WI0400115_GEO THERMAL_20120517

AVA~
NCDE~-~
North __ Carolina D_ep_artment ot Environment-and-Natural-Resour-ces --~--~
Beverly Eaves-Perdue=-=---
Governor
Historic Property Preservation, LLC
349 Arbor Road
Winston-Salem, NC 27104
Division of Water Quality
Charles-Wakild~-P:-E:--
Director
May 17, 2012
Subject: Notification-of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0400115
To Whom it May Concern:
Dee Freeman-
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title ISA Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells inc_luding geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http ://portal.ncdenr.org/web/wq/aps.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Seivice Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity\ Aflinnalive Ac tion Employer
Ni~h Carolina
l(Jatura/l!f
NON RESIDEArTLIL WELL CONSTRUCTION RECORD
North Carpi ina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATjON#. .ir.;
1. WELL CONTRACTOR:
,mod cn,A\�s
Well Contractor (Individual) Name
YADKIN WELL. COMPANY, INC.
Well Contractor Company Name
STREET ADDRESS 1908 HAMPTONIAL-E ROAD
HAMPTONVILLE NC 27020
City or Town Stale Zip Code
(336 ).466-4440
Area code. Phone number. (rEn
2. WELL INFORMATION: ! ! O ,
431
SITE WEU. !D#(irappkcabte)
WELL CONSTRUCTION PERMIT#(repplicabie},__
OTHER ASSOCIATED PERMIT# (it appkicabfe)).4J cry YiDoJ !S
3. WELL USE (Check Applicable Box) Monitoring CI MunIc1pal/PubliCO
Industrial/Came/dell] Agricultural Recove 13 InjeclIon0
Irrigation!)Other (Ilstt use) (�KC'a i e i i4rti
DATE DRILLED 70. fs "° 9
TIME COMPLETED AMID PMI7
4. WELL LOCATION:
CITY: WI' y1 f c — S !'l I G "^ couisi-Y rcir3i; ]�P1
q /1-v44s- tis
(street Name, Numbers, Community, SubdIvis+on, Lot No., Parte], 21p Code)
TOPOGRAPHIC 1 LAND SETTING:
0 Slope I] Valley 0 Fiat 0 Ridge 0 Other
(check apprroprla(e box}
LATITUDE 3 (, (Jl. (��
LONGITUDE -'-- .4. Lv 9 7
Latitude/longitude source: PfGPS 0 Topographic map
(Iocef?on of t]eltmust be shown on a USG( topo map and
allached io this form if not using GPS)
May be In degrees,
minutes, seconds or
in a decimal format
6. FACILITY. is Us Wilma er Inr buitness *ilea, (hewed ra lau[ed.
FACILITY ID #(if applicable) {{
NAME GF tt1TY Ta/tA lu Jf(.:,A 1 STREET ADDRESS j �j � "hob, ,f
(U. 5
City or Town Slate Zip Coda
[/r CONTACT PERSON.r] i{ rrl.51 kJe/c.0 c (c4 so A
MAILING ArDDRE S
P9ir•Uu,(it- A.itr 27 320
City or Town Stale Zip Code
133L /- G 13 Cii--2o
Area code • Phone number
6.WELL DETAILS:
a, TOTAL DEPTH: 3(0 0
b. DOES WELL REPLACE EXISTING WELL? YESU
c• WATER LEVEL Below Top of Casing: FT
(Use'+" if Above Top of Casing) •
3 t9
ail •O r1
d. TOP OF CASING IS FT. Above Land Surface'
'Tap of casing terminated attar betovr land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHOD OF TEST AIR PUMP
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth):
From (.6 3 To (014 Ram To
From To Rom To
From To Rom To
7. CASING: Depth Diameter Thloweashvv1 hr Material
From To Ft
From To Ft.
From To Ft.
S. GROUT: Depth Material Method
From 0 To3(5d FEAll;C g-GzG,& r]M?4
Fromm To EL "Y"� l
From To Ft.
8. SCREEN: Depth Diameter Siot Slze Material
From To Ft. In. In,
From To R. In. In,
Ram To Ft. in in.
10. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
FrOm To Ft.
Ram To Ft.
11.DRILLUNO LOG
Fron'} To , Formation Description
- 30a r n,et� Sc - - 40, tAciizt G- •
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
I DO HERESY CER7IFY THAT THIS WELL WAS CONSTRUCTED IN ACOOROANCE Nf1TH
r 5A iecAC 2C, WELL CONSTRUCTION STANDARDS, Ar iD THAT A COPY OF THIS
RECORD HAS SEER PROVIDED TOTHE WEL C' / ]ER.
/ ILJ Y 4.- /71- (6,-459
ATUR CERTIFIED WELL CONTRACTOR DATE
Z-c ,e_k , L. 0/ 1.1 k,V
PRINTED NAME1OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mai! Service Center-- Raleigh, NC 27699.1617 Phone No. [phone] extEb8.
Form GVV•1b
Rev.12107

NONRESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WELL CONTRACTOR:
Well Contracoo (Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREET ADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NO 27020
City or Town State Zip Code
( 336 ). 4613-4440
Area code- Phone number LO0 ro
a. WELL INFORMATION: �ty'rF
SLTE WELL ID #[rrspplicabrey
WELL CONSTRUCTION PERMITir(ilapplicable)
OTHER ASSOCIATED PERMIT d(if applicebte) i 4 0 YOO I13
3. WELL USE (Check Applicable Sox) Monitoring° Municipal/Publiclj
IndustrlallCommerciarU Agrfcu tural0 11 Vecovary0 InJectlona
Irrlgailorq Others (IIsI uee) (Y o iLkQ1est.e I
DATE DRILLED (0- 7 -09.
TIME COMPLETED AMO Pm13
4. WELL LOCATIO
((`` j
coy: �L! r • ' ►-tsLt1 CAL]NTY_C,aIr.J J,�!"
C /l f " / II
(Slice Name, Numbers, Corn u„ Try, Subdivision. Let fro_, Parcel, Zip Cods)
TOPOGRAPHIC 1 LANO SETTING:
Mope 0 Valley ti Flat 0 Ridge 0 Other Y ---
(check appropriate box) May be in degrees,
LATITUDE L L G to l sninulcs,sccondsor
Cs �` in a decimal forma!
LONGITUDE �L cj 7
Laiitudeftongitude source: , GPS 11 Topographic map
(location at wen must be shown on e USGS topo map end
attached to !Ns form ffrrot using GPS)
5. FACILITY-1=the non.* or the owions wllerethe mu is loosed.
FACILITY ID Cif applica bte)
NAMECI!"9'tl6ttITY JJ /64 9
STREET ADDRESS 3 v9 y i,,v /Z
6v, .27
City or Town Slate /s / Zip Code
CONTACT PERSON J 41� dit'4 F/ft`/ Cei/atia +►
MAILING ADDRESS
i41lcti([e. it 2732o
City or Town Slate Zip Code
[334. 1=G(J- 2c�
Area code • Phone number
B. WELL DETAILS:3 r
a. TOTAL DEPTH: ��
b. DOES WELL REPLACE EXISTING WELL? YESO Nt
C. WATER LEVEL Below Top of Casing; FT.
(Use "*" If Above Top of Casing)
d, TOP OF CASING 1S FT. Above Land Swface"
"Top of casing termfnaled at/or below land surface may require
a vartance in accordance with 15A NCAC 2C .0118.
ii
e. YIELD Wpm): LLLI METHOD OF TEST AIR PUMP
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
7. CASING: Depth Diameter Tbk. r asIV rohl Material
From To FL
From To Fl.
From To Fr.
S. GROUT: Depth )Material latelhod
From 0 To 3 ° FI,T €t"me GmiA p uip
From To F1. 4-.'+..
From To Ft.
9, SCREEN: Depth Diameter Slot Size Material
From To FI. In- In.
From To Ft. In. In,
From _ To Ft. fn. In.
10.SANDIGRAVEL PACK
Depth Size Material
From To Ft.
From To Ft.
From To Fi.
11.DRILL1Hc3 LOG
From ` .To , F&rrrnetion Description
qt) ' 36 0 ` ill Sd3 - �o.{.7( n;4e
SIZE OFF
BIT SERIAL NO:
1 2. REMARKS:
140 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORMICE WITH
15A NCAC 2C., ► ELL CONSTRUCTION STANDARDS. ATM THAT A COPY OF T - S
RECORD HAS BEEN P °MED TO THE WELL
ii1LJr,I {] id-7-O
2
$ TURE 0 RTIFIED WELL CONTRACTOR DATE
JaeLi G r vu
PRINTED NAME/OF PERSON CONSTRUCTINGT 1E WELL
Submit the ortglnal to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Canter - Raleigh, NC 27699.1617 Phone No, [phone] ext 658.
Form GW.lb
Rev.12107

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #1 S 7 oR•
1. WELL CONTRACTOR:
".- r,L- ls1 rY\O1 i 5
Well Coontracit& (individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREET ADDRESS 190E HAMPTONV1LLE ROAD
HAMPTONV1LLE NC 27020
City or Town State
{ 336 ). 466-4440
Zip Code
40°e
Area code- Phone number
2, WELL INFORMATION:
SITE WELL ID 4(irappiica<b1e)
WELL CONSTRUCTION PERMIT#(i1 ap>:ticab:e)
OTHER ASSOCIATED PERMIT #ttf applicable):ti
I WELL USE (Check Applicable Box) MonttaringLi
Ii;dustriallComrnerGelp AgricullvratO fqcovery0
Irrlgatior0 Other (list use) eo - LWiti
.r O Y 00 i1 ]A
MunIcipa1/PubHcC
iftlection0
i 1
.0
DATE DRILLED /0T5C'C79
PMD
�Sr ,...,/ g
TIME COMPLETED AM0
4. WELL LOCATION: fr
CITY: atiitt yh Jr( Nit COUNTY
5' I" 4-11:70k, p a I
_1
(Street Name. Numbers, Community, 5ubdlvistor., Lot No... Parcel, Zip Cade)
TOPOGRAPHIC i LAND SETTING'
,SIope 0 Valley 0 Flat 0 Ridge 0 ❑Iher
(check appropriate box)
LATITUDE 2 L [)G A Z.
May be in dagrcea,
minutes, seconds or
in a decimal flmral
LONGITUDE1. c-_� .
Lalitndellartgitude source: GPS t7 Tapographic
Vocation of well must be shown on a USGS
aIrached to this farm if not using GAS)
5. FACILITY -is men err vl the ba s:na s s where u:r n ea la i
FACILITY ID #(Ilappiicabie)
neap
lopo map end
acate tl
r
NAMEq�Gde4ttrrY ,)v(n COX,' /0A J
STREET ADDRESS
City or Town State ] Zi Code
CONTACT PERSON fiO.0/)%S.7"Gi,..iJPv- c ey4(J[!4.1
MAILING t DDRl S
City or Town Stale'
( 3;. C0 _ -20
Zip Code
YESU NCt<
FT.
_1•
Area code • Phone number
b.WELL DETAILS:
a. TOTAL DEPTH: (DOr
b, DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Delon Top of Casing:
(Use "+" if Above Top of Casing)
10
d. TOP OF CASING IS FT_ Above Land Surface'
'Top of Casing terminated al/or below land surface may require
a variance In accordance with 15A NCAC 2C .0119.
e. YIELD (gprn): METHOD OF TEST AIR PUMP
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth):
From(/3 To /83- From To
From To From To
From To From To
7. CASING: Depth Diameter 7hickne4&AVolght Material
From To FI.
From To Ft -
From To Ft
9. GROUT: Depth Material Method
From C To3(a0 .l 1 Cf a- rr f7u"` .,,.
c
From To FL �`
From To FI.
9. SCREEN: Depth Diameter Slot Size Material
From To Ft- In, In.
_
From V To Ft. in. In.
From To Ft. In. in.
10. SAND/GRAVEL PACK:
Depth Size Material
From To F I.
From To Ft.
From To Ft.
11.DRILLINO LOG
From { rrnalion Description
d V\Cyt G-trp-K
SIZE OFF
_ BIT SERIAL NO:
12. REMARKS:
t DO HrREBYCERTIFY THAT THIS WELLLSAS CONSTRUCT EDir4ACCORDANCE WITH
t6A r;CAO 2C, WO.L CONSTRUCT:ON STANDARDS, AND 111AT A COPY OF TMS
RECORD HAS BEEN 'tONDFOTOTHE WELL iE
/
$' ATURt: 0 ERTIFIEJ WELL CONTRACTOR DATE
e..k.�IN iv\u\,` ITS
PRINTED NAME br PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality wlth(n 30 days. Attn: Inrormatlon Mgt.,
1617 Mail Service Center — Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GWitr
Rev.121Q'1

