WI0500040_GEO THERMAL_20170327

Permit Number W10S00040
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Central Files: APS _ SWP _
3/27/2017
Permit Tracking Slip
Status
Project Type
Active
Renewal
Version
Permit Classification
4.00
Individual
Permit Contact Affiliation
Facility Name
Major/Minor Region
Charles and Gwendolyn Davis SFR
Minor Raleigh
Location Address
County
1422 Ridge Rd
Wake
Facility Contact Affiliation
Raleigh NC 27607
Owner
Owner Name Owner Type
Individual
Charles Alfred Davis Owner Affiliation
Charles Alfred Davis
1422 Ridge Rd
Dates/Events Raleigh NC 27607
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
4/26/2002 1/10/2017 3/23/2017 3/23/2017 2/28/2022
Repulated Activities Requested /Received Events
Heat Pump Injection RO staff report requested 1/13/17
RO staff report received 3/15/17
Outfall
Waterbody Name Streamindex Number Current Class Subbasin

N- ra
Water Resources
EnvironmentalQu ty
March 23, 2017
Gwendolyn and Charles Davis
1422 Ridge Road
Raleigh, NC 27607
Re: Issuance.of Injection Well Permit
Permit No. W10500040
Geothermal HcatinglCooling Water Return Well
Wake County
Dear Mr. and Mrs. Davis:
ROY COOPER
Governor
MICHAEL S. REGAN
secretm'y
S. JAY ZIIvIMERMAN
.Director
In accordance with your permit renewal application received January 10, 2017,1 am forwarding Permit
No. WI0500040 for the continued operation of geothermal heating/cooling water return well(s) located
at the above referenced address. This permit shall be effective from date of issuance, until February
28, 2022, and shall be subject to the conditions and lirnitations stated therein.
Please Note:
Samples from the influent and effluent sampling ports of your geothermal well system
were collected on February 2, 2017. Laboratory analytical result is attached.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this
pertnit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Resources. If you have any questions regarding your permit or the Underground
Injection Control Program, please call me at [phone].
Best Regards,
01
Shristi Shrestba
Underground Injection Control (UIC)- Hydrogeologist
Division of Water Resources, NCDEQ
Water Quality Regional Operations Section
-- -,- Ni C11 htrig Cornparcc.
State of North Carolina I Environmental Quality { Division of Water Resources
Water Quality Regionat Operations Section
1636 Mail Service Center I Raleigb, North Carolina 27699.1636
919-707-9129

cc: Rick Bolich — Laura Robertson, Raleigh Regional Office
Central Office File, W10500040
Wake County Environmental Health Department

ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 97; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Gwendolyn and Charles Davis
FOR THE CONTINUED OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defined in Title 15A North Carolina Administrative Code 02C .0224(a), which will be used
for the injection of heat pump effluent. The injection well(s) located at 1422 Ridge Road, Raleigh, Wake County,
NC 27607 will be operated in accordance with the application submitted January 10, 2017 and in conformity with
the specifications and supporting data, all of which are filed with the Department of Environmental Quality and
are considered a part of this permit.
This permit is for continued operation of an injection well shall be in compliance with Title 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 February 28, 2022, and shall be
subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 23rd day of March 2017.
S. Jay Zimmerman, P.G.
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Permst #W10500040 UIC15A7 Pagel of 5
per. 11/15/2015

PART I --- PERMIT GENERAL CONDITIONS
The Permittee shall comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is grounds
for enforcement action as provided for in N.C_G.S. 87-94
2. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data [IS A NCAC 02C .0211(a)] .
This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data [15A NCAC 02C .0211(1)].
4. This permit is not transferable without prior notice and approval. In the event there is a desire for the facility
to change ownership, or there is a name change of the Permittee, a formal permit amendment request must
be submitted, including any supporting materials as may be appropriate, at least 30 days prior to the date of
the change [ 15A NCAC 02C .0211(q)].
5_ The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met [I 5A NCAC 02C .0203].
PART II - WELL CONSTRUCTION GENERAL CONDITIONS
I . The well supplying water for the geothermal heating and cooling system shah be constructed in accordance
with the requirements of rile 15A NCAC 02C .01 07 except as required in Item #2 below.
Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC 02C .0107
except that the entire length of the casing shall be grouted in such a way that there is no interconnection of
aquifers or zones having differences in water quality that would result in degradation of any aquifer or zone.
For screened wells, grout shall be emplaced from the top of the gravel pack to the land surface_ For open-
end wells, the casing shall be grouted from the bottom of the casing to the land surface [I 5A NCAC 02C
.0224(d)(2),(3 )].
Bentonite grout shall not be used to seat any water -bearing zone with a chloride concentration equal to or
greater than 1,500 nulligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing conditions.
[ 15A NCAC .0225(g)(8)] .
4. The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [ 15A NCAC 02C .0224(d)(4)],
Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal. as defined in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [ 15A NCAC 02C .0107(j)(2)].
Permit #WI0500040 UIC15A7 Page 2 of 5
ver. 11 / 1512015

T A completed Well Construction Record (Foam GW-1) shall be submitted as described in Part V.5 of this
permit.
PART III — OPERATION AND USE CONDITIONS
The Permittee shall comply with the conditions of this permit and properly operate and maintain the
injection facility in compliance with the conditions of this permit and the rules of 15A NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C .02110)].
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface water
or groundwater resulting from the operation of this facility. In the 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 that may be required,
such as the repair, modification, or abandonment of the injection facility [15A NCAC 02C .02061.
PART IV — INSPECTIONS [I 5A NCAC 02C .021 I (k)]
Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation of credentials, enter and inspect any property, premises, or place on or related to the
injection facility at any reasonable time for the purpose of determining compliance with this permit, may
inspect or copy any records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwater, surface water, or injection fluids.
DWR 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.
Provisions shall be made for collecting any necessary samples of the injection facility's activities.
PART V — MONITORING AND REPORTING REQUIREMENTS
Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on -site and available for inspection [ 15A NCAC
02C .0224(f)(2), (4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State and
compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
.0224(f)(1)].
The Permittee shall report any monitoring or other information that indicates noncompliance with a specific
permit condition, that a contaminant may cause a violation of applicable groundwater quality standards, or
that a malfunction of the injection system may cause the injected fluids to migrate outside the approved
injection zone or area. As specified in rule I5A NCAC 02C .0211(r), noncompliance notification shall be
as follows:
(A) Oral notification shall be given within 24 hours of the occurrence, or first knowledge of the
occurrence, to the Raleigb Regional Orrice, telephone number 919-791-4200.
(B) Written notification shall be made within five days of the occurrence and submitted to the addresses
in Item #5 below.
Permit #W10500040 UIC15A7 Page 3 of 5
per. 11 /15/2015

(C) The written notification shall contain a description of the noncompliance and its cause; the period of
noncompliance, including dates and times; if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and any steps taken or planned to reduce, eliminate, and
prevent reoccurrence of the noncompliance.
4. The Permittee shall record the number and location of the wells with the register of deeds in the county in
which the facility is located. [ 15A NCAC 02C .0224(f)(3)].
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
UIC Program Staff Water Quality Regional Operations Section
Division of Water Resources and DWR Raleigh Regional Office
1636 Mail Service Center 3800 Barrett Drive
Raleigh, NC 27699-1636 Raleigh, KC 27609
PART VI — PERMIT RENEWAL [ l 5A NCAC 02C .0224(c)]
As required by rule an application for permit renewal shall be made at least 120 days prior to the expiration
date of the permit. This permit condition does not apply if the Permittee chooses to discontinue operation
of the well for injection of effluent from the geothermal heating and cooling system associated with this
permit.
PART VII — CHANGE OF WELL STATUS [I 5A NCAC 02C .0240)
Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permttee bears the responsibility of
complying with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to rule
15A NCAC 02C .0113(b) in order to prevent the well from deteriorating and acting as a source or conduit
of contamination, which is prohibited by General Statute 87-88(c).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water -tight cap or well
sea] that cannot be removed without the use of hand or power tools.
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall permanently abandon that injection well in accordance with the procedures specified in 15A
NCAC 02C .0113(b), which include, but are not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected prior to sealing in accordance with rule 15A
NCAC 02C _0111(b)(1)(A), (B), and (C).
Permit #W10500040 U105A7 Page 4 of
►+er. 11/15/2015

(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 those cases when a subsurface cavity has been created as a result of the injection
operations, each well shall be abandoned in such a manner that will prevent the movement
of fluids into or between underground sources of drinking water.
(F) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0224(f)(4) within 30 days of completion of abandonment.
The written documentation required in Part VII (4)(F) shall be submitted to the addresses specified in Part
V.5 above.
Pernxit #WI0500040 UICI5A7 Page 5 of 5
ver, 11/15/2015

AC35465 North Carolina Division of Water Resources Water Sciences Seetion Laborator. Results
Lac, Doscr.-. 1422 RIDGE ROAD
County: A&M
Region EN
River Basin tiFU
Emergency
COC YeslNa
Collector
L ROBERTSON
ReportTo
�g
Collect Date:
9210212017
Collect Tim a:
18'G4
Sample Depth
Sample ID:
AC35455
VOID
PC) Number $1
Location ID: RPD92Mi0800040
Data Received
WM 12017
Priority COMPLIANCE
Time Recelved:
1a:30
Sample Matrlx: QROUNDW_,AlE
Labwarks LoglnID
JASCENZ01
Loc. Type: Water Suaaly
Delivery Method
Hand slellvered
Final Report Date:
313117
Report Print Date:
0310312017
Final Report
If this report Is labeled prellrnfnary report, the results have not been validated. Do not use for Regulatory purposes.
ReSul
nl
Method
Analysis
AS # Analyte Names -Ql
Qualifier
Reference
Date Vslldated 5v
LAS
Sample temperature at receipt by lab
4.6
212117 MSVUIFT
IY11C
Coliform, MF Fecal in liquid 1
1 9201
CFU1100mi
SM 9222 0-1997
213117 ESTAFFORDI
Coliform, MF Total in liquid 1
1 8201
CFU1100m1
SM 9222 El-1997
213M7 ESTAFFORDI
NUT
NO2+NO3 as N in liquid 0.02 1.4 mgk as N EPA 353.2 REV 2 213117 CGREEN
VWET
Bromide 0.4 DA U rrtglL EPA 300.0 rev2.1 213117 CGREEN
Chloride
1.0
12
mt/L
EPA 300.0 nav2.1
7J3r17
CGREEN
Fluoride
0.4
0.4 U
mglL
EPA 300.0 rev2.1
213117
CGREEN
Sulfate
2.0
2.0 U
mg1L
EPA 300.0 rev2.1
2J3117
CGREEN
Total Dissolved SdidS in liquid
12
52
-WL
SM 2540 C-1997
2I0117
CGREEN
1429-90-6
AI by ICP
50
MET
120
u61L
EPA 2003 Rav4.4
7J10117
ESTAFFORDI
7440-70-2
Ca by iCP
0.10
1.0
mA
EPA 200,7 Rev4.4
219117
ESTAFFORDI
7440-47.3
Cr by ICPMS
5.0
5.0 U
u01L
EPA 200.8 Hev5A
2JI3117
ESTAFFORDI
7440-50-8
Cu by fCPMS
2.0
160
u61i.
EPA 200.8 Rev5.4
2J13117
ESTAFFORDI
7439-89-0
Fe by 1CP
50
110
uglL
EPA 200.7 Rev4.4
2110117
ESTAFFORD1
744040-7
K by ICP
0.10
0,89
mg1L
EPA 200.7 Rev4.4
219117
ESTAFFORDI
7439-95-4
Mg by fCP
0.10
1.3
mplL
EPA 200.7 Rev4.4
219117
ESTAFFORDI
7439-90-5
Mn by ICP
10
28
uglL
EPA200.7 Rav4.4
2110117
ESTAFFORDI
744a23-5
Na by ICP
0.10
10
rnpll-
EPA 200.7 Rav4.4
219117
ESTAFFORDI
7440-02-0
Ni by ICPMS
2.0
2.0 U
uWL
EPA 200.8 Rev5.4
2113/17
ESTAPFORD1
7439-92-1
Pb by ICPMS
2.0
2.0 U
vWL
EPA 200.8 Rav5.4
2113117
ESTAFFORDI
7440-68-8
Zn by ICPMS
10
15
uglL
EPA 200.8 Rev5.4
2/13117
ESTAFFORDI
WSS Chernistry L-abondwy-a 1523 Mail Service Center, Raleigh, NC 2TB99.1623 1919] 733-3908
"Not Detected" or" UL'does net indicate the sample is anaiyle bee but that the an a" is not delected at or ahave the P0L.
Page 1 Of 1

AC35456 North Carolina Division of Water_ Resources Water Sciences Section Laborato Results
Results
Luc. Desc►.; 1422 RIDGE
ROA
County: WAKE
Collector L ROBERTS dH
Vialb[I
Region: RRO
Report To Bffl
Locatlon la: se yWQ,¢opog
River Baalfl
Collect Dale, 0210212017
Priority COMPLIANCE
Emergency
Collect Time. IR:40
Sample Matrlx: GROUNW&M
COC YeslNo
Sample Depth
Loo, Type: Water Suurly
Final Report
Sample ID:
AC3"S
PO Number
Date Received:
02102120
Time Received:
ia^,3g
Labworhs Log in10
TASCEN701
Delivery Method
Hand deftared
Final Report Date:
313117
Report Print Date:
31�17
Nthis report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
Raswy Me hod sl
CAS # Analyte Name • foPQL r is Reranoe ❑ate Validated by
LAS
Sample temperature at receipt by lab 4.5 'C 712117 iMSv41FT
MIC
Col€farm, MF Focal in €Iquid
1
1 52Q1
CFulloOml
SM 9222 0-1997
213117
ESTAFFORDI
CoIiform, MF Total in liquid
1
1 0201
CFU1100ml
SM 9222 B-1997
213117
ESTAFFORDI
NO2+NO3 as N in liquid
0.02
NUT
1.5
mglL as N
EPA M.2 REV 2
213111
CGREEN
Bromide
0A
WET
OA U
mg1L
EPA 30U.0rev2.1
213117
CGREEN
Chloride
1.0
12
mUfL
EPA 300.0 rev2.1
213117
CGREEN
Fluoride
0.4
CA U
mglL
EPA 300.0 rev2.1
213117
OGREEN
Sulfate
2.0
2.0 U
mglL
EPA300.fl rev2.I-
21all7
CGREEN
Total Dissolved Solids in liquid
12
54
mglL
SM 2540 G1997
218117
CGREEN
7429-90-5
Al by ICP
50
MET
so U
ugrL
EPA 200.7 Rev4,4
210117
ESTAFFORD1
7440-70-2
Ca by ICP
0.10
1.1
m91L
EPA 200,7 Rev4.4
210117
ESTAFFORDI
744"7.3
Cr by ICPMS
&0
SIG U
uglL
EPA200.8 Rev5.4
21113/11
ESTAFFORDI
7440-50-a
Cu by ICPMS
2.0
430
uglL
EPA 2 00. 8 Rev5.4
2113/17
ESTAFFORDI
743E-0"
Fe by ICP
50
5a U
uglL
EPA 200.7 Rev4.4
2110117
ESTAFFORDI
7440-09-7
K by ICP
0.10
0.87
mglL
EPA 200.7 Rev4.4
21W 17
ESTAFFORDI
7430-954
Mg by ICP
0.10
1.3
m91L
EPA 200.7 Rev4.4
219117
ESTAFFORDI
7439-96-5
Mn by ICP
10
24
ug1L
EPA200.7 Rev4.4
2110117
ESTAFFORDI
7440-23-6
Na by ICP
0.10
10
mglL
EPA 200.7 Rev4.4
219117
FS7AFFOR01
7440-02-0
Ni by ICPMS
2.0
2.0 U
uglL
EPA200.6 Rev5.4
2113117
ESTAFFORDI
7439-92.1
Pb by ICPMS
2.0
2.0 U
uglL
EPA 200.8 Rev5.4
711Ill 7
ESTAFFORDI
744""
Zn by ICPMS
10
15
uglL
EPA200.a Rev5A
2113117
FSTAFFQRDI
WSS Chemistry Lahomtorya> 1823 Mail Service Center, Raleigh, NC 27699.%23 [phone]
Not Detected" or "U" does act Indicate the sample is anaiyto free but that the analyte is not detected at a above the PQL.
Page 1 of 1

WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
Permit No. WI0500040
Date: 03/10/2017 County: Wake
To: Shristi Shrestha Permittee/Applicant: Charles & Gwendolyn Davis
Central Office Reviewer Facility Name: Davis Geothermal Well
L GENERAL INFORMATION
1. This application is (check M that apply): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification
a. Date of Inspection: 02/02/2017
b. Person contacted and contact information: Charles Davis. 919-782-0112
c. Site visit conducted by: Laura Robertson
d. Inspection Report Printed from BIMS attached: ❑ Yes ® No
e. Physical Address of Site including zip code: 1422 Ridge Road, Raleigh. NC 27607
f, Driving Directions if rural site and/or no physical address:
g. Latitude: 35.806736 Longitude:-78.685748
Source of Lat/Long & accuracy (i.e., Google Earth, GPS, etc.)__Google Earth _
II DESCRIPTION OF INJECTION WELLiS) AND FACILITY
l , Type of injection system:
® Geothermal Heating/Cooling Water Return
❑ In situ Groundwater Remediation Q�Qsn � 'Q', NO,
❑ Non -Discharge Groundwater Remediation R� lv �-
1417
❑ Other (Specify:_ al
4ua1i[y R$gion
?. For Geothermal Water Return Wells) only W a to o�5 spcuon
a. For existing geothermal system:
Were samples collected from Influent/Effluent sampling ports? ® Yes ❑ No.
Provide well construction information from well tag: The well total depth is 450 feet and all
3.
4.
5.
6.
information is available on renewal application. it was not visible on the well.
b. Does existing or proposed system use same well for water source and injection? ❑ Yes ® No
If No please provide source/supply well construction info (i.e., depth, date drilled, well contractor,
etc.) and attached map and sketch location of supply well in relation to injection well and any other
features in Section IV of this Staff Report.
Are there any potential pollution sources that may affect injection? ❑ Yes ® No
What is/are the pollution sources)?
What is the distance of the injection well(s) from the pollution source(s)?
What is the minimum distance of proposed injection wells from the property boundary?
Quality of drainage at site: ® Good ❑ Adequate ❑ Poor
Flooding potential of site: ® Low ❑ Moderate ❑ High
Rev. 6/1l2015 Page 1

WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
7. For Groundwater Remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. If No,
attach reap of existing monitoring well network if applicable and recommend any changes to the groundwater -
monitoring program.
8. Does the map included in the Application reasonably represent the actual site (property lines, wells, surface
drainage)? ❑ Yes ❑ No. If No, or no reap, please attach a sketch of the site. Show property boundaries,
buildings, wells, potential pollution sources, roads, approximate scale, and north arrow.
9. For Non -Discharge groundwater remediation systems only:
a. Are the treatment facilities adequate for the type of waste and disposal system? ❑ Yes ❑ No ❑ NIA.
If no, please eapiain:
b. Are the site conditions (soils, topography, depth to water table, etc.) consistent with what was reported by
the soil scientist and/or Professional Engineer? ❑ Yes ❑ No ❑ NIA. If no, please explain:
III. EVALUATIONAND RECOMUENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ®No. If yes, explain.
^. List any items that you would like WQROS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
3. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition _ _ `1 Reason
4. Recommendation
❑ Deny. If Deny, please state reasons: 77CENEDINCDEWWR
❑ Hold pending receipt and review of additional information by regional office MAR 15 2017
❑ Issue upon receipt of needed additional information
® Issue Water ❑uallty Regional
Qner,,sbc3ns See!ion
5. Signature of report preparer(s):
Signature of WQROS Regional Supervisor' ff/
Date:
Rev. 5/l/2015 Page 2

WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
IV ADDITIONAL REGIONAL STAFF RE VIEW COMMENTSIA TTA CHMENTS (If Needed)
-The well appears to be in very good condition, and is protected by a large cover.
- Access to the irrigations sprinklers is in the same cement pad as the well, although the irrigation sprinklers are
connected to the City of Raleigh water supply. The home is also supplied by City of Raleigh water supply.
- Mr. Davis noted the high copper content in the samples collected in 2012. This is likely due to the copper
fittings on his system in the house in conjunction with the slightly acidic pH of the water. DWR RRO staff
contacted Mr. Davis by phone to discuss the results before sending the letter.
►VDl� L u VQ u6 qJrft4r to �el ko(eok AJ ov
5 46�Alc_ F ii fu�r, AA
Rev. 61112015 Page 3

