WI0400088_GEO THERMAL_20120523

r,4~-;;;;-;;-;,,____ --
NCDENR _--_____ .
North-Carolina·-0epartme-nlof Environment-and-Natural Resources-~--
Division of-Water Quality --
Beverly Eaves Perdue
Governor
Marianne Janssen-
104 Oakview Drive
Elon, NC 27244
Charles Wakild, P. E.
·Director
May 23, 2012
N ot1fication-of RitlifRevisions·Affecting--·
Closed-Loop Geothermal-Injection-Well Permit Holders
Permit Number: WI0400088
Dear Ms. Janssen:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop ge·othermal injection well
system.' This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you tl1at your closed-loop geothen11-al injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and ·are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http://portal.ncdenr.org/web/wq/aps.
If you have any questions regarding your-current permit or the rule -revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.O.
Hydrogeologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
LocatiQn: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affim1alive Action Employer
One ·-
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North Carolina Department of Environment and Natural Resources
March 22, 2012
Marianne Janssen
104 Oakview Dr,
Elon, NC 27244
Ref: Issuance of Injection Well Permit WI0400088
Issued to Marianne Janssen
Eton, Alamance Countv
Dear Ms. Jenssen:
In accordance with the application received on March 6, 2012, 1 any forwarding permit number WI0400088 for the
continued operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system located at the above
referenced address. This permit shall be effective from the date of issuance until February 28, 2017, and shall be subject
to the conditions and limitations stated therein.
NOTE: During the renewal process for this permit, it was noted that the following records were not submitted when the
geothermal wells were originally installed.
• Well Construction Record (GW-1)
• Triangulation Data
+ Mechanical Integrity Pressure testing data (if available)
Also, please pay special attention to Part V.2. The Permittee shall retain all records of repairs, pressure tests,
maintenance, and other activities needed to maintain normal operating conditions.
In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an application
to renew the permit 120 days prior to its expiration date. This permit is not transferable to any person without prior notice
to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or [e-mail] if you have any questions about your permit.
Best Regards,
i �-
Michael Rogers, P.G (NC & FL)
cc: Sherri Knight, Winston-Salem Regional Office
WI0400088 Permit File
Alamance County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Servipe Center, Raleigh, Nadh Carolina 27699-1635
Location: 512 N. Salisbury 5t., Raleigh, North Carolina 27604 One
Phone: [phone] FAX: [phone]% NQ 'ra�l�Crarohna
]ntemet:wwwcw ,neteroualitV.aro
An Equal Opportunity I AffirmOve Action Employer �tLi

NORTH. CAROLINA
ENVIRONMENTAL MANAGEMENT COM.MISSION
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In ac~ordance with the provisions of Article 7, Chapter 87; Article 21, Ghapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Marianne Janssen
FOR THE OPERATION OF 5. (FIVE) TYPE SQM INJECTION WELL(S), defined in Title ISA North
Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed-loop
geothermal-mixed-fluid heat pump system. This system is located at 104 Oakview Dr., Elon, Alamance
County, NC 27244, and will be constructed and operated in accordance with the application received March 6,
2012, 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 of an injection well and shall be in complian.c·e with Title 15A North Carolina
Administrative ·code 2C .0100 and .0200, and any· other Laws; Rules, and Regulations pertaining io welf
construction and use.
This permit shall be effective, unless revoked, from the date ofits issuance until February 28, 2017, and shall be
subject to the specified conditions and limitations set forth in.Parts I through VII hereof.
Permit issued this the 22 nd day of March 2012.
J \.charles W akild, P~E., Director ·t Division of Water Quality
By Authority of the Environmental Management Commission.
WI0400088 UIC/5QM-M.F. Renewal
Version i/2010
Page 1 of 4
PART I-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume ·of materials and rate of injection, as
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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.
4. In the event that there are multiple wells with separate clusters, one well identification tag per 'cluster' of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
PART II-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or · failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART III -OPERA TIO NS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or· additions in the permitted facility or activity not specifically authorized by
the perinit.
WI0400088 UIC/5QM-M.F. Renewal
Version 1/2010
Page 2 of 4
PART IV-INSPECTIONS
1. Any duly-authorized _officer, employee, or representative of the Diyision of Water Quality may, upon
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samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have teasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities. · ·
PART V ~·MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed· necessary by the
Division of.·Water · Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting sch:edule shall be followed.
2. The Permittee shall retain all records of repairs, p"ressure tests, maintenance, and other activities'
needed to maintain normal operating conditions. .
3. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Winston-Salem Regional Office, telephone number 336-771~5000, any of the ·
following:
(A) Any occurrence at the. injection facility that results in any unusual operating circumstances;
(B) Any failur_e due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
4. Where the Perrnittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect infonnation submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
5. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VI-PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration o:fthis permit, request an extension.·
WI0400088 UIC/5QM-M.F. Renewal ·
Version 1/2010
Page 3 of 4
PART VII-CHANGE OF WELL STATUS
1. The Permittee shall prov1de written notification within 15 days of any change of status of an injection
'q_rf?H. ~pr>h :-' rl-.0 :1 ~!f' '}-'fl1 JH ;n,,.,_h 1 r1i:: i-J1 e r11c:r:-n~-:1 ir:11 r->(l 1~-::0 0 f ~ V/f"n fr11-· inj ,..,d:nn Tf ~ '\:Uf:'n i ~ t ak Pn
cot np}i;>tc;y :J -It ,Jf s,._:r·J icc: rnri)u1ar:i :y~ tLr~ J\rn11U c c nnt.sl in~1.all a s;-ini tary :;~~:tl. LC ~t \\\'.1} ;~, 1.;.dL tl :: be us i:'.d
.. r1t. ~-·: 1·~/ ::!)/ ).,~ G}'.:.l ·.f ··rl1q /1 (-.... A J(J-~)(i) -.; .... ·f:"'.J}
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 abandonmentprocedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing . operations.
(C) Each well shall be thoroughly disinfected, prior to .sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
· water.
(D) · Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel-packed wells in which the casing and screens have not · been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when,. as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such amanner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part VII (1) and (2) (G) shall be submitted to:
WI0400088
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/5QM-M.F. Renewal
Version 1/2010
Page 4 of 4
F: }gers, Michael
From: Mitchell, Patrick _
Sent: Wednesday, March 14, 2012 3:10 PM
To: Rogers, Michael
Cc: Knight, Sherri
Subject: RE: Wl 0400088 Janssen
Michael,
I will not be conducting a pre -permitting inspection for this one.
