WI0500040_GEOTHERMAL_20170327

Permit Number
Program Category
Ground Water
Permit Type
WI0500040
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Charles and Gwendolyn Davis SFR
Location Address
1422 Ridge Rd
Raleigh
Owner
Owner Name
Charles
Dates/Events
Orig Issue
4/26/2002
NC
Alfred
App Received
1/10/2017
Reaulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27607
Davis
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
3/27/2017
Permit Tracking Slip
Status
Active
Version
4.00
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Charles Alfred Davis
1422 Ridge Rd
Raleigh
Region
Raleigh
County
Wake
NC
Issue
3/23/2017
Effective
3/23/2017
27607
Expiration
2/28/2022
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
1/13/17
3/15/17
Subbasin
Water Resources
Environmental Quality
March 23, 2017
Gwendolyn and Charles Davis
1422 Ridge Road
Raleigh, NC 27607
Re: Issuance of Injection Well Permit
Permit No. W10500040
Geothermal Heating/Cooling Water Return Well
Wake County
Dear Mr. and Mrs. Davis:
ROY COOPER
Governor
MICHAEL S. REGAN
.Secretory
S. JAY ZIIvIMERMAN
Director
In accordance with your permit renewal application received January 10, 2017, I 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 limitations 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
permit 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,
(21 a
Shristi Shrestha
Underground Injection Control (UIC)- Hydrogeologist
Division of Water Resources, NCDEQ
Water Quality Regional Operations Section
�-No1 htrrig Compares
State of North Carolina I Environmental Quality { Division of Water Resources
Water Quality Regional Operation' Section
1636 Mail Service Cater r Raleig}t, North Carolina 27699• 1636
919-707-9129

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

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
hi 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
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 weli(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 23th day of March 2017.
„to,
S. Jay Zimmerman, P.G.
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Permit #W10500040
UIC15A7
per. l I/15/2015
Page I of 5

PART I -PERMIT GENERAL CONDITIONS
1. 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 [15A NCAC 02C .021 l(a)].
3. 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 .021 l(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 [15A NCAC 02C .0203].
PART II -WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed in accordance
with the requirements of rule 15A NCAC 02C .0107 except as required in Item #2 below.
2. 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 [ 15A NCAC 02C
.0224(d)(2),(3)].
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams 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)].
5. 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)].
Pennit#WI0500040 UIC/5A7
ver. 11/15/2015
Page 2 of 5
7. A completed Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 of this
permit.
PART ID ~ OPERATION AND USE CONDITIONS
1. 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 ISA NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02G .021 l(j)].
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 -O2C .0206].
PART IV -INSPECTIONS [15A NCAC 02C .021 l(k)l
1. :Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation ofcredentials, enter aild inspect any property, premises~ or place on or related to the
injection facility at any reasonable time for the purpose of determining compliance with this permit, may
inspect or copy any records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwater, surface water, or injection fluids.
2. 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.
3. Provisions shall be made for collecting any necessary samples of the injection facility's activities.
·PART V -MONITORING AND REPORTING REQUIREMENTS
1. 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)(l )].
3. The Permittee shall 1:'eport 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 15A NCAC 02C .021 l(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 Raleigh Regional Office, 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#WI0500040 UIC/5A7
ver. 11/15/2015
Page 3 of5
(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
Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Water Quality Regional Operations Section
DWR Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
PART VI-PERMIT RENEWAL [15A 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 [15A NCAC 02C .0240]
1. 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 Permittee 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
seal 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 .01 ll(b)(l)(A), (B), and (C).
Permit #WI0500040 UIC/5A7
ver. 11/15/2015
Page 4 of 5
(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 so:urces 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.
5. The written documentation required in Part VII (4)(F) shall be submitted to the addresses specified in Part
V.5 above.
Permit #WI0500040 UIC/5A7
ver. 11/15/2015
Page 5 ofS
AC35455 North Carolina Division of Water Resources Water Sciences Section Laborator. Results
Loc. Diem: 1422 RIDGE ROAD
County: MU Collector J, RQBERTSON VlaRlD
Region FAQ ReportTa BM Location !D: ¢P092W1060444Q
River Basin NEU Collect Date: 92/0212017 Priority COMPLIANCE
Emergency Collect Time: UM Sample Matrix: QROUNDWA h
COC Yes/No Sample Depth Lac. Type: Water Suogly
Final Report
Sample ID: AC35455
PO Number #
Date Received 02/021Z017
Trme Received: J0:30
Labworks LoglnID TASCENZDI
Delivery Method Ham delivered
Final Report Date: 313/17
Report Print Date: 03/0312017
if this report is labeled prellmInary report, The results have not been validated. Do not use for Regulatory purposes.
Result)
AS # Analyte NE1e PQL. Qualifier
LAB
Sample temperature at receipt by lab 4.5
Units
'C
Method Analysis_
Reference _gate Validated ay
2/2/17 MSW1FT
M1C
Coliform, MF Fecal in liquid 1 1 8201 CFU1100mt SM 9222 D-1997 2/3117 ESTAFFORDI
Coliform, ME Total in liquid
1 1 8201
CFU1100m1 SM 9222 B-1997
2J3117 ESTAFFORD1
NO2+NO3 as N in liquid
Kn
0.02 1.4 fg/L as N EPA 353.2 REV 2 213117 CGREEN
WET
Bromide 0.4 0.4 U mp/L EPA 300.0 rev2.1 2/3/17 CGREEN
Chloride 1.0 12 mg/L EPA 300.0 rev2.1 2/3/17 CGREEN
Fluoride 0.4 0.4 U mglL EPA 30010 rev2.1 213/17 CGREEN
Sulfate 2.0 2.0 U mg1L EPA 300.0 rev2.1 2J3117 CGREEN
Total Dissolved Solids in liquid 12 52 rng1L SM 2540 C-1997 21e117 CGREEN
7429-90-6 Al by ICP
MET
50 120 ug1L EPA 200.7 Rev4.4 2/10117 ESTAFFORD1
7440-70-2 Ca by ICP 0.10
1.0 rngfL EPA 200.7 Rev4.4 2/9/17 ESTAFFORDI
7440-47.3 Cr by ICPMS
5.0 5.0 U u91L EPA 200.8 Rev5.4 2113117 ESTAFFORD1
7440-50-8 Cu by fCPMS 2.0 180 u911 EPA 200.e Rev5.4 2/13/17 ESTAFFORD1
7439-89-B Fe by 1CP 50 110 ug1L EPA 200.7 Rev4.4 2/10/17 ESTAFFORDI
744049-7 K by ICP 0.10
0.89 mg1L EPA 200.7 Rev4.4 219117 ESTAFFORDI
7439-95-4 Mg by iCP 0.10
1,3 mg/L EPA 200.7 Rev4.4 219117 ESTAFFORDI
7439-99-5 Mn by ICP 10 25 ug/L EPA 200.7 Rev4.4 2110117 ESTAFFORD1
7440-23-5 Na by ICP 0.10 10 mg/L EPA 200.7 Rawl 2/9/17 ESTAFFORD1
744a-02-o Ni by 1CPMS
2.0 2.0 U u91L EPA 200.8 Rev5.4 2113117 ESTAFFORDI
7439-92-1 Pb by ICPMS
2.0 2,0 U ug/L EPA 200.8 Rev5.4 2J13117 ESTAFFORDI
740-66-8 Zn by ICPMS 10 15 ug)L EPA200.8 Rev5.4 2/13/17 ESTAFFORD1
WSS Chemistry Lelsorator}r>a 1823 Mail Service Center, Raleigh, NC 27899.1823 [phone]
"Not Detected" or "U" does not Indicate the sample is analyte free but that the analyte is not detected at or above the POL.
Page 1 of 1

2A\1~
AC35456 North Carolina Division of Water Resources Water Sciences Section LaboratoCY Results
Loe. Descr.: 1422 BIQGE RQAD Sample ID: AC~5456
County: WAKE Collector: bBQliBIIQ~ VisitlD PO Number#
Region: BBQ Report To !liQ Location ID: 1eouwH1sggo~ Date Received: 02/02/2017
River Basin l!l§U Collect Date: 02/02/2017 Priority CQMfLIANg§ Time Received: 15:30
Emergency Collect Time: .1li1A Sample Matrix: iBQ!.!t:tgifyA!ER Labworks LoginlO m1g§t:tm1
COC Yes/No Sample Depth Loe. Type: Wl1!£§uaa~ Delivery Method 1::11D51 dall!ll!S
Final Report Date: 3/3/17
Report Print Date: 03/03/2017
Final Reeort
« this report Is labeled preliminary report, the results have not been val/dated. Do not use for Regulatory purposes.
Result/ Units Method Anal~§il
CAS# Anall'.te Name .eQb Qualifier Reference Date Validaled blf
LAB
Sample temperature at receipt by lab ·4_5 ·c 2/2/17 MSWIFT
MIC
Coliform, MF Fecal in liquid 1 1 B2Q1 CFU/100ml SM 9222 0-1997 2/3/17 ESTAFFORD1
Coliform, MF Total in liquid 1 1 82Q1 CFU/100ml SM 9222 B-1997 2/3/17 ESTAFFORD1
NUT
NO2+NO3 as N in liquid 0.02 1.5 mg/L -asN EPA 353.2 REV 2 2/3/17 CGREEN
WET
Bromide 0.4 0.4 U mg/L EPA 300.0 rev2.1 2/3/17 CGREEN
Chloride 1.0 12 mg/L EPA 300.0 rev2.1 2/3/17 CGREEN
Fluoride 0.4 0.4U mg/L EPA 300.0 rev2.1 2/3l17 CGREEN
Sulfate 2.0 2.0 U mg/L EPA 3po.o rev2.1 · 2/3/17 CGREEN
Total Dissolved Solids in liquid 12 54 ITig/L SM 2540 C-1997 2/6/17 CGREEN
MET
7429-90-5 Al by ICP 50 50 U ug/L EPA200.7 Rev4.4 2/10/17 ESTAFF0RD1
•7440-70-2 Caby ICP 0.10 1.1 mg/L EPA 200. 7 Rev4.4 2/9/17 ESTAFFORD1
7440-47-3 Crby ICPMS 5.0 5.0 U ug/L EPA 200.8 Rev5.4 2/13/17 ESTAFFORD1
7440-50-8 Cuby ICPMS 2.0 430 ug/L EPA 200.8 RevS.4 2/13/1.7 ESTAFFORD1
7439-89-8 Feby ICP 50 50 U ug/L EPA 200.7 Rev4.4 2/10/17 ESTAFFORD1
7440-09-7 Kby ICP . 0.10 0.87 mg/L EPA 200.7 Rev4.4 2/9/17 ESTAFFORD1"
7439-95-4 Mgby ICP 0.10 1.3 mg/L EPA 200. 7 Rev4.4 2/9/17 ESTAFFORD1
7439-96-5 Mnby ICP 10 24 ug/L EPA 200.7 Rev4.4 2/10/17 ESTAFFORD1
7440-23-5 Naby ICP 0.10 10 mg/L EPA 200.7 Rev4.4 2/9/17 ESTAFFORD1
7440-02-0 Ni bylCPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 2/13/17 ESTAFFORD1
7439-92-1 Pbby ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 2/13/17 ESTAFFORD1
7440-66-6 Znby ICPMS 10 15 ug/L EPA 200.8 RevS.4 2/13/17 ESTAFFORD1
WSS Chemistry Laboratory>> 1823 Mall-Service Canter, Raleigh, NC 27899-1823 [phone]
"Not Detected" or "U" does not indicate the sample is analyte free but that U,e analyte Is not detected at or above the PQL.
Page 1 of 1
WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
Date: 03/10/2017
To: Shristi Shrestha
Central Office Reviewer
Permit No. WI0500040
County: Wake
Permit-tee/Applicant: Charles & Gwendolyn Davis
Facility Name: Davis Geothermal Well
L GENERAL INFORMATION
I , This application is (check all that apply): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification
a. Date of Inspection: 02/02/2017
b. Person contacted and contact information: Charles Davis. 919-782-0I I2
c. Site visit conducted by: Laura Robertson
d. Inspection Report Printed from BIMS attached: ❑ Yes 1l 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
IL DESCRIPTION OF INJECTION WELL(S2 AND FACILITY
1. Type of injection system:
® Geothermal Heating/Cooling Water Return
❑ hi situ Groundwater Remediation
❑ Non -Discharge Groundwater Remediation
❑ Other (Specify:_
For Geothermal Water Return Wel(s) only
R
WIAR 15 1.017
Water Ovality Recfiarnkal
aFetatt°n5 5
edio
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
information is available on renewal application, it was not visible on the well.
h. 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 IY of this Staff Report.
3. Are there any potential pollution sources that may affect injection? ❑ Yes ® No
What is/are the pollution source(s)?
4.
5.
6.
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
Flooding potential of site: ® Low
❑ Adequate
❑ Moderate
❑ Poor
❑ High
Rev. 6/1/2015
Page 1

WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
7. For Groundwater Remediation systems, is the proposed andlor existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. If No,
attach map 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 ❑ N/A.
If no, please explain:
b. Are the site conditions (soils, topography, depth to water table, etc.) consistent with what was reported by
the soil scientist andlor Professional Engineer? ❑ Yes ❑ No ❑ N/A. If no, please explain:
III. EVALUATION AND RECOMMENDATIONS
I. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, explain.
u. 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
Reason
4. Recommendation
❑ Deny. if Deny, please state reasons: RECENEDINCDE WR
❑ Hold pending receipt and review of additional information by regional office BAR15 n17
® Issue Water Ouallty ReMona!
OOyler-Minns Section
)11164(/•641A)
❑ Issue upon receipt of needed additional information
5. Signature of report prep arer(s) :
Signature of WQROS Regional Supervisor: �`•�/• % `%,f/�
Date:
Rev. 6/1/2015 Page 2

WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
IV. ADDITIONAL REGIONAL STAFF REVIEW COMMENTS/ATTACHMENTS flfNeeded)
-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.
VDe VRlve5 qpPp,ta to ,b, d&t'eik 1ti4 kve, bAou
AGal'a r kilar4e 4 Conf+'LYL 14.6‘t'
Rev. 6/1/2015 Page 3