NONRESIDENTIAL WELL CONSTRWWCTION RECORD
North Carolina Departnscni of Environment and Natural Resources- Division of Waltz -Quality
WELL CONTRACTOR CERTIFICATION 4
1. WELL CONTRACTOR:
a..� 1�.1 Well Contract r (Individual) name
YADKIN WELL COMPANY, INC,
Weft Contractor Company Name
STREET ADDRESS 1908 HAMPTQNVILLE ROAD
HAMPTONVILLE NC 27020
City or Tovm Stale Zip Code
( 336 ).468-4440
Area code- Phone number
2. WELL INFORMATION:
boo
SITS; WELL ID*pi applicable)
'NELL CONSTRUCTION PERMIT (llapplicable)
OTHER ASSOCIATED PERMIT g(if applicable)J.'J '='V 001 f ,S
3. WELL USE (Check Applfcabte Box) Monitoring° Municipal/Public°
InduslrlalfCommerciaJD Agriculturart3 pcoveryl} IpjectIonO
rrrig@tlora Olheig (list use) far e3'
DATE ❑RILLED_/0-9'0S
TIME COMPLETED AMO PMtJ
4. WELL LOCATION)
CITY: & ?7l l Oir--ate iY► COUNTY_
(Sveet Mama, Numbers, Community. Subdivision, Lot flo., Parcel, ZtpCode)
TOPOGRAPHIC / LAND SETTING:
Slope 0 Vaney D Flat 0 Ridge CI Other
[[heck appropriate box)
LATITUDE ,� C , �](i { e 3
LONGITUDE 0 {e fi i
Latitude/IDngiludc source: GPS 11 Topographic map
{focaIlon of well most be shown on a LISGS lop° map and
attached lv (JILT form if not using GPS,
May be in degrees,
minutes, seconds Or
in a decimal format
5. FACILITY. It tha name or Ow bu3lAcas where the t ea fa Iccarea.
FACILITY ID *Or applicable)
NAME OP.COiraTiL•I-T-Y .3-0 I A ..c1 C-i`,S R #
STREET ADDRESS 7f771
Slater Zfp9gde
CONTACT PERSON ({i4[!1 Jjr`1 /e Ce/q,i'tlfc
City or Town
MAILING AQ9RESS r5,t u if le- JJ
City or Town Stale
3 3C s- 6/5-• S/4-'20
Area code • Phone number
8. WELL DETAILS:
a. TOTAL DEPTH:
.") 7 3 20
Zip Coda
b. DOES WELL REPLACE EXISTING WELL? YES(] NCl/
C. WATER LEVEL Below Top Df Gasing: FT.
(Use'4' if Above Top of Casing)
d. TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated uJor below land surface may require
a variance in accordance with 15A NCAG 2C .0118,
e. YIELD {9pm}: 5' METHOD OF TEST AIR PUMP
f, DISINFECTION: Type HTH Amount
g. WATER ZONES (depth :
From al To ) From To
From To From To
From To From To
7. CASINO: Depth Diameter Thickness/Weight Material
From To Ft.
From To Ft.
From To Ft.
8. GROUT: Depth �}MaterlaI Method
From d To 341 O F1. I Ii2err"t b -1-714i1t— puA
From To 1=1. ep Sex
From To Ft.
9, SCREEN Depth Diameter Slot Size Material
From To Ft. In. in. _
From To Ft. In- in,
From To Ft. in. in.
10, SAND/GRAVEL PACK:
Depth Size Materi21
Frorn To Ft.
From To FL
Frorn To I1.
1 S,DRILLING LOG
From r LtTp , Fprrmal�on Description
0113 - 360 So;C "J 110 G. ,, i
12. REMARKS:
SIZE OFF
BIT SERIAL NO:
I DP HEREBY CERTIFY TKO THIS WELL WAS CONSrRUCTEDINACCORDANCE WITH
15A NCAC 2C, WELL CONS TF UCT ION STANDARDS, AriD THAT A DOPY or TN 5
RECO'r HAa E.EVI PROVIDED TO THE WEL OWtIER.
rr
CERTIFIED WELL CONTRACTOR DATE
4 1,N. 1-05
PRINTED !TOE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GIN-1 b
Rev.12/07

NONRESIDENTLAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Nature! Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 9 5` ' 1
1, WELL CONTRACTOR:
Weil ContracTur(Individual) Name
YADKIN WELL COMPANY, INC.
Weil ConlractorCompany Name
STREET ADDRESS 1905 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town Stare zip Code
( 336 ).468-4440
Area code- Phone number
2, WELL INFORMATION:
SITE WELL ID gig applicable)
WELL CONSTRUCTION PERMIT#(irapplicable)_
OTHER ASSOCIATED PERMIT#p( applicable)W T G03
S. WELL USE (Check Appiicabte Box) Monitoring° MunicipaifPubilcD
lndushlsl!CommerccaID AgrlcutluratO p cavery0 InjectiknZ
trrigatlorU 0lher (list use), (-E'D LQrrlvttX `
GATE DRILLED /0- /) -0 9
TIME COMPLETED AM❑ PMD
4. WELL LOCATION?
CITY: C.A) ?A/ rt—lc�e h.t cowry
3_31o�Di^ i
e
(Street Name,umbers, Community, SubdMslen, Lot No., Parcel. Zip Code)
lTt]OGRAPHIG !LAND SETTING:
ope 0 VaIley 0 Flat 13 Ridge 0 Other
(ohec?c appropriate �b{ox} May be in drgreea,
LATITUDE 3 V {, „ { {r '3 minutes, seconds or
in a decimal format
44 5
LONGITUDE S [�, (ta 14:'
Latitude/longitude source: AMPS 0 Topographic map
(location of well must be Shown on a USGS fops map end
attached to this form if not using GPS)
S. FACILITY -is the namx cr via buslrksswhare Mt well is IOcalad.
FACILITY ID NCl/applicable)
NAME QrF-r44$IL'tF . V • (s 1.r'1 b A
STREET ADDRESS
City or Town Stale
CONTACT PERSON a si,x l I1 J T t 1F i ' Ied es"
MAII ING A uRr vn ES.�
City o To tale
3? ,- t; 13 = 31 S -0
Area code • Phone number
2_i 720
Zip Coda
S, WELL DETAILS; ��
a, TOTAL DEPTH;
b. DOES WELL REPLACE EXISTING WELL? PESO NOJ(
C. WATER LEVEL Below Top of Casing: FT.
(Use"+' II Above Top of Caging)
d. TOP OF CASING 1S FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0115.
e. YIELD (gpm): I METHOD OF TEST AIR PUMP
1. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth): ,
From 415 To to From To
From To From To
From To From To
T. CASING Depth Diameter ThlckneaslNelght Materiel
From To FI.
Ftom To Ft.
From To FL
B. GROUT: Depth Malarial Method
From ❑ To340 Ft' .ere,,Grp} lL1+►tWs(
From To Fl. ' Sc' t _
From To Ff.
9. SCREEN: Depth Diameter Slot Size Material
From To Ft. to. In.
From Ti,_______ Ft. tn. in.
From _ To FI. in. in.
10. SAND/GRAVEL PACK:
Deplh Size Material
From To Ft.
From To FI
From To Ft.
11.DRILLING L00
From + s_jf F atjafr Description
LLJJ
- 396- tS r a 6-tan;14
12. REMARKS:
SIZE OFF
SIT SERIAL NO:
l CO HERBY CERTIFY THAT /HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NCAC 2C, WELL cousTRucrimi STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDE° TO THE WELL R
ATURE %F CERTIFIED WELL CONTRACTOR DATE
ks iglu \VS"
PRINTED HAM OF PERSON CONSTRUCTING TIIE WELL
Submit the original to the Division of Water Quality within 30 days. Attn; information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699.1617 Phone No. {919) 733 7015 ext 568.
Form GW-lb
Rev.12/07
C.

NON QN RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department orFnvironment and Natural Resources- Division of Water Quality
WELL, CONTRACTOR CERTIFICATION it S 7
1. WELL CONTRACTOR:
00 1\ cs
Wall Contractor Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Narne
STREET ADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
CityorTown State
{ 336 J.468.4440
Area Code- Phone number
Zip Code
2. WELLINFORMATtON:��
SITE WELL ID #(rappilcable)
WELL. CONSTRUCTION PERMIT#(rapplieabie)
OTHER ASSOCIATED PERMIT' Of app1TCeble);Q G D 1''L)0(
3. WELL USE (Check Applicable Box) MonitoringD MunicipalIPubiicO
InduslrialfCommerclaID AgricullurstE ecoveryD n edlori]
irrIgaIIior11 ❑lher - {lls[ use) [Y ec fJ e
GATE DRILLED () f 3' 0 9
TIME COMPLETED AIM PMO
4. WELL LOCATION:
CITY: CA-1mm1)' ) ^Sep ['.4%-COUNTY
I'J
(4r A Eby_ J
{Street Name, Numbers, Community, Subdivision, Lot 14o„ Parcel. Zip Code}
�T.JOPOGRAPHIC, LAND SETTING:
L 'S1ope 0 Valley El Nat 0 Ridge 0 Outer
'] . {ebeck appropriate box} L! Maybe in degrees
LATITUDE 3 ,()G r ��> 7 minutes, seconds or
rG ,. cq'r Ina decimal format
LONGITUDE 2 o
Latitude/longitude source: .W 3PS 0 Topographic map
trocallon of well most be shown an a USGS fopo map and
attached to this form l[nol using GPS)
3. FACILITY• la he narca al she business xsrere the r fs tccsrad.
FACILITY ID {!(if apptircable)
NAMED TFY -rLY,Arl Sl' fJ!b h I
STREET ADDRESS r ivv --
City or Town State ZZipode
CONTACT PERSONfTs.)ii/1_Si-Yitti@d 4iiIrf1(.£►-1
MAILING AQ RESS
e-O U , I le_ ,v L.- 27 32o
City or Town Stale Zip Code
f .33C _I-G - Y
Area code - Phone number
8. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YESU P
G. WATER LEVEL Below Top Of Casing: Ff.
(Use "+" -f Above Top of Casing)
3 0/
d. TOP OF CASING IS _ FT. Above Land Surface
'Top of casing Terminated at/or below land surface may requfre
a variance in accordance with ISA NCAC 2C ,b118,
e. YIELD Igpm); J METHOD OF TEST AIR PUMP
f. DISINFECTION: Typel-1TH _ Amount _
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
7. CASING: Depth Diameter Thickness/weight Material
From To Ft.
From Ta Ft;
From_ To Ft,
8, GROUT: Depth Material Method
From 0 To3gO
From To FL 4-' ""'
FT.
From To
F1hmb'-i7rar+v
9. SCREEN: Depth Diameter SIol Size Material
From To Ft. In, in.
From To FL in. in,
From To Fl. In. in.
10. SAND/GRAVEL PACK:
Depth
From To
From To
From To
Size Material
FL.
Ft.
Fl,
1 L.DRILLUNG LOG
Fr i ry SI? Fors? lion Description
12. REMARKS:
SIZE OFF
BIT SERIAL NO:
AD HEREBY CERTIFY THAT THIS WELL WAS CONSTTWCTEta IN ACCORDANCE 1MTI4
IsA NCAC 2C, WELL CONSTRUCTION STArrDARDS, MID THAT ACOPY OF THIS
RECORD HAS BE EN F RON DE D To THE WELL OARIc
L.JQ•13-05
ILIRE OF RTIFIED WELL CONTRACTOR DATE
4dL W1711y�
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Wator Quality within 30 days, Attn: Information Mgt.,
1617 Mall Service Center-- Raleigh, NC 27699-1617 Phone No. [phone] ext 868.
Form GWlb
Rev.12/07

