WI0400114_GEO THERMAL_20120517

AWA~-c __
NCfiEM R:::_-cc=:_--.
North Carolina Department of Environment and . Natural Bes_ources::_ _______ ~-
Beverly Eaves Perdue
Governor
Kenneth Miller ·
300 North Greene Street, Suite 1750
Greensboro, NC 27401
Division of Water-Qualtty
Charles WakildFP-:·E:.-
Director
May 17, 2012
Subject: Notification of Rule Revisicn1s·Affecting ----------
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0400114
Dear Mr.· Miller:
Dee FreemaA
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012;the North 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 letteds also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefmitely 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·you.t current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service· Center, Raleigh, North Ca.rolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affinnative Action Employer
N~rth Carolina
:;vaturall!I
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3971 -A
1. WELL CONTRACTOR:
William B. Jefferson
Well Contractor (Individual) Name
Geo Design Group Inc.
Well Contractor Company Name
10025 HWY 264A - POB 9
Street Address
Middlesex NC 27557
City or Town Stale Zip Code
252 235-2209
Area code Phone number
x. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#W I0400114
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID Cif applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED11120109
TIME COMPLETED12/04109 AM ❑ PM
4- WELL LOCATION:
CITY: Summerfield couNTyGuilford
6367 Lake Brandt Road 27358
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOG • IC 1 LAND SETTING: (check appropriate box)
© Slope ❑ Valle' a Flat ❑ Ridge D Other
LATITUDE 36 o "DMS
LONGITUDE 75 ° " DMS
DD
"-DD
Latitudellongitude source: ❑GPS Dropographic map
(location of well must be shown an a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Kenneth David Miller
Owner Name
6367 Lake Brandt Road
Street Address
Summerfield NC 27358
City or Town State Zip Code
336 272-4400
Area code Phone number
6. WELL DETAILS: I
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 1'
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS NIA FT Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118-
e. YIELD (gpm): NIA ETFHO OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top
Top
Top Bo
7. CASING: Depth
Top Bottom
Top ottom
Top Bo
Bottom
ottom
330422
Top Bottom
Top Bottom
Top Bottom
Thickness)
-NDIameter Weight Material
8. GROUT: Depth Top 0 Bottom r1 O
Top
Top
Bottom
Bottom
9. S EEN: Depth
Top adorn_
Top
Top
10. SAND/GRAVEL PACK:
Depth
Top Bottom
Top Bottom
Top Bottom_
11. DRILLING LOG
Top Bettorp-
(i
1
1
1
1
1
Ft.
Ft.
Ft.
Material Method
FI.Mix Thermex Grout
Ft,Bentonite & Silica
Ft. Sand
Diameter Slot Size
Ft- in. In,
Ft. in, in.
Ft. in, in,
Size
Ft.
Ft.
Ft -
Material
Material
Formation D cription
p.-)r
ji44 2 0.213w[i
WATrr t'�un • nit
InformTion , ::..,., ,.•.
wells turned 4'-5' below grade and grouted bottom to top.
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE i • 15A[ - ° ' ELL CONSTRUCTION
STANDA• 0ND T �A CPY ■ RECORD HAS BEEN
PROVIDED : •E to ,
ERTIFIED W: -L,Ze., CTOR DATE
SIGNATURE
William B. Jefferson
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev, 2/09

fin milhif
eizo 671/ruT
Earthloop Equipment lnfmation
Driling Information
Company Name
Earthloop Installer
Driller/Excavator
Grout installer1er
Project Owner
GRD,G
„_
. D q
I
CDC -_
i
f \ (v a /,`! e y
Address
I ozs- U52. 4R
t oc2._ US2641;
RMLS u5z ff
City, State, ZIP
iYW dd tic NC-
'
f`lLOsIAhe scc Nc.