AC35455 North Carolina Division of Water Resources Water Sciences Section Laboratory Results
Lot:. Deem 1322RIPGF ROAD
County; WAKE Collector. L ROBERTSON ViaitlD
Region: Report To BM Location ID: 5P492W10500040
River Basin NEU Coiled Date: 92a12017 Priority COMPLIANCE
Emergency Collect Time: lug Sample Matrix: gRQUNDWATER
COC Yas/No Sample Depth Loc. Type: Witter autaglY
Final Report
Sample ID: AC3545§
PO Number#
Date Received: 02J0212017
Time Received- 15;34
Labworka LoginID TAS4ENZ01
Delivery Method Hand danvareg
Final Report Oats: 3I3117
Report Print Date: 0310312017
if this report is labeled preliminary report, the results have not been validated Do not use for Regulatory purposes.
Resuft/ Units Method Analysis
CAS # Analyte Name PQL Qualifier Reference Date VaIrdated by
LAB
Sample temperature at receipt by lab 4.5 'C 212117 MSWIFT
M1C
Coliform, MF Feca1 in liquid 1 1 B201
CFU/100m1 SM 9222 D-1997
2/3/17 ESTAFFORDI
Collform, MF Total in liquid
1 1 6201 CFUI100m1 SM 9222 B-1997
2/3/17 ESTAFFORDI
NO2+NO3 as N in liquid 0.02
NUT
i.4
mg/Las N EPA 353.2 REV 2 2/3/17 CGREEN
WET
Bromide 0.4 0.4 U mg/L EPA 300.0 rev2.1 213f17 CGREEN
Chloride 1.0 12 mg/L EPA 300.0 rev2.1 213/17 CGREEN
Fluoride 0.4 0.4 U mg/L EPA 300.0 rav2.1 2/3/17 CGREEN
Sulfate 2,0 2,0 U mg/L EPA 300.0 rev2.1 2/3/17 CGREEN
Total Dissolved Solids in liquid 12 52 mg/L SM 2540 C-1997 2/6/17 CGREEN
7429-90-5 Al by ICP
MET
50 120 ug/L EPA 200.7 Rev4.4 2/10/17 ESTAFFORDI
7440-70-2 Ca by ICP 0.10 1.0 mg/L EPA 200.7 Rev4.4 2/9/17 ESTAFFORD1
7440-47-3 Cr by ICPMS
5.0 5.0 U
ug/L
EPA 200.8 Rev5.4 2113/17 ESTAFFORD1
7440'50-8 Cu by ICPMS 2.0 180 ug/L EPA 200.8 Rev5.4 2/13/17 ESTAFFORD1
7439-89-6 Fe by ICP 50 110 ug/L
EPA 200,7 Rev4.4 2110117 ESTAFFORDI
7440-09-7 K by ICP
0.10 0.89
mg/L EPA 200.7 Rev4.4 2/9/17 ESTAFFORDI
7439-95-4 Mg by ICP
0.10 1.3 mg/L EPA 200.7 Rev4.4 219117 ESTAFFORD1
7439-96-5 Mn by ICP 10 26 ug/L EPA 200.7 Rev4.4 2/10117 ESTAFFORDI
7441)-23-5 Na by ICP
0.10 10 mg/L EPA 200.7 Rev4.4 2/9/17 ESTAFFORD1
7440-02-0 Ni by ICPMS
2.0 2.0 tl ugh. EPA200,8 Rev5.4 2/13/17 ESTAFFORD1
7439-92-1 Pb by ICPMS
2.0 2.0 U ug/L EPA 200.8 Rev5.4 2/13/17 ESTAFFORDI
7440•68-8 Zn by ICPMS
10 15 ug/L EPA 200.8 Rev5.4 2/13/17 ESTAFFORD1
WSS Chemistry Laboratory -pa 1623 Mall Service Center. Raleigh, NC 27690.1623 [phone]
"Not Detected" or "U" does no! indicate the sample is analyte Free but that the enalyte is not detected at or above the POL.
Page 1 of 1

~w
AC35456 North Carolina Division of Water Resources Water Sciences Section Laboratory Results
Loe. Descr.: 1422 RI DG E ROAD Sample ID: AC35456
County: WAKE Collector: LRQBERTSQN VisitlD PO Number#
Region: BBQ Report To RRO Location ID: 5P092WI0500 040 Date Received: 02/02/2017
River Basin NEU Collect Date: 02/02/2017 Priority cgr.,~1i.1a~c1; Time Received: ~
Emergency Collect Time: ll.i.1J2 Sample Matrix: ~RQIJNDWAIEB Labworks LoginlD TASCENZO1
COC Yes/No Sample Depth Loe. Type: Wa!!rSyggl]t Delivery Method l:IIDd d1llvered
Final Report Date: 3/3/17
Report Print Date: 03/03/2017
Final Report
If this report Is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
Result/ Units Method Anal~sis
CAS# Analyte Name POL Qualifier Reference Date Validated b)i'.
LAB
Sample temperature at receipt by lab 4.5 ·c 2/2/17 MSWIFT
MIC
Coliform, MF Fecal in liquid 1 B2Q1 CFU/100ml SM 9222 D-1997 2/3/17 ESTAFFORD1
Coliform, MF Total in liquid 1 B2Q1 CFU/100ml SM 9222 B-1997 2/3/17 ESTAFFORD1
NUT
NO2+NO3 as N in liquid 0.02 1.5 mg/Las N EPA 353.2 REV 2 2/3/17 CGREEN
WET
Bromide 0.4 0.4 U mg/L EPA 300.0 rev2.1 2/3/17 CGREEN
Chloride 1.0 12 mg/L EPA 300.0 rev2.1 2/3/17 CGREEN
Fluoride 0.4 0.4 U mg/L EPA 300.0 rev2.1 2/3/17 CGREEN
Sulfate 2.0 2.0 U mg/L EPA 300.0 rev2.1 2/3/17 CGREEN
Total Dissolved Solids in liquid 12 54 mg/L SM 2540 C-1997 2/6/17 CGREEN
MET
7429-90-5 Al by ICP 50 50 U ug/L EPA 200. 7 Rev4.4 2/10/17 ESTAFFORD1
7440-70-2 Ca by ICP 0.10 1.1 mg/L EPA 200. 7 Rev4.4 2/9/17 ESTAFFORD1
7440-47-3 Crby ICPMS 5.0 5.0 U ug/L EPA 200.8 Rev5.4 2/13/17 ESTAFFORD1
7440-50-8 Cu by ICPMS 2.0 430 ug/L EPA 200.8 Rev5.4 2/13/17 ESTAFFORD1
7439-89-8 Fe by ICP 50 50 U ug/L EPA 200. 7 Rev4.4 2/10/17 ESTAFFORD1
7440-09-7 Kby ICP 0.10 0.87 mg/L EPA 200. 7 Rev4.4 2/9/17 ESTAFFORD1
7439-95-4 Mg by ICP 0.10 1.3 mg/L EPA 200.7 Rev4.4 2/9/17 ESTAFFORD1
7439-96~5 Mn by ICP 10 24 ug/L EPA 200.7 Rev4.4 2/10/17 ESTAFFORD1
7440-23-5 Na by ICP 0.10 10 mg/L EPA 200.7 Rev4.4 2/9/17 ESTAFFORD1
7440-02-0 Ni by ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 2/13/17 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 2/13/17 ESTAFFORD1
7440-86-8 Zn by ICPMS 10 15 ug/L EPA 200.8 Rev5.4 2/13/17 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mall Service Center, Ralelgh, NC 27699-1623 [phone]
"Not Detected" or "U" does not indicate the sample is analyte free but that the analyte is not detected at or above the PQL.
Page 1 of 1
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FOR.i'1
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: [e-mail]
Permit Number: WI0500040
A. Applicant: Gwendolyn and Charles Davis
B. Facility Name:
C. App lication:
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 fpr your
review, comment, and/or action. Within 30 calendar days, please return a completed WOROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: _________________ Date: ____ _
COMMENTS:
NOTES:
FORM: WQROS;.ARR ver. 092614 Page 1 of 1
nvironmen ►al
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:
ROY COOPER
Governor
WILLIAM G. ROSS, JR.
Acting Secretary
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on January 10th 2017. Your application
package has been assigned the number listed above, and the primary reviewer is Shristi 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 Shristi
Shrestha at 919-807-6406 or email at Shristi.shrestba[ci7ncdenr.gov.
Sincerely,
For Debra 1. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch Division of Water
Resources
cc: Raleigh Regional Office, WQROS
Permit File WI0500040
-11-' Nor ling Compar
State of North Carolina I Environmental Quality f Division of Water Resources
Water Quality Regional Operations Section
I636 Mail Service Center I Raleigh, North Carolina 27699-1636
919-707-9129

1
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal beating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application )LRenewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illregible Applications Will Be Returned As Incomplete.
DATE: Tom '' ,20 / 1 PERMIT NO. YVgi0�O 4 (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 Geothermal Well Drinking Water Supply Other Water
Supply
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of t)O_Wbli Abandonment
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:
Names)
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence 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 person de egated authority to sign:
Mailing Address: / `/i2& 1f dq�
City: 16z...eelyState: fie —Zip Code: 0?"76 7:' l'� County: P✓
Day Tele No.: g1'ct179 1CeZ Ce11 No.:
EMAIL Address: Fax No.:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 1

D. WELL OPERATOR (if different from well owner) -For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authqrity to sign on behalf of the business
or agency: GrcJ~rJo f yPt ~ Ch_ arf e.J:; fi--. D4'.-Vl-S
Mailing Address:,,, t f-;;__~ ~R/Jg:-: r/(oo.4_
City: f¾J.-9k State: f.[c__ Zip Code:~ (:,o rJ County: W ~
Day Tele No.; °TJ~/1 ~ ~-~If;)..... Email Address.:
E. LOCATION OF WELL SITE -Where the injection wells are physically located:
F
G.
H.
I.
(1) Parcel Identification Number (PIN) of well site: __________ County: _____ _
(2) Physical Address (if different than mailing address): _..S_~_. _____________ _
City: _______________ State: NC Zip Code: ________ _
WELLDRILLERINFORMATI3'Ni na.1~, ~Suh~~,:
Well Drilling Contractor's Name: t'\~. s ·~J>rt.{G 'J_nc.... l{, ~ "'Poa( e., PidP.. cf>orn. c~.
NC Well Drilling Contractor Certification No.: _J_q_'f--_o/ _________________ _
CompanyName: A/.µ[, Po"l':>)e--Will "4~vrve Qo .
Contact Person: _Ha..Y'"~ Let:"QJ_Ltvt)rt-fu EMAIL Address: fe,,tc.hwvr~nlv\)rroJe-.C'...Cr<Yv
Address: 35"Qe> :R,'Q\~'lln~ 1<_o~ (170 ~ JC,~8)
City: -Wu~r Zip Code: {).__ 151 I S~ate: ff~ County: _yJ__._~_-e..,;, ____ _
Office Tele No.: ... Cf ( 9/~{p(;-9'~~ Cell No.: ______ Fax No.: °If%/~~ --75o 7
HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: ~ye ./3trWTh~
NC HVAC Contractor License No.: --,-/,-~---'--J_D_q __________________ _
CompanyName: ~m~ r(ecJi~ Oi!rV~C-eS 7 ffic_..,
Contact Person"--: ______________ EMAIL Address: __________ _
Address: t'-1-5 ,ec.J,n~ c:1urT
City: 6fG.X'nf;,f' Zip Code: ;?]5,:J.,4 State: d:'C--county: ,vJ~~-·e..,.., ______ _
Office Tele No.: q1q / 1'1l). -),15j Cell No.: _______ Fax No.: Cff '1 / '11 1 -CJ-:J...C/f
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES K NO ___ _
YES ___ _ NO -,_.,( __
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 20 15) Page2
(3)
(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 SPECIFICATIONS
(1)
Specify the number and type of wells to be used thr the geothermal heating/cooling system:
*EXISTING WELLS PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another,
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
r
(a) Depth of each boring below land surface viatt de -- ` 6
rl
(b) Well casing and screen type, thickness, and diameter'
(c) Casing depth below land surface et/
(d) Casing height "stickup" above land surface
(e) Grout materials) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water -bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107 0(8_1
(1) Length of well screen or open borehole and depth below sand surface
(g)
Length of sand or gravel packing around wcil screen and depth below land surface
K. OPERATING DATA 'Lk. Av.O 1'
(1) Injection Rate: Average (daily) I a- gallons per minute (gpm).
(2) Injection Volume: Average (daily) 3AOgaIlons per day (gpd).
(3) Injection Pressure: Average (daily) Ak pounds/square inch (psi).
(4) Injection Temperature: Average (January) 48 ° F, Average (July) a8 ° F,
L. SITE MAP — As specified in 15A NCAC 02C .0224(h)(4), attach a site -specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
slp;ll include the following:
t.5-(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .DJ 07(a1(2) located within 250
feet of the proposed injection weil(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 3

NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures ran 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
tiara
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(e) requires that all perrnit applications shall be signed as follows:
I . 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 personts) 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. 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 weer/Applicant
C- A 1Yis
Print or Type Full Name
te.1rC r ,
Signature of Property Owner/Applicant
GitieinGLa1 Pt Z P S t 1 YT�G1r' IS.
Print or Type �'ul] Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division of Water Resources
Vs'ater Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return WeI1 Permit Application (Revised !an 2015) Page 4

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 PERMIT NO. WI DATE ;
4? r
o
NAME OF OWNER 1}_ii , 4 6
ADDRESS OF OWNER /4�-��
(Street/ road or lot and suddivision, county. town)
._2
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable) 'o
II f ^t 1 1
Ai .f./-. ! +yam F".� .4-4 s Cc� --
(Street/road or lot and suddiwsion . count. town, if different than owner's address, plus description of location on sue
Potential pollution source
Potential pollution source
Potential pollution source
Distance from well
Distance from well Sr. �
Distance from well ------
Minimum distance of proposed well from property boundary 7 f
Quality of drainage at sj Flooding potential of site
;adequate, poor) (high.moder4to w)
DRAW SKETCH OF Slit
(Show property boundaries, buildings. wells, potential pollution sources, roads, approximate scale, and north arrow.)
+ I,
�. 40►.. ‘"'
f ) '
I.
t �•5-0
ci 2
r
frF! f
Ar45---c
FL

.F a ..7159 - L3arrer
# -4 f]13 - Cary
4UH-
BOWMAN leiLCI-IANICAL St.fIVICE5
1219 $turdivant Drive
Cary, NC 27511
High Efficiency IIVAC • Geothermal
ZtfAA/ /• fd.-
/'lea
50
r
FAX (919) 77e14n4
ft,
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IC
Water Resources
ENVIRONMENTAL QUALITY
December 20, 2016
CERTIFIED MAIL # 7015 1520 00007838 4399
RETURN RECEIPT REQUESTED
Charles and Gwendolyn Davis
1422 Ridge Road
Raleigh, NC 27607
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0500040
Wake County
Dear Mr. & Mrs. Davis,
Secretary
S. JAY ZIMMERMAN
Director
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
requirenwnts 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 Beim! Used for Infection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title I5A, 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://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Beini Used for Infection:
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 ptupose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title i 5A, Subchapter 2C, Section
State ofNorth Carolina I EnvironrrumN1Qunlity I Water Resources
1611 Mail service Center I Raleigh, North Camlina 27699-1611
919 707 9000

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 Change 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 found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email at shristi.shresthaC ncdenr.gov.
Regards,
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Raleigh - Regional Office — WQROS wlo enclosures
Central Files - Permit No. W10500040 w/o enclosures

7015 1520 0000 7838
U.S. Postal Service'"'
CERTIFIED MAIL° RECEIPT
Domestic Mail Only
For delivery information, visit our website at www.usps.com-.
0
Certified Mall Fee
Extra " Aces & Fees (chockbar, add foe es appropriate)
❑Return Rece!pl (hardcopf) $
❑ Rearm Aecerpl (electronfc) 5
Q Codified Moll ReetrInted D&We♦y $
❑ Milt RION: we Required
El Adult signature Reet 1cted Denary $ --
Postage
�Ol�1eoS18 Charles and Gwendolyn Davis
cant To 1422 Ridge Road
-a-nd Raleigh, NC 27607
Postmark
Here
PS Form 3800, April 2015 PSN 7530-02-000-0047 See Reverse tor Instructions
SENDER: COMPLETE THIS SECTION
• 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 mailplece,
or on the front if space permits.
1. Article Addressed to:
Charles and Gwendolyn Davis
1422 Ridge Road
Raleigh, NC 27607
IIIII1lI IIII IIII1IIIIIIIIIIIUUIiIlI 1IIII11III
9590 9403 0730 5196 3165 78
COMPLETE THIS SECTION ON DELIVERY
A. Signature
B. Received by (Printed Name)
7�r7� 0 Agent
© Addressee
C. Date of Delivery
0. Is delivery address different from item 1? 0 Yes
if YES, eater delivery address below: El No
2. Article Number (Transfer from service label)
3. Service Type
I7 Adult Signature
0 Adult Signature Reetrkrted Delivery
© Corned Mall®
0 Certified Mall Restricted Delivery
0 Collect on Delivery
0 Collect on Delivery Restricted Delivery
0 Insured Mail
7015 1520 0000 7838 4399 a)ail R3atnctedDelivery
• PS Form 3811, April 2015 PSIS 1530-02-0a`i3-0050 --
o Prfortty Mall )ipressID
0 Registered Man'
❑ Registered Mall Restricted
ry
n RRetleiurn Receipt for
Mercfrandle )
0 Signature Confirmation/.
0 Signature Confirmation
Restricted Delivery
Domestic Retyrn Receipt

ATA
w.
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 16, 2012
MEMORANDUM
S4
To: Michael Rogers, The Central Office, APS
Through: Jay Zimmerman ', y
From: Lin McCartney )j
Subject: Analytical Result Report- WI050040, Charles Davis,
Geothermal Underground Injection Control Well, 5A7
Wake County
Aquifer Protection Section
1628 Mad Service Center, Raleigh, North Carolina 27699-k628
Locations 3800 Barrett Dr., Raleigh, North Carolina 27609
Phone: [phone] FAX: [phone] L Customer Service: 1-877.623-6748
Internet: www.nc,-waterquality.0re
An Equal Opportunity 1 Affirmative Action Employer
REDEIVEDIDENRIDWQ
APR 202012
Aquifer Protection Section
NorthCarolina
Naturally

ATA
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.200) except copper. The copper concentrations were 1,700 micro gram per
Iiter (ug/1) for influent and 2,200 ug/1 for effluent. These results indicate that the copper concentration
was elevated above the 2L Groundwater Quality Standard of 1,000 ug/1. 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 ug/1). 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,
Lin McCartney
Environmental Senior Tech
Cc: RRO-APS Files
The Central Office- APS Files
Aquifer Protection Section
1628 Mail Service Center, Raleigh, Norte Carolina 27699-1628
Location: 3800 Barrett Or., Raleigh, North Carolina 27609
Phone: [phone] i~AX: 919-571-47181 automat Service: 1-877-62.3-67a8
Internet: www,ricwaterqualify,org
An Equal Opportunity 1 Affirmative Action Employer
Car "Y7
ort
Ile
hCarolina
Natural!!!