Patrick L. Mitchell, LSS
NC DENR - DWQ
Aquifer Protection Section
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [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.
-----Original Message -----
From: Rogers, Michael
Sent: Monday, March 12, 2012 4:16 PM
To: Knight, Sherri; Mitchell, Patrick
Subject: WI 0400088 Janssen
Attached is a 5QM geothermal renewal application. Please let me know if you wish
to conduct a pre -permitting inspection or not.
Thanks
NOTE: On January 6th, the Aquifer Protection Section (APS) is scheduled to move
to the 6th floor of the Archdale Building located at 512 N. Salisbury Street in
Raleigh. ❑ur mailing address will remain the same (1636 Mail Service Center,
Raleigh, NC 27699-1636). If you need to visit APS staff or review files, please
call ❑r email in advance to ensure availability. Please check the APS website
for updates on office numbers and phone numbers as they become available.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist

NC Div of Water Quality-Aquifer Protection Section (APS)
1'6'36 Mail Service Center
Raleigh, NC 27699-1636
Direct Line 919-807-6406
htt p ://portal.ncdenr.org/web /wq/a ps /gwpro /permit-a pp lications#geothermA pp s
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
-~---Original Message-----
From: Jennings, Heather
Sent: Monday, March 12, 2012 3:08 PM
To: Rogers, Michael
Subject: FW:· Scan doc
Just wanted to ·make sure you received this
Heather B Jennings
Nonpoint Source Unit -319 Grant Program NC Division of Water Quality -Planning
Section .
1617 Mail Service Center
Raleigh, NC.27699-1617
[phone] phone
[phone] fax
heather.b.j ennin [e-mail]
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.
-----Original Message-----
From: Michael -Rogers [mailto:[e-mail] ]
Sent: Monday, March 12, 2012 3:06 PM
To: Jennings, Heather
Subject: •
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 03.12.2012 14:06:17 (-0500)
Queries to: [e-mail]
2
WENEWAR
North Carolina department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governer Director
March 7, 2012
Marianne Janssen
104 Oakview Drive
Elon, NC 27244
Dear Ms. Janssen:
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI0400088
Marianne Janssen, SFR
Injection Mixed Fluid GSHP
Well (5QM) System
Alamance County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on March 6, 2012. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Winston-Salem Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section 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
Michael Rogers at [phone] or [e-mail],
Sincerely,
6 U, 6 . 6&V
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Winston-Salem Regional Office, Aquifer .Protection Section
Permit File W10400088
AQUIFER PROTECTION SECTION
1636 Mall Servioe Ow [or. Raleigh, r'torih Carolina 27699-16.36
Location: 512 N. Salisbury St, Rslel h. North Caroil na 27604
Phone: [phone] FAX:[phone]
Internet: wwwnmaterqualily.org
An Equal OppnMn4 I Ormilve Adorn Employer
One
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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 .0200
CLOSED -LOOP MIMED -FLUID GEOTHERMAL INJECTION WELLS
These wells circulate fluids other than potable water as parts of a geothermal heating and cooling system
(check one) New Application ►/ Renewal* Modification
* For renewals complet�:Parts A-C nd the signature rage.
int or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete,
DATE: MhgC t) ,) , 201a_
PERmYr NO. W1 C40WRS (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence V/ Businesslarganization
Government: State Municipal County Federal
B, PERMIT APPLICANT - For individual residences, list each owner on property deed. For all others,
state name of entity and naive of person delegated authority to sign on behalf of the business or agency:
Mailing Address: 1 D q QAKVitAl 1-42W
City: E LLW State: X Zip Code: County:
Day Tele No.:
EMAIL Address:
C. LOCATION OF WELL SITE - Where the injection wells are physiccally located:
(1) Parcel Identification Number (PIN) of well site: Lqq3 4 County:
(2) Physical Address (if different than mailing address): SAM A<
City: State: NC Zip Cade:
D. WELL DRILLER INFORMATION p��
Well Drilling�fitxector's Name: T ._ _E
NC Well Drilling Contractor Cerlifsatiq No.:
Company Name:
Contact Person: i1AAg, Address: Aquffer kxft Se*fl
Address:
City: __ Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
GPUMIC 5QM Pemsit Application (Revised 1/20011) Page 1

E. HEAT P 11P CONTRACTOR INFORNL-kTION (if different than driller)
Company Native:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
Zip Code:
F. WELL CONSTRUCTION DATA
Cell No.:
State: County:
Fax No.:
(1) Number of borings to be constructed*: Depth of each boring (feet):
* If existing water supply wells wild be used then provide the information in item (d) Below.
(2) Chemical additives to be used: R-22
Other
Propylene glycol
Ethanol
(other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc):
(4) WelI casing. If the well(s) will use casing then provide the tyke (steel, PVC, plastic, etc.), diameter. depot.
and extent of casing appearing above ground:
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite** Other (specify)
**By selecting bentonite grout, a variance is hereby requested to I5A N1 AC 2C ,0213(d)(f )(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from to (feet)
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS — Maps trust be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1)
(2)
Attach a site -specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites. drain fields, or repair areas
* Existing or potential sources of groundwater contamination
Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lutes and structures can be
obtained and downloaded from rite 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.
GPUIUIC 5QM Permit Application (Revised 1124/2011) Page 2

H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1, for a corporation: by a responsible corporate officer;
2, for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3, for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the propei deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
`'I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. F 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." 10
V. -
__.S�Pat a re' Vr rtvowner/ pplie t
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECENECI)ENMWQ
MAR 0 6L';,
Aquifer Pmwcbon Section
GPUfUIC 5QM Permit Application (Revised 1/24/201 t) Page 3

Michael F. Faulty, Governor
William G. Ross Jr., Secretary
North Caroiina Department of Environmen t rind Natural Resources
Colecn Sullins, Director
Division of Water Quality
January 10, 2008
Dwayne Akers
Akers Custom Comfort
128 Garden Drive
Stokesdale, NC 27357
Subject: Geothermal Well Installation Data
Dear Mr. Akers:
In review of our records concerning closed -loop geothermal mixed -fluid injection well systems,
classified as 5QM type permits, we have found the following records have not been submitted
for permits where your company is listed as the heat pump installers:
Well Construction Record (GW-1)
Triangulation Data
Mechanical Integrity Pressure or Vacuum/Leak testing data
In order to assist your clients (those who hold 5QM permits) in meeting the condition of their
permits, we request your assistance to provide the above information no later than February 29,
2008, For future reference, we recommend you provide this information to your clients as soon
as construction is complete to assist therm in meeting the condition of their permits. Also, please
remember their permits require them to keep this information on -site as well.
