WI0400172_GEO THERMAL_20170206

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
Water Resources
Environmental Quality
S. JAY ZIMMERMAN
February 6, 2017
Glen and Cynthia Smith
900 Evans Rd.
Thomasville, NC 27360
Subject: Permit Rescission
UIC Permit No. WI0400172
Geothermal Heating/Cooling Water Return Well
Davidson County
Dear Mrs. and Mrs. Smith:
Reference is made to your request for rescission of the subject Geothermal Heating/Cooling Water
Return Well Permit located at the above referenced address. Staff from the Winston-Salem
Regional Office has agreed that a permit is no longer required. Therefore, in accordance with your
request, Underground Injection Control (UIC) Permit WI04001 72 is rescinded, effective
immediately.
If in the future,·you wish to operate a Geothermal Heating/Cooling Water Return Well injection
system, you must first apply for and receive a new permit. . Operating a geothermal heat pump
injection system without a valid permit may result in the assessment of civil penalties and/or the
use of other enforcement mechanisms available to the state.
If it would be helpful to discuss this matter further, please do not hesitate to call Shristi
Shrestha at(919) 807-6406.
r
Attachment( s)
Sincerely,
Jay Zimmerman, P .G., Director
Division of Water Resources
cc: Winston-Salem Regional Office -WQROS
Central Files -Permit No. WI0400172
Davidson County Environmental Health Dept.
--~.:Y-Nothing Compa~s\:.--
State of North Carolina I Environmental Quality I Division of Water Resources
Water Quality Regional Operations Section
1636 Mail Service Center-I Raleigh, North Carolina 27699-1636
919-707-9129
Director
Rogers, Michael
From: Rogers, Michael
Sent: Monday, January 23, 2017 2:17 PM
To: Gonsiewski, James J
Cc: Knight, Sherri
Subject: RE: Permit #W10400172
Attachments: W10500211 Smith Rescission Request Form.doc
Yes, please conduct a site inspection and complete the attached form and return.
Thanks
From: Gonsiewski, James J
Sent: Monday, January 23, 2017 1:22 PM
To: Rogers, Michael <[e-mail]>
Cc: Knight, Sherri <[e-mail]>
Subject: FW: Permit #W14400172
Michael,
1 avid be out tomorrow and can easily check this site to make sure the work has been done (Mr. Smith told me he had
buried the line). I assume it'll be OK to d❑ it then
Thanks,
Jim G
Jim Gonsiewski, PG
Hydrogeologist
Division of Water Resources
Department of Environmental Quality
336-776-9704 office
336-486-7584 mobile
Winston-Salem Regional Office
450 W. Hanes Mill Road, Suite 30D
Winston-Salem, NC 27105
Email ccrrespondefice to ,and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

From: Glenn Smith Imailto:glennsmith(u)abf.com]
Sent: Monday, January 23, 20171:17 PM
To: Rogers, Michael <[e-mail]>
Cc: Gonsiewski, James J <iim.gonsiewski@ncden_r.gov>
Subject: Permit #W10400172
Mr. Rogers,
This email is to confirm that I am not using nor is the new owner of 900 Evans Rd. Thomasville, NC 27360 using the
return well for the Geo Thermal System. The water from the system has been diverted to flow back into Rich Fork
Creek. At this time I would like for you to cancel permit #W10400172.
Thanks,
Glenn smith
Glenn Smith I Regional Manager Safety and Security I ABF Freight— An ArcBest5m Company j p: 336-993-9500
Office, 336-416-6269 Cell I leg nnsmith0abf.com
ABF

Permit Rescission Request Form
Information to be filled out by Central Office
Date: 1/23/17
Permit No.: WI0400172
Permittee: Glenn Smith
Facility Name: Smith SFR
Regional Office: Winston-Salem
County: Davidson
Date Rescission Requested: 1/23/17
RECEIVED/NCDEQ/r)WR
JAN 3 1 2017
Water Quality P~eg1onal
Operations Section
Received Original Request: [KJ Central Office* D Regional Office
*email also rec'd by RO
Form of Received Request: I X I Letter/Email D Signed Annual Fee Invoice D Other {form)
Annual Fees Paid to Date: NI A
Information to be filled out by Regional Office
Please Check Appropriately:
!2J Site Visit Performed
Recommendations ( check one block below):
~ Rescind Permit Immediately
D Groundwater Concerns Addressed
Reason for Approval ~ r-n. ~ ~ t\~ SD \c1, ~CL~ O\AS(( ~ nd. 'n ets ~t tj-tf\~ N. net>
J ;'i@\()ri ~ ~ l,\J <-cJ,'v::n V-'~\ \ ~ YV) '½'he. !.' !:1 i-e m
D Require Renewal with Suspended Actions
Recommended Actions to be Taken -----------------------
D Do Not Rescind/Recommend Renewal
Reason for Denial -----------------------------
Typed or Printed Name of RO Certifier: �cl ri-) e S T, C� C) nS , -cw S I i
Date Certified: 1 I �.S I 1
Return Completed an Slgned Form to the WQROS Section in the CO. Thanks.
Any other
eamments/notes: nz -�orn ^-e- e YN e C��t'►
Page 2 of 2

Rogers, Michael
From:
Glenn Smith <[e-mail]>
Sent:
Monday, January 23, 2017 1:17 PM
To:
Rogers, Michael
Cc:
Gonsiewski, James J
Subject:
permit #W10404172
Mr. Rogers,
This email is to confirm that 1 am not using nor is the new owner of 900 Evans Rd. Thomasville, NC 27360 using the
return well for the Geo Thermal System. The water from the system has been diverted to flow hack into Rich Fork
Creek. At this time I would like for you to cancel permit #WI0400172.
Thanks,
Glenn smith
Glenn Smith i Regional Manager Safety and Security
Office, 336-41.6-6269 Cell I [e-mail]
A6F Freight' —An Arc6ests' Company I p: 336-993-9500

5A -7 .
Rogers, Michael Pv-T 0 1.�00 ( 4 2-
From:
Gonsiewski, .fames J
Sent:
Wednesday, January 18, 2017 2:49 PM
To:
Rogers, Michael
Cc:
Knight, Sherri
Subject:
RE: W10400172
Attachments:
Smith Data 1117-pdf
Michael,
I'm thought I sent it. Anyway the data is attached. Please let me know if you have any questions or need anything else.
Thanks;
Jim G
Jinn Gonsiewski, PG
Hydrogeologist
Division of Water Resources
Department of Environmental Quality
336-776-9704 office
336-486-7584 mobile
Winston-Salem Regional Office
450 W. Hanes Mill Road, Suite 300
Winston-Salem. NC 27105
t
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Rogers, Michael
Sent: Wednesday, January 18, 2017 2:37 PM
To: Wang, Shuying <[e-mail]>; Knight, Sherri <sherri.knight @ncdenr.gov>; Gonsiewski, James J
<j i m.go nsi a wsk i @ n cde n r,gov>
Cc: Watts, Debra <[e-mail]>
Subject: RE: W10400172
Jim-

I rec'd the staff request form. You indicated lab results were attached, but there was none attached. You can send in
reply to this email.
Also, I called Mr. Smith and he will be sending the permit rescission request email today or tomorrow.
Thanks
From: Wang, Shuying
Sent: Thursday, January 05, 2017 3:03 PM
To: Rogers, Michael <[e-mail]>; Knight, Sherri <[e-mail]►r>; Gonsiewski, James J
< i im.go nsiewski @ ncden r.gov>
Cc: Watts, Debra <[e-mail]>
Subject: RE: W10400172
Sherri,
Should this be given to Jim? Let me know. Thank you!
Shuying Wang, P.G.
Hydrogeologist
Division of Water Resources
NC Department of Environmental Quality
Winston-Salem Regional Office
Phone: {336y 775-9702
Mobile_ [phone]
Fax: [phone]
Email: Shuying.Wang@)ncdenr.gov
450 W Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
http: //po rta 1. ncd en r.o rj�/web/wq
� �, �-r'"i'+,Fo�i°►ing �cantparcti -__
11 _
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 unless the content is exempt by statute or other regulation.
From: Rogers, Michael
Sent: Thursday, January05, 2017 2:59 PM
To: Wang, Shuying Knight, Sherri <sherri*night@ncdenr _govr, Gonsiewski, James J
[im . eg nn s ie wsk ia+ ncdenr, g ova
Cc: Watts, Debra rdebra.watts[ ncdenr.gau>
Subject: RE: W10400172
Attached is the permit renewal package.