Drt1)0 Laboratory Section 12eiur s
County: Wake
River Basin
Report To RROAP
Collector: L MCCARTNEY
Region: RRt]
Sample Matrix: WASTEWATER
Loc. Type: INFLUENT
Emergency Yes/No
COC Yes/No
12r,
VisitiD
Sample ID: AB80558
F W? rE.g PO Number it 12G0056
Date Received: 02/20/2012
Time Received: 12:45
Labworks LoginlD MSWiFT
Report Generated: 3/22112
Date Reported: 03/22/2012
Loc. Descr.: CHARLES DAVIS
Location ID: 5P092Wf0500040INF
Collect Date: 02/20/2012
Collect Time: 12:00
Sarnple Depth
CAS # Analyte Name
LAB
Sample temperature at receipt by lab
PQL
Result/
Qualifier
Units
2.8 °C
Method Analysis Validated by
Reference Date
2/20/12 DLEAVITT
MIC
Coliform, MF Fecal in liquid
1 132
CFU/100m1 APHA92220-20th 2/20/12 CGREEN
Coliform, MF Total in liquid
1 1 132
CFU/100m1 APHA92228-20th 2/20/12 CGREEN
WET
Ion Chromatography
TITLE mg/L EPA 300.0 2/27/12 CGREEN
Chloride
1.0 13 mg/L EPA 300.0 2/27/12 CGREEN
Fluoride 0.4 0.4 U mg/L EPA 300.0 2/27/12 CGREEN
Sulfate 2.0 2.0 U mg/L EPA 300.0 2/27/12 CGREEN
Total Dissolved Solids in liquid 12 64 mg/L APHA2540C-19TH 2/23/12 CGREEN
NUT
NQ2+NC3 as N in liquid
0.02 1.6
mgfL as N lac10-107-04.1-c 2/23f12 CGREEN
MET
7429-90.5 Al by ICP 50 50 U ug/L EPA 200.7 2/24/12 ESTAFFORD1
7440-70-2 Ca by ICP
0.10 1,4 mg/L EPA200.7 2/24/12 ESTAFFORD1
7440-47-3 Cr by ICPMS 10 10 U ug/L EPA 200.8 2/24/12 ESTAFFORD1
7440-50-8 Cu by ICPMS
2,0 1700 ug/L EPA 200.8 2/24/12 ESTAFFORD1
7439-89-6 Fe by ICP
50 50 U ug/L EPA 200.7 2/24/12 ESTAFFORD1
7440-09-7 K by ICP 0.10 0.98 mg/L EPA 200.7 2/24/12 ESTAFFORD1
7439-95-4 Mg by ICP
0.10 1.5 mg/L EPA 200.7 2/24/12 ESTAFFORD1
7439-96-5 Mn by ICP
10 30
ug/L
EPA200.7 2/24/12 ESTAFFORD1
7440-23-5 Na by ICP
0.10 11 mg/L EPA 200.7 2I24/12 ESTAFFORDI
7440-02-0 Ni by ICPMS 2.0
2,0 U ug/L EPA240.8 2/24112 ESTAFFORD1
7439-92-1 Pb by ICPMS
2.0 2.2
ug/L
EPA 200.8 2/24/12 ESTAFFORDI
7440.66-6 Zn by ICPMS 10 22 uglL EPA 200.8 2/24/12 ESTAFFORD1
Laboratory SectionN> 1623 Mail Service Center, Raleigh, NC 27699.1823 [phone]
For • detailed description osthe qu®Itrw codas refer to j•L{,te:Jjpgrtal,nµ}cnr,nrgJvf0/wstAahf,Rtlntot,14r,scolRgmi„r, lyi!gr• cedxp e.4rip•ji{pnal,,xprnrolden'iIY+Ad4ib1_=IlififnfNrecs•.siy :.
Page 1 of 1

GROUNDWATER FIELD/LAB FORM
Location code �o-2 i -25 be, C4C1'
County ` c- L e
Quad No Serial No.
I -at_ Long
Report To. ARO, FRO, MR0i WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other.
Shipped by: Bus. Courier, anri1, Other.
Collector(s): L (6 " F
FIELD ANALYSES
pH 490
SAMPLE TYPE
Water
❑ Soil
❑ Other
❑ Chain of Custody
Date '
_, E7
Spec. Cond.sa 7 2 at 25°C
Temp-10 /� i °C Odor ) 7 v r l ['
Appearance LI E.
Field Analysis By: - 1r11 L- (c- , f rk-s /
LABORATORY ANALYSES
BOO 310 mg/L
COO High 340 mgR
COO Law 335 rrtgR
Carom' irF Fecal 31616 11Oom1
Colirorm: MP Total 31504 r100m1
TOC 680 rIL
Turbidity 76 hTTU
Residue, Total Suspended 530 mg&
pH 403
units
Alkalinity to pH 4.5 410
m91L
Alkalinity to pH 8-3 415
mL
Carbonate 445
Bicarbonate 440
Carbon dioxide 405
Chloride 940
rngR
mgIL
SAMPLE PRIORITY
Routine
❑ Emergency
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALf Y-GROUNDWATER SECTION
7_C700
Lab Number
Date Receiv
Rec'd By: %
Other:
Data Entry By:
Date Reported:
4 ?D55
2-10 Time: i2.'45
From: Bus, Courier, a-ien3T31-,
Ck:
Purpos
Time j c% L\ 'Baseline, Complaint, Compliances LUST, Pesticide Study, Federal Trust, Other:
Owner Ch 6r/es Dow is [arcle one)
Location or Site 3 4 2 Td r=
J2ct eit, -] 6 s7
Description of sampling point e._I! f 1 e r-ci S
Sampling Method rc
Remarks C'u: , — Z*+ F 1 to �'" bailer CI:
Diss- Solids 70300
mglL
Fluoride 951
m glt-
Hardness: Total 900
mgfL
Hardness anon -carp} 902
mglL
Phenols 32730
u
Specific Cond. 95
µ4Mhoslcrn
Sulfate 945
mg1L
Sufliide 745
mg,IL
ON and Grease
rng1L
NH3 asN610
mgIL
x
T10H as N 625
NO2. NO, as N 630
P: Total as P 865
mg/I.
mglL
rnglL
Sample Interval
(Pumping lens. air :emp-, etc)
AgSilver 46566
AI-Alttminuun 46557
As -Arsenic 46551
Ba-barium 46558
Ca -Calcium 46552
Cd-Cadmium 46559
vy1L
ug/L
ug1L
u`
m9lL
)( Cr-Chromium 46559
Cu-Copper46582
U9 L
Fe -Iron 46563
Hy-lderzury 71900
K-Potassium 45555
uso-
uNL
y
x
Mg -Magnesium 46554
Mn-Manganese 45585
Na-Sodium 46556
Ni-Nickel
Pb-Lead 46554
Se -Selenium
mg1L
ug/L
mg1L
ug1L
ug/L
uL
Chromium: Hex 1032
Color. True 80
DO-
CU
Nitrate NO, as NI
Nitrite (NO3 as N 615
mgiL
mg1L
Cyanide 72U
mg&L
Zs nc 46567
ugll
Organoctdorine Pesticides
Organophospharus Pesticides
IGtrogen Pesticides
Acid Herbicides
PCBs
Semivoiatile Organics
TPH-oieset Rance
Volatile Organics (VOA bottler
TPH-Gasoline Range
TPH-BTEX Gamine Range
LAB USE ONLY
Temperature on arrival (' C): 2 t[ j
Lab Comments
GW54 REV, 7103 for Dissolved Analysis -submit Filtered sample and write'OLT in Hock

wr'sD:Wo Laboratory
County: Wake
River Basin
Report To RROAP
Collector: L MCCARTNEY
Region: RRO
Sample Matrix: WASTEWATER
Loc. Type: EFFLUENT
Emergency Yes/Na
COC Yes/No
J
VlsitrD
Loc. Descr.: CHARLES DAVtS
Sample iD: AB80557
PO Number # 12G0055
Date Received' 02/20/2012
Time Received: 12:45
Labworks LoginI❑ MSWIFT
Report Generated: 3/22/12
Date Reported: 03/22/2012
Location ID: 5P092W10500040_EFF Collect Date: 02120(2012
Collect Time: 12:30
Sample Depth
CAS #
LAB
Analyte Name
PCL
Result!
Qualifier
Sample temperature at receipt by lab 2.8
Units
Method Analysis Validated by
Reference Date
'C 2120r12 DLEAVIT r
MIC
Coliform, MF Fecal in liquid
1 1 B2
CFU/l00m1 APHA9222D-20th 2/20112 CGREEN
Coliform, MF Total in liquid
1 1B2
CFU1100m1 APHA92229-20th 2/20/12 CGREEN
WET
Ion Chromatography
_TITLE_ mg/L EPA 300.0 2/24/12 CGREEN
Chloride
1.0 14 mg/L EPA 300,0 2/24/12 CGREEN
Fluoride 0.4 0.4 U mg1L EPA 300.0 2/24112 CGREEN
Sulfate 2.0 2.0 U mg/L EPA 300.0 2/24/12 CGREEN
Total Dissolved Solids in liquid 12 62 mg/L AP•HA25IOC-18TH 2/23/12 CGREEN
NUT
NO2-1-NO3 as N in liquid
0.02 1.6
mg/L as N Lac10-107-04-1-c 2/23/12 CGREEN
MET
7429-90-5 Ai by ICP 50 50 U
ug1L
EPA 200.7 2/24/12 ESTAFFORD1
7440.70-2 Ca by iCl
0.10 1.4 mg/L EPA 200.7 2/24/12 ESTAFFORD1
7440-47-3 Cr by ICPMS
10 10 U ug/L
EPA200.8 2/24/12 ESTAFFORD1
7440-50-8 Cu by ICPMS 2.0 2200 ug/L
EPA200.8 2/24/12 ESTAFFORD1
7439-89-6 Fe by !CP 50 50 U ug/L EPA200.7 2/24/12 ESTAFFORD1
7440-09-7 K by ICP
0.10 0.97 mg/L EPA 200.7 2/24/12 ESTAFFORD1
7439-95-4 Mg by ICP
0.10 1.5
m g/L
EPA200.7 2/24/12 ESTAFFORD1
7439-96-5 Mn by 1CP 10 32 ug/L EPA200.7 2/24/12 ESTAFFORD1
7440-23-5 Na by ICP
0,10 11 mg/L EPA 200.7 2/24/12 ESTAFFORD1
7440-02-0 NI by ICPMS
2,0 2.7 ug/L EPA200.8 2/24/12 ESTAFFORD1
7439-92-1 Pb by ICPMS
2.0 2.9
ug/L
EPA 200.8 2/24112 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 33 ug1L EPA 200.8 2/24/12 ESTAFFORD1
Laboratory Section» 1623 Man Service Center, Raleigh, NC 27699-1023 [phone]
rot a dalaiied description of the e-'ariiler codes refer to JJr1 ytilJ,nrdtnr.nrglwgtrlwylLtih.'z10ii llkrnnFsi51k41jgt7,gUifip± nsfr. 13ep'jf ilal,,gykr,etiOateim _PatOrsrl7nr jie.rifnp+rss:•
Page 1 of 1

GROUNDWATER FIELD/LAB FORM
Location code
Wake_
County
W L L,,) 1520040
Quad No Serial No.
Lat. Long.
Report To: ARO, FRO, MRO RRO WaRO, WiRO,
WSRO, lGnston FO, Fed. Trust, Central Off., Other.
Shipped by: Bus, Courier. , Other,
SAMPLE TYPE SAMPLE PRIORITY
lg Water vl Routine
D Soii D Emergency
0 Other
❑ Chain of Custody
Coliectoris): L 171 rCar ..-t e y Date
FIELD ANALYSES
pH 400 4 ' Spec.
Temp.lu d/ .3 °C Odor
Appearance r f k cci
Field Analysis By: C. 1-7'1. t C
LABORATORY ANALYSES
Cond.w 6 l
r1 e
BOO 310 ntglL
COD Figh 340 mg&L
COO Low 335 mgR
x
Colirorm: MF Fecal 31616 1100ml
Coliiorm: MF Taral 31504 1100ml
TOC 680 mglL
Turbidity 76 NTU
Residue, Total Suspended 530 malt_
pit403 units
Alkalinity to pH 4.5 410 mgrL
Alkalinitylo pH 8.3415 myL
Carbonate 445 mgR
Bicarbonate 440 mg&L
Carbon dioxide 405 mgli
Purpose: p rv►
Time i 3 G/ 8aseiine, Complaint,Compliarira'/ LUST, Pesticide Study, Federal Trust, Other:
owner C.i•cr) I?S De-NA!'S ldrrSe9r'e]
at 25°C Location or Site r/ 4 d e 12ck "1, AJ C- 31 o e i]
Description of sampling point ....deg
Sampling Method C. rc"- J
Remarks ,
3)L ilt _6f f i0umo.Bader.Bit,
i
North Carolina
Department of Environment and Natural Resources
DMSICN OF WATER QUALITY -GROUNDWATER SECTION
Lab Number
Date Received
Rec'd By:
Other.
Data Entry By:
i] cJ y � - EEFfJei4Date Reported:
Ck:
Dias. Solids 70300
mL
Fluoride 951
nrglL
Hardness- Total 900
mglL
Hardness (non-carb) 902
mglL
Phenols 32730
u9
Specific Cond. 95
pMhoslem
Sulfate 945
mglL
Sulfide 745
mglL
Oil and Grease
mglL
NH3 asN610
mg
TKN as N 625
mgfL
NO= + NO, as N 630
mad_
Chloride 940 rrtglL
Chromium: Hex 1032 uglL
Color. True 80 CU
P: Total as P 665
mgrL
Nitrate (NO1 as N) 620
myL
Nitrite (NO2 as N) 615
mglL
Cyanide 720 mg .
Lab Comments
Sample Interval
umpirrg tone, air temp„ elm.)
Ag-SiImr 46566
ugR
4
Al -Aluminum 46557
1-
As -Arsenic 46551
Be -Barium 46558
y
Ca -Calcium 46552
mg&
Cd-Cadmium 46559
fkil-
X
Cr-Chromium 46559
ugiL
y[
Cu-Capper 46562
ugJL
ye
Fe -Iron 46563
41
fig -Mercury 71900
1-1911-
y
_K-Potassium 46555
rnO.
)t
Mg -Magnesium 46554
L
X
Mn-Manganese 46565
will.
j(
Na-Sodium 46556
frltit-
,g
N1i-N iickel
mil
Pb-Lead 46564
' in-
SeSelenium
DWI-
h(
Zn-Zinc 46567
ugiL
Organochtorine Pesticides
Organc'hosphorus Pesticides
Nitrogen Pesticides
Add Herbicides
PC9s -
Semivoiatlle Organics _
TPF+Diesel Range
Volatile Organics (VOA batUe)
TPH-Gasoline Range
TPH-STEX Gasoline Range
LAB USE ONLY
5i
Temperature on arrival (°C):
GW-54 REV. 7I03
For Dissolved Analysis -submit filtered sample and write •OtS' in block.