To assist you, we have attached a list of permits where you are lasted as the heat pump installer.
We have also attached a form to fill out the results of your mechanical integrity tests. Thank you
in advance for your cooperation and timely response. If you have any questions regarding this
letter, please call me at [phone] or Michael Rogers at [phone].
Sincerely,
Debra J. Watts
Environmental Supervisor
Groundwater Protection Unit
Attachment(s)
cc: APS Central Files (copy to each permit file on attached list)
Each Permittee on attached list
Aquifer Protection Section 1636 Mail Service Center
Internet: Location 2728 Capital Boulevard
An Equal OppottuOylAifirmOve Action Employer— 50% Recycledl10% Post Consumer paper
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Caro ina
Unl z1f
Raleigh, NC 27699-1636 Teiephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: (919) 7 15-6048
Customer Service: (877) 6234748

Issued Permits with Akers Custom Comfor1 Listed as Heat Pu.mp Contractor
January 10, 2008
Permit No. Name Date Permit Issued
WI0400038 Charles Collins · 4/14/2004
WI0400039 Jason Mohorn · 4/14/2004
WI0300103 Joan Summerha ys , 2/15/2005
WI0300109 Dan Hurlbut · ·3131/2006
1 WI0400088 Marianne Janssen 8/13/2007
WI0300119* David Revelle 11/27/2007
*Permit recently Issued.
/
Mechanical Integrity Test Record
(For SQM Geothermal Heat Pump Injection Well System) .
Owner/PermitteeName: PermitNumber: WI ----------------~-----
Facility Address: ____________________________ _
Home Phone: Cell Phone: ----------------=-=:=...:::;.-==-==-------------
Heat Pump Contractor Name: _________________________ _
Office Phone: Cell Phone: ________________ ..;;;....;..=--:--==..:=..;;;...;_. __________ _
Tester Name: ______________ Signature: ______________ _
Date of Test: --------
Loop Initial Pressure (p si) Final Pressure (p si) Duration (minutes)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Any additional loop testing add to back of this form
Comments:
Pass (Y es or No)
--------------------------------
Other Test Methods and Results:
This form must be filled out and signed by the tester. The record must be received by Aquifer Protection Section 24 hours
prior to the initiation of the operation of the facility. You can send the form by mail: UIC Program, Mail Service Center 1636,
Raleigh, NC 27699 or by fax: [phone] .
Mechanical Integrity Test Form 11/2007
Permit Number WI0400088
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael. rogers
Permitted Flow
Fa cilit
Facility Name
Marianne Janssen, SFR
Location Address
104 Oakview Dr
Elon
Owner
Owner Name
Marianne
Dates/Events
Orig Issue App Received
05/07/07
NC 27244
Janssen
Draft Initiated
Scheduled
Issuance
Central Files: APS_ SWP_
08/28/07
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Alamance
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Marianne Janssen
104 Oakview Dr
Elon NC
Public Notice Issue
K/JJ/07
Effective
27244
Expiration
-i/11/t<
_R_e~g_u_la_t_ed_A_c_t_iv_it_ie_s _______________ Re q uested/Received Events
Heat Pump Injection RO staff report requested
Outfall ~J; ·: !
Waterbody Name
RO staff report received
RO staff report received
RO staff report received
Stream Index Number Current Class
05/10/07
08/13/07
08/15/07
08/15/07
Subbasin
Michael F. Essley, Govemor
williarn G. Ross Jr., Secretary
North Carolina Departruent of Envitorunent and Natural Resources
Cohen H. Sullins, Director
Division of Water Quality
August 13, 2007
Marianne Janssen
104 Oakview Drive
Elon, NC 27244
Re: Issuance of Injection Well Permit
Permit No. WI0400088
Issued to Marianne Janssen
Dear Ms. Janssen:
In accordance with your application received May 7, 2007, 1 am forwarding Permit No.
W10400088 for the operation of a "direct expansion" type vertical closed -loop geothermal heat
pump injection well system to be located at 104 Oakview Drive, Elon, Alamance County, North
Carolina 27244, This permit shall be effective from the date of issuance until July 31, 2012, and
shall be subject to the conditions and limitations staters therein.
Pay special attention to the well construction standards in Parts II and V of your permit.
You must notify this office (Raleigh Central Office) and the Winston-Salem Regional Office at
least forty-eight (48) hours prior to constructing the system, and forty-eight (48) hours prior to
initiation of the operation of the system.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit
an application to renew the permit three months prior to its expiration date. As indicated in the
permit, this permit is not transferable to any person without prior notice to, and approval by, the
Director of the Division of Water Quality. If you have any questions regarding your permit or
the Underground Injection Control Program please call Mr. Qu Qi at [phone] or me at
[phone].
Best Regards,
Michael Rogers
Environmental Specialist
cc: Sherri Knight — Winston-Salem Regional Office
Central Office File — W10400088
Whitney Battestilli/Andrew Messer — Effecta Solutions
Attachment(s)
One
Np Carolina
Naiurrr!!{1
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 21699-1636 Telephone' [phone]
Internet: htm:l/www.ncwaterauaiitv.org 2728 Capital Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
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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
Marianne Janssen
FOR THE CONSTRUCTION AND OPERATION OF 5 TYPE. 5QM INJECTION WELLS,
defined in Title 1.5A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of
operating a "direct expansion" type vertical closed -loop geothermal mixed -fluid heat pump
system. This system is located at 104 Oakview Drive, Eion, Alamance County, North Carolina,
and will be constructed and operated in accordance with the application received May 7, 2007,
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 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, unless revoked, from the date of its issuance until July 31, 2012,
and shall be subject to the specified conditions and limitations set forth in Parts I through IX
hereof
Permit issued this the 1z day of 52007.
y� �Coleen H. Sullins, Director
V Division of Water
Quality
By Authority of the Environmental Management Commission.
Permit No. WI0400088 Page 2

·PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
.criteria specified in Criteria and Standards Applicable. to Injection Wells (1 SA NCAC 2C
.0200). Any noncompliance with conditions of this permit .constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions .of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically conn~ct separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that
are generally subject to flooding include those with concave slope, alluvial or colluvial
soils, gullies, depressions, and drainage ways.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use.· Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well $hall be afforded reasonable protection against damage during
construction and use.
