, John
Sent: Tuesday, August 31, 2010 2:31 PM
To: Knight, Sherri
Subject: WI0400065 SA7 permit renewal
Ms. Knight,
Attached you will find a renewal application for SA7 permit WI0400065. Note thatalso attached is a request for a Staff
Report.
Best Regards,
John McCray
1
A.VA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
August 27, 2010
Mark Oliphant
Christel Oliphant
1259 Elon Place
High Point, NC 27263
Subject: Acknowledgement of Application No. WI0400065
Mark L. Oliphant -SFR
Injection Heating/Cooling Water Return Well (5A7)
Guilford
Dear Mr. & Mrs.-Oliphant:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on August 24, 2010. This ~pplication package has been assigned the riumber listed .above and will be reviewed by
John McCray.
The reviewer will perform a detailed review and contact you with a· request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 -90 days after receipt of a complete
application. ·
If you have any questions, please contact John McCray at 919-715-6168, or via e-mail [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://h2o.enr.state.nc.1:1s/documents/dwq orgchart.pdf.
PLEASE REFER TO fflE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
O~A-~
for Debra J. Watts
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Permit Application File WI0400065
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location : 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-£748
Internet: www.ncwaterguality.org
An Equal Opportunity \ Affirmative Action Employer
rfo¥tbcarolina .:Watutallg
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A GEOTHERMAL HEAT PUMP -SYSTEM
TYPE 5A 7 "OPEN LOOP" INJECTION WELL (S)
(check one) __ New Permit Application ✓ Renewal Modification
DATE:£-!li 20 IQ
PERMIT NO.: WI ()~00 ~ ~ (leave blank if NEW permit application)
A. PROPERTY OWNER/PERMIT APPLICANT
Name of each owner listed on property deed. · For a business or government agency, state name of entity and
name of person d.ylegated authority to sign application on behalf of the business/agency: ______ _
M ~ ~ Chr,ste\ d ipbao +
(1) Mailing Address: \ Z Sc::=:\ E \ OY7 ?'\ae-~
City: t1 \ qi, p O t n t State~ tC-zip Code: ?. 7~-k:, ~ County: Giuj ~~
Home/Offic'Jrele No.: Cell No.: C-:k,9 -lo I 'C> 7
Fax No. ___________ Email Address: _____________ _
(2) Physical Address of Well Site (if different than above)=---~-----------
City: _________ State:_·_ Zip Code: ______ Cqunty: ____ _
Home/Office Tele No.: ____________ C-=-e=l.=....;1 N~o.;...:.,_: __________ _
Fax No. ___________ Email Address: _____________ _
B. PROPERTY OWNERSIIlP DOCUMENTATION
Provide legal documentation of property ownership, such as a contract, deed, article of incorporation, etc. and
a PLAT map showing the property. This information may be obtained from county Register of Deeds or GIS
website.
C. AUTHORIZED AGENT, IF ANY
If the property owner/permit applicant wants to authorize someone else to sign the permit on their behalf, then
attach a signed letter from the property owner/permit applicant specifying and authorizing their agent (well
driller, heat pump contractor, ~r other type of contractor/agent) to sign this application on their behalf.
Company Name: _____________________________ _
Contact Person"--: ----------------=E=m=a=ilc....:..A==d=dr:::....:e=s.::..:s: __________ _
Address:--------------------------------
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Fax No. Cell No.:
Website Address of Company, if any: _________ __,r-n-T"r1"'mr-n-1-nt"~-t-f"m~------RECElvED I DENR / OWQ
AQUlFF=R'PROTECTION SECTION
Type 5A7 Injection Well Permit Application (Rev. August 2009) AUG·! 4 2010 Page 1 of 4
D.
E.
F.
G.
H.
WELL DRILLER INFORMATION
Company Name: H at { w~ p D .,..; ( h 1t3 I 11 C .
Well Drilling Contractor's Name: ~5~·--=-0.......a.m"""---'-'e _____ a ___ s_~cl~b~D~V_e,; ____________ _
NC Contractor Certification No.: =t:::l~_2-_7◄_D_l ____ ~C.....co_n""'-"ta-'--'-c-'--t =-P =er""'-so_n~=------------
Company Website: WWW. N /A
Address: q 3o ~ td w V '--{ 2 .1
Email Address:
City: C aL&l :f St~teNC Zip Code: ;z 7 ;;J... 35
Office Tele No.;2?b 99b·-73 Lf 5 Fax No.: ·
County: _______ _
Cell No.: ---------
HEAT PUMP CONTRACTOR INFORMATION (if different than Driller)
Company Name: SG/ f-Contact Person: f'\.~ 0 (: pLv,&
Company Website.:....: W...;...:....._;WWc.:.....:_:....;•-----------------=E=m=ai=-1.::....:A=d=d=--=re=s=s: ________ _
Address: t z...s Cf G\ QI'\ P\ac e,.....,
City: l:::U Cb p Q •' I<..---'r State~ip Code: :)...-72_-'=, 2 County: (:.s u\ Lfkr-d
Office Tele Jo.: FaxNo. _______ CellNo. ,3 ~ 8"'~3~°, Ov
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Cleo ~ ~--K\ ~+ "~
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ✓
YES===..:;.---'===
NO ___ _
NO ___ _
WELL CONSTRUCTION DATA
(1)
(2)
(3)
____ PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(7) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
/ EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (7)
L•:-: · .v to the bes1 o~ your knowledge. Attach a copy of the Well Construction Record (Form
:~: ·.: -· 1) if available.
Well Construcuon Date: I-/ Y--oL/ Number of borings: 1
Depth of each boring (feet): }2 ?.. a -ft-d~ ---
Well casin.7' Is the well( s) cased?
(a) YES -"'✓--Ifye0hen provide the casing information below.
Type: Galvanized steel_/_ I Black steel __ Plastic __ Other (specify)_~--------
Casing thickness: __ diameter (inches):h3A/ depth: from '-/I' to /!/ ~t av feet (relative to land surface)
Casing extends above ground / ~ inches ,DQ,~h o-f' ~(A,mf> 115 1
(b) NO
Grout material surrounding well casing:
(a) Grout type: Cement__ Bentonite* Other (specify) ______ _
*By selecting bentonite grout, a variance is hereby requested to 1 SA NCAC 2C .0213( d)( 1 )(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from ___ to ___ feet
Type SA7 Injection Well Permit Application (Rev. August 2009) Page 2 of 4
(4)
(5)
(6)
Well Screen or Open Borehole depth (relative to land surface): from ____ to ___ feet
N .C. State Regulations (Title 1 SA NCAC 2C .0200) require the _Permittee to make prov1S1ons for
monitoring wellhead processes. A faucet on both Influent. (groundwater entering heat pump) and Effluent
(water being injected back into ~11) lines is required. Will there be a faucet on: ·
(a) Influent line? Yes_, __ No_·_ (b) Effluent line? Yes ~o __
Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Form· GW-1 ). If Form GW-1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment units will the groundwater be withdrawn? ( e.g.
granite, limestone, sand, etc.)
Depth: _______ Formation: ______ Rock/sediment unit: _______ _
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHERWISE UNAVAILABLE.
I. OPERATINGDATA
(1)
(2)
(3)
(4)
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
J. INJECTION-RELATED EQUIPMENT
Average ( daily) Lgallons per minute (gpm).
Average ( daily)~.ef,t1t;ia11ons per day (gpd).
Average (daily)~ # pounds/square inch (psi).
Average (January)~° F, Average (July)~ 2 ° F.
Attach a schematic diagram or cross-section of the well construction that shows the total depth, length of casing,
extent of grout, $tickup, location of influent/effl.uent sampling ports, etc. If this is a modification, show 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 if needed.
K. LOCATION OF WELL(S)
( 1) Attach a site map ( can be drawn) showing: houses and other structures, property lines, surface water bodies,
potential sources of groundwater contamination, and the orientation of and distances between the proposed
injection well(s) and any other existing well(s) or waste disposal facilities such as septic tanks or drain fields
located within 1000 feet of the ·geothermal heat pump well system. Label all features clearly and include a
north arrow.
(2) Attach a scaled topographic map of the area extending 1/4 mile from the property boundary that indicates
the facility's location, a north arrow, and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by owner
name or address. The location of the wells in relation to property boundaries, houses, sepdc tanks, other wells, etc.
can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or elevadon data.
Type 5A7 Injection Well Pennit Application (Rev. August 2009) Page 3 of 4
L. CERTIFICATION (to be signed as required below or by that person's authorized agent)
NCAC 15A 2C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
1 for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner.
If an authorized agent is signing an behalf of the applicant, then submit a letter signed by the
applicant that names and authorizes their agent as specified in Part C of this permit application.
"I hereby certify, under penalty of law. that I have personally examined and am familiar with the information submitted in
this document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible for
obtaining said information, I believe that the information is true, accurate and complete. I am aware that there are significant
penalties, including the possibilik, of fines and imprisonment. for submitting false information. I agree to construct. operate,
maintain, repair, and if applicable. abandon the injection well and all related appurtenances in accordance with the approved
specifications and conditions of the Permit."
421
Si a e of Property wnerlaplicant
Mark 0/1/01L
Print or Type Full Name
Signature of Property Owner/Applican
.�,riSte ( 01 ON l-
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit TWO signed copies of the completed application package and all attachments to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED / DENR i DWp
AQUIF t ppffTRTION SECRON
AUG 242010
Type 5A7 Injection Well Permit Application (Rev. August 2009) Page 4 of 4

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number:
Permittee Name: f 1%i - t` .i j 1 •1 t v`1
Address: 1 2-5 ) °' ' P LO Ce. HP NC
Please check the selection which most closely describes the current status of your injection well system:
1) 'Well(s) still used for injection activities, or may be in the future.
2) C Well(s) not used for injection but is/are used for water supply or other purposes.
3) E, Injection discontinued and: a) ❑ Well(s) temporarily abandoned
b) ❑ Well(s) permanently abandoned
c) ❑ Well(s) not abandoned
4) ❑ Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well, (Include a description 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:
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
Signature Date
Revised 5/05 GW/UIC-68
RECENED I OENR! DWO
AOUIFRR'PPrawrnoN SECTION
AUG 24 2010

ti
6i1RU1l990 516.00
Real Estate
Ertctse Tsx
Guilford County
hteilbCoa •i sdLmrr
Me Ma
A Noty O sT Prtdie is Wm Certified to
he eartesa. This inprosesa and Iles eritilkate
are dolt' rgdsirsed et the doe sad time shown
1t�ro.
b Hit I
el bush
(.9T
- Thi* inatrutneut *ni prepared liy
` Iiirier dawelpti.m for Ihr Nate%
ti
iv 103700
RECORDED
KATHERINE LEE FAVPIE
REGISTER OF DEEDS
GUILFORD COUNTY. NC
BOOK: 4636
PAGEt$10440 TO 0442
01/21./t99El 14:37t43
! ens
OEM NM PIN
! PRfffhWE FEE
f FICA tett sum
Elizabeth M. Koonce, Attorney at Law law)
NORTH CARU1.1NA GENERAL WARRANTY i)1:H)
TH18 DEED wads Oita 22 day Rif
GRANTOR
December
WILMA S. KERSEY, Trustee of
the Kersey Family Trust, and
WILi1A S. KERSEY, Individually,
and KEITH GRADY KERSEY, Single
.19 97 .by and (between
GR.f N Tf E
MARX LEWIS OLIPIIANT and wife,
CHRISTlI. L. OLITHANT
1924 Baker Rd.
High Point, NC 27263
Emus In atria girls alark car earn pnriy; Rams..d.Irrsa, and. If urtewPrtsre, rhsgrter ad ratklr. r.R. rrrparimen .r partnrr*tlt.
The dptgnatien Creator and Granter as used herein shall inriude'saki parties. their helm ■ ierrxxurs, and assigns. and
shall Include singular, plural, manruiine. feminine tie neuter Ra required by realest.
W1irtESSETIi, that the Grantor, fur n valuable cons:ideruliun paid by lite Grantee. the receipt of which is hereby
aciusuwiedfed, has and by these pre:wain dues grant, bargain. n41 and convey oat. the Grunter €n fee simple, ail that
rertnin h;t ur parcel of land mitnated in the City of Jamestown 'lii>,•nxhitil
Guilford County. Ninth Carotins and 1n..re iH rli+ ulariy deli rilae t ax f,rlhan•><
See Schedule A attached hereto and made a part hereof. the
same as if fully set out herein.
%t P.a Vox. twpm \ 1.a 1076.rl..t.4• Ir" „.e, ,..... •••;r •..-•. rc..
- Iry .r..,.•.r^.xca, tip....

i
1
The property hereina.twve described was acquired by Grantor by instrument returned iti
A may showing the above ilestrihed property is recorded In Nut Book phgc
TO HAVE: AND TO HOLD the aforesaid lot or pared of land and ati privileges end appurtenances thereto belonging to
the Granter In fte simple.
And the Grantor covenants with the Grantee, that Grantor is seined of the premises in fee simple. boa the right In convey
the same in Lee simple. that 11llr is marketable and free and clear of all CnCumhraile s, and that Grantor will warrant aid
defend the tide against list lawful rinlm, of all per -Antis whomsoever. except el.t for the exceptions hereinafter slated.
T{tk to the property hereina,tne described ti subject to the following careptione:
This conveyance is made subject to all rights of way.
easements and restrictions of record, if any.
is wrrrras wateriinV. tar rriatnst I Agir..4. %MI Its !rand awl IraL .i p errorsI4. kat roots Lib karieaaerd i. as Wed Is 11.
.ae}np. savor 1y its duty raar.risfi .pY•en sad ill heal I. Irl• lart.gaer alli►r.l ■a ...emus t Vr. hard .r Illmel.ra tr.r der oral rear elf 01
oast isles.
Itertaratr Nuns?
ATTirtt
rraaldent
-... _ - . .. _ _,serialler thcesual seer
yr WG ear`et ._„J ?(.1'ma .1. A - 11iA Li
r WILMA S. KERSEY. Trustee of the
c Kersey FamilyTrust
4.
al
WILMA S. K$RSETI Iyidivi
xse .�L
KEITU GRADY
1tpRYlr ['A1YLrrfa• ILF D _ _ Comely.
d
I. ■ !lase,/ Public or ore ninety sad flair sl..n4M. really rhai _$1f..li{H4--$... JHXSeya•. 7'xuSt.ce
of the Kersey Family Trust and Indiil3dually and nt.M...
KeIti-•GreAy -Kersey, Single
n }e...af1r aataair 1rl.1e ate t day and arharoirdrN e1r eaccalbdi M ape Nr.10414 IMiilMen . WNaen ray
O ar* wad .tidal .e...r .r .rat, 111.. 2R. day of -. -_ --e e!9bI.. ........ Oa.?
3tio
[Rfa.T r
ualiy
r
71r um.aa.la. raiders; .11/.4 f 23302
t p.1•J.6 -_ tL4t zdrow*
N onni vinoLrr1A, __..__..._-..,----- ... __.._.cowry.
I. a solar} !dirk of il.e Cease" aa4 OM. .r.n..1 . riKllr Oa _---_--_--_.._"---"-..•
2 prassalfy cams Wiwi am lW day ..t a.I .wffrsed sisal ....... Iry la . _ areredry M
✓ ▪ .. - . North rar.wa r.rp.rtnW, aa4 tlal ar mutt orltr cal!
a▪ bees nod as ad art sir lime raeparletso. tut taardsdn. Iu.tr.na111 .a..arari in Ns name Pr 1a
s 'raging. leafed Pali its r.rprnte rear and .ter.lad ar
a
yearn goy !mad and official stamp as seal, ihla day .1
!ly esamlri/.. .seder -
arertiadif.
• 4I.Mfy yurdle
Tine l•ne•lar r.rrrrwal or -
s'nr retiltlr4 i. 1e rutin% Ilk larf.11frn/ SSA leq crrtVk.ir ate duly r.SiMMnil at list dais *Ed lira. rod 10 lb. vial sad rare menu sin far
raw gory bro f.
tercraTT4 41 tltiEA4 I01_ -.. _. .. _ cavort.
7 e t • err er+er.i f err, .•. a.
snooty A.imain-11ar11lrr el gird.

•
SCHEDULE A
•
- • ;: ;14:17.1:47;
Beginning at an established iron pin and stone at the base
of an 11 inch diameter post oak, which iron pin and stone
mark the northwest corner of property belonging (now or
formerly) to Ellen C. Robertson as described in Deed
recorded in Book 1825, Page 92, Guilford County Registry;
running thence along the north line of the property of Ellen
C. Robertson (now or formerly) South 78 degrees 23 minutes
38 meconds East 303.14 feet to an established iron pin
marking the northwest corner or the property (now or
formerly) of Roger D. and Santina Kivett, as described in
deed recorded in Book 2424, Page 639, Guilford County
Registry; running thence along the north line of the
property of Roger D. and 'Matins Kivett (new or formerly)
South 78 degrees 23 minutes 38 seconds. East 633.58 feet to a
new iron rod and stones in the west line of property
belonging (now ar formerly) to Sally N. Noon as described in
Deed recorded in Book 1649, Page 640, Guilford County
Registry; running thence along the line of property
belonging (now or formerly) tn Sally H. Moon North 9 degrees
27 minutes 29 seconds East 313.62 feet to a new iron rod;
continuing thence along the line of Sally M. Noon (now ar
formeriy) South 70 degrees 26 minutes 13 seconds East 585.40
rest to a new iron rod in the line of property belonging
(now or formerly) to Wilma S. Kersey as described in Deed
recorded in Book 1208, Page 524, Guilford County Registry;
running thence along the line of Wilma S. Kersey (now or
formerly) North 00 degrees 44 minutes 31 seconds Weat
1087.58 feet to a new iron rod and stones; continuing thence
along the line of Wilma S. Kersey (now or formerly) Korth 82
degrees 16 minutes 51 seconds West 1290.55 feat to an
established iron pin and stones in an old stump hole in the
centerline of an old roadbed, which iron pin marks a corner
of the property (now ar formerly) of William Lester Jackson
as described in Deed recorded in Book 3227, Page 822,
Guilford County Registry; running thence along the line (now
or formerly) of William Lester Jackson South 9 degrees 21
minutes 22 seconds West 615.34 feet to an eatablished iron
pin and stones lurking the northeast corner or property
belonging Olow or formerly) to Lester A. Smith as described
in Deed recorded in Book 786, Page 309, Guilford County
Registry; running thence along the line (now or formerly) of
Lester A. Smith South 11 degrees 40 minutes 41 seconds Weat
591.89 feet to the point and piece of beginning, the same
containing approximately 37.193 acres as shown on survey by
Cagle Survey. dated December 10, 1997, designated Job /8746
0-11, entitled manrvey of Existing Tracte: Nark L. Oliphant
and wife, Christel L. Olipbantw.
The above described property is all that property described
In Deed recorded in Book 2860, Page 501, Guilford County
Registry.