Permit Number WIO5OOO4O
Cenfiii Files: APS SWP
03/13/12
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Status Project Type
Active Renewal
Version Permit Classification
3.00 Individual
Primary Reviewer Permit Contact Affiliation
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Charles and Gwendolyn Davis SFR
Location Address
1422 Ridge Rd
Raleigh NC 27607
Owner
MaJorlMlnor Region
Minor Raleigh
County
Wake
Facility Contact Affiliation
Owner Name Owner Type
individual
Charles Alfred Davis Owner Affiliation
Charles Alfred Davis
Dates/Events
1422 Ridge Rd
Raleigh
NC 27607
Scheduled
Oriq Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
04/26/02 01/24/12 03/09/12 03/09/12 02/28/17
Regulated Activities
Heat Pump Injection
Outfall NULL
Requested/Received Events
Additional information requested 01/27/12
Additional information received 02/07/12
RO staff report requested 02/13/12
RO staff report received 02/24/12
Waterbody Name Stream Index Number Current Claes Subbasin

ATA,
Ribm
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
March 9, 2012
Charles and Gwendolyn Davis
1422 Ridge Rd.
Raleigh, NC 27607
Re: Issuance of Injection Well Permit
Permit No. W19500040
Issued to Charles and Gwendolyn Davis
Wake County
Dear Mr. and Mrs. Davis:
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 system located at the above referenced addres. 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. (Nl.. & FL)
Environmental Specialist
cc: Jay Zimmerman, Raleigh Regional Office
Central Office File, W10500040
Wake County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location' 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone [phone] FAX: [phone]
Internet www.ncwatergoalitv.oro
An Equal Oppaquni y 1 Affirmative Action Employer
One
NorthCarolina
Vat1ira/IM

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 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, 2012, all of which are filed with the Department of
Environment and Natural Resources and are considered a part of this permit.
This permit is for operation of an injection well shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until 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 q day off 2012.
434;ka
Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #Wi0500040
UIC/5A7
per. 03J2010
Page l of 5

... , r. , .... -, . ._. • .. ~ ... ~ . .
PARTI -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 ~njection Wells (l SA NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North-Carolina Well Construction Act and· is
grounds for enforcement action as provided for in N.C ■-G.S. 87-94.
2. This perm.it 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.
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 duri~g construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
PART II -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice t9, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Perm.ittee, a formal 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 ina degrading of water quality of the aquifer.
PART III -PERFORMANCE ST AND ARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
Permit #WI0500040 UIC/SA7 Page 2 of 5
ver. 03/2010
facility fails·· to p·erf orm satisfactorily, including the creation of nuisance conditions or failur~ 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 rep~r,
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
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
PART V -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and 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 ground~ater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART 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 report~g 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 nwnber 919-791-4200, any of the following:
(A) Ariy 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;
P~rmit #WI0500040 UIC/SA7
ver. 03/2010
Page 3 of 5
3. ~ere the Permittee becomes aware of ari omission of apy relevant facts in a permit application, or of any
incorrect information submitted in said application or fo 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 talce such
immediate action as may be required by th.e Director.
PART VII -PERMIT RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
PART VIII-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. · If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to ISA NCAC 2C .0213(h)(l), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordanc-e 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 inay 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, tl\.e casing shall ~e 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 #WI0S00040 UIC/SA7
ver. 03/2010
Page 4 of 5
(G) The Permittee shall submit a Well Abandonment Record (Form GW.:.30)'~· specified in
ISA NC~C 2C .. 02J3(h)(l) within .. 30 days of completion of abandonment. · ..
· 3. The written documentation required in Part VIII (I) and (2) (G) shall be submitted to:
Permit #WI0S00040
Aquifer Protection Section-VIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/SA7
ver. 03/2010
Page 5 of S
Permit Number WI0500040
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Charles and Gwendolyn Davis SFR
Location Address
1422 Ridge Rd
Raleigh
Owner
Owner Name
Charles
Dates/Events
NC 27607
Alfred Davis
Scheduled
Orig Issue
04/26/02
App Received Draft Initiated Issuance
01/24/12
Central Files: APS_ SWP_
03/09/12
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Charles Alfred Davis
1422 Ridge Rd
Raleigh NC 27607
Public Notice Issue Effective Expiration
Regulated Activities Re uested/Received Events --=-------------------------
Heat Pump Injection Additional information requested
Outfall , ULL
Waterbody Name
Additional information received
RO staff report requested
RO staff report received
Stream Index Number Current Class
01/27/12
02/07/12
02/13/12
02/24/12
Subbasin
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: February 21, 2012
To: Aquifer Protection Central Office
Central Office Reviewer: Michael Rogers
Regional Login No: __ _
L GENERAL INFORMATION
1. This application is (check all that apply): D New IZ! Renewal
County: Wake
Permittee: Charles Davis
P:1~oject Name: Iniection 5A 7 Well
Application No.: WI0500040
· D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation IZ! Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ~ Yes or D 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: IZ! Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
)
1
J ,
IZ! Yes or D No. Ifno, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities: -.. -
a. Location: (
T
r.,t (
b. Driving Directions: __ ..... , ('Tl
( )
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Disposal and Injection Sites:
(If multiple sites either indicate which sites the information applies to, copy and paste a new section into the
document for each site~ or attach additional pages for each site)
a. Location(s): .1422 Ridge Road, Raleigh, NC 27607
b. Driving Directions: Take 440 W , take Wade Ave. exit turn left, tum left onto Ridge rd.
c. USGS Quadrangle Map name and number:
d. Latitude: 35-48-23 Longitude: 78-41-9
IL NEW AND MAJOR MODIFICATION APPLICATIONS {this section not needed for renewals or minor
modifications, skip to next section)
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
2. Are the new treatment facilities adequate for the type of waste and disposal system?
FORM: Staff.Repor-tCharles Davis
AQUIFER PROTECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection. wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well{S) And Facilities-New, Renewal, And Modification
1. Type· of injection system:
!ZI Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (5QM/5QW)
D In -situ remediation (SI)
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge'')
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes ~ No
3. Are there any potential pollution sources that may affect injection?~ Yes D No
What is/are the pollution source(s)? The septic tank. The septic tank is approximately 100 feet distance from
the well.
4. What is the minimum distance of proposed injection wells from the property boundary? 2511
5. Quality of drainage at site: cgj Good D Adequate D Poor
6. Flooding potential of site: rgj Low D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: N/ A
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? cgj Yes or D No. If
no or no map, please attach a sketch of the site. Show property: boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Iniection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes cgj 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? D Yes D No. Ifyes, 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? D Yes D 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? D 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 recomme11d to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
FORM: Staff.Repor-tCharles Davis 5
AQUIFER PROTECTION REGIONAL STAFF REPORT
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information; ~
Issue; D Deny. If deny, please state reasons: __
8. Signature of report preparer(s ): /:: i Y\ ¥Y\ (CAd-1'\: {J
Signature of APS regional supervisor: 0(11 L---
Date: 4 w/z,o /V {
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 are awaiting the lab results of the well water to complete this application process.
FORM: Staff.Repor-tCharles Davis 6
Compliance Inspection Report
Effective: 05/14/07 Expiration: 04/30/12 Owner: Charles A Davis Permit: WI0500040
SOC: Effective: Expiration: Facility: Charles and Gwendolyn Davis SFR
County: Wake
Region: Raleigh
Contact Person: Gwendolyn P Davis
Directions to Facllity:
Title:
1422 Ridge Rd
Raleigh NC 27607
Phone:
From 1440, Exit Ridge Rd at Glenwood Ave. and go south appx 2 miles. Property is on left.
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representatlve(s):
Related Permits:
Inspection Date: 02/20/2012
Primary Inspector: Lin McCartney
Secondary lnspector(s):
Certification:
Entry Time: 12:00 PM Exit Ti'11e: 01 :00 PM
Phol',le:
Phone: [phone]
Ext.4243
Reason for Inspection: Routine Inspection· Type: Compliance Sampling
Permit Inspection Type: Injection Heating/Cooling Water Return Well (5A7)
Facility Status: ■ Compliant D Not Compliant
Question Areas:
■Wells ■ System Operations
(See attachment summary)
Page: 1
Permit: WI0500040
Inspection Date: 02/20/2012
Owner -Faclllty: Charles A Davis
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 owner/operator noticed any abnormalities (turbidity, air in system, poor heating/cooling, etc) in
system operation?
Comment'on system operation
Is system operation and construction consistent with that described in application?
Describe inconsistencies between application and observed operation/construction
Comment:
Yes No NA. N~
■DOD
•□□□
■DOD
■DOD
•□□□
Page: 2
AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: February 13, 2012
To: ❑ Landon Davidson, ARO-APS ❑ David May, WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Morelia Sanchez King, WiRO-APS
❑ Andrew Pitner, MRO-APS ❑ Sherri Knight, W-SRO-APS
® Jay Zimmerman, RRO-APS
From: Michael Rovers Groundwater Protection Unit
Telephone: [phone]
E-Mail: Michael.RogersL ncdenr.gav
Fax: [phone]
A. Permit Number: WI 0500040
B. Owner: Charles and Gwendol►n Davis
C. Facility/Operation: -
❑ Proposed ® Existing
❑ Facility n Operation
D. Application:
1. 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 0 Surface Disposal
❑ 503 ❑ 503 Exempt 0 Animal
2. Project Type: ❑ New ❑ Major Mod. ❑ Minor Mod. ® Renewal ❑ Renewal w/ Mod.
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-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
- fisted above.
RQ APS Reviewer
FOR% APSARR 07106
Paget of 1
Date:

Rogers, Michael
From: Rogers, Michael
Sent:
To:
Tuesday, February 07, 2012 10:24 AM
'[e-mail]'
Subject:
Attachments:
Mr. Davis-
FW: WI0500040 Davis
20010527004854152.pdf
We received the renewal application for your geothermal w~ll. 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 updat~s 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/wq/aps/gwpro/permit-applications#geothermApps
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:[e-mail]]
Sent: Sunday, May 27, 2001 12:49 AM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0 11 (Aficio 2075).
Scan Date: 05.27.2001 00:48:54 (-0400)
Queries to: [e-mail]
1
ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water.Quality
Beverly Eaves Perdue
Governor
Charles Davis
Gwendolyn Davis
1422 Ridge Road
Raleigh, NC 27607
Dear Mr. and Mrs. Davis:
Charles Wakild,.P.E.
Director
February~; 2012
Subject:
Dee Freeman
Secretary
Acknowledgement of
Application No. WI0500040
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 b~en 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, arid · may contact you with a request. for additional information. -To ensure maximum
efficiency in processing p~rmit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additi~nal information requests.
Please note that processing standard review_permit applications may take as long as 60 to· 90 days
after . receipt -of . a complete application. If you have any questions; please contact
Michael Rogers at [phone] or [e-mail].
Sincerely,
,n~A•.~
for oWraJ: Watts
cc: · Raleigh Regional Office, Aquifer Protection Section
Permit File WI0500040
AQUIFER PROTECTION SECTION
1636 Mail Seivice Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: 919-807~496
Internet www.ncwaterguality.org :
An Equal Opportunity \ Affirmative Actlon Employer
Groundwater Protection Unit-Supervisor
.::One:.:: .. : .... : ..
N~. o .: ··Carolina :.:; :·: · iitlittt/A:: ................ ,
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
(check one) New Application 4.1/ 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 Applications Will Be Returned .As Incomplete.
DATE: Fie..1nrva-v-y 4 . 20
PERMIT NO. \1g A jr b0 0 kp (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: individual Residence 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:
�- *A-V L.S.5 �4 �. 12 t I -i fly L i
"GGSiFt�DD LY'ts Ck, LE I k..v-e_ 44 Ls
Mailing Address: L'612- RCPiV'�
City: terif State: ?` dip Code: . i4i,' County:
Day Tele No.:
EMAIL Address:
�" 3r -- -(V Z - O t tz-- Cell No.:
c.ors 8 R •Z dot 1pcG. ) x No.:
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: County: 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: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No,: Ce11 No.: Fax No.:
GPU/UIC 5A7 Permit Application (Revised 3/1 not t) Page I

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) ' --.: ~ ~ J.< ~•:' $;;:;_
Company Name: ___________________ ~------------._..,. r,,.
Contact Person-'--: ______________ _____,cE=MAc.....=..=I=L"""'A-=-d=d=r-""es=s-'--: _·' __ j ___ •.:_':_~-----
Address: __________________________________ _
City: Zip Code: ____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: -------------------~---------
F. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES __ _ NO ___ _
YES ___ _ NO ___ _
G. WELL CONSTRUCTION DATA
(1)
____ 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 (1) through (6)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
G W-1) if available.
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 __ ,. B~ntoni!e* -----1 · OtJ;le{ (sp_ecify) _______ _
*By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(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 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-1). If Form GW-1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment 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.
GPU/UIC 5A7 Permit Application (Revised 3/18/2011) Page 2
H. OPERATING DATA
(1) Injection Rate: Average {daily) gallons per minute (gpin).
.....
(2) Injection Volume: Average { daily} · gallons pefday (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
I. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) 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)
• • f, ., • ·: ; ·:
Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name. . . " '' ~
NOTE: I~ mo~t ~dses, a'-n ;~,eriai'photograph ~f ih; ~roperty parcel showing property lines and structures can be
obtained and downloaded from the applicable county GJS website. -Typically, tlie property ca,i be searched by
owner name or address. The location of the well$ in relation to property boundaries, houses, ·septic tanks, other
wells, etc. can then be drawn in hy _h,and. Also, a .'layer' can be selected showing topographic -contours or
elevation data.' · ·· ·• ' · · ;· .·-' ·:. ·~ · · ... , · ·
GPU/UIC 5A 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;
?. 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.
"1 hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, 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 Otwner/Applicant
0—:2- L A :A
Print or Type Full Name
Signature of Pro rty Owner/Applicant
Print or Type FuII 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]
GPUIUIC 5 A7 Permit Application (Revised 3/18/20 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: W 005 b d p 4"-a
Permittee Name: C R1-- S 1)-4*
L S
Address: j422- 12[- rr- 123) , m- 021fo a7
Please check the selection which most closely describes the current status of your injection well system:
1) 'Well(s) still used for injection activities, or may be in the future.
2) ❑ Well(s) not used for injection but islare used for water supply or other purposes.
3) E Injection discontinued and: a) E 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 a description of how the well
was sealed and the type of material used to, ill the well if permanently 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."
021?--
Signature rate
Revised 5/05 GWIIJIC-68
RECEIVED 1 DENR WQ
Aquifer Protection Simon
JAN 2 4 RECD 000..