7. Each injection well shall have permanently affixed an identification plate.
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection
well to: . 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
1. Prior:to constructing the injection well system, the Permittee or his agent shall test the pH of
the soil at a depth of three feet at the planned well location. If the resulting soil pH is less
than 6 standard units or greater than 11 standard .units, .the well system shall be equipped with
a compatible cathodic protection system .. All testing results shall be kept on site available for
inspection. ·
2: At least forty-eight ( 48) hours prior to constructing system, the Pennittee shall notify the
Aquifer Protection Section's Underground Injection Control (UIC) Program Central Office
staff, telephone number [phone] and the Winston-Salem Regional Office Aquifer
Protection Section Staff, telephone number [phone].
3. All underground tubing shall be refrigeration grade copper tubing.
Permit No. WI0400088 Page3
4. Prior to installation, all tubing to be placed in boreholes ("loops") shall be checked for leaks
by pressurizing the loop to a gage pressure of at least 350 pounds per square inch (psig),
immersing the loop in water and examining ·it for leaks. Loops with leaks shall not be
installed.
5. Prior to installation, each loop shall be visually inspected for damage such as kinks, dents,
and scrapes. Each loop shall be checked to verify that the nitrogen charge applied to the loop
by the manufacturer before shipping is still present at a pressure of at least 300 psig. The
loop manufacturer shall be notified in the event of damage or pressure loss, and the
manufacturer's instructions shall then be followed. The nitrogen charge may be released
only when the loop is installed and ready to be connected to the manifold.
6. Boreholes shall be large enough to allow insertion of the loop plus a tremie pipe for grouting.
7. After insertion of the tubing into the boreholes, an approved grout (as defined in Title 15A
North Carolina Administrative Code 2C .0100) shall be pumped via tremie pipe into the
annular space of each borehole so as to completely fill it from bottom to top.
8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material
shall have a galvanic potential as close as practicable to that of the tubing material.
9. Dry nitrogen shall be circulated through the tubing during brazing to prevent oxidation.
10. After installation and prior to operation of the system, a mechanical integrity test shall be
conducted by pressurizing the injection well system to 400 psig with dry nitrogen and
monitoring for leaks using an ultrasonic or other leak detector of equal sensitivity and
monitoring pressure in the system for at least 2 hours. Alternatively, an equivalent vacuum
test is acceptable. Any pressure fluctuation other than that due to thermal expansion and
contraction of the testing medium shall be considered a failed mechanical integrity test. Any
leaks shall be located and repaired prior to charging the system with refrigerant. A copy of
the post-installation pressure or vacuum test record (initial pressure reading, final pressure
reading, and the duration of the test) shall be submitted to the Aquifer Protection Section.
The test records must be received by the Aquifer Protection Section at least twenty-four (24)
hours prior to the initiation of the operation of the facility for injection;
11. The location of each of the system manifolds shall be recorded by triangulation from two
permanent features onthe site (e.g., building foundation comers). The Permittee shall retain a
copy of the triangulation records. The Permittee shall also submit a copy of the triangulation
records to the Aquifer Protection Section within 30 days of completion of well construction.
12. The written documentation required in Part II, paragraphs (10) and (11) shall be submitted to:
Permit No. WI0400088
Aquifer Protection Section-DIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Page4
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This perm.it 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 perm.it is not transferable without 'prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there -is a name change of the Pennittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as . may be
appropriate, at least 30 days prior to the date of the change.
3. Th~ 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 regulatoryrequirenients 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 that will render it unsatisfactory for normal .use. In the
event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take _immediate corrective actions including those actions that ·-may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2; The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. Tiie issuance of this permit shall not relieve the Permitteeofthe !esponsibi11tyf~r damages
to surface or groundwater resulting 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
not specifically authorized by the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section's
Underground Injection Control · (UIC) Program Central Office staff, telephone number
[phone], and the Winston-Salem Regional Office Aquifer Protection Section Staff,
Permit No. WI0400088 Page5
telephone number [phone]. Notification is required so that Division staff can
inspect or otherwise review the injection facility and determine if it is in compliance with
permit conditions.
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place
on or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART 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.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Winston-Salem Regional Office, telephone number
[phone], any of the following:
(A) Any occurrence at the injection facility that results m 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;
( C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
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.
Permit No. WI0400088 Page 6.
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
The Pennittee shall, at least 120 days prior to the expiration of this permit, request an
·extension.
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within i 5 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the .Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to· ISA NCAC 2C .. 0213(h)(l), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used f~r any
purpose, the Permittee· shall abandon that injection well.in accordance with the procedures
specified in 15A NCAC 2.C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds . such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire. depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure · to ·do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe, which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
Permit No. WI0400088 Page 7
sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion
of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Permit No. WI0400088
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail-Service Center
Raleigh, NC 27699-1636
Page 8
Name clarification UIC permit
1 of2
Subject: Name clarification UIC permit
From: "Marianne Janssen" <[e-mail]>
Date: Wed, 22 Aug 2007 09:54:39 -0400
To: <[e-mail]>
From: Marianne Janssen
Sent: Wednesday, August 22, 2007 9:51 AM
To: '[e-mail]'
Subject: Name clarification UIC permit
Good morning Mike,
My nick namefs'~t's the name I use on a day to day basis. However, my
official name o~ort and all other formal documents is Johanna Hendrina Maria
Janssen.
I hope this clarifies it. Please let me know if you have any other questions.
Make it a great day.
Marianne
8/22/2007 9:56 AM
Name clarification UIC permit
2 of2
Marianne Janssen, PT, EdD, ATC
Director of Ciinical Education
Department of Physical Therapy Education
Elon University
Elon, NC 27244
jj [e-mail]
336-278-6356
I defen d
BioGems
8/22/2007 9:56 AM
Michael F Easley, Governor
Willlem G Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
May 9, 2007
MARIANE JANSSEN
104 OAKVIEW DR
ELON NC 27244
Subject: Acknowledgement of Application No. WI0400088
Mariane Janssen, SFR
Injection Mixed Fluid GSHP Well System (5QM)
Alamance County
Dear Ms, Janssen
Alan W. Klimek, P.E. Director
Division of Water Quality
Tile Aquifer Protection Section of the Division of Water Quality (the Division) acknowledges receipt of
your permit application and supporting materials on May 7, 2007. This application package has been
assigned the number listed above and will be reviewed by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if
necessary. To ensure the maximum efficiency in processing permit applications, the Division requests
your assistance in providing a tamely and complete response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior
to final action by the Division. Please also note at this time, processing permit applications can take as
long as 60 - 90 days after receipt of a complete application.