f lketei .rc-sic MC,
Telephone
025A-a35•4�b7
9;Se9a3s-col
asa-M - -cloy'
Earth Loop Model Number:
CPS Model Number:
Soil pH:
Earth Loop System Seal Test: (400psi( no
Triangulation map attached: (required)
Compresor Start Up Date:
Compressor Unit Model Number:
Compressor unit Serial Number:
�.5
yr_
no
(circle one)
(circle one)
ft
Bentonite Grout
Bags
X-fine silica sand 3 c -r Is Bags
Holes/ollos 1 V
Length/Largo Lupas Sd Feet
Angle/Angulo a 6 Degrees
'iZock<-)
&al))

Mechanical Integrity Test Record
(For 5QM Geothermal Heat Pump Injection Well System)
Owner/Permittee Name: Kenneth David Miller Permit Number: WI0400114
Facility Address: 6367 Lake Brandt Road Summerfield. NC 27358
Home Phone: [phone] Cell Phone:
Heat Pump Contractor Name: Geo Design Crroup Inc.
Office Phone: [phone], Cell Phone:
Tester Name:Signature:
Date of Test: 12 1 L+ Q �(
Loop
Initial Pressure (psi)
Final Pressure (psi)
Duration (minutes)
Pass (Yes or No)
1
400
400
24 krS
yes
2
3
4
1
5
1,
6
7
g
10
11
12
-\
13
14
VI
15
-o Ci
`,
,- 4 h' 5 .
y C$
Any additional loop testing add to back of this form
Comments: All loops held 400 psi for min. of 24 hours.
Other Test Methods and Results:
Prior to install all loops held in water for 5 min.
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 farm by mail: UIC Program, Mail Service Center 1636,
Raleigh, NC 27699 or by fax: [phone].
Mechanical Integrity Test Form 11/2007

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71-

Permit Number WI0400114
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Kenneth David Miller SFR
Location Address
6367 Lake Brandt Rd
Summerfield
Owner
Owner Name
Kenneth
Dates/Events
NC 27358
David Miller
Orig Issue
09/08/09
App Received Draft Initiated
08/06/09
Scheduled
Issuance
Central Files: APS_ SWP_
09/18/09
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Afflllatlon
Anna Jeffreys
PO Box 238
Wendell NC
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Kenneth David Miller
424 Prescott St
Greensboro NC
Public Notice Issue
09/08/09
Effective
09/08/09
27591
27401
Expiration
08/31/14
_R_e_g_u_la_te_d_A_c_ti_v_it_ie_s _______________ "'""R'"""e ...... a-=u-=-es=-t=e-=d""""/R~e~c~e~iv-"-'e"--'d"--=E--'-ve=n=t=s __________ _
Heat Pump Injection Additional information requested
Outfall NJ
Waterbody Name
Additional information received
RO staff report requested
RO staff report received
Stream Index Number Current Class
08/14/09
08/14/09
08/21/09
08/28/09
Subbasin
Permit Number WI0400114
Central Files: APS SWP
09/03/09
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Faci it
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Anna Jeffreys
PO Box 238
Wendell
NC 27591
Facility Name
Kenneth David Miller SFR
Location Address
6367 Lake Brandt Rd
Sumrnerfield NC 27358
Major/Minor Region
Minor Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Name
Kenneth David Miller
Paate,f; E'Vr;r't
Orlg Issue
App Received Draft Initiated
08/06/09
Re elated Activities
Heal Pump Injection
Outfail
Scheduled
Issuance
Owner Type
Individual
Owner Affiliation
Kenneth David Miller
424 Prescott St
Greensboro
NC 27401
Public Notice IsSu Effective Ex irxtl n
este. 1 ece•ved Eve is
Additional information requested
Additional information received
RO staff report requested
RO staff report received
08/ 14109
08/14/09
08/21/09
08/28/09
Waterbody Name Stream Index Number Current Class Subbasin

North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Kenneth David Miller
424 Pre_scott Street
Greensboro, NC 27401
Re: Issuance of Injection Well Permit
Permit No. WI0400114
Issued to Kenneth David Miller
Guilford County
Dear Mr. Miller:
Coleen H. Sullins
Director
September 8, ~009
Dee Freeman
Secretary
In accordance with your application received August 6, 2009, I am forwarding Permit No. WI0400114 for the
operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system located at 6367
Lake Brandt Road, Summerfield, NC 27358. This permit shall be effective from the date of issuance until
August 31, 2014, and shall be subject to the conditions and limitations stated _therein.