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 • ' harge groundwater directly into the subsurface ats part of a geothermal heating and coolin - , ystcm
(check on
New Application Renewal* Modific
ton
* For renewals complete Parts A-C and the . gnature page.
Pr nt or Type Information an Wail to the Address on the Last Page. Illegible Applications Will Be R turned As Incomplete.
DATE: o.w." 20 i-
PERMIT NO. )T € DQ $ (leave blank if New Application)
A. STATUS OF APPLICANT (cho se one)
Non -Government: Individual - sidence Business/Orga tzation
Government: State Municipal County Federal
//
B. PERMIT APPLICANT - For individual res ences, list eacl owner on property deed. For all others,
state name of entityand name ofperson delegated a • thori to -
g ty gm on behalf of the business or agency:
C--Of-Pk-CZ- S ftt- ja. de, ca C � r7.S tic LL6 t t� � + - ` -U 15
I
Mailing Address: 1` .2- 2 123
City: �[-. L /. C.,- t - State: ip Code ') County: Co_ k P
Day Tele No.: I � -''� 6 .1 -- K c 1
EMAIL Address:
Lba�sJts
Cell No
h u-+ Fax No.:
C. LOCATION OF WELL SITE --- Whe the injection wells are physically loca
(1) Parcel Identification Numb (PIN) of well site: Z
(2) Physical Address (if diffi
City:
County a�.
ent than mailing address):
D. WELL DRILLER INS ORMATION
Well Drilling Contractor's Name:
NC Well Drillin
Company Na
Contact Pey§on:
Address:'
City. Zip Code: State: County:
State: NC Zip Cod `EGEJV DNFt r,
Acp ar Pro(- ion Sect+an
JAN 24
Contractor Certification No.:
EMAIL Address:
Office Tele No.: Cell No.: Fax No.:
GPUMC 5A7 Permit Application (Revised 3/181Z011)
Page 1

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
F.
Company Name: _________________________________ _
Contact Person_: ________________ E_M_A_IL_A_d_dr_e_s_s: ___________ _
Address:-----------------------------------
City: _________ Zip Code: _____ State: __ County:
Office Tele No.: Cell No.: Fax No.: ------------------------------
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
G. WELL CONSTRUCTION DATA
(1)
____ 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 (1) through (6)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
G W -1) if available.
Well Construction Date: ________ Number of borings:
Depth of each boring (feet): _______ _
(2) Well casing type: Galvanized steel __ Black steel __ Plastic __ Other (specify) _____ _
(3)
(4)
(5)
Casing thickness (in.): __ Diameter (in.): __ _
Well depth: from: ___ to: ___ feet below land surface
Casing extends above ground ____ inches
Grout material surrounding well casing:
(a) Grout type: Cement__ Bentonite* Other (specify) ______ _
*By selecting bentonite grout, a variance is hereby requested to ISA NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from ___ to ___ feet
Well Screen or Open Borehole depth (relative to land surface): from _____ to ____ feet
N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make prov1s1ons 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 rock/sediment 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.
GPU/UIC SA 7 Permit Application (Revised 3/18/2011) Page2
H. OPERATING DATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average ( daily) gallons per day (gpd).
(3) Injection Pressure: Average ( daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
I. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
( 1) 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 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property 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.
GPU/UIC 5A7 Permit Application (Revised 3/18/2011) ' Page3
J. CERT1i;:1cATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021 l{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/UIC 5A 7 Permit Application (Revised 3/18/2011) Page4
A.7A
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Charles A. Davis
1422 Ridge Road
Raleigh, NC 27607
Division of Water Quality
Coleen H. Sullins Dee Freeman
Director Secretary
December 2, 2011
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WI0500040
Wake County
Dear Mr. Davis:
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 due 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 Currently 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, Section .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 httn:llPortal.ncdenr.ore/weblwglans/c-wnrolrenortim-forms.
If Your Infection 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 permit renewal by Januars 1. 2012.
AQUIFER PROTECTION SECTION
16636 Mail Service Center. Raleigh. North Carolina 27699-163E
Location: 272E Capital Boulevard. Raleigh, North Carolina 27604
Phone: 91S-733-3221 I FAX [phone]B; FAX 2: 919-715- 04 Customer Seroice 1-677-23-674L
Internet www.ncwateroualitv.oro
An Fqudf trpconunin Affirmative Action. Employe,
_One
Nei/MI/if
4

In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title ISA, Subchapter 2C, Section .0211, you must submit one of the following
enclosed forms:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for Injection with
Geothermal Heat Pump System for Type 5A7 Well(s) if the injection well system on your
property is still active.
-OR-
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
httu ://p ortal.ncdenr.orrr/web/wq/aos/2:wpro/p em1it-applications#2:eothermApos.
Thank you in advance for your cooperation and timely response. If you have any qu_estions,
please contact me by phone at [phone] or by email at e1ic.Q.smith<@ncdenr.gov.
Sincerely,
/1 ( ~-. j Jt{t:-{11'"-s/J ~
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Raleigh Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0500040 w/o enclosures
2
Permit Number W10500040
Central Files: APS SWP
05/24/07
Permit Tracking Slip
Program Category
Ground Water
Status Project Type
In review Renewal
Permit Type Version Permit Classification
Injection Heating/Cooling Water Return Weil (5A7) Individual
' Primary Reviewer
michael.rogers
Permitted Flow
Facility
Facility Name
Charles and Gwendolyn Dads SFR
Permit Contact Affiliation
Gwendolyn Davis
1422 Ridge Rd
Raleigh
Major/Minor Region
Minor Raleigh
Location Address County
1422 Ridge Rd Wake
Raleigh NC 27607
Owner
Facility Contact Affiliation
NC 27607
Owner Name
Charles
Dates/Events
Owner Type
Individual
A Davis Owner Affiliation
Charles
1422 Ridge Rd
Raleigh
Davis
NC 27607
Orig Issue App Received Draft Initiated
04/26/02 02/27/07
Scheduled
Issuance
Public Notice Issue Effective Expiration
Regulated Activities Requested/Received Events
Heat Pump Injection RO staff report received 02/14/07
Additional information received 04/24/07
Outfall NULL
Waterbody Name Stream Index Number
Current Class Subbasin

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alen 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 Permit
Permit No. WI0500040
Issued to Charles and Gwendolyn Davis
Dear Mr. and Mrs. Davis:
In accordance with your signed application received February 27, 2007, I am forwarding Permit
No. WI0500040 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,
4/1"-e2c4)
Michael Rogers
Environmental Specialist 11
CPU - UIC Control Program
cc: Jay Zimmerman - Raleigh Regional Office
Central Office File
Attachments)
N Carolina
Naaturally
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone! [phone]
Internet htin:liwww.ncwaterconliry org 2728 Capital Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal Opportunity/Affirmative Action Employer- 50% Recycled/10% Post Consumer Paper Customer Service: [phone]

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 AND GWENDOLYN DA VIS
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 the2~ day of ~-. , 2007.
~2:),~
~ Alan W. Klimek, Director
~ Division of Water Quality
By Authority of the Environmental Management Commission.
WI0500040 Page 2
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions.of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (l SA NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each inJection well shall not hydraulically 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 acces.s 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.
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection
well to, DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1636
Mail Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well
construc.tion;
PART II -OPERATION AND USE GENERALCONQ.ITIONS
1. This permit is effective only with respect to the nature, volume of materials. and rate of
injection, as described in the application and other supporting ·data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior tq 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 perm.it does not imply that all regulatory requirements have been met.
WIOS00040 Page 3
PART III -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater, 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 inclu4ing 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 -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.
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.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
WI0500040 Page4
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed
necessary by the Divi_sion 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 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 ~lectrical
failures.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report to
the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
PART VII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART VIII-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the 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)(l), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
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)(l) within 30 days of completion
of abandonment.
3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
WI0500040
Aquifer Protection Section-DIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Page6
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RENEW AL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM
Type 5A7 and SQM Wells
In accordance with the provisions QfNCAC Title 15A: 02C.0200
complete application and mail to address on the back page.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: Fe/Jn,1 .uy -<~ , 201J J I __,_ __ _
A. PERMIT APPLICANT
Permit Number: fl(rb!>OO£>'f-o (WIO######, listed at the bottom of each page of your permit)
Name: Cltarfes. /4 ?Id li1JX-11.dio 7·11 P.. 7>ct"lrs
Address: /'f-~ Rf~? f(4'a(.<£·
city: Rtd'w,!t,
7
State: i./C Zip code:~~7_~G_O_J ___ _
County: 'N~ Telephone: qrq ( 1J;~-CJ!( JJ
I
B. PROPERTY OWNER (if different from applicant)
Name: S~
Address: _____________________________ _
City: _______________ State: __ _ Zip code: ______ _
County: ___________ Telephone: ______________ _
C. STATUS OF APPLICANT
Private: ~X _________ 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: __ ?jc__,__a,,, ____________________ _
Address: _____________________________ _
City: _______________ State: __ _ Zip code: ______ _
County: ___________ Telephone: ______________ _
Contact Person: ~1 __________________________ _
Standard Industrial Code(s) which describe commercial facility: ____________ _
Revised 7 /06 GW/UIC-57 HPR
RECEIVED' DENR / owa
AQUlr-J:R'PRn~r.rrnN SF=CTION
Page 1 of 3
, ,
E.
F.
G.
H.
I.
J.
K.
L.
INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
1.i1 ,,;1y c1.txJ", ree k.uc/_ f Vfft.f M#!c ¾f-rl~ l:L jfrY"I ~'b~;u~ /t:,Jtlf> -l-'v1cit~r,
1,~/ r'' r->'le. d.rr;t p r~;) 1G~' 1t1?j;2Jtoh sl/J,, ~r~
WELL USE I~( ~e )_ the inject~on well( s) also used as the supply well( s) for either of th7 following?
1
• , _ ;· _ r
(1) The mJectionoperati<;m? YES_K_ NO__ friJV1th..:s. .hedt1t.:r:r:..tc~o '11.J
(2) Your personal consumption? YES_ NO..JL_ •fm--re~~ca...,
CONSTRUCTION DATA
(1)
(2)
Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection permit.
1~
NC. State Regulations (15A NCAC, 2C, Section .0200) require the 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-4-NO __
(b) on the effluent line? YES~ NO __
CURRENT OPERATING DATA
(1) Injection rate: Average (daily) i :2.., gallons per minute (gpm)
(2) Injection volume: Average (daily) .,!'a) gallons per day (gpd)
(3) Injection pressure: Average (daily) /-c; pounds per square inch (psi)
(4) Injection temperature: Annual Average ~ degrees Fahrenheit (°F)~;) Gt3 'I •S ')
INJECTION-RELATED EQUIPMENT -,(<J ~J/Eeft~ "f
Attach a diagram showing any modificatio~)~ to injecti<n. equipment 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 ,3 ~ ~~
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.
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: ~~ .J _ _1
(1) Hazardous Waste Management program permits under RCRA ~
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits ·
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.
f(p·~~~
' Revised 7 /06 GW/UIC-57 HPR Page 2 of 3
M. CERTIFICATION
"I hereby certify, under penally 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. 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 the approved specifications and conditions of the Permit "
(Signature of Wei Owner or Authorized Agent)
If 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 nghrs in the
well(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 15A N'CAC
Subchapter 2C .0200)
(Signature of Property Owner if Different From Applicant)
Please return the completed Application package to:
UTC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Revised 7/06 GW/UIC-57 HPR 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
PERMISSIQN 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 welt 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 der-
day of i
, 2002.
ed L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. W10500040 PAGE 1 OF 6
Ver.3ICI 1 GWfUIC-5

North Carolina Department of Environment and Natural Resources
Division of Water Quality -Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTIC
REPORT -FORM A
INJECTION WELL PERMIT NO. WI DATE / p 4.
NAME OF OWNER
ADDRESS OF OWNER - -r
-4 .
•
•-. -
(Strati road or lot and suddivision, county. town)
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable) (,o
L—r• a 1. •- / C'r
IG•-
(Street/ road or lot and suddtviston , county. town. tfdierent than owner's address, description
Potential pollution source
Potential pollution source
Potential pollution source
Distance from well
Distance from Well ''D
Distance from well
Minimum distance of proposed well from property boundary bD
Quality of drainage at si
adequate poor)
Flooding potential of site
(high.moder'.low)I
DRAW SKETCH OF SITE
pFw.ern boundarses, buildings, wells, potentialpollurron sowerces, roads. approximate scale, anti north arrnn
sp
f
:, �„ • .•

PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cont.)
COMMENTS
•
• -%„(- 'am •� +. 4-
/ �I �7JJJN
ei
INSPECTOR
Office if: -
WITNESS
Address
WITNESS
Address

-Page 1 of~
North Carolina Department of Environment and Natural Resources
Division of \Vater Quality-Groundwater Section
•` 7 .i$ Gaw r
T, - Cary
BOWMAN MECHAN1cAL SERVICE*
1219 Sturdivant drive
Carat, NC 27511
High Eifivioncy I IVAC • Geothermal
I Ij
5e)
FAX (919)7_7 ^•
t �C
AY,rL t.t r r J -
ctiC
atsc',^ a /
f � tr.,/ el

/4/1,&-) ilec.r.R g/ap.
User: Wilcox, Betty
NC Natural Res and Env Health
Date: 04/24/2007 Time: 10;43
Sample: A813188 Loc Code: RRQAPNLC Samp Descr: MR. CHARLES DAVIS Lag 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
Sarni) Colct: J GREER P.O, Numbr: 7G0062 Proj Code: ---
Page: 1
Ant Code 'Analysis Name
PRNO2N_LTQ Peer Review for Nitrite as N In liquid_
PRCOLIFFECMF LIQ Peer Review for Coliform_MF Fecal In II
PRCOLIFTOTMF LIQ _
PRCHLORIDE_LIQ
PRNH3N_LIQ
PRNO2&NO3_LIQ
PRNO3N_LIQ
PRSULFATE_LIQ
PRPHOSTOTP_LIQ
PRTDS_LIQ
PRTKNN_LIQ
COLIFFECMF_LIQ
COLIFTOTMF_LiQ
$ALK45 LIQ
PRALK45_LIQ
CHLORIDE_ IQ
TDS LIQ
SULFATE_LIQ
NH3N_LIQ
NO2&NO3_LIQ
TXNN_LIQ
PHOSTOT'P LIQ
CD_LIQ
PR CD
CHROMIUM_LIQ
PR_CHROMIUM
CU_LIQ
PRCU
N1_LIQ
PR_NI
PB LIQ
PR'-PB
ZNJ1Q PR_ZN
AL_LIQ
PR_AS
AL_LIQ
PR_AL
l+E_UQ
PR FE
MG_LIQ
PR_MG
MN_LIQ
PR MN
NA_LIQ
PR_ZA
CA_LIQ
PR CA
Peer Review for Conform_ MF Total In II
Peer Review for Chloride In liquid
Peer Review for NH3 as N In liquid
Peer Review for NO2+NO3 as N In liquid
Peer Review for Nitrate as N In Ilquld
Peer Review for Sulfate In liquid
Peer Review for Phosphorus, total as P i
Peer Review for TDS in llquld.
Peer Review for Total Kjeldahl N as N I
Coliform, MF Fecal in liquid
Conform, MF Total In Iiquld
Alkalinity to pH 4.5 of liquid
Peer Review for Alkalinity to pH 4.5 of
;Chloride In liquid
Total Dissolved Solids In liquid
Sulfate In liquid
NH3 as N In liquid
NO2+NO3 as N in liquid_
Total kjeldahl N as N In liquid
Phosphorus_total as P In liquid
Cd by ICPMS _
Peer Review Cd
Cr by ICPMS
Peer Review Cr
Cu by ICPMS
Peer Review Cu
Ni by ICPMS
Peer Review Ni
Pb by ICPMS
Peer Review Pb
Zn by ICP
Peer Review Zn
Un
; CFU/100rnI
CFU/100m1
Result
MO
DEO
DEO
mg/L , IAS
MO
GB
MD
mg/L 3AS
MO
mg/L M I
MA
1
1
mg/L as CaCO3 Complete
LB
mg/L 18
64
2.0
0.02
1,9
,0.20
CFU/100m1
CFU/100ml
mg/L
mg/L
mg/L as N
mg/L as N
mg/L as N
mg/L as P
ugJL
ug/L
ug/L
ug/L
As by ICPMS
Peer Review As
AI by ICP
Peer Review AI
Fe by ICP
Peer Review Fe
ug/L
ug/L
0,02
1.0
ES
10
ES
420
ES
35
IES
10
E5
19
ug/L
ug/L
ug/L
Mg by ICP
Peer Review Mg
Mn by ICPMS
'Peer Review Mn
_ _ 1NabyICP
Peer Review Na
Ca by ICP -
Peer Review Ca
g/L
ug/L
mg/L
5.0
ES
50
DS
ISO
DS
DS
38
DS
12
DS
1,6
Ds