If you have any questions, please contact Michael Rogers by phone at [phone] or by email at
[e-mail], If the reviewer is unavailable, you may leave a message, and they will
respond promptly. Also note that the Division has reorganized, To review our new organizational Chart.
go to htti)://h2o.enr,state.nc.us/documents/dwq orgehart.pdf,
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES
ON THIS PROTECT.
�J
Sincerely,
for Debra J. Watts
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Permit Application File W10400088
Aquifer Protection Section 1635 Mail Service Center
Internet: www.nawaterauality.org location: 2728 Capital Boulevard
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AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 8/9/07
To: Aquifer Protection Central Office
Central Office Reviewer: Michael Rogers
Regional Login No:_
County: Alamance
Permittee: Marianne Janssen
Project Name: None (UIC -(SQM) closed loop
Application No.: WI 0400088
L GENERAL INFORMATION
1. This application is (check all that apply): X New D Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
0 Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation X Other Injection Wells (including in situ remediation}
Was a site visit conducted in order to prepare this report? X Yes or D No.
a. Date of site visit: 8/8/07
b. Person contacted and contact information: Dwayne Akers (Akers Custom Comfort) 336-681-8496
c. Site visit conducted by: C. Greene
d. Inspection Report Attached: D Yes or X No.
2. Is the fo11owing information entered into the BIMS record for this application correct?
D Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
RECEIVED/ DENR / owa
AQUIF~R·PRnTFr.TION !iFCTION
AUG 15 2007J
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For Disposal and Iniection Sites:
(If multiple sites either indicate which sites the information applies to, cop and · paste a new section into the
document for each site, or attach additional pages for each site)
a. Location(s): 104 Oakview Dr., Elon, NC 27244-9630
b. Driving Directions: I-AO E. to exit 140 (Elon .University), left at end of ramp. Proceed to 5th stop light to
right (Westbrook Rd.); immediate left on Oakview Rd. to last house on left before stop sign.
c. USGS Quadrangle Map name and number: Gibsonville
d. Latitude: 36°05 '24.90" Longitude: 79°31 '03.l l" (fr. "Google Earth" -source)
IL NEW AND MAJOR MODIFICATION APPLICATIONS (t/iis section not needed for renewals or minor
modifications, skip to next section)
Description Of Waste(S) And Facilities
I. Please attach completed rating sheet. Facility Classification:
FORM: RegionalStaffReportJanssen UIC August 2007
AQUIFER PROTECTION REGIONAL STAFF REPORT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No D NI A. If no, please explain:
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No D NIA. If no, please explain:
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wel1s, surface drainage)? D
Yes D No D NIA. Ifno, please explain:
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No0
NI A. If no, please explain:
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D NIA. Ifno, please explain:
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Ye·s D No D NI A. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV:
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit:
9. Is proposed and/or existing groundwater monitoring program (nomber of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No D NIA. Attach map of existing monitoring well
networ_k if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program:
10. For residuals, will seasonal or other restrictions be required? D Yes D No D NI A If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or maior modification
systems)
Description Of Waste(S) And Facilities
1. Are there appropriately certified ORCs for the facilities? D Yes or D No.
Operator in Charge: __ Certificate#:
Backup-Operator in Charge: __ Certificate #:
2. Is the design, maintenance and operation ( e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D No.
If no, please explain:
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? D Yes or D No. Ifno, please explain:
FORM: RegionalStaffReportJanssen UIC August 2007 2
AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Has the site changed in any way that may affect permit (drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain:
5. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
D Yes or D No. Ifno, please explain:
6. Are the existing application rates (hydraulic or nutrient) still acceptab]e? D Yes or D No. If no, please
exp]ain:
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, exp1ain and recommend any changes to the
groundwater monitoring program:
8. Will seasonal or other restrictions be required for added sites? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, please attach a
map showing conflict areas or attach any new maps you have received from the applicant to be incorporated
into the perm it:
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? D
Yes or D No. Ifno, please explain: __ _
11. Were monitoring wells proper]y constructed and located? D Yes or D No D N/A. If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? D Yes or
D No D N/A. Please summarize any findings resulting from this review: _
13. Check all that apply: D No _compliance issues; D Notice(s) of vio]ation within the last permit cycle; D
Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc): __ _
14. Have all comp1iance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied-with? D Yes
D No D Not Determined D N/A .. Ifno, please explain:
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? D
Yes or D No D N/A. If yes, please explain:
FORM: RegionalStaffR.eportJanssen UIC August 2007 3
AQUIFER PROTECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
D Heating/cooling water return flow (SA 7)
X Closed-loop heat pump system (SQM/SQW)
D In situ remediation (51)
D Closed-loop groundwater remediatfon effluent injection (SL/"Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes X No
3. Are there any potential pollution sources that may affect injection? D Yes X No
What is/are the pollution source(s)? . What is the distance of the iniection well(s) from the pollution
source(s)? ft.
4. What is the minimum di.stance of proposed injection wells from the property boundary? Approx. 25 ft.
5. Quality of drainage at site: X Good D Adequate D Poor
6. Flooding potential of site: X Low D Moderate D High
7. For groundwater remediation systems, is the proposed arid/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: N/ A
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? X Yes or D No. If
no or-no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow. (Very crude drawing submitted, but qualitatively represents
features).
Injection Well Permit Renewal And Modification Only:
.L For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes D No.-If yes, explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes. explain:
3. For renewal or modification of groundwater remediation permits (of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes D No. If yes, explain:
FORM: RegionalStaffR.eportJanssen UIC August 2007 4
. '
AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Drilling contractor: Name:
Address:
Certification number:
5. Complete and attach Well Construction Data Sheet.
FORM: RegionalStaffReportJanssen UIC August 2007 5
AQUIFER PROTECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.: System will consist of a "manifold
pit", located in the approximate center of the front yard of the property; with five (5) diagonal boreholes of
approximately 70' each in depth, and each grouted, leading to two (2) "distributors", also located in the
"manifold pit", connected to a "compressor section" of the system, located on the west side .of the house. The
footprint of the system will be sufficiently small to forgo any removal of tree and shrubbery clearing. There is
neither a well or septic system on the premises (municipal water and sewer are present); no setback issues for
this system. The overland flow is toward the street (southerly, approx. 7% gradient). The system as a whole is
closed loop.