Please pay special attention to the following bolded language in the permit:
Per Part I, paragraph 6, please submit copies of the Well Constructi~n Completion form (GW-1)
after construction.
Per Part II, paragraph 2, notify the Winston-Salem Regional Office (Stephen Berry) at (336) 771-
5000 at least 48 hours prior to starting drilling.
Per Part II paragraph 13, 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.
Please submit the data within 30 calendar days_ofreceipt of this letter to the following address:
Aquifer Protection Section (APS)
Underground Injection Control (UIC) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
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 ine at [phone].
Best Regards,
;t;iJ~ i ~
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
cc: Sherri Knight -Winston-Salem Regional Office
Central Office File -WI0400114
Guilford County Environmental Health Dept.
Home Energy Inc. -Anna Jejfi·eys (~s'ent USPS andfaxed)
Attachment(s)
NORTH CAROLLNA
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
Kennett~. David Miller
FOR THE CONSTRUCTION AND OPERATION OF 18 TYPE 5QM INJECTION WELLS, defined in Title
15A 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 6367 Lake
Brandt Road, Summerfield, Guildford County, NC 27358, and will be constructed and operated in accordance
with the application submitted August 6, 2009, 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 of an injection well and shall be in compliance with Title 15A
North Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations
pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until August 31. 2014, and shall be
subject to the specified conditions and limitations set forth in Parts I through TX hereof.
Pennit issued this the 1 f y day of , 2009.
1oleen H. Sullins, Director
. Division of Water Quality
li
By Authority of the Environmental Management Commission.
W10400114

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 p_ermit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall 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 afforded reasonable protection against damage during construction and use.
6. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to
the Aquifer Protection Section Central Office and the Winston-Salem Regional Office within 30
days of completion of well construction at the addresses below in Part U, paragraph 14. Copies of
the GW-1 form{s) shall also be give to the Per0mittee and retained on-site and available for
inspection.
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 Permittee 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.
4. Prior to installation, all tubing to be placed in boreholes ("loops") shall be checked for leaks bypressurizing
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.
WI0400114 2
7. After insertion of the tubing into the boreholes, an approved gi-out (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 dose 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 integi-ity 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. This testing data
shall be recorded on · the attached Mechanical Integrity Test Record Form and submitted to the Aquifer
Protection Section Central Office and the Winston-Salem Regional Office at least 24 (twenty-four) hours
prior to the initiation of the operation of the facility for injection. A copy of this form shall also be retained
on-site for inspection.
11. The location of each of the system manifolds shall be recorded by triangulation . from three -pe_rmanent
features on the site (e.g., building foundation corners) and shown on ari updated Site Map. The Permittee
shall retain a ·copy of this record _and submit a copy· of the updated map to the Aquifer Protection Section
Central Office and the Winston-Salem Regional Office,within 30 days of completion of well construction.
12. Boreholes shall not connect separate aquifers which have differences in water quality (e.g., shallow surficial
aquifers, saprolite, fractured bedrock, etc.) as specified in 15A NCAC 2C .0213(d)(8)(C) and shall be filled
with-bentonite &:rrout from the . lowermost water bearing zone to land surface as spe~ified in the permit
application.
13. One well identification tag per 'cluster' of w.ells ·shall be perm.anently affix.ed to tbe heating _and
cooling unit or other itearby permanently fixed location in a clearly visible location according-to 2C
.0213(g).
14. All of the documentation referenced above that is required to be submitted shall be sent to:
WI0400114
Aquifer Protection Section ~ Central Office UIC Staff
DENR-Division of Water-Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
(336) 771~5000
3
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.
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. The issuance of this permit shall not relieve th~ Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this 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 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]. 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
WI0400114 4
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
samp~ing associated with.injection and any.._related facilities as provided for inN.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 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;
(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 Pennittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Perm.ittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director . .
PART VIII~ PERMIT. RENEWAL
The Permittee shall, at least 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 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to lSANCAC 2C .0213(h)(l), Well
Construction Standards.