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Map Scale
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http:llgcgis.co.guilford.nc.uslguilford newlprintPreview.aspx?PrintOptData=... 8/6/201 Q

.A /
Iwnk Carorwa - Gia[nni Cowity
TN- ,dAnr* lid d
A Notary 1Ndarinal Panic 1'. tttey certHled in
Ale arxrtct. Zlu► imstrur chi sat this crtiiu-a[c
ire duty rrdi.tcruf u she &Lee and Tuft shown
hcrefa
• -•earl
Asiae.a irir ke=bts d heeds
JeOF DEEDS
This Ica O Of True* Pr!p.ed inn X
lt,• Slot
f+EC L1t1I)E I�
WOIFHERirfi 1.1:E Yf1YNL
F1EGTti 1 ER tin 1M•F E.1';
FWDLI-URI) GIANT v, h11:
HIM: p6 Sh
t'A iE1Slp'44 _'. TO 4I1I4'r
Qtf 1 •1 # I1 lot S-247,
Karen J. Taylor
ifsliNS "I'm
1MDT FIT 12.10
SPACE ABOVE THIS LSE IS FOR RECORDERS USE OM.Y
DEED OF TRUST
THIS GELD OF TRUST 1S DATED JANUARY 20. 191d. wrong MARK LEWIS OL PHANT and CFW1ISTEL L.
OLIPHANT, WIFE, whose address Is 1924 BAKER ROAD, HIGH POINT. II4C 27253 (referred to below es
"Grantork High Poled Sank & Trust Company. whose eddfesa le 300 Pd. Lialn Street, P.Q. Boor 2275. High Point,
NC 27201-2275 (referred to below eometfmas as "Lender" and eomadmes as 'Illenellcieryll and John A
Hamilton, whom' address Is 300 North Mail Street, High Point. North Careikls 27290 (referred to below as
'Trustee'}
CONVEYANCE Ala GRANT. Now. TIVIISZFICIRE, as ty ler et. Inde*ISdrraa, +drFwmetus and tsar araae attpetttANR W use
erefiet.Y pummel! to 11* Deed el Tne1 Jea c0efe of coescaen Dodetilne monayr Nee as preeMed r eta Note) .,d ewe saarlbla
aertaYNe.en, >1N receipt or stemma 14 WeRrl aet.Otdedp,A Granby tee brgdrred, eon. oh s% anted abed lam cyst Ned dee4 W throb
teem• bmagolo. we, ohlre, rim* MI Wormy to Troolok .id Trustee's /Ake el loacoss.es mid naive', fee Me bend. OWNS! Ns
Aeasesclety, d of Granter% rgrd, Ib. end Werra in and 10 the folbwmo ds aIb.d rod pcWp.ty. topelher.mn NI annoy or SOIWNIMOoliwadad a
armed buildings. biproeatnsnrs and betinw Ptauarr.*. rights Of were and appurl.ancos; M ryWr.watnr riDll..ord d>ch datapnaiitiea stock to
Oates ARS ditch orirr�tien erred; and id aetw , lerraa� rAs and pelts -rMWie to Ps east y. sewn ItseeMtitherats. d kalw d.
Des. oboe+.nree and Seis ms/1+rs.IoceteTd in GULFgRig bounty, State of North 4 ri he�eal Property,:
SEE EiOMBIT "A" ATTACHED HERETO AND MADE A PART HEREOF.
To have and to hold seed Thal Property with en privileges and appurtenances lhereunto belonging, to
Rea Trustee, hie het, wbeessora and MOM forever, upon the trusts, terms and condtforra end for
the uses hereinafter set forth.
The Rest Properly or /Is address le comma* knewen w 1253 ELON PLACE, HIGH POINT, NC V210.
Grantor earnestly ems. to Lands (else Moen es Bsodt1Nty rn N.s Deed or Trott) sJ of Games& tight frame end Weed In and to as prawn and
future Aeons d eta P1epry and as Fenn sera Ora Properly. rn addeva, Grantor $ants Lander a Waimea Com.rbecir Coda security :+less! fn ea
Rents and the Pareome A[pertyowned balos-
DEF1NITlQrt$. PHI I01o* 4 aprdk RAD Aare Se Mole% taaseirtos when tread is Its Dead 01 Trait Teen. nor Orhuaesn leaned in lies Deed 01
Thad at l ewe IM neerdage nibbled tot sins tenter In the Union Common sit Cods M .Skean es to data amount' stet Dean amuses In Annul
money alto thlIDd Siam Oh Americo.
seedtelery. Me wad,4teaciery' besets% Hlgh Petri Blink A TRIM Company, s secretes and assigns. High Raid aattk a Trust Company
oho a rderted PO as tend.' in Mee Deed d Trust
Dead el Tre & its moons Void of Truer mean fro Deed d Trost among Cisenke. Lends. and Thaler. and ardetdia *Sheet b•Mtrtlien Y
eisigna.et and Pen* Mara 1 prod ioosratatine 1o1he Parease Property mind Rarer
GrlOicc Taw Intl iiarltr` grams ero and ai poems and nines Parterre Its bend d Trust irtc5,r in wdtoul uneaten UAW LEWIS
DIJPHMfT and CHRISM. L. OL1PFWPT.
Qi.erllor. The Aped "Esarantor intent and Freeman wrinwA emrbkon any and all gnuardors, Umbra. and accammodalion Wets in
✓ onmAbbn4 *alb de kufaCtindrw.
Ingromeleele. flu. read Tirlti'rwrretdr meant see+ uhGhurlans 1YInall,t ameaaan ai.cicam end lute* improssoords. bindings. structures,
=Me MOW 'Need on Do Heal Proust', reales. adorn era. replacements and Wet consitcedrt on thin Rssl Pnan y-
h ufebtedANw. tiro word wmaprleanasr maim as princspd end arrest parade etude, tee None and any .sweats swended or advanced by
Leader to discomfit obligations or Grantor or expenses Acme' by Trudge ale barren In edmca obrigabixis or (Nano Linder this Oiled 01 Trust
legdf•e wlPsInterest on such misses as praridad am eta Deed Of Tryst
Lender. The wend lands' mauls Ho Point Barra & Truer Conyeray. a Acc seo-. and zeisgre.
Note. Ire ewe "ewe- resew in Note Rend Jeremy se, fees, In the principal amount of $111,50000 from hanker to Lead.,
i0gedter seen 11 rMaeratc. enesstoer aedagagne, rsfaennest. end Hotaltulwis ton ow note. The dukiap dale of Rnt Owed of Trost Is
Jamey a).1100.
Pumas Properly. The wads Tussle P1Wp.ty main alb equipment, twines. and Whir artletes d p.sor at property now a taraaftr owned
by Grantor: and lhow Or /Mealns elected r a114ed Id Us nail Porielyi topstetr rah eel accestbra. pads. and .ddebds to, d replecemants d1.
and all subsa lobonf tor. pry of slam, cropelr, and together Alas as p.CCaatts 0rrduduq *About Weeks Al Amerce succeeds and return% d
pranwmsy ham any sole or War daposAon of the Raptly.
Property. The wprd'Wgrgrlir MO cynogtirely Ito noel ekoparly and eats Paraonil Properl•.
feed Properly. 'the words 'Red Property' omen ens property. interests and Deers desbnaed store in Ma 'Conveyance and Grans' soden.
Related Ocesuroella, ins wadi 'Remind Uocuineras- Mill end trepan without Im nelson ea promissory notes. Credal apreatrenbb. ban
agreements. erraoneeea*1 ap7amerl . guarartes. saLvnay erearoo'sh, seegseef. deeds of bust, aced as athof Irnireratnntr., ngteerronts and
doc7r'u*, whether nor r hereeler ar14ey, °leotard 1n connection we l Ina imbibe /nem
R a da. The word 'Hants mean of pearl and irkwa ranri, revenues. asccma, rssetei, MOANS. prole. and darer Nenethi amend WTI ins
MOM. T1e word cretin mane Jare4 A. patroller and any mete hider e4reseer eoslgi.
Tf4S DES OF TRUST. OfaIEING T ASSIGINIERT OF RENTS AIM TIE ICCUnirY MEREST RI TIE RENTS AND PERSONAL
PR IATERTY. IS GIVEN TO SECURE DI PATIEMT OF THE NAIESTEI5BS AND IN PERFORNANCE Cr MT Alai ALL CJGATTON$ OF
GRANTOR UNDER ER DM NOTE Tiff RELATED DOCUMENTS, AND nits DEED OF TRUST. MI DEED OF TRUST 15 OTYIN AND ACCEPTED
ON THE F E.LOSIOKI TERMS:
PAYMENT AND PERFORMANCE. Eseepl as otherwise provided At the OW et Trust. Grantor site& pay to Lander eaamoerna secured by ttnh Deed of
Teal as bey beonee flail. and sloe decay and In a A *y manner sense ea of Gramme's obeuetcrs under tte ROW Art eased d Trust and Pe
R4i1Sd AOCiLmerea.
IOINIessai API) MAIRTINAPICE OF THE ASICPE7iTY. Smoke agrees abut Grantor's poises onn and ass IV Me Fisp.erMae De warned by Re

01,20-1993
Lain NO
DEED OF TRUST
(COROROed)
Paege 2
kflo W10Q pr0srot0nf`
Pguaaalon and Llee. Una the 000gn44Cl at en Evora el DOM. Grantor may Se1''trem ln possession and oanlyd of Ira PioPoly- lb1 use.
*Prato of maned the Roped. and lc) collect any newt horn Herr Piopeny,
Daly Ill FaalCtaln. Ordlor shall maintain Ilia Propely .n let anI.04 co moon and wordily pe.(orm ati rapers. repnCetneNS, end mainl0nlreps
ns'c'eearf la palierre rI va1Ve.
Iialtir1Y111a 8ubalrecaa. Tba Mimi 9aar000s dale: Um/deue aided': "dispose, tialeasa,` and-Vereat.nod dolt*; s cared rn this
Osid of Trust, shalt fever We same dammed as set foiV en tea Caraplahertsae Eaxrvnwa+dd Resperea. erepens.arl and L.abuy ref 01
+9eO era a.rrandadd 42 U-S.G Section toot, et see: QA*4, lha Supertrrrd *n endrneres seed fadurlhanmhnn we of 19e6, Pub. L. hop SO-199
t"$A1on; bra !!**riles Meler..a. Transp:einem lect 44 4-S-C Section 1801..4 see.. iir AesOuise Cond. dad and Recovery hat 42 !1 S.C.
Section 6901, of s.V-, a alter addable slat* ce Fade. tt+ra, rielf` er neuebgm ad0pl0 Owsuan1 to argr ri 0o toloidng the tames
%adlyded dale and "haarclo1s aubelatEo• ehal also r.Clvdirnorelppl Maertalc r, patrvWrr and petroleum by-oddss-1s or any eleban rota
and lekeSias.. Cramer Mpresents and derants to Lender that tore Odd tie wood of GI.riorri olrnash.p or the Rwary. intro has been n0
use. gen1Men, r.anlrfaes ee, stamp, neahmnt, disposal, name or fhreMarrd release d .ny hazardous waste or subside, 6r any Person dM1
under. about or some the Property; tip) 4ratdOr has no knowledge of. or rend labelled lei there has bed. weep, w pres+pn1ty dsclosad to
and Wine, rd0sd by Lend" in *lane, by eery ssd, generation, manufacture. d olga, trwerient disposal !*lose. a trr.aloned ndeeta 01 any
hazarded waste tx sublhnci der. wait, abort et lromn the Raparty by eery pnr owners 0r OCciatink of the Adolfly 04' in, airy *crud on
Irspyned fagalbn or alters 01 any and by anyo.t0*0 dating t0 sunh matters; and (ci Erdepl as p eercoaly disclosed 1 dad .c0Aneeodged *y
Diode In *army. ttl neither Grady 1 i Or/ *Mid,. comrade, owl oe oger addled d use of the Properly shad use, genera!*. rrtanulaetw..
* foie. trill, CtSPOSe .t, or feeds way hedardous waste or substance on. inn*. eb0A or tram the Properly and {at any such eddy .1d1 lee
coddled in Willialierce loth .a &pascal* faded. stare. and keel IIk . madded ed and ord eras. •+acaabfltt wareol in.e.ban *hoer laws,
widens. end ced4t.rrCe3 Oasa.bad &b doe. Grantor eiihoods tondo end mi lamb le *reef Loan the Ropeaty 10 MOW StiC0 inspections and
le.. al Grad1Or's edema, as Lewd man deeds apOken la 10 44 1KmrW oorreleff is 9t pro POW? rah the sorer 01 Ili Dead d Null- Ad
hiSlascdrs 1e hole Rid by tend, area be ter Lenders o41peise gray and stall sml be candied le weer any'espousedy Or imbed On the
P an 0a Lands 10 Rama a 10 any ode persona Tree nepna5Oreet.ena end warranties tweeted heron ere laded Ora t'rebe s old ~OM in
inea1e11arg ter IkOParty la lest ndoas walla ow mamas substances- Gunter hereby (a) releases and wards any lulu* dent alleRlL4
tuner for inclen day 0r c0'Mebokrn in the event Grander becomes babe leer de/NO Cr Cater Coals under any such taws, and ib1 eprile t0
diem* and hoid tenelas Lander moral any end rl deans. toms. t.lpteies. damages. 4ereble. and capered when Lends may der c11f or
lnd*.Cly 5lrsleir+ Or Sell& i'eStiihe Iron a *each of leaf whoa of lha Odd 01 Trott et as a oar+:'dperca of Any usn. genaab4n. manut14He.
alatei*, depM& release or a elerep feeds dowimg end to Grand. odrsihe or unreel et aK PihpOrty, wheeler 01 not She boric was or
should rain bails known to &*note The ptdusruns e11his gallon 01 tie Owed of Tent including the ObldieCo to indented, shed scurrva ee
partite i al tna Indebtedness and the S estacti*n end re derdainte al the tern of 11a Dud el Trneai ord Shad rat b. actuated by tender's
acquisition el any k best in the Pmprry. whether by lonec40suie a Olhrwaaa. -
Ilraatne, WPM. Gratin .hat nal rate*. conduct v pease any rruead nm crrlaet preml. w self" any shippm0 of of waste door tat Ihe-
Prpperle v awy OildiO a Or Rue RoOarry_ Wilmot imam the pewuelly d tree kragareg. Create e laic net renege., a elaml 10 any Cel.1 pity all!
✓ ight laremora. any im0r. rani r4M tacking W and gees, soe.giawi Or rock predicts nebula Rua pates whiten console 0r Lender.
Pommel re loprews uen4. Gi.r ice Owl a01 dampish r teemve any Improver en4 tom Yee ONO Property %reheat lir poor eaten crowd of :-
ladder. As a oddness to bee rendre olany 1mOkhemial4. Lander may recites Gloater 10 nuke anrargmmetds sebslactny l0 Lender l0 repf0C*.
Stealer hniirOvernent lord* Lrlpreirenint5 or at least equal value_
lede , Raid le Enter. tender and 4 atfaeaa and lepneiereldwa5 met 'filar aircm led fief Ptopaly a1 ell rsAarebl• tuts la &lard 10
L madaes ih4NSSh eyed l4 ti*Pect the Ropwly is pwpred 0f Grantor's compound with Ifs terms wed candler* 0 ea feted M Thad.
Cdrgerea rfer G.ranreu1W Reedri eel*. &Il*Cr seed Pr0pply badly tech a6 laws. oedlolidd. and'. 40 *RM. new et homily "
Meat, d eIl gatanee0f1 abed* d appleada IC 44 die er eati14ircy 01 the Property- Glares* may cnrderd In good WI are such ter,
arewen procre regllallpnafar diMRe ialdlong
es. n ed duds any Lander a ceihhln�t,endirs i,1*i.bInclodled y aeppad, so logy es Prroperly are id lopar end lad coaled Lender In
ed:led- end* may reads
wen pro" doing lerQ as.
Oland b Pest adwyee se tsay Dr a surely bend. mews* s .tenter ley Lender, le probe Lander! Irhrvsl.
day 10 Finks., Grand swan reeld No abandon nor lead unallandsd he Property_ Garda slid der aR othe eels, in added W area de
a01 had abets In sus satel0R rich been lie chancier end use of the Poverty era reasonably emcee/ 10 doled and prestree the Properly_
DIE ON SALE — COMMIT NY WIDER. Lander may, al di Option. OSWre immadi&0ly due awl payable a9 sums secured by Yes Geed et Reel
upon Ihs axle or kar4la, wadi the traders ode dorm Loosen*. of al Or ant pan der ea Rut Properly, ore shy Wowed to ballad Peap01y. A We
a horns nears ow amegyereo of Rob 14apsly or any relit les or *detail deed =fader legit b0Aeiaaf Or tglenble. *h*Re l vduelaiy a
irw40ea1Y. ladder by outdid sale. deed beanpole Sete SOae&t Wed cornea contract for dead. leasehold interest wall 4 rm greed than !hoes
ia1 halts, l4-opts+ ca+Mdi or by ald esiaversed, or bead of any **true d e mi incur fo a.y land trust herby de t0 nn Ail I4apaefy,
by any *err meted d coerp,arr(4 of Real Priddy drew. a any Grantor is a e"p0aW art padoloofep at [mood Isd for =opal,. transfer do
admen anydat4g4ln erelaelllb et eras then fiewar+rve emelt (25%) of the Indio tech, ptd'erlryp imbued o- hideed4O4.%44 Medan" wen*ti.
is the COS* rod be, d Grantor. t4pwedr, ens oaten shell tit be eaacesad b! Landr i wen examen is prohWcd by nodal lore a by ntbim Card*'*
teat.
TAXES Aril L IM. The 4eeesdee Pietro pre relaong eo der Wes aid dens oh nee daddy as a pare of Ihie Odd of Trust.
► spider On a tir 0a&e fey rend sea fared ei a swab pelor to daddia+eyj ay laze, Specie Mils, neesernerds, cards tkir#lang wake and
ea*erk e1t16 and Freraea4Ons eyed !!gems! of 0n *Ceded of ire Property, arld S1rf pay when due at: deed for +de done oft 0r 10+ weed
rendered or mead namded to tore Property. Grader sly. steeled ore Plopeny ese 01 all [ens hiving primly over Or equal le +tee eaerisS of
Lender under Rd Odd el Trust, noel for the rid d fear Ladassessilents net doe ate deed as olterar+5e prewdad milks Dowd of Trost
fil*4rl TO+tllyeef. Grantor may wahhold payment d any f.L dense/A dr deem 4 *0nnectioa ew0l a good teen dyed *sir we wigwam to
PAY. s0 Iowa w trend?, e*rs14 We Properly is not eapparddad. II a hen bale Cie is .fed as a molt at nprylym0nt Grand shad teem mere
CIS) cWV1of k tens Ilan arbaa a. d a 4n M zed. weed alien (1 S) d.i. aft Grantor has nude et she atop, side sea diehard al ie. Wet r 8
t epuaeled by Lander, degree rub tailor txa4 el addend scr40rnie surety bard or der sacuid sayefaelnry to died in on amours wilfdre
t0 Coded all Sew etas any pasta and .been lee allae+4+ Met *r Oder shards *Model *caul* n a taste of a teraciosure et sale **wilt fie
scan. la stay camas+. Graa f°, Shut dales* dad and Leeed did shall salty any whams tral0le re Astor* enfoldment ■owe! ifs Ropily.
Grantor shall earls Lends es an additional *bless under any surely head ruenahsder lea crude snceedal0s.
Evaded of Fermat Grand sell upon demand Awash t0 dada satislaced diddle of peyr+errd of ad NOS " e,SSeiSeene a144 shall
aided far appropeird g0varar.rdal demi la thew l Linda al any bane a wean dement 01 ore lama and aselead res wed Ind
Peopertyt
Vetere of Gooebusien. Grade she rely tender at Mid bind (IS days bears any ewe d coauranced. easy *Tula w 1urlash.d. a any
mend we smear' 10 Are Repair, a any aecfra.c, lark .nee *!sews lien. 4r Oaf fen could be asseeed en woad d Ike work, carves,
a aa1i14. [.ardor +Itie weer agar] of tend, hnrnse 4 Lender 51*4*4 damn safebolory to Lender Mai Griraa can and +nor psi the
costa such elegyd marts.
PROP;a4T11 DAYAGE INSiIRANCE. Tice Idapwrrg prcmions reeling In estekea the Peeped area part 01 Any Dad 0t Trust
4011*0*05 d Insleaece. Guarder eras procure and marataln prices of ela inseam, with addend asienCed o0teraea 4ndwsrralls 0e1
npd0aersene basis le Ina tip vaurde rake cording ea frrerowerren1 an the Feed f4dp61y heart rnorsn strident to ward apprsaeon or any
ccietwance chess, and mei a standard mortgagee darn* to lased d tendeo% loped ales atic4 filer hazard are ambler wounds as tender
may raesandly mithie. POkras strri be ✓Warn et Wen, ensure. snvragas add baits reasonably aecepra0le t0 Lender and .sued by a
carped orc1mp nias1easenebler aeaeollble l0 tender. ream... te0n mewl d dada. will darer to t.atdee Sere Mee TO true the pekoes 0r
.osylikele5 of oesdaaoe .e Iwo saesectory 10 Lander. wchridrig sepulal4ns that common wee net be cancMad d 1*.nd4ed mom! at teat
Rid 1891 dale Weer wed t+a4ae t0 tender EOM malaltd0 pdeey oho shall wcl*4 an enenner lord wdv*no that Menge m level ea s.41*0
waea mot bit in ii.e4 lei ai91 way by any act. onessran or daleue of Granter or any deer patois S loMd the Reef Repack al any erre become
ladled in an aaN ridg .fed by the Deecto1 of the Federal Etta rgency uiteaennehi Agency is a slave ewe haled area. Glamor agrees 10
dean end warr4M Federal fled Insurance for Id toil taped pnrceea balance of IIR ken, up f0 be radium poky ands set under lie
Madre' Flood inner** Program. or as dthrwwse 'actor ad by Lancer, red to mamMin sec h adource ter the arm 04 44* loan_
Appel:aeon of P1001sla Granite she 050rapey autk tenor 0I any teas er dread agd le All Prawn?. Weider day nooks prod d eoai R &end
fee to der w wean dims (151 digs el tee caaued. Made Or ?POI Lemurs Mu* s rape4ed tends( may. at nfi Wickes, ream r14 rafein
the proad*4 ei any *!*baste ilea eery Ire proceeds le di fadued* ce 1* Indalrsdniaa. mewl al anti Len trine ma tree 140p4Hy. or des
rasleraioe and Moir is RW 44gpaly. rudder 4kc1: t0 dfd the pdrr5Aa 10er4pr.Icd and alpOr, !*rimy. Shp wog es rooms rip dsatawa
a dssk4ye0 h4lOWrnwn1 in a manner saei[acaury la Lender.. tender star. o da sateldery proof or soca rgand4eue. ploy ce renews,
Grantor horn gal prdcead lee Ma demand* Coat o4'weer 0r leikireeee Gran* a ref in wan undo Ire Deed 01 Trek. Any pl01*4s wl.ch
• ed not den dsbe.sed nnm.m MI days altar Ind Wept tee which Lead" his dot conliedsci b nil .spa./ of ressons*w d Me Property 41dr
..ai'`1,.

