WI0500109_GEOTHERMAL_20040607

William E. Dean
216 West Gannon A venue
Zebulon, NC 27597
Dear Mr; Dean:
June 7, 2004
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
Coleen H. Sullins, Deputy Director
Division of Water Quality
Your Status of Injection Well System form GW/UIC-68 has been received and reviewed. I have
amended your file to reflect the change of status of your injection well, which has been converted
into a closed-loop water-only injection system. The Groundwater Section appreciates your response
to our written inquiry about the status of your geothermal heat pump system. Please bear in mind
that you are required to notify us of any similar changes of your injection well system in the future.
If you at any time decide to resume using your well for injection purposes, you will need to submit
an application for injection well use to the Division of Water Quality/Groundwater Section/UIC
Program. Please contact the, Division of Water Quality's Groundwater Section at the address or
telephone number printed on this letterhead for an injection well permit application or a copy of the
Well Construction Standards: Criteria and Standards Applicable to Injection Wells.
If you have any questions regarding injection well rules please contact me at [phone] or Evan
Kane at [phone].
Sincerely,
~~ n/J .<f,ta~_
Thomas Slusser
Hydrogeological Technician II
Underground Injection Control Program
Cc: Jay Zimmerman, Regional Groundwater Supervisor
Raleigh Regional Office
CO-UIC Files
N. C. Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27699-1636
Phone: [phone] Fax: [phone] Internet: http://gw.ehnr.state.nc.us
Customer Service
1-877-623-6748
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
June 4, 2004
MEMORANDUM
To:
From:
Re:
Jay Zimmerman, Regional Groundwater Supervisor
Raleigh Regional Office
Thomas Slusser 7-1$
Central Office /.
Status Change of Injection Well Associated With Permit Number WI0500026
William E. Dean, the permitee of the permit number referenced above, is no longer using his well for
injection purposes and has submitted the enclosed form, STATUS OF INJECTION WELL SYSTEM
(GW/UIC-68), documenting this change in status. While we are not requesting a site visit, please
use your discretion to determine if it is necessary to verify this change in status.
Thank you and your staff for all of your help with the UIC Program. If you have any questions
regarding this matter please contact me at [phone] or Evan Kane at [phone].
cc: CO-UIC Files
Enclosures
Permit Number:
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY, GROUNDWATER SECTION
STATUS OF INJECTION WELL SYSTEM
�GOO oZ(
Perrnittee Name:
Address:
WiI,-ect,Vl
/ i'& - : 3a►�Or--1
Please check the selection which most closely describes the current status of your injection well.
In addition, please provide the requested information.
1)
2)
3)
Well is still used for injection activities.
Well is not used for injection but
Se e- 6L-14-6- ke--off
Injection discontinued and: a)_
b)
c)
4) injection well never constructed
If you checked (2),
relevant informgtio
Ot
Is used for water supply or other purposes.
Well temporarily abandoned
Well permanently abandoned
Well not abandoned
tAJ v v1
2�s l
describe the well use (potable water supply, irrigation, etc), including pumping rate and other
n.
too e vr-re_ k-9-4---1"
fh i r
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 fill the well if permanently abandoned):
Certification: (For well abandonment)
"1 hereby certify, under penalty of law, that 1 am personally responsible for the proper abandonment of any
injection well as required in Title 15A NCAC 2C .0214 Criteria and Standards Applicable to injection Weiss."
Signature Date
Certification: (For information verification)
"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."
Signature
1
Date
ver.9/03 GW/UIC-68

05/07/26u4 14:32
919-71n5813
NCD£&NP/WATER f_,UI" PAGE 02
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type SQW Wells
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
This is not the proper form to be used for injection wells in an open -loop geothermal system.
pQL got Ilse this form for systems that circulate any sub ances other than water,
TO: DIRECTOR, NORTH INA DIVISION OF WATER QUALITY
DATE: t) -T. CAROL, 20 04
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES
ayes, then continue completing this foam_
NO If no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And./Or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
B. SYSTEM FLUB? Will any additives be introduced to the syslem's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifree2es.
YES
If yes, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Wells) For Injection With A Heat
Pump System, should be completed.
NO If no, then continue completing this form.
C. PROPERTY OWNER
�7 �nrn
Name: 1,1\1 1 1, �� L) e L r i
Address: 'Z- (rya 4;1_6_0I 01 , : s ►f a Yl jl e.'
City: State; ► ° Zip Code: - 1 5-4 3-
County: Telephone: 1 — of
D. STATUS OF OWNER
Private:
State:
Federal: Commercial:
Municipal: Native American Lands.
Ver.3/41 GW'UIC-57 CL Page 1 of 4