2. Attach Well Construction Data Sheet -if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? D Yes X No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information; X
Issue; D Deny. If deny, please state reasons:
FORM: RegionalStaffReportJanssen UIC August 2007 6
AQUIFER PROTECTION REGIONAL STAFF REPORT
8. Signature ofreport preparer(s): ~C-::'.'.....¾_' ~--~:d~:,._.,j-J.~./~==----------------
J , ,1 J/,~: -) L Signature of APS regional supervisor: ----=---(L-~-=---.....,. .... :;..._Y_._~_~~)1--------=-----'----------------
Date: g /7 /v 7
t t
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: RegionalStaffR.eportJanssen UIC August 2007 7
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 8/9/07
To: Aquifer Protection Central Office
Central Office Reviewer: Michael Rogers
Regional Login No:_
County: Alamance
Permittee: Marianne Janssen
Project Name: None (UIC -(SQM) closed loop
Application No.: WI 0400088
L GENERAL INFORMATION
1. This application is (check all that apply): X New D Renewal
D Minor Modification D Maj or Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
D Attachment B included
0 Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation X Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? X Yes or D No.
a. Date of site visit: 8/8/07
b. Person contacted and contact information: Dwayne Akers (Akers Custom Comfort) 336-681-8496
c. Site visit conducted by: C. Greene
d. Inspection Report Attached: D Yes or X No.
2. Is the following information entered into the BIMS record· for this application correct?
D Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Disposal and Injection Sites:
(If multiple sites either indicate which sites the information applies to. copy and paste a new section into the
document for each site, or attach additional pages for each site)
a. Location(s): 104 Oakview Dr., Elon, NC 27244-9630
b. Driving Directions: 1-40 E. to exit 140 (Elon University), left at end of ramp. Proceed to 5th stop light to
right (Westbrook Rd.); immediate left on Oakview Rd. to last house on left before stop sign.
c. USGS Quadrangle Map name and number: Gibsonville
d. Latitude: 36°05 '24.90" Longitude: 79° 31 '03.11" (fr. "Google Earth" -source)
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications. skip to next section)
Description Of Waste{S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
FORM: RegionalStaffR.eportJanssen UIC August 2007
AQUIFER PROTECTION REGIONAL STAFF REPORT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
0 Yes D No D N/A. Ifno, please explain: __
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No D N/ A. If no, please explain: __
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes D No D N/A. Ifno, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to· the Division. 0Yes0No0
NI A. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D N/A. Ifno, please explain: __
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No D N/A. ffyes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or O No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEW AL AND MODIFICATION APPLICATIONS (use previous section for new· or maior modification
systems)
Description Of Waste(S) And Facilities
1. Are there appropriately certified ORCs for the facilities? D Yes or D No.
Operator in Charge: __ -_ Certificate #:_· __
Backup-Operator in Charge: _. __ Certificate #: __
2. Is the design, maintenance and operation ( e.g. adequate aeration, sludge wasting, sludge. storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D No.
If no, please explain: __
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? 0 Yes or D No. Ifno, please explain: __
FORM: RegionalStaffR.eportJanssen UIC August 2007 2
AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Has the site changed in any way that may affect permit ( drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain: __
5. Is the residuals management plan for the facility adequate and/or acceptable to foe Division?
D Yes or D No. If no, please explain: __
6. Are the existing application rates (hydraulic or nutrient) still acceptable? □-Yes or D No. If no, please
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring progra111:: __
8. Will seasonal or other restrictions be required for added sites? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, please attach a
map showing conflict areas or attach any new maps you have received from the applicant to be incorporated
into the permit: __
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? D
Yes or D No. Ifno, please explain: ____ _
11. Were monitorin~ wells properly constructed and located? D Yes or D No D N/A. If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? D Yes or
D No D N/ A. Please summarize any findings resulting from this review: __ _
13. Check all that apply: D No compliance issues; D Notice(s) of violation within the last permit cycle; D
Current enforcement action( s) D Currently under SOC; D Currently under JOC; D Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc): ____ _
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? D Yes
D No D Not Determined D N/A .. Ifno, please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? D
Yes or D No D N/ A. If yes, please explain: __
FORM: RegionalStaftR.eportJanssen UIC August 2007 3
AQUIFER ·PROJECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two se.ctions for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation.injection wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
D Heating/cooling water return flow (5A7)
X Closed-loop heat pump system (5QM/5QW)
□ In situ remediation ( SI)
D Closed-loop groundwater remediation effluent injection (SL/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes X No
3. Are there any potential pollution sources that may affect injection? D Yes X No
What is/are the pollution source(s)? . What is the distance of the injection well(s) from the pollution
source( s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? Approx. 25 ft.
5. Quality of drainage at site: X Good D ~dequate D Poor
6. Flooding potential of site: X Low D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: N/ A
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? X Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow. (Very crude drawing submitted, but qualitatively represents
features).
Injection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)? .
D Yes D No. If yes, explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or.last inspection? D Yes · D No. If yes, explain:
3. For renewal or modification of groundwater remediation permits (of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes D No. If yes, ·explain:
FORM: RegionalStaffR.eportJanssen UIC August 2007 4
AQUIFER PROTECTION REGIONAL STAFF REPORT
4. 'Drilling contractor: Name: __
Address:
Certification number: __
5. Complete and attach Well Construction Data Sheet.
FORM: RegionalStaftReportJanssen UIC August 2007 5
AQUIFER PROTECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.: System will consist of a "manifold
pit", located in the approximate center of the front yard of the property, with five (5) diagonal boreholes of
approximately 70' each in depth, and each grouted, leading to two (2) "distributors", also located in the
"manifold pit", connected to a "compressor section" of the system, located on the west side of the house. The
footprint of the system will be sufficiently small to forgo any removal of tree and shrubbery clearing. There is
neither a well or septic system on the premises (municipal water and sewer are present); no setback issues for
this system. The overland flow is toward the street (southerly, approx. 7% gradient). The system as a whole is
closed loop.
2. Attach Well Construction Data Sheet -if needed information is available
3: Do you foresee any problems with issuance/renewal of this permit? D Yes X No. If yes, please explain
briefly. __ .
4. List any items that you· would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending .review of draft permit by regional office; D Issue upon receipt of needed additional information; X
Issue;_ D Deny. If deny, please state reasons: __
FORM: RegionalStaffReportJanssen UIC August 2007 6
AQUIFER PROTECTION REGIONAL STAFF REPORT
8. Signature ofreport preparer(s): ___________________ _
Signature of APS regional supervisor: _________________ _
Date: _____ _
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: RegionalStaffR.eportJanssen UIC August 2007 7
Re: [Fwd: UIC Region~l Staff Report,;; Janssen WI 0400088, WSRO]
1 of2
. . .