From: Wang, Shuying
Sent. Thursday, January 05, 2017 9:52 AM
To: Rogers, Michael <michaeI.ro�ers(@ncdenr,E;tiv>; Knight, Sherri <Sherri.knight@ncdenr,Fov>; Gansiewski, James i
�'ii ,gonsiewski��nodenr.�ov-.
Subject: RE: W10400172
I have not seen this one.
Shuying Wang, P.G.
Hydrogeologist
Division of Water Resources
NC Department of Environmental Quality
Winston-Salem Regional Office
Phone: [phone]
Mobile: [phone]
Fax: [phone]
Email. 511uyIng.Wan ncdenr.Egv
450 W Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
http://Portal.ncdenr.oi- lweblvvq
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 unless the content is exempt by statute or other regulation.
From: Rogers, Michael
Sent: Thursday, January 05, 2017 9:50 AM
To: Knight, Sherri <sherrUni6ht&ngdenr.gov>; Gansiewski, James J ciim.gonsiewskijPncdenr. ova; Wang, Shuying
Esh uyi ng, wa nR @ n cde n r.gov>
Subject: W10400172
Hello -
I was checking on the status of the staff report for the geotherrnaI well permit renewal for:
W10400172 Smith
L
____ __L ___ — ___ -
l sent over the request 11j1/2016
Thanks

Michael Rogers, P.G. {NC & FL)
Underground Injection Control {UIC) Program Manager -Hydrogeologist
NCDEQ-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6412
htt p://de g .nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch /g round-water-
p rotection /g round-water-a pp lications
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
4
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Water Resources
ENVIRONMENTAL QUALITY
February 5, 2016
CERTIFIED MAIL # 7014 1200 0001 3432 8640
RETURN RECEIPT REQUESTED
Glen and Cynthia Smith
900 Evans Rd.
Thomasville, NC 27360
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0400172
Davidson County
Dear Mr. and Mrs. Smith:
seerefmy
S. JAY ZIMMERMAN
Direclor
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on February 17, 2011, and expired on January 31, 2016. Per permit conditions and
requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior to expiration of the permit if you wish to continue operating the injection well
on your property. According to our records, the permit renewal application is now past due.
Please submit your renewal application (attached) as soon as possible if you wish to continue using
the well for injection.
If Your Geothermal Water Return Well is Still Currently Bein, Used for Injection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http://poi-tal.acdenr.org/web/wq/aps/gwpro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Being Used for In'ection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
State of North Cam9na I Envirot=antal Quality j Water Resoutcrs
1611 Mail setvi= Center I Raleigh, North Caroluia 2761,*-1611
919 707 9WO

Page 2 of2
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
If There has been a Change of Ownership of the Pro perty :
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email at [e-mail].
:~
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Winston-Salem Regional Office -WQROS w/o enclosures
Central Files -Permit No. WI0400172 w/o enclosures
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rq Glen and Cynthia Smith
"r r 900 Evans Road
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M Thomasville, NC 27360
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- PS Form 3s0U, AVgUST ZVVb aee neverac wr „IWIU VI I� 1
■ Complete items i, 2, and 3.
■ Print your name and address on the reverse
so that we can retum•the card to you.
■ Attach this card to the back of the mallplece,
or on the front N space permits.
1. Article Addressed to:
Glen and Cynthia Smith
900 Evans Road
Thomasville, NC 27360
Shristi Shrestha
A
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Agent
B. Racelved by (Printed yfine) C. Dffts of Dal
D. Is delivery address drfferent from item 17 ❑ Yas
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Domestic Return Receipt

WATER QUALITY REGIONAL OPERATIONS NS SECTZO�
APPLICATION REVIEW REQUEST FORM t�virorrme Talent Q>
e�eivedQuallty
Date: November I, 201E NOV 0 3 2016
Wlrtstan-salam
Sherri Knight —George Smith Itegionr► Offirn
�: Michael Rogers, WQROS — Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Far. [phone] E-Muii: [e-mail]
A. Permit Number: W10400172
B. Applicant: Glenn and Cynthia. Smith
C. Faciliv, Name:
❑. Application: i,ECE VEDINCDEGIOV i
Permit Type: Geothermal Heating/Cooling Water Return Well 2AN 17 2017
Project Type: Renewal Water ❑iialltyr Reginly!
Operatians sficw n
& Comments/Other Information:
❑ I would like to accompany you on a site visit.
Attached., you will find all information submitted in support of the above -referenced application for your
review-, comment, and/or action. Within 30 calendar days, please return a com�,leted W. ROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this shee-, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WQRO4 Reviewer: Date:
X1131u l Aat1 RT
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FO%M: WQROS-ARR tier. 092614 Pago i of f

PAT MCCRORY
Governor
DONALD.R. VAN DER VAART
Secretary
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
October 31, 2016
Glenn and Cynthia Smith
900 Evans Road
Thomasville, NC 2 73 60
RE: Acknowledgement of Application No. WI0400172
Geothermal Heating/Cooling Water Return Well
Davidson County
Dear Mr. and Mrs. Smith:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application on October 26, 2016. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Winston-Salem Regional Office staff will perform a detailed review of the
provided application, and may contact you with a request for additional information. To ensure
maximum efficiency in processing permit applications, the Water Quality Regional Operations
Section (WQROS}.requests your assistance in providing a timely and complete response to any
additional infonnatfon requests. ·
P]ease note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. If you have any questions, please contact Michael
Rogers at 919-807-64 l 2 or [e-mail].
/µ,f ~ (J 11 r Debra.J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
cc: Winston-Salem Regional-Office, WQROS
Permit File WJ0400172
Division of Water Resources
State ofNonh Carolina I.Enviromnental Quality I Water. Resources
1'636 Mail Service Center !:Raleigh, North Carolina 27699-1636 ·
j-l9' 707 9,129
Director
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES .
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL (S)
·These well(s) inject groundwater cµrectly into the subsurface as part of a geothermal heating and cooling system
. CHECK ONE OF THE FOLLOWING:
__ New Application /2.en~wal* __ Modification __ Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: (J'}_, .. JZ-,20 Ito PERMIT NO.Wl()l./oO 17 2.. (leave blank ifNew Application)
A. CURRENT 'WELL .USE AND ·OWNERSHIP STATUS (leave Blank if New Application)
B.
C.
1. Current Use of Well
a. Continue to use as ✓ Geothermal Well __ Drinking Water-Supply · __ Other Water
Supply .
b. Terminate Use: If the well is no longer being used as a geothermalinjectioti well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30). RECE(VEO/NCDEQ/DWR
D Yes, I wish to rescind the permit . OCT 2-·} 2016
2. Current Ownership Status Water Quality Regional
Has there been a change of ownership since permit last issued? 0 YES ~ N§perations Section
If.yes, indicate new owner's contact information:
Name(s) _____________________________ _
Mailing Address: ___________________________ _
City: __________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: Email Address.:
STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence~ Business/Organization __
Government: State Municipal __ County __ · Federal
WELL OWNER(S)/PERMIT APPLICANT -For individual residences, list owner(s) on pr~erty deed. For
all others, list name of entity and name of person delegated authority to sign: C!:A DJ ,J /1\ ..... s;~n ;:-n( ~ YJ.J r>fH/
£ ✓ /114.';. Sm~;){
Mailing Address: · 2Jtt> € V 11/\1.S t'LJ ...
City: 7?A>m11s~aa:~ State:~ Zip Code: Z73CtD County: J:y; ✓Q}J~µ
Day Tele No.: 33l, .. t/72-1254 . Cell No.: s~ ·· ¢/(, .. 4•26'/
EMAIL Address: q/e.1111 Sm ,& tl,{')-l'~if/,1 1)£1: ti'n? Fax No.:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 1
D. WELL OPERATOR (if different from well owner) -For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the business
or agency: _____________________________ _
Mailing Address:--------------------------------
City: ____________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: Email Address.:
E. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1)
(2)
Parcel Identification Number (PIN) of well site: __________ County: _____ _
Physical Address (if different than mailing address): ________________ _
City: ________________ State: NC Zip Code: _________ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: __________________________ _
NC Well Drilling Contractor Certification No.: _____________________ _
Company Name: ________________________________ _
Contact Person.-=-: _______________ EMAIL Address: ___________ _
Address: __________________________________ _
City: __________ Zip Code: _____ State: __ County: _________ _
Office Tele No.: _________ Cell No.: Fax No.: ________ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: ____________________________ _
NC HVAC Contractor License No.: _________________________ _
Company Name: ________________________________ _
Contact Person'-'-: _______________ EMAIL Address: ___________ _
Address:-----------------------------------
City: __________ Zip Code: _____ State: __ County:
Office Tele No.: _________ Cell No.: __________ Fax No.: _______ _
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS-As specified in 15ANCAC 02C .0224{d):
( 1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page2
NOTE. In most cases an aerial photograph of the property parcel showing property lines and ,structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to properly boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC U2C .021 i e requires thatall permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3, for a municipality or a state, federal, or other public agency- by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the erson s listed on the property deed.
P
If an authorized agent is signing on behalf of the applicant, then supply a levier signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
Signature of Property Owner/Applicant
Print or Type Full Name
(Sjfns of Noperty Own icant -
rint'or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geotbennal Water Return Well Permit Application (Revised Ian 2015) Page 4