05/07/2004 14:32 919-71f· ~588
I
NCDE&NR/WATER rur·
I
PAGE 03
E.
F.
G.
FACILITY (SITE) DATA
(Fill out ONLY if the Status of O~ is FJfuaJ, State, Municipal or Commercial).
Name of Business or Facility: ---,..~-----t-, -=t~___._ _______________ _
Address: __________________________ _
City: ________ State: __ Zip Code: ____ County: ____ _
Telephone: _________ ContactPerson: ___________ _
Standard Industrial Code(s), SIC, which describes commercial facility: _______ _
HEAT~UMP CONTRACTOR DATA @i
Nameµ; s e,,y V l ch e 1: pvt f ~ t7vA t ,z, B i Y:1 l,J .eAt ( Dv i \l i i:::o/
Address: __________________________ --,,-_
City: ________ State:_ Zip Code: _____ County: ____ _
Telephone: _________ ContactPerson: ___________ _
CONSTRUJTION DAT A (check one)
(1)
(2)
(3)
/ EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (3) below to the best of your
knowledac. Attach a copy of Form GW-1 (Well Construction Record) if
available.
PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump
well{s). Provide the information in (1) through (3) below as PROPOSED
construction specifications . Submit Form GW~l after construction.
Well Drilling Om .. otot's Name: B j ~ t,J e,, I I fu i // {i)j'
NC Contractor Certification number: ________________ _
Date to be constructed: _______ Number of borings: _ ___. _____ _
'-!o ,-/ Approximate depth of each boring (feet): __ ~ ___ :> ___________ _
Well casing: Is the weU(s) cased?
(a) YES .J/_ If yes, then provide the casing information below.
Type: Galvanized steel __ Black steel_ Plastic~ Other (specify) ____ _
cas;ng depth: From () to ~s' ft. (reference 10 land surface)
Casing extends above growtd _ _,O,e__ inohes
(b) NO L
Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.J,s.):
(a) Grout type: Cement_L Bentonite _ Other (specify) ______ _
(b) Gr~ted surface and grout depth (reference to land surface):
_j£_ around closed loop piping; ftom 6 to 5 (feet).
__ around well casine; from_ to __ (feet).
NOTE: THE WELL 'ORJU.r.NG CONTRACTOR CAN SUP.Pl. YTHE DATA FOR EITlfER EXISTfNG OR
~0POSED W!U.S IPTIUS INFORMATION JS UNAVAILABU! BY O'Illl!R MEANS.
Vcr.3/01 GW /UIC-57 CL Page 2 of4
05/07/2004 14:32 91 9-11 r '588 NCDE&NR/WATER QLJr ·
I
PAGE 04
H. .INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL($) Attach two maps.
(l) Include a site map (can be drawn) showing: buildings, property lines surface water bodies,
potential sources of groWldwater 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 witrun 200 feet of the growid-coupled heat pump well system. Label all
features clearly and include a north arrow.
(2) location map referencing the site to two nearby permanent reference points (such as roads.
streams ind highway intersections).
J. PERMIT LIST: Attach a list of all permits or construction approvals that are related t.o the site.
Examples include:
(1) Hazardous Waste Management proaram permits under RCRA
(2) NC Division of Water Quality Non-Diseharae permits
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
Ver.3/01
"I hereby certify. under penalty oflaw, that I have personally exami.ned and am familiar with the
information submined in this document and all attaduttems thereto ar.id 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 possibilit)'
of fines and imprisonme.nt, for submitting false infonnition. I agree to consuucr, operate, maintain,
repair, and if applicable, abandon the ground-source heat pump system and all related appurtenances in
accordance with the approved specifications and conditions of the Petmit."
(Signature of Well Owner or Authorited Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the l>Wner
authorizing the above agent.
GW/UIC-57 CL Page 3 ot'4
05/07/2004 14:32 919-71 ~· "188
' NCDE&NR/WATER QU( PAGE 05
L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other propetty
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.)
Ver.3/01
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 01.1tlined in this application and that it shall be
the responsibility of the applicant to ensure that the ground-source heat pump systero' s well(s)
conforms to the Well Construction Standards (Title lSA NCAC 2C .0200)
(Sigoature Of Property Owner If Different From Applicant)
'.Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
I 636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
OW/UIC-S7 CL Page 4 of4
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— . DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION OF WATER QUALITY
tt. GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
RALEIGH, NC 27699-1636
2728 CAPITAL BLVD, RALEIGH, NC 27604
FAX: '[phone]
PHONE: [phone]
WEB ADDRESS: http://GW.EHNR.STATE.NC.US
TELECOPY TO: W I L L l ,q/i i & it/
'COMPANY NAME:
FAX #:,97 71 0&(%--O2 4TELE: / DATE: S/ 7o
NO. OF PAGESGEINCLUDING THIS SHEET:
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FROM: ! Zohl 1,5 S/tj-e —
COMMENTS:
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FBIXSII F:I 1 A1 l'IGI I31y0I] I