AC35455 North Carotina Division of Water Resources Water Sciences Section Laboratory Results
Loc. Doser-, 1422 RIDGE ROAD
County; WAKE
Collector. L ROBERTSON
VisitlD
Region: R-P-O
Report To FtRO
Location ID:
5P092VY10500040
River Basin NEU
Cdilact Date- o2r0&2017
Priority
COMPLIANCE
Emergency
Coll act Time: i5:00
Sample Matrix:
GRQLlNDWATER
COC Yetallo
Sample Depth
Loc, Type:
fter S�uIY
Final R_.eport
Sample ID:
AC35453
PQ Number 9
Date Received-
e21021201P
Tlma Received:
.N
Labworks Logwil)
TAWENZ01
Delivery Method
Hang dellypa
Final Report Date:
3I311
Report Print Date:
031OW201
if this report is labeled preliminary report, the raasults have not been validated Do not use for Regulatory purposes.
Resuftl Units Method Analysis
CAS # Analvte Name PQL ualifler Reference Date
LAS
Sample temperature at receipt by lab CS 'C 212117
Validated by
MSVVIFT
Coliform, MF Fecai in liquid
1
mic
1 B201
CFU1100mi
SM 9222 D-1997
=117
ESTAFFORDI
Collform, MF Total in liquid
1
1 6Y09
CFU1100m1
SM 9222 9-1997
213117
ESTAFFORDI
NO2+NO3 as N in liquid
0.02
NUT
1.4
m01Las N
EPA353.2 REV 2
213117
CGREEN
Bromide
0.4
WET
0.4 U
mglL
EPA 300.0 rav2.1
213117
CGREEN
Chloride
1.0
12
mg&
EPA 300.0 rav2.1
213117
CGREEN
Fluoride
0.4
0.4 U
mglL
EPA 300.0 rev2.1
213117
CGREEN
Sulfate
2,0
2.0 U
mgil
EPA300.0 rev2.1
213117
CGREEN
Total Dissolved Solids in liquid
12
52
mglL
SM 2540 C-1997
WWI
CGREEN
7429-90-5
A] by ICP
50
MET
120
ug1L
EPA 2007 Rev4.4
2110/17
ESTAFFORDI
7440-70-2
ova by ICP
0,10
1.0
mgA.
EPA 200.7 Rav4.4
219117
ESTAFFORDI
7440-47-3
Cr by ICPMS
5,0
5,0 U
uWL
EPA200-8 RevSA
2113/17
ESTAFFORDI
7440-50-8
Cu by ICPMS
2.0
180
ug1L
EPA 200.8 Rev5,4
2/13117
ESTAFPORD1
7439-89-6
Fe by ICP
50
110
ug/L
EPA 2007 Rev4.4
2110117
ESTAFFORD1
7440'08-7
K by ICP
0.10
0,89
mglL
EPA 200.7 Rev4.4
219117
ESTAFFORDI
7439-95-4
Mg by ICP
0.10
1.3
mglL
EPA 200.7 RWA
219117
ESTAFFORDI
7439-98-5
Mn by ICP
10
Zg
ug1l.
EPA 200.7 ReAA
2110M7
ESTAFFORD1
744(-23-5
Na by ICP
0.10
10
mg(L
EPA 200.7 ReAA
219117
ESTAFFOR01
7440-02-0
Ni by ICPMS
2,0
2.0 U
uWL
EPA 200.8 Rav5.4
2113)17
ESTAFFOR01
7439-92-1
Pb by ICPMS
2.0
2.0 U
uglL
EPA 2008.Rev5,4
2/13)17
ESTAFFOR01
7440.98-5
Zn by ICPMS
10
15
ug1L
EPA 200.a Rev5.4
2113117
ESTAFFOR01
W33 Chemistry Laboratorysa 1623 Mal Service Cerrtsr, Rai9lgh, NC 27999.1623 [phone]
"Not Detected" or "U" does not indicate the sample is analyte Free bu! that the aralyte is not detected at or above the POL
Page 1 of 1

AC35458 North Carolina Division of Water Resources Water Sciences Section LaboratorN Results
Loc. Descr.:
1422 RIDGE
ROAd
County:
WAKE
Collector
L ROBE ON
VlslllD
Region:
RRO
Report To
RRO
Location ID: 5PO92W10500040
River Sasin
i
Collect Date:
0 1fj1
Priority gOMPLIANCE
Emergency
Collect Time:
15;19
Sample Matrix.: GROUNDVSIATER
COG Yea1No
Sample Depth
Lac. Type' w4far sko p)
final Rep-9
H this report is labeled preliminary report, the results have not been validated. Do not use for Regulatorypurposes.
Result/ Method Analysis
CAS # Anaiyte Name PQL Qualifier Units Reference Date
LAB
Sample temperature at receipt by lab 4.5 C 2/2117
Validated by
MSWFT
Coliform, MF Fecal in liquid
t
MIC
1 B2Q1
CFU)100mi
SM 9222 D-1997
213117
ESTAPPORD1
Coliform, MF Total in liquid
1
1 B2Q1
CFUI100mi
SM 9222 8-1997
213117
ESTAFFORDI
NO2+NO3 as N in liquid
0.02
NUT
1,5
mg/L as N
EPA 353.2 REV 2
218117
CGREEN
Bromide
0.4
WET
0.4 U
mg/L
EPA 300.0 rev2,1
213117
CGREEN
Chloride
1.0
12
mg/L
EPA 300.0 rev2.1
213117
CGREEN
Fluoride
0.4
0.4 U
mglL
EPA 300.0 rev2.1
213117
CGREEN
Sulfate
2.0
2.0 U
mgfL
EPA 300.0 rev2A
213117
CGREEN
Total Dissolved Solids in liquid
12
54
mglL
SM 2540 C-1997
218/17
CGREEN
7429.90-5
Al by ICP
50
MET
so U
ug)L
EPA 200.7 Rev4.4
2110117
ESTAFFORDI
7440-70-2
Ca by ICP
0.10
1.1
mWL
EPA 2003 Rev4.4
2J9117
ESTAFFORDI
7440-47-3
Cr by ICPMS
5.0
5.0 U
uglL
EPA 200.8 Rev5.4
2J13117
ESTAPFORD1
7440-50-8
Cu by ICPMS
2.0
430
uglL
EPA 200.8 Rev5.4
WaI17
ESTAFFORDI
7439.89-8
Fe by ICP
50
so U
uglL
EPA 200.7 Rev4.4
2110117
ESTAFFORDI
7440-09-7
K by ICP
0.10
0.87
mglL
EPA 200.7 Rev4.4
7/9117
ESTAFFORDI
7439-95-4
Mg by ICP
0.10
1.3
mg1L
EPA 200.7 Rev4.4
219117
ESTAFFORDI
7439-96-5
Mn by ICP
10
24
ugli.
EPA 200.7 Rev4.4
2J10117
ESTAFFOR01
7440-23-5
Na by ICP
0.10
18
mg/L
EPA 200.7 Rev4.4
2/9117
ESTAFFORDI
7440-02-0
Ni by ICPMS
2.0
2.0 U
ug&
EPA 20a.8 Rev5.4
2113117
ESTAFFORDI
7439-92-1
Pb by ICPMS
2,0
2.0 U
ugll-
EPA 200.8 Rev5.4
2113/17
ESTAFFORDI
744M"
Zri by ICPMS
10
15
ug/L
EPA 200.a Rev5.4
2113117
ESTAFFORD1
W88 Chemistry Laboretoryra 1E23 Mail Service center, Rate lgh, NC 27590.1623 1919) 733.390a
Not Detected" or "U" does not indicate the sample is analyte free but that the analyte is not detected at a above the PQL
Page i of 1

WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: January 13, 2017
To: Danny Smith, Rick Bolich
From: Shristi Shrestha, WQROS — Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail.• Shristi.shrestha a7ncdenr,gov
Permit Number- W10500040
A. Applica_n_t: Gwendolyn and Charles Davis
B. Facilih Name-
C. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a completed WQROS Staff
R. epo rt.
When you receive this request form., please write your name and dates in the spaces below, snake a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO--WQRQS Reviewer: _ _ Date:
CONVdENTS:
Ai11TCC•
FORM. WQROS-ARR ver. 092614 Page 1 of 1

nviron►nen ►a!
Quality
January 13, 2017
Gwendolyn & Charles Davis
1422 Ridge Road
Raleigh, NC 27607
RE: Acknowledgement of Application No. WI0500040
Geothermal Heating/Cooling Water Return Well
Wake County
Dear Mr. and Mrs. Davis:
RGY COOPER
Govemor
WILLIAM G. ROSS, JR.
Acting Seeretwy
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on January 10"' 2017. Your application
package has been assigned the number listed above, and the primary reviewer is 5hristi Shrestha
Central and Raleigh 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 Sbristi
Shrestha at 919-807-6406 or email at [e-mail].
Sincerely,
0
For Debra I Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch Division of Water
Resources
cc: Raleigh Regional Office, WQROS
Permit File WI0500040
I No, ling Comp.-r .
State of North Carolina I Environmental Quality [ DivWon of Water Resources
water Quality RegLonW operations Section
1636 Mail Service Center I Raleigh, Vorth Carolina 27699-1636
919-707-9129

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
1n Accordance With the Provisions of 15A NCAC 02C .Q224
GEOTHERMAL HEATINGICOOLING WATER RETURN WELLS)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Paces 1 and 4 (signature page) only
Print or 2��pe Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: � ',� 'T 20/ ` PERMIT NO. WTIQ� 40 (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
supply
_.,�_Geotherrnal Well Drinking Water Supply Other Water
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 pf ft Wbli AbAfid;Dmi nt
Record (GW-30).
-❑ Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES [(NO
If yes, indicate new owner's contact information:
Name(s)
Mailing Address;
City:
State: Zip Code: County:
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence X— Business/Organization
Government: State Municipal County -— Federal
C. WELL OWNER(S)IPERMIT APPLICANT — For individual residences, list owner(s) on property deed. For
all others, list name of entity and name of on de egated authority to sign:
C7r4i n rI t. 1 cr V C. ,1 rl F-, s 'Daw-,
Mailing Address:-' fIt6 a2, I
City: 6Ai4l`7
Day Tele No.: f '`
EMAIL Address:
State: /ip Code: -2> 'l County:
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: W �`��Z ct�i� �,r ��S Twi5
Mailing Address' k"a':6
City7 5 j
State: zip Code: ,Z:7�C' I County:
Day Tele No.: �]J f� t Email Address.:
E. LOCATION OF WELL SITE - Where the injection wells are physically located:
F
L"
Parcel Identification Number (PIN) of well site:
Physical Address (if different than mailing address):
City:
501r_�
State: NC Zip Code:
WELL DRILLER INFORMATION r �+
r��t r' �
Well drilling Contractor's Name: 'Or rti4 S VewPrL(6 YJ J_V •
iLI&-"-
NC Well Drilling Contractor Certification No,:
County:
W'QLr__,
ems-
be (tom WeOA 4--Ar p .
Company Name: A/�. __W , Qr�T>�'� � 4 '-T Vy� � .
Contact Person: tl�u't L �' �''+ E MAIL Address:
Address: 3 SQ d e�sV �- Tea 4 Pa 9�3
City: _ WeAk _ Zip Code: State: W�' County: 4
Office Tele No.: f (�4(-Z;R3Cell No.: Fax No.:_,mI 4 447
HVAC CONTRACTOR INFORMATION (if different than driller)
I-1VAC Contractor's Name: ` e rurrn6vt-�
NC HVAC Contractor License No.:
Company Name: Zru� ryi aln,
A;3a a
P�CJW,4� se r- V; ae 5 �r7t✓
Contact Person: EMAIL Address:
Address: j Tt✓[�4'�r i r
City: Zip Code: State: ,C—County: 44C-0'
Office Tele No.: �°f q � �*�a o3ie-y Cell No.: Fax No.: 119
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following,
(1) The injection operation? YES X' NO
(2) Personal consumption? YES NO
I. WELL CONSTRUCTION REQUIREMENTS - As specified in 15A NCAC 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) Page;

(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.
[_, } 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 SPECICF`ICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTINO WELLS PROPOSER WELLS
*For existing welds, please attach a copy of the Well Construction Record (Form G t- 1) if available.
(2 Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagrain can be used for wells having the same construction
specifications as tong 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 constriction specifications:
r
(a) Depth of each boring below land surface �4'�'Ot �.
�.0
(b) Well casing and screen type, thickness, and diameter
(c) Casing depth below land surface oil
(d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: hentonite grouts are prohibited_for sealing water -bearing zones with 1500
mglL chloride orgreaterper 15A NCAC 02C .0107ltlt$1
(1) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around wcll screen and depth below land surface
K. OPERATING DATA.[,
(1) Injection Rate: Average (daily) I a- gallons per minute (gpm).
(2) Injection Volutne: Average (daily) S}��gallons per clay (gpd).
(3) Injection Pressure: Average (daily) `{ , pounds/square inch (psi).
(4) Injection Temperature: Average (January) �AE ° F, Average (July) (;B ° F.
L. SITE MAP — As specified in 1SA NCAC 02C .0224(b)(4], attach a site -specific map that is scaled or otherwise
accurately indicates distances and on-entadons of the specified features from the injection well(s). The site trap
s4kill 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).
G (2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a)[2) located within 250
feet of the proposed injection wells).
(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

NOTE. In most cases an aerial photograph of the property parcel shosving properfj, lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc, can then be drawn in by hand Also, a 'layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(e) requires that all pen -nit applications shall be signed as fellows:
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 verso (s)listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the infortation is true, accurate and
complete. 1 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 . wnerlApplicant
C$rw W'Q A «" .5
Print or Type Full Name
rf Zr
Signature hof Property Owner/Applicant
Print or Type Full Natne
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]
Geotiierrnai Water ttettirn Well Permit Application [Revised !an 201 ]) Page 4

Page i of 2
North Carolina Department of Environment and Natural Resources
Division of Water Quality -Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTION
REPORT -FORM A
VIUI I16_ i:lnrujilml
DATE � 1". 4,' r 0 ,,
NAME OF OWNER �`_� �f'> SGfGd •�r•=-
ADDRESS OF OWNER
(Street) rood or lot and suddivision, county. town)
r
LOCATION OF PROPOSED INFECTION WELL (and source well(s), if applicable)
err' Xr �r .-•- �r /1 � r : r= r- ritry.' "
(5treetl road or lot and suddivisiov. . couny. town, if dierent than owner's address, plus description of location on site
Potential pollution source ,uy�r Distance from well
Potential pollution source ,;.`-,] Distance from well —r.
Potential pollution source
Distance from. well
Minimum distance of proposed well from property boundary 67 f
Quality of drainage at sitc, Flooding potential of site _
(goy ,adetluaze,poorj (high,moder ,lvT�)J
DRAW SKETCH OF SITE
(Show properly boundaries, buiddings. wells, potential pofhttion sources. roads, approximate scale, and north arrow.)

.7a-�i1 (�rrec
M'465B - Caay
0
BOWMAN MUCHAN{CAL &�tFCVICE*
1219 StUrdivant Drive
Cary, NC 27511
High Efficiency WAG • Geothermal
PVV6
f L-n
FAX (91 % 771, 4,M
I,OLrtGIIa�
,t', I
f

� L� c �;a
� � ��
�•

PAT MCCRDRY
Governor
DONALD R. VAN DER VAART
Water R esourres
ENVIRONMENTAL QUALITY
December 20, 2016
CERTIFIED MAIL # 7015 1520 00007838 4399
RETURN RECEIPT REQUESTED
Charles and Gwendolyn Davis
142.2 Ridge Road
Raleigh, NC 27607
Subject: Notice of Expiration (NOE)
Geothermal Water ReturnlOpen-Loop Injection Well
Permit No. W10500040
Wake County
Dear Mr. & Mrs. Davis,
secrwy
S. JAY ZIMMERMAN
Dimcior
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 March 9, 2012, and expires on February 28, 2017. Per permit conditions and
requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior to expiration of the permit if you wish to continue operating the injection well
on your property.
If Your Geothermal Water Return Well is Still Currently Being Used for Infection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you roust 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:llportat.ncdenr, orglweblwglapslgwprolpermit-applications.
If Your Geothermal Water Return Well is NO LONGER Being Used for Iniection:
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 ofNmih Csroiina I Environmental Quality I Water Resources
1611 Mail service Center I Raleigh, North Carolina 27699-1611
919 707 90W

Page 2 of
.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 Chance of Ownership of the Property:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be fount] at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
L]IC 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 shristi.shresthaAncdenr.gov.
Regards,
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Raleigh - Regional Office — WQROS w/o enclosures
Central Files - Permit No, W10500040 w/o enclosures

u-
D
m
Domestic
cO
j 0 A L U
m
CWUfred Merl Fee
et
$
Extra Smvkm a e- (check baw add f" as oAwopdoV
C3
❑Rstum Rwcarpi (hatcow $--
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❑ P-- "P1 (elec w[cl S
Postma*
C3
❑ Catted M10 Ree41Glod Del" S
Hale
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❑Adull stprwhLre Requirod $ —
❑Adele srn.,tum RmmHcWd UPmy a --
C-3
Postage
ru
Ln
5
-9
"eo"1" Charles and Gwendolyn Davis
Ln
Sant To 1422 Ridge Road
M
57iveie r�AF Raleigh, NC 27607
6ity; 3W ;tl
■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the maitplece,
or on the front if space permits.
t. Article Addressed to:
Charles and GLNendoiyn Davis
1422 Ridge Road
Raleigh, NC 27607
A. Signature
7�h • . d [� h 7�r7� ❑ Agerrt
© Addressee
B. Received by (Printed Name) C. Date of Delivery
D. Is delivery address differerd ham lteTn 17 0 Yes
If YES, enter deiivery address below. 0 No
3. 5 Type
R Prforttyrred Express
ill Slg
p +°'dun Signature
0 fiegistered Man-
Ij
Ir
0 AduR SlgRaturs ReeririCted Datlrery
❑ le<ered Mslt RealrkYed
9590 9403 0730 5196 3165 78
n CCea%d �I �d Delivery
n RRellS t eFpt ax
© Co W on Delivery
Me[rfiandiea
P. Article Number (Tiar+sler from service ladeq
❑ Coilect on Delivery Restricted Delivery
❑ Irrsured Mail
0 Signature CanflrmationTM
0 Signature Conflrmatign
7 015 1520 0000 7838 4399
0). t;aetncted °�'"g`y
Restricted Detivery
l PS Form 3811, April 2015 PSN 7530-02-00(3-9M
—
Domestic RONM fleoelpt

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
April 15, 2012
MEMORANDUM
To: Michael Rogers, The Central Office, APS
Through: Jay Zimmerman 1 �V
From: Lin McCartney
Subject: Analytical Result Report- WI050040, Charles Davis,
Geothermal Underground Injection Control Well, 5A7
Wake County
RECEIVERENROW0
APR 20 2012
Aquifer Protection Section
Aquifer Protection Section
1628 Mail Service Center, Raleigh, North Carolina 2 7699 -162 8
One
Locations 3900 Barrett Dr., Raleigh, North Carolina 27609
NorthCarohna
Phone; 919-79142001 FAX: [phone] L Customer Service: 1-877.623-6748
Internet: www.nLwtnerqualily.tng
NaturallyAn
Equal Opportunity 1 Affirmative Action Employer