NONRESIDENTIAL WELL CONSTRUCT1OK RECORD
Nardi Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION i P-5'1 a-
1. WELL CONTRACTOR:
Well Conlraclhr(Individual) Name
YADKIN WELL COMPANY, INC.
WTI Contractor Company Name
STREET ADDRESS 1908 HAMPTONVIL-LE ROAD
HAMPTONVILLE NC
City or Town Slate
336 1-468-444❑
Area coda. Phone number
2, WELI. INFORMATION:
SITE WELL ID dl+r epplIcablef
WELL CONSTRUCTION PERMITINIapplicable)
OTHER ASSOCIATED PERMIT Of applicable) it2 +3 S46 D
3, WELL USE (Check Applicable Box) Monitoringil MunlclpallPubllcEl
Induslrtal/ComrnerclalD Agnew turaIU , Recovery° I+sleciionf
Irrigallorti Other (listuse) Q► Irn_t
DATE DRILLED l0 4 V-D`?
TIME COMPLETED AMO PMEI
4. WELL LOCATIO rr
CITY: CU(nJ n•jQl�F-•
27020
Ztp Coda
COUNTY A
Inapt Name. Numbers. Com-unity, Subdiviilon, Lot No., Parcel, Zip Coda)
POGRAPHIC / LAND SETTING:
Slope p Valley E Fiat El Ridge 0 Other
(check aappraprlate boxy May be in degrees,
LATITUDE 67,- iIG . f minutes,scconds or
in a decimal formal
LONGITUDE 1:0 �L c
Latitude/longitude source: ) 'GPS 0 Topographic map
(location of waif must belhown on a USGS Sopa map and
attached to this form If nal using GP5)
S. FACILITY• la the nrra_ or the buslnase where the wen If Iscsied.
FACILITY ID tl'tif applicable)R
NAME Q�war tTY 0 AA f ,rut 4 )
STREET ADDRESS
City or Town Stater ! Zde
CONTACT PERSONDcth Il► J t` Ql C'r A..
MA1Lit-K3 ADDRESS
�r:„Ilf ur c. i)L. r1-7 ; 20
City or Town Stele Zip Code
'� G 3• (Z3 .Y2 o
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 396.
b. DOES WELL REPLACE EXISTING WELL? YES° NQIc
e. WATER LEVEL Below Tap of Casing: FT.
(Use "*' if Above Top of Casing)
d, TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated et/or below land surface may require
a variance fin accordance with I SA NCAC 2C .011 B.
e. YIELD (gpm): METHOD OF TEST AIR PUMP
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth]:
From To
From To
From To
From To
From To
From To
7, CASING: Depth DlaMete r ThicknesalWelghl
Metetiel
From To Ft.
From To Ft.
From To Ft.
El. GROUT: Oepth Material Method
From 0 To3et0 F{: err..a-G4ify4-- 1'akt
From To Ft. ��
From To FL
S. SCREEN: Depth Diameler Slot Size Material
From To Ft. In. In.
From To Ft. In. in,
From To Ft. In. In.
40, SANDIGRAVEL PACK:
Depth She Material
From_ To Ft.
From To FI.
From To FI.
14,DRILLING LOG
9
F.ormation Description
Oe
34v` ryi eSIW4---o
12. REMARKS:
SIZE OFF
BIT SERIAL NO:
1 CO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED !r! ACCaRDAr10E WTI/
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, ANO THAT A COPY or THIS
RECORD HAS SEEN Feovio>:a TOTHE WELL Oyvt+ER
(0. 447
ATURE F CERTIFIED WELL CONTRACTOR DATE
rv\ vtt s
PRINTED N E OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water quality within 30 days. Attn: information Mgt.,
1617 Mail Service Center — Raleigh, NC 27690.1617 Phone No. (919) 7337015 ext 568.
Form GWlb
Rev.12107