(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
____ *EXISTING WELLS ____ PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(0(8)
(f) Length ofwell ·screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATINGDATA
(1) Injection Rate: Average ( daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) lJ:\iection Pressure: Average ( daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP -As specified in I SA NCAC 02C .0224(b)(4). attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following: ·
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential ·sources of contamination listed in 15A NCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page3
W ater Resources
ENWRONM047AL QUA41TY
JAN 17 Z017
W11W dLuality Hagton
()O'atgati�nt S(V%bor
Mx, Glen Smith
2992 Bethesda Road
Lexington, North Carolina 27295
December 16, 2016
SUBJECT: Laboratory Analytical Results
Geothermal Heating/Cooling Water Return Well
Permit No. WI0400172
Davidson County
Dear Mr. Smith:
PAT MCCRQRY
r'e; 0wrlar
DONALD R. VAN DER VAART
Sefrpwapy
S. JAY ZIMMERMAN
,t}invaw•
oV W631 ',e.D1�
Jim Gonsiewski and Min Xiao of the Division of Water Resources (DWR) collected
groundwater samples from the influent and effluent access points to your Geothermal Heating/Cooling Water
Return Well. The samples were sent to R&A Analytical Laboratories in Kemersville, NC and the DWR
Central Laboratory in Raleigh, NC for analysis.
The samples were analyzed for fecal coliform, bromide, fluoride, chloride, sulfate, total dissolved solids,
hardness, nitrate, nitrite, aluminum, arsenic, calciurn, chromium, copper, iron, lead, magnesium, manganese,
nickel, potassium, sodium, and zinc, Laboratory analytical results from the samples did not detect any
constituents above the State of North Carolina 15A NCAC 02L .0202(g) (NC2L) groundwater standards.
Copies of the laboratory analytical reports are attached.
We appreciate your cooperation in the collection of these samples. If you have any questions, please contact
me at [phone] or via email [e-mail].
Sincerely,
.Tames J. Gonsi� F.G.
s
Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ — WSRO
enc.: Laboratory Analytical Reports
cc: Davidson County Environmental Health
WSRO Piles
450 W. F anes MITI Road, Suite 300, Winston -5afom, North Carolina 27105
Phone; 336.776-98001 FAX: [phone] I Customer Service 1.877-623.6748
Internet www. ncderrr. e ov - www.ncwater.Ora

AC33792 North Carolina Division of Water Resources Water Sciences Section Laborato1y Results
Loe. Descr.: SMITH RESIDENCE
,
Sample ID: AC33792
County: DAVIDSON Collector: J GO NSIEWSKI VisitlD PO Number#
Region: WSRO Report To ~ Location ID: 4P029WI0400172 Date Received: 11/18/2016
River Basin YAO Collect Date: 11/17/2016 Priority ~ Time Received: 08:30
Emergency Collect Time: 11:54 Sample Matrix: GROUNDWATER Labworks LoginlD ~
COC Yes/No Sample Depth Loe. Type: WATERSUPPLY Delivery Method NC Courier
Final Report Date: ll!!!1i
Report Print Date: 12/08/2016
Final Re port
If this report is labeled preliminary report, 'the results have not been validated. Do not use for Regulatory purposes.
Result/ Units · Method Analysis
CAS# Analyte Name PQL Qualifier Reference Date Validated b)'.
LAB·
Sample temperature at receipt by lab 1.3 ·c 11/18/16 MSWIFT
NUT
Nitrate as N in liquid 0.02 0.02 U mg/Las N EPA 353.2 REV 2 12/2/16 CGREEN
Nitrite as Nin liquid 0.01 0.01 U mg/Las N EPA 353.2 REV 2 11/18/16 CGREEN
N02+N03 as N in liquid 0.02 0.02 U mg/Las N EPA 353.2 REV 2 12/1/16 CGREEN
WET
Bromide 0.4 0.4 U mg/L EPA 300.0 rev2.1 11/29/16 CGREEN
Chloride 1.0 4.7 mg/L EPA 300.0 rev2.1 11/29/16 CGREEN
Fluoride 0.4 0.4 U mg/L EPA 300.0 rev2.1 11/29/16 CGREEN
Sulfate 2.0 47 mg/L EPA 300.0 rev2.1 11/29/16 CGREEN
Total Diss.olved Solids in liquid 12 265 mg/L SM 2540 C~1997 11/21/16 CGREEN
MET
7429-90-5 Al by ICP 50 50 U ug/L EPA 200.7 Rev4.4 11/28/16 ESTAFFORD1
7440-38-:2 As by ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 11/23/16 ESTAFFOR,D1
7440-70-2 Ca by ICP 0.10 70 mg/L EPA 200.7 Rev4.4 11/28/16 ESTAFFORD1
7440-47-3 Crby ICPMS 5.0 5.0 U ug/L EPA 200.8 Rev5.4 11/23/16 ESTAFFORD1
7440-50-8 Cu by ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 11/23/16 ESTAFFORD1
7439-89-6 Fe by ICP 50 50 U ug/L EPA20b.7 Rev4.4 11/28/16 ESTAFFORD1
Hardness by Calculation 1.0 190 mg/L SM 2340B-199T 12/8/16 ESTAFFORD1
7440-09-7 Kby ICP 0.10 1.9 mg/L EPA 200.7 Rev4.4 11/28/16 ESTAFFORD1
7439-95-4 Mg by ICP 0.10 2.9 mg/L EPA 200.7 Rev4.4 11/28/16 ESTAFFORD1
7439-96-5 Mn by ICP 10 12 ug/L EPA 200.7 Rev4.4 11/28/16 ESTAFFORD1
7440-23-5 Na by ICP 0.10 19 mg/L EPA 200.7 Rev4.4 11/28/16 ESTAFFORD1
7440-02-0 NibylCPMS ·2.0 2.0 U ug/L EPA 200.8 Rev5.4 11/23/16 ESTAFFORD1
7439:.92-1 Pb bV ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 11/23/16 ESTAFFORD1
7440-66-6 Zn· by IC.PMS 10 22 ug/L EPA 200.8 Rev5.4 11/23/16 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
"Not Detected". or "U" does not indicate the sample is analyte free bL!t that the analyte is not detected at or above the PQL.
Page 1 of 1
T_�;
North Carolina Division of Water Resources
Central Laboratory
ry CWaterSciences Section]
Water Sample Collection & Submittal Form
" V!%1t II3:
j..ylrxnu,']
:iarl
lA
Lob �ISe:Uitl�r __
__-_ ____..__--____--
Laboratory
,�
location t7��scription:, '� �q + r�
l� 1� �G C�
tracoEion Cwde:
k.�{� � 'a['� � [� p� rt j �]
v 10 0 1 L
Sample Number.
❑ofA R�teived'
rounry ' 0. V ` So Y\
Collector:- + r
y
Priority'
❑ Amblem
t�
inHoutine
❑Compliance
❑COC
❑Ernergenc�r
❑UA
Lilnter Ma trlx:
❑ Surface
Ground
❑Waste
❑Blank
❑Solution
--
Lacotion Type:
❑River/Stream
❑Estuary
❑stormwater
❑MonitaringWell
❑Efftuent
❑geld Blank
❑F[tW Blank
❑Other,
Lake
❑Canal
�AlaterSupply
[]influent
❑Trip Blank
-----
Time keceiveQ:
` DwV Renion; �
!!:n;ed ru rncrn:; ! S
t7WR r3jflte "
❑oercu �nR r-9 �--y
R
Rere+ved $y:
state Courier
Delivery iuerhod�
rf ❑Hand Delivery
❑other.
-
Ri'verSvsirr: r
Date, j i
L b
Notes.
Time: ! � r� L
Chlorinated D5-rNorinated in Field
❑ ❑
sampling XGraq Composite
rV)eihnd: _I Cher
Temperature ('C)
on Arr+val :
Dissolved amlysiw Enter'DIS"
❑ Filtered in Field in cherk-0uxes far parameters
l,rlc'c:rrtrsCc�rr�t,ts��'
Sample Depth:
' V b ���
Miero4fiofvgy Parariieterg:�:N.MflMBAS
(surfactants)
mg/L
NetaTs Parameters:''
Tin (Sn)
µfill
Acidity, as CaCO3, to pH 4.518.3 mg/L
Oil and Grease, HEM, Total Recoverable
mg/L
UXAlurninurn
(Al)
ntlmony (Sb)
_ iig/L
µg/L
Titanium (Ti)
µB/L
Alkalinity, as CaCO3, to pH 4.51&3 mg/L
Phenols, Total Recoverable µB/L
Vanadium (V)
µB/L
HOD: 8lochemlcal Oxygen Demand, 5-day mg/L
Residue: Total (Total Solids)
mg/L
Arsenic (As)
Ng/L
Zinc {Zn}
µB/L
cHOD: Carbonaceous HOD, 5-day mg/L
Residue: Volatile/Fixed, Total
mg/L
Barium (Ba)
µg/L
Coliform: Fecal MF /100ml
Residue: Suspended (SuspendedSollds)
mg/L
Beryllium (Be)
µg/L
Boron (8), Total
µB/L
Cvliform: Total MF /10Dml
Resldue: Volatile/Fixed, Suspended
mg/L
Cadmium (Cd)
µB/L
Mercury 1531, low-level
ng/L
Coliform: Tube Fecal /1DDmi
IDS - Total Dissolved Solids
mg/L
Calcium (Ca)
mg/L
CcHom: Tube Total /loom(
Silica
mg/L
Chromium (Cr), Total
µg/L
Organics. Parameters:
_
Specific Conductance, at25 °C umhosl=
Sulfide
mg/L
Cobalt (Co)
}ig/L
Acid_ Herbicides
TDC-Total Organic Carbon mg/L
Tannin & Ugnin
rng/L
Copper (Cu)
lrg/L
_
ftanochlorine Pesticides
Turbidity NTi1
Ir n (Fe)
Pg/L
Organonitrogen Pesticides
ead (Pb)
µg/L
Orpnophosphorus Pesticides
Fie
et.Cmnm istry. Pa�aeWfi: cY
S.U.
Lithium (LI)
µg/L
PCBs (polychlorinated biphenyls)
I-Promide mg/L
Hardness, Total as CaCO3 - by titration
mg1L
lagnesium (Mg)
mg/L
Chloride mg/L
Manganese (Mn)
µg/L
Semi -Volatile Organics (BNAs)
Fluoride mg/L
Mercury (Hg)
µB/L
TPH Diesel Range
Sulfate mg/L
k
' x_ -
Molybdenum (Mo)
}tg/L
Chlorophyll a µg/L
Ammonia as N (NH3-N)
mg/L
Nickel (M)
µg/L
Volatile Organics (VOA)
Cclar: ADM) r_u.
Nitrate -Nitrite as N (NO3+NO2-N)
mg/L
otassium (K)
mg1.L
Color: Platinum Cobalt C.U.
Total Kjeldahl Nitrogen as N (TKN)
m&IL
Selenium (Se)
µB/L
TPH Gasollne Range
COD: Chemical Oxygen Demand mg/L
Total Phosphorus as P (TP)
mg/L
611ver (Ag)
Ng/L
-
Cyanide, Total rng/L
>itrtte as N (NO2-N)
mglL
Sodium (Na)
Formaldehyde mg/L
Nitrate as N (NO3-N caicuiated)
mg1L
Strontium (Sr)
µgAL
Ph yto p Ian kto n / Algae
Hexava tent Chromium (Cr6+) mg/L
Orthophosphate as P (PO4)
mg/L
Thailium (TI)
pg/L
LAO COMMENTS :
ions 2/06/2015