A';-A'V
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
April 18, 2012
Charles A. Davis
1422 Ridge Road
Raleigh, NC 27607
Subject: Analytical Results of Well Water
Permit No. WI 0500040
UIC-5A7 Geothermal Well
Wake County
Dear Mr. Davis,
Enclosed please find the analytical results of the well water which was sampled on February 20, 2012.
The influent (groundwater entering heat pump) and the effluent (water being injected into the well) of
the geothermal well system were sampled.
All the parameters which were analyzed were in compliance with North Carolina Groundwater Quality
Standards (NC AC 15A 2L.240) except copper. The copper concentrations were 1,700 micro gram per
liter (ugll) for influent and 2,200 ug/l for effluent. These results indicate that the copper concentration
was elevated above the 2L Groundwater Quality Standard of 1,000 ugll. Historical analytical data, also
shows that, in 2002, effluent copper concentration was elevated above the 2L Groundwater Quality
Standards (the effluent copper concentration was 1,500 ugll). The pH of the groundwater is 6.0, which
is slightly acid. Within the heat pump system, the slightly acid groundwater could possibly dissolve
copper from the copper tubing. Elevated levels of copper in water can produce sediment, impart a
metallic taste and cause greenish staining of plumbing fixtures and laundered items. The groundwater
with such elevated copper concentrations is not recommended for consumption. If you have any
questions, please contact me at [phone].
Sincerely,
4�e, n M (C"(+Y7
Lin McCartney
Environmental Senior Tech
Cc: RRO-APS Files
The Central Office- APS Files
Aquifer Protection Section
16281v1afI Service Center, Mcigh hbnh Carolina 27699-1629 n�
Location: 3800 Barrett fh,. Raleigh, North Carolina 27609
Phone: [phone] FAX: [phone] � Customw Service: 1-877-623-674R Tqoor hCarolina
Internet: www,rtcwateryuali'%' )Vaturallil
An Equal Oppornunity 1 A#inrm4tive Action Employer

County:
River Basin
Wake
OF WA rr
Q
Sample ID:
PO Number #
ABB0558
12GO056
Report To
RROAP
Date Received;
02/2012012
_O
Collector;
L MCCAR7IYEY
���`
�
�'
�
Time Received:
12.45
Labworks Loginln
MSWIFT
Region:
RRQ
Report Generated:
3122112
Sample Matrix
WASTEWATER
Date Reported:
0312212012
Lac, Type:
INFLUENT
Emergency Yes/No
VisidD
COC YeslNo
Loc. Descr.: CHARLES DAVIS
Location ID:
5PO92WI0500040_INF
Collect Date: 0212012012
Collect Time: 12:00
Sample Depth
CAS #
LAB
Analyte Name
-
Sample temperature at receipt by lab
PQL
Result!
Qualiflei.
2.8
nits
00
Method
Reference
Analysis
Date
2120M2
Validated by
DLEAVITT
MIC
Coliform, MF Fecal in liquid
1
1 B2
CFU1100ml
APFiA9222D-20th
2120/12
CGREEN
Coliform, MF Total in liquid
1
1 B2
C17101100ml
APHA922213-20th
2120112
CGREEN
WET
Ion Chromatography
_TITLE_
mg/L
EPA 300.0
2/27/12
CGREEN
Chloride
1.0
13
mg/L
EPA 300.0
2127112
CGREEN
Fluoride
CA
OA U
mglL
EPA 300.0
2/27112
CGREEN
Sulfate
2.0
2.0 U
mglL
EPA 300.0
2/27112
CGREEN
Total Dissolved Solids in liquid
12
64
mglL
APHA254OC-1BTH
2/23/12
CGREEN
NUT
NO2+NQ3 a5 N In liquid
0.02
1.6
mg/L as N
LaC10-107-04-1-c
2/23/12
CGREEN
MET
7429-90.5
Al by ICP
50
50 U
ugIL
EPA 260.7
2124112
ESTAFFORDI
7440-70-2
Ca by ICP
0.10
1 A
rng/L
EPA 200.7
2124112
ESTAFFORDI
7440-47-3
Cr by ICPMS
10
IOU
ug/L
EPA 200.8
2/24/12
ESTAFFORDI
7440-50-8
Cu by ICPMS
2.0
1700
UgIL
EPA 200 s
2/24/12
ESTAFFORDI
7439-89-6
Fe by ICP
50
50 U
uglL
EPA 200-7
2124112
ESTAFFORDI
7440-09-7
K by !CP
0.10
0.98
mg1L
EPA 200-7
2/24112
ESTAFFORDI
7439-95-4
Mg by ICP
0.10
1.5
mg1L
EPA 200.7
2124112
ESTAFFORDI
7439-96.5
Mn by ICP
10
30
uglL
EPA200.7
2124/12
ESTAFFORDI
7440-23.5
Na by ICP
0.10
11
mg1L
EPA200.7
2124112
ESTAFFORDI
7440-02.0
Ni by ICPMS
2.0
2.0 U
ug/L
EPA200.8
2/24112
ESTAFFORDI
7439-92-1
Pb by ICPMS
2.0
2.2
ug/L
EPA200.8
2/24/12
ESTAFFORDI
7440-66-6
Zn by ICPMS
10
22
ugIL
EPA200.8
2124/12
ESTAFFORDI
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699.1623 [phone]
For a de1w ed rims criplion of the quel I Rar codes refer to 13#pRVjpo rta 1, rKgnr: n1µ1y�o1�1'.'9�3 +rdtfl^!41!.S'� �'!«stNL7�1 [.i„r.�y�IJi!gr. �ydrp !bF Ljk'j/Durwr.nrglrnr..g:R1'Hg�f'Y�r�uihls!l7lffnfnfrecnN•sisr+
Page 1 of 1

North Carolina
GROUNDWATER FIELD/LAB FORM department of Environment and Natural Resources
'Z.r, DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Location Code Z W r 0 r G 6 ❑ f SAMPLE TYPE SAMPLE PRIORITY I Z Cy o()
County w ` e Water Routine Lab Number A 2
Quad No Serial No. ❑ Soil ❑ Emergency Date Receiv 2.2d l Z Time:
Lot Long. ❑ Other Rec'd By: From Bus, Courier, H na
❑ Chain of Custody Other'
Report To. ARO, FRO, MRO RO WaRO, WiRO, �u Data Entry By: Gk:
WSRO, Kinston FO, Fed. Trust, Central Oft., Other. r> G �!�`S ` Date Reported'
Shipped by: Sus, Cootie►, and a r, Other. Purpose m
Callectogs): n1 � Date � — �7 Time _ L: 0Baseline, Complai , Cr� pliaanCe' LUST, Pesticide Study, Federal Trust, Other: -
FIELD ANALYSES pc'Vts l _
PH auv ; ` Spec. Cond.a4at 25°C Location or Site _I 44 z x R F 4 e J2 - -' � I C + A� /t 6 �7 r
Temp.lo_ 'f j °C Odar. 1 7 L; . r yr Description of sampling point •4C/1 ►� e c. s w
Appearance g�_l rr. t�- f' Sampling Method C—rC+ Sample Interval
Field Analysis By' ' (_ 6, r, Remarks P G�v� S' — 7- 711, -e
LABORATORY ANALYSES f -
BOb 310
mgiL
COO High 340
mglL
COO Low 335
milk
Coldorm_ W Fecal 31616
Moom1
CoMorm: W Total 31504
1100ml
TOC 680
Ing&
Turbidity 76
NTU
Residue, Total Suspended $30
m9lL
pH 403
units
Allmlinhy to pH 4.5 410
m91L
ABceii city to pH 8.3 415
TAIL
Carbonate 445
m91L
Bicarbonate 440
mgli
Carbon diobde 405
mak
j�
Chloride 940
rr,91L
Chromium: Hex 1032
vg1L
Color. True to
Cu
Cyanide 720
mtp1L
Lab Comments
x
Dist. Solids 70300 mg(L
Fluoride 951 mgli
Hardness: Tole) 900 m9fL
Hardness [rpn-carp] 902 w4L
Phenols 32730 u9ll
Specific Cand. 95 lrMhosfcm
Suirge 945 mg1L
Stlride 745 m9k
ail and flrease mg1L
Nt1� as N 610 milk
T*4 as N 625 mgrL
NO2 + NO, as N S30 mgfL
P: Total as P 665 mg1L
Mrate (NO, as N) 6.20 mg1L
Wrft (NCs as Nj 615 mglL
G -54 REV. 7103 For Dissolved Analysis-subrrrt hitered sample and wrft "D 5' in block
(Pumpmp forte, air temp., ets)
AgSiher 46566
29!L
AI-Aleminum 46557
Vg1L
As -Arsenic 46551
ugIL
Ea -Barium 46568
UCVL
Ca -Calcium 46552
Cd-Cadmium 46559
Cr-Chromium 46M
uWL
Cu-Copper 46562
Fe4mn 46563
LVL
149 mercury 71900
L
K-Patasslum 46SM
m
Mg-klagnesium 46554
M91L
fit;
6do-Mirrganese 46565
u
j(
IN& ck d = 46556
m
Nib .kel
uqJL
Pb.-Lead 46564
u
Se -Selenium
7n-Zinc 46567
L
Organachlod PesWdes
Organophosphorus Pesticides
f G1r en Pesticides
Acid HerrWdea
PCB5 —
5ernludatile organics
s
i'PH-i]iesd Ra e
VdOle Organics EOA tattle)
TPH-Gasoline Ra
TPF!-STE% C,asdne Range
LAB USE ONLY
Temperatureun anival rQ: 2

'Results
County:
Wake
Sample ED:
ABS0557
River Basin
(}FA �q
PO Number #
12GO055
Report To
RROAP
�O,
G
j'i r
Date Received
02120/2012
LIL7l
Time Received:
12;45
Collector:
Region:
L MCCAR7NEY
RRp
_
�jq?}a
Labworks Loginl❑
MSWIFT
Report Generated:
3/22/12
Sample Matrix:
WASTEWATER
J'
Date Reported:
0312212012
Lac. Type:
EFFLUENT
Emergency YeslNa VlsitrD
COC Yes/No
Loc. Descr.: CHARLES DAVIS
Location ID: 5P092WI0500040_EFF Collect hate: 02/2012012 Collect Time: 12:30 Sample Depth
CAS #
LAB
Analyte Name
Sample temperature at receipt by lab
ROL
Result/
Qualifier
2.8
units
wG
Method
Reference
Analysis
Date
2120112
Validated by
DLEAVIT r
M[C
Coliform, MF Fecal in liquid
1
1 82
CFL11100ml
APHA9222D-20th
2/20112
CGREEN
Collform, MF Total in liquid
1
1 B2
CFLY100ml
APHA92228-20th
2/20/12
CGREEN
WET
]on Chromatography
_'TITLE_
mg1L
EPA 300.0
2/24/12
CGREEN
Chloride
1.0
14
mg/L
EPA 300,0
2/24112
CGREEN
Fluoride
0A
0.4 U
mg1L
EPA 300.0
2124112
CGREEN
Sulfate
2.0
2.0 U
rng/L
EPA 300.0
2124112
CGREEN
Total Dissolved Solids in liquid
12
62
mg1L
APHA254OC-18TH
2123112
CGREEN
NUT
NO2+NC3 as N in liquid
0.02
1.6
mg1L as N
1-300-107-04-1-c
2/23/12
CGREEN
MET
7429-90-5
Al by ICP 5Q
5d U
ug/L
EPA 200.7
2/24/12
ESTAFFORDI
7440.70-2
Ca by ICP
0.10
1 A
mglL
EPA 2007.
2/24112
ESTAFFORDI
7440-47-3
Cr by ICPMS
10
IOU
ugIL
EPA200.8
2124112
ESTAFFORDI
7440-50-8
CU by ICPMS
2.0
2200
ug/L
EPA200.8
2124112
ESTAFFORDI
7439-89-6
Fe by 1CP
50
50 U
ug/L
EPA200.7
2124/12
ESTAFFORDI
7440-09-7
K by ICP
0-10
0.97
mg/L
EPA200.7
2124/12
ESTAFFORDI
7439-95-4
Mg by 1CP
0.10
1.5
mglL
EPA200.7
2/24/12
ESTAFFORDI
7439-96-5
Mn by JCP
10
32
uglL
FPA200.7
2/24/12
ESTAFFORDI
7440-23-5
Na by ICP
0.10
11
mg/L
EPA200.7
2124/12
ESTAFFORDI
7440-02-0
NI by ICPMS
2,0
2.7
ug1L
EPA200.8
2124112
ESTAFFORD1
7439.92-1
Pb by ICPMS
2.0
2.9
ug1L
EPA200.8
2124112
ESTAFFOR01
7440-66.6
Zn by ICPMS
10
33
ug1L
EPA 200.8
2124/12
ESTAFrORD1
Laboratory Section» 1623 Masi Service Center, Raleigh, NC 27599-1023 [phone]
ror a daiaiVed description of the e-'alifior codes 7efor io 1, yp. Alo i,nr.+itnr.nrgjwSttlwyjLtih.'zi�ffis h+ ! rnnFsn�ff�1��[1�.Uifid+ G:nsfr. hisp'jf i1�I,, y Ar rx weyjwtf :r: ll7nrorlrrifnp+rxs:•
Page 1 of 1

GROUNDWATER FIELD/LAB FORM
Location code S fUGfd CV2-C,> 6100 0 -off
County w a lk e
❑uad No Serial No.
LaL Long.
Report To: ARO, FRO, MRO RRO WaRO, WiRO,
WSRO, Knston FO, Fed. Trust, Central Off., Other.
Shipped by: Bus, Courier, 1-16-nUlFe-1), Other:
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUNOWATER SECTION
SAMPLE TYPE SAMPLE PRIORMY I Z� D 055 El water Routine Lab Number A T3 ❑551
❑ Soil ❑ Emergency
Date Received ?--Zo• L' Time-
❑ Other Reed By: From:Bus, and el), r�
❑ Chain of Custody Other.
Data Entry By: Ck:
off/4'errCate Reported:
Purpose: m
Collector(SY L m cCar +� Date '7 Time_ i _1 � 42 Sasefine, Complaint,ymv tanr�a LUST, Pesticide Study, Federal Trust, Other:
FIELD ANALYSES /'Cn � ,
Owner C_`►Cnr) eS
pH 400 L Spec. Cond.94 at 2VC
Temp.ln n °C Odor Y] C F
Field
BOO 310 m92
COD Figh 340 mg1L
COD Law 335 mgrL
it
Colifvrm: bid Fecal 31616 1100m1
1(
Coldwm. MF ToW SIS04 Moomt
TOC 680 MWL
Turbidity 76 NTLI
Residue, Tour Suspended 530 mg1L
pH 403
units
Alkalinity to pH 4.5 410
M91L
Alk>alinitylo pH 8.3415
MOIL
Carbonate 445
mgR
Bicarbonate 440
mg1L
Carbon diaxide 405
_AA
Chloride "a
rrlgrL
Chromium: ilex 1032
u9IL
Color. True 80
CL1
Cyanide 720
mg&
Comments
Location or Site 14 o-)-.2 ACIe Rd ^t c- r e-j n A/
Description of sampling point :.JQf t " e
Sampling Method t4_4� Puma- Sample Interval
Remarks_ rZs1ti 5 - �� aver, a c,r —
rP runping tern e, air lemp.. 91F
3[
Dias. Solids 70300 M9h_
Fluorbde 951 mWL
Hardress' TOW 900 M90L
Hardness (norrcarb] 9D2 mglL
Phenols 32730 ugA
Specific rand. 95 },Mhoslcm
Sulfate S45 mg1L
Surfide 745 M90L.
Oil and Grease rng/L
NH-1 as N 610 M91L
TKN as N 625 mgrL
NO, + NO, as N 630 m91L
P: Tntal as P 666 m}rL
Mrate (Ng as N) 620 MOC
Write [NOi as N] 615 mgrL
GW-64 REV. 7103 For Dissolved Anaiysis-subrrdl filtered sample scut write 'OLT in block.
Ag-VI%W 46W
ugfL
�{
AJ Aluminum 46557
R
As-ArsertiC 46551
Boaan urn 46558
Ca -Calcium 46562
m L
Cd-Cadmium 46$59
tKVL
Cr-Chromium 46559
u L
S[
Cu-Capper 466,562
VL
?[
Fe, -Iron 46563
L
HU-M emery 71900
p
K-Potassium 46555
mgfL
}�
Mg -Magnesium 46554
Mn-Manganese 46565
L
}(
Na-Sadiron 46556
j(
wgrekel
tvL
Pbkl-.d 46564
Se -Selenium
uWL
Zrr-Zinc 46567
UWL
Or ar,orhlarine Pes4pdes
Dr hos horns Pesticides
Mroqen Pesticides
Acid )*dAcidels
PC%
Semivaiatile Organics
TM4-Diesel Range
Volalde Organkcs OA boWe
TPFFGasdine Range
TPFFSTEX Gasoline Range
LAB USE ONLY
Temperature on arrival t'Cj:

Permit Number W105OOO4O
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Charles and Gwendolyn Davis SFR
Location Address
1422 Ridge Rd
Raleigh NC 27607
Owner
Owner Name
Charles
Dates/Events
Alfred Davis
Scheduled
Orig Issue App Received Draft Initiated Issuance
04/26/02 01 /24/12
Regulated Activities
Heat Pump Injectlon
Cenfiel Files' APS 5WP
03/13/12
Permit Tracking Slip
Status
Project Type
Active
Renewal
Version
Permit Classification
3.00
Individual
Permit Contact Affiliation
MajorlMlnor Region
Minor Raleigh
County
Waite
Facility Contact Affiliation
Owner Type
I ndividual
Owner Affiliation
Charles Alfred Davis
1422 Ridge Rd
Raleigh NC
27607
Public Notice Issue Effective
Expiration
03/09/12 03/09/12
02/28/17
RequestedfRecelved Events
_
Additional information requested
01/27/12
Additional information received
02/07/12
RD staff report requested
02/13/12
RO staff report received
02/24/12
Out€all NULL
Waterbody Name Stream Index Number Current Class Subbasin

A171"A
NCDE R
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Division of Water Quality
Charles Wakild, P.E.
Director
March 9, 2012
Charles and Gwendolyn Davis
1422 Ridge Rd.
Raleigh, NC 27607
Re: Issuance of Injection Well Permit
Permit No. W10500040
Issued to Charles and Gwendolyn Davis
Wake County
Dear Mr. and Mrs. Davis;
Dee Freeman
Secretary
In accordance with your application received January 24, 2012, and additional information received February 7, 2012, I
am forwarding Permit No. W10500040 for the operation of a 5A7 geothermal underground injection control (UIC) well
heat pump systcra located at the above referenced address. This permit shall be effective from the date of issuance until
February 28, 2017, and shall be subject to the conditions and limitations stated therein.
The Raleigh Regional Office collected groundwater samples from your geothermal system on February 20, 2012. After
the laboratory analytical results are received, the results will be forwarded to you 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 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,
Michael Rogers, P.G. (N(.. & FL)
Environmental Specialist
cc: Jay Zimmerman, Raleigh Regional Office
Central Office File, W10500040
Wake County Environmental Health Dept.
AQUIFER PROTECTION SECTION
636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location' 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone 919-807-CA64 I FAK 919-807-6496
Internet www.newatemualitv.ora
No rthCarolina
An Equa[ Oppminity l AI(frrrmtivB Adion Employer

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMNIISSION
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 1S HEREBY GRANTED TO
Charles and Gwendolyn Davis
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 1422 Ridge Rd., Raleigh, Wake County, NC 27607, and will be constructed and
operated in accordance with the application received January 24, 2012, and in conformity with the
specifications and supporting data submitted February 7, 20 12, 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 .4100 and .020D, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revolted, from the date of its issuance until February 28, 2017, and shall be
subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
Permit issued this the 9_ day of 2012.
AA Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit 4Wi0500040 UIC/5A7 Page 1 of 5
per. 03/2010

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.
1 Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be sealed with a water -tight cap or well sealed, as defined in G.S. 87-85(16).
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 11 — OPERATION AND USE GENERAL CONDITIONS
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.
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.
PART III -- PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so chat there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
Permit 4WI0500040 UIC/5A7 Page 2 of 5
ver 03/2010

facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee-shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART IV — OPERATIONS AND MAINTENANCE REQUIREMENTS
The injection facility shall be properly maintained and operated at all times.
1 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 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.
?. 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 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.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Raleigh Regional Office, telephone number 919-791-4200, 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;
Permit #W10500040 UIC/5A7 Page 3 of 5
ver. 03/2010

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.
1n 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 VM — CHANGE OF WELL STATUS
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 l5A NCAC 2C .0213(h)(1), 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.
(E) In the case of gravel -packed wells in which the casing and screens have not been
removed, tke 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.
Permit #WI0500040 LJlC/5A7 Page 4 of 5
Ver. 03/2010

(G) The Permittee shall submit a Well AbandownetitRecord (Form GW-30) as specified in
15A NCAC 2C A2 3 3(h)(i) within, 30 days of completion of abandonment. '
3. The written documentation required in Part VIII (1) and. (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Permit #WI0500040 UIC/5A7 Page 505
per. 03/20I0