User: Wilcox, Betty
NC Natural Res and Env Health
Date: 04/24/2007 Time: 10:43
Sample: AB13188 Loe Code: RROAPNLC Samp 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 Colet: J GREER P.O. Numbr: 7G0062 Proj Code: ---
Page: 2
Amf Code· f Analysi s Name on• ~t ~· MET_PREP !Samples Prepared BY ES
TEMP RECEIVE Sample temperature at receipt by lab oc 5.0 - -
NO2N_LIQ Nitrite as N in liquid mg/Las N 0.01
NO3N_LIQ Nitrate as N In liquid mg/Las N 1.9
User: Wilcox, Betty
NC Natural Res and Env Health
Date: 04/24/2007 Time: 10:43
Sample: AB13188 Lac Code: RRCAPNLC Samp Descr: MR. CHARLES DAVIS Lag 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: 1 GREER P.O. Nurnbr: 7G0062 Pro.' Code: ---
Page: 3
Violation Value Sec Result
Qualifier
B2
4B2
[32
u
u
u
u
u

User: Wilcox, Betty
NC Natural Res and Env Health
Date: 04/24/2007 Time: 10:43
Sample: A813188 Loc Cade: RROAPNLC Samp 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 Proj Code:
Pale: 4
Violation Value Sec Result . Q

Coliform, total
Coliform, fecal
Chloride
Total Dissolved Solids
N02-+ N03-as 'N
Aluminum, Al
Arsenic, As
Barium, Ba
Calcium, Ca
Cadmium
Chromium, Cr
Copper, Cu
Iron, Fe
Mercury, Hg
Potassium, K
Magnesium, Mg
Manganese,Mn
Sodium, Na
Nickel, Ni
Lead, Pb
Selenium, Se
Zinc, Zn
State Groundwater Quality Standards:
Classification and Water Quality Standards Applicable To The Groundwater of North Carolina
(North Carolina Administrative Code Title 15A: 02L.200)
1/100 ml
1/100 ml
250mg/L
500 mg/L
10mg/L
nss
50 µg/L
2000
nss
1.75 µg/L
50 µg/L
1,000 µg/L
300 µg/L
1.05 µg/L
nss
nss
50 µg/L
nss
100 µg/L
15 µg/L
50 µg/L
1,050 µg/L
mg/L = milligrams per liter = parts per million
µg/L = micrograms per liter = parts per billion
1,000 µg/L = 1 mg/L
( 1 gram/1,000grams )/1,000grams
(lgram/1,000,000grams)/l,OOOgrams
na = not analyzed
ns = no state standard
WC DWf Laboratory Section 1Wesutts
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
� F W�i
RECEIVED i
9A�_
AafiFFRvparrenrol SFc rx els
MAR 16 2007i a
A� # Analyte Name
Sidi— J pAttL'i i
Sample ID: •
PO Number #
VisitID
Collect Date:
Collect Time::
Date Received:
Time Received:
Labworks LoginlD
Date Reported:
Emergency YeslNo
COC Yes/No
AB13187
TGO081
02/07/2007
10:00
02J07/2007
10:40
MMA
03/12/2007
PQL
Result
Qualifier
Units Approved By
LAB
Sample temperature at receipt by fah
4.3
'C MMATHIS
MIC
Colifarm, MF Fecal in liquid
1
1 B2
CFiJI100m1 CGREEN
Coliform, MF Total in liquid
1 62
CFU1100m1
CGREEN
WARO
Alkalinity4.5
6
rnglL as CaCO3
ESTAFFORD
Alkalinity8.3
1
U
mg/L as CaCO3
ESTAFFORD
Bicarbonate
6
mg/L as CaCO3
ESTAFFORD
Carbonate
1
U
mg/L as CaCO3
ESTAFFORD
pH
5.3
mg/L as CaCO3
ESTAFFORD
WET
Chlonde in Eiquid
5
16
mg/L
MOVERMAN
Sulfate in liquid
5
2.0 U
mg/L
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
mg/L as N
CGREEN
Phosphorus_totai as P in liquid
0.02
0.02
U
mg/L as P
CGREEN
Nitrate as N in liquid
0.01
1.7
mg/L as N
CGREEN
Nitrite as N in liquid
0.01
0.01
U
mg/L as N
CGREEN
MET
7429-90-5 Al by ICP
50
50 L1
uglL
ESTAFFORD
Laboratory SectIon>5 1623 Mali Service Center, Raleigh, NC 27699-1623 [phone]
Page 1 of 2

D`i 2Q Laboratory Section Results
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
O. \Ist A�FR
Sample ID:
PO Number #
VisitI❑
AB13187
7G00¢1
Collect Date: 0210712007
Collect Time:: 10:00
Date Received: 02/07/2007
Time Received: 10:40
Labworks LoginlD MMA
Date Reported: 03/12/2007
Emergency Yes/No
COC Yes/No
CAS #
Analyte Name PQL Result
Qualifier
Units
Approved By
7440-38-2
As by ICPMS
5.0
5.0
U
uglL
ESTAFFORD
7440-70-2
Ca by ICP
0.10
1.6
mg/L
ESTAFFORD
7440-43-9
Cd by ICPMS
1.0
1.0
U
uglL
ESTAFFORD
7440-47-3
Cr by ICPMS
10
10
U
uglL
ESTAFFORD
7440-5D-8
Cu by ICPMS
2.0
_ _ 490
uglL
ESTAFFORD
7440-48-4
Fe by ICP
50
50
U
uglL
ESTAFFORD
7439-95-4
Mg by ICP
0.1D
1.8
mglL
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
ugiL
ESTAFFORD
7439-92-1
Pb by ICPMS
10
10
U
uglL
ESTAFFORD
7440-66-6
Zn by ICP
10
22
uglL
ESTAFFORD
Laboratory Sectlonaa 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page 2 of 2

GROUNDWATER F1ELD/LAB FORM
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
County
Quad No Serial No
Lat. Long
Report To: ARO, FRO, MROGRa WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other:
Shipped by: Bud, Courier, Hand Del , u 1 L
SAMPLE TYPE SAMELEpRtIQRITY
tinNeter ('Routine
❑ Soil ❑ Emergency
❑ Other
❑ Chain of Custody
Callector(s): Date Time )pi) v
FIELD ANALYSES Owners r .
pH Spec. Cond.94 100.1 at 25° C
Ternp.i0 3 °C Odor r
Appearance (
Field Analysis By:
LABORATORY
)
NAL=YSES
Purpose:
Baseline, Complai
Lab Number 26-79496'
Date Received Ojt 49 Time
/
Rec'd by: 7 � e-( rom: Bus, Courier, i rtd ,
Other.
Data Entry By Ck-
Date Reported-
L ST,.Peslicide Study, Federal Trust, the LI ! ` 1111P
arm
Location or site 14 /2- i,�j r A � - ,tC ' G D -7
Description of sampling point 14 -'v 11 t.4 c
Sampling Method
Remarks
Limp. rim. etc-)
l
i W. .)
Sample Interval 4 S
BOP, 310 mg/I
,isc
Solid 70300 mg/I
Ag - Silver 46566 ug/l
Organochlorine Pesticides
COD High 340 mgll
Flouride 951 mall
/
Al - Aluminum 46557 ug/l
Organophosphorus Pesticides
COD Low 335 mg/1
}Hardness:
Total 900 mg/I
As - Arsenic 46551 ug/l
Nitrogen Pesticides
Coliform: MF Fecal 31616 1100m1
J`
Hardness (non-carb) 902 m.
Ba - Barium 46558 uglt
Acid Herbicides
j[
Conform: MF Total 31504 1100m1
Phenols 32730 win~
X.
Ca - Calcium 46562 moll
PCB's _ i
TOC 680 mill
soecific Cond. 95 uMhoslcm'
Cd - Cadmium 46559 ug/l
RQtjlt=Palast' =rt:Yi:
Turbidity 76 NTU
X
Sulfate 945 _ mg/1
X
Cr - Chromium 46560 ug/l
1, =r1i97
Residue., Suspended 530 mg/I
Sulfide 745 mq/l
;�
Cu - Co2per 46562 ug/l
u
,
}[
Fe - Iron 46563 ug/l
Semivolatile Organics
011 and Grease mgll
H9 - Mercury 71900 ug/l
TPH - Diesel Range
pH 403 units
K - Potassium 46555 mg/I
Alkalinity to pH 4.5 410 rng/l
)(
Mg - Magnesium 46554 mill
Alkalinity to pH 8.3 415 mg
Mn - Manganese 46565 ug/1
Carbonate 445 Al �r mg/I
NH as N 610 mgll
Na -Sodium 46556 mgll;
Volatile Organics (VOA battle]
Bicarbonate 44o mgll
TKN N 625 n1g11
Ni - Nickel ug11
TPH - Gasoline Range
Carbon dioxide 405 mg/1
NO, + NO. as N s30 moll
)
Pb - Lead 46564 ug/l
TPH - BTEX Gaso!lrie Range
Chloride 940 mg/!
'
P: Total as P 665 mg/1
Se - Selenium ugll
Chromium: Hex 1032 ug/l
/'
Zn - Zinc 46567 ug/I
Color: True 80 CU
X
r �
N a-7- -j -- c.1Al Pre,_. e i 4
Cyanide 720 rng/l
Lag Comments:
4- 6
rodirki
.12/0\
�..� . 6 r� ► f �� Q 4 - C' ter--.- 6 I/..- d r+r�� ��1.� Cal .l_Aj
S� 4 4 _ -� 2-, n 9 -nv QL
6) - z ‘.,1 , L7 3
For Dissolved Analysis - submit filtered sampie'and write "DIS" in b1e.\

NC DENRIDWQ Laboratory
Feport to: _RROAP Sample Anomaly Report (SAR)
Lab Number: AB13187 Sample ID:
Station Location: Mr. Charles Davis County: Wake
Sample Type: Water Priority: Routine
)ate collected: 2/7/2007 Date received:
Affected Parameter(s): Dissolved Solids
2/7/2007
1
Region: RROAP
Collector: J. Greer
Date analyzed: 2/9/2007
Analytical Area (check one):
®WCH
NUT
['METALS
❑MICRO
The following anomalies occurred (check all that apply):
['Samples
['Improper container used
❑ VOA vials with headspace
['Sulfide samples with headspace
❑Samples not received, but listed on fieldsheet
❑Samples received, but not listed on fieldsheet
❑ Mislabeled as to tests, preservatives, 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 preserved properly
❑pH out of range (record pH):<2
['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:
❑VOA
['PEST
❑SVGA
®Quality Control
instrument failure - no reportable results
['Analyst error- no reportable results
❑Surrogates
['None added
❑ Recovery outside acceptance limits
DSpike 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: A. Williams
Lead Chemist v ew initial): MI
• ❑BIOCHEM
❑METALS
?�1i•p'1
Branch Head Review (initial); -_
QAIQC Review (initit /10/0-7
OA%Forrasl-aboruioryS A R
❑PEST
❑VOA
Date: 2/16/2007
❑S VOA
Logged into database by (initial):
I W23/01 dts

fk.c_ ' & J /r{
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 02/072007
To: Aquifer Protection Section Central Office
Central .Office Reviewer: Micheal Rogers
Regional Login No: 05
County: Wake
Permittee: Charles & Gwendolyn Davis
Project Name: UIC (5A7)
Application No.: WI0500040
L GENERAL INFORMATION
1. This application is (check all that apply): D New [8J Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation [8J Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? [8J Yes or D No.
a. Date of site visit: 02/07 /2007-09:30AM
b. Person contacted and contact information: Gwendolyn Davis-Phone# [phone]
c. Site visit conducted by: JGreer, RRO-APS
d. Inspection Report Attached: [8J Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
[8J Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions: __
c. USGS Quadrangle Map name and number: _
d. Latitude: Longitude: _
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): NIA
For Disposal and lniection Sites:
(If multiple sites either indicate which sites the information applies to, copy and paste a new section into the
document for each site. or attach additional pages for each site)
a. Location(s): 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
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section)
Description OfWaste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: _
FORM: WI0500040.CD
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No D N/A. Ifno, please explain: __
3. Are the new site conditions ( soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No D N/A. Ifno, please explain: __
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes D No D N/ A. If no, please _explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No0
NI A. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D N/A. Ifno, please explain: __
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No D NI A. If yes, please attach a map showing areas . of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
8. Are there arty buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit: __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certi~cation B?)
IIL RENEW AL AND MODIFICATION APPLICATIONS (use previous section for new or maior modification
s vstems)
Description Of Waste{S) And Facilities
1. Are there appropriately certified ORCs for the facilities? D Yes or D No.
Operator in Charge: ___ Certificate #: __
Backup-Operator in Charge: __ Certificate #: __
2. Is the design, maintenance and operation (e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D No.
If no, please explain: __
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? D Yes or D No. If no, please explain:
FORM: WI0500040.CD 2
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
4. Has the site changed in any way that may affect permit ( drainage added, new well~ inside the compliance
boundary, new development, etc.)? If yes, please explain: __
5. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
D Yes or D No. If no, please explain: __
6. Are the existing application rates (hydraulic or nutrient) still acceptable? D Yes or D No. If no, please
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Will seasonal or other restrictions be required for added sites? D Yes D No D N/ A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, plea~e attach a
map showing conflict areas or attach any new maps you have received from the applicant to be incorporated
into the permit: __
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? D
Yes or D No. Ifno, please explain: ____ _
11. Were monitoring wells properly constructed and located? D Yes or D No ~ N/ A. If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? D Yes or
D No D N/ A. Please summarize any findings resulting from this review: __ _
13. Check all that apply: D No compliance issues; D Notice(s) of violation within the last permit cycle; D
Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc): ____ _
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? D Yes
D No D Not Determined D N/A .. Ifno, please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? D
Yes or D No D N/A. If yes, please explain: __
FORM: 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
1. Type of injection system:
~ Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (5QM/5QW)
□ In situ remediation (5n
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source.and injection? D Yes ~ No
3. Are there any potential pollution sources that may affect injection? Dyes ~ No
What is/are the pollution source( s )? --~Wh~=a,..c_t =is'--'t=h..c....e-=d=is=ta=n=c-"-e--"o-=-f-=th=e'---'m=· =j ec....;;;c=ti=o=n----'w-'--e=--=1=1(-=-s)L.-'fr=om~t=h;.;:;..e"""'p-=o=ll=utt=· o=n
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 D Adequate D Poor
6. Flooding potential of site: ~ Low D ·Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: __ _
8. Does the map presented represent the actual site (property lines, wells, surface drainage)?~ Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, :wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes ~ No. If yes, explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
orlast inspection? D Yes D No. If yes, explain:
3. For renewal or modification of groundwater remediation permits ( of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes D No. If yes, explain:
4. Drillin~ contractor: Name: CW Bing 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 5
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
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:
Item
Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition
Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition
Reason
7 Recommendation: ❑ 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(
Signature of APS regional supervisor:
Date: / 7
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
System is Good/running OK.
iC L
s
FORM; WI0500040.CD 6