WI0400114 5
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water 'and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .02 l 3(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:
WI0400114
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
6
This Page Left Blank
WI0400114 7
Mechanical Integrity Test Record
(For 5QM Geothermal Heat Pump Injection Well System)
Owner/Permittee Name: _________ Permit Number: _W_I _____ _
Facility Address: _______________________________ _
Home Phone: Cell Phone:
Heat Pump Contractor Name:
Office Phone: __________________ C_e_ll _P_h_on_e_: _________ _
Tester Name: _______________ Signature: _____________ _
Date of Test: --------
Loop Initial Pressure (ps i) Final Pressure (psi ) Duration (minutes) Pass (Yes or No)
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: ---------------------------------------
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 fonn by mail: UIC Program, Mail Service Center 1636, Raleigh, NC
27699 or by fax: [phone].
Loop Initial Pressure (psi) Final Pressure (psi) Duration (minutes) Pass (Yes or No)
Rog.ers, Michael
From: Berry, Stephen
Sent:
To:
Friday, August 28, 2009 1 : 11 PM
Rogers, Michael; Knight, Sherri
Subject: RE: 5QM App for Miller W 10400114
Mike,
I would like to conduct an · inspection of this system during one of the days ttie drill rjg is onsite. The application states a
start date of three days ago, so I am unsure of when the drilling is to commence. I have left a message with Mr.
Jefferson of Home Energy Inc. stating my intentions. Please issue the permit with a condition that WSRO (specifically
me) be notified prior to drilling.
I have no way of flagging/tracking whether notification has occurred. And I feel ·like there has been permits in the past
that I have requested notification, yet was not notified. I would appreciate any suggestions you may have regarding this
matter (Tracking via GW-1 submittal is not acceptable).
As for this site, I expect to schedule (with Mr. Jefferson) a specific date and time in which to conduct the inspection.
Enjoy the week's endi
Stephen Berry
NC DENR
Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown 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:. Rogers, Michael
Se.nt: Friday, August 21, 2009 11:36 AM
To: Knight, She~ri
Cc: Berry, Stephen
Subject: SQM App for Miller WI0400114
Please find attached an App for a SQM well for your review. Please let us know if you wish to conduct a pre-permitting
inspection or not.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
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
2
Ro gers, Michael
From: Anna Jeffreys [[e-mail]]
Sent: Friday, August 14, 2009 3:48 PM ·
To: Rogers, Michael
Subject: RE: WI 0400114 Miller
Michael,
I confirm that the grout will be from 0-75' (bottom to top).
I have faxed over the site map showing location of potable well.
Thank you,
Anna
-----Orig ina I Message-----
From: Rogers, Michael [mailto:[e-mail]]
Sent: Friday, August 14, 2009 2:14 PM
To: Anna Jeffreys
Cc: [e-mail]
Subject: WI 0400114 Miller
I n·eed the following info:
1. Please confirm for the record that grout will be from Oto 75 feet (this was blank on the APP).
2. The App indicated a potable well on site was not shown on the site map. Please send revised map w/location
for well.
If this info is on the App when I email to the RO, this can aid them in making a determination ·whether they need
to make an appointment to conduct a pre-p~rmitting inspection or not.
Thank_s
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
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
1
Beverly Eaves Perdue
Governor
Kenneth David Miller
424 Prescott Street
Greensboro, NC 27401
.A.VA
NC D HR
North Carolina Department of Environment and Natural Resources
. Division of W ~ter Quality
Coleen H. Sullins
Director
August 12, 2009
Subject: Acknowledgement of Application No. WI0400114
Kenneth David Miiler SFR
Injection Mixed Fluid GSHP Well System (SQM)
Guilford
Dear Mr. Miller:
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 6, 2009. 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 informationifnece~sary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a tiinely 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
~~~ . .