01-20.-1293 . DEED OF TRUST Pate 3
Loin MG ([churn* 1)
be mad brat lb pay any sltaeat !mere ler Lender imam lea Used d Trust. than io pay strum! Inlw I. and Me remainder, I any. arse bo applied
to Ina pnr4CWa1 below= el is lndebblareo a. P I.Iiidlr holds any proceeds mho payttenl an kill al Ilse indebtedness. must proceeds s1ea be pad
in Wader as Gantt" wtlaIlk may MSS.
Ursrpkad Irdedence el 3e10. key intend tetliehca wall .wr. to the iramal of. and pass ma, ltra purchaser of Ilse Povp ery canoed by am
Dead d Teel et any 1ruSla4T, nab Or c41 file Iwed under Me prearmons d eta aced of Tttdt Cr n any Iorepasurr sale or soda sty.
TAX MD ISSURaltiE RESERVES. Slas(ae111 NV lkmlatans sal by ippateble bet. Lander may require G ronlar to anairdan wit Lender rUeervla Id
payaroidot annual tam. unsunals, and vecre;one perN*1ne, Mich moms coal b3 CrIIbU by ed maim paymed ar rnatdhy puyirtenb al a sum
asbmaled by Larder to be oracles to produce amounts at best moat 10 t1a Sun. xssossrMMs. era raining* fronhUale to Ire pad. The Men"
brads Pal D. held by Lender as s gaols* deposit Irani Granter. abets Lender may merely b7 p trmnt ot Ire !chat. asaisfr*aiao, and incline°
premiums nestled to be pad by Grantor as Atilt Wane due. Lender Stye beds rw right b dew upon Ice resew P44 ICI Vet such gems. gad
Lands shall hot be retailed b dalersina tie vaaaddy or actmeey of any Hatt betas patsrto t. NOON in iht Deed al Trust shad be croslusel
regrivel'Water b advrees Naar moats is etch pwpales. Al ttu0i*t% on xa mare actcurtl are israby pledged b foam same the
IndebLaMgse. end tinder 4 hereby auelereeQ to %10Amw and appy such antra on Ise rn0eo4drwse upon Ito oco mean den EvWi1 col palaui
Leader Maloof be requ ad to pay any Indeed or sammps on the Mesa tuna VIM wooed by leer er tit by Landis In wimp.
Fitt sy LEINIEN. 11 aconite Salle to Comply wrdl wry pronsran v1 Its head a1 Truth„ a tl any action a proceadtrb 10 eaegalerrcSd that
sited or le1mly anti Leaders touch In the Psuperb. Lards 1n Crunisl beans/1 only, ail shall nol he t,qurod lo. Iake any seadn SS ulnae,
deem apprIipt . Any !MUM that Lando 1t¢hids *so dime ma boar mead i1 we rat• poosded far In 1ho Note frost be able Mimed or paid
by lands In tin Alb of rapes w.nl by Glaner. R; ma* aapenies. at Lender% option, ail (aj see payed 0h dmrwnd, (b) be added b Via ballet ad
tfa Rafe and be apbo1ranted imam sad be Payet4 alp any Iineblimarrl payments to bacons duo dudnp Whets (m) the tsar ue any applcide
bowlI era peaty a P)1e tartetgne Min el !e Nab. or le) be beard as a balloon pa4ma0t w11Qi ell be doe and parable al Se+ Nos% diluny.
Thal goads True also was antis sword el vise ansuris. Tie+Igils prdalded Tar rn rha paagrapb OW be in addelan m arty Wee' algae Or airy
manatee 1d winch Lender may be welled sea apcywt a11e Molt. Any such Mellon by undo chat not be core hued as ming Its Merit me es ID
bsRaader from ear raw*ady ttal it othuwee neap fans bad_
RIdefiri Tt;DEFENSE OF TITLE. Tim fallowing provisions re4dng to ormseleti eh urn Prepay am Wei:1 11'3 Reed of Tsusl.
Tile. Grantor warrants Piet tam Gnnfar haldt good and dyrkapbet aced scorn to ate Properly in fee atingle. bee err* carer a1f a1 cent and
iiCwrtberancal other Ian *base tan *prat in the Heal Pioasty d*1aiplon s in a17 bl insurance poacy. ado report' 01 MS tla upinlon traa0d 1n
Wear d, Nod accepted try. Loader is cormod oo en h MO peed d Twat and (b) Groom sea the hal dtla. Pars_ and eulhtrey b meta and
darner lade Dead of Trust to Lander.
O slo see d TIM. $ub$ 1 to the =caption in the paagraph adore. Gram warrants and . 11 Fetal ddeed We bale 16 Pe Raptly mains' Ind
beds MMus at ea pumas*. In norm* age Won a flycomfy" is caannanaed that queslians G i aor s Sao p eye M IMS of Trudge or Lends
under thk dad or 'boat Granter dal dead Ire SIAM al Graraor'i asperse. Grants they ba the noreast play in aanch pocseckg, bun Lenart
ass' ba mated b honlo ab al Ina priCsadng and b be iwpsraded in Ma proms/so by Mama of Lar*dar% in stadia. rind Grams *11
diver. sr Mile 10 be deassed.10 Leads rich 1sfnonanls as (cider trey sweat Mae Mtn *o tare* b paned sues parallpaacm
Caeplaece WMr Law& Greeks glam*Wb that the Popov are Gal bases me el the Properly dampest w11R .1 Seta me eppicaSe lams,
adaenowa. and ►agiibord rl gmern reaaat alltamess.
C0IAICEiMATiON. Thu teeming prowlma fabmag 11 condermition prcc sdklgs are a Para of Iris Deed al TWO.
Appaaseti of Neat Pretests. CPI Or anal pen of the Mowry rc oosionned by emirate domain procaatlllp or by arty prfltaatanp or pt*chose _ ..
w sew d co ndemnaaod. Lender may alas a sass raquea bat as or say portion of ate on proceeds d Ili awed be aged b Mr Indobledraet - '
or the warm redbasfien M Pia Misty. law nal prom& at the card shoe man tar award inter mime of ail reasonable costs, s pares.
and alltem e' new Meumea by Inaba or. Lender In canrwcaon wilt Vie coodenentioo.
Pioetadalga, 1l any Preeeld,Io In coadammeloe a lad Gumbo seal promptly corny Lando In wring, and G3rante slog promptly la a saran
t+MPS do May ae+raeesiaty to dotard the item and e6Wit to mod. Granite dlybe the merinal part' in such pnaceadrO. but Larder boa be
!MOW 11 psrelpa1 as its procaa1ig and 1d be sa mswilod in Me pbceslare by comsat el lb own chorea. and Grants era dearer ar cause to
bs alawbrdn ar tenoed[b otobahendo as fart be mail kid Iraq ham late to blots perm! such pesfeilation.
ISVCR {TIOli OF TAMS, tiiEif ANN CHUMS arachi a otaseu4. ionnrz. Tile ryi Li woos i.tidal lams leas
and Magna sue we d Sds Oast d Trust:
Cm5451 1-M511. I sae mild Charges Upon marl by Lander. Gi*mear shall Emu* iota damsons in adilalon b 11tia Daed d trod and take
"Male* veer State i% 1lgtsifel by Lander b parted and a0riout Lit4r1 pen art era Ravi Wopa*y_ Grantor stew minibus. Larder to ea
lama as dnoend balm. imago, rota as Manta labored In ratvrgetg, paladin a continuing d*a Dead d TnasL Indidng wild bad anon
al bras lois. dominants', dense. tad law degas he t1411og Or nagklarep ills Used al Trust
Tan. Tfre Lint Wig anal cwa4rib bin to reach aril rattan appfin: (al a fauc tt: lax capon cis typed Deed of Tod/ s upon as or any pen
ar sr leaahRadre sa..cure by leis Deed of Trust (IN a spac4c fax on tramcar whlah Grantor Is sultmeibed w respdad to Woo/ from peynw4
on bow indabladson waged by Pia lypa d Dead of Trap; (C) a car on fhb type.of Deed of Trust chargesbts sweat be Larder or la bolder of
iba Nolo end Id) a spank rx an al ro any p*4os of the indebtedness or oo payments of principal and nearest made by Overdo,
$abaagwal times II mobs in ouch ant section WAS is sdeded subsequent b Ile dale d BM Owl of Tn4. sae sort shad Hate the each
aliad ea se Even* d Debbi lea daMad Moot and Lender may fasciae any or al a Its mailable remarks for era Bead of palatal as prodded
balms sift' Girds *4*ar Get pays Its ler beam a becomes daingoedrl ar (t) colleen !fin ba es mended oboes it Ira Taws ad Unto
swiss yid daises. Mos Lind* dash era auicheol corporate safety bands CO* Src01ly sresbd dry le Lander.
SSctso'c Amami/Err; FINANCING STATE/OBITS. The loiorning provisions MON b the and 2I Trail as ■ weeny egraeer1a as a out of
Its Dead of Treat
leearNy Agree This Malltaista !daltortstsie ■ swirly women' 10 Use ache env 01 ate Properly oaor>Aamres Odom or oltm personal
property, and Launder trod basset at Se +Iona ce a woad party undo; Iv 1Al0lnn Committal Coda ad amortI d ham erne b *mama
Setalby Ialmed. Upon Aqu.st by Lander. Grander Mod nneCela Orassi*g gramm % mid rake teWarwr otter maw+A neatened ned by Lander to
poled and coranue Laade's magi roamed in Its pleb and Panora) Properly. In addlstn io racadmg pis peat al TOM In Ike net prepergr
records. Lents any, al cry One and Mesa forther aathoirsaae iron Dfrdki, lea saaculed ca nlerp 11. costae or opical0Cloha 01 11*Y Died
or Trap es a 1*i1*rp shaman[ Ammar 1Ma manbeine Lander for 1a slptr*es Wised In perlecano fr amain ltig elk locwly Interest Lyon
dolma. Earnif r a1a l an amble Ss Persona Rop4 y as a same and al a plan raaacrabfy tumefied to Gordy awl Land/ end mean
e siabb la Leader raisin then (a) days as >aeatpa of indigo parnand turn tender.
AMegaaa. The edam mailmen e1 Grantor (deals) and Lander (saanld pay). from rlath rntun if o Caretimmlg 1ha asslt1y netaal
g ranted by era Goad or Trust may be obiwisd teach as aspired by the Uniform Commoremat Code), areas slated on use and pays of nits Dead of
Trust.
FUNNIER ASSURANCES; ATTt ►-1114ACT. Tie fatowuq provisions 1*1141 it Whir assurances end allarruy-rot-fete as a pal a1 hats paean
of Trust.
Pw411 Alletabe0ta AI my brae, and from brae 10 Urns, Loon request al Lender, Grant& wad make. smuts and dapsr. at nil Conn to be
nods saatuiad ax debated. ad Ladder a to Lender's austergtk and wren toques/ad by Linder. rates to to Ssd, !Sc0seed, robed, a
rraoorded, es *scamp may Is, a etch Ones and in SuCY1 caress and prams as Latch may deem appraprisls any and as tames taspagss,
doses o1 Mat wooly MPS. MOM agdoanants4±lnurc1g 1Lgnrmds. cvahnua tun 0le4minle, rividUr IMIS ail hilts atsuraea. Cirdal1l63,
and othaf decattende as may, M go yob opinion, a1 Lender, to neaalaarll ar demob% in tads W .imab; Caweplalaa pabd. Cansnue.Or
greasier (aj ens *Manors of f7ia*4crids 1W Nab, gas twit of "(not and Ma Rrlsbd Dpturnenls. cad (1s) Ise nun and slowrly s allots
created by ahc bead d Truss as Tat Nod p0ar lard On Ne Property, whew now erred s leraaam loginad by &order. Ths ern d !Iris peed
et Trust and Ire molly Werra gelded hereby wS 1ubmseesara4edh. ashore tatter net to M slier-eCyemad prosy limbed a and er wad
M am epochs@ at Ie Plopugr Or airy pal MOW. Unless potbied t it 4. at earned Io da contrary by Lands b 1MtiiIR, (Odor sled
ramburae Lana; Gar Scads endesperaws lemma in connection obi dw mailers WNW' 10 rn 141 peregreph-
Ablawairp Jnfacl, a Grantor tiers la d0 soy of the hangs rabnee to on the prated % parag aph, Lards slay de so lot and in Its ryas d
Grants and a Grantor's operas. Far each purpose . Grantor hmaby raaart 04 SPer:o h Lander es Grantor% albrnsy4r.lacl for Mt impose
of rpc1.g. aresasng. damoi g. ennp, ra1Gdkie, and dory ea otter Pops es racy be necessary or da6+tbli. „ La*ds%s sole tpir►ere, >A
ac1ontpksls are masers Warred to Intro pacwrang pmeraph.
RAI FEf parpsa 11C. 1t Gramlmr ons it 11p selabischsi ps share dark and Siloam prisms W to d4g1Uaa ardiel rd upon Glades wade Iha
Disd et Truest tender shad seer" and steam 1a Trusted a mead fd lull few meyatce as Noe made and cheer b (hare aaeabb stllanreoit
011anati01 of sn7 mamma sla ansal on S evidencing Landoll' secul*r interest In the Rents and 04 Pommel P►opub►. Any noomrsyirri 11a
rowed by law eha[14e pitrd by Gran10n. I perrated by.0010 lots sea.