Subject: Re: [Fwd: UIC Regional Staff Report -Janssen WI 0400088, WSRO]
From: Sherri Knight <[e-mail]>
Date:· Mon, 13 Aug 2007 13:18:44 -0400
To: Micha~! Rogers <[e-mail]>
Signed copy is in the courier -I'm OK with it. I'm looking for Barger.
Sherri Knight, PE
NC DENR Winston-Salem Regional Office
Division· of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
On 8/13/2007 1:01 PM, Michael Rogers wrote:
Sherri-
Debra and I were going over my permit renewal list and have the following questions.
1. Are you OK with the attached report (Janssen)?. We need a signed copy from you.
However, if you are OK with it, just reply to this email and indicate you are OK with
it, and we will not need to wait on signed copy to get to us.
2. Barger (WI0400006). you indicated you had completed the site inspection back in
May, but we never received a written staff report. What is the status of this report?
Thanks
--------Original Message --------
Subject: UIC Regional Staff Report -Janssen WI 0400088, WSRO
Date: Thu, 09 Aug 2007 12:04:47 -0400
From: Chris Greene <[e-mail]>
Reply-To: [e-mail]
Organization: NC DENR -Winston-Salem Regional Office
To: Michael Rogers <[e-mail]>, Sherri Knight
<[e-mail]>
Michael,
Hard copy to follow. I was unable to log-into BIMMS today. Hopefully, the Raleigh
8/13/2007 1 :30 PM
Re: [Fwd: UIC Regional Staff Report-Janssen WI 0400088, WSRO]
2 of2
.. . , .
folks can take care of this aspect of the permit's processing. I have added some
narrative within the Staff Report to supply the necessary information for BIMMS
entry.
Your prompt attention is greatly appreciated in processing this permit.
Thanks, Chris Greene ·
Sherri Knight <[e-mail]>
WSRO
NCDENR
8/13/2007 1 :30 PM
AQUIFER PROTECTION S_EMON
APPLICATION REVIEW REQUEST FORM
Date: Ma\ I0.2007
REMElVED
C• 0W. a1 EHR
,..nston.splrm
Regional ofrCq
! D: ❑ Landon Davidson, ARO-APS ❑ David May, WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Charlie Stehman, WiRO-APS
❑ Andrew Pitner, MRO-APS ® Sherri Knight, WSRO-APS
❑ Jay Zimmerman, RRO-APS
�oF Michael Roeers , Groundwater Protection Unit
Telephone. [phone] Fax: 919�_ ) 715-0588 IRECEWEi1 t �R! Qwa p
R��t��►� 5�I
F-Mail. Michael.Rogerya ncmail.net
A. Permit Number: W110400088
B. Owner: Mariane Janssen
C. Faellity/Operation:
® Proposed ❑ Existing ❑ Facility ❑ Operation
D. AuPlleation:
1. Permit Type: ❑ Animal ❑ SFR-Surface Irrigation❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Remediation (ND)
® UIC - (5QM) closed loop mixed fluid geothermal
For Residuals: ❑ Land App, ❑ D&M ❑. Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type: ® New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the alcove -referenced application for your
review, cornment, and/or action. Within 21 calendar days, please take the following actions;
® Return a Completed APSARR Form.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: �_Ln ��-f�._ Date:
FORM: APSARR 07/06 Page 1 of 1

AQUIFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: May 10, 2007
D Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS
0 Andrew Pitner, MRO-APS
D Jay Zimmerman, RRO-APS
From: Michael Rogers, Groundwater Protection Unit
Telephone: [phone]
E-Mail: [e-mail]
A. Permit Number: WI 0400088
B. Owner: Mariane Janssen
C. Facilitv/O peration: __
1:8:1 ~roposed D Existing
D. App lication:
□ David May, WaRO-APS
0 Charlie Stehman, WiRO-APS
1:8:i Sherri Knight, WSRO-APS
Fax: [phone]
D Facility D Operation
1. Per~it Type: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D l/E Lagoon D GW Remediation (ND)
1:8:1 UIC -(SQM) closed loop mixed fluid geothermal __
For Residuals: D Land App. D D&M D. Surface Disposal
D 503 D 503 Exempt D ·Animal
2. Project Type: 1:8:1 New D Major Mod. D Minor Mod. D Renewal D Renewal w/ Mod.
E. Comments/Other Information: D 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 21 calendar days, please take the following actions:
[gl Return a Completed APSARR Form.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue· an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this -sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above. ·
RO-APS Reviewer: __________________ _ Date: ____ _
FORM: APSARR07/06 Page 1 of 1
ORQF W A?E Michael F. Eastey, Governor
WIIllarn G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
>� ,r
Q ==y^ £ Alan W. Kiimek, P.E. Director
7 Division of Water Quality
May 9, 2007
MARIANE JANSSEN
104 OAKVIEW DR
ELON NC 27244
Subject: Acknowledgement of Application No. W10400088
Mariane Janssen, SFR
Injection Mixed Fluid GSHP Well System (5QM)
Alamance County
Dear Ms. Janssen.
The Aquifer Protection Section of the Division of Water Quality (the Division) acknowledges receipt of
your permit application and supporting materials on May 7, 2007, This application package has been
assigned the number listed above and will be reviewed by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if
necessary. To ensure the maximum efficiency in processing permit applications, the Division requests
your assistance in providing a timely and complete response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior
to final action by the Division. Please also note at this time, processing pen -nit applications can take as
long as 60 - 90 days after receipt of a complete application.
If you have any questions, please contact Michael Rogers by phone at [phone] or by email at
[e-mail]. If the reviewer is unavailable, you may leave a message, and they will
respond promptly. Also note that the Division has reorganized. To review our new organizational chart,
go to http_//h2o.enr.state, nc,usldocumentsldwq orgchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUTRIES
ON THIS PROJECT.
Sincerely,
n
for ❑ebra . Watts
Supervisor
CC: Winston-Salem Regional Office, Aquifer Protection Section
Permit Application File WI0400088
Aquifer Protection Section 1636 Mail Service Center
Internet. www.ncwaterauality.ora Location: 2723 Capital Boulevard
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TO:
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 5A 7 and SQM Wells
In Accordance with the provisions of NCAC Title 1 SA: 02C.0200
Complete application and mail to address on the back page.
DIRECTQ:S., NORTH CAROLINA DNISION OF WATER QUALITY
DATE: 4-ol"' ·, 20 01
RECEIVED I OE~ R / DWQ
AQUJFFR· ;1 SFCTION
MAY O 7 2007J
A SYSTEM CLASSIFICATION Please check column which matches proposed system.