Compliance Inspection Report
Pennit: WI0500040
SOC:
Effective: 04/26/02 Expiration: 04/30/07 Owner: Charles Davis
Effective: Expiration: Facility: Davis, Charles -SFR
County: Wake
:Region: Raleigh
Contact Person: Charles Davis
Directions to Facility:
PIN: 0794382666
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Pennits:
lnsp_~ction Date: 02/07/2007
Primary Inspector: Jimmie W Greer
Secondary lnspector(s):
Reason for Inspection: Routine
1422 Ridge Rd
Raleigh NC 27607
Phone: [phone]
Certification: Phone:
Entry nme: 09:30 AM Exit Time: 10:30 AM
Inspection Type: Compliance Evaluation
Pennit Inspection Type: Injection Heating/Cooling Water Return Well (5A7)
Facility Status: ■ Compliant D Not Compliant
Question Areas:
■Other
(See attachment summary)
Page: 1
Parma: W10500040 Owner - Fecflity: Charles Levis
Inspection Date: 02/07/2007 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
Other
Comment
le 5
Al Rif 313►E'7J
E Ie = 1 13 Pe-S
Z./" 7/ �7
— / P9Soiani
Yes No NA NE
Page: 2

Michael F. Easley, Governor
William G. Ross Jr.. Secretary
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. WI0500040
Davis, Charles - SFR
Injection Heating/Cooling Water Return Weil (5A7)
Wake County
Dear Mr. Davis:
The Aquifer Protection Section of the Division of Water Quality (the Division) acknowiedges 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 http:f/h2o.enr.state.nc.usldocunzentsldwq_ornchart.pdf.
PLEASE REFER TO 1'HI ABOVE APPLICATION NUMBER WHEN MAKLIIG LNQUIRIES
ON THIS PROJECT.
Sincerely,
for De L . Watts
Supervisor
cc. Raleigh Regional Office, Aquifer Protection Section
Permit Application File W10500040
Aquifer Protection Section 1636 Mail Service Center
Internet www.ncwaterquafity.oro Location: 2728 Capital Boulevard
An Equal apportunitylAffirmative Action Employer— 5O% Recycted110%o Past Consumer Paper
Nor hCaro inu
Naturally
Raleigh, NG 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

A Q UIFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: February 27 , 2007
To: 0 Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS -
0 Andrew Pitner, MRO-APS
~ Jay Zimmerman, RRO-APS
From: Michael Rogers , Groundwater Protection Unit
Telephone: [phone]
E-Ma.il: [e-mail]
A. Permit Number: WI 0500040
B. Owner: Charles Davis
C. Facilitv/O peration: __
D Proposed
D. A pp lication:
~ Existing
0 David May, WaRO-APS
□ Charlie Stehman, WiRO-APS
□ Sherri Knight, WSRO-APS
Fax: [phone]
D Facility D Operation
1. Permit Type: □ Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D I/E Lagoon D GW Remediation (ND)
~ UIC -(5A7) open loop geothermal __
For Residuals: D Land App. D D&M □ Surface Disposal
D 503 D 503 Exempt □ Animal
2. Project Type: D New D Major Mod. D Minor Mod. · ~ Renewal D Renewal w/ Mod.
E. Comments/Other Information: ~ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 21 calendar days, please take the following actions:
~ Return a Completed APSARR Form.
D Attach Well·Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
\D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional ·
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: ------------------Date: ____ _
FORM: 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: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: TTi:"'ram , 204 7
A. PERMIT APPLICANT
Permit Number: rri OgiN>¢7 (WI0i0#####, listed at the bottom of each page of your permit)
Name: Cd cZj1 S S /: -1)tz..iws
Address:.'r42,2 ,'I' '-• 1c044
City: State: /VC Zip code: Z'c'7
County: Wait- Telephone: 9 q j� - o I (Z
B. PROPERTY OWNER (if different from applicant)
Name: 5tr
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:
RECEIVED I DENT, / D'WQ
ACSlltii P orrlt nytrnN SFCTiott
Revised 7/06 GWIUIC-57 HPR Page 1 of 3

f V
E.
F.
G.
H.
I.
J.
K.
L.
INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
Pl ~/y e:;.CCJ~, re.ek.uc( ftlfflf hi~ -¾-J-1~ 1:;..,jfM ~b~ib(~ }:':'(1?-1-f\1af-~r,
/Gt:1 / /11 .pre. d.rwr prj:,v,., 1G~1 1f'f?/;Jjto/J St/b,, ~r~
WELL USE I~(~re)_ the inject~on well(s) also used as the supply well(s) for either ofthf following?,-, _ / _,
(1) The lllJeCtion operat1<;m? YES_&_ l'J"O__ frlJVJ'tfu .heti:tA;ccv c:ec '"5
(2) Your personal consumption? YES_ NO JL_ -{:;«--n: ~~ca_
CONSTRUCTION DATA
(1)
(2)
Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection permit.
?1 ~
NC. State Regulations (15A NCAC, 2C, Section .0200) require the 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? YES~ NO __
CURRENT OPERATING DATA
(1) Injection rate: Average (daily) I fL gallons per minute (gpm)
(2) Injection volume: Average (daily) .,J'C() gallons per day (gpd)
(3) Injection pressure: Average (daily) t{o pounds per square inch (psi)
(4) Injection temperature: Annual Average -1!1 degrees Fahrenheit (°F)~~) Gf3 If •S ) 4 ·
INJECTION-RELATED EQUIPMENT -,(~ ~~efr,~ ~ .
Attach a diagram showing any modificatio~r to injectil'n equipment since the issuance of the previous injection
permit including the engineering layout of the (l} injection equipment, and (2) exterior piping/tubing associated
with the injection operation. The manufac~er's brochure, ifdetailed, 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.
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: _ ~" ,J .. _1
(1) Hazardous Waste Management program permits under RCRA ~
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits ·
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. ·
ftp ~~~
I
Revised 7 /06 GW/UIC-57 HPR Page 2 of 3
I\,
M. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the infonnation
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 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.''
(llo..J..,.__ ~~►-..
(Signature ofWeIOwner or Authorized Ag~nt)
If 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
well(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 15A NCAC
Subchapter 2C .0200) '
Revised 7 /06
(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 Maii Service Center
Raleigh, NC 27699-1636
Telep~one: [phone]
GW/UIC-57 HPR Page 3 of3
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 d day of ! jQ , 2002.
))Q L AJAS
+\u 'i -ed L. Plush, Ji., ASSlstal►i Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management. Commission.
Permit No, W10500040 PAGE 1 OF 6
V er.3101 GW [UIC-5

Paze 1 o7 2
North Carolina Department of Environment and Natural Resources
Division of Water Quality -Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTIC
REPORT -FORM A
INJECTION WELL PERMIT NO, WI
NAME OF OWNER �` , %, S -
ADDRESS OF OWNER
DATE
t' ;41-r -
f /F�
(Street/ road or lot and suddivision, county, town+
LOCATION OF PROPOSED INJECTION WELL (and source wells), if applicable)
�- e'er J C'i�. ff�,." �y �- «��'G;••-
V f ,
{Street/ mad or for and suddivision countv. lawn, if d jere'n than owner's address, phis description of location vn suet
•
Potential pollution source d y+t,(jr Distance from well S-0
Potential pollution source
Potential pollution source
rt Wiz,
Distance from well
Distance from well
Minimum distance of proposed well from property boundary c6.0
r
Quality of drainage at si Flooding potential of site
(gowf,adeguate,poor) (high,rodertue,lowt J
DRAW SKETCH OF SITE
(Show properny haundortes, brrrldrngd, wells. potet:no! polhulon sources. roads, approximate seaiE. and north arrow,/
L
E
Tip
1

Page
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (coat.)
COMMENTS
Ail
0..
/ I' r
INSPECTOR
r'
Office
WITNESS
Address
WITNESS
Address

'71-'759 - C arrrer
trY:4108 - Cary
.�k
BOWMAN MECHANICAL SERVICE:
..f
1219 Sturdivant Drive
Cary, NC 27511
High Efficiency { IVAC • Geothermal
idatvA 1,(rn
5-6
/V';J
%If
FAX (9'I9) 7?9- S.1
Ar• J.1
• frtr'
4/9
4r
er-

1/

Michael F. Easley, Governor
William G, Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Akan W. Klimek, P.E. Director
Division of Water Quaiity
February 27, 2007
CHARLES DAV1S
1422 RIDGE RD
RALEIGH NC 27607
Subject: Acknowledgement of Application No. WI0500040
Davis, Charles - SFR
Injection Heating/Cooling Water Return We11 (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@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 hrtp://h2o.enr.state.nc.us/documents/dwii orVchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES
ON THIS PROJECT.
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Permit Application File WI0500040
Aquifer Protection Section 1636 Mat Service Center
Internet: www.ncwateraualitv.orq Location: 2728 Capital Boulevard
An Equal opportunity/Afrmative Action Employer- 5D% Recycledl109'a Post Consumer Paper
Nay` Carolina
VQlllra//j
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service; [phone]

Michael F Easley, Governor
William G. Ross Jr.. Secretary
North Carolina Department of Environment and Natural Resources
Alan W Kimmel:, P.E. Director
Division er Water Quality
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
Wake County
Dear Mr. & Mrs. Davis:
The Underground Injection Control (UJC) 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 ISA, Subchapter 2C. Section .0211, you must take one of the following
actions:
A. Submit the form RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WIT/ A
HH.4TPUMP SYSTEM (form GW/UIC-57 HPR) if the injection well system on your
property is still active;
S. Submit the form STATUS OF INJECTION WELL SYSTEM (form GWJUIC-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]]irta
)Vat# rail j
Aquifer Protection Section 16.36 Mail service Center
Internet: www.newaterflualLocation: 2728 Capital Boulevard
An Equal Opportunity/Affirmative Action Employer- 50%Recycled1W% Post Consumer Paper
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: (919) 7t5-6048
Customer Service: [phone]

Charles & Gwendolyn Davis
January 29, 2007
Page 2 of2
properly conducted. If the injection well system is still active, a renewal application is to be
submitted atleast 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 at [e-mail].
Enclosures
1; GW /UIC-57 HPR
2. GW /UIC-68
J,
•J,
Sincerely,
;7--w
Jesse Wiseman
Aquifer Protection Section
cc: Raleigh Regional Office -APS w/o enclosures
AP:s CijittaJ 'Files' -Petmit No. WI05QQQ4~ w/-o enclo@ie&J
,;' .
North Caro1h . Department of Environment and Ni _rat Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO.
NAME OF OWNER
ADDRESS OF OWNER f 41
r
DATE S r =a
(Street,/ road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable)
(Street/ road or lot and subdivision , county, town, if different titan owner's address, plus description of location on site)
Potential pollution source
Potential pollution source
Distance from well
a Distance from well „5"-jD
)
Potential pollution source Distance from well
Minimum distance of well from property boundary 442
Quality o • ainage at site Flooding potential of site
(good, �dequate,poor) (high,modera , ow
GPS Data:
Latitude: •J� Longitude: - " aE •
tit* - d 136,24 & PS Lr'a r rlo�� {ram p L �• 1c5
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources. roads, approximate scale, a
north arrow.)
5-c
xt2e,l1
sn
DESCRIBE INJECTION SYSTEM (vertical closed loop, uncased borehole or cased water well; separate source well and
injection well combination source and injection grill; or other descript' n as applicable) �r
JI/rn d !r'ir'
V er.3/O I G t,IC-2

INJECTION CILITY INSPECTION REPORT -FORM CONTINUED)
WELL CONSTRUCTION
Date constructed j 9 99
Drilling contractor: Name 0,
Address 627 c{ " L-i / 1 5r)411.,
Ale - 7s
Certification number 4 L D E+ Z .
Ll���d� ry �f �+--•
Total depth of well Total depth of source well z e
(rf applicable)
Measurement Meets minimum standards Comments
Yes No
Inspection point
Casing
Depth
Diameter
Height (A.L.S.)
Grout
Depth
Screens
Depth(s)
Length(s)
I.D. Plate
Static water level
Well yield
Enclosure
Enclosure floor
(concrete)
Sampling port
(labeled)
Water tight pipe entry
Well enclosure entry
Vent
� f
cdP
L 6,.
Eff- iQ
Functioning of heat pump system (Determine from the owner if heat pump functions properly)
INSPECTOR
WITNESS
2
CD )
EAR%rs cam
Office
Address
WITNESS
Address
Ver.3101 GWIUIC-2

COUNTY : WAKE
QUAD NO:
U1VISION4 OF WATER QUALITY
Chemistry lrboratary Report 1 Ground Wafer Qulgry
SAMPI.QRi.:I_Y
LJROUTINEEMERGENCY
REPORT TO : RRO Regional Office n CNA1N OF CUSTODY
COLLECTOR(S) : JCRE£R
DATE: 512912002 0 SAMPLE TYPE
TIME:
PURPOSE:
LABORATORY ANALYSLS
i1p1J 310
mg/L
COD High 390
mg/L
COD Low 335
mg/L
X
Coll form: MF Fecal 31616
1 B2
/I00m1
X
Coliform- MF Total 31504
1 B2
/ l00m1
TOC
mg/1
Turbility
NTU
Residue., Suspended 530
mg/L
Total Suspended solids
mg/L
_pH
7.7
units
Alkalinity to pH 4.5
20
mg/L
Alkaliniy toyH 8.3
1U
mg/L.
x
Carbonate.
1U
mg/I-
X
onatr
20
mF/L
Cafoon dioxide
mg/L,
X
Chloride
16
mg/L.
Chromium: Hex 103Z
ug/1.
Color. True 80
c.u-
Cyanide 720
mg/L
COMMENTS
1-IN
Owner: CUARLbS A IJAY18 .{
Location or Site: i
Description of -sampling point / - 4 +'
Sampling Method: /
t. Remarks:
X
Dias. Solids 70300
91
rng/L
Fluoride 951
mg/L
Iardness: total900
mg/L
X
hardness- (non-carb) 902
mg/1_
Phenols 32730
ug/L
Specific Cond. 95
umhos/cm2
Sulfate
mg/I.
Sulfide 745
mg/L
MIBAS
mg/L
Oil and GYMS
mg/L
Silica
mg/1_
Boma
Formaldehyde
mg/I.
X
NH3 as N 610
0.01 U
mg/l.
X
TKN as N 625
0.20 U
mg/1,
31
NOZ+NO3a9n630
3.4
rng.'1.
P: Total as P 665
mgli_
PO4
mg/L
Ag•Silver 46566
ug/L
AI -Aluminum 46557
ug • L
As -Arsenic 4fi551
ug/L
0a-Valium 46558
ug/L
X
Ca -Calcium 46552
5.1
mg/L
X
Cd-Cadium 46559
2.01)
ug/1.
X
Cr-Chromium 46560
250
ujt/1.
X
Cu.. Cn1+•prr 1047
940
ug/L
X
Fe- Iran 1045
50U
ug/L.
11g. Mercury 71900
ug/i.
K-Pou•sium 46555
mg/L
X
Mg. Magnesium 927
3.3
mg/L
X
Mn-Manganese 1055
57
tart.
Na-Sodium 929
mg/L
X
Ni-Nickel
120
ug/1.
X
Pb-Lea 46564
100
ug/I_
Se -Selenium
ug/L
X
'7_n_7_inc 46567
180
ug/i_
Lab Number ; 2G0984
Date Received : 5129/2002
Time Received : 11:10 AM
Received 13y : HMW
eatc) SID
f�Rticased By. A
Date reported : 6/24/2001
Or9anochlarine pesticides
Organophoaphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
SemivoIasilts
TPI',Theset Range
Volatile Organic (VOA bottle)
TPfI-Gasoline Range
TPH.LTEX Gasoline Range