01-2D-19I DEED OF TRUST
Latin NO [CoMkried)
Pegt t
DEFAILT. Each cl ma wheelie al ee option of Lends, snail earseut4 sr avant of deepest [Erem1 al Dafeul7 under Ws Deed d Trost.
Waal i1n Indebbblens Faaure d Grebe to rein any payment when en on 1he+i deaMdnees.
OafynA en Over Petereda. /see* oe Oriel& ether the /tees flamed by ens Dear/ ei Trot to mee any payment for taw%, a immune e or any
ono annexe rrca.6ey to pwavenl Peng a or to eons dnsetargel el any hen.
codlltwloa Debate. Takeo d Genie ha comply with any own +ernk obm gates, covenant te tendons+ contained m tees Deed of Trls1. the Note
sr in any of lee fiStlad Deco/noes.
Fates Illitle wda. Any se.iardy, repr6sen11bdn Or i1tamenf ahede or twined le Lander by Or on Wet! of Gr.rror minder they Deed at Trust.
rho Note w the Fleeted Documents ss bin or wrtayleadeto n any realest' reIpecl, a.ler now or at the era men or lurn,shed.
Menthe Collatesaiwthon. ihis Dead d Trust or any of !ha Fleeted Documents ceases to be In MI late and street Including failure 01 any
contend documents la create a valid and peet4Cled seemly snllres1 d, Bane el any lime and toe any reason.
Death or Ineotr.ncy. The death at Ettentan. the rnsoWenr, of Drente?, She appointment of a recover fur any Pin of Gierrloi% proem!', any
assignment for Use bane of caedfia,,. any type of creditor workout, or the commencemen! of any proceedng and* any bankruptcy or imdvency
taws by or most Geo1e_
Terniees., Farlelelar. sac. Con itioscer*ert at bred! ttaee ix ferfml1sre pros eerie es, weaves byjudrnet proceeding sae -help. repossession or
fry olthr method, by an creator of Granter or by any Seovernmentar agency against any of the limpeetr. However. this subseceon anal not apply
in be Moe of oP good leak depub by Grantor al to be vines! ar ,sasereblencss d the Beim when ss 1M bags of the toraclostee er laraMlkure
proceeding. grinned 1da1 Greece gives Lander neon nines el such cream and iirsryras analyse e ■ wily bond Ira Lha claim satisfactory to
Lando,
arena of Oen/ Aleseeaeene- An emeriti by Granted under tin tomes al any per beaaeen Grantor end Lander bet as no+ r.m.dud
%tea any wad period pie Idud ewers mein no 'atheist eniislion any agreement ao,san►nw er7 indebtedness es owner oblige/on as 0r.tter tr
Lsnden: x1wY•e erg now or ens, --
Eu.Itte lie rind tluore.loe. arty of e. promisee Molts nos with rest ect to any Motown et any al the trdebteseieat a any 0mgrr.nbr drat
et became[ irevrroaaarlL o 7Swelgor disputes the n1dilyet. or !.beep under. eery Guaranty of rho indebtedness.
beectelly. Loner In goad lane deers 14i11 Insecure. .�
MUM MD I 4EDIE$ 011 0111FAINT. Upert (ha Comnitincts d ens Eyes C1 Odeon and at arty !rips themmalfaa, Teadoe d Larder. al ill option, nay—,
men any Cola rXonus of be beo.lwe desks pad r..ennn. in eddllar+ la sere ober rig% a reneges warded by Soar.
Aiscabdie belabitereselL Lends honed ebn. Ire non el art new wined mono. to Downer l &doe Ise olio Indebtedness anrnedi del' dee
and peywdft reabmue ens wits. Beet poet, which Orient would be.encased le poo-
&pees Pa.ei' as spa Pievel on. sleep eta appacawn at ngmest a Leete.e Web be load tar and the d,ar r>f the Truewe. ems ern Tltewa II
heeler subtitled and rmperreed. le anew b sale and to ni lbw Proper'? et penis median for rash, etlr hong frst complied *Mh el
eaplilble raf41A'eelanle al limb C elan Yaw WM respect h be esenctte at powers al sate mobbed In deeds d het er such .Rey edge
naleado4 cocker the drrevalaness: and upon an soap tide. she Trustee stets canny We 1a she purchaser in led sample in Ifs even d a►h!
SW Under this Deed at Tried by isles el to eewrose at the powers wanted re Ufa Deed of Trost m pusuarl b art, sided amp any *kW
p.00eeaop a o*Rsea . i1Re y prey be old is as windy a to capon. parcels and in soh owner or eider es Linden in yes Sign
Ala:ROM may rasa Trustee :bee be eareearbed ee sow a sale pl,soant err North Coders General Steens Moen As. d Trustee ea ems.
Dune may Ball tbne limpet, awered try 1lw Dead m Tone as error Saar, sapspats sates ia ear ma Mal dolmrraad by aniezeble North Camayo
tour. odd nay stoke ee the Femurs graded in '!els Deed d Trust stele riot weinwase as eeheus+ suit. powers. one ?tea aria, Propmy Is sold or
the Mdipblednws1 is peel In IM. a such Indebtedness a coo or hareader teenier =cured by arty chain rslorbpee pledges. contracts .t
peotaree aingemrterlb Ref red a snow nee* taewee enbe iamb, mi► dip as coon rrrwn:ka ore iernedes repented ender any 91 the semen
e0aamwetsOther cerouerordy cc indeponally end in stet pea Lender trey determine.
Regnante- Wilb.atpeoito era a eql tad of Ce Final peeaarty, nee Trr ON nee have the right to Iwadase by none and stye. aid Leader stintl
have the melt l lending by LOW toq.gss.e. en weer ass at a¢ordir s nqh and testa iva Rodin provided by word:ebb Yew
UCC 1Mrltd1s. felt moped lye all et any put of tee Person Pwope.ty, Lemke Shin haw el the rights end runnels of a secured fery ender
the Metre Command Cede.
*Awl nerd. Lawlor .iri Ilya she !OIL mahout nape 1. Gawdor. lit 1dw seeryteseleee of erect nonage be Pipped! end clone/ Ina acres.
bakfxby a..o 10b MI due Odd u,prM0. Gerd epee Ina nel priest's, one end abase es derb coda, ,pean the hlde0tedeass. In hi+lfoaran= of
Des right. Lando Inn ramie nay Ward or ether metier 01 ore Propwey to nine panwies d rantl a sere fees are* to Lender. II eta firsts m
nalenlid by Leaden. nest Granger arna QWy dietaries Lards ere Cireilars el* icy-hY-6l3 b endorse 14141 twlt% semi snit in mewl* t .net
In the eerie a Gann end la newton the stire and soled the p.oc*44. Ferments by beanie or tree ua.rs to Londe In imposes es Lunde*
nde*
demon sloe sandy the obsgedeq lbr voila+ ale perms s era +lade. /.!.ease or sae any prop wounds 1Q the demoRd erred. Lunar pay
e.wdle in nabs ruder ibis su1pepegrap4.+wUr M penny!. f!y apse. at through a ./coin*.
Appohet Rletdeee. sander shell have er dee/ to hens a nicher eapobed le tea paaieeetoe of al or any part of the Properly, with Pw parer to
protscl and pies.. tied Properly, to cease. be Probity peaCeang ierealoeeae w owe. arid to coleecl,ISae Aeons area per knob and apart in
premeds, over and abayw the wet at We raeiyaralty. teael[a1 es helebleines■. Tye receiver may sew blunt bad a puraeted by law.
Lander% tight to sea appointment al * seem Wel bet neater or not be apparent rake 0 the Property nomads the kedebledrrsea by a
nabol.red amount. Employment Intender Hiss not degtelly • pwenn km swing as ■ pees.
laaff Cy at lul*panre. a Omar* senates to 001506110n of here i►Caety Min the PYapely It sob as provided abase or Lando aneevrila
b oraar.s .wdidod b paasessbn d ohm Prapey open dead W {i*anto. Owner seal become a bow* et srtaeramse at Lender ar tea paetrser al
ere Falbely sad sea, oat I.endw 5 Zpeen. mbar Olt pay a maso r.ble rental fa the arse at the f1ollerty. or On mete she Property amerfdiaio y
mooned demand of Lender.
COO ile.waee. Treabe at Leader shallow any abet tight or +weedy prnMded in this Deed al Trust ce be Nate or by law.
atolln et bee. Lambe del are ii'art.r iessenetde none n Ina Ins seep Plate 01 ern public sale d Olt P.rmftpf Rawly*: al the tits ease
alike ewe WNa1n ante er gate!Awned >7epareon d be Persona Props* la la be made. ib 5..01 mace sh.1 men hares ;linen id tot'
lee (10) eon beam be Irene of the tare of Mobiles Any sale d P.....d Paopoly pray as male a9 cooywnehon wan errs said of the Ted
Preps rd.
eate at the Properly. Te the mere maraud Of nspae5e new, matte eareby.rwwnee me! erd d cedes le have ohs Pr3.r/y Inertleeln In
emaMp 1e.l3s and ramedaa, wed Toddle or tender sled be few le anal a try pad d See Propey ldp.lh.r a Wine*. yhtl , iel one We IN b/
womb sales. lama atoll Wonted kr bet al any Ruble sea en se W any wade d tle Pmperty.
Weber/ wean of fhm.dTea. A weer by any pope a breach of ■ probers d erti Owed d Trust Shay pal coretauta a nh.lrtir of w praoudlpe
the partyi righlt elberrise Ia dimwit dad cempleren ..set the! panache. or GP? Meer pww*siw- Elec oe by Lender la pursue en tweedy
proi.dod n Ihet Owed of Inst. tie Web, la any added Denemwnt, d. mudded by Law VW nit eratude paste d ant, etlher eem.dy. Ind W
eYcece ea Make wpa.d+hxls Of Ig Wm sown to peuxrn an 5M olio n or fr01ar under this Chad a+ Tod ewe+ lawn at Garda la petloaa wall
not ailed Landers ?told la donate • Odin and to oalausn anrt of se rrernereas,
Alforl.rp' Fear EspirawF a Lender Mines an sue or anon Io srebeap any d Ile twins d els Deed of Treat, Landes Wet be Main la
Mover size minas tee Cent ate/ WO*. reatorupb .S Monne lams al octal and on any appal. Whel en et not any cool aoaon fs lw0Poed.
at rrsoneble espan0K mowed by LaMar which to Lioclo s opl.on o nac.Tlery at any tree foe law prencian et is mopes/ a the
arleetedoarrt et es Vex O en become ■ pea el de Indebtedness payable On demand and anal beer newest al the ten isle eon the dale d
renewileme pinta mould. F /mows cowed by iha seasapn rnkrtdw, salbeet acme! err. however steed la any fines mat .ppfrab1 lore
l.mbrk a.,aoad+b aeawwye toss *Ws* or nos mate e a brawl, taodndiact reexomb% attorneys' loot. sr Oan+aupley ptorhadmps Lirdudhg
.ants to nerdy ar vow* any a ions stay is ruefeLdab, sppaats and any anecpwea anti*-hedarnord caution swam. tree eat di 1..1.1.1
•ecsds, oloam%1e w woe e pneeding fired s1vw reports). ai.. on' repots, epareisal tees, be ruwaaen, and ones to the Twilit b 0*
idel penned by writable low. &eaor area we pay art carve seals. in eddnti en 10 el d1n.r suMa Provided by Iasi.
Mph eel Trades. Trtgsee shwa bee ate el ilia refs and dales el larder as set sett In tea caCiio*L
PCalliele AMID OOL1GAT1Cf6 OF MIME, The Wowing enroddre ranee to ate pones and abayallons of Trustee ere pen et thee Deed of TII.4&
Palma 01 Tyo4a. kr like ao1R ie es camera of Thalia taxiing as a wore at am. Toms %ne Peeve the mew to Wye ens Tdlesidne aeons was
respect le be Bopse upon ere masa imam. at Wolof and Grantor. to) kin in plapetlne and olio a *nap ow pet of tw Rot Ptar.rty,
fndeang e, otecenion d sees er aerw!ONs to Me ben: OM On sort er+wtee gm/.eaamww m crwkny pry mancam dI Ile Final Propety:
.n.d Oct OP to .ny sdatido aha.e a offer sere heroes L dot o° Pei Mee o+Tem CV ey now c Lander under the Deed d Trost
.rioWm. Testss that na.1 .a queli4ale.s maimed lot THAW undo( mondani law. In addniaat in an ryats end remackii spat Forth above,

01-20-1996 DEED OF TRUST Prat: s
LEWD No (Icnfdlnu.d)
sill went to as a any part d rr Property, the Twins she i*s dr Opt 1e leader* by NAM and sire. and Lena sham Mite lee Tight b
kee Sere by {incise toradatamar, M erne :mein Keted.nrr with and b 1ha m11 sleet pl0iedea trf app1Cabr• 1aww.
T iabiob FOIL The Trusfe.S Cewrnbaml afar to bee percent ten%) 01 trim pram paeroeettt d 1he Gala tar a clonipl*md 1ri.lenir► ih Rim crams
laaelCew. b comereieed. compbbd, thanks shay pay at eoer as mewed by Trustee end pale opnniseon computed an be
Ae+ca* IS%) of the ouarmdllr *dabiadaras.10wding to the Wove* Madre car-lowth or the commission bWols Truro, basin a mks
of haring .n tie right to lendosUlar, tee f41 m al r1e CaomAeamn ass" issuance at n0ICa of heew thram.loolme e119. ca m01 too abet a
names and to tie c0mmeaereo afire the!Mal sear.
I Iaaa POW le Subside!! a Thisbe Leach meat haw de nerec44 rpla to r.wrasa at any Mr and Iron Sins la One without 10 1 t1.
Teethe rained 1n ti Oaad d Trent Mead acids a Crew and to appeira a seewasOr by en anatirared H weep. dray edindwaridpa0. In such a
lams am to alb SKr maim Irelminemi to bm mooned it the Slab of Nob harder: sad. u to evert at Ism deeti Of gehltalon of Ina Trust,
named In 1Ms O.ad dVaal. trader shag have the rlphl10 Kee* a summit by Such mien eetmmsnt. and any Tlaske so uppenfad!hall0.
maid wetRae Ma to Ala Property. and and passe* at t+a pine*. dupla aria aaepa1drrs basin cordons* en 11r Triodes In the same meanie
and b ire imam Wet as Mar* Pis erbesfer bribe well remit im pre Dope et Tale as Mars
HOMES 70 GRANTOR AND OTHER PARTIES. Any mica undo rile Wad M Trull sect to in swirls may Ev swat by beirbe ins* and sham be
sancli a what uIK* deemed, or whin tepeatod Mb a Womb, rcoprelsd ovarr+ghl comer..r, M Sneed. she bo dammed each* when
deprdMd ire ire llnmed `.Seem art 0st bass. 001bd of ntbeead rime. p011.ge pspalQ dreetad to the .**east shown nay the haginnitlr d 1118
Dead d T1WL Amy party wry Marra me areas for totems under 11ks awed d Trot by eptdrig fame Kean sidles h rem *he pn+sm eldest ig 11et
Pr tampers of Or man Is Is crape Or puffs adder* Pee n.ecw purposes, uremia tram lo #.ep Lander and Trona, Wanner at all bras end
iIISCE LNIEOIA PROVIt100111. Tee Mortat misc./enmons prote►srrs are a part of Ibb O.Id.r Trust:
Ariareatable T111s Deed of Trost bpi* weir are Realer Dc Serene, bmaaaaaw We erect. rrdandandlo and amairre 'L of lee pet'* el so
ter mares sot bah In be Dead* Truk No atrs1ore of or trnrldosent 1f0 Ras Dead of That ahq Oa ul.Csea urawt awn inn',atm and ogre*
bl tam Pooh ne pulls emit 1O bm dwrp.d a bound by Ur a.*aaan or runendwl*V.
Applicert Ism Tam Oea. of Trot hens Most dd.mewd *irate and seceplad 4 LaMar In lie She Of Not Catalan. Thee Lead 01
Trust maM ke Oo.nmM by and eanartat tit rcmedeK'. W.r.r lava of tilt Stilt et 110rtr Carslbea
Cig0.n Ifie1lg.. Calrbia Ordegs In lea Deed of Trine era log cw1t14eeca peepedes arty and sea not b be emir to Wow' a doter re
preleronf of WIS wee of Tnnt
taafgar. Wart 141 be no raw of Ise rawest a estate weals* by Lila Omad 0f Trial wih any other i it rant d scum 111 WE Praparly al my
Wm had by rw la the beret of Lards" in may capac1y, nerd tin within cares* at /erode.
Neilpl. P* a. Al Kroft* et tier#m older tins Quad of null Mhd Tie and s.var1L sod as rakeor Cee to &ardor one moan faadr are
Mary Orrlte. 'nee Swans tud.eli al ram femora Aping briar 10 neporama>♦ car d abmtarO 11 a ids Dar clime.
Sallsrbadbt. t a twat .) comport tiawdl1Mn ands any pmowklon at tee need of Taal la be Sails* s Ktanton abal as 10 wny pinion .r
Olttleshaina, d10h andaq stem not men lea preptalon Intrld or unsermearam as i0 my ertm parl.re !tcisaisferess. r . any suck
.heading pmarfsen OK W Mmrd 10 hoHoned 1v be wain to erns of reefer ce rsir►Y h4Tralee, a Pea t111IaaQra pr.vsiom canna km
s naod.wd. A shag bap riba.o red eh e,.r.rprOw Boras d 1hk BOW d Tnwl in d Mai m sp.ba sham ..meld mid end air
taaaraema ante Assign, S le Ur andatun. amid 10 Sat pent di Trull On *rear el &ae o n henna OW Deed of Vag she bs
teems upon seed alum Io be betel d Les pals% tear stemma a and ampgns_ r owner* of the Properly eaconas erred Ina parson Dear
*can $ydm. Landr, rawer mike do 9wndr, ouy der web Ellariars satoclawS +•pm t.rnento b Iha lewd of Trust and Ire imdabtadne m by
way of iala.laA0a er seine* wiled rwlaa9 Orm*a Recline oatplNers et MOW oat Trust or I14 y tee* era tndebt.dnw.
TTtm b of 16e Esmsnce_ Tiar is d Or nne<a 1n gin pweoreennoe of the Dyad d Trutt
maMla'a fad Cowan tardy anal not Ma deemed 13 Iwo witted nay debt t adr tali Oiled al Mel la tattler .r brelad 0auioenb)
twins such ne e a In waft and slide* by Londe. Horan *. beltstlm cs fhI part of tender n.arardrde .oey right 1101 WOWS S as. car
of such del ce any Darr tahl. A RAW My awry party of a plaminel d O* Dan* of Trust slat not cematYAa a wire .f ar psa{ldom t» DWI
*pat etherwae 10 dame* I1eel comae.. .I r+eir that prole*, or any shy paoralara lea pprior vm .s1by Linear. nor my tarmac of *ant& *Mee tattle fad arm'. seem Corneuh d a wrier any of Wide% dabs a area 01 Bn eel's Molars u la iw blare bwrt eaki+n.
ytlrataar creed by Wale is rembnl try rib Dud or Tart We sassing of such carat by Under 1n are Imams a stria not sons**
uerahteat carer 1C eltesquant btraw s wterm arch Consort b gagtered.
fit1AMTCR Al]f11011N.axes memo Pm ILL T1t£ PIl0Ymm ads OF 7101 liter OF mom MID ea Amp Wan Tr0 to TRAM.
IM WHEN WHEREOF EACH G %M1T M 1ML. SET SRAMiOR'1 HAIM AND VEAL TO TifIS DERV OF TRUST OM THE DATE SOCACH AT pc
UEAOti.IIIU OF THIS pew OF TRUST.
GRANTOR
w..t eda1Mg.i and *mused R tr. poems arty
x_Avne ] 1! arrt..L.Q—
x
Mersa

1'1-64-f9Y0
Loan 11d
•
DEED OF TRUST Psis d
(f
wr of NORTH CAROLINA
coueiras GUILFOPD
INDIVIDUAL ACKNOWLEDGMENT
1M
s
i. Jovice B. Olmstead a scan Pubic Por.6a Cdugr and Stil., coign lie
mum LEWIS OLIPHAN1 *KS crimsfa L OLIFIRVIT pew* even Sobs ors vs My and ad.rocolocipel fa Ws souaueen or Pie rvsporq
WM ry_____ AMr
nierfedMsus 20th ees January
t1DTAIS?. '
Aws 1
LAsswPna, Ass ws. Fax a ma. on.. wr. aiaatio.r p9lrskeravK. a*- N+.iginarsw.ra Mc -on, ►uax+u
e 98.