AC33793 North Carolina Division of Water Resources Water Sciences Section Laborato ry Results
Loe. Descr.: SMITH RESIDENCE Sample ID: AC33793
County: DAVIDSON Collector: J GONSIEWSKI VlsitlD PO Number#
Region: WSRO Report To WSRO Location ID: 4P029WI0400172 Date Received: 11/18/2016
River Basin YAO Collect Date: 11/17/2016 Priority ROUTINE Time Received: 08:30
Emergency Collect Time : .1tli Sample Matrix: GROUNDWATER Labworks LoginlD MSWIFT
COC Yes/No Sample Depth Loe. Type: WATERSUPPLY Delivery Method NC Courier
Final Report Date: 12/8/16
Report Print Date: 12/08/2016
Final Re port .
If this report is labeled preliminary report1 the results have not been validated. Do not use for Regulatory purposes.
Result/ Units Method Anal~sis
CAS# Anal yte Name E.Q.b Qualifier Reference Date Validated bl!
LAB
Sample temperature at receipt by lab 1.3 ·c 11/18/16 MSWIFT
NUT
Nitrate as N in liquid 0.02 0.02 U mg/Las N EPA 353.2 REV 2 12/2/16 CGREEN
Nitrite as N in liquid 0.01 0.01 U mg/Las N EPA 353.2 REV 2 11/18/16 CGREEN
N02+N03 as N in liquid 0.02 0.02 U mg/Las N EPA 353.2 REV 2 12/:1/16 CGREEN
WET
Bromide 0.4 0.4 U mg/L EPA 300.0 rev2.1 11/29/16 CGREEN
Chloride 1.0 4.8 mg/L EPA 300.0 rev2.1 11/29/16 CGREEN
Fluoride 0.4 0.4 U mg/L E;PA 300.0 rev2.1 11/29/16 CGREEN
Sulfate 2.0 46 mg/L EPA 300.0 rev2.1 11/29/16 CGREEN
Total Dissolved Solids in liquid 12 264 mg/L SM 2540 C-1997 11/21/16 CGREEN
MET
7429-90-S Al by ICP 50 520 ug/L EPA 200.7 Rev4.4 11/28/16 ESTAFFORD1
7440-38-2 · As by ICPMS 2.0 2.0 U ug/L EPA 200.8 Revs.~ 11/23/16 ESTAFFORD1
7440-70-2 Ca by ICP 0.10 69 mg/L EPA 200. 7 Rev4.4 11/28/16 ESTAFFORD1
7440-47-3 Crby ICPMS 5.0 5.0·U ug/L EPA 200.8 Rev5.4 11/23/16 ESTAFFORD1
7440-50-8 Cu by ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 11/23/16 ESTAFFORD1
7439-89-6 Fe by ICP 50 50 U ug/l EPA 200.7 Rev4.4 11/28/16 ESTAFFORD1
Hardness by Calculation 1.0 180 mg/L SM 23408-1997 12/8/16 ESTAFFORD1
7440-09-7 K by ICP 0.10 1.7 mg/L EPA 200.7 Rev4.4 11/28/16 ESTAFFORD1
7439-95-4 Mgby ICP 0.10 2.7 mg/L EPA 200 .7 Rev4.4 11/28/16 ESTAFFORD1
7439-96-5 Mnby ICP .10 12 ug/L EPA 200.7 Rev4.4 11/28/16 ESTAFFORD1
7440-23-5 Na by ICP 0.10 18 mg/L EPA 200. 7 Rev4A 11/28/16 ESTAFFORD1
7440-02-0 Ni bytCPMS 2.0 2.0 U ug/L EPA ~00 .8 Rev5.4 11/23/16 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 11/23/16 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 10.U ug/L EPA 200.8 Rev5.4 11/23/16 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
"Not Detected" or "U" does not indicate the sample is analyte free but that the analyte is not detected at or above the PQL.
Page 1 of 1
North Carolina Division of Water Resources
Central Laboratory [Water Sciences Section}
- -- �G
=d C[t C10:'i I3PSCi1�3 Cis rl:'• i�
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Water Sample Collection & Submittal Form__,._
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a. ti
r,--.-.^---r.Y_.
Priority,'
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❑Comp#ante
❑ CDC
❑Emergency
❑CIA
..-_ --
i�VR°er MorriY.
. -' .
❑Surface
,Ground
❑ Waste
❑Blank
❑Solution
_
lUeatiarrType:
❑Rive;/Strearo
Est
❑Stormwater
❑Monitoring Well
❑Effluent
❑Field 6iank
❑Filter Blank
❑ other:
_
EILakrl
❑Canai
ate Supply
❑Influent
OTAp Blank
.
---
..Time kiec eoir- i;
-Gplleciur-
l IM9 Office:
WQRfJ
S
`Rowtine
Dam, 1 l
841 CFiVed i3:•
1 State Courier
r),,r,VCry rvrelhcjd: ❑Hand Delivery
r . ❑Crther•
-
Hares:
time:. j f L
❑ Chlorinated ❑De -chlorinated in Field
'°"Jpjrnq Grab Composite
hferhn i Other_.
-����-
Sample DQF]IOr;
icmprPrarure I CI
1n.Rrrly ,i
1
Dissolved analysis: Enter'"DIS'
❑ Filtered In Field in check-tmxes for parameb"
i rirlr<;rnr'.s i �rrrurerlrs.��
Niicrppirtlagy Pasarneters�±.rs..;w ;± „ "{
A+IBAS (sus#actants)
mg/L
e
Iylgtafs.Rararrletdrs,:
Tin (5n) µg/L
Acidity, as CaCO3, to pH 4-5/&3 mg/L
Oil and Grease, HEM, Total Recoverable
mg(L
p,1TAlurn1nurn
(Al)
pg/L
Titanium (Ti} Ng/L
Alkalinity, as CaCO3, to pH 4-5/8.3 mg/L
Phenols, Total Recoverable
Pg/L
Ay ±imony (Sb)
Ng/L
nadium (V) N6/L
BQpx slochemk ai oxygen Darnsr45-day mg/t
Residue: Totai (VotalSolfds)
mg/l.
arsenic (As)
NgA
ar
Zinc (Zn) WL
.cBOD: Carbonaceous BOO, 5-day mg/L
Residue: Volatile/Fixed, Total
mg/L
Barium (Be)
well-
Coliformx Feral MF /100M)
Residue: Suspended (Suspended Solids)
mgjL
Beryllium (6e)
NgjL
Baran (B), Total Ng/L
ColiforM.- Total MF j16Om1
esidue: Volatile/Fixed, Suspended
mg/L
Cadmium (Cd)
pg/L
Memury 1631, low-level ng/L
Coliform: Tube Fecal /100mi
TOS - Total Dissolved Solids
mg/L
Calcium (Ca)
mglL
Callform: Tube Total /Iooml
Silica
mg/L
Chromium (Cr), Total
Ng/L
jrie R, ra►n` =1
Specific Conductance, at 25'C umhosjcm
Sulfide
mg/L
•::obalt (Co)
pg/L
Add Herbicides
TOC - Total organic Carbon mg/L
Tannin & Lignin
mg/L
Copper (Cu)
iron (Fe)
pg/L
}ig/L
Organoworine Pesticides
Organonitrogen Pesticides
'Turbidity NTU
'i7xher i'afdil'1etPr5: .. ., _�
�s.u.
Lead (Pb)
tlg/L
Organophosphorus Pesticides
F_ YiretiixeesiisiryParame4Pl ;1,;;;., %ate,+
—mg/t. _LA
H
titttium(Lt]
pg/L
PCBs (palychiorinatedbtphen Is)
Bromide
fie rdness, Total as CaCO3 - byt1tration
malt
agnesium (Mg)
mglL
i
Chloride mg/L
5anganese (Mn)
pg/L
Semi -Volatile Organics (BNAsj
Fluoride rng/L
Mercur (Hg)
}lg/L
TPH Olesei Range
sulfate mg/L
'Molybdenum (Mo)
Pg/L
thloraphyll a pg/L
Ammonia as N (NH3-N)
mg/L
local [Ni)
Pg/L
Volatile Organics (VQA)
Color: ADMI C.U.
ltrate-Nttrke as.N (NO3+NO2-N)
mg/L
Potassium (K)
mglL
Color. Platinum Cobalt cu.
Total Kjeldahi Nitrogen as N (TKN)
mg/L
Selenium (Se)
11I /L
TPH Gasoline Range
Cop: ChernkaI oxygen Demand mg/L
r
-xrtal Phosphorus as P (TP)
mg/L
Silver (Ag)
lag/L
Cyanide, Tots! mg/L
r 'tribe as N (NO2-N)
mg/L
}r
Sodium (Na)
mglL
Formaldehyde mg/L
NPtrate as 1V. (NO3-N calculated)
mg/L
Strontium (Sr}
pg/L
Phyta tankton / Atgae
Hexava$ent:Chromium (Cr6+) mg/L
Orthophosphate as P (Pfl4)
mg/L-
Thalllum (TI)
pg/L
TAB COMMENTS :