SE • : COMPLETE TH►S SECTION
a Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
• 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 mailpiece,
or on the front if space permits.
1. Article Addressed to:
William Dean
216 West Gannon Avenue
Zebulon, NC 27597-2626
s
COMPLETE THIS SECTION ON DELIVERY
A. Received by {Please'Print Clearly)
11� L !
�l.• � 1 �,-frJi-+ ram. �tSi'�
B. Date of Delivery
C. Signature,
x i44 ,P(',
D. Is delivery address dt* from t
If YES, enter delivery address b
Yffil
NO!f
I n06 ". !U
'Certified Mail CI Express Mail
J C j I. INgt,Im Receipt for Merchandise
ka� 1164ur41d Malt' 'i.i ❑
4. Restricted Delivery? (Extra Fee)
Cl Yes
7003 1010 0001 2611 4292
PS Form 3811, July 1999
Domestic Return Receipt 102595.00-M-0952

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
Coleen H. Sullins, Deputy Director
Division of Water Quality
April 21, 2004
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
William Dean
216 West Gannon Avenue
Zebulon, NC 27597-2626
Ref.: Expired UIC Permit # WI0500026
Dear Mr, Dean:
The Underground Injection Control (UIC) Program of the North Carolina Division of Water Quality
is responsible for the regulation of injection well construction and operation activities in the state.
Our records show that a geothermal heat pump system with an associated injection well was
constructed and permitted on your property under the name of William E. Dean. The permit for this
injection well expired on January 31, 2003; therefore, your well may be in violation of North
Carolina General Statute Section 88-87(j) and other state regulations.
The UIC Program would like to help you resolve this situation by completing one of the following
procedures:
I.)
If a geothermal heat pump system is operating on your property and you have an injection
well as part of this system, please complete and sign the enclosed form "APPLICATION
FOR PERMIT RENEWAL TO USE A WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM."
2.) If an injection well is not operating on your property, please complete and sign the
enclosed form "STATUS OF INJECTION WELL SYSTEM" indicating that an injection
well is not in operation on your property.
3.) If you are unsure whether you have an injection well, please contact us at the phone
number below so that we can help you make that determination,
N. C. Division of Water Quality 1 Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27699-1636
Phone: [phone] Fax: [phone] Internet: http:llgw.ehnr.state.nc.us
atm
Customer Service
1-877-623-6748

Mr. Dean
Expired UIC Permit# WI0500026
April 2 I, 2004
Page 2 of 2 .
The me Program is sending this letter in expectation that you respond regardless of whether or not
you currently have an injection well as part of your heating and cooling system. Please note that if
you do not respond to .this letter within 30 days an inspection of your property may be forthcoming
to determine if an injection well is operating on your property.
If you would like assistance completing any of the forms, or if you have any questions regarding the
UIC Program or injection well rules, please contact me at [phone] or Evan Kane at (919)
715-6165.
cc: CO-UIC Files
Enclosures
Best regards,
~J?~.
Thomas Slusser
Hydrogeological Technician II
UIC Program
Please initial and return
to Amy for processing.
Ted Bush
Bob Cheek II'"? c
Amy Axon
Marcus Geist
(r