NON ON_RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division afWater Quality
WELL CONTRACTOR CERTIFICATION t 5 7 L
1. WELL CONTRACTOR:
Well Contra ttor (indheduaI) Name
YADKIN WELL COMPANY, INC.
Wel CantrectorCompany Name
STREET ADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NO 27020
City or Town State
( 336 Ir 468-4440
Area code- numberPhoneA. !1
2. WELL INFORMATION:
SITE WELL ID #(a applltahte)
WELL CONSTRUCTION PERMIT#¢f appllcable)
OTHER ASSOCIATED PERMIT Rif applicable)1,,r 0i; OO((.
3. WELL USE (Check Applicable Box) Monitoring{) Municpal!PubiicD
tndustrialrComm rrialD Agricullurali] gecoveryp 17lectionp
Irrlgatiorif 011ie{ { (list use) l)-gyp T oYtii,t t
DATE DRILLED /O-/6 V ci
TIME COMPLETED AMC) PMEI
4, WELL LOCATION:
CITY: Wi ' h-fed t4.0- COUNTY Ad w iyit
3 S(et 1kd ,, !21
(Sheet Norm, Number(. Community, Subdivision, Lot No., Parcel, Zip Cads)
T POGRAPHIC f LAND SETTING:
Slope 13 Valley I7 Flat 0 Ridge D Other
(cheek appropriate box)
LATITUDE 3_ tZ (.{ (6 rft m?styn be in doods o
� r r minutes, woods or
LONGITUDE d [ Ip {[ in a decimal formal
Latitudeltungitude source:(GPS 0 Topographic map
(tocafion of well must ha shoivrt on a USGS lopn map and
sneered to this form if not using GPS)
Zip Code
6, FACILITY.16 thinnn! or ins WErsiness when u:e Kea le tocarU
FACILITY ID #(if applicable)
NAME BpffsestETTY ` 'J 1 !: e �'e +sn.}
STREET ADDRESS > ' A-* .. l- PA
City or Town Stale Ip Code
CONTACT PERSON &kJ 4./ rt <7J tt1#0_11,A u
MAILING ADDRESS
re. 1 A-t;,, I1
City or Town State
(334 1- Cii- ! 2f )
Area code • Phone number
6. WELL DETAILS: s
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL'? YESO UO'
;. WATER LEVEL Below Top of Casing: FT.
(Use •+` If Above Top of Casing)
rL 7 2'
Zip Code
d. TOP OF CASING IS FT, Above Land Surface'
lap of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2G .0118.
e. YIELD (gpm): 4— METHOD OF TEST AIR PUMP
f. DISINFECTION: Type HTH Amount
g, WATER ZONES (depth):
From To From To
From To From To
From To From To
7. CASING: Depth Diameter ThleknasuWelght Material
From To Ft.
From To Ft.,
From To Ft.
9. GROUT: Depth Material Method
From C) To370 F1i ken*to40# fC1 0-yraf
From To Ft. d- da►-`-t
From To Fi._-
T 9. SCREEN: Depth Diameter Slot Size Malerlel
From To F. 1n- In.
F►OM To Ft. in in
FromTo Fi. In, In,
10. SANDIG RAVEL PACK:
Depth Size Material
From To Ft.
_. _.
From To Fl.
From To Ft.
11.DRILLING LOG
F�m Tot Eormakjon Description
�c]7G4 r
- 3 f �i 6.61:?- ad Hn,ot 6-.t5 .
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
r DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA HCAC2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD A5 6EE1 RGV170 iHEYyEL
fA.r/,] fO I6'09
TURE .ERTIFIED WELL CONTRACTOR DATE
J " `oki
PRINTED NAN. OF PERSON CONSTRUCTING THE WELL
it
Submit the original to the Divlsion of Water Quality within 30 days. Attn: information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW-lb
Rev.12l07

Ye"
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it wire..9a A l�►l ( ,J
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0 �•

Permit Number WI0400115
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
. Historic Property Preservation LLC
Location Address
349 Arbor.Rd
Winston Salem
Owner
Owner Name
NC
Historic Property Preservation LLC
Dates/Events
27104
Orig Issue
09/07/09
App Received Draft Initiated
08/10/09
Scheduled
Issuance
Central Files: APS_ SWP_· _
09/16/09
Permit Tracking Slip
Status
Active
Version
1.00 ·
Project Type
New Project
Permit Classification
Individual
Permit Contact Afflllation
Major/Minor
·· Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Unknown
Owner Affiliation
John Sessions
349 Arbor Rd
Winston Salem NC 27104
·Public Notice Issue
09/07/09
Effective
09/07/09
Expiration
08/31/14
_R_e_g_u_la_te_d_A_c_ti_v_it_ie_s _________________ R~e-g=ue~s~t=e~d~/R~e~c~e~iv~e~d~E~ve~n~t-s __________ _
Heat Pump Injection RO staff report requested
RO staff report received
Outfall !•J :JL ,
Waterbody Name Stream Index Number Current Class
08/19/09
08/28/09
Subbasin
Permit Number WI0400115
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
m ichael. rogers
Coastal SW Rule
Permitted Flow
a c ilitv
Facility Name
Historic Property Preservation LLC
Location Address
349 Arbor .Rd
Winston Salem
Owner
Owner Name
NC 27104
Historic Property Preservation LLC
Dates/Events
Orig Issue App Received Draft Initiated
08/10/09
Re q ulated Activities
Heat Pump Injection
Outfall NUL;_
Scheduled
Issuance
Central Files: APS_ SWP_
09/02/09
Permit Tracking Slip
Status
In review
Project T.ype
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Unknown
Owner Affiliation
John Sessions
349-Arbor Rd
Winston Salem NC
Public Notice Issue Effective
7/99
Req uested/Rec ivecl Events
RO staff report requested
RO staff report received
27104
Ex iration
~ 31 j1Lj
08/19/09
08/28/09
Waterbody Name Stream Index Number Current Class Subbasln
AVI
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Mr. John Sessions
Historic Property Preservation, LLC
349 Arbor Road
Winston-Salem, NC 27104
Division of Water Quality
Coleen H. Sullins Dee Freeman
Director Secretary
September 7, 2009
Re: Issuance of Injection Well Permit
Permit No. WI04(W115
Issued to Historic Property Preservation, LLC
Forsyth County
Dear Mr. Sessions:
In accordance with your application received August 10, 2009, I am forwarding Permit No. W10400115 for the
operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system to be located at the
above referenced address. 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 Construction Completion form (GW-I)
after construction.
Per Part H, paragraph 2, the location of each of the system manifolds shall be recorded by
triangulation from three permanent features on the site (e.g., building foundation corners) and
shown on an updated Site Map.
Per Part II paragraph 4, one well identification tag per 'cluster' of wells shall be permanently
affixed to the beating and cooling unit or other nearby permanently fled location in a clearly
visible location.
Please submit the data within 30 calendar days of receipt of this letter to the following address:
Aquifer Protection Section (APS)
Underground Injection Control (LTIC) 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 me at [phone].