Permit Number WIOS00040
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well {5A7)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Charles and Gwendolyn Davis SFR
Location Address
1422 Ridge Rd
Raleigh NC 27607
Owner
Owner Name
Charles
Alfred Davis
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance
04/26/02 01/24/12
Regulated Activities
Heat Pump Injection
Central Files. APS SWP
03/09112
Permit Tracking Slip
Status Project Type
In review Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major)Minor Region
Minor Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Charles Alfred Davis
1422 Ridge Rd
Raleigh
Public Notice Issue
ReguestedlReceived Events
Additional information requested
Additional information received
RO staff report requested
RO staff report received
❑utfall L1L�-
Waterbody Name Stream Index Number Current Class
NC 27607
Effective Expiration
01/27/12
02/07/ 12
02/13/12
02/24/ 12
Subbasin

AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: February 21. 2412
To: Aquifer Protection Central Office
Central Office Reviewer: Michael RoLers
Regional Login No:
County: Wake
Permittee: Charles Davis
Project Name: In'ection 5A7 WeH
Application No.: W10500040
L GENERAL INFORMATION
l . This application is (check all that apply): ❑ New N Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Mltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation N Other Injection Wells (including in situ rernediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
a. Date of site visit: 02-20-2012
b. Person contacted and contact information: Charles Davis. 919-782-0112
c. Site visit conducted by: Lin McCartney
d. Inspection Report Attached. ® Yes or ❑ No.
2. Is the following information entered into the RIMS record for this application correct?
® Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment lKacillties:
a. Location:
b. Driving Directions:
c. LTSGS Quadrangle Map name and number:
d. Latitude
Longitude:
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For Disposal and Infection Sites:
f 1f multiple sites either indicate which sites the information applies to, coCv and paste a new section into the
document for each site, or attach additional pages for each site]
a. Location(s): 1422 Ridge Road, Raleigh, NC 27607
b. Driving Directions: Take 440 W, take Wade Ave. exit turn left, turn left onto_Ridge_rd.
c. USGS Quadrangle Map name and number:
d. Latitude:35-48-23 Longitude: 78-41-9
II. NEII`AND Af 4JOR MODIFICATION APPLICA 770AIS (this section not needed f'or ren",uls or minor
Modifications, skip to next section) ^
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification:
2. Are the new treatment facilities adequate For the type of waste and disposal system:?
FORM: Staff.Repor-tCharles Davis i

AQUIFER PROTECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed -loop groundwater retnediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well{SIAnd Facilities — New. Renewal, And Modifieadon
1. Type of injection system:
® Heating/cooling water return flow (5A7)
❑ Closed -loop heat pump system (5QMJ5QW)
❑ In situ remediation (5I)
❑ Closed -loop groundwater remediation effluent injection (5Ll"Non-Discliarge")
❑ Other (Specify:
2, Does system use same well for water source and injection? ❑ Yes ® No
3. Are there any potential pollution sources that may affect injection? Z Yes ❑ No
What is/are the pollution source(s)? The septic tank. The septic tank is approximately 1QU feet distance from
the well.
4. What is the minimum distance of proposed injection wells from the property boundary? 25 f.
5. Quality of drainage at site: ® Good ❑ Adequate ❑ Poor
G. Flooding potential of site: ® Low ❑ Moderate ❑ High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program.
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: NIA
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? ® Yes or ❑ No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal And Modification Onb,
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
❑ Yes ® No. If Yes, explain:
:. For closed -loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? ❑ Yes ❑ No. If yes, explain:
For renewal or modification of groundwater remediation permits (of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? ❑ Yes ❑ No. If yes. explain:
Staff.Repor-tCharles Davis 4

AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Drilling contractor: Name:
Address;
Certification number:
5. Complete and attach Well Construction Data Sheet,
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, please explain
briefly.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
i
Condition �� -- Reason.
FORM: Staff.Repor-tCharles Davis 5

AQUIFER PROTECTION REGIONAL STAFF REPORT
7, Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
8. Signature of report preparer(s):
Signature of APS regional supervisor:
Date: 7 / Z.4�/I'D / -z--
yy\���'n�.
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
Well inspection and well water sampling were conducted on February 20, 2012.
The geothermal well was in good condition.
Over all, this geothermal injection well is in compliance with the subject permit.
However, we arc awaiting the lab results of the well water to complete this application process -
FORM; Staff.Repor-tCharles Davis 6

Compliance Inspection Report
Permit: WIOS00040 Effective: 05/14/07 Expiration: 04/30/12 Owner: Charles A Davis
5OC: Effective: Expiration: Facility: Charles and Gwendolyn Davis SFR
County: Wake 1422 Ridge Rd
Region: Raleigh
Raleigh NC 27607
Contact Parson: Gwendolyn P Davis Title: Phone:
Directions to Facility:
From 1440, Exit Ridge Rd at Glenwood Ave. and go south apex 2 miles. Property is on left.
System Classifications:
Primary ORC: Certificatlon:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
inspection Date: 02/20/2012
Primary Inspector: Lin McCartney
Secondary Inspector(s):
Entry Time: 12:00 PM Exit Time: 01:00 PM
Phone:
Phone- 919.791-4200
Ext.4243
Reason for Inspection: Routine inspection Type: Compliance Sampling
Permit Inspection Type: ln)ection Heating/Cooling Water Return Well (5A7)
Facility Status: ■ Compliant ❑ Not Compliant
Question Areas:
M Wells System Operations
(See attachment summary)
Page: 1

Permit: W10504040 Owner • Facility: Charfes A Davis
Inspection Date: OZ20/2012 Inspection Type: Compliance Sampling
Reason for Visit: Routine
Inspection Summary:
Well inspection and well water sampling were conducted on February 20, 2012.
The geothermal well was in good condition. Over all, this geothermal injection well is in compliance with the subject
permit. However, we are awiting the lab results of the well water to complete this application process.
System Operation
is same well used as source well and injection well?
Is injection well capable of assimilating injected fluid?
Injection flow rate at time of inspection (gpm)
Has system own erloperator noticed any abnormalities [turbidity, air in system, poor heatinglcoeling, etc] In
system operation?
Comment'on system operation
Is system operation and construction consistent with that described in applicatlon?
Describe inconsistencies between application and observed operation/construction
Comment:
■ ❑ ❑ ❑
■ ❑ ❑ ❑
■ ❑ ❑ ❑
■ ❑ ❑ ❑
■ ❑ ❑ ❑
Page: 2

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: February 13. 2012
To: ❑
Landon Davidson, ARO-APS
❑
Art Barnhardt, FRO-APS
❑
Andrew Pitner, MRO-APS
®
Jay Zimmerman, RRO-APS
❑ David May, WaRO-APS
❑ Morelia Sanchez King, WiRO-APS
❑ Sherri Knight, W-SRO APS
From: Michael Roeers Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E-Mail. Michael.Roger a nedenr.gav
A. Permit Number: W10500040
B. Owner: Charles and Gwendolvn Davis
C. Facility/Operation.
❑ Proposed ® Existing ❑ Facility ❑ Operation
D. Application:
L Permit Type: ❑ Animal ❑
SFR-Surface Irrigation❑
Reuse
❑ H-R Infiltration
❑
Recycle ❑
IIE Lagoon ❑ GW
Remediation (ND)
®
UIC — 5A7 Open
Loop Geothermal Well
For Residuals:
❑ Land App.
❑ D&M
❑
Surface Disposal
❑ 503
❑ 503 Exempt
❑
Animal
Z Projecl Type. ❑
New ❑ Major Mod. ❑ Minor Mod. ®
Renewal
❑ renewal wl Mott.
E. Comments/Other Information: ❑
NOTE:
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or 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-AP5 representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
ti of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
a listed above.
RO APS Reviewer: Date:
FORN4' APSARR 07106 Page 1 of 1

Rogers, Michael
From:
Rogers, Michae#
Sent:
Tuesday, February 07, 2012 10.24 AM
To:
'cdavis'[e-mail],corn'
Subject:
FWD W10500040 Davis
Attachments:
20010527004854152-pdf
Mr. Davis -
We received the renewal application for your geothermal well. Thank you very
much. However, the application was not signed. Please find attached the
signature page. Please have you and your wife sign you it. You may if you want,
scan and e-mail back as an attachment to this e-mail in lieu of the U.S. Postal
Service.
Thank you for your cooperation.
NOTE: On January 6th, the Aquifer Protection Section (APS) is scheduled to move
to the 6th floor of the Archdale Building located at 512 N. Salisbury Street in
Raleigh. Our mailing address will remain the same (1636 Mail Service Center,
Raleigh, NC 27699-1636). If you need to visit APS staff or review files, please
call or email in advance to ensure availability. Please check the APS website
for updates on office numbers and phone numbers as they become available.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality- Aquifer Protection Section {APS}
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line 919-807-6406
http_://portal.ncdenr.org/web/wg/aps/gwpro/permit-applications#p,eothermApps
E-mail correspondence to and from this address may be subject to the North
Carolina Public Records Law and may be disclosed to third parties
_-- Original Message -----
From: Heather Jennings mailto:heather.b.ienning�i�ncdenr .gov1
Sent: Sunday, May 27, 2001 12:49 AM -
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 05.27.2001 00:48:54 (-0400)
Queries to: robin.markham(lncdenr.g!gv
1

fi'rjx5?A`�NR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Charles Davis
Gwendolyn Davis
1422 Ridge Road
Raleigh, NC 27607
Dear Mr. and Mrs. Davis:
Division of Water Quality
Charles Wakild, P.E.
Director
February 6, 2012
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. W10500040
Charles and Gwendolyn Davis SFR
Injection Heating/Cooling Water
Return Well (5A7) System
Wake County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on January 24, 2012. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Raleigh Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or michael.rogers@ncdear-gov-
Sincerely,
fx�
for De rA.
a �. Watts
cc: Raleigh Regional Office, Aquifer Protection Section
Permit File WI0500040
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699.1636
Locaton: 512 N. Salisbury St., Ralabh, North Carolina 27604
Phone: 91 M07-64641 FAX: 91U07.6496
Internet; W6W.nmplemuallty.oM
An Equal ❑pparWnity 1AYrmadve AeUon Ernpbyer
Groundwater Protection Unit Supervisor
one.
No Carolina
atoru l

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
OPEN -LOOP GEOTHERMAL INJECTION WELLS
These wells discharge groundwater directly into the subsurface as part of a geothermal heating and cooling system
(cheep one) New Application ''� Renewal * Modification
* For renewals complete Parts A-C and the signature page.
Print or Type Information and Mail to the Address on the Last Page. Illegible AppPications Will Be Returned.4s Incomplete.
DATE: Fr p- to 20 [y
PERMIT NO. \91 A j 60,0 kg(leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non-Goverrunent: Individual Residence 'e' Business/Organization
Government: State Municipal County Federal
B. PERMIT APPLICANT — For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
�- �►�'eRl..�.S �4lV.�T•��n �i fit �,<
Mailing Address:
City: _ RAL*— State: tl�ip Code: A2 7 County: w'
Day Tele No.: " L_ 0'L_(71-- ^ Cell No.:
EMAIL Address: _ _ 0-4 &-Vti 8 R W 1QG . )U 7)+w, C'.ea_ ftx No.: _ r
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) ParceI Identification Number (PIN) of well site: County:o•.i� e
(2) Physical Address (if different than mailing address):
City: State: NC Zip Code:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
Contact Person:
Address:
City: Zip Code:
Office Tele No.: Cell No.:
EMAIL Address:
State: County:
Fax No.:
GPUIUIC 5A7 Permit Appiication (Revised 3/1 V2011) Page I

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Marne:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
Zip Code: State: County:
Cell No.: Fax No.:
F. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO
G. WELL CONSTRUCTION DATA
PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(6) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
EXISTING Well(s) being proposed for use as an injection well. Provide the data in { I) through (6)
below to the best of your knowledge. Attach a copy of the Well Construction Record (form
G W-1) if available.
(1) Well Construction Date: Number of borings:
Depth of each boring (feet):
(?) Well casing type: Galvanized steel Black steel - Plastic Other (specify)
Casing thickness (in.): .Diameter (in.):
Well depth: from: to: feet below land surface
Casing extends above ground inches
(3) Grout material surrounding well casing:
(a) Grout type: Cement Bentonite* ' Other (specify)
`Hy selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .021](d)(1)(A), which mquires a cement type grout_
(b) Depth of grout around well casing (relative to land surface): from to feet
(4) Well Screen or Open Borehole depth (relative to land surface): from to feet
(5) N.C. State Regulations (Title 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. Is there a faucet on:
(a) Influent 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-l). If Form GW-i is not available, provide
the following data:
From what depth, formation, and type of rocic/sediment units will the groundwater be withdrawn? (e.g.
granite, 1 imestone, sand, etc.)
Depth: Formation: Rock/sediment unit:
NOTE: THE WELL, DRILLING OR HEAT PUW. CONTRACTOR CAN HELP SUPPLY TH1r DATA IF THIS
INFORMATION IS OTHERWISE 11NAVA LABLE,
GPLIIUIC 5A7 Permit Application (Revised 3/18/201 l) Page 2

H. OPERATING DATA
(I)
Injection Rate:
Average (daily) _gallons per minute (gpm).
(2)
Injection Volume:
Average (daily) gallons per day (gpd).
(3)
Injection Pressure:
Average (daily) pounds/square inch (psi).
(4)
Injection Temperature:
Average (January) ° F, Average (July) ° F.
L WELL LOCATIONS — Maps must be seated or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(I) Attach a site -specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation; sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 114 mile from the injection well site that indicates the
facility's location and the map name.
NOTE. In most cases, an aerial photograph of the property parcel showing property 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 to relation to property boundaries, houses, septic tanks, other
wells, etc. can their be drawn tri by _hand. Also, _a `layer' can he selected showing topographic contours or
elevation data.
GPUMC SA7 Permit Application (Revised 3/1 V2011) Page 3

J. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
I . for a corporation: by a responsible corporate officer;
? for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, 1 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 -ner/Applicant
Print or Type Full Name
Signature of Pro rty Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699.1636
Telephone [phone]
GPUIMC 5 A7 Permit AppheaEion (Revised NMI) t t) Page 4

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: f wz- &Jya d p �--a
Permittee Name: C �-- 5 A-, 7) ;�-'( l :5-
Address: 14? 2[ TZD `7r�-r� -�- i , -Ke, zl ec a 7
Please check the selection which most closely describes the current starts of your injection well system:
1) 'LWell(s) still used for injection activities, or may be in the future.
2) ❑ Well(s) not used for injection but is/are used for water supply or other purposes.
3) ❑ Injection discontinued and: a) ❑ Well(s) temporarily abandoned
b) ❑ Well(s) permanently abandoned
c) ❑ Well(s) not abandoned
4) ❑ injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information,
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well, (Include o description ofhow the well
was sealed and the type of material used to, f ll the well if permanent1v abandoned):
Permit Rescission:
If you checked (2),(3), or (4) and will not use a well for injection on this site in the future, you should request rescission of the
permit. Do you wish to rescind the permit?
Yes ❑ No
Certification:
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
Revised 5105
Signature ate
RECEIVED 1 I)ENR 10 WQ
Aquifer Protsction SeMon
�wruiG-ss JAN 2 d
REC-D

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
OPEN -LOOP GEOTHERMAL INJECTION WELLS
These wellsXwharge groundwater directly into the subsurface as art of a geothermal heating and ;gnature
olie . ystem
{check an New Application Renewal* Modinn
* For renewals complete Parts A-C and the page.
Print or 2]pe Information an Ltail to the Address on the Last Page. Illegible Applications Will Be Ii' turned As Incomplete.
DATE: .S e.w J e v 20 ! �
PERMIT NO. W� D_pa A \eone)
lblnk if New Application)
A. STATUS OF APPLICANT (
Non -Government: Indivnce Busint
Government: StateMunicipal
B. PERMIT APPLICANT — For individual resii�t
state name of entity and name of person delegated
Mailing Address: 1 `#' 2-2 l ��
City: State:
Day Tele N o.: Z i 1 -�L,
ENVIAIL Address: Lt (4� ike _., A d
C)u_.,
Federal
list earl owner on property deed. For all others,
ty to gn on behalf of the business or agency:
Co
C. LOCATION OF WELL SITE -- Whe the injection wells are physically
(1) Parcel Identification Numb (PIN) of well site: -,
(2) Physical Address (if diff9/ent than mailing address):
D. WELL DRILLER I ORMATION
Well Drilling Contr ctor's Name:
NC Well Drillin�V/Coutractor Certification No.:
r
Company Na� le:
Contact Person:
Address;
State: NC Zip C
EMAIL Address:
County: Lq-� G-(!� 2
County: W]
NeJAN 2Q6(�
City. Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
GPUMC 5A7 Permit Application (Revised 3/18/201 l) Page 1

E. HEAT PIMP CONTRACTOR INFORMATION (if different than driller)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
Zip Code: State: County:
C0if�fo
Fax No.
F. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO
G. WELL CONSTRUCTION DATA
PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(5) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (6)
below to the best of your knowledge, Attach a copy of the Well Construction Record (Form
GW-1) if available.
(1) Well Construction Date: Number of borings:
Depth of each boring (feet):
(2) Well casing type: Galvanized steel Black steel Plastic Other {specify}
Casing thickness (in.): Diameter (in.):
Well depth: from: to: feet below land surface
Casing extends above ground inches
(3) Grout material surrounding well casing:
(a) Grout type: Cement Bentonite* Other (specify)
*By selecting bentot ite grout, a variance is hereby requested to 15A NC AC 2C .0213(dX 1)(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from to feet
(4) Well Screen or Open Borehole depth (relative to land surface): from to feet
(5) N.C. State Regulations (Title 15A NCAC 2C .0200) require the Pertxtittee 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. Is there a faucet on:
(a) Influent 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 GW-1 is not available, provide
the following data:
From what depth, formation, and type of rocklseditnent units will the groundwater be withdrawn:' (e.g.
granite, limestone, sand, etc.)
Depth: Formation: Rock/sediment unit:
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHERWISE (UNAVAILABLE.
GPUrfUIC SA? Permit Application (Revised R18/2011) Page'_

H. OPERATPgG DATA
(1)
Injection Rate.
(2)
Injection Volume:
(3)
Injection Pressure:
(4)
Injection Temperature
Average (daily) gallons per minute (gpm).
Average (daily) gallons per day (gpd).
Average (daily) pounds/square inch (psi).
Average (January) ° F, Average (July) F,
1. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection welts). Label all features clearly and include a north arrow.
(1) Attach a site -specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface: water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic snap of the area extending 114 mile from the injection well site that indicates the
facility's location and the neap name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can he
obtained and downtoaded front the applicable county GIS website Typically, the property can be searched br
owner name or address. The location of the Hells in relation to property boundaries, houses, septic tanks, other
Hells, etc, can then be drawn in by hand. Also, a `layer' can be selected showing topographic contours or
elevation data.
GPUIUiC 5 A 7 Permit Application (Revised 3/18/2011) Page 3

J. CERTIFICATION (to be signed as required below or by that person-s authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1. For a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3, for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their.behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete, 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
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
QPU/UtC 5A7 PeEmit Application (Revised 3118/201 l) Page 4

AA
MEN
North Carolina Department of Environment and Natural Resources
Division of Water quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
December 2, 2011
Charles A. Davis
1422 Ridge Road
Raleigh, NC 27607
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WI0500040
Wake County
Dear Mr. Davis:
Dee Freeman
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Quality (DWQ) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for
the underground injection well system located on your property at 1422 Ridge Road in Raleigh,
NC, which was issued to you on May 14, 2007, and expires on April 30, 2012, is soon clue for
renewal. If you wish to keep this permit and operate the injection well system, the permit must
be renewed and issued in your name.
If Your Iniection Well is Current]%- inactive:
If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed under NCAC Title 15A, Subchapter
2C, Suction .0214, When each well is plugged and abandoned, the well abandonment record
(Form GW-30) must be submitted to our office to certify that the abandonment was properly
conducted,
If there has been a change of ownership of the property, an Injection Well Permit
Narne/Ownership Change Form must also be submitted. The GW-30 and Name/Ownership
Change forms can be found at htti-,:llaortal.nedenr.or«/web/wolapslfr«Trolrenortin�=-forms.
If Your lniection Well is Currently Active:
If the injection well system is still active and you wish to renew your permit, the renewal
application must be submitted within 120 calendar days of the expiration of your permit.
According to our records, you must submit your pernnit renewal by ,la nuar1. 2012.
ACLIIFER PROTECTION SECTION
1636 Mail Service Center. Raleigh. North Carolina 27699-163E
Location: 2728 Capital 8oufevartt, Raleigh. North Garokna 27604 One
Pnone : 915.733-3221 I eAY 1. 919-71 5-05W -1 FAX Z: 91 "15-604? 1 customer Seroice 677-623-674b ���� L�� ���nM
Imernet, www.ncwalemualitv.or�
,4n w_qudf Gpcammn , < Atrmaiive A cdor, cnplove; NFL G -7 il
�- ram..*�
4