;.. ,; Water
Ra m to ' ' Am
._ .,
Cd a ,.•. Method Resulf gpi_€ Standard - Analyst [ia� _rt ''-.E. Coli SW43B C 4ife. r Ahserrt LIP i 1;1'71E4t� 1;63p
nv recai �uue�rr��t�,r�nu,
T. .13-200.4 Cafi[ert
Absent
LP
1MP2015 -1,530
i liert'SOAPf0.lM.....-" 4 pesl ertC�a
U.b &W&M
21378-02
.
Slte:. EG, _
oile Fie.:
1111.71241E
11..14
• , �_
����] "
unn
''pig, `.
• '�
- •M.
-
_
- i- - .�s _ _ _
`3 -
- tl _.
;5t...
�,:::�:,:. =�' -'Water. -
- Anal►e�rs
��e.
-parameter. lVlethad: '• _ .;:.
_
S ';3 -
dti;::z SiarSdaFii
nal st
�;
ia#e lme.
E. Coii. 1i11�2238 Caliie►i
,. :: Absent
LP
1 #11'712NS 1630
a mat r9miAl rattan Found
-"otat60t ior: , Stir 82;.a B.-2004 CaiilerE. ' `
• .. Abse� :.:::.
' : =' _
L.P
11.11712016. IP.3(
Nn �actedk C.a#atinr�.fa�md
• = ummm'No"W u t
NA = nO orr-ary o
rngFL =- EI9 ► ,pb-t.. Fit t = R rt per rillllfa7l .[ppm]
� - "ies$ >t4� .fir 1�w Cj@�@CIi4Ff.�.lc�lt8
:
l*i FiPO..Bw43€6.SlF : *l# .

i
E
QLt
At

I
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE QUEST FORM
Date: November 1, 2016
To: Sherri Knight -George Smith
From: Michael Rogers, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
A. Permit Number: WI0400172
B. Applicant: Glenn and Cynthia Smith
C. Facility Name:
D. A pplication:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
D I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a completed WOROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: __________________ Date: _____ _
COMMENTS:
NOTES: Please record all well construction indicated on the well ta g. if present.
Thanks.
FORM: WQROS-ARR ver. 092614 Pagel of l
, .....
PAT MCCRORY
Governor
DONALD.R. VAN DER VAART
Secretary
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
Glenn and Cynthia Smith
900 Evans Road
Thomasville, NC 27360
October 31, 2016
RE: Acknowledgement of Application No. WI0400172
Geothennal Heating/Cooling Water Return Well
Davidson County
Dear Mr. and Mrs. Smith:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
pennit application on October 26, 2016. Your application p·ackage has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Winston-Salem Regional Office staff will perform a detailed review of the
provided application, and may contact you with a request for additional information. To ensure
maximum efficiency in processing permit applications, the Water Quality Regional Operations
Section (WQROS).requests your assistance in· providing a timely and complete response to any
additional information requests. ·
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. If you have any questions, please contact Michael
Rogers at 919-807-6412 or [e-mail].
Sincerely,
/~fdr-(5•r Debra.J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
cc: Winston-Salem Regional Office, WQROS
Penn it File WI0400172
Division of Water Resources
State ofNorth Carolina I.Environmental Quality I Water Resources
1'636 Mail Service Center I Raleigh, North Carolina 27699-1636
j)9707 9,1.29
D irector
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELLN
These well(s) inject groundwater directly into the subsurface as part of a geothermal beating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application /Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 02-- 12- _,20_ge _ PERMIT NO. WIN60 17 Z. (leave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave Blank if New Application)
1. Current Use of Well
a. Continue to use as �Geotherr al Well Drinking Water Supply Other Water
Supply
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30). RECENEDINCDEUDWR
❑ Yes, I wish to rescind the perniit
OCT S ,3 2016
2. Current Ownership Status Water alga 4 Regional
Has there been a change of ownership since permit last issued? ❑ YES N N@per atlofts Sedan
If yes, indicate new owner's contact information:
Name(s)
Mailing Address:
City:
State; Zip Code:
Day Tele No.: Email Address.:
County:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence—V BusineWOrganization
Government: State Municipal County Federal
C. WELL OWNER(S)IPERMIT APPLICANT — For individual residences, list owner(s) on pro erty deed. For
all others, list name of entityand name of person delegated authority to sign: CAFN+J 1Yi ••�►n i T11 0yw�tJ
Mailing Address:Cev E�r4i►S 40,
City: 77Aomw4ze State: _&�- zip Code: Z73416 County: `
Day Tele No.: _jWw _ �� ` �� 5 _ Cell No.:
EMAIL Address: ir eM Fax No.:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page I