.s:.•'RI' :'IT • iv e?
I_.
x•
$XHTBIT A
Beginning at an established iron pin and stone at the base
of an 11 inch diameter post oak, which iron pin and stone
mark the northwest corner of property belonging (now or
formerly) to Men C. Robertson as described in Deed
recorded in Book 1825, Page 92, Guilford County Registry;
running thence along the north line of the property of Ellen
C. Robertson (now or formerly) South 78 degrees 23 minutes
38 seconds East 303.14 feet to an established iron pin
marking the northwest corner of the property (now or
formerly) of Roger D. and Santina Kivstt, ae described in
deed recorded in Book 2424, Page 639, Guilford County
Registry; running thence along the north line of the
property of Roger D. and Santina i[ivett (now or formerly)
South 78 degrees 23 minutes 39 seconds Bast 633.58 feet to a
new iron rod and stones in the rest line of property
belonging (new or formerly) to Sally N. Noon as described in
Deed recorded in Hook 1649, Page 640, Guilford County
Registry; running thence along the line of property
Belonging (now or formerly) to Sally N. Noon North 9 degrees
27 minutes 29 seconds Bast 313.62 feet to a new iron red;
continuing thence along the Line of Sally k. Noon (now or
formerly) South 70 degrees 26 minutes 13 seconds East 585.40
feet to a new iron rod in the line of property belonging
(now or formerly) to Wilma S. Kersey as described in Deed
recorded in Book 1200, gage 524, Guilford County Registry;
running thence along the line of Wilms S. Kersey (now or
formerly) north 00 degrees 44 minutes 31 seconds west
1087.58 feet to a new iron rod and stones; continuing thence
along the line of Wilma S. Kersey (now or formerly) North 82
degrees 16 minutes Si seconds west 1298.55 feet to an
established iron pin and stones in an old stump hole in the
centerline of an old roadbed, whloh iron pin :narks a corner
of the property (now or formerly) of William Lester Jackson
as described in Deed recorded in Book 3227. Page 822,
Guilford County Registry; running thence along the line (now
or formerly) of William Lester Jackson South 9 degrees 21
minutes 22 seconds West 615.34 feet to an established iron
pin and stones marking the northeast corner of property
belonging (now or formerly) to Lester A. Smith as described
in Deed recorded in Book 786, Page 309, Guilford County
Registry; running thence along the line (now or formerly) of
Lester A. Smith South 11 degrees 40 minutes 41 seconds West
591.89 feet to the point and place of beginning, the same
containing approximately 37.193 acres as shorn on survey by
Cagle Surveys dated December 10, 1997, designated Job 18746
0-11, entitled "Survey of Existing Tracts: Mark L. Oliphant
and wife, Christel L. Oliphant".
The above described property ie all that property described
in Deed recorded in Book 2860, Page 501, Guilford county
Registry.

NA
NCDENR .
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
August' 3, 2010
CERTIFIED MAIL 7007 0220 0003 0155 8150
RETURN RECEIPT REQUESTED
Mark L. Oliphant
1259 Elon Place
High Point, NC 27263
Subject: Notice of Violation with Intent to Enforce (NOV-2010-PC-0925)
SA7 Geothermal Injection Well
Permit No. WI0400065
Guilford County
Dear Mr. Oliphant: ,
Dee Freeman
Secretary
As we indicated in our. May 24, 2010, letter, the above-referenced permit, which was issued on
August 1, 2005, and expires on July 31, 2010, has not been renewed. This permit was issued for
the operation of a 5A7 geothermal injection system on your property located at 1259 Elon Place
in High Point, North Carolina.
On May 24, 2010, our office issued you a Notice of Expiration (NOE) and a perm.it renewal
application package with instructions to submit the necessary paperwork within 30 days of its
receipt. To date, the Groundwater Protection Unit has not received your completed renewal
application package. In addition, our records do not indicate that the well system has been
plugged and abandoned.
Therefore, the following violation(s) exists:
VIOLATION 1:
Failure to submit a permit renewal request at least 120 days prior to the permit's expiration date
is a violation of Part VIII of the permit and 15A NCAC 2C .021 l(j).
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North °Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity I Affirmative Action Employer
Nol!S.1. C 1· 01u1 aro 1na
/vatural/11
REQUIRED CORRECTIVE ACTION FOR THIS VIOLATION
Please take one of the following corrective actions within 30 davs of receipt of this letter:
1. APPLY FOR PERMIT RENEW AL. When you apply for and receive a
renewal, operation of your well system will be permitted to continue. As
such, all sampling requirements and any operation and maintenance
procedures specified in your previous permit will be required. To renew, you
must submit the following information to the address below:
A completed Application for Permit (Renewal) to Construct and/or Use a
Well(s) for Injection with Geothermal Heat Pump System for Type
5A7Well(s) (Enclosure 1). This form must be signed by each
property/permit owner.
2. APPLY FOR PERMIT RESCISSION. If the geothermal well system has
not been constructed or is no longer being used for injection purposes, the
permit may be rescinded. Indicate on the attached Status of Injection Well
System (Enclosure 2) your desire to rescind your permit and one on the
following:
a. Current use of UIC well if it is still being used for other purposes
(i.e.irrigation, drinking, etc.).
b. Well abandonment information if the well is inactive and no longer in
use.
NOTE: For a well system that is no longer active and is no longer being used
for any purpose, it must be permanently abandoned according to the
regulatory requirements listed under NCAC Title 15A, Subchapter 2C,
Section .0214. When each well is plugged and abandoned, the well
abandonmer: .. ,e:;o:·c (Fom1 GW-30) must be submitted to the address below
to certify th~·· t11:> abandonment was properly conducted.
All forms must be submitted to the following address within 30 calendar davs 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 ://p ortal.ncdenr .orn/web/wq/ ao si £!\,vp ro/permi t-app lications.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call Eric G. Smith at 919-715-6196, or email him at eric.2.smith(a).ncdenr.e ov.
Enclosures:
1. SA 7 Renewal Application
2. Injection Well Status
Sincerely;
~~ . W1),
Debra J. Watts, Supervisor
Groundwater Protection Unit
cc: Winston-Salem Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0400065 w/o enclosures
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U.S. Postal Service,:.,
CERTIFIED MAIL,M, RECEIPT
(Domestic Mail Only; No Insurance Coverage Provided)
For delivery information visit our websits at www.Usps.Contn
Postage
Certrfled Fee
Retum Receipt Fee
xtoreement Required)
•astricted Delivery Fee
ndorsernertt Required}
Total Postsg
or Po Box No.
Peetrnark
Here
Mark L. Oliphant
1259 Elon Place
High Point, NC 27263
PS Form 3840.Auqu51 2006
See Actlersr stir instructions
SENDER: COMPLETE THIS SECTION
• Gampleta Items 1, 2, and 3. Also complete
Item 4 if Restricted Delivery Is desired.
• Print your name and address on the reverse
so that we can return the card to you.
• Attach this card to the back of the maitpiece,
or on the front if space permits.
1. Article Addressed to:
Mark L. Oliphant
1259 Elon Place
High Point, NC 27263
COMPLETE THIS SECTION ON DELIVERY
A. Sigrys}ture
Agent
(LeL : t
�3 Addressee
G ��- ssee
8. Received by ( Printed Na
C. Date of Delivery
D. 1s delivery address different from Item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
„
s
3. ServjcdS
❑ Certified Mail
❑ Registered
❑ Insured Mail
❑ Express Mall
❑ Return Receipt for Merchandise
❑ C.O.D.
4. Restricted Delivery? (Fare Fee)
❑ Yea
2. Article Number
(T►aansfer from service label)
7007 0220 0003 0155 8150
1 PS Form 3811, February 2004
Domestic Return Receipt 102595-02-M-t540

ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
May 24, 2010
Mark L, Oliphant
1259 Eton Place
High Point, NC 27263
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WI0400065
Guilford County
Dear Mr. Oliphant:
The Underground Injection Control (TTIC) Program of the North Carolina Division of Water
Quality (DWQ) is entrusted to protect the groundwater quality and resources of the State of
North Carolina., and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for
the underground injection well system, which was issued to you on August 1, 2005, and expires
on July 31, 2010, has not been renewed. If you wish to keep this permit and operate the injection
well system, the permit must be renewed and issued in your name. Our records do not indicate
that the well system has been plugged and abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit one of the following
forms:
A. Application for Permit (Renewal) to Construct and/or Use a Wells) .for Injection with
Geothermal Heat Pump System for Type 5A7 Wells) if the injection well system on your
property is still active.
-OR-
B. Status of Injection Well System if the injection well system is inactive or has been
temporarily or permanently abandoned.
If there has been a change of ownership of the property, an injection Well Permit
Name/Ownership Change Form must also be submitted.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard. Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1' 919.715.0588; FAX 2: 919-715.6048 1 Customer Service'•1-877.623-6748
Internet www.ncwvaterqualitv.orq
An Equal Gppanunny AGRon Employer
One
orthCarolina
Naturally

If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements Listed under NCAC Title 15A, Subchapter
2C, Section .0214. When each well is plugged and abandoned, the well abandonment record
(Form GW-30) must be submitted to our office to certify that the abandonment was properly
conducted. If the injection well system is still active and you wish to renew your permit, the
renewal application must be submitted within 30 calendar days of the receipt of this letter to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
http://h2o.enr.state.nc.us/aps/gpu/forms.htm..
Thank you in advance for your cooperation and timely response. If you have any questions,
please call me at [phone]_
Sincerely,
A •
Eric G. Smith, P.G.
Hydrogeologist
Attachments
cc: Winston-Salem Regional Office - APS w/o enclosures
APS Central Files - Permit No. WI0400065 w/o enclosures

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: W I 0 OD Oh—i
Pennittee Name: IT 16 irk L.
Address: 1,9T(1 F11 P (1(1
�i.C. .9,112;1-3
Please check a selection which most closely describes the current status of your injection well system:
1) Well(s) still used for injection activities, or may be in the future.
2) ❑ Well(s) not used for injection but is/are used for water supply or other purposes.
3) ❑ Injection discontinued and: a) ❑ Well(s) temporarily abandoned
b) ❑ Well(s) permanently abandoned
c) ❑ Well(s) not abandoned
4) ❑ Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well, (Include a description of how the well
was sealed and the type of material used to fill the well 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:
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
Signature Date
Revised 5/05 GWNIC-fib
R CE VED f} DENR DWO
AQUIFFR PPr1TFr' T i[]N :S'CTTQN
JUN 07 1D 1G

*WA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
August 3, 2010
CERTIFIED MAIL 7007 0220 0003 0155 8150
RETURN RECEIPT REQUESTED
Mark L. Oliphant
1259 Elon Place
High Point, NC 27263
Subject Notice of Violation with Intent to Enforce (NOV-2010-PC-0925)
5A7 Geothermal Injection Well
Permit No. W10400065
Guilford County
Dear Mr. Oliphant:
As we indicated in our May 24, 2010, letter, the above -referenced permit, which was issued on
August 1.2005, and expires on July 31, 2010, has not been renewed. This permit was issued for
the operation of a 5A7 geothermal injection system on your property located at 1259 Elon Place
in High Point, North Carolina.
On May 24, 2010, our office issued you a Notice of Expiration (NOE) and a permit renewal
application package with instructions to submit the necessary paperwork within 30 days of its
receipt. To date, the Groundwater Protection Unit has not received your completed renewal
application package. In addition, our records do not indicate that the well system has been
plugged and abandoned.
Therefore, the following violation(s) exists:
VIOLATION 1:
Failure to submit a permit renewal request at least 120 days prior to the permit's expiration date
is a violation of Part VIII of the permit and 15A NCAC 2C .0211(j).
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raleigh, North Carolina 27699.1836
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588: FAX 2: 919.715.6048 I Customer Service: 1-877.623-6748
Internet: www.nrwaterquaiity.ottl
An Euua[ Oppo:ilmnity I Affirmative Action Ernplcyer
NonrthCarolina

REQUIRED CORRECTIVE ACTION FOR THIS VIOLATION
Please take one of the following corrective actions within 30 days of receipt of this letter:
1. APPLY FOR PERMIT RENEW AL. When you apply for and receive a
renewal, operation of your well system will be permitted to continue. As
such, all sampling requirements and any operation and maintenance
procedures specified in your previous permit will be required. To renew, you
must submit the following information to the address below:
A completed Application for Permit (Renewal) to Construct and/or Use a
Well(s) for Injection with Geothermal Heat Pump System for Type
5A7Well(s) (Enclosure 1). This form must be signed by each
property/permit owner.
2. APPLY FOR PERMIT RESCISSION. If the geothermal well system has
not been constructed or is no longer being used for injection purposes, the
permit may be rescinded. Indicate on the attached Status of Injection Well
System (Enclosure 2) your desire to rescind your permit and one on the
following:
a. Current use of UIC well if it is still being used for other purposes
(i.e.irrigation, drinking, etc.).
b. Well abandonment information if the well is inactive and no longer in
use.
NOTE: For a well system that is no longer active and is no longer being used
for any purpose, it must be permanently abandoned according to the
regulatory requirements listed under NCAC Title 1 SA, Subchapter 2C,
Section .0214. When each well is plugged and abandoned, the well
abandonmeri. ; ~::o:·{: (Fom1 ,J-\V-30) must be submitted to the address below
to certify fr--,·-':h ~ ahandonr:;ent was properJy conducted.
All forms must be submitted to the following address within 30 calendar davs of the receipt of
this letter to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
163 6 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these fonns 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 :/ /portal.n.cdenr .oni/web/wg/ ap s/ !!\\1 oro/permi t-applications.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call Eric G. Smith at 919-715-6196, or email him at eric.~.smith(a;,ncdenr.gov.
Enclosures:
1. SA 7 Renewal Application
2. Injection Well Status
Sincerely;
~~.~-
Debra. J. Watts, Supervisor
Groundwater Protection Unit
cc: Winston-Salem Regional Office -A.PS w/o enclosures
APS Central Files -Permit No. WI0400065 w/o enclosures
(DW
awar'C
Michael F. Easley. Governor
William C. Ross .lr., Secretary
North Carolina department of Envirsmmemand Natural Resources
Alan W. Klimek, P.E. Direcurr
Division of Water Quality
August 2, 2005
Mark Oliphant
1259 Elon Place
High Point, NC 27263
RE: Issuance of Injection Well Permit WI0400065
Dear Mr. Oliphant:
In accordance with your application submitted July 14, 2004 the Division of Water Quality's Underground
Injection Control (UIC) Program is forwarding Permit No, WI0400065 for the operation of a geothermal heat
pump injection system at 1259 Elon Place in High Point, Guilford County. This permit shall be effective
from the date of issuance until July 3 L, 2010, and shall be subject to the conditions and limitations stated
therein. Please read your permit carefully to make sure you thoroughly understand its requirements and your
responsibilities.
Please find enclosed a copy of the water quality test results for samples of your heat purnp influent and
effluent that were collected on 26 January 2005, 28 February 2005, and 16 June 2005 as part of the permit
application process.
Please contact me at 919-715-6166 or Evan Kane at 919-715-6182 if you have any questions regarding the
Underground Injection Control Program or injection well rules and regulations.
Best Regards,
Attas-e4
Thomas Slusser
Hydrogeological Technician II
IJIC Program
Cc: Sherri Knight, Winston-Salem Regional Office
CO-U1C Files
�C7nr1tCaroliria
llfllillhIlf
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Phone [phone]I Customer Service
Internet: http'llh2o.enr.state.nt.us 2728 Capital Boulevard Raleigh, NC 27604 Fax [phone].623-6748
Fax [phone]
An Equal OpportunityfAiflrmaiive Action Employer-- 50% Recycled!1 O% Post Consumer Paper