In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit one of the following
enclosed forms:
A. Application , far Permit (Renewal) to Construct an"r Use a Wells) for Injection with
Geothermal Heat Pump 5vsrem for Type 5A7 Wells) if the injection well system on your
property is still active,
B. Status of Injection Well System if the injection well system is inactive or has been
temporarily or permanently abandoned.
Please submit the appropriate forms to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
http_IlPortal.ncdenr.orglweblwcq/ap5/gwprolpermit-atmli cations#geotherm Anus.
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 eric.g.smithOinedenr_gov.
Sincerely,
`
t' R
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Raleigh Regional Office - APS w/o enclosures
APS Central Files - Permit No. W10500040 w/o enclosures

Central Files: AP5 SWP
05/24/07
Permit Number W10500040
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
In review Renewal
Permit Type
Version Permit Classification
Injection Heating/Cooling Water Return Well (5A7)
Individual
' Primary Reviewer
Permit Contact Affiliation
michael.rogers
Gwendolyn Davis
Permitted Flow
1422 Ridge Rd
Raleigh NC 27607
Facility
Facility Name
Major/Minor region
Charles and Gwendolyn Davis SFR
Minor Raleigh
Location Address
County
1422 Ridge Rd
Wake
Raleigh NC 27607
Facility Contact Affiliation
Owner
Owner Name
Owner Type
Individual
Charles A Davis
Owner Affiliation
Charles Davis
1422 Ridge Rd
Raleigh NC 27607
Scheduled
Orig Issue App Received Draft Initlated Issuance Public Notice Issue Effective Expiration
04/26/02 02/27/07 O 1ld-Y1O 0 V
e Mated Activities Requested/Received Events
Heat Pump Injection RO staff report received 02/14/07
Additional information received 04/24/07
Outfall MULL
Waterbody Name
Stream index Number
Current Class Subbasin

Michael F. Easley, Governor
William G. Ross Jr- Secretary
North Carolina Drparttuent of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
May 14, 2007
Charles and Gwendolyn Davis
1422 Ridge Road
Raleigh, NC 27607
Re: Issuance of Injection Well Peru
Permit No. WIa500040
Issued to Charles and Gwendolyn Davis
Dear Mr. and Mrs. Davis:
In accordance with your signed application received February 27, 2007, 1 am forwarding Permit
No. W10500040 for the operation of a 5A7 geothermal underground injection well (UIC) heat
pump system located at 1422 Ridge Road, Raleigh, Wake County, North Carolina. This permit.
shall be effective from the date of issuance until April 30, 2012, and shall be subject to the
conditions and limitations stated therein.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit
an application to renew the permit three (3) 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.
Also attached is a summary of the laboratory sampling results from water samples collected from
your geothermal well on December 5, 2006.
If you have any questions regarding your permit or the Underground Injection Control (UIC)
Program please call Mr. Qu Qi at [phone] or me at [phone].
Best Regards,
Z7 e-1 I ------
Michael Rogers
Environmental Specialist 11
GPU — UIC Control Program
cc: Jay Zimmerman — Raleigh Regional Office
Central Office File
Attachment(s)
Aquifer Protection section 1636 Mail Service Center Raleigh, NC 27699-1636
Internet: httn://www.newatemp_a)Lty, 2728 Capital Boulevard Raleigh, NC 276G4
An Equal Opportun4lAffirmabve Action Employer- 50% Recycled110°%Post Consumer Paper
SY Camlina
Naaturally
Telephone--
[phone]
Fax 1:
[phone]
Fax 2:
[phone]
Customer Service:
[phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
f��s���M��Ir�:��.I.�IiIrI���:�ifryllCr�►/:�.1r=i���;�MC*]fir]�►►►I�1�1A.�L�]:i1��1�I�llMCr��i
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
CHARLES AND GWENDOLYN DAVIS
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 1422 Ridge Road, Raleigh, North Carolina, and
will be operated in accordance with the application received February 27, 2007, and in
conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Operation only, and does not waive any provisions of the Water Use Act or
any other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall
be in compliance with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and
any other Laws, Rules, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until April 30, 2012,
and shall be subject to the specified conditions and limitations set forth in Parts I through VIII
hereof.
Permit issued this theA day of 72007.
Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
WI0500040 Page 2

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
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 be constructed in such a manner that water from land surface
cannot migrate into the gravel pack or well screen.
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 injection well shall have permanently affixed an identification plate,
A completed Well Construction Record (Form GW-1) must be submitted for each injection
well to, DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1636
Mail Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well
construction.
PART II - OPERATION AND USE GENERAL CONDITIONS
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.
4. 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.
WI0500040 Page 3

PART III - PERFORMANCE STANDARDS
The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater. which will render it unsatisfactory for 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 -
The issuance of this permit small not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART IV - OPERATION AND MAINTENANCE REQUIREMENTS
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 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.
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.
W10500040 Page 4

PART VI - MONITORING AND REPORTING REQUIREMENTS
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 acceptabie 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 Raleigh Regional Office, telephone number (919) 791-
4200, any of the following:
(A) Any occurrence at the injection facility which 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.
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 VII - PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART VIII - CHAINGE OF WELL STATUS
The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinuation of 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)(1), Well Construction
Standards.
?, 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.
WI0500040 Page 5

(B ) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water,
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe, which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel -packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30}
as specified in 15A NCAC 2C .0213(h)(1) within 30 days of completion
of abandonment.
The written documentation required in Part VIII (1) and (?) (G) shall be submitted to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
WI0500040 Page 6

NORTH CA.ROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM
Type 5A7 and 5QM Wells
In accordance with the provisions ofNCAC Title 15A: 02C.0200
complete application and mail to address on the back page.
TO: DIRECTOR, NORTH CAROL.INA DIVISION OF WATER QUALITY
DATE:r'v
A. PERMIT APPLICANT
Permit Number: f+T66-o4lo110 (WIC, listed at the bottom of each page of your permit)
Name: CAaWe s A - -i laV dirt J. DIZV S
Address: ��l__5���2, - ►�� k04�
City: "'{- State: J4C Zip code:-4-WO
County: bilk Telephone: `I iq `%•�.� 1
B. PROPERTY OWNER (if different from applicant)
Name: 5'4" `CI
Address:
City: State: Zip code:
County: Telephone.
C. STATUS OF APPLICANT
Private: �: Federal: Commercial: State: Public:
Native American Lands:
D. FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Public or Commercial)
Name of Business or Facility;
Address:
City: State: Zip code:
County: Telephone:
Contact Person:
Standard Industrial Code(s) which describe commercial facility:
Revised 7106 GWfUIC-57 HPR Page I of 3

E. INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
F_ WELL USE Is(are) the injection well(s) also used as the supply well(s) for either of the following?
f-
(1) The injection operation? YES 9 NO f ra ;1jgg; Q o �F nj
(2) Your personal consumption'? YES NOS! rr V c a ;-
G. CONSTRUCTION DATA
(1) Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection perrnit.
(2) NC State Regulations (ISA NCAC, 2C, Section .0200) require tine permittee to make provisions for
monitoring well head processes. A faucet on both influent (groundwater entering heat pump) and
effluent (water being injected into the well) lines is required. Is there a faucet on:
(a) the influent line? YES NO
(b) on the effluent line? YE5 NO
H. CURRENT OPERATING DATA
(1 ) Injection rate:
(2) Injection volume:
(3) injection pressure:
Average (daily) I Z
Average (daily) JaO
gallons per minute (gpm)
gallons per day (gpd)
Average (daily) _ _! pounds per square inch (psi)
(4) Injection temperature: Annual Average degrees Fahrenheit (°F)
INJECTION -RELATED EQUIPMENT '0 i ��
Attach a diagram showing any modcation tD injecti n equiment since the issuance of the previous injection
permit including the engineering layout of the (1) injection equipment, and (2) exterior piping/tubing associated
with the injection operation. The manufacturer's brochure, if detailed, should satisfy (1).
LOCATION OF WELL(S) Attach a map
Include a site map (can be drawn) showing: the orientation of and distances between the injection well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
ground -source heat pump well system; include buildings, property lines, surface water bodies, any other potential
sources of groundwater contamination. Label all Features clearly and include a north arrow to indicate
orientation.
K. PERMIT LIST: Attach a list of all permits or construction approvals, received or applied for by the applicant
that are related to the site. Examples include:
(1 ) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
L. OTHER MODIFICATIONS: Indicate any other modifications to the injection well system (equipment, fluid,
operation, etc.) that have occurred since the issuance of the previous injection permit and have not been noted
elsewhere on this application.
alf
Revised 7146 GWIUIC-57 HPR rage 2 of 3

M. CERTIFiCATTON
I hereby certify, under penalty of law, that I have personally examined and am familiar with the informations
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. l am aware that there are significant penalties, including the possibility of fines and imprisonment, for
submitting false information, I agree to operate, maintain, repair, and if applicable, abandon the injection well
and all related appurtenances in accordance with time approved specifications and conditions of the Permit "
(Signature of Wei Owner or Authorized Agent)
If authorized agent is aefing on behalf of'rhe well owner,
please supply a letter sign ad Tiy the owner
authorizing the above agent.
N. CONSENT OF PROPERTY OWNER (Owner means any person who bolds the fee or other property nghrs in the
weIl(s). A well is real property and its construction on land rests ownership in the land owner in the absence of
contrary agreement in writing,)
If the property is owned by someone other than the applicant, the property owner hereby consents to show time
applicant to operate an iniection well(s) as outlined in this application and that it shall be the responsibility of the
applicant to ensure that the injection well(s) conform to the Well Construction Standards (Title 15A NCAC
Subchapter 2C .0200)
(Si.grature of Property Owner if Different From Applicant)
Please return the completed Application package to:
UTC Program
Aquifer Protection Section
North Carolina DENR DW4
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Revised 7105 GW/WC-57 HPR Page 3 of

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
PERMI551 1S HEREBY GRANTED T�
Ca11FMf-f:1IRx-Iby,
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5A7 INJECTION WELL,
defined in Title 15A North Carolina AdminiWative Code 2C .0249(e)(3)(A), which yr-ill be used
for the injection of heat pump effluent. This system is located at 1422 Ridge Road, Raleigh,
North Carolina, in Wake County, and will be constructed and operated in accordance with the
application dated December 5, 1999, and in conformity with the specifications and supporting
data submitted, all of which are filed with the Department of Environment and Natural Resources
and are considered a part of this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the
Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an
injection well shall be in compliance with Title 15A North Carolina Administrative Code 2C
.0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well construction and
use.
This permit shall be effective, unless revoked, from the date of its issuance until April 30, 2007,
and shall be subject to the specified conditions and limitations set forth in Parts I through X
hereof.
Permit issued this the day of , 2002.
ed L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Nlanagement Conumsstoi-:.
Permit No. W10500040 PAGE 1 OF 6
Ver.3!01 GWILEC-5

North Carolina Department of Environment and Natural Resources
Division of Water Quality -Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTI❑
REPORT -FORM A
INJECTION WELL PERMIT NO. W1
NAME OF OWNER e, i
DATE 2 A ' - / P j�-
ADDRESS OF OWNER - �:,: _-
(5treetl road or lot and suddMsian, county. town? r
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable) �Q T
fl ��'• $ � ► / C'�' - G•' - ,.r,F � = �-� i Gi � - r�r - �.' —� Jam=•'
(5ireed road or for and suddtvtaton , county. town, tf d fferew that owner's address, 3 description
Potential pollution source +s, 3, Distance from well 's
Potential pollution source _:f Aaci _ Distance from well
Potential pollution source
-� Distance from well
Mintinurn distance of proposed well from property boundary bD l
(duality of drainage at si Flooding potential of site
{g .adequarepoor] (high.tnpdera�.lvwll
DRAW SKETCH OF SITE
Yitom prrivern boundaries, buildings, wells• potential pollution sources, roads, approximarescale, and north'IrrnK .
d "5r r — - -- � -
A
� 1

' i',i,_ _
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cont.)
CONMENTS
r
I
i
INSPECTOR
Office_
WITNESS
Address
WITNESS
Address

North Carolina Department of Environment and Natural Resources
Division of Water Quality -Groundwater Section

r
--'7:i9 C�arrter
t=
HOWMAN M1-CUTANICAL SERVICES
1219 5turdiVant drive
Cary, NO 27511
High Eftionay I IVAG • Goothennoi
FAX (919) 7
/+ �trr"C r■
oy
etc

a ;J
SC? /

fzj4(tQ qlaql
User: Wilcox, Betty
NC Natural Res and Env Health
Date: 04/24/2007 Time: 10:43
Sample: A813188 Loc Code: RROAPNLC Samp Descr: MR. CHARLES DAVIS Lag Record: 070207104424 Status: Inactive
AGENCY: RRCAP COUNTY: WAKE
Collected: 02/07/2007 10:20 Submitted: 02/07/2007 10:40 Sample Due Date: 04/08/2007
Sarnp Colct: I GREER P.O. Numbr: 7GO062 Proj Cade: ---
Page: 1
Ant
I Analysis Nwo
Una
- - -
PRNWN_IQ
Peer Review far Nitrite as N In liquid
PRCOLIFFECIVIF LIQ
Peer Review for Callform_MF Fecal In II
ICFU/100mi
PRCOLIFTOTMF LIQ
Peer Review for Conform_ MF Total In t
v
CFU/1OOml
PRCHLOR,IDE LIQ
Peer Review for Chloride In liquid
mg/L
PRNH3N_LIQ
Peer Review for NH3 as N In liquid
_
PRN02&NO3_UQ
Peer Review for NO2_+NO3 as N In liquid
PRNO3N_LIQ
Peer Review for Nitrate as N In I#quld
PRSi1LFATE_LIQ
Peer Review for Sulfate In liquid
mg/L
PRPH06TOTP-UQ
Peer Review for Phosphorus, total as P i
_
PRTDS_UQ
Peer Review for TDS in liquid
mg/L_
PRTKNN_LIQ
Peer Review for Total Kjekiahl N as N I
Result
MO
DEO
DEO
']AS
MO
GB
MO
3AS
MO
MI
MA
COLIFFECMF-JLIQ Coliforrn, MF Fecal in liquid CFU/100ml 1
COLIFFM4LIQ Coli6m, MF Total In liquid CFU/100m1 1
$ALK45 LIQ Alkalinity to pH 4.5 of liquid mg/L as CaCO3 Complete
PRALK45 UQ
Peer Review for Alkalinity to pH 4.5 of
CHLORIDE LIQ
;Chloride In liquid
mg/L
TDS_LIQ
Total DlssDIved Solids In liquid
mg/L
SULFATE LIQ
Sulfate In llquld
mg/L_ _
NH3N_LIQ
NH3 as N In liquid_
mg/L as N
NO2&NO3-LIQ
NO2fNO3 as N in liquid
mg/L as N
TKNN_LIQ
Total Kjeldahi N as N in liquid
mg/L as N
PHOSTOTP LIQ
Phosphorus_total as P In liquid
- - -
mg/L as P
Ci]_LIQ
Cd by ICPMS
ug/L
Ptt_CD
Peer Review Cd
_
CHROMIUM LIQ
Cr by ICPMS
- - ug/L
PR_CHROMIUM
Peer Review Cr
CU_LIQ
Cu by ICPMS - -
ug/L
PR-CU
Peer Review Cu
NI_LIQ
Ni by ICPMS
-
ug/L
PRVI
Peer Review. Ni
P_B LIQ -
Pb by ICPMS
ug/L
PR PB
Peer Review Pb
ZN_LIQ -
Zn by ICP
ug/L -
PR_7N
Peer Review Zn
AS_LIQ
As by ICPMS
ug/L
PR -AS
Peer Review As
LB
18
64
2.0
0.02
1,9
0,20
0.02
1.0
ES
10
ES
420
ES
35
- -!E
10
E5
- - --
19
IDS
5.0
AL_LIQ
Al by ICP
ug/L 50
PR_AL
Peer Review Al
D5
FE_LIQ
Fe. by ICP
— -
ug/L 150
--- — -IDS
PR FE
Peer Review Fe
MG�LIQ
Mg by ICP
mg/L
PR -MG
Peer Review Mg
D5 -
MN_LIQ
-- -_
Mn by ICPMS
ugJL -- -
PR MN
Peer Review Mn
NA_LIQ
_ _
Na by ICP
PR -NA
Peer Review Na
CA_LIQ
Ca by IC_P - - - - — mg/L
- - - - -- --
PR CA
Peer Review Ca
- 138
12
IDS
IDS

User: W I [cox, Betty
NC Natural Res and Env health
pate: 04/24/2007 Time: 10:43
Sample: AB13188 Loc Code: RROAPNLC Samp Descr: MR. CHARLES DAVIS Log Record: 070207104424
AGENCY: RROAP COUNTY: WAKE
Collected: 02/02/2007 10:20 Submitted: 02/07/2007 10:40 Sample Due Date: 04/08/2007
Samp Colct: ] GREER P.O. Numbr: 7GO062 Prof Code: --
Page: 2
Aral Code
lAMalysis No"
MET_PREP
Samples Prepared BY
TEMP_RECEIVE
Sample temperature at receipt by lab
NO2N_LIQ
Nitrite as N in liquid
N031'LLIQ
Nitrate as N in liquid
L1�
oC
mg/L as N
mg/L as N
Status: Inactive
hest t
E5
5.0
0.01
1.9

User: Wilcox, Betty
NC Natural Res and Env Health
Date: 04/24/2007 Time: 10:43
Sample: A813188 Loc Code: RROAPNLC Sam{ Descr: MR. CHARLES DAVIS Log Record: 070207104424 Status: Inactive
AGENCY: RROAP COUNTY: WAKE
Collected: 02/07/2007 10:20 Submitted: 02/07/2007 10:40 Sample Due Date: 04/08/2007
Samp Colct: ] GREER P.O. Numbr: 7G0062 Prat Code: ---
Page: 3
Viola
tin Value Sec Result
A�
Qualifier
B2
�92
]2
U
U

User: Wilcox, Betty
NC Natural Res and Env Health
Date: 04/24/2007 Time: 10:43
Sample: A313166 Loc. Cade: RROAPNLC Samp Descr: MR. CHARLES DAVIS Log Record: 070707IG4424 Status: Inacbve
AGENCY: RROAP COUNTY: WAKE
Collected: 02/07/2007 10:20 Submitted: 02/07/2007 10:40 Sample Due Date: 04108/2007
Samp Coict: I GREER P.O. Numbr: 7G0062 Proj Code. ---
Pa�e: 4
Violation Value 'Sec Result que�Ner
-- - U

State Groundwater Quality Standards:
Classification and Water Quality Standards Applicable To The Groundwater of North Carolina
(North Carolina Administrative Code Title 15A: 02L.200)
Coliform, total
11100 uil
Coliform, fecal
1/100 m1
Chloride
250 rnWL
Total Dissolved Solids
500 mglL
NOz' + NO3' as N
10 mglL
Aiurnintun, Al
nss
Arsenic. As
50 €tg/L
Barium, Ba
2000
Calcium, Ca
nss
Cadmium
1,75 pg/L
Chromium, Cr
50 µg/L
Copper, Cu
1,000 µglL
Iron, Fe
300 pglL
Mercury, Hg
1,05 pglL
Potassium, K
nss
Magnesium, Mg
nss
Manganese, Mn
50 µglL
Sodium, Na
nss
Nickel, Ni
100 lig/L
Lead, Pb
15 µg/L
Selenium, Se
50 µglL
Zinc, Zn
1,050 µg/L
mglL = milligrams per liter = parts per million
µglL = micrograms per liter = parts per billion
1,000 µg/L = 1 mg/L.
na = flot analyzed
ns = no state standard
(lgram11,000grarns)I I,000grams
(1 grarn11,000,000grams)/1,000grams