rlUNDWATER FIELD/LAB FORM
County
Quad No Serial No.
Lat. Long
Report To: ARO, FRO, MRO, ;VW aRO, WiRO,
SAMPLE TYPE SAMPLE PRIORITY
2 Water ❑ Routine
0 Soil ❑ Emergency
RI Other 1.+1c
❑ Chain of Custody
WSRO, Kinston FO, Fed. Trust, Central Off., Other:
Shipped by: Bus, Courier, Hand Del.,ntlya0Y
Collector(s): Jk:.= .D Date . - Zr-oz
.D ANALYSES
pH400 G . b Spec. Cond.04
Temp.10 / 4F.5- oC Odor
Appearance C-/r—
Field Analysis By -
Purpose:
Time lb �� a aseline, Complai'�jCCom Iian-
Owner-T C�• Zi,f i
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
Location or site /'71ZZ
Description of sampling point
Sampling Method
Remarks
Lab Number
Date Received 0v705Time//"
Rec'd by:f /2 i -"From: Bus, Courier a e
Other -
Data Entry By:
Ck•
Date Reported:
ST, Pesticide Study, Federal Trust,
N i l7Z.-07
4.,E ma. co.)
Sample Interval
LABORPVTORY ANALYSES
__r _--_._-_ r_- .
BODE 310
mglt
X
Diss. Solids 70300
mqA
Aq - Silver 46566
ugll
!
Organochlorine Pesticides
COD High 340
mgll
Flouride 951
mall
Al -Aluminum 46557
ugll
Organvphvsphorus pesticides
COD Low 335
mg/1
Hardness: Total 9o0A%.51_
rngll
As - Arsenic 46551
ug/1
Nitrogen Pesticides _ ,
Colitorm: MF Fecal 31616
li QOmt
�{
Hardness {nvn-carb} got
mall
Da -Barium 45558
t�gll
Acid Herbicides .�
Colifvrm: MF Total
11 QQm1
Phenols 32730
ugll
Ca - Calcium 46552
mg/1
PCB's
TOC 680
mg/l
Specific Cond, 95
UM119skin2
Cd - Cadmium 46559
ug/l
k�
Turbidity 76
NTU
Sulfate 945
mg/I
X
Cr - Chromium 46560
uq/l
Residue., Suspended 530
mgll
Sulfide 745
mall
)<
Cu - Copper 46562
ugll
1e
Fe - Iron 46563
ugll
Semivolatile Organics
_
Oil and Grease
mg11
Hg - Mercury 71900
ugll
TPH - Diesel Range
pH 403
units
a
K - Potassium 46555
mgll
Alkalinity to pH 4.5 410
mg/1
-
Mg - Magnesium 46554
mgll
Alkalinity to pH 8.3 415
mg/1
Mn - Manganese 46565
ugfl
Carbonate 445
mall
NH, as N 610
mall
Na -Sodium 46556
mgll
Volatile Organics (VOA bottle)
Bicarbonate 440
moll
TKN as N 625
mnll
Ni - Nickel
uWl
TPH - Gasoline Range
Carbon dioxide 405
mg/I
NO, + NO, as N 630
mgll
)
Pb - Lead 46564
ugl
TPH - BTEX Gasotfre Range
X
Chloride 940
mgll
LP: Total as P 665
mg/1
Se - Selenium
ugll
Chromium: Hex 1032
ugll
ki
Zn - Zinc 45567
ugll
Color: True 80
GU
Cyanide 720
mg/1
Lab Comments:
Cip-it44
GW-54 REV.12/G
For Dissolved Analysis - submit filtered sample and write "DIS" in bli

Report to:
caitt
Collector_ • �'; o
Priority. _
Affected Parameters.
NC DENRIDWQ Chemistry Laboratory
ample idltion Upon Receipt Anomaly Report (SC
TIrrle Belt1:
The condition of these samples were not acceptable because (check all that apply):
❑ CooIers 0 Samples (affected samples are described below)
❑ Samples were not received on wet ice CI Samples not received, but listed on fieldsheet
❑ ❑ Samples received, but not Iisted on fieldsheet
Samples not received, but listed an CDC
Samples received, but not listed on CDC
❑ 'C • Mislabeled as to tests, preservatives, etc.
O • Holding rime expired
Improper container used
❑ • Insufficient quantity for analysis
No temperature blank submitted:
❑ Sample T° reading : °C
❑ Cooler T° reading: °C
Temperature >6°C, T° reading:
Samples frozen
Containers
❑ Leaking
❑ Broken
❑ Without labels
❑ VOA vials with headspace
❑ Sulfide samples with headspace
❑ Container Labels
O Not the same ID/info. as on CDC
0 Not the same ID/info. as on fieldsheet
❑ Incomplete. Missing the following:
❑ Station #/Sample ID
❑ Collection date
❑ Collector
❑ AnaIysis
❑ Preservative
C] Other:
❑ Markings smeared or illegible
❑ Torn
Comments:
0 Chain of Custody
❑ No custody seals
O Custody seals not intact
❑ Not relinquished.
❑ No date/time relinquished
❑ No signature
❑ Incomplete information
Documentation
❑ Fieldsheet wet/illegib
Fieldsheet incomplete
❑ Records not written in indelible ink
Other (s, ecify)
Corrective Action:
❑ -:Samples were rejected 6y DWQ Lab. `Authorized by:'
❑ Accepted and analyzed per collector's request after notifying the collector,
O 'Accepted and analyzed after.notifying the: clientptid deterininirigthat another sample could not be secured.
❑_::Satnple(s) on hold until: ==: -- ,
Samples) accepted and analyzed.
O _Other (explain): r r
acatioa-req_ riired. -
Petson'Contacted: - _ ' _ = _ .-._. - � '='. Date: 1 •:/ -
Unit Leader Review (initial],
NUT
WCH
AVermy%Samplc Rec eiringkSCUR
Form completed by:
VOA
PEST
Date:
SVOA
MI C
+MET
r

MEMORANDUM
DMSION OF WATER QUALITY
GROUNDWATER SECTION
April30,2002
To: Jay Zimmerman, L.G., Regional Groundwater Supervisor
. Groundwater Section
Raleigh Regional Office
From: Mark Pritzl /1.P [e-mail]
Hydrogeological Technician II
Underground Injection Control (UIC) 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
W A rF Michael F. Easley, Governor
RQWilliam G. Ross Jr., Secretary
C. North Carolina Department of Environment and Natural Resources
2 '{ r Gregory J. Thorpe, Ph.D.
7 { Acting Director
.' Division of Water Quality
April 15, 2002
Charles Alfred Davis
1422 Ridge Road
Raleigh, NC 27607
Dear Mr. Davis:
In accordance with your application dated December 6, 1999, we are forwarding Permit No.
WI0500040 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
Sincerely,
Evan O. Kane
Hydrogeologist
Underground Injection Control Program
Customer Service
1 BOO 623-7748
Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: http://gw.ehnr.state.nc.us

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 I5A 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 1 through X
hereof
Permit issued this the d day of 0, 2002.
CoQ uLv1
Ted L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0500040 PAGE 1 OF 6
Ver.3/01 GWIUIC-5

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (1 SA NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulicalty 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.
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.
8. 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 Pennittee shall
notify the Groundwater Section-Underground Injection Control (UIC), Central Office staff,
telephone number [phone].
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data._
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal pennit amendment
PermitNo. WI0500040
Ver.3/01 GW/UIC-5
PAGE2 OF 6
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall .not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances which may be
imposed by other local, state, and federal agencies which have jurisdiction. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater 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.
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 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 (UIC), 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 ~y property, premises, or place on
Permit No. WI0500040
Ver.3/01 GW/UIC-5
PAGE3 OF6
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any recor:ds that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made .for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including· groundwater, surface water, or soil sampling) deemed necessary
by the Division of Water Quality to insure surface and ground water protection, will be
established and an acceptable sampling reporting schedule shall be followed.
2. The Pennittee 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 ~ailure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report to
the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
Permit No. WI0500040
Ver.3/01 GW/UIC-5
PAGE4 OF 6
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(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)
Permit No. WI0500040
Ver.3/01
as specified in 15A NCAC 2C .0213(h){l) within 30 days of completion of
abandonment.
PAGES OF 6
GW/UIC-5
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Groundwater Section-VIC Staff
,DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X -OPERATION AND USE SPECIAL CONDITIONS
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
violation(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 ofW~ter Quality such as repair, modification, or abandonment of
the injection facility.
Permit No. WI0500040
Ver.3/01 GW/UIC-5
PAGE 6 OF 6
------
Name Date Initials Type of permit
Mark Pritzl 'I/J6/um t!1_I' ~,1, . -Evan Kane I 'I/~ 2,/ ,n,,-1k__ --
Debra Watts 4-/2<.lo 'L c\.)\>J.
F w A rF Michael F. Easley, Governor
dC1�Q William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
7 Gregory J. Thorpe, Ph.D.
Lyw� ~I Acting Director
Division of Water Quality
Febntary 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: CO-UIC files
RRO-UIC files
ATraw
NCD F
Customer Service
1 800 623-7748
Sincerely,
Evan O. Kane
Program Manager
UIC Program
Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: http://gw.ehnr.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 ,i.fJ. [e-mail]
Hydrogeological Technician II
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 Facilitylnspection Report (form J3)
to the CO-UIC by January 15, 2000 .. If the inspection can not be accomplished by this
date, please inform theCO-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] .
cc: 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 PERMIT NO. WI DATE
NAME OF OWNER C, ;
ADDRESS OF OWNER /
'L�rs�'ei
(Street/ road or lot and suddivision, county, town)
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable)
r b•l"'��� 1- • �- 4 -/
I Y -fit+ +.a
(Street/ road or lot and suddivision , county, town, if different than owner's address, plus description of location on site)
Potential pollution source
Potential pollution source
t.lbr.
Distance from well
/7—r, Distance from well sr)
Potential pollution source Distance from well
Minimum distance of proposed well from property boundary 6ND /
Quality of drainage at site...,Flooding potential of site
(go ,adequate,poor) (high,modlow}
DRAW SKETCH OF SITE
(Show property, boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and north arrow)
O 4
a
Q rr
xrn
March 98

Page 2 of 2
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cont.)
COMMENTS
94)
/ rn:.) ,LA_577
f-F'r'ta
INSPECTOR
r
Office /-2�
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 !4{! [e-mail]
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 SA 7 well.
1. Please review the application and submit any comments to CO-UIC. Retain the
application for your UIC file.
2. Please inspect the proposed injection well site to verify that the location and construction
plans submitted in the application are accurate and t_hat the NCAC Title 15A 2C.0200
standards are being complied with, using the enclosed Preconstruction Injection Facility
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 {919) 715-6166.
cc: UIC Files
Enclosures
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
December 15, 1999
~,.:~,. ~-e,,.,}t;}}!
GOVER~OR· ,. . '
',."
'~,i.:C :-.~'.~iM-AN'•
s1::·c::Ri::t"ARY
Charles Alfred Davis
·:_ .. •:. J 422 Ridge Ro~d
_:-<\r;:Raleigh, NC 27607
·near Mr. Davis:
KERR T. 5,TEVE'NS
DIREC:'i'OR 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].
UIC Files
RRO Files
Sincerely,
f{o.42 /Jf
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
GROUNDWATER SECTION
1836 MAIL SERVICE CENTER, RALIIGH, NC 27899-1836 • 2728 CAPITAL, BLVD.; RALEIGH, NC 27604
PHON IE 91 9-733-322 t FAX 91 9-7 t S-0!588
AN E9UAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER • !50% RECYCLED/I 0% POST•CONSUMER PAPER
... •
TO:
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COl\,fMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR 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
DIRECTOR,_NORTH CAROLINA DMSION OF WATER QUALITY
DATE: :r v \ '/ ;(~ , 19j$
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)
(3)
Type SQM 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; ·
Type 5 QW wells contain a subsurface systei::n, 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, Notification Of Intent To
Construct A Closed-Loop Geothermal-Water Only Injection Well System.
B. PERMIT APPLICANT
C.
D.
Name: C..tiA-~L--e~ AL.FRE:.D ""DAV\!:>
Address: 14 z... z.-. R \ --0 G. ~ ·g t) f[j)
City: 'RPr(....el"tt . Zip Code: ~ ,~ ·tq . County: __ \JJ_.,..._~----"-~--
Telephone: ( tt l '\) '1 ~ i. -o \ l "?--.
C7
\.0 ::.::
U) :C..,
0 C')-;;
rr, 5r•1 PROPER1Y OWNER (if different from applicant) n ~ f,
~(/ c_;:;-; Name: _________________________ a.____ ~·~~~-1
Address: :P ~;; --------------------------=-'...... ,-..,,~
City: z· Code· C ty 't? tf----------· 1p .. ___ . oun : _______ ... .,
w ~
\,,0 0 Telephone: ________ _ :..:
STATUS OF APPLICANT
Private: / Federal: Commercial:
State: Municipal: __ Native American Lands:
GW-57 HP (February 1998) Page 1 of 4
�•
FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial)
Name of Business or Facility:
Address:
City: . Zip Code: . County:
Telephone: . Contact Person:
HEAT PUMP CONTRACTOR DATAy
Name: ?Gw,r►",) %/I (C As tea./ �c'�e-�/. c.cs -f
Address: 42/ 9 ��e4A,,' i a,a e► u
City: Zip Code:' 7. County: jit%i`C11
Telephone: It 9 `fd' *"'Toe . Contact Person: ,-'1'd
G. INJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.)
/411(� E /2 # PPI'a /;VA.64 •►IeA?VC !e r 4
im Art k; ov
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation?
(2) Personal consumption? YES NO
YES NO
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-
f 1 (WeIl Construction Record) if available.
I/f PROPOSED WELL to be'cbnstructed for use akan injection well. Provide the
data in (l) through (7) below .as PRO>OSED construction specifications. Submit
Form GW-1 after construction.
(1) Well Drilling Contractor's Name: ►:4,7 4//-1 FC ►ry '
NC Driller Registration number: /�4fI
(2) Date to be constructed: 4.3/1 Number of borings: l
Approximate depth of each boring (feet):
(3) Well casing: Is the well(s) cased?
(a) YES 1.,/ 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 /2. inches
(b) NO
GW-57 HP (February 1998)
Page 2 of 4

(4)
(5)
(6)
(7)
Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement ✓ Bentonite _·_ Other (specify) ______ _
(b) Grouted surface and grout d~~-(r~ference to ~d surface):
__ around closed loop piping; from __ to __ (f~).
__ around well casing; from _L to 1.,-1) (feet).
Screens (for Type SA 7 wells)
(a) Depth: From /to / feet below ground surface.
N.C. State Regulations (Title 15A NCAC 2C .0200) require the pennittee to make provisions
for monitoring wellhead processes. A fa~cet on both influent (fluid entering heat pump) and
effluent (fluid being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? yes / no __ _: (b)J · · the effluent line? yes_L no __
SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well).
Attach a copy ofFonn GW-1 (Well Construction: Record). If Form GW-1 is not available,
provide the data in part K (1) of this appµcation form to the best of your knowledge.
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF nns INFORMATION IS UNAVAILABLE BY OTHER MEANS.
J.-PROPOSED OPERA TING DATA (for Type 5A 7 wells)
(l)
(2)
(3)
(4)
Injection rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
K. INJECTION FLUID DATA
Average (daily) /)-gallons per minute (gpm).
Average (daily) ·J't O <l gallons per day (gpd).
Average (daily) · t°t' pounds/square inch (psi).
Average (January) ff1 ° F, Average (July) fi!_ ° F.
(1) Fluid source (for Type SA7 wells) If underground, from what depth, fonnation and type of
rock/sediment unit will the,fluid·be dra:wi;i (~;$,,-granite; lime~one;sand, etc.). .
Depth: 5dtJ ~ Formation: ... A~"~· Rocklsedimentunit: 6/JJl,1/,frJ..
(2) Chemical Analysis of Source Fluid (for Type ·sQM wells)
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 equipmentand ·exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
GW-57 HP (February 1998) Page 3 of 4
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.
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
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 appances in accordance with
the approved specifications and conditions of the Permit."
�N L
(Signatun. of Owner or Authorized Agent)
Please supply a letter signed by the owner
authorizing the above agent. if authorized agent is signer_
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)
enature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
INC Program
Groundwater Section
North Carolina DENR DWQ
P.G. Box 29578
Raleigh, NC 27626-0578
Telephone [phone]
GW-57 HP (February 1998) Page 4 of 4

DEC-10-99 FRI 14:15 BOWMAN MECHANICAL SVC
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F34WMAN MECHANICAL 6ERV1CFS
1219 Sturdivant Drive
Cary, NC 27511
High Efficiency.HVAC + Geothermal
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