D. WELL OPERATOR (if different from well owner) -For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the business
or agency: _____________________________ _
Mailing Address:--------------------------------
City: _____________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: ________________ E_m_a1_·1 _A_d_d_re_s_s_.: ___________ _
E. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1)
(2)
Parcel Identification Number (PIN) of well site: __________ County: _____ _
Physical Address (if different than mailing address): ________________ _
City: _______________ State: NC Zip Code: ________ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.: _____________________ _
Company Name: ________________________________ _
Contact Person-'--: _______________ EMAIL Address: ___________ _
Address:-----------------------------------
City: Zip Code: _____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ---------------------------
G. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: ____________________________ _
NC HVAC Contractor License No.: _________________________ _
Company Name: ________________________________ _
Contact Person_: _______________ EMAIL Address: ___________ _
Address:-----------------------------------
City: Zip Code: _____ State: __ County: _________ _
Office Tele No.: _________ Cell No.: __________ Fax No.: ______ _
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS -As specified in 15A NCAC 02C .0224 (d):
(1)
(2)
The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 2
NOTE In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county CIS website. Typically, the property can be searched bti,
owner name or address: The location of the wells in relation to proper(}, boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand Also, a 'layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211Ie! requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
I for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the person(s) listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply s letter signed by the
applicant that names and authorizes their agent to sign this application on their hebalf.
"1 hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
Signature of Property Owner/Applicant}
Print or Type Full Name
�Q f
�S4911a -e of Property OwnerrArplicant
r Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application (Revised Jan 20 15) Page 4

(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
____ *EXISTING WELLS ____ PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
( e) Grout material( s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107{0(8)
( f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATING DATA
(1) Inject.ion R3te: Ave.raee (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP-As specified in 15A NCAC 02C .0224(b)(4), attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
( 1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 3
Permit Number WI0400172
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (SA?)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facili
Facility Name
Glenn and Cynthia Smith SFR
Location Address
900 Evans Rd
Thomasville
Ow ner
Owner Name
Glenn
Oatee:/Even s
NC 27360
Merritt Smith
Scheduled
Orig Issue App Received Draft Initiated Issuance
01/27/11
Re qulated Activities
Heat Pump Injection
Outfall
Central Files: APS_ SWP_
02/10/11
Permit Tracking Slip
Status
In.review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Patrick Smith
PO Box 171
Stoneville NC
Major/Minor
Minor
Region
Winston-Salem
County
Davidson
Facility Contact Affiliation
Owner Type
Individual
.Owner Affiliation
Glenn Merritt Smith
900 Evans Rd
Thomasville NC
Public Notice Issue Effective
Re oue sted/Re ce ive d Ev en ts
RO staff report requested
RO staff report received
27048
27360
Expiration
01/31/11
02/07/11
Waterbody Name Stream Index Number Current Class Subbasln
North Carolina
Beverly Eaves Perdue
Governor
0946VA
NCDENR
Department of Environment and
Division of Water Quality
Coleen H. Sullins
Director
February 17, 2011
Glenn and Cynthia Stith
900 Evans Road
Thomasville, NC 27360
Re: Issuance of injection Well Permit
Permit No. W10400172
Issued to Glenn and Cynthia Smith
Davidson County .
Dear Mr. and Mrs. Smith:
Natural Resources
Dee Freeman
Secretary
In accordance with your application received January 27, 2011, 1 am forwarding Permit No. W10400172 for
the operation of a 5A7 geothermal underground injection control (LUC) well heat pump system located at the
above referenced address. This permit shall be effective from the date of issuance until January 31. 2016, and
shall be subject to the conditions and limitations stated therein.
Please contact Sherri Knight with the Winston-Salem Regional office at (3M) 771-5000 when the geothermal
system becomes fully operational with influent and effluent sampling ports. Water samples will then be
collected, and sent to the Division of Water Quality's laboratory for analysis. Results will be forwarded to you
when received by the regional office.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the peranit, 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 the at [phone].
Best Regards,
f
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
cc: Sherri Knight, Winston-Salem Regions? Office
Central Office File — W10400172
Davidson County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699.1636
Location: 2728 Capita Souleverd. Raieigh. Worth Carolina 27604
Phone; 919-733-3221 l FAx 1: 919-715.0588; FAX 2r 919.715-60481 Customer 5erv;ce 1 -87 7-623-674 8
Internet www.newateraualitv.ora
An Equa! DpportaMy I1VFtm9va A..I*ri Er"Mykr
NorthCarolina
Naturglll

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
Glenn and Cynthia Smith
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 900 Evans Road, Thomasville, Davidson County, NC 27360, and will be constructed
and operated in accordance with the application received January 27, 2011, and in conformity with the
specifications and supporting data submitted, all of which are filed with the Department of Environment and
Natural Resources and are considered a part of this permit.
This permit is for operation of an injection well 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 January 31, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
Pen -nit issued this the �_ day of Lorv--s , 2011.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0400172 UIC/5A7 Page 1 of 5
ver.03/2C10

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 aqu~fers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. · Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
PART II -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 Pennittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
Permit #WI0400172 UIC/SA7 Page 2 of 5
ver. 03/2010
PART III -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. 1n· 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 Pennittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not ·relieve the Pennittee of the responsibility for damages to surface or
groundwater resulting from. the operation of this facility.
PART IV -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.
PART V -INSPECTIONS
1. Any duly authorized -officer, employee, or representative of the Division of Water Quality may, upon
-presentation of credentials, enter and insp~ct 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 sa,mples associated with the
injection facility activities.
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, -or soil _ sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
· Permit #WI0400172 UIC/SA7 Page 3 of 5
ver. 03/2010
2. The Permittee shall report by telephone~··· within:·· 48 hours of the occurrence or first knowledge of the
occurrence, to the Winston-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 b~ 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 VII -PERMIT RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
PART VIII-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 m\lst oe 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:
(A) All casing and materials may'be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
Permit #WI0400172 UIC/SA7 Page 4 of 5
ver. 03/2010
(E) In the· case of gravel-packed wells• in which the casing and screens have not been
removed, the casing shall be perforated opposite _the . gravel pack, at interv?,ls 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
lSA NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Prui VIII _( 1) and (2} (G) shall be submitted to:
Permit #WI0400172
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/SA7
ver. 03/2010
Page 5 ·of 5
Ro gers, Michael
From: Knight, Sherri
Sent:
To:
Monday, February 07, 2011 4:30 PM
Rogers, Michael
Subject:
Attachments:
Staff report attached.
Sherri Knight, PE
wi0400172
Staff Report -Smith Res.docx
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: {336) 771-4632
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed-to third parties.
1
�aO 7jZ,�Gy State of North Carolina
20
` p Department of Environment and Natural Resources
Division of Water Quality
o -c
Aquifer Protection Section
Regional Stall' Report
February 6, 2011
To: Ac uifer Protection Section Central Office
Attu: Michael Rocers
From: Sherri Knia
Winston-Salem Regional Office
L GENERAL SITE VISIT INFORMATION
1. Was a site -visit conducted? ® Yes or ❑ No
a. Date of site visit: February 6. 2011
b. Site visit conducted bv: Sherri Kninht
c. Inspection report attached? ❑ Yes or ® No
Application No.: W1004001.72
Regional Login No.:
d. Person contacted: Glenn Smith and their contact information: (336) 472 - 1254 ext.
e. Driving directions: From Winston-Salem, take Hwv 109 South - 14_5 miles to the US 29 S ramp. Take 29 S
4.3 miles to Evans Road on the riuht. The home is located on the left — 0,8 from the intersection.
II. PROPOSED FACILITIES FOR NEW AND MODIFICATION APPLICATIONS
1. Facility Classification: (Please attach completed rating sheet to be attached to issued permit)
2. Are the new treatment facilities adequate for the type of waste and disposal system? ❑ Yes or ❑ No
If no, explain:
3. Are site conditions (soils, depth to water table, etc) consistent with the submitted reports? ❑ Yes ❑ No ® NIA
If no, please explain.
4. Do the plans and site map represent the achW site (property lines, wells, etc.)? ® Yes ❑ No ❑ NIA
If no, please explain:
5. Is the proposed residuals management plan adequate? ❑ Yes ❑ No ® NIA
If no, please explain:
6. Are the proposed application rates (e,g., hydraulic, nutrient) acceptable? ❑ Yes ❑ No ® N/A
If no, please explain:
7. Are there any setback conflicts for proposed treatment, storage and disposal sites? ❑ Yes or ® No
If yes, attach a map showing conflict areas.
8. is the proposed or existing groundwater monitoring program adequate? ❑ Yes ❑ No ® NIA
If no, explain and recommend any changes to the groundwater monitoring program:
FORM: APSRSR 04-10 Paee 1 of 5