_`NC (DW . LaboratoSection Wesufts
Loc. Descr.: MR. CHARLES DAVIS Sample ID: AB13i57 � �
PO Number tl 76O081
Location ID: RRaAPNLC��� "'{ VisillD
County WAKE9F warms'- Collect Date: 02107/2007
River Basin I pwn Q
ut� �Q G Collect Time:: 10:00
Report To RRGAP �R PIm7r`lin�t.�sF�¶l. vi r
Region: F RRO ry Date Receved: 02M712007
Collector: J GREER MAR Z L407j 'K ) Time Received: 10:40
Sample Matrix: GROUNDWATER Labworks LoginlD MMA
Lac. Type: WATER SUPPLY Hate Reported: 03/1212007
Sample Depth
Emergency Yes/No
Sample Comment COG Yes/No
��1FI u � a! � -
A. Analyte Name P L Result Qualifier tints Approved By
LAB
Sample temperature at receipt by fab I 4.3 'C MMATHIS
MIC 4
Coliform, MF Fecal in liquid 1 1 B2 CFU1100ml CGREEN
Coliform, MF Total in liquid Ili 1 62 CFU1100m1 CGREEN
WARQ
Alkalin4y4.5
6 mg1t- as CaCO3 ESTAFFORD
Alkalinity&3
1 U mgJL as CaCO3 ESTAFFORD
Bicarbonate
6 mg1L as CaCO3 ESTAFFORD
Carbonate
1 u mg/L as CaCO3 ESTAFFORD
pH
5.3 mg/L as CaCO3 ESTAFFORD
WET
Chloride in liquid 5 16 mg1L MOVERMAN
Sulfate in liquid 5 2.0 U mgIL CGREEN
Total Dissolved Solids in liquid 10 68 J2 mg/L CGREEN
NUT
NH3 as N in liquid
0.02
0,02
U
mg/L as N
CGREEN
Total Kjeldahl N as N in liquid
0.2
0.20
U
mg/L as N
CGREEN
NO2+NO3 as N in liquid
0.02
1.7
mglL as N
CGREEN
Phosphorus total as P in liquid
0.02
0,02
U
mg1L as P
CGREEN
Nitrate as N in liquid
0.01
1.7
mg1L as N
CGREEN
Nitrite as N in liquid
0.01
0.01
U
mg1L as N
CGREEN
MET
7429-90-5 At by ICP 150 50 U ug/L _ ESTAFFORD
Laboratory Section>> 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone] Page 1 of 2

bona
ection `h'esults
Loc. Descr.: MR. CHARLES DAVIS
Location ID:
RROAPNLC
County_
WAKE
River Basin
Report To
RROAP
Region:
RRO
Collector:
J GREER
Sample Matrix:
GROUNDWATER
Loc. Type:
WATER SUPPLY
Sample Depth
Sample Comment
Sample ID:
AB13187
PO Number #
7GO001
VisitID
Collect Date:
02J07/2007
Collect Time::
10:00
Date Received:
0210712007
Time Received:
10:40
Labworks LoginlD MMA
Date Reported: 0311212007
Emergency YeslNo
COC Yes/No
CAS 9
Analyte Name
PQL
Result
Qualifier
Units
Approved By
7440-38-2
As by lCPMS 1
5.0
5.0
U
ug/L
ESTAFFORD
744(-70-2
Ca by ICP
0.14
1.6
mglL
ESTAFFORD
7440-43-9
Cd by ICPMS
1.0
1A
U
uglL
ESTAFFORD
7440-47-3
Cr by ICPMS
10
10
U
ug/L
ESTAFFORD
7440-50-8
Cu by ICPMS
2.O
490
ug/L
ESTAFFORD
7440-48-4
Fe by ICP
50
50
U
ug/L
ESTAFFORD
7439-954
Mg by lCP
0.10
1.8
mg/L
ESTAFFORD
7439-96-5
Mn by ICPMS
10
40
ugfL
ESTAFFORD
7440 23-4
Na by ICP
0.10
12
mglL
ESTAFFORD
7440-02-0
Ni by ICPMS
10
45
ug)L
ESTAFFORD
7439-92-1
Pb by ICPMS
10
10
U
ug/L
ESTAFFORD
7440-66-6
Zn by ICP
10
22
ug/L
ESTAFFORD
Laboratory Sectionaa 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page 2 of 2,

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources 1
DIVISION OF WATER QUALMY - GROUNDWATER SECT10N
County 1011�� 6AMPLE TYPE SAiY
❑uad No Serial No. Water ['Routine
❑ Sall ❑ Emergency
Lat. Long. ❑ Other
Report To: ARO, FRO, MR RCj _WaRO, WiRO, rl� ❑ Chain of Custody
WSRO, Kinston FO, Fed. Trust, Central Off_, Other:
Shipped by: Bu , Courier, Hand Del_, u i L
Purpose:
Collector[s): Date 0 0 Time j 9y Baseline,
FJ E LD ANALYSES Owner r .
pH4 Spec. Cond.94 l Uc7 • at 260 C Location or site
Temp.to oC Odor al• rl Description of sampling point 4&Je- 2 f t` g_,s_d ' - _:--
Appearance WA Sampling Method etc, I Sample Interval 5a
Field Analysis l3y: Remarks S
rvw"v4+o - WfrkpL ek-a
Lab Number 2e2
Date Recelved Time
Reed by rom: Bus. Courier, d >3 ,
Other.
0
Data Entry By:_
Date Reported:
Ck:
ide Study. Federal Trust, the c,, ! e- — -T-4)c
LABORATORY AYE h a
BOp 310 m 11 Dis5. SOjid.3703W m A A - Silver 46566 uqA Or anochlorine Pesticides
COD High 34o mgll
Flouride 951 mco
Al - Aluminum 46557 uQA
Organophosphorus Pesticides
COD Low 335 m IIHardness:
al 900 m I
As - Arsenic 46551 u A
Nitrogen Pesticides
Colitorm: MF Fecal 31616 11 Doml
Hardness non-c r 902 m
Be - Barium 46558 u R
Acid Herbicides
Cplibrm: MF Total 31504 1100mi
P n Is 7 o
Ca - Calcium 46552 mQA
PCB's _RR) DWO
TOC 680 nW
Si2ecificCd
- Cadmium 46559 u A
JPPk TF�^ 'i 5Fr7
Turbidity 76 NTU
Sulfate 945 m n
Cr - Chromium 46560 ugli
zr
Residue., Suspended 530 mgfl
Sulfide 745 m n
Cu - 992per 46562 ugA
Fe - Iron 46563 u I
Semivolatile Organics
Oil and Grease mg/1
H - Menu 719ou ugA
TPH - Dlesel Range
pH 403 unit
K - Potassium 46555 m I
Alkalinity to pH 4.5 414 mgll
M - Magnesium 46554 m I
Alkalinity to pH B.3 415 mgll
X
Mn - Manganese 46565 u A
Carbonate 445 mgA
NH as N 610 mQA
Na - Sodium 46556 m !I
Volatile Organics (VOA battle)
Bicarbonate 44o m n
TPH - Gasoline Range
Carbon dioxide 405 mgll
NO + NO as N SM mqA
Pb - Lead 46664 uqA
TPH - BTEX Gasoline Range
Chloride 940 mgll
P: Total as P 665 m A
Ss - Selenium UCO
Chromium: Hex 1032 u I
Zn - Zinc 46567 UCIA
Color. True 6o CU
U r
Cyanide 720 rry
Comments:
Z.n
v
") r;2 G.:�z ra�' Lf9r f - t_ __sL
G -54 REV. 1219�1' For Dissolved Analysis - submit filtered sampidand write "DIS" in ble
C

P eport to: _RROAP
Lab Number:
Station Location:
Sample Type:
)ate collected:
NC DENRIDWQ Laboratory
Sample Anomaly Report (SAR)
AB13187
Mr. Charles Dads County: Wake
Water
2/7/2007
Priority: Routine
Date received
Affected Paramete(s): Dissolved Solids
Analytical Area (check one):
®WCH ❑METALS
[]NUT ❑MICRO
The following anomalies occurred (check all that apply):
❑Samples
❑Improper container used
❑VOA vials with headspace
❑Sulfide samples with headspace
El Samples not received, but listed on Feldsheet
❑Samples received, but not listed on fteldsheet
❑Mislabeled as to tests, presen•atives, etc.
❑Holding time expired
❑Prior to receipt in lab
❑After receipt in lab
❑Insufficient quantity for analysis
❑Sample exhibits gross non -homogeneity
❑Sample not chemically presenyed properly
❑pH out of range (record pH):<
❑Improper chemical
❑Residual chlorine present in sample
❑Color interference
❑Heavy emulsion formed during extraction
❑Sample bottle broken in lab - no reportable results
❑Other (specify):
Comments: Recovery 43.84%
Corrective Action:
Sample ID: 1
Region: RROAP
2/7/2007
Collector:
Date analyzed:
J. Greer
2/9/2007
❑VOA ❑SVGA
❑PEST
®Quality Control
01ristrumew failure - no reportable results
❑Analyst error- no reporlabie results
❑Surrngaies
❑None added
❑Recovery outside acceptance limits
❑Spike recovery
❑None added
❑Recovery outside acceptance limits
❑Failed to meet criteria for precision
[]Internal standards
❑Blank contamination
®QC data reported outside of controls (e.g., QCS, LCS)
❑Incorrect procedure used
❑SOP intentionally modified with QA and Branch Head
approval
❑Invalid instrument calibration
❑Elevated detection limits due to:
❑Insufficient sample volume
❑Samples were rejected by DWQ Lab. Authorized by: Date:
❑Accepted and analyzed after notifying the collector or contact person and determining that another sample could not be secured.
❑Sample(s) on hold until:
®Sample reported with qualification. Data qualification code used:J2
❑other (explain):
Notification Required? ❑ Yes ❑ No
Person Contacted; Date:
Form completed by:
Lead Chemist ew tnitial): M 1
❑BIOCIIEM � ❑Pi;ST
"METALS ❑VOA
Branch Head Review {initial}; -
QAIQC Review (initit�/��
QA%Fonni; tUborator?SAR
c
Date: 2/16/2007
OSVOA
Logged into databutby (iniIial):
ltux�rolae.

k 'co
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 02/072007 County: Wake
To: Aquifer Protection Section Central Office Permittee: Charles & Gwendolvn Davis
Central Office Reviewer: Micheal Rozers Project Name: i)IC (5A7)
Regional Login No: 05 Application No.: WI0500040
I, GENERAL INFORMATION
1. This application is (check all that apply): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification
Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B secluded 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation ® Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
a. Date of site visit: 02/0712007-09:30AM
b, Person contacted and contact information: Gwendolyn Davis -Phone# [phone]I2
c. Site visit conducted by. lGreer. RRO-APS
d. Inspection Report Attached: ® Yes or ❑ No.
2. Is the following information entered into the BIMS record for this application correct?
® Yes or ❑ No, If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
e, Regulated Activities 1 Type of Wastes (e.g., subdivision, food processing, municipal wastewater): NIA
For Disposal and Infection Sites:
(if multiple sites either indicate which sites the information anulies to. coov and oaste a new section into the
document for each site. or attach additional pages for each sitel
a. Locations): 1422 Ridge Road. Raleigh NC 27607-6729
b. Driving Directions: 1440W exit Ridge Road at Glenwood_ go one mile on Left.
c. USGS Quadrangle Map name and number: Raleigh
d. Latitude: 35.48.24 Longitude: 78.41.08
II. NE WAND AM4JOR MODIFICA TION APPLICA TIONS this section not needed for renewals or minor
rnodi, jications, skip to next section)
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification:
FORM: W10500040.CD

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
?. Are the new treatment facilities adequate for the type of waste and disposal system'?
❑ Yes ❑ No ❑ NIA. If no, please explain:
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? ❑ Yes ❑ No ❑ NIA. If no, please explain:
4. Does the application (snaps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? ❑
Yes ❑ No ❑ NIA. If no, please explain:
S. Is the proposed residuals management plan adequate and/or acceptable to the Division. ❑ Yes ❑ No ❑
N/A. If no, please explain:
G. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable:'
❑ Yes ❑ No ❑ NIA. If no, please explain:
7. Are the new treatment facilities or any new disposal sites located in a 1 00-year floodplain?
❑ Yes ❑ No ❑ N/A. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV:
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? ❑ Yes or ❑ No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit:
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring.
monitoring parameters, etc.) adequate? ❑ Yes ❑ No ❑ NIA. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program:
10. For residuals, will seasonal or other restrictions be required? ❑ Yes ❑ No ❑ NIA If yes, attach list of sites
with restrictions (Certification B?)
IHL RENEWAL AND MODIFICATION APPLICATIONS (use previous section for neK, or muior modification
systems)
Description Of Waste(S) And Facilities
1. Are there appropriately certified ORCs for the facilities? ❑ Yes or ❑ No.
Operator in Charge: Certificate #:
Backup- Operator in Charge: Certificate #:
?. Is the design, maintenance and operation (e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? ❑ Yes or ❑ No.
If no, please explain:
3. Are the site conditions (soils, topography. depth to water table, etc) maintained appropriately and adequately
assimilating the waste? ❑ Yes or ❑ No. If no, please explain:
FORM: W10500040.CD 2

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
4. Has the site changed in any way that may affect permit (drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain:
S. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
❑ Yes or ❑ No. If no, please explain:
6. Are the existing application rates (hydraulic or nutrient) still acceptable? ❑ Yes or ❑ No. If no, please
explain:
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? ❑ Yes ❑ No ❑ NIA. Attach snap of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program:
K Will seasonal or other restrictions be required for added sites? ❑ Yes ❑ No ❑ NIA If yes, attach list of sites
with restrictions (Certification B?)
9. Are them any buffer conflicts (treatment facilities or disposal sites)? ❑ Yes or ❑ No. If yes, please attach a
trap showing conflict areas or attach any new maps you have received from the applicant to be incorporated
into the permit:
1 U. Is the deseription of the facilities, type and/or volume of waste(s) as written in the existing permit correct? ❑
Yes or ❑ No. If no, please explain:
11. Were monitoring wells properly constructed and located? ❑ Yes or ❑ No ® NIA. If no, please explain:
12. Has a review of alI self -monitoring data been conducted (GW, NDMR, and NDAR as applicable)? ❑ Yes or
❑ No ❑ NIA. Please summarize any findings resulting from this review:
13. Check all that apply: ❑ No compliance issues; ❑ Notice(s) of violation within the last permit cycle; ❑
Current enforcement action(s) ❑ Currently under SOC; ❑ Currently under JOC; ❑ Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc):
14. Have all compliance dates/conditions in the existing perrnit, (SOC, JOC, etc.) been complied with? ❑ Yes
❑ No ❑ Not Determined ❑ NIA.. If no, please explain:
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? ❑
Yes or ❑ No ❑ NIA. If yes, please explain:
FORM. WI0500040.CD 3

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
IV INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed -loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells)
Description Of Well(S) And Facilities — New, Renewal, And Modification
l . Type of injection system-
® Heating/cooling water return flow (5A7)
❑ Closed -loop heat pump system (5QM/5QW)
❑ In situ remediation (51)
❑ Closed -loop groundwater remediation effluent injection (5Ll"Non-Discharge")
❑ Other {Specify:
2. Does system use same well for water source and injection? ❑ Yes ®No
3. Are there any potential pollution sources that may affect injection? ❑ Yes ® No
What is/are the pollution source(s)? . What is the distance of the injection well(s) from the pollution
source(s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 50' ft.
5. Quality of drainage at site: ®Good ❑ Adequate ❑ Poor
G. Flooding potential of site: 0 Low ❑ Moderate ❑ High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(-number of wells, frequency of monitoring, monitoring parameters. etc.) adequate? ❑ Yes ❑ No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program:
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? ® Yes or ❑ No. If
no or no Wrap, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north. arrow.
Iniection Well Permit Renewal And Modification Onlv:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
❑ Yes ® No. 1f yes, explain:
I For closed -loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? ❑ Yes ❑ No. If yes, explain:
3. For renewal or modification of groundwater remediation nenruts (of anv type). will
continued/additionallmodifFed in ections have an adverse impact on migration of the plume or management of
the contamination incident? ❑ Yes ❑ No. If yes, explain:
4. Drilling contractor: Name: CW Bins Well Drilling
FORM: WI0500040.CD 4

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address: Out Of the Country
Certification number:
5. Complete and attach Well Construction Data Sheet.
FORM: WI0500040.CD

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVALUATIONAND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, please explain
briefly.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
7 Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
8. Signature of report
Signature of APS n
Date:
ADDITIONAL REGIONAL STAFFREVIEW ITEMS
System is Goodlmmning OK.
FORM; WI0500040.CD 6

Permit: WI0500040
8OC:
County: Wake
Region: Raleigh
Compliance Inspection Report
Effectlne:04/26102 Expiration: 04130/07
Effective: Expiration:
Contact Person: Charles Datis
Directions to Facility:
PIN:0794382886
Primary ORC:
Secondary ORC(s):
On-8tte Representati►►e(s):
Related Permits:
Inspection Elate: OV0712007 Entry Time: 09:30 AM
Primary Inspector: Jimmie W Greer
Secondary Inspector(s):
Certtflcatlon:
Owner: Charles DavJs
Facility: Darns, Charles - 5FR
1422 Ridge Rd
Raleigh NC 27607
Phone: [phone]
Exit Time: 10:30 AM
Phone:
Phone: [phone]
Reason for inspection: Routine Inspection Type: Compliance Evaluation
Permit inspection Type: Injection Heating/Cooling Water Realm Well (5A7)
Facility Status: ■ Compliant Q Not Compliant
Question Areas:
E Other
(See attachment summary)
Page: 1

Permit: WI0500040 Owner - Paciiitq: Charles Davis
Inspection Date: 02(07rA07 Inspection Type: Complience Evaluation
inspection Summary:
Comment:
C�Zzmr,ple- S 1#
/Q- s
2AMP7
Reason for Visit: Routine
Yaeio MA AIE
Pa$e: 2

�F WA��� Michael F. Easley, Governor
� / Q William G. Ross Jr.. Secretary
7 North Carolina Department of Environment and Natural Resources
Alan W. KllmeK P E, 01rector
Division of Vvater Qua lily
February 27, 2007
CHARLES DAVIS
1422 RIDGE RD
RALEIGH NC 27607
Subject: Acknowledgement of Application No. WI0500040
Davis, Charles - SFR
Injection Heating/Cooling Water Return Well (5A7)
Wake County
Dear Mr. Davis:
The Aquifer Protection Section of the Division of Water Quality (the Division) acknowledges receipt of
your permit application and supporting materials on February 27, 2007. This application package has
been assigned the number listed above and will be reviewed by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if
necessary. To ensure the maximum efficiency in processing permit applications, the Division requests
your assistance in providing a timely and complete response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior
to final action by the Division. Please also note at this time, processing permit applications can take as
long as 60 - 90 days after receipt of a complete application.
If you have any questions, please contact Michael Rogers by phone at [phone] or by email at
Michael.Rogers@a ncmail,net. 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:Jlh2o.enr.state.nc.us/docurnentsYdwq orachart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN NIAKLIIIG LNQIJIRMS
ON THIS PROJECT.
Sincerely,
for De . Watts
Supervisor
cc. Raleigh Regional Office, Aquifer Protection Section
Permit Application File WI0500040
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone:
Internet: vvww.ncwaterguality.org location: 2728 Capital Boulevard Raleigh, NC 27604 Fax 1:
Fax 2:
An Equal apportunitylAffirmaM Action Employer— 50% Recycl:900% Post Consumer Paper Customer Service:
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AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: February 27.2007
To: ❑ Landon Davidson, ARO-APS ❑ David May, WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Charlie Stehman, WiRO-APS
❑ Andrew Pitner, MRO-APS ❑ Sherri Knight, WSRO-APS
® Jay Zimmerman, RRO-APS
From: Michael Rogers, Groundwater Protection Unit
Tetephone: [phone] Fox: [phone]
E-Mail. Michael.Roaers(irncmailmet
A. Permit Number: W10500040
B. Owner: Charles Davis
C. Faciiitv/Operation:
❑ Proposed ® Existing ❑ Facility ❑ Operation
D. Application:
L Permit Type: ❑ Animal ❑ SFR-Surface irrigation❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Remediation (ND)
® UIC - (SA7) open loop geothermal
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
1. Project Type: ❑ New ❑ Major Mod. ❑ Minor Mod. ® Renewal ❑ Renewal wl Mod.
E. Comments/Other Information: ® I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 21 calendar days, please take the following actions;
® Return a Completed APSARR Form.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO, *
Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer:
Date:
FORM: APSARR 07/06 Page 1 of 1