Best Regards,
/1~~~ ~<U'~
Michael Rogers, P.G. /
Environmental Specialist
cc: Sherri Knight -Winston-Salem Regional Office
Central Office File -WI0400115
Forsyth County Environmental Health Dept.
•
David.Brovvn -Yadkin Well Co., Inc. (.\'ent via Fax and USPS)
Attachment( s)
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
Historic Property Preservation, LLC
FOR THE CONSTRUCTION AND OPERATION OF 8 TYPE 5QM INJECTION WELLS, defined in Title
1 5A 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 349 Arbor Road, Winston-Salem, Forsyth
County, NC 27104, and will be constructed and operated in accordance with the application submitted August
10, 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 fX hereof.
Penuit issued this the I day of —j r .t 2009.
o - u�
irl❑teen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically 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 II, paragraph 5. Copies of
the GW-1 form(s) shall also be give to the Permittee and retained on-site and available for
inspection.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. 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].
2. The location of each of the system manifolds shall be recorded by triangulation from three
permanent features on the site ( e.g., building foundation corners) and shown on an 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.
3. 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 grout from the lowermost water bearing zone to land surface as specified in
the permit application.
4. 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).
5. All of the documentation referenced above that is required to be submitted shall be sent to:
WI0400i15
Aquifer Protection Section -Central Office UIC Staff
DENR-Division of Water Quality
2
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -·winstoh-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
[phone]
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 Perm.ittee, a formal perm.it 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 perm.it 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 conditio:r;is 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 relievC?.the Pennittee 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.
WI0400115 3
3. At least forty-eight ( 48) hours prior to the initiatio~ 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
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 in any unusual operating circumstances;
(B) Any failure due to· known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART IX-CHANGE OF WELL STATUS
WI0400115 4
I •
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 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 for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 1 SA 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 contaminatic;m 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 movem.ent of
fluids into or between underground ·sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Pennittee 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:
WI0400115
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
A/VA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
September 7. 2009
Mr. John Sessions
Historic Property Preservation, LLC
349 Arbor Road
Winston-Salem, NC 27104
Re: Issuance of Injection Well Permit
Permit No. W10400115
Issued to Historic Property !'reservation, LLC
Forsyth County
Dear Mr. Sessions:
In accordance with your application received August 10. 2009. I am forwarding Permit No. WI0400115 for the
operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system to be located at the
above referenced address. 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 bolded language in the permit. Please submit copies of the Well
Construction Completion form (GW-1) Part 1, paragraph 7.
Please submit the data within 30 calendar days of receipt of this letter to the following address:
Aquifer Protection Section (APS)
Underground Injection Control (U1C ) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
Additionally, your UIC system is subject to inspection by the APS and at the time of the inspection must display
a permanently affixed identification plate in accordance with requirements of 2C .0213(g). Please insure this is
completed in accordance with permit condition Part 1, paragraph 6 of this permit issued September 7, 2009.
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 me at [phone].

Best Regards,
'
~-G ~
Environmental Specialist
cc: Sheni. Knight -Winston-Salem Regional Office
Central Office File -WI0400115
Forsyth County Environmental Health Dept.
David Brown -Yadkin TiVell Co .. Inc. (~'ent via Fax and USPS)
Attachment(s)
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
Historic Property Preservation, LLC
FOR THE CONSTRUCTION AND OPERATION OF 8 TYPE SQM INJECTION WELLS, defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed-loop
geothermal-mixed-fluid heat pump system. This system is located at 349 Arbor Road, Winston-Salem, Forsyth
County, NC 27104, and will be constructed and operated in accordance with the application submitted August
10, 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 perm.it.
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, fro,m the date of its issuance until Au1:,,ust 31, 2014, and shall be
subject to the specified conditions and limi!ations set forth in Parts I through IX hereof.
Permit issued this the ___ day of _______ , 2009.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
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 witl).
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 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. Each geothermal injection well system shall have permanently affixed an identification plate
according to 2C .0213(g).
7. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section -UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Winston-Salem Regional Office
585 W augh town Street
Winston-Salem, NC 27107
[phone]
GW-ls must be submitted within 30 days of completion of well construction. Copies of the GW-1
form(s) shall be retained on-site and available for inspection.
PART II-WELL CONSTRUCTION SPECIAL CONDITIONS
1. 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 (336) 7 71-5000.
2. 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 grout from the lowermost water bearing zone to land surface as specified in
the pem1it application .
WI0400115 2
'.
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.
PARTIV~PERFORMANCESTANDARDS
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 shail not relieve the 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 Perrnittee 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
Perrnittee 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
WI0400115 3 ,
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 in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information· submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly. submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
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 15A NCAC 2C .0213(h)(l), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
WI0400115 4
(A)
(B)
(C)
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.
The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
WI0400115
Aquifer Protection Section-VIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
Rogers, Michael
From: Berry, Stephen
Sent: Friday, August 28, 2009 1:23 PM
To: Rogers, Michael
Subject: RE: 5QM App
Mike,
Please issue the permit: WSRO wilt not conduct an inspection prior to permit issuance.
Sorry for the delay,
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
Sent: Wednesday, August 19, 2009 10:22 AM
To: Knight, Sherri
Cc: Berry, Stephen
Subject: SQM App
Please find attached an App for a SQM well. 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)
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