LABORATORY TEST RESULTS Date: July 19, 2005
To: Mark Oliphant
From: Thomas Slusser [phone]
Re: Groundwater Sampling Results for January 26, 2005, February 28, 2005, and June 16, 2005.
Influent Water sa·m 12 le sam 12 led. sam Qled sam 12 led Effluent Water Sam Qle sam ~led sam Qled
on 1/26/05 on 2/28/05 on 6/16/05 on 1/26/05 on 6/16/05
Cai iform, total ns ns <1/100 ml Coliform, total ns <1/100 ml
Coliform, fecal ns ns ns Coliform, fecal ns ·ns
pH 7.89 ns 7.58 pH 7.98 7.62
Chloride, .ci <5 mg/L 4 mg/L ns Chloride, Cl <5 mg/L ns
Dissolved Solids 200 mg/L 200 mg/L ns Dissolved Solids 200 mg/L ns
NO2-+ NO3-as N 0.25 mg/L 0.20 mg/L ns NO2-+ NO3-as N 0.25 mg/L ns
Aluminum, Al <50 mg/L 280 mg/L <50, ing/L Aluminum, Al <:50 ug/L 130 ug/L
Calcium, Ca 47 mg/L 46 mg/L ns Calcium, Ca 47 mg/L ns
Cadmium, Cd ns ns <2.0 ug/L Cadmium, Cd ns <2.0 ug/L
Chromium, Cr <25 ug/L <25 ug/L <25 ug/L Chromium, Cr <25 ug/L <25 ug/L
Copper, Cu 7_7 ug/L . 38 ug/L 26 ug/L Copper, Cu 95 ug/L 78 ug/L
lror:,, Fe <50. ug/L 400 ug/L <50 ug/L Iron, Fe <50 ug/L 190 ug/L
Mercury, Hg ns ns ns Mercury, Hg ns ns
Potassium, K 2.9 mg/L 3.0 mg/L ns Potassium, K 2.9 m9./L ns
Magnesium, Mg 8.7 mg/L 8.7 mg/L ns Magnesium, Mg 8.9 mg/L ns
Manganese, Mn 55 ug/L 61 ug/L 43 ug/L Manganese: Mn 57 ug/L 47 ug/L
Sodium, Na 12 mg/L 12 mg/L hs Sodium, Na 12 mg/L ns
Nickel, Ni <10 ug/L <10-ug/L <10 ug/L Nickel, Ni <10 ug/L <10 ug/L
Lead, Pb 43 ug/L <10 ug/L <10 ug/L Lead.Pb <10 ug/L <10 _ug/L
Selenium, Se ns ns ns Selenium, Se ns ns
Zinc, Zn 84 ug/L 150 ug/L 86 ug/L Zinc, Zn 95 ug/L 160 ug/L
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSIQN
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordai1ce with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
MARK OLIPHANT
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5A7 INJECTION WELL,
defined in Title 15A N01th Carolina Administrative Code 2C .0209(e)(3)(A), which will be used
for the injection ~f heat pump effluent. This injection well will be located at 1259 Elon Place,
High Point, Guilford County, Nmih Carolina, and will be operated in accordance with the
application submitted July 14, 2004 ai1d in conformity with the specifications and supp011ing
data submitted, all of which are filed with the Department of Environment and Natural Resources
and are considered a part of this permit.
This pennit 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 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, ui1less revoked, from the date of its issuance until July 31, 2010,
and shall be subject to the specified conditions and limitations set fo11h in Pa11s I through X
hereof.
Permit issued this the
Alan W. Klimek, Director
Division of Water Quality
By Author~ty of the Environmental Management Commission.
Permit No. WI0400065
GW/UIC-5 ver. 7/05
, 2005.
PAGE lOF 6
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Pem1ittee must comply with all conditions of this pem1it and with the standards ai1d
criteria specified in Criteria and Stru.1dards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditimis of this pennit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement actioi1 as provid~.d
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is .constructed in accordance with the
conditions of this pem1it,.the approved plans and specifications, and other supp01iing 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 injectio:riwell shall be afforded reasonable protection against damage during
construction and use.·
7. Each injection well shall have pennanently affixed an identification plate.
8. A completed Well Construction Record (Fann GW-1) must be submitted for each injection
well to, DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1636
Mail Service Center, Raleigh, NC 27699-1636, 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 Pennittee shall
notify the Aquifer Protection, Se~tion-Underground hljectionControl (UIC), Central Office
staff, telephone number [phone] and the Winston-Salem Regional Office Aquifer
Protection Section Staff, telephone number [phone].
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This pem1it 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 pennit is not transferable without prior notice to, and approval by, the Director of the
Permit No. WI0400065
GW/UIC-5 ver. 7/05
PAGE 20F 6
Division of Water Quality (Director)'. In the event there is a desire for the facility to
charige ownership, or there is a name change of the Pem1ittee, a formal peni1it amendment
request must be_ submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Pennittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances that may be imposed
by other local, state, and federal agencies that have jurisdiction. Furthennore, the issuance
of this pennit 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 groundwater, which will render it unsatisfactory for nonnal use. In·
the event tl~at the facility fails to perfonn satisfactorily, including the creation of nuisance
conditioils·or failure of the injection zone to adequately assimilate the injected fluid, the ·
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility ..
2. The Pemfittee shall be required to comply with the terms and conditions of this pennit
even if compliance requires a reduction or elimination of the pennitted activity.
3. The issuance of this pem)it shall not relieve the Pennittee of the responsibility for damages
to surface or groundwater 1~esulting from the.operation of this facility.
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
riot specifically authorized_ by the pennit.
3. At least fo1ty-e~ght (48) hours prior to the initiation of the operation of the facility for
injection, the Pem1ittee must notify by telephone the Aquifer Protection Section-·
Underground Injection Control (UIC), Central Office staff, telephone number (919) 715-
6166. Notification is required so that Division staff can.inspect or otherwise review the
injection facility and detem1ine if it is iii compliance with pem1it conditions.
PART VI-INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
Permit No. WI0400065
GW/UIC-5 ver. 7/05
PAGE30F6
may, upon presentation of credentials; enter and inspect any property, premises, or place on
or related to the injectioi1 facility at any reasonable time for the.purpose <;>f determining
con~pliance with this permit, may inspect or copy any records that must be maintained
under the tenns and conditions of this pennit, 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 injectjon and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary anq appropriate samples associated
with the injection facility activities.
PART VII -MONITORING AND REPORTING REQUIREMENTS
l. Any monitoring_(including groundwate~,-surface water, or soil.sampling) deemed necessary
by the Division of Water Quality to insure surface and ground water protection, will be
established and an acceptable sampling reporting schedule shall be followed.·
2. The Pem1ittee 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 that results in any unusual
·operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable.of proper injection operations, such as mechanical or electrical
failures.
3. ·Where 'the Permittee becomes aware of an omissioi1 of any relevant facts in· a permit
application, or of any incorrect information submitted in said applicatio·n or in any repo1i 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 perfonn satisfactorily,' the Pennittee shall
take such inimedi.ate action as may be required by the Director.
PART VIII -PERMIT RENEWAL
The Permitte·e shall, at least 120 days prior to the expiration of this permit, request an
extension.
Perinit No. WI0400065
GW/UIC-5 ver. 7/05
PAGE40F 6
PART IX -CHANGE OF WELL STATUS
1. The Pe1111ittee shall provide written n:otification within 15 days of any change of status of
an injection well. Such a change would include the discontinuation ofuse·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 facilfty and a well will no longer be used for any
purpose, the Pennittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, ii1cluding 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) TI-ie 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 b~tween underground ·
sources of drinking water and in acco1~dance with the terms and conditions
of the permit.
(G) The Pennittee· shall submit a Well Abandonment Record (Form GW-30)
Pennit No. WI0400065
GW/UIC-5
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion of
abandonment.
PAGE5OF6
ver. 7/05
3. The written documentation required in Paii IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-DIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X-OPERATION AND USE SPECIAL CONDITIONS
None.
Perm.it No. WI0400065
GW/UIC-5 ver. 7/05
PAGE 60F 6
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COUNTY: GUILFORD
QUAD NO:
DIVISION OF WATER QUALITY
Chemistry Laboratory Report/ Ground Water Quality
SAMPLE PRIORITY
□ROUTINE □EMERGENCY
REPORT TO _W_S_R_O _________ Regional Office □ CHAIN OF CUSTODY
~ SAMPLE TYPE
I I
COLLECTOR(S) :_T_S_L_U_S_SE_R _____ _
DATE : 6/16/2005
TIME: 12 :19
MOGUIC2
l e f f.,I
PURPOSE: sa ¥11 a [,rVlA v~r r \{ecchot11. , ~
Owner: MARK OLIPHANT
Location or Site: l±_O mG
Description of sampling point_e_:=·;..>,~--"·£~/u,,_-e~n...,__._f=_&1=-=-f---'~ .... -e=1 ..... f----Jn.,<..1Lu-'-'m"-'+"/l'-_,u""-L..Q......,_,9...::f ___ _
Sampling Method: I I
Remarks:
LABORATORY ANALYSIS
BOD310 mg/L Diss. Solids 70300 mg/L Ag-Silver 46566
COD High 340 mg/L Fluoride 951 mg/L X Al-Aluminum 46557
COD Low 335 mg/L Hardness: total 900 mg/L As-Arsenic 46551
Colifonn: MF Fecal 3 I 616 1100ml Hardness: (non-carb) 902 mg/L Ba-Barium 46558
X Colifonn: MF Total 31504 1 82 1100ml Phenols 32730 ug/L Ca-Calcium 46552
TOC mg/I Specific Cond. 95 umhos/cm2 X Cd-Cadmium 46559
Turbidity NTU Sulfate mg/L X Cr-Chromium 46560
Residue., Suspended 530 mg/L Sulfide 745 mg/L X Cu-Copper 1042
Total Suspended solids mg/L MBAS mg/L X Fe-Iron 1045
Oil and Grease mg/L Hg-Mercury 71900
pH 7. 6, L--units Silica mg/L K-Potassium 46555
'\lkalinity to pH 4.5 mg/L Boron Mg-Magnesium 927
-Alkalinity to pH 8.3 mg/L Formaldehyde mg/L X Mn-Manganese I 055
Carbonate mg/L NH3 as N 610 mg/L Na-Sodium 929
Bicarbonate mg/L TKN as N 625 mg/L X Ni-Nickel
Carbon dioxide mg/L NO2 +N03 as n 630 mg/L X Pb-Lead 46564
Chloride mg/L P: Total as P 665 mg/L Se-Selenium
Chromium: Hex I 032 ug/L PO4 mg/L X Zn-Zinc 46567
Color: True 80 c.u. Nitrate (NO3 as N) 620 mg/L
Cyanide720 mg/L Nitrite (NO2 as N) 615 mg/L
COMMENTS:
Lab Number : SG1556
Date Received : 6/16/2005
Time Received : 2:50 PM
Received By : HMW
Released By : EAS
Date reported : 6/24/2005
ug/L Organochlorine Pesticides
130 ug/L Organophosphorus Pesticides
ug/L Nitrogen Pesticides
ug/L
mg/L Acid Herbicides
2.0U ug/L
25U ug/L Semivolatiles
78 ug/L TPH-Diesel Range
190 ug/L
ug/L Volatile Organics (VOA bottle)
mg/L
mg/L TPH-Gasoline Range
47 ug/L TPH-BTEX Gasoline Range
mg/L
10U ug/L
10U ug/L
ug/L
160 ug/L
SG1556.xls
COUNTY : GUILFORD
QUAD NO:
DIVISION OF WATER QUALITY
Chemistry Laboratory Report / Ground Water Quality
SAMPLE PRIORITY
Ei ROUTINE EMERGENCY
REPORT TO : WSRO Regional Office El CHAIN OF CUSTODY
COLLECTOR(S) ; T SLUSSER
W❑ SAMPLE TYPE
DATE: 6/16/2005
TIME: 11:45 r
PURPOSE:
LABORATORY ANALYSIS
BOD 310
mg/L
COD High 340
mg/L
COD Low 335
mg/L
Coliforrn: MF Fecal 31616
/100m1
X
Coliforrn: MFTotal 31504
1 B2 /100m1
TOC
mg/I
Turbidity
NTU
Residue., Suspended 530
mg/L
Total Suspended solids
mg/L
pH
7-5 1 units
llkalinity to pH 4.5
mg/L
Alkalinity to pH 8.3
mg/L
Carbonate
mg/L
Bicarbonate
mg/L
Carbon dioxide
mg/L
Chloride
mg/L
Chromium: Hcx•1032
ug/L
Color: True 813
c.u.
Cyanide 720
mg/L
COMMENTS :
i
MOGUIC 1
Owner: MARK OLIPHANT
Location or Site: C1 ' Y F=
Description of sampling point to li la Q.ad i i1 I1Jt' 4 - p [ C f
Sampling Method:
Remarks:
Diss. Solids 70300
mg/L
Fluoride 951
mg/L
Hardness: total 900
mg/L
Hardness: tnon- rb) 902
mg/1-
Phenols 32730
ug/L
Specific Cond. 95
umhos/cm2
Sulfate
mg/1.
Sulfide 745
mg/L
MBAS
mg/L
Oil and Grease
mg/L
Silica
mg/I.
Boron
Formaldehyde
mg/L
NH3asN610
mg/L
TKN as N 625
mg/L
NO2 i-NO3 as n 630
mg/L
P: Total as P 665
mg/L
PO4
mg/L
Nitrate (NO3 as N) 620
mg/L
Nitrite (NO2 as N) 615
mg/L
Ag-Silver 46566
uglL
X
AI -Aluminum 46557
50U ug/L
As -Arsenic 46551
ug/L
Ba-Barium 46558
ug/l.
Ca -Calcium 46552
mg/L
X
Cd-Cadmium 46559
2.011 ug/L
X
Cr-Chromium 46560
25U ug/L
X
Cu- Copper 1042
26 ug/L
X _
Fe- Iron 1045
50U ug/L
Hg- Mercury 71900
uglL
K-Potassium 46555
mg/L
Mg- Magnesium 927
mg/L
X
Mn-Manganese 1055
43 ug/L
Na- Sodium 929
mg/L
X
Ni-Nickel
10U ug/L
X
Pb-Lead 44564
10U ug/L
Se -Selenium
ug/L
X
Zn-Zinc 46567
86 ug/L
Lab Number : 5GI557
Date Received : 6/16/2005
Time Received : 2:50 PM
Received By : NMW
Released By : EAS
Date reported : 6/24/2005
Organochlorine Pesticides
Organophasphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
Semivolatiles
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
5G t 567.xis

COUNTY : GUILFORD
QUAD NO:
REPORT TO : CO Regional Office
COLLECTOR(S) : 0 H AG G E
DATE: 2/28/2005
TIME:
PURPOSE!
LABORATORY ANALYSIS
BOD 310
mg/L
COD High 340
mg/L
COD Low 335
mg/L
Coliform: MF Fecal 31616
1100m1
Colifomt: MF Total 31504
1100m1
TOC
mgl1
Turhitity
NTU
Residue., Suspended 530
mgjL
Total Suspended solids
mg1L
pH
units
Alkalinity to pH 4.5
mg/L
Alkalinity to pH 8.3
mg/L
Carbonate
mg/L
Bicarbonate
mg/L
Carbon dioxide
mg/L
X
Chloride
4
mg/L
Chromium: Hex 1032
ug/L
Color: True 80
c.u.
Cyanide 720
tng/L
COMMENTS :
DIVISION OF WATER QUALITY
Chemistry Laboratory Report / Ground Water Quality
SAMPLE PRIORITY
flRO1JTlNE ❑ EMERGENCY
0 CHAIN OF CUSTODY
W❑ SAMPLE TYPE
Owner: MARK OLIPHANT
Location or Site:
IN 1
Description of sampling point
Sampling Method:
Remarks: CS2►>•t_t2
�2 Y r 1i•'?.!i
X
Diss. Solids 70300
200
mg/L
Fluoride 951
mg/L
Hardness: total 900
mg/L
Hardness: (non -cart) 902
mg/I.
Phenols 32730
uglL
Specific Cond. 95
umhos/cm2
Sulfate
mg/L
Sulfide 745
mg/L
MBAS
mg/L
Oil and Grease
m4(L
Silica
mg/L
Boron
Formaldehyde
mg/L
NH3 as N 610
mg/L
TKN as N 625
mg/L
X
NO2 +NO3 as n 630
0.20
mg/L
P: Total as P 665
0.04
mg/L
PO4
mg/L
Nitrate (NO3 as N) 620
mg/L
Nitrite (NO2 as N) 615
mg/L
Ag-Silver 46566
ug/L
X
Al -Aluminum 46557
280 ug/L
As -Arsenic 46551
ug/L
Ba-Barium 46558
ug/L
X
Ca -Calcium 46552
46 mg/L
Cd-Cadium 46559
ug/L
X
Cr-Chromium 46560
25U ug/L
X
Cu- Copper 1042
38 ug/L
X
Fe- Iron 1045
400 ug/L
Hg- Mercury 71900
ug/L
X
K-Potassium 46555
3.0 mg/L
X
Mg -.Magnesium 927
8.7 mg/L
X
Mn-Manganese 1055
61 ug/L
X
Na- Sodium 929
12 mg/L
X
Ni-Nickel
10U ug/L
X
Ph -Lead 46564
10U uga -
Se -Selenium
ug/L
X
Zn_Zinc 46567
150 ug/L
Lab Number : 5G0419
Date Received : 3/1/2005
Time Received : 9:00 AM
Received By : DS
Released By : CG
Date reported : 3/22/2005
0rganochlorine Pesticides
Organophospborus Pesticides
Nitrogen Pesticides
Acid Herbicides
Semivolatiles
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
?L 14.1= Sc-)
err