9. For residuals, will seasonal or other restrictions be required? D Yes D No [8] N/A
If yes; attach list of sites with restrictions (Certification B)
FORM: APSRSR 04-10 Page 2 of 5
ID. EXISTING FACILITIES FOR MODIFICATION AND RENEWAL APPLICATIONS
1. Are there appropriately certified Operators in Charge (ORCs) for the facility? D Yes O No D NIA
ORC: Certificate#:__ Backup ORC: __ .Certificate#: __
2. Are the design, maintenance and operation of the treatment facilities adequate for the type of waste and disposal
system? D Yes or D No
If no, please explain: __
3. Are the site conditions (e.g., soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? D Yes or D No
If no, please explain: __
4. Has the site changed in any way that may affect the permit ( e.g., drainage added, new wells inside the compliance
boundary, new development, etc.)? D Yes or D No
If yes, please explain: _· __ .
5. Is the residuals management plan adequate? D Yes or D No
Ifno, please-explain: __ ·
6. Are the existing application rates (e.g., hydraulic, nutrient) still acceptable? D Yes or D No
If no, please explain: __
7. Is the existing groundwater monitoring progr3:Ill adequate? D Yes D No D N/ A
If no, explain .and recommend any changes to the groundwater monitoring program:
8. Are there any setback conflicts for existing treatment, storage and disposal sites?· D Yes or D No
If yes, attach a map showing conflict areas. ·
9. Is the description of the facilities as written in the existing permit correct? D Yes or D No
If no, please explain: __ _
\
10. Were monitoring wells properly constructed and located? D Yes .D No D N/ A
If no, please-explain: __
11. Are the monitoring well coordinates correct in B™S? D Yes D No D NI A
If 1 1 t th £ 11 . ( d tabl . f ) no, p ease comp e e e o owing expan e 1 necessary :
Monitoring Well Latitude Longitude
0 ' " 0 ' ;, -
0 ' " 0 ' " -
0 ' " 0 ' " -
0 I " 0 I " -
FORM: APSRSR 04-10 Page 3 of5
0 ' " 0 ' "
12 . Has a review of all self-monitoring data been conducted (e.g., NDMR, NDAR, GW)? D Yes or D No
Please summarize any findings resulting from this review: __
13. Are there any permit changes needed in order to address ongoing BIMS violations? D Yes or D No
If yes, please explain:
14. Check all that apply:
D No compliance issues D Current enforcement action(s) D Currently under JOC
D Notice(s) of violation D Currently under SOC D Currently under moratorium
Please explain and attach any documents that may help clarify answer/comments (i.e., NOV, NOD, etc.)
15. Have all compliance dates/conditions in the existing permit been satisfied? D Yes D No D N/A
If no, please explain: __
16. Are there any issues related to compliance/enforcement that should be resolved before issuing this pennit?
OYesONoON/A
If yes, please explain: __
IV. REGIONAL OFFICE RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? D Yes or 1:8:1 No
If yes, please explain: __
2. List any items that you would like APS Central Office to obtain through an additional information request:
Item Reason
3 . List specific permit conditions recommended to be removed from the permit when issued:
Condition Reason
4. List specific special conditions or compliance schedules recommended to be included in the permit when issued:
FORM: APSRSR 04-10 Page 4 of 5
Condition
5. Recommendation:
.
~
Reason
D Hold, pending receipt and review of additional information by regional office
D Hold, pending review of draft permit by regional office
D Issue upon receipt of needed additional infomiation
~ Issue
D Deny (Please state reasons: _)
6. Signature of report preparer: _____________________________ _
Signature of APS regional supervisor: _________________________ _
Date: _____ _
V. ADDITIONAL REGIONAL STAFF REVIEW ITEMS
Both wells have been installed. The influent well was installed a pp roximately 15 years a go and has been used as an
irrigation well. The injection well was installed in November 2010. The house is on county water.
FORM: APSRSR 04-10 Page 5 of 5
AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: Ianuary 31. 2011
To: ❑
Landon Davidson, ARO-APS
❑
Art Barnhardt, FRG-APS
❑
Andrew Pitner, MRO-APS
❑
Jay Zimmerman, RAG APS
❑ David May, WaRO-APS
❑ Charlie Stehman, WiRO-APS
® Sherri Knight, W-SRO-APS
From: Michael Rovers Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E-Mail: Michael.Rogersiwncmailmet
A. Permit Number: WI 0400172
B. Owner: Glenn and Cynthia Smith
C. Facility/Operation:
❑ Proposed ® Existing ❑ Facility ❑ Operation
D. Application:
I. Permit Type: ❑
Animal ❑
SFR-Surface Irrigation[]
Reuse
❑ H-R Infiltration
❑
Recycle ❑
IIE Lagoon ❑ GW Remediation (ND)
®
UIC —SA 7 Well
Far Residuals: ❑ Laud App.
❑ D&M
❑
Surface Disposal
❑ 503
❑ 503 Exempt
❑
Animal
Z. Project Type: ®
New ❑ Major Mod, ❑ Minor Mod. ❑
Renewal
❑ Renewal wl Mod.
E. Comments/Other Information: ❑
NOTE:
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, andlor action. Within, please take the following actions:
® Return a Completed APSARR Form and attach laboratory analytical results, if applicable.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO. *
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail,
When you receive this request form, please write your name and elates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer:
Date:
FORM: APSARR 07/06 rage 1 of i

Ad
MCDENR
North Carolina Department of Environment and Naturai
owision of water Quality
Beverly laves Perdue Coleen H. Sullins
Governor Director
January 28, 2011
Glenn Merritt Smith
Cynthia Evans Smith
900 Evans Road
Thomasville. NC 27360
Subject: Acknowledgement of Application No. WI0400172
Glenn and Cynthia Smith SFR
Surface Irrigation system - SFR
Davidson
Dear Mr. & Mrs. Smith:
Resources
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on January 27, 2011. This application package has been assigned the number listed above and will be reviewed
by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing -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 michael.rogers(oyncderingov. If the
reviewer is unavailable, you may leave a message, and they will respond promptly.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKL`iG INQL-,=S ON THIS PROJECT
Sincerely,
00—ME, 0.42200aMub-AN,
for Debra J. Watts
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Carolina Virginia Well Co. (Patrick Smith)
Permit Application File WI0400172
AQUIFER PROTECTION'' SECTION
1635 Mail Service Center, Raleign, North Camiina 27699.1G36
Location. 2728 Capi al Boulevard. Raleigh. North Carolina 27604
Phone: [phone] FAX 1, 919-71M58B, FAX 2' 919.715.6048 l Customer Semn 1-877-623.6748
1nterner www.newatermueIIL .m-
One
Nonb Caral11 i3<i
Ali Equ;:l C�ppartupir, i Arhrmaliva k.cbm Employer