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM
Type 5A7 and 5QM Wells
In accordance with the provisions of NCAC Title I5A: 02C.0200
complete application and mail to address on the back page.
TO: DIRBCTOOR,, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: NrU-'r-' 4� .204y
A. PERMIT APPLICANT
Permit Number: rr1sC CC?�[]�� (WIO######, listed at the bottom of each page of your permit)
Name; 'bav� 5
Address:
City: State: % Zip: code:47;t7 7-
County: W44 k . Telephone: It
B. PROPERTY OWNER (if different from applicant)
Name: 5-c�
Address.
City;
County:
State: Zip code:
Telephone:
C. STATUS OF APPLICANT
Private: ;%., Federal: Commercial: State: Public:
Native American Lands:
D. FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Public or Commercial),
Name of Business or Facility: ��
Address:
City:
County:
Contact Person:
State: Zip code:
Telephone:
Standard Industrial Code(s) which describe commercial facility:
RECEIVED I DENP I DIINO
AOUIFPP Prf)1'rr71nN cFCT10N,
Revised 7106 GWfMC-57 NPR Page 1 of 3

0 r
E. INJECTION PROCEDURE
previous injection permit)
'm +rfy 4006, ryl4
16
6 f / rr PI'd df-VF
(specify any modifications to the injection procedure since the issuance of the
eec pvrr� aril f-�P, la �1 ,A� 5JAlr. P �� �m dr,
16,01, V`"sA4um A stl� . ca4Ie-,
F. WELL USE Is(are) the injection well(s) also used as the supply well(s) for either of the following'? l41
(1) The injection operation? YES R NO Prtvl.4s k*elvn� �' f tT
(2) Your personal consumption? YES_ _ NOS
G. CONSTRUCTION DATA
(1) Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection permit.
(2) NC. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes, A faucet on hotly influent (groundwater entering treat pump) and
effluent (water being injected into the well) lines is required. Is there a faucet on:
(a) the influent line? YES NO
(b) on the effluent line? YES NO
H. CURRENT OPERATING DATA
(1) Irtj ection rate:
(2) Injection volume:
(3) Injection pressure:
Average (daily) ,P
Average (daily) d6w
gallons per minute (gpm)
gallons per day (gpd)
Average (daily) � pounds per square inch (psi)
(4) Injection temperature: Annual Average �/g_ degrees Fahrenheit (IF)
L INJECTION -RELATED EQUIPMENT ,40
Attach a diagram showing any mod fcafion to injection equipment since the issuance of the previous injection
permit including the engineering layout of the (1) injection equipment, and (2) exterior piprngltuhing associated
with the injection operation. The manufacturer's brochure, if detailed, should satisfy (1).
d LOCATION OF WELL(S) Attach a map y a o- ..t,4
Include a site map (can be drawn) showing: the orientation of and distances between the injection well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
ground -source heat pump well system; include buildings, property lines, surface water bodies, any other potential
sources of groundwater contamination. Label all features clearly and include a north arrow to 'indicate:
orientation.
K. PERMIT LIST: Attach a list of all permits or construction approvals, received or applied for by the applicant
that are related to the site. Examples include.
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
L. OTHER MODIFICATIONS: Indicate any other modifications to the injection well system (equipment, fluid,
operation, etc.) that have occurred since the issuance of the previous injection permit and have not been noted
elsewhere on this application.
Revised 7106 GWlUIC-57 NPR Page 2 of 3

q,
A C.) WFIFICATION
"I hereby certify, under penalty of law. that I have personally examined and am familiar with the information
submitted in th'ss document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I relieve that the information is true, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment. for
subrrutting false information. I agree to 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 Weir Owner or Authorized Agent)
ff authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
N. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property rights in the
weU(s). A well is real property and its construction on land rests ownership in the land owner in the absence of
contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the
applicant to operate an injection well(s) as outlined in this application and that it shall be the responsibility of the
applicant to ensure that the injection well(s) conform to the Well Construction Standards (Title l i A NCAC
Subchapter 2C .0200)
(Signature of Property Owner if Different From Applicant)
Please return the completed Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Revised 7106 GWMC-571 PR Page 3 of 3

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
Charles Alfred Davis
FOR THE CONSTRUCTION AND 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 system is located at 1422 Ridge Road, Raleigh,
North Carolina, in Wake County, and will be constructed and operated in accordance with the
application dated December 6, 1999, and in conformity with the specifications and supporting
data submitted, all of which are filed with the Department of Environment and Natural Resources
and are considered a part of this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the
Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an
injection well shall be in compliance with Title 15A North Carolina Administrative Code 2C
.0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well construction and
use.
This permit shall be effective, unless revoked, from the date of its issuance until April 30, 2007,
and shall be subject to the specified conditions and limitations set forth in Parts I through X
hereof.
Permit issued this the day of � , 2002.
v
eu I.. Dusil, .1E., AS:iI'uldlli C11IG�i
1` Groundwater Section
Division of Water Quality
By Authority of the Environmental Management. Commission.
Permit No. W10500040 PAGE 1 OF 6
ver.314 i GWfUIC-5

Nee 1 of 2
North Carolina Department of Environment and Natural Resources
Division of Water Quality -Groundwater Section
PRECONSTR UCTION INJECTION FACILITY INSPECI`IO
REPORT -FORM A
INJECTION WELL PERMIT NO, W1 DATE y7 ! P
NAME OF OWNER
ADDRESS OF OWNER_
r (Streetl road or lot andsuddivision, countip, town+
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable)
fSrreetl mad or for and =ddivuion , counrY. town, if'dierenz than owner's address. plus dcseriptdon of locatian on suet
Pnterttial pollution source _ +s,15r Distance from well S0 �
Potential pollution source Distance from well 5D. r
Potential pollution source Oiswicc from well
Minimum distance of proposed well from property boundary 60r
Quality of drainage at sit:--. Flooding potential of site
(gowf, adeguaie,poor) (high, modernle, 117
DRAW SKETCH OF SITE
(%how propprty houndo ri is, &&dings. WEtts. potentis! PODU11an sourcesrands, approximate s040 E, and narrh arrow f
i
i
r <;
u2 Z '1 ,�

Page 2
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cant.)
COMMENTS
�• ,p ••--y—.., ,� � � -- 4 _+ ram__ 1�l1c.r .
INSPECTOR
VA'TTNESS
.Address
WITNESS
Address
I
P

BOWMAN MECHANICAL 3ERVIC[.5
1219 Sturdivent Drive
Cary, NO 27611
1-"759 - Gamor High Efficiency tIVAC • Geothermal
TI V-:508 - Cary
I�
FAX (919) 779-VS4
S
Rrr-OAT / �
1.2
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17
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ter- I
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Jrl�• � j�L* �� � �r � �^ F''

D of W A T § Michael F. Easley, Governor
William G. Ross Jr., Secretary
�!1 7 North Carolina department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
February 27, 2007
CHARLES DAVIS
1422 RIDGE RD
RALEIGH NC 27607
Subject: Acknowledgement of Application No. W10500040
Davis, Charles - SFR
Injection Heating/Cooling Water Return Well (SA7)
Wake County
Dear Mr, Davis:
The Aquifer Protection Section of the Division of Water Quality (the Division) acknowledges receipt of
your permit application and supporting materials on February 27, 2007. This application package has
been assigned the number listed above and will be reviewed by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if
necessary. To ensure the maximum efficiency in processing permit applications, the Division requests
your assistance in providing a timely and complete response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior
to final action by the Division. Please also note at this time, processing permit applications can take as
long as 60 - 90 days after receipt of a complete application.
If you have any questions, please contact Michael Rogers by phone at [phone] or by email at
Michael.Rogers@ncmail,net, 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 hitt3:/lh2c3.enr.state.iie.us/duuumertts/ciwLi or{1chart.pff.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUMUES
ON TEIIS PROJECT.
Sincerely,
far De 'Natty
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Permit Application File WI0500040
Aqulfer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636
Internet, www.ncwaterauality.org Location: 2728 Capital Boulevard Raleigh, NC 27604
An Equal apportunitylAffirmative Action Employer- 50% Recycledl10% Post Consumer Paper
Now Carolina
Telephone:
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_W A_�tc/� - K4ichaeI F. Easley, Covemor
_❑�i �G V William G. fuss Jr.. Secretary
' � f North Carolina Department of Environment and Now raI Resources
Atan W Klimek, P.E. Director
"'-"� c Y•r Divis ion 0 r Water Qual ay
January 29, 2007
Charles & Gwendolyn Davis
1422 Ridge Road
Raleigh, NC 27607-6729
CERTIFIED MAIL
_RETURN RECEIPT REQUESTED
7006 2150 0003 5465 0365
Subject: Notice of Expiration
Injection Heating/Cooling Water Return Well (5A7) Permit
UIC Permit No, WI0500040
Davis, Charles - SFR
Waite County
Dear Mr. & Mrs. Davis:
The Underground Injection Control (UIC) Program of the Division of Water Quality is
responsible for the regulation of injection well construction and operation activities within the
state of North Carolina, Our records show that the operating permit referenced above for the
geothermal heat pump injection well system on your property at 1422 Ridge Rd in Raleigh,
North Carolina will expire on April 30, 2007. In addition, our records do not indicate that the
injection well system has been. abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must take one of the following
actions:
A. Submit the form RENEWAL APPLICATIDN FOR PERMIT TO USE WELL FOR INJECTION WfTNA
HL4TPUAV Si=m (form GWIUIC-57 HPR) if the injection well system on your
property is still active;
B. Submit the form STATUS OFINJECTION WELL SYSTEM (form GWIUIC-68) if the injection
well system is inactive or has been temporarily or permanently abandoned.
If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed under NCAC Title 15A, Subchapter
2C, Section .0214. If the injection well system is to be permanently abandoned, the well
abandonment record(s) must be submitted to our office to certify that the abandonment was
,, o� Caro]]iaa
NatAU'RIlIf
Aquifer Protection section 1636 Mail Service Center
IMemel: www.ncwaterclualit%-ors Location: 2779 Capital Boulevard
An Equal Qpportunity)Affumative Action Employer- 50%Recycle dl70% Post Consumer Paper
Raleigh, NC 2769 9- 1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax [phone]N8
Customer Service: [phone]

Charles & Gwendolyn Davis
January 29, 2007
Page 2 of 2
properly Conducted. If the injection well system is still active, a renewal application is to be
submitted at least 3 months prior to the expiration of this permit.
Please submit the appropriate form(s) within 30 calendar days of the receipt of this letter. If you
have any questions regarding the permit or injection well rules, or if you would like assistance
completing these forms please call Qu Qi at [phone], or email him atg_u.gjQ)ncmail.net.
Sincerely,
/11�- U..) - r-
Jesse Wiseman
Aquifer Protection Section
Enclosures
1. GW/UIC-57 HPR
2. GW§JIC-68
cc: Raleigh Regional Office - APS w/o enclosures
Aps Genoa! Hcl% - Permit No. W10590"q'wln enclos*W

North Carol- Department of Environment and Nd__.ral Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. DATE
NAME OF OWNER` -
ADDR/ESS OF OWNER_ /.4�.--,x-2
AIK
(Streetl road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL [and source wells), if applicable)
(Streetl road or lot andsubdivWon , county, town, if different than owner's address, plus description of location on site)
Potential pollution source E Distance from well 6 D
Potential pollution source Distance from well �ZJ
Potential pollution source
Distance from well
Minimum distance of well from property boundary 4z-V f
Quality o aznage at site
( ood, dequate, poop )
GPS Data:
Flooding potential of site
(high,modera , oK,
Latitude: Ke- Longitude: pE c'�
1)0e,- dhea-4 4-;,I&�,- &P, dDI) Lr'dr t. AOL--
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, a
north arrow.)
2Z Z
0c, r
x c,7e.,Ir
Sn
N
r. .
L.�
1 �
ca -
ry
DESCRIBE MJECTION SYSTEM (vertical closed loop, uncased borehole or cased water well; separate source well and
injection well; mb'nation source and injection 0; or other descript' n as applicable)
u
Ver.3l01 L.-I GYf7UIC-2

INJECTION CILITY INSPECTION REPORT -FORM ::ONTINUED)
WELL CONSTRUCTION
Date constructed S'
Drilling contractor: Name(,
Address 6 Z> -*-.z
/ /-1 Al 7
Certification number -46 Z a h Z
C j rrLtd e- icy
Total depth of well Total depth of source well
(f applicable)
Inspection point Measurement Meets minimum standards Comments
Yes No
Casing
Depth
Diameter
Height (A.L.S.)
e/
Grout
Depth
L- c ;?'v �
_ Gr71 V, P .
Screens
l
Depth(s)
Length(s)
I.D. Plate
c�
Static water level
Well yield
tic.
Enclosure
Enclosure floor
(concrete)
Sampling port
(labeled)
Water tight pipe entry
Well enclosure entry
t�
Vent
Functioning of heat pump system (Determine from the owner ifheat pump functions properly.)
INSPECTOR r t Office!
WITNESS U Address
WITNESS
Ver.3101
Address
GWIUIC-2

DIVISION OF WATER QUALITY
Chernhrry iAboretary Report 1 Ground Water Quvgty
COVNY : WAKE �MPLU-MR.:U
QUAD NO-. EJROUTINE �EMCRGrN4"Y y
REPORT TO RRO Regional office � CHA1N OF CUSTODY
COLLECTOR(S) JCRE£R 1•[ill
DATE: 5I191S441 W� SAMPLE- TYPE I ��
17ME: ' -
PURPOSE: Ovrmrr: CHARLFS A DAV15 ti
Location or Site: i
Description of sampling point -� r
Sampling Mrlhod:
Remarks;
LABORATORY ANALYSIS
DOD 310
m /L
COD High 340
m IL
COD Low 335
m L
Y
Coliform: MF Fecal 31616
1 B2
/lwirl
X
Coltrorm- MF Total 31504
1 132
/ 100ml
TOC
mR+1
Turbility
NTU
Residue., Sus ended 530
m /L
Total Sus nded solids
mg/L
l3
7.7
unit-.1
Alkalinity to pH4.5
20
m IL
A lkali!.tt to pH S.3
lU
mg/l,
x
Catbonatr
lU
m /I-
r
orate
Camon dioxide
20
m /L
mg/1,
X
Chlonde
16
m L.
Chromium: Hex 103Z
ug/L
Cu4or. True SO
C.u-
C anide 720
m L
COAMIENTS
X
Dias. Solids 70300
91
m iL
Flupride 951
mg/L
hardness: total900
m L
X
l-lardne3s-(nontarb)9D2
m /1_
Phenols 32730
u IL
Specific Co nd- 95
umhos/rm2
Sulrate
mg/1-
Su1Tde 745
m S/L
MBAS
mg/L
Oil and Grease
mg/L
Silica
Mg/1-
Boma
Formaldehyde
rri •/I.
x
NH3mN610
l3.OlU
m /l.
X
T KN as N 625
0-20 U
mg/i,
X
NOZ +NO3 ax n 630
3-4
mR.' L
P: Total as P 665
mg/L
PO4
mF/L
A8•5ilvu 46566
ug/L
AI -Aluminum 46557
ug/L
As-Atsenic 46551
u /I-
Ba-Rarium 4655S
u IL
X
Ca�Calciam 46552
5.1
mg/L
X
Cd -Cadi a m 46559
2.0U
u 1.
X
Cr-Chromit, rn 46560
250
ug1l.
X
Cu• Cn+ rr 11142
940
ugIL
%
Fr- Iran I W 5
50U
ug/L
IIg- h(Mvq 71900
kigiL
K-Por.4+siurn 46555
m L
x
M • Ma .nesiuin 9Z7
3.3
mg1L
x
Mn-Manganese 1055
57
uR,L
Na-Sodium 929
m /L
X
Ni-Nickel
120
ug/L
I'b-[,cad 46564
IOU
uK/L
Se-Sclrnium
ug/L
X
7_n Zinc46567
ISO
u /1-
Lab Number 2GO994
Date Received 5I2912002
Time Received 11.10 AM
Received By 11MW
�l sa
k*e,-ed By . Ap
i' Darr raported : 6124nW2
_ Or inochlOrine Pesurades
❑r anophos homes Pe560dr3
Nl[ro en Pesticides
Arid Herbicides
$rmiV0lat11e5
TP11,Diesel Ra rw
Volaiile Or ni3 (VOA bottle)
-TPfl-Gasofior Range
TP24-BTEX Gasoline RanSr
_3
r
200954-us

North C a r o I I n a
GROUNDWATER FIELDILAB FORM Department of Environment and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
County _(���- SAMPLE TYPE SAMPhe PRIORITY
Quad No Serial No. Q Water ❑ Routine
❑ Soil ❑ Emergency
Lat. tong. W Other U&•,
Report To: ARO, FRO, MRO, R� aRO, WiRO, JIL ❑ Chaln of Custody
WSRO, Kinston FO, Fed, Trust, Central Off., Other:
Shipped by: Bu , Courier, Hand Del.,.F3._ r» Y _
Purpose;
Collector{s): Date `0Z Time ti 7? a aseline
Lab Number
Date Received d S Time
Rec'd by: From: Bus, Courier a e
Other:
Data Entry By -.-
Date Reported:
Ck:
ST, Peslicide Study, Federal Trust,
.D ANAL E Owner
PH4W .;!5 Spec. Cond.94 at 250 C Location or site
Temp.10 oC Odor Ile Description of sampling point 7 '
Appearance r- Sampling Method a Sample Interval -4/Tb
Field Analysis By: Remarks
LABORATORY ANAl1 SES
BOD 310 m "--X
Diss. Solids 70300 m 11
A - Silver 46566 u 11
COD High 34D mgll
Flouride 951 m
A] - Aluminum 46557 ugh
COD Low 335 m
Hardness: T91alrTlgzl
As - Arsenic 46551 u
Coliform: MF Fecal 31616 110omt
Hardness non-carb 902 m l
Ha - Barium 46558 u 11
K.
Coliform, MF Total 315D4 1100ml
P n 3273 1
Ca - Caldum 46552 m A
TOC 680 m l!
Cd - Cadmium 46559 u A
Turbidity 76 NTU
Sulfate 945 m 11
Cr - Chromium 465W u A
Residue., Suspended 530 mgA
Sulfide 745 m 11
Cu - Copper 46562 u Il
Fe - Iron 46563 u tl
Oil and Grease mg/1
Hg - Mercury 71900 ugll
pH 403 unit
K - Polassium 46555 Mgt
Alkalinity io pH 4.5 410 mgfl
M - Ma nesium 46554 m 11
Alkalinity to pH 8.3 415 mgA
Mn - Manganese 46565 u A
Carbonate 445 mgA
NH as N 610 rnq#
Na - Sodium 46556 me/1
13icarbanate 440 m A
Carbon dioxide 405 mgA
NO + NO, as N 630 m Il
Pb - Lead 46564 u II
Chloride 940 mg11
P: Total as P 666 m n
Se - Selenium u 11
Chromium: Hex 1032 u
Zn - Zinc 46567 ucjIl
Color: True 80 GU
Cyanide 720 mg/1
Lab Comments:
-e-1 7 7
anochlorine Pesticides
Nitrogen Pesticides _
Acid Herblcldes
PCH's
Semivolatile Organics
TPH - Dlesel Range
j Volatile Organics (VOA bottle)
I TPH - BTE X Gasollre Range
GW54 REV.171G
For Dissolved Analysis - submit filtered sample and write "DIS" in bli
Z-
3