AVA MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
August 18, 2009
John Sessions
Historic Propety Preservation LLC -SQM
349 Arbor Road
Winston-Salem, NC 27104
Subject: Acknowledgement of Application No. WI0400115
Historic Property Preservation LLC -5QM
Injection Mixed Fluid GSHP Well $ystem'(5QM)
Forsyth
Dear Mr. Sessions:
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 10, 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 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 ~y the
Division. Please also note at this time, processing permit applications can take as long as 60 -90 days after receipt of a complete
application. ·
If you have any-questions, please contact Michael Rogers at 919-715-6166, or via e-mail at [e-mail]. If the
reviewer is unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To
review our new organizational chart, go to http://h2o:enr.sta.te.nc.us/documents/dwq ornchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
Ou.!ttA.~
for Debra J. Watts
Supervisor
cc: Winston-Salem Regional Office, Aquifer. Protection Section
David Brown (Yadkin Well Co -1908 Hamptonville Rd, Hamptonville, NC 27020)
Dwain Strader (Cellusun Heating & Air -1175 Oregon Hill Rd, Reidsville, NC 27320)
Permit Application File WI0400115
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588;-FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity \ Affirmative Action Ernployer
Nirthcarolina
/;atural~tt
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 5QM WELL(S)
f ') New Permit Application OR Renewal (check one)
DATE: fly l+51
PERMIT NO.
A.
, 20 t 1
(leave blank if NEW permit application)
PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): jj s tb ter Propel" )ores t va 1-ro►l,
(1) Mailing Address: 391 Arbor Rd
(2)
City: Wivis1 V'- S.) awr State: Nc Zip Code: 2 "7 r ❑ t
Horne/OfFice Teie No.: 33 6- 7 z s- O y 3 a Cell No.:
EMAIL Address: )Q1rtn_,5eS +r. &owa
County: Frsyt12
Physical Address of Site (if different than above):
City: State: Zip Code: County:
Horne/Office Tee No.: Cell No.:
EMAIL Address:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: s r5tor17 Preye-flyPre Se-rVel ' o 7 LLC
Contact Person: -Sn kAv' Sj € s S o' 15 EMAIL Address: i o w+ S e55 i v el 5 Q
Address: 399 Ai- L.or 12d
City: W ivlStlo+? - Se } r a State: WC Zip Code: 2'7 / v 9 County: Po, S
Office Tele No.: ).6 - 72 S- v y 3 ❑ Cell No.:
Website Address of Company, if any:
C. STATUS OF APPLICANT
Private: i` Federal:
State: Municipal:
Commercial:
Native American Lands: RECEIVED / DENR I DWC�
Aquifer Protection Section
AUG 102009
GP1L3Jtl[C 5QM Well Permit Application (Revised 7/2008)
Page I

D. WELL DRILLER INFORMATION
CompanyName: 1/JM>10.IJ UJ £L-L. C.O .. ,. Le..
Well Drilling Contractor's Name: _J)~, ~&J---=---"1~·0_3....--ac ....... 'R ...... o=--w__.N _______________ _
NC Contractor Certification No.: __ o?__.__J ___ 'j_~ ___ -_,4-__________________ _
Contact Person: =:i) A:v , D J5 Ro w kl EMAIL Addre ss: a H:, e f J r i I I e (l. Q ms 1.J. C<l /YI
Address: ) CJo g' 1-kmpJD N v, c....<.e FD
City: ~-r,)NV,~tf: ZipCode: ~?oq-0 County: ___________ _
Office Tele No.: '-60 ~ -d"""'ff -93 6 S Cell No.: 3 ,3k -3 '7 if:: ~ 7 3"
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyName: C£,A.,wsuAJ ~ i f1L, :I;,J(.,
Contact Person: :I> w A-I AJ 'S m~ Ea.. EMAil.. Address: Ceu.µsc,, ,J (!_ ]O U c k/-Ne. • N E-T
Address: 1 1 7 ~ 0 R E. Qunl tfi u.. Clo1
City: i?e, Dsv 1 t...-'-€. Zip Code: 2:"'> 3 e:Q County: 7?oq c,'M; hem
Office Tele No.: 3 ~(p .. ~<fl ... / 0 CJ '-r Cell No.: 3 31, ., l, I 3-lf: R;)-b
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
weus JD 8 e 72n ,:o,·u5 h&r--7 6,c e,,1htJy,c fu(l. khv1e +-
:pr;o L-
G. WELL CONSTRUCTION DATA (Ski p to Section H if this is a Permit RENEWAL)
(1) Proposed date to be constructed: 4 7 o 9 Number of borings: __ cg __ _
Approximate depth of each boring (feet): _ _;;;:.3c......,t,,c,_o;;___ ___ _
(2~ Chemical additives to be used in closed-loop system ( only those ~hemicals indicated have been approved):
___ R-22 __ _.pr opylene glycol __ ethanol eNw ~ IJf) Lor other ( other additives will
need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): _-P_v_c:,_... __________ _
(4) Well casing. Is the well(s) cased? (check either (a.) YES m: (b.) NO below)
(a) YES ___ if yes, then provide casing information such as~ (steel, PVC, plastic, etc.), diameter,
de_pth, and extent of casing appearing above ground: _______________ _
(b) NO )(
I
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement_ Bentonite A Other (specify) ______ _
(b) Grout depth of tubing (reference to land surface): from O to 6 i, o (feet)
If well has casing, indicate grout depth: from ___ to ____ (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
infonnation.
GPU/UIC SQM Well Permit Application (Revised 7/2008) Page2
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothermal heat pump well system. Label all features 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)
Are there any potable water wells) on the subject property or adjacent properties?
If Yes, than indicate location on attached map(s).
K. CERTIFICATION
YES t NO
Note: This Permit Application must be signed by each person appearing on the recorded legal property deed.
"I hereby certify, under penalty of law, that f 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"
S. _ ature of Pr erty Owner/Applicant
s-srev/ s 14'.rtorr1210 tyemfer nLLC
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
5isfure of Ayoriaed Agent, if any
S 1^I.,I Se s s!'vr►
Print or Type Full Natne
Please return two copies ate completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QM Well Permit Application (Revised 7/2008) Page a

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cannot guarantee the accuracy
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as to the accuracy of this
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