,./AMES B. HUNT,JR.
:GqVERNOR
WAYNE MCDEVITT
SECRETARY
·•A. PRESTON HOWARD,
JR., P.E.
lllRll!:CTOR
Mr. William E. Dean
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
GROUNDWATER SECTION
January 22, 1998
DIVISION OF WATER QUALITY
216 W. Gannon Avenue ,,,,..,/
Zebulon, NC~587 z.,"1-591---~tel qJ11,,19 ~
"Pd.i:1
Dear Mr. Dean:
In accordance with your application dated October 20, 1997; we are forwarding Permit
No. WI0500026 for the operation ofa geothermal heat pump injection well at 216 W.
Gannon Avenue, Zebulon, NC, in Wake County. A copy of the laboratory test results
of water samples collected on November 12, 1997 is also enclosed. Please note the
high concentration of iron detected in your water. The iron level entering your heat
pump system (influent sample) is significantly higher than the iron level exiting your
heat pump system (effluent sample). You might experience clogging problems with
your system, unless the iron concentrations are reduced through a treatment unit.
This permit shall be effective from the date of issuance until January 31, 2003 and shall
be subject to the conditions and limitations stated therein, including the requirement to
notify this office by telephone 48 hours prior to initiation of operation of the facility. In
order to continue uninterrupted legal use of this well for the stated purpose, you should
submit an application to renew the permit three months prior to its expiration date.
If you have any questions regarding your permit please contact me at (919) 715 -6166
or Amy Axon at [phone] .
cc: lilCFdes
RROFiles
Enclosures
Sincerely,
Marcus A. Geist
Underground Injection Control Program
GROUNDWATER SECTION
P.O Box 29578, RALEIGH, Ne 27626-0578 • 2728 CAPITAL BLvo., RALEIGH, NC, 27604
PHONE [phone] FAX [phone]B
AN EQUAL OPPORTUNITY/ AFFIRMATIVE ACTION EMPLOYER• 50% RECYCLED/I Oo/o POST-CONSUMER PAPER
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE 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
William E. Dean
FOR THE OPERATION OF AN INJECTION WELL for the purpose of injecting heat pump
effluent. This well is located at 216 W. Gannon Avenue, Zebulon, North Carolina, in Wake
County, and will be operated in accordance with the application dated October 20, 1997, and in
conformity with the specifications and supporting data submitted, all of which are filed with the
Depai:tment 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 January 31, 2003,
and shall be subject to the specified conditions and limitations set forth in Parts I through VIII
hereof.
Permit No. WI0500026
Permit issued this the 21 ~f day of January, 1998. <[7 {& < ~;;_-;--~
Ted L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
PAGE I OFS
_,_, ....
PART I-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 (ISA 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 is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
3. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to change
ownership, or there is a name change of the Permittee, a formal permit amendment request
must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
4. 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 II -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is
no contamination of groundwaters which will render them 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 (Division) 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 groundwaters resulting from the operation of this facility.
PermitNo. WI0500026 PAGE20F 5
PART ill -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 IV -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained under
the terms and conditions of this permit, and may obtain samples of groundwater, surface
water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided for
in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART V -MONITORJNG 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 sample 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 Groundwater Section Staff, Raleigh Regional Office,
telephone number [phone], any of the following:
(A) Any occurrence at the injection facility which results in any unusual
operating circumstances~
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or
electrical failures.
Permit No. WI0500026 PAGE 3 OF 5
(
3. Where the Pennittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report to
the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the 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 VI-PERMIT RENEWAL
The Permittee shall, at least three (3) months prior to the expiration of this Permit,
request an extension.
PART VII-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 Pennittee 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, Well Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment
procedures if the Director finds such removal will not be responsible for, or
contribute to, the contamination of an underground source of drinking
water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
Permit No . WI0500026 PAGE 4 OF 5
(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 ISA NCAC 2C .0213(h)(l) within 30 days of completion of
abandonment.
3. The written documentation required in Part VII (1) and (2) (G) shall be submitted to:
Groundwater Section -UIC Staff
DEHNR -Division of Water Quality
P.O. Box 29578
Raleigh, N.C. 27626-0578
PART VIlI -SPECIAL CONDITTONS
NONE
Permit No. WI0500026 PAGES OF 5
GROUNDWATER SECTION
January 22, 1998
MEMORANDUM
To:
From:
Jay Zimmennan
Groundwater Section
Raleigh Regional Office
Marcus Geist If Ab
UIC Group
Groundwater Section
Raleigh Central Office
Re: Issuance of injection well permits.
Permit Nos. WI0500025 and WI0500026 to use a well for the injection geothermal heat pump
effluent have been issued to Ms. Peggy Clayton of Stem and Mr. William E. Dean; copies of these
permits are enclosed for your files. The Underground Injection Control Group appreciates your
staff's assistance with injection well inspection and sampling tasks. If you have any questions
regarding this permit or the UIC program, please contact me at [phone] or Amy Axon at
[phone].
cc: UIC Files
RROFiles
Enclosures
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COM