If you have any questions, please contact Michael Rogers at 919-715-6166, orvia e~mail at [e-mail]. If the
reviewer is unavailable, you may leave·a message, and they will respond promptly. Also note that the Division has reorganized. To
review our new organizational chart, go to http://h2o.enr.state.nc.us/documents/dwg orgchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
0 WR., f\. W\-L
for Debra J. Watts
Supervisor
cc: Winston-Salem Regional Office·, Aquifer Protection Section
Anna Jeffreys (Home Energy, Inc -PO Box 238 Wendell, NC 27591)
Permit Application File WI0400114
AQUIFER PROTECTION SECTION
1636 Mail Service Center. Raleigh, North Carolina 27699-1636
Location: 2728 Caoital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity I Affirmative Action Employer
N°1!S.i..c 1· 01.ui aroma .lvaturallg
NORTH CAROLiNA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 50M WELL(S)
New Permit Application OR Renewal (check one)
DATE: (111_,__VI
31 , 204_
PERMIT NO. (leave blank if NEW permit application)
A. PROPERTY OWNER{S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a busi r ess or vernme agency, to name of
entity and a representative w/authority for signature): VI!v' i LPak- i 4i'v\ [ ey
(1) Mailing Address: 0, '` Ore 5 cal
City: Crkree I IC7 State: Ac2ip Code:ig..1q O I County: - -
53 -2 1 )% 1.1OO Cell No.: '') ( r 3'6) -
Home/Office Tele No.:
EMAIL Address:
v r (2) Physical Address of Site (if different than above): C,O 3� -1 �-[.1� ' � ._�G .
City: 6,kwlm►CQc C eAci State: A .Zip Code: 1 74ti County
Home/Office Tele No.: t-1 00 Cell No.: 'D 3(,3 - �•' 3S ii ,�.
EMAIL Address: . (OK%
H. AUTHORED AGENT OF OWNtJL 1 h ANY (if the Permit Applicant does not own the subject property,
A
Private: x Federal: Commercial:
State: Municipal: Native American Lands:
D. WELL DRILLER INFORMATION
GPU/UIC 5QM Weil Permit Application (Revised 7/2008) Page 1

Company Name: Home Energy Inc.
Well Drilling Contractor's Name: William B. Jefferson
NC Contractor Certification No.: 397I-A
Contact Person Anna Jeffreys EMAIL Address: anna®TheHomeEnergyCompany.com
Address: PO BOX 238/ 302 E Third Street.
City: Wendell Zip Code: 27591 County Wake
Office Tele No.: 919.366.0261 Cell No.: n/a
E. HEAT PUMP CONTRACTOR INFORMATION (if different titan driller)
Company Name: Home Energy Inc.
Well Drilling Contractor's Name: William B. Jefi'erson
NC Contractor Certification No.: 3971-A
Contact Person: Anna Jeffreys EMAIL Address: annatu TheHomeEnergyCompany.c❑m
Address: PO BOX 238/ 302 E Third Street
City: Wendell Zap Code: 27591 County. Wake
Office Tele No.: 919.366.0261 Cell No.: n/a
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Geothermal HVAC with closed loop copper piping
G. WELL CONSTRUCTION DATA. (Skip to Section 13 if this is a Permit RENEWAL)
(1) Proposed date to be constructed: _ - � Number of borings: /0
Approximate depth of each boring (feet): } 75-
(2) Chemical additives to be used in closed -loop system (only those chemicals indicated have been approved):
X R-407C propylene glycol ethanol other (other additives will need prior
approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): f r
(4) Well casing. Es the well(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES if yes, then provide casing information such as type (steel, PVC, plastic, etc.), diameter.
depth, and extent of casing appearing above ground:
(b) NO X
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite X Other (specify)
(b) Grout depth of tubing (reference to land surface): from to (feet)
If well has casing, indicate grout depth: from na to na (feet)
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/ tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
1. LOCATION OF WELL(S)
GPt1MC SQM Well Permit Application (Revised 712008) Page 2

Attach two copies of maps showing the following information:
(1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing wells) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet riffle
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.
J. POTABLE WATER WELL(S)
Lr
Are there any potable water well(s) on the subject property or adjacent properties? YES NO
If Yes, than indicate Iocation on attached map(s).
K. CERTIFICATION
Note: This Permit Application must be signed by max person appearing on the recorded legal property deed.
"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 d . onditions of the Permit."
Sig r kfue a fo C1'wner/Applicant
/4r"fribitiL
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUfUIC 5QM Well Permit Application (Revised 7/2OO) Page 3

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