NC D)ErNR/DWQ Chemistry Laboratory
Report to:
'Sample idltion Receipt Anomaly Report (SC )
�Upon
i
r N--ij �ai�.:•
tp-v vr.Y y
.iyy. �.^L.:?:•i• ^M'.1 Sri. �. ��- i'���. tT .i. :. :i'w ' � - _ • . _
y .
-
.�=nJ'1'
i
MILO
tr...
i1, :'•'"Yj-'-
.. .
;'ram.
�,{
= -- =-
yy� ryl•
�-'�i►�_ r :� w"�w. _ - _ _
tlaii�tyi:r .
.•1'4•i. r,lw' i+ili�_f'-:3�''�_
fN F =" ± {
Cotiector'� — .,� �Y"
_ >�v"+r�=$aatn. -•_- - � �M:-. _
.�'�`-_ -A!_ -r� �' q�[� r i4:'.:� —'�r �'.+ — _ _
' r- v }c . i;r _ c r • �ImE BE�Ip' (!
81e;�� -1Zr:
. •
'4- �'•�:=''-;w'_ •`-tire' ! ,. - - �� �.. �^=��i`'ti " � n, _
Affected Parameters. - - -
The condition of these samples were not acceptable because (check all that apply):
❑ CooIers ❑ Samples (affected samples are described below)
C] Samples were not received on wet ice CI Samples not received, but listed on fieldsheet
❑ No temperature blank submitted: ❑ Samples received, but not Iisted on fieldsheet
C3 Sample T° reading : °C ❑ Samples not received, but listed on CDC
❑ Cooler T° reading: °C ❑ Samples received, but not listed on CDC
❑ Temperature >6°C, 7 reading: °C ❑ Mislabeled as to tests, preservatives, tic.
❑ Samples frozen ❑ Holding time expired
❑ Improper container used
Containers ❑ insufficient quantity for analysis
❑ Leaking
❑ Broken
❑ Without labels
❑ VOA vials with headspace
❑ Sulfide samples with headspace
❑ Container Labels
❑
Not the same ID/infra. as on CDC
❑
Not the same ID/info. as on feldsheet
❑
Incomplete. Missing the following:
❑ Station #/Sample ID
C] Collection date
❑ Collector
❑ AnaIysis
❑ Preservative
* Other.
Cl
Markimgs smeared or illegible
❑
Torn
Comments:
❑ Chain of Custody
❑ No custody seals
❑ Custody seals not intact
❑ Not relinquished.
❑ No date/time relinquished
❑ No signature
0 Incomplete information
Documentation
❑ Fieldsheet wet/illegib e t
rX Fieldsheet incomplete ,
❑ Records not written in indelible ink
Other (s ecify)-
Corrective Action:
❑ -:Samples were rejeeted.by I]WQ Lab.=:Autlioi ized by;
❑ Accepted and analyzed per collector's request after tiotifyirig the collector,
❑ . Accepted and analyzed a8er iotifyina the:clielit' id dewriiiinirig that another sample could not be secured.
❑ - .Sam- ple(s) on hold until:
,,4-.�Sanzple(s) accepted aad analyzed.Vo'-notitxcation-regtiired. -:
❑ --=other (explain): t=:_- = f r.7;, _.:.; __ =, __:
Petson:Cotitaetrrd: e' Date:
_ _ ��'_
e r
Form completed %��PDate:
by!! "9 �
Unit Leader Review (initial);
NUT VOA SVOA �L&ET
WCH PEST MIC
4�AVQMV%Sa Plc Receirirty�SCy,fR tl±9JOldhs

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
April 30, 2002
Jae 210a)"w"giP1013lI
To: Jay Zimmerman, L.G., Regional Groundwater Supervisor
Groundwater Section
Raleigh Regional Office
From: Mark Pritzl MP [e-mail]
Hydrogeological Technician II
Underground injection Control (LW) Group
Central Office (CO)
Re: Request for inspection and sample collection of Charles Alfred Davis' geothermal
injection well system. This system is located at 1422 Ridge Road, in Raleigh, NC,
1, Inspect the injection well site to verify that the location and construction plans
submitted in the application are accurate and the NCAC Title 15A 2C .0200 standards are
being complied with, using the enclosed Injection Facility Inspection Report (form B) as
appropriate.
2. Collect samples from the influent and effluent sampling ports and submit the results to
the CO-UIC Group.
You are requested to return the completed Injection Facility Inspection Report (form B) to
the CO-UIC by May 15, 2002. If the inspection can not be accomplished by this date,
please inform the CO-UIC group. The UIC group greatly appreciates Jim Greer's
assistance with this review. If you have any questions regarding this review or the UIC
program, please contact me at [phone] or Evan Kane [phone].
cc: UIC Files
Enclosure

Michael F. Easley, Govemor
William G. Ross Jr„ Secretary
North Carolina Department of Environment and Natural Resources
April 15, 2002
Charles Alfred Davis
1422 Ridge Road
Raleigh, NC 27607
Dear Mr. Davis:
Gregory I Thorpe, Ph,D.
Acting Director
Division of Water Quality
In accordance with your application dated December 6, 1999, we are forwarding Permit No.
W10500040 for the construction and operation of a geothermal heat pump injection system at
1422 Ridge Road, Raleigh, North Carolina, in Wake County. Water samples will be taken at the
influent and effluent sampling ports of your geothermal heat pump. Please note, if these sample
results exceed groundwater quality standards, it is the well owner's responsibility to take
corrective action as stated in Title 15A Subchapter 2C, Section .0206.
This permit shall be effective from the date of issuance until April 30, 2007, and shall be subject to
the conditions and limitations stated therein. In accordance with NCAC Title 15A, Subchapter 2C,
Section .0213(h), the well owner is responsible for submitting a record of well construction within
30 days of completion. The well construction data for every well constructed for this project should
be submitted on the GW-1 form and this form is enclosed for your convenience.
If you have any questions regarding your permit please feel free to contact Mark Pritzl at (919)
715-6166.
CC: CO-UIC Files
RRO-UIC Files
Enclosures
�A
Kb M—Ft
Customer Service
1 000 623-7748
Sincerely,
Evan Q. Kane
Hydrogeologist
Underground Injection Control Program
Divisions of Water Quality 1 Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: httpJ/gw.ehnr.state.nc.us

ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RA.LEIGH, 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
Charles Alfred Davis
FOR THE CONSTRUCTION AND 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 system is located at 1422 Ridge Road, Raleigh,
North Carolina, in Wake County, and will be constructed and operated in accordance with the
application dated December 6, 1999, and in conformity with the specifications and supporting
data submitted, all of which are filed with the Department of Environment and Natural. Resources
and are considered a part of this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the
Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an
injection well shall be in compliance with Title 15A North Carolina Administrative Code 2C
.0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well construction and
use.
This permit shall be effective, unless revoked, from the slate of its issuance until April 30, 2007,
and shall be subject to the specified conditions and limitations set forth in Parts 1 through X
hereof.
Permit issued this the day of , 2042.
��fed L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0500040 PAGE I OF 6
Ver.3101 GWfUIC-5

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
The Perrnittee 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.
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.
Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface
cannot migrate into the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use, Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
& Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each injection well shall have permanently affixed an identification plate.
A completed Well Construction Record (Form GW-1) must be submitted for each injection
well, to the Division of Water Quality (Division), within 30 days of completion of well
construction.
PART II - WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall
notify the Groundwater Section -Underground Injection Control (UIC), Central Office staff,
telephone number [phone].
PART III - OPERATION AND USE GENERAL CONDITIONS
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
Permit No. W10500040 PAGE 2 OF b
Ver.310 t G WIUIC- 5

request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 34 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.
The injection facility shall be effectively maintained and operated at all times so that there
is no contarnination of groundwater which 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
Pennittee 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.
The Permittee shall he required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
The issuance of this permit shall not relieve the Pemittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART V - OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Groundwater Section -Underground
Injection Control "C), 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
Permit No. WI0500040 PAGE 3 OF 5
Ver.3101 GWIUIC-5

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.
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
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 Raleigh Regional Office, telephone number (919) 571-
4700, any of the following:
(A) Any occurrence at the injection facility which 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,
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 Pennittee shall
take such immediate action as may be required by the Director.
PART VIII - PERMIT RENEWAL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
Permit No, WI0500040 PAGE 4 OF b
Ver.3101 GWIUIC-5

PART IX - CHANGE OF WELL STATUS
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)(1), Well Construction
Standards.
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) Drilled wells 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, neat -cement shall be injected into the well completely
filling it from the bottom of the casing to the top.
(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)(1) within 30 days of completion of
abandonment.
Permit No. W10500040 PAGE 5 OF 6
Ver.3101 GWIUIC-5

The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Groundwater Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
I' .__;_ i.�i�-�IT1ti�►��1��������[�L����]JI�ILi�^;
Water samples will be taken at the influent and effluent sampling ports from the
geothermal heat pump -system after construction is complete. If the sample results reveal
viotation(s) of groundwater standards, it is the well owner's responsibility to take
corrective action as stated in Title 15A North Carolina Administrative Code 2C .0206. in
addition, the well owner shall take immediate actions including those actions that may be
required by the Division of Water Quality such as repair, modification, or abandonment of
the injection facility.
Permit No. WI0500040 PAGE 6 OF 6
Ver.3101 GWIUIC-5

Name
Date
Initials
Type of permit
Mark POW
Evan Kane
Debra Watts
- Z 4 0
d �►�•

F W A TF Michael F. Easley, Governor
�4 0 �QL William G. Ross Jr., Secretary
North Carolina department of Environment and Natural Resources
r Gregory J. Thorpe, Ph.D.
Acting Director
p Y Division of Water Quality
February 25, 2002
Charles Alfred Davis
1422 Ridge Road
Raleigh, NC 27607
Dear Mr. Davis,
The Groundwater Section's Underground Injection Control (UIC) Program received your
application to use a well for the injection of ground -source heat pump effluent on December 6,
1999. However, we have been unable to process your application because your heat pump system
has not been completely constructed or operating, which has prevented us from collecting water
samples from your system for compliance purposes. Please inform us as to what date your system
will be completely constructed and operating. If we do not hear from you within 30 days from the
date of this letter, we will return your application as incomplete. If you have any questions
regarding your injection well application, please contact Mark Pritzl at [phone]
cc
A ME
Customer Service
1 800 623-7748
CO-UIC files
RRO-LJIC files
Sincerely,
Evan D. Kane
Program Manager
UIC Program
Division of Water Quality 1 Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone]. Fax: [phone] Internet http:llgw.ehnf.state.nc.us

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
January 12, 2000
MEMORANDUM
To: Jay Zimmerman, L.G.
Groundwater Section
Raleigh Regional Office
From: Mark Pritzl 0. [e-mail]
Hydrogeological Technician 11
Underground Injection Control (UIC) Group
Central Office (CO)
Re: Request For inspection and sample collection of Charles Davis' geothermal injection
well system. This system is located at 1422 Ridge Road, Raleigh NC.
1. Inspect the injection well site to verify that the location and construction plans
submitted in the application are accurate and the NCAC Title 15A 2C .0200 standards are
being complied with, using the enclosed Injection Facility Inspection Report (form B) as
appropriate.
2. Collect samples from the influent and effluent sampling ports and submit the results to
the CO-UIC Group.
You are requested to return the completed Injection Facility Inspection Report (form B)
to the CO-UIC by January 15, 2000. If the inspection can not be accomplished by this
date, please inform the CO-UIC group. The UIC group greatly appreciates Jim Greer's
assistance with this review. If you have any questions regarding this review or the UIC
program, please contact me at [phone] or Amy Axon at [phone].
M. UIC Files
Enclosure

Page 1 of 2
North Carolina Department of Environment and Natural Resources
Division of Water Quality -Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTION
REPORT -FORM A
INJECTION WELL PERNUT NO. Wl
DATE
NAME OF OWNER
*111AI1 107 -,1W��Ax
r
76p7
(Street) road or lot and suddtviston, county, town)
LOCATION_ OF PROPOSED INJECTION WELL (and source well(s), if applicable) - Ze,,, .
(Streetl road or lot and suddivision , county, town, if dierent than owner's address, plus description of location on site)
Potential pollution sourced rl�r. Distance from well .tea
Potential pollution source �f a,-/ Distance from well 5D
Potential pollution source
Distance from well
Minimum distance of proposed well from property boundary !�,o r
Quality of drainage at si Flooding potential of site = _,
(gam ,adequatepoor) {high,mod low}
DRAW SKETCH OF SITE
(Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and north arrow,)
LJ a -
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4.0 P
Q
March 98

4
Page 2 of 2
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cant.)
COMMENTS
n�
INSPECTOR
Office r ;i
WITNESS
Address
WITNESS
Address
March 98

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
December 16, 1999
MEMORANDUM
To: Jay Zimmerman, L.G.
Groundwater Section
Raleigh Regional Office
From: Mark Pritzl 0 [e-mail]
ncinail.net
Hydrogeological Technician II
UIC Group
Groundwater Section, Central Office
Re: Request review of a new injection well permit application for the operation of an open loop
geothermal heat pump system.
The CO-UIC has received an application by Charles Davis for a new permit for the construction
and operation of an injection well located at 1422 Ridge Road, Raleigh, NC. The proposed
injection well will be part of an open loop geothermal heat pump system, therefore a type 5A7 well.
1. Please review the application and submit any comments to CO-UIC. Retain the
application for your UIC file.
Please inspect the proposed injection well site to verify that the location and construction
plans submitted in the application are accurate and that the NCAC Title 15A 2C.0200
standards are being complied with; using the enclosed Preconstruction Injection Faciiiry
Inspection Report -Form (A) as appropriate.
Please return any comments immediately upon application review. You are requested to return the
completed Preconstruction Injection Facility Inspection Report -Form (A) to the CO-UIC by
January 15, 1999. If the inspection can not be accomplished by this date, please inform the CO-
UIC. The UIC Group appreciates your assistance in the review and evaluation of this permit
application. Please contact me if you have any questions or comments at [phone].
cc: UIC Files
Enclosures

A74*Al'-
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
December 15, 1999
JAMES B. HUNTJR,
GOVERNOR
Charles Alfred Davis
'
1422 Ridge Road
BILL HOLMAN :,,,Raleigh,
1V C 2I 6V I
SECRETARY
Dear Mr. Davis:
DIVISION OF WATER QUALITY
KERR T. "EVENS
DIRECTOR Your application for a permit to use a well for the injection of geothermal heat
pump effluent has been received and is under review. A member of the Groundwater
Section's Raleigh Regional Office staff will be contacting you to arrange an
inspection of the injection well and collect water samples as part of the review.
If you have any questions regarding the permit or injection well rules please
contact me at [phone] or Amy Axon at [phone].
:- Sincerely,
Mark Pritzl
' i ! Hydrogeological Technician II
Underground Injection Control Program
- f
cc: UIC Files
RRO Files
GROUNDWATER SECTION
1636 MAIL 5ERVICH CEIVTIER, RAI.SIGH, NC 27699-5636 - 2720 CAPITAL, BLVD., RALE IGH, NC 27604
PHONE [phone] F'AX 919.715.0588
~ AN EQUAL OPPORTUNITY 1 AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED/}O% POST -CONSUMER PAPER

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMNUSSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT ANDIOR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
Type 5A7/5QM Wells
TO: DIRECTOR NORTH CA.ROLINA DIVISION OF WATER QUALITY
DATE: i A rX 19�
Please type or print clearly.
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1) V'- Type 5A7 wells inject water used to provide heating or cooling for structures-
(2) _ Type 5QM wells contain a subsurface system of continuous piping, that is
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes and/or corrosion
inhibitors.
(3) _ Type 5 QW wells contain a subsurface system of continuous piping, that is
isolated from the environment and only circulates potable water. If you selected
this well type, then complete form GW-57 CL, Notij7cation Of Intent To
Construct A Closed -Loop Geothermal --Water Only Injection Well System.
B. PERMIT APPLICANT
Name. C.tiPCRkt►E5 RLFRe--D �5
Address: ! A Z l _t-0 G PR -;-_1 b f4D
City: iR A- Zip Code. a 74 67 County: er
Telephone. (1 l LO
LO
C. PROPERTY OWNER (if different from applicant)
Name:
Address: T'-
City. Zip Code: County:
Telephone.
D. STATUS OF APPLICANT
Private: Federal: Commercial:
State Municipal: Native American Lands:
GW-57 HP (February 1998)
Page 1 of 4

E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial)
Name of Business or Facility:
Address:
City:
Telephone:
Zip Code:
Contact Person:
County:
F. HEAT PUMP CONTRACTOR DATA
Name: � %/I erClV1► -e-vl �fx-✓c� ,� c
Address: I•'7/ 9 Jr-7-,'Qd► P4AX Al u �
City: C Zip Code:' 7�l� County'
Telephone: `}e9 `►t'�I *)—vof . Contact Person:
G. INJECTION PROCEDURE (Briefly describe how the injeetion well(s) will be used.)
/�er1•v •fie 1,2 ��l?'� ��r�r►11 Ars7G !e rs
�r -y A7'r .r,e.off
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO
I. CONSTRUCTION DATA (check one)
EXISTING WELL being proposed for use as an injection well. Provide the data in
(1) through (7) below to the best of your knowledge. Attach a copy of Form GW-
I (Well Construction Record.) if available.
PROPOSED WELL to be'consstmcted for use as'an injection well. Provide the
data in (1) through (7) below as PROPOSED construction specifications. Submit
Form GW-1 after construction,
(1) Well Drilling Contractor's Name:►�/��1 FC ►rv� '
NC Driller Registration number:
(2) Date to be constructed: !�//a f Number of borings: l
Approximate depth of each boring (feet):
(3) Well casing: Is the well(s) eased?
(a) YES L-'� If yes, then provide the casing information below.
Type: Galvanized steel ✓ Black steel Plastic Other (specify)
Casing depth: From to ft. (reference to land surface)
Casing extends above ground _ /z inches
(b) NO
GW-57 HP (February 1998) Page 2 of 4

J
K_
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement V/ Bentonite Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
around closed loop piping; from to (feet),
around well casing; from d to ��` (feet)-
(5) Screens (for Type 5A7 wells)
(a) Depth: From ! to feet below ground surface.
(6) N.C. State Regulations (Title 15A NCAC 2C .0200) require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent (fluid being injected into the well) tines is required. Will there be a faucet on:
(a) the influent line? yes ✓ no (b) the effluent line? yes no
(7) SOURCE WELL CONSTRUMON INFORMATION (if different from injection well).
Attach a copy of Form GW-1 (Weil Construction Record). If Form GW-1 is not available,
provide the data in part K (1) of this application form to the best of your knowledge.
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EM ER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
PROPOSED OPERATING DATA (for Type 5A7 wells)
(1)
Injection rate-
(2)
Injection Volume:
(3)
Injection Pressure:
(4)
Injection Temperature:
INJECTION FLUID DATA
Average (daily) aallons per minute (gpm),
Average (daily) ,d 0 0 gallons per day (gpd).
Average (daily) %4 pounds/square inch (psi).
Average (January) ! of ° F, Average (July) i�t ° F.
(1) FIuid source (for Type 5A7 wells) If underground, from what depth, formation and type of
rock/sediment unit will the fluid -be drawn (e.g., granitd, limestone, sand, etc.),
Depth: ds7 Formation: a Rocklsediment unit. 6�A,0''y'iq
(2) Chemical Analysis of Source Fluid (for Type 5QM welds)
Provide a complete listing of all chemicals added to the circulating heat transfer fluid:
L. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
GW-57 HP (February 1998) Page 3 of

M. LOCATION OF WELL(S) Attach two maps.
(1) include a site map (can be drawn) showing: buildings, property lines, surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks or
drain fields located within 1000 feet of the geothermal heat pump well system, Label all
features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LIST- Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
O. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the information
is true, accurate and complete. I am aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the injection well and all related app antes in accordance with
the approved specifications and conditions of the Permit."
(Signature of Owner or Authorized Agent)
Please supply a letter signed by the owner
authorizing the above agent. if authorized agent is signer-
P. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing,)
If the property is owned by someone other than the applicant} the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the injection well(s) conforms to the Well
Construction Standards (Title 15A NCAC 2C .0200)
{S'ignature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR DWQ
P.O. Boa 29578
Raleigh, NC 27626-0578
Telephone [phone]
GW-57 HP (February 1998) Page 4 of 4

DEC-iB-99 FRI 14:15 BOWMAN MECHANICAL SVC 9197799294 P.92
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F30WMAN MrGHANEGAL $ERviGES
1219 Sturdivent Drive
Cary, NO 27511
MMI ?? '•P759 - Garner High Ef lency.HVAC + Geothermal
Vo- -on - Cary FAX (919) 'r19-094
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