Re: UIC Inspection for Mark Oliphant on 1/26/2005
1 of3
Subject: Re: UIC Inspection for M"··"' Oliphant on 1/26/2005
From: Detlef Hagge <[e-mail]>
Date: Thu, 10 Mar 2005 12:35:02 -0500
To: Thomas Slusser <[e-mail]>
Thomas,
I resampled the Oliphant well last week. I was only able to sample the influent. Mr. Oliphant was not present when I
sampled and I have talked with him since. I think that there is a chance that he has discontinued the use of the
injection part of system. You will probably see the results before I do. If you would be so kind as to let me know
what they, are that would be great. The Oliphants are eagerly waiting the results as they also use this well for
drinking.
detlef
Detlef Hagge
NC DENR Winston-Salem Regional Office
Division of Water Quality, Ground Water Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone] ext 335
FAX: [phone]
On 2/23/2005 9:21 AM, Thomas Slusser wrote:
Hi Detlef,
Resampling for lead sounds like a good idea. We should make sure there is indeed a problem before we ask the
homeowner to do something about it. Thank you for your help with this!
-Thomas.
Detlef Hagge wrote:
There are two different kind of people in our office; Those who have never had anything lost by the lab and
therefor don't make copys. Those who have had the lab lose something and diligently make copys of everything. I
fortunately (unfortunately in this case) have never had the lab lose anything. Usually on the forms that I get back
from the lab the original field fom1 is stapled to it and that is sole location of the missing data. I have yet to
receive any results so there is a chance that I will get the info in the mail shortly.
I don't think that I switched the samples unless my definitions of effluent and influent are switched. Effluent is
what gets pumped back into the grow1d?
It sounds as though I should go and resample to resolve the lead issue.
detlef
Detlef Hagge
NC DENR Winston-Salem Regional Office
Division of Water Quality, Ground Water Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone] ext 335
FAX: [phone]
On 2/21/2005 3: 11 PM, Thomas Slusser wrote:
4/5/2005 2:30 PM
COUNTY : GUILFORD
QUAD NO:
DIVISION OF WATER QUALITY
Chemistry Laboratory Report I Ground Water Quality
SAMP1 F. PRIORITY
El ROUTINE EMERGENCY
REPORT TO : CO Regional Office ❑ CHAIN OP CUSTODY
COLL LI Cr0R(5) : D HAGGE
DATE: 1/26/2095
TIME: L - i Z p,1
PURPOSE:
LABORATORY ANALYSIS
BOD 310
mg/L
COD High 340
mJL
COD Low 335
m
Coliform: MF Fesa131616
Il00ml
Coliform: MF Total 31504
I I00m1
TOC
mg/1
Turbitity
NTU
Residue.. Suspended 530
mgfL
Total Suspended solids
mg/L
pH
units
Alkalinity to pH 4.5
mg/L
Alkalinity to pH 8.3
mg/L
Carbonate
mg/L
Bicarbonate
mg/L
Carbon dioxide
mg/L
X
tlloride
5U
mg/L
Chromium: Flea 1032
ug/L
Color. True 80
e.u.
Cyanide 720
mg/L
COMMENTS
E SAMPLE TYPE
Owner.
Location or Site:
Description of sampling point
Sampling Method:
Remarks:
MARK 01.1PH ANT
EF
X
Diu. Solids 70300
200
mg/L
Fluoride 95!
mg/L
Hardness: total 900
mg/L
Hardness: (non-carb) 902
m
Phenols 32730
ug/1.
Specific Cond. 95
umhos/cm2
Sulfate
mgfL
Sulfide 745
mg/L
MBA
mg/L
Oil and Grease
mg/L
Silica
mg/L
Boron
Formaldehyde
mg/L
NH3 as N 610
mg/L
TKN as N 625
mg/L
NO2 +NO3 as n 630
0.25
mgfL
P: Total as P 665
mgfL
PO4
mg/L
Nitrate (NO3 as N) 620
mg/L
X
Nitrite (NO2 as N) 615
mg/L
Ag-Silver 46566
ug/L
X
Al -Aluminum 46557
50U ug/L
As -Arsenic 46551
ug/L
Ba-Barium 46558
ug/L
X
Ca -Calcium 46552
47 mg/L
Cd-Cadium 46559
ug/L
X
Cr-Chromium 46560
25U ug/L
X
Cu- Co 1042
95 ug1L
X
Fe- Iron 1045
50U ug/L
Hg- Mercury 71900
uglL
X
K-Potassium 46555
2.9 mg/L
X
Mg- Magnesium 927
8.9 milt.
X
Mn-Manganese .1055
57 uglL
X
Na- Sodium 929
12 mg/L
X
Ni-Nickel
10U ug/L
X
Ph -Lead 46564
10U ug/L
Se -Selenium
ug/L
X
Zn_Zinc 46567
95 ug/L
Lab Number : 5G0159
Date Received : 1/27/2005
lime Received : 9:00 AM
Received By : DS
Released By : JC
Date reported : 2J17/2005
0rganochlorine Pesticides
Organophosphoru8 Pesticides
Nitrogen Pesticides
Acid Herbicides
Scmivolatiles
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
_
So "3!i_
5G0159.xis

COUNTY : GUILFORD
QUAD NO:
REPORT TO : CO
COLLECTOR(S) : D HAGGE
DATE: 1126/2005
TIME: 12t ; .ffen
PURPOSE:
��t R 49
= 12.w°C
LABORATORY ANALYSIS
Regional Office
BOD 310
mg/L
COD High 340
mg/L
COD Law 335
mg/L
Coliform: MF Fecal 31616
1100m1
Coliform: MF Total 31504
1100m1
TOC
mgll
Turbitity
NTU
Residue.. Suspended 530
mg/L
Total Suspended solids
mg/L
PH
units
Alkalinity to pH 4.5
mg/L
Alkalinity to pH 8.3
mull.
Carbonate
mg/L
Bicarbonate
mg/L
Carbon dioxide
wgfL
X
Chloride
5U
mg/L
Chromium: Hex 1032
ug/L
Color. True 80
c.o.
Cyanide 720
mg/L
COMMENTS :
DIVISION OF WATER QUALITY
Cbemistry Laboratory Report 1 Ground Water Quality
SAMPM.R PRIORITY
EROUT1NEEMERGENCY
CHAIN OF CUSTODY
W❑ SAMPLE TYPE
Owner-
Location or Site:
Description of sampling point
Sampling Method:
Remarks:
MARK OLIPHANT
IN
X
Diss. Solids 70300
200
mglt.
Fluoride 95I
mg/L
Hardness: total 900
ru /l
Hardness: (non-carb) 902
mg/L
Phenols 32730
ug/L
Specific Cond. 95
umhoslcm2
Sulfate
mg/L
745
mg/L
rsulfide
MBAS
mg/L
Oil and Grease
mgIL
Silica
mg/L
Boron
Formaldehyde
mull.
NH3 as N 610
rng/L
TKN as N 625
mg/L
X
NO2 +NO3 as n 630
0.25
mg/L
P: Total as P 665
mg/L
PO4
rug/L
Nitrate (NO3 as N) 620
mg/L..
Nitrite (NO2 as N) 615
mg/L
Ag-Silver 46566
ug/L
X
Al -Aluminum 46557
50U ug/L
As -Arsenic 46551
ug/L
Ba-Barium 46558
ug/L
X
Ca -Calcium 46552
47 mg/L
Cd-Cadium 46559
ug/L
X
Cr-Chromium 46560
25U ug/L
X
Cu- Copper 1042
77 ug/L
X
Fe- iron 1045
50U ug/L
Hg- Mercury 71900
ug/L
X
K-Potassium 46555
2.9 mg/L
X
Mg- Magnesium 927
8.7 mg/L
X
Mn-Manganese 1055
55 ug/L
X
Na- Sodium 929
12 mg/1.
X
Ni-Nickel
10U ug/L
X
Pb-Lead 46564
43 ugli
Se -Selenium
u8IL
X
Zn_Ziuc 46567
84 ug/L
Lab Number : 5G0158
Date Received : 1/27/2005
Time Received : 9:00 AM
Received By : DS
Released By : IC
Date reported : 2/17/2005
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
Semivolatiles
TPH-Diesel Range
Volatile Organics (VOA bottle)
TM-i-Gasoline Range
TPIi-BTEX Gasoline Range
1
..i_ !fli + j¢� L'oL_
1t: , = 5-0 "11/L.
5[aat5a.x1e.

GROUNDWATER FIELD/LAB FORM
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
COUNTY : Guilford
QUAD NO: Serial No.
Lat. Long.
REPORT TO : Central Office Groundwater Section UIC
SHIPPED BY : COURIER
COLLECTORS DATE • 1 [26/p5
FIELD ANALYSES TIME: .,: .. __3C
pH 4ce 7. % Spec. o Cond-� at 25°C
Temp.r . _..... :....... .
p �....�... �:� Odors.....:.: he—c't
Appearance —
Field Analysis By:L..
LABORATORY ANALYSIS
BOD 310
mg/L.
COD High 340
mg/L
COD Low 335
mg/L.
colif°rrn: MF Frew 31616
/100m1
Colifsxm: MF Total 3I504
11O0m1
'IOC
mg/1
Turbidity
NTU
Rt,idue, Suspended 530
mg/L
pH
units
Alkalinity to pH 4.5
mg/L
Aikaliniiv to pH 8.3
mg11..
Carbonate
mg/1.
Bicarbonate
mg/L
Carbon dioxide
mg/L.
I
Chloride
me'
Chromium: Hex 1032
KA-
Color. True 80
c.u.
Cyanide 720
mg&
LAB COMMENTS
SAMPLE TYPE SAMPLE PRIORITY
Q Water O Routine
]Soil
❑ Other
❑ Chain of Custody
Emergency
EF
Lab Number•
01
Date Received
Rec'd By:
Other:
Time:
From: Bel Oi n s , Hand Helm,
Data Entry By:
Data
Reported:
Ck:
Purpose: Baseline, Complaint, Compliance, LUST, Pesticide Study, Other UIC RESOURCE EVALUATION
Owner. Mark Oliphant
Location or Site: 1 aSci
Description of sampling point
Sampling Method:
Remarks:
E\ew
Effluantjsorce well)
_ GRAB
(Pulp. weer. )
S!'.` N"e.S 17 L4' L! ,� C
Sample Interval:
a
Dist Solids703t10
ingot
Fluoride 951
m g/l.
z
f
Hardness: total900 !L5
S
mg/1.
9
w Hardness: (nonarb)902 999
mWL
Phenols 32730
ug/L
spedrrcCoed. 95
umboda 2
Sulfate
m3/L
Sulfide 745
g/L
mg/L
Oil and Grease
mg/L
S1r.1CA
mg/L
NH3 as N 610
me.
MN as N 625
mg/L
z
ND2+NO3 as N 630
mg/L
P: Total as P 665
rngll.
Nitrate (NO3 as N) 620
m$/L
Nitrite (NO2 as N) 615
nng/L
;Pumping Timm, w romp.. etc.)
As -Silver 46566
WA-
■
Al-Alumimnm 46557
ug/L
As-Arsenic46551
u&R.
Ra-Barium 4655E
ug/L
a
Ca -Calcium 46552
mat
Cd-Callum 46559
ug/.
z
Cr-Chrsmium 46560
Le-
a
Co- Copper 1042
41-
z
Pe- Iron 1045
ug/L
Hg- Mercury 71900
ug/L
I
K-Pplasrsium 46555
mg/L
z
Mg- Magnesium 927
mg/L
1
Mn-Manganese 1055
u8R.
z
Nis- Sodium 929
mg/L
z
Ni-Nickel
4 -
z
Pb-Lead 46564
ug1L
Se -Selenium
u*tL
z
in -Zinc 46567
ng*I,
Organochlorine Pesticides
Organnpbosphmus Pesticides
Nitrogen Pesticides
Acid Herbicides
Snnivolatites
TPH-Diesel Range
Volatile Organics r VOA bottle)
TPH-Gesolirie Range
TPH-DTEX Gasoline Range
LAB USE ONLY J
TEMPERATURE 0 AAL:
GW-54 REV. 7103 FOR DISSOLVED ANALYSIS - SUBMIT FILTERED SIMPLE AND WRITE "D1S"IN BLOCK

RECEnlE°/ DENR1 DWO
AQUIFER PROTECTION SECTION
FEB 2 3 2005
GROUNDWATER FIELDILAB FORM
COUNTY : Guilford
QUAD NO: Serial No.
Lat. Long,
REPORT TO : Central Office Groundwater Section WC
SHIPPED BY : COURIER
COLLECTOR(S) :o,
FIELD ANALYSES
pH400 _ 1
Temp. -
Appearance
Field Analysis By:` Name
IMF
North Carolina
Departrnent of Environment and Natural Resources
DIVISION OF WATER QUALITY • GROUNDWATER SECTION
SAMPLE TYPE SAMPLE PRIORITY
x❑Water Routine
Elsa nEmergency
❑ Other
❑ Chain of Custody
6 DATE:.'U25/a5 Purpose:
TIME: 4 2 3a Owner.
Baseline, Complaint, Compliance, LUST,
Mark Oliphant
Spec. Cond.g, at 25°C Location or Site:
12 1
Odor vva Description of sampling point
Sampling Method:
Remarks:
LABORATORY ANALYSIS
50D 310
rnpjl.
COD High 340
reg/1_
COD Low 335
mg/L
Coliform- MF Fecal 3t616
/100mi
Coliform: MF Total 31504
/100m1
-roc
mg/1
Turbidity
NTH
Residue., Suspended 530
mg/L.
pi{
units
Alkalinity to pH 4.5
mg1
l
Alkalinity to pH 83
mgll.
Caonate
mg/L1rb
Bicarbonate
m$IL
Carbon dioxide
mg/L
x
Chloride
mtel
Chromium: 13es 1032
ug/L
Color- True 8p
Cyanide 720
raga.
LAB COiti'IMF N TS :
Influent
Pesticide Study,
icy
Lab Number G
Date Received rrr Time: I : 7?2
Rec'd By: From: Bu -Cot rie Hand Del„
Other:
Data Entry By:
Data
Reported:
Other UIC RESOURCE EVALUATION
Gt e 5
to -1 V1 Ili C
Ck:
GRAB
(Pump, ndr. r. eX)
Sample Interval:
IPumong Time, Ayr Term.. etc-)
s
Diss. Solids 70300
me/L
Fluoride 951
mg/L
s
Hardrass: total 900 Ns 105
mg/L
Hardness: (non-xrbl i102
mg/L
Phenols 32730
ug/L
SpecirtcCoed 95
mhos/urn-2
Sulfate
mglL
Sulfide 745
mglL
mg/L
Oil and Grease
mg/L
SILICA
mgll..
NH3asN610
mg/L
T1CN as N 625
mg&
NO2 +NO3 as N 630
mg/1-
P. Total as P 665
mg/L.
Witrale (NO3 as H) 620
mg/L
Nitrite (NO2 as N) 615
tng/4
Ag-Silver 46566
ug/L
Al -Aluminum 46557
ug/L
As -Arsenic 46551
ug/L
Ha- Barium 46558
ugli..
x
Ca -Calcium 46552
mg/1.
Cd-Cadium 46559
ug/l,
x
Cr-Chromium 46560
ug/L.
x
Cu- Copper1042
ug/L.
x
Fe- Iron 1045
u.1
Hg- Mercury 71900
ug/I-
x
IC -Potassium 46555
m 1L.
s
Mg- Magnesium 927
mg/L
.
Mu -Manganese 1055
ug/l.
x
Na- Sodium 929
mg/L
x
Ni-Nickel
w/L
x
Pb-Lead 46564
rep/L
Sc-Selenium
vita-
x
Zn-Zinc4656]
uWR_
Organochlorine Pesticides
Oi ganophoephorus Pesticides
Nitrogen Pesticides
Acid licrhrcidcs
Sern1volatiled
Till -Dim' Range
Volatile Organics (VOA bottle)
TPH-Oasolrne Range
TPH-BTF_X Gasoline Range
LAB USE ONLY
t.
TLMPERATURS ON RRIVAL-
GlAL54 REV 7103 FORD:SSOLVEDANALYSIS -SUBMIT FIL.TEREDS4MPI.EAND WRITE Dl.S"IN BLOCK
pe_an_u1e

North Carolii,5epartment of Envirgnment and N; 'al Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. u!I 0110 DATE 1 ' D. - d
NAME OF OWNER M„ / l` p 4 a,`T-
ADDRESS OF OWNER S a,5 y ri„ ,� W I r p So. ►•-) c 5 'taw 4-1C
(Street/ road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable) see
irnet
(Street/ road or lot and subdivision , county, town, if different than owner's address, plus description of location on site)
Potential pollution source .,.a•s
Potential pollution source
Potential pollution source
Distance from well
Distance from well
Distance from well
Minimum distance of well from property boundary ry pp ya 5
Quality
drainage at site _ Flooding potential of site
, adequate, poor)
GPS Data:
Latitude: 3 v S Ci
5 S, D 5i F5
36-'01Y54 1i.2
(high,►noderat
Longitude: 3-147 6 r s J 9 5 a
?.(1$1W8_
DRAW SKETCH OF SITE (Show property boundaries, l rildings, wells, potential pollution sources, roads, approximate scale, and
north arrow.)
DESCRIBE INJECTION SYSTEM MI,ilMttr+))
injection well; combination source and injection we
rncased borehole or cased water well; separate source well a d
cription as applicable)
Ver.3/O1
GW(UIC-2

CONSTRUCTION
Inspection point
Casing
Depth
Diameter
Height (A.L.S.)
Grout
Depth
Screens
Depth(s) '
Length(s)
ate constructed I q
p t, Drilling contractor: Name 1-16,[i \-JeIl 8, th
Address 6c) I ecKx A/c a -?-
Certification number
?-Ot
Total depth of well `2O-0 Total depth of source well
(if applicable)
Measurement Meets minimum standards Comments
Yes No
Lj
C L,
LI/. Plate
Static water level SO
'Well veld
Enclosure
Enclosure floor
(concrete)
Sampling port
(labeled)
Water tight pipe entry
Wel! enclosure entry
Vent
I; 6 taiii
Lf
17
V
..„,--vzovege,w4Vi.794214-iia.,'-
i't.funett?jrn.m.g.o I ea,,,LPul:111)::,Y0.94 Meterniiffrom the owner if heat pump fienctions properly.)
... 44'.7, 43.'-'3&• , e'IVA ; A
, . ed ev Foot. 1 e.
f. :6;ct-17kier.; Rilliec3I6ligtal-e4.-% '. •
*
• , ,
‘,.k. ..
Office `1..) 5 h2 0
'INSPECTOR:A tile ltle,, q f...!.. . •
,wrniEss !:,,,,Ifyil:- , . _.,...`Ac:".•,:or .
,:. Address
-4.1TNESS, .,......... • i t -
' '',;:.-ritt• ,*-.."
0, ' - : A; L.V4E,k; •••
'5
... • N.:2 144 ' 11r —
. .e.,17 '--;•:,,r N' i.. ; - - ' '
dziii:tAddress
GW
el/UIC-2
u. •

REZONING CASE 99-30
Request From: Li 8s R5-9
To: CXI AG
Existing Zoning Boundary
Proposed Zoning Boundary
Scale: 1" = 700'
il6eyi119997pilaeptapr