B.
C.
D.
(1) Type 5A7 wells inject water used to provide heating or cooling for structures.
(2) 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.
(3) Type 5QW wells contain a subsurface system of continuous piping, that is
isolated from the environment and only circulates potable water. If you selected
this well type, then complete form GW-S7 CL, Notification Of Intent To
Construct A Closed-Loop Geothermal-Water Only Injection Well System.
PERMIT /~~PLICANT
Name: VVI AfifmE ~SS&J
Address: JOc./: Q.qi;aJlE:W I;k
City: E/a, State: tr_ Zip Code: d-7J.,L/4 County: LJ~
Telephone: 33lo -5'B<J. .. / ~ / 3
PROPERTY OWNER (if different from applicant)
Name: _______________________ _
Address: _______________________ _
City: ________ Sate: __ Zip Code: ___ County: ___ _
Telephone: _______ _
STATUS OF APPLICANT
Private: L Federal:
State: Municipal: __
Commercial:
Native American Lands:
GW-57 HP (Jan, 2000) Page 1 of 4
E. FACILITY (SITE) DATA
F.
G.
H.
I.
(Fill out ONLY if the Status of Owner is Fede~ State, Municipal or Commercial).
Name of Business or Facility: _________________ _
Address: _______________________ _
City: ________ Zip Code: ____ County: ______ _
Telephone: ________ Contact Person: ________ _
HEAT PUMP CONTRACTOR DATA
Name: 8¥-cfS C;•srori [an{;,e:c
Address: I z i C::::r:ii};v\ a
City: Srak£SD.J/..e Zip Code: 7/~S] County: i?xJa;1~
Telephone: ~3<o -"181 ... 1,'/-Cj(p Contact Person: LA.uA<.jt"1t A!e2S
INJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.)
Keffl6ERAAr lcq;s fu2. Dx C:ecrn~r41 lk /14
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES t>l-. NO __ _
(2) Personal consumption? YES ___ NO o<...,
CONSTRUCTION DATA (check one)
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 ofFomt -OW;;.-
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
Fonn GW-1 after construction.
(I) WellDrillingConttactm'sName: ~ -5:ilu:nMS (Snpben kff-4)
NC Contractor Certification number: __ 3~L/~fa~ir----. _____ _
(2) Date to be constructed: 4 54(2 Number of borings: _5=·--
Approximate depth of each boring (feet):_________,_3o"-""'------
(3) Well casing: Is the well(s) cased?
(a) YES Jfyes, then provide the casing information below.
Type: Galvanized steel __ Black steel __ Plastic __ Other (specify) _____ _
Casing depth: From ___ to ___ ft. (reference to land surface)
Casing extends above ground inches
(b) NO +
GW-57HP Qan,2000) Page 2 of 4
( 4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite __ Other (specify) ~
(b) Grouted surface and grout depth (reference to land surface):
-i,__ around closed loop piping; from 6 to -'gD (feet).
__ around well casing; from __ to __ (feet).
(5) Screens (for Type SA 7 wells)
(a) Depth: From __ to __ feet below ground surface.
(6) N.C. State Regulations (fide 15A NCAC 2C .0200) require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent (fluid being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? yes __ noL (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). ff Form GW-1 is not available,
provide the data in part K (I) of this application form to the best of your knowledge.
NOTE: THE WEIL ORR.LING CONTRACTOR CAN SUPPLY THE DATAFOREmmR EXISTING OR
PROPOSED WELLS IF THIS JNFORMATION IS UNAVAILABLE BY OTIIER :MEANS.
J. PROPOSED OPERATING DATA (for Type SA 7 wells)
K.
(1) Injection rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
INJECTION FLUID DATA
(1) Fluid source (for Type SA 7 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: _____ Fonnation: _____ Rock/sediment unit: ____ _
(2) Chemical Analysis of Source Fluid (for Type SQM wells)
PrJvide a com~ete listing of all chemicals added to the circulating heat transfer fluid:
1\-J -:J K6flt~4rr
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.
GW-57 HP (Jan, 2000) Page3 of4
M. LOCATION OF WELL(S) Attach two Wisps.
(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 Iiom 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
O. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
information submitted m 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."
(Signature of Well Owner or Authorized Agent)
tf authorized agent is acting on behalf of the we 11 mmer,
please supply a letter signed liv the oxmer authorizing the above agent
R 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 Elie 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 15A NCAC 2C .0200); ,'
tom -
Owner If Different From Applicant)
Please return two copies of the �4nplc;W Application package to:
MC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW-57 HP (]an, 2000) Page 4 of

(1) Include a site map (Gan 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 neap 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, 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."
_____45ig o ell Owner or Authorized Agent)
If autho ixed agent is acting on beha ff 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 t}te injection well(s) conforms to the Well
Construction Standards (Tide 15A NCAC 2C .0200)
nature p operty Owner If Different From Applicant)
1
Please return two copies of the comic e d Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]

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Alamanee County
p-
r _..
i U451y;20661 i
�. � fi 1 .a 4�/ 8L4i629d17
i
ILON
AN5721587
■
71
aa4572021r .9'
*"SW2A3
�r
Parcel ID
; 8845629399 Year Built
11974
Old Tax #
1 3-30A-22
Building SgFt �~
2303
Ownert ~�
' JANSSEN JOHANNA H
Plat Book Page
Owner2�-
Deed Book Page
1773598
Billing Address
�i 104 OAKVIEW�DR�
_
-Sales Date
, Monday, December 09, 2002
City State Zip
i ELON NC 27244
,
Sales Price $155,fl00
Prope►tyAddress
104 OAKVIEW DR
Bedrooms-,..._,._ 4
Deeded Acres
1 0.5831
Full Bath
Nalf Bath
Z
Market Land Value . $44,577
1
Market Building Value $125,077
Stories
2
Market Total Value
$169,654
Grade
J B
THIS IS NOT A LEGAL DOCUMENT
DISCLAIMER: ALAMANCE COUNTY shall assume no liability for any errors, omissions,
or inaccuracies in the information provided regardless of how caused; or any decision Map Scale
made or action taken or not taken by user in reliance upon any information or data 1 inch = 65 feet
furnished hereunder. The user knowingly waives any and all claims for damages against
any and all of the entities comprising the Alamance County GIS System that may arise
from the mapping data.
http:llwww. alatnmce-nc.cornlalamancegislprintPreview. aspx?PnntOptData=Alatnance%2... 8/20/2007