I
1
j
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NORIB CAROLINA
DEPARTMENT OF ENVIRONMENT AND NA 11JRAL RESOURCES
APPUCATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A GEOTHERMAL BEAT PlJMP SYSTEM
TYPE 5A7 "OPEN LOOP" INJECTION WE~L(S)
(check one) / New Permit Application ·Renewal --__ Modification
DA TE: 0 t / 15 20_1_1 _
PERMITNO.: wr (J t+OO 11 'd: 0eave blank ifNBW permit application)
A. PROPERTY OWNER/PERMIT APPLICANT
Name of each owner listed on property deed. For a business or governmel)t agency, state name of entity and
name of person delegated authority to sign applicati_.pn on behalf of the business/ag~~
Gl.e-NJJ /f'JfFHlCrr &,,cnl c yµTrlwl EVA/IS ~mr 7JI
(1) MailingAddress: q()o tVANS Ro.
City: l #IJf!J IJ .Sv.£t.,,LC State: N C..ZipCode: 27c3<,cJ County: OA"&0~,.J
Home/Office Tele No.: .Iii#--I/ 11-12..~t/: ·· Cell No.: 33(p -S"tf/{,-3() '1 7
Fax No. 336 • I/ 72 ~ / 2 SI/. Email Ad<lre§: '1 oCSt:lS· e no~#/ Si?f R:. ,I t:-1
(2) Physical Address of Woll Site (if different than above):_. ____________ _
City:-----.,...-----State:_·_ ZiP. Code: _____ County: ____ _
Home/Office Tele No.: -----------=Ce=l =-=l N"'"""o=.='------------
Fax No. _________ Email Address: ___________ '----
B. PROPERTY OWNERSHIP DOCUMENTATION
Provide legal documentation of property ownershipt such as a contract, deed. article of incorporation, etc. and
a PLAT map showing the property~ This information may be obtained ftom county Register of Deeds or GIS
website. ·
C. AUTHORIZED AGENT, IF ANY
If the property owner/permit applieant wants to authorize someone else to sign the permit on their behalf. then
attach a signed letter from the property owner/pennit applicant specifying and authorizing their ~gent (well
driller, heat pump contractor, or other type of comractor/agent) to sign this application on their behalf.
CompanyNamo! _________________________ _
Contact Person""-: ______________ E ... m __ w=·t ___ A ____ d......,dr ...... ess=--:· _________ _
Address: ___________________________ _
City: ________ State:_Zip Code: _____ County: ______ _
Office Tele No.: Fax No. Cell No.:
Website Address of Company, if any: ___________________ _
Type SA 1 Injection Well Permit Application (R.ov. August 2009) RECEIVED/ DENR / DWQ
Aquifer Protection Section
JAN 2 7 2011
Page 1 of4
D.
E.
WELL DRILLER INFORMATION
Company Name: CR R D c.J;uA
Well Drilling Contractor's Name: VArk M lk
NC Contractor Certification No.: ZtroContact Person: V '+47-R rZ
Company W}
ebbsite_ W W W.4'A"c-rWA ►jzR � WRI OPL.Ca►fmail Address:
Address: r ' 0. QUx 171
City: �TUsr1 Ira State: NX--Zip Cade: 2-700 County:
Office Tele No.:3g4-5`?-9tll5 Fax No.: 334" 572 -3104?4 Cell No.:43�(� -3G Z- �19 ? 7
HEAT PUMP CONTRACTOR INFORMATION (if different than Driller)
Company Name: Contact Person:
Company Website: W W W, _ _-_ Email Address:
Address:
City-,
Office Tele No.:
State: Zip Code: County:
Fax No. Cell No.
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
CkA ra 1karn &F6 wru DyiN P X4.476 WIC
Wm W4L ►B7 -1ZS60 Ta 4,56X:
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO V
(2) Personal consumption? YES NO w _ V.
H. WELL CONSTRUCTION DATA
PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(7) below as PROPOSED construction specifications. Submit Form GW-i after construction.
f EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (7)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
GW-0 if available.
(1) Well Construction Date; 1 l)1S 2.010 Number of borings:
Depth of each boring (feet); 4 Z-$
(2) Well casing. Is the well(s) cased?
(a) YES ✓ If yes, then provide the casing information below.
Type: Galvanized steel Black steel Plastic_. _V Other (specify)
Casing thicicness::9]t!! V diameter (inches): G VP `depth: from ❑ to W feet (relative to land surface)
Casing extends above ground i 2- inches
(b) NO
(3) Grout material surrounding V
casing:
(a) Grout type: Cement Bentonite* Other (specify)
■By sclecting bmtoniLc ,grout, a variance is hereby regocstad to 1 SA NCAC 2C .0213(01)(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from Q to 2-0 fret
Tj pe 5A7 to wjon Well Permit Application (Rev. August 2009) Page 2 of

1 ' I '
(4) Well Screen or Open Borehole depth (relative to land surface): from ____ to ___ feet
(5) N.C. State Regulations (fitle 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Will there be a faucet on:
(a) Influe~t line? Yes / No___ (b) Effluent line? Yes~ No __
(6) Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Form GW-1). If Form ow .. 1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment units wiU the groundwater be withdrawn? ( e.g.
granite, limestone, sand, etc.)
Depth: t./OO Formation: bflAµr;,€ Rock/sediment unit: GL,J,J rr£
NOTE: THE WELL DRD..LING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF nns
INFORMATION IS OTHERWISE UNAVAILABLE.
L OPERATINGDATA
( l) Injection Rate:
(2) Injection Vo_lurne:
(3) Injection Pressure:
( 4) Injection Temperature:
J. INJECTION-RELATED EQUIPMENT
Average (daily) g gallons per minute (gpm).
Average (daily) f 2OOgallons per day (gpd).
Average (daily) --1.tL_ pounds/square inch (psi).
Average (January) 'I 2. ° F. Average (July) 'lg ° F.
Attach a schematic diagram or cross-section of the well construction that shows the total depth, length of casing,
extent of grout, stickup, location of influent/effluent sampling ports, etc. If this is a modification, show the
engineering layout or proposed modification of the injection equipment and exterior piping/tubing associated with
the injection operation. The manufacturer's brochure may provide supplementary information if needed.
K. LOCATION OF WELL(S)
(1) Attach a site map (can be drawn) showing: houses and other structures, property lines, surface water bodies,
potential sources of groundwater contamination, and the orientation of and distances between the proposed
injection well(s) and any other existing well(s) or waste disposal facilities such as septic tanks or drain fields
located within 1000 feet of the geothermal heat pump well system. Label all features clearly and include a
north arrow.
(2) Attach a scaled topographic map of the area extending l/4 mile from the property boundary that indicates
the facility's location, a north arrow, and the map name.
NOTE: In most cases, an aerial photograph of the properzy parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, tl1e property can be searched by o,11ner
name or addre1s. The location of the wells In relation to property boundarle1, houses, septic tanks, other wells, etc.
can then be drawn In by h1111d. Also, a 'layer' can be selected showing topographic contours or elevation data. . .
Type SA 1 Injection Well Pennit Application (Rev. August 2009) Page 3 of 4
L. CERTIFICATION (to be signed as required below or by that person's authorized agent)
NCAC 15A 2C .0211(b) requires that all permit applications shall be signed as Maws:
l . for a corporation: by a responsible corporate officer,
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3, for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner,
If an authorized agent is signing on behalf of the applicant, then submit a letter signed by the
applicant that Barnes and authorizes their agent as specified In Part C of this permit application,
"i hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted in
this document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible for
obtaining said information, I believe that the Information is true, accurate and complete. I am aware that there are significant
penalties, including the possibility of fines and imprisonment, for submitting false information. I agree to construct, operate,
maintain, repair, and if applicable, abandon the injection well and all related appurtenances in accordance with the approved
specifications and conditions of the Permit."
Signature of Property Owner/Applicant
_CX66- W 17')C-Wc1'7-
�i r
Print or Type Full Name
Sign• tire ofpro ertyOwner/Applicant
Print r Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit TWO signed copies of the completed application package and all attachments to:
UiC Program
Aquifer Protection Section RECEIVED 1 DENR ► n)Arj
North Carolina DENR-DWQ Aquifer Pmlec%on c -,,,n
1636 Mail Service Center JAN $ 7 2011
Raleigh, NC 27699-1636
Telephone [phone]
Type 5A7 Infection Well Permit Application (Rev. August 2004) Par4 of4

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Davidson County GIS
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Parcel Number : 1633100000005A Land Units: 2.99 AC
Pin Id : 6757-01-45-2544 Deed Book: 908 Pg: 1460
SMITH GLENN M & CYNTHIA D
Owner: 900 EVANS RD Deed Date: 01/27/1994
THOMASVILLE NC 273600000
Property Address: 000900 EVANS RD Account Number: 000009017834
Township: Thomasville Exempt Code:
Building Value: $185,800 Other Building Value: $4,610
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Davidson County Map Output Page Page 2 of 2
s
Land Value:
Assessed Value:
Legal Description 1 : L5A BK908-1460
Fire Service Districts
Sq.Miles
Name
Townships
Sq. Miles
Name
County Zoning Districts
Zone
Soil Types
DSLName
Soil Name
$48,690 Market Value:
$239,090 Dererred Value:
Legal Description 2
Additional Attributes
At point :78542313,776528
19.68
PILOT FD
64.87
THOMASVILLE
RA-3
PnB
POINDEXTER AND ZION
SANDY -LOAM
$239,090
$n
EVANSRD
Percent Si 2-8
Hydric
Municipal Boundary
No Featur" found.
The information contained on this map does not replace information that may be obtained by
consulting the official source of the information. Ln no event shall Davidson County, NC or the
consultants of Davidson County, NC be liable for any damages, direct or consequential, from the use
of the information contained on this inay.
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Davidson County Map Output Page Page 1 of 2
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Pin Id : 6757-0145-25" Deed Book- 908 Pg: 1460
SMITH GLENN M & CYNTHIA ❑
Owner: 900 EVANS RD Deed Date: 01/27/1994
THOMASVILLE NC 273600000
Property Address: 000900 EVANS RD Account Num ber: 000009017834
Township: Thomasville Exempt Code:
Building Value: $185,800 Other Building Value: $4,610
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Land Value:
Assessed Value:
$48,680 Market Value:
$239,090 Deferred Value:
$239,090
$0
Legal Description l : L5A BK908-1460 Legal Description l : EV ANS RD
Fire Service Distric~
S q.Miles "
Name
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Sq. Miles
Name
County Zoning Districts
Zone
Soil Types
DSL Name
Soil Name
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No Features found.
Additional Attributes
At point :1654239,775528
19.68
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THOMASVILLE
RA-3
PnB
POINDEXTER AND ZION
SANDY-LOAM
2-8
Page 2 of2
The information contained on this map does not replace information that may be obtained by
consulting the official source of the information. In no event shall Davidson County, NC or the
consultants of Davidson County, NC be liable for any damages, direct or consequential, from the use
of the information contained on this map.
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