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
July 22, 2004
To: Sherri Knight, Groundwater Supervisor
Winston-Salem Regional Office
From: Thomas Slusser z:.B
Central Office
Re: Request for review of an injection well application, type SA7 injection well (open loop
water only), submitted by Mark Oliphant, for the construction and operation of a heat
pump injection well system in High Point, North Carolina.
1. Please review the application and submit any comments to CO-UIC group. Retain the
application for your UIC file.
2. Please inspect the injection well site to verify that the location and construction plans
submitted in the application are accurate and that the NCAC Title 15A 2C.0200 ·standards
are being complied with~ using the enclosed Preconstruction Injection Facility Inspection
Report (Form A) as appropriate.
You are requested to return The Review Comments and the completed Preconstruction
Ini ection Facility Inspection Report (Form A ) to the CO-UIC by August 13, 2004. If the
inspection and review can not be accomplished by this date, please let me know.
The UIC group appreciates your assistance with this review. If you have any questions regarding
this review or the UIC program, please contact me at [phone].
cc: CO-UIC Files
Enclosures
AT71.1
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Michael F. Easley, Governor William G. Ross, Jr., Secretary
Alan W. Klimek, P.E., Director
July 23, 2004
Mark L. Oliphant
1259 Eton Place
High Point, NC 27263
Dear Mr. Oliphant:
Your application for a permit to use an existing well to operate a Type 5A7 injection well for the
injection of geothermal heat pump effluent has been received and is under review. A member of
the Winston-Salem Regional Office staff will be contacting you to arrange an inspection of the
injection well site as part of the review.
Please contact me at [phone] or Evan Kane at [phone] if you have any questions
regarding the Underground Injection Control Program, permitting, or injection well rules.
Sincerely,
Thomas Slusser
Hydrogeological Technician II
Underground Injection Control Program
cc: CO-UIC Files
Aquifer Protection Section
1636 Mall Service Center, Raleigh, North Carolina 27699-1636
2728 Capital Blvd., Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] / Internet: http:llgw.ehnr.state.nc.us
An Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper
NonrthCarolina
Naturalli/

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 5QM Wells
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
TO:
A.
DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 7-
SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1) 1
(2)
(3)
Type 5A7 wells inject water used to provide heating or cooling for structures.
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 antifreezes and/or corrosion
inhibitors.
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, Notification Of Intent To
Construct A Closed -Loop Geothermal -Water Only Injection Well System.
B. PERMIT APPLICANT
C.
Name: : c 1C k L • 11 1A.i\+
Address: I 5 gi � t�
City "- It Stair _. Tap Code: b-1- 3 County:
33f0)l-Rt.r.re, 115- ctox- 6 64) �- t .•►,.---b -' r
336 — 461- 6 137 fps; /e] 4..t ti p- 7 ft/
PROPERTY OWNER (if different from applicant)
Name:
"Telephon:
Address:
City: _ _ Sate: Zip Code:
Telephone:
D. STATUS OF APPLICANT
Private:. Federal: Commercial:
Municipal: Native American Lands.
State:
GW-57 HP (Jan, 2000)
County:
Page 1 of4
•
ry

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. HEAT PUMP CONTRACTOR DATA
Name:WW [�
Address:
City: Zip Code: County:
Telephone: - _ _ Contact Person:
G. INJECTION PROCEDURE (Briefly describe how the injection wells) will be used.)
1. i..�: (- lL.k Y\ J L 1 Y r'�'] �� t E �i� LYE' i is -I
((= r' Y�i-1 5 s i x
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
YES NO
YES NO
(1) The injection operation?
(2) Personal consumption?
i. CONSTRUJCTION DATA (check one)
V/ 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 G W-
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-I after construction`. C
(1) Well Drilling Contractor's Name: _ L 1 \,I II �.1 ti. �1 1 1 , j
NC Contractor Certification number: Daly -afo .2 .4- 61
(2) Date to be constructed: 41-4 ; f V. Number of borings:
Approximate depth of each boring (feet):
(3) Well casing: Is the well(s) cased?
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel Ni Black steel.
PIastic Other (specify)
r�
Casing depth: From g A)vioxo Li 1 ft., (reference to land surface)
Casing extends above ground -_ inches
(b) NO
GW-57 HP (Jan, 2000) Page 2 of 4

J.
K.
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cw.rent:}_ Bentonite __ Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
__ around closed loop piping; from __ to __ (feet).
__ around well casing; from __ to __ (feet).
(5) Screens (for Type SA7 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,-t 1he well) lines is requiml. Will there be a Lon:
(a) the influent line? yes __ no__ (b) the effluent line? yes 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: THE WEIL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION JS UNAVAILABLE BY OTHER MEANS.
PROPOSED OPERATING DATA (for Type SA7 wells) )!.._
(1) Injection rate: Average ( daily) 11 gallons per minute (gpm). / (l, \ _ :-0,{'
(2) Injection Volume: Average ( daily) /0 0 gallons per day (gpd). \),. """]~' r_;'t--<f.'
(3) Injection Pressure: Average (daily) 4 0 pounds/square inch (psij'.f'-~~Ct,,
(4) Injection Temperature: Average (January) !:1..5__ ° F, Average (July)5(1_ ° F.
INJECTION FLUID DATA
(1) Fluid source (for Type SA7 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:
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. $r(l;(Z, {3etek, ~Q s Df Fo-on ,
GW-57 HP (Jan, 2000) Page 3 of 4
M. 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 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 permits
(3) Sewage Treatment and Disposal Permits
0. 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, accumte and complete. I am aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting false infonnation. I agree to construct, operate, maintain,
repair, and if applicable, abandon the injection well and all related appurtenances in accordance with
the approved specifications and conditions of the Permit."
@ afdc~~ (ignature of Well Owner or A~ed Agent)
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(s) conforms to the Well
Construction Standards (Title ISA NCAC 2C .0200) d
cs:ill{B/f/£41!:i~~~ Applicam)
GW-57 HP (Jan, 2000)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Page4 of4
REZONING CASE 99-30
Request From: LI & RS-9
To: CU AG
Existing Zoning Boundary
Proposed Zoning Boundary
Department of Planning
and Development
City of High Point
Date:
Scale: 1" = 700'

apsfs ¢s 14444P'. P
So W"iJ 7 Ls
f-k P' p
0
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{
/VVA,J Work,_ SL 6,t i-64sc
Hrb'F ka P )Q#4'« Rck•r,+ r► a It
!oar(sitis)
Wel

HEAT CONTROTLE1?
1 %-6 Tons
Water Source Heat Pumps VPY/HPYNGYIHGY SERIES
High Efficiency Residential Ground Water & Geothermal Models
VPY 1 HPY - (Open Loop)
These units are designed for ground water
applications often referred to as open loop
system with water temperatures that can
vary from 45° to 70°F. Open Loop systems
use 'stable ground water. Minimal
excavating is required minimizing initial
installation costs. The ground water can be
discharged into a lake, stream, pond or returned to the
aquifer where it was removed
VGY 1 HGY - (Closed Loop)
These units are designed for closed loop
applications with entering fluid
temperatures from 30°F to 100°F. Closed
loop systems utilize heat exchangers that
have been designed for practically , any
installation and can be installed /in many different
configurations including vertical, horizontal, pond or lake
loops.
piication
Vertical - VGY 1 VPY
The vertical configurations lend
themselves to closet installations and
easy replacement of conventional fossil
fuel furnace applications.
(Stock units are right hand return)
Horizontal - HGY 1 HPY
The compact nature of the
horizontal systems, available
in capacities ranging from
18,000 Btu to 72,000 Btu, make them ideal in confined
space applications like drop ceiling, crawl space or attic
installations.
(Stock units are right hand return)
Standard Sizes
VPY/HPY - Ground Water
t. Application
VGY/HGY - Ground Loop
(Geothermal) Applicat
on
Btuh
Btuh
Btuh
Btuh
Model
Cooling
EER
Heating
COP
Cooling
EER
Heating
COP
018
19,600
21.1
16,900
4.6
18.300
15.0
13,400
3.7
024
27,000
19.0
22,200
4.3
24,500
15.1
16,200
3.3
030
35,700
18.5
31,100
4.1
32,100
14.2
23,500
3.6
036
37,700
18.E
32,500
4.1
35,800
14.9
24,100
3.5
042
46,000
17.3
39,300
4.0
43,100
14.4
30,000
3.4
048
56,200,
18.0
46,200
4.0
52,000
14.9
35,000
3.5
054*
56,600
17.0
49,900
3.8
54,500
14.9
40,700
3.2
060
, 62,700
17.2
61,800
3.8
60,200
14,1
48,900
3.2
072
83,000
19.0
65,900
4.1
76,300
15.9
55,400
3.7
"VGY and VPY models only.

Supplemental Electric Heaters for VPY and VGY Units
Unit Model
Heater Modal
KW@208/230180/1
018
443-042
3.7515.0
024
443-042
3.75/5.0
443-043
7.5110.0
030
443-042
3.75/5.0
443-043
7.5110.0
036 .
443-042
3.7515.0
443-043
7.5/10.0 '
042
443-0.42
3.7515.0
443-043
7.5/10.0
443.044
11.25115.0
048
443-042
3.75/5.0
443-043
7.5110.0
443-044
11.25115.0
054
443-042
3.7515.0
443-043
7.5110.0
443-044
11.25115.0
060
443-042
3.75/5.0
443-I43
7.5/10.0
443-044
11.25/15.0
443-045
15.0/20.0
072
443-042
3.7515.0
443-043
7.5/10.0
443-044
11.25115.0
443.045
15.0/20.0
Heaters fisted above are Maximum kW applicable per model.
Minimum air flow Is 100 CFM/kW. Heaters are field Installed.
Consult factory for HPY & HGY heaters.
TYPICAL FIELD POWER
WIRING
Typical Field Wiring Connections
CONNrCTION 0AARRAFI YSTM CLICTRIC ++EA•
/.rw.ed UNIT
CV 0 CD 40
1� I�{1
11 11 11 11 '1---LC �_iI_��- -n - 1 _
II �
11 1
tl 1
1l
14
Ij
11
I
11 11 11 11 II �
11 { 11
1 •err^Yr-� N-
r--rr- T r n
i' 1
ii
41, rLEc1R7@ ME*"
AI ZMULT
V
I�
rr I , 1
1 11
11 1 11
11 11
11
it
11�11�11-11-f1� �I:
[RN i • y - vi
R C Y vI v 2 Y2 !
CONNECTION OYAORAI1 WIT.tOL1T CWICTNic Ng&T
NOTE:
ccexclE UNIT
Cooling Correction Multipliers - At Various Entering Air D.B. and W.B. Temperatures
Ent.
Multipliers
Multipliers for Sensible Cool ng
Air
Total
Total
Heat
At Ent. Air Dry Bulb Temperatures
W.B.
Cooling
EER
Watts
Rel.
70
72'
74
76
78
80
82
84
86
88
90
�M 4')1, 63 ell
CO CO CO CO CO I- n
.911
.925
.983
.927
.826
.914
1.003
1.091
1.179
-
-
-
-
-
--
.938
.948
.989
.949
.738
.828
.914
1.002
1; 092
1.182
-
-
-
-
--
.988
.973
.994
.973
.849
.738
.825
.910
1.002
1.091
1.180
1.270
-
-
-
1.000
1.000
1.000
1.000
.559
.646
.734
.824
.911
1.000
1.088
1.175
1.265
-
-
1.035
1.029
1.007
1.029
-
.558
.645
.734
.821
.908
.995
1.084
1.173
1.260
--
1,072
1.057
1.012
1.060
-
-
.555
.642
.730
.816
.902
.990
1.079
1.167
1.255
1.108
1.087
1.019
1.092
-
L -
-
-
.639
.724
.810
.897
.985
1.073
1.161
4

VERTICAL & HOR12.-•"TAL SERIES MODEL 018 WA1 .... -t SOURCE HEAT PUMPS
SPECIFICATIONS VPY/HPY VGY/HGY
Rating Conditions: 650 SCFM -4.9 GPM -208,265-1-60 Ground Water
COOLING BTUH @ 80.6/66.2°F ENT Air, 59°F ENT LIQ. 19,600 -
EER 21.1 -
HEATING BTUH @ 68/59°F ENT AIR, S0°F ENT LIQ. 16,-900 -
COP 4.6 -
Rating Conditions: 65~ SCFM -4.9 GPM -208,265-1-60 Ground Loop ·•
COOLING BTUH @ 80.6/66.2°F ENT Air, 77°F ENT LIQ. -18,300
EER -15.0
HEATING BTUH@ 68/59°F ENT AIR, 32°F ENT LIQ. -13,400
COP -3.7
SERVICE Voltage-Phase-Hz 115-1-60 208/230-1-60 265-1-60
..J Rotary {Qty.) 1
c(
COMPRESSOR RLA 7: 1 5.6 u -
i2~ ,J' LRA -38.0 32.0 .... <C
~c Name Plate Amps -2.0 1.6
..J ¼HP w FAN MOTOR Unit Minimum Circuit Ampacity -10.9 8.6
Max. Time Delay Fuse or HACR Breaker -15 15
Face Area -Sq. Ft. 1.83
INDOOR AIR COIL Alum. Rows Deep -Fins per Inch 3-14 Fins on Rifled Copper
<C Tubes Refrigerant Control {Qty.) HGV, HPY, VGY,VPY -TXV ~ 0
..J EVAPORATOR BLOWER DWDI, Dia." x Width" {Qty.) 9x7
c( u COAXIAL WATER COIL Connections FPT {Qty.) ¾ (2)
ii.i CONDENSATE DRAIN Size -FPr (Qty.) ¾ (1) ► :c
0.. FILTERS: Disposable Type Standard Size (Qty.) 16x20x1 (1)
WEIGHTS (Base UnltOnly) Unit Only VPYNGY-185 I HPY/HGY-166
Shippi_ng Weight{lbs) VPY/VGY-192 I HPY/HGY-177
Rated in accordance with ARI Std. 13256-1
BLOWER PERFORMANCE (CFM)
Available External Static Pressure (ln.H20 Including allowance for wet coil and 1" filter)
Fan Speed .10 .20 .30 .40 .50 .60 .70 .80 .90 1.0 1.1 1.2
· HIGH 770 700 680 650 610 570 530 ----
MEDIUM 670 650 615 570 530 -- - - ---
LOW 560 520 510 ---- --- --
Condenser Water Flow Data Coolin a Performance Correction Factors
Cooling Pressure Dro p Total Watts Heat Sensible
Cycle GPM PSI Ft.HD. Capacity Input Rejection Capacity ·EER
Desi g n AT BTUH BTUH BTUH
80 5.5 11.2 25.9 1.004 0.995 1.003 1.002 1.010
10° 4.9 8.7 20.1 1.000 1.000 1.000 1.000 1.000
12° 4.3 6.7 15.4 0.994 1:009 0.996 0.996 0.986
14° 3.6 4.8 11.1 0.986 1.020 0.990 0.994 0.967
16° 3.0 3.3 7.5 0.979 1.031 0.985 0.984 0.953
20° 2.4 2.0 4.6 0.956 1.058 0.975 0.982 0.904
7
VERTICAL & HORILJNTAL SERIES MODEL 036'WA11..R SOURCE HEAT PUMPS
SPECIFICATIONS VPY/HPY VGY/HGY
Rating Conditions: 1200 SCFM -8.6 GPM -208,265-1-60 Ground Water
COOLING BTUH @ 80.6/66.2°F ENT Air, 59°F ENT LIQ. 37,700 -
EER 18.6 -
BTUH @ 68/59°F ENT AIR, 50°F ENT LIQ. 32,500 -HEATING
COP 4.1 -
Rating Conditions: 1200 SCFM -8.6 GPM -208,265-1-60 Ground Loop
COOLING BTUH @ 80._6/66.2°F ENT Air, 77°F ENT LIQ. -35,800
EER -14.9
HEATING BTUH @68/59°F ENT AIR, 32°F ENTUQ. -24,100
COP -3.5
SERVICE Voltage-Phase-Hz 208/230-1-60 265-1-60 208/230-3-60 460-3-60
...J Reciprocating (Qty.) 1
<C COMPRESSOR RLA 14.2 8.7 S:? <C -It -
~~ LRA 73 -.~ 68 -fdC Name Plate Amps 4.4 -4.4 -...J ½HP w
FAN MOTOR Unit Minimum Circuit Ampacity 22.2 -15.3 -
Max. Time Delay Fuse or HACR Breaker 35 -20.0 -
Face Area -Sq. Ft. 3.5
INDOOR AIR COIL Alum. Rows Deep -Fins per Inch 3-14 Fins on .Rifled Copper
i Tubes Refrigerant Control (Qty.) HGY, HPY, VGY, VPY -TXV
...J EVAPORATOR BLOWER DWDI, Dia." x Width" (Qty.) 9x7 <C
CJ COAXIAL WATER COIL Connections FPT (Qty.) ¾ (2) ;;
CONDENSATE DRAIN Size -FPr (Qty) ¾ (1) -► :c FILTERS: Disposable Type Standard Size (Qty.) VPY/VGY-24x24x1 (1) HPY/HGY-18x30x1 (1) Q.
WEIGHTS (Base Unit Only) Unit Only VPYNGY-245 HPY/HGY-240
Shipping Weight(lbs) VPYNGY-250 HPY/HGY-260
Rated in accordance with ARI Std. 13256-1
BLOWER PERFORMANCE (CFM)
Available External Static Pressure (ln.H20 including allowance for wet coil and 1" filter)
Fan Speed .10 .20 .30 .40 .50 .60 .70 .80 .90 1.0 1.1 1.2
HIGH 1500 1440 1370 1290 1210 1120 1000 900 ----
MEDIUM 1410 1350 1290 1220 1150 1060 900 -----
LOW 1290 1250 1200 1150 1080 1000 --- ---
Condenser Water Flow Data _Cooling Performance Correction Factors
Cooling Pressure Drop Total Watts Heat Sensible
Cycle· GPM PSI Ft.HD. Capacity Input Rejection Capacity EER
Desi gn AT BTUH BTUH BTUH
so 10.6 7.2 16.6 1.005 0.987 1.002 1.001 1.018
10° 8.6 4.7 10.9 1.000 1.000 1.000 1.000 1.000
12° 7.1 3.1 7.2 0.987 1.012 0.992 0.996 0.975
14° 6.1 2.3 5.4 0.973 1.025 0.985 0.992 0.950
16° 5.3 2.0 4.6 0.960 1.037 0.977 0.988 0.926
20° 4.3 1.2 2.8 0.958 1.054 0.973 0.980 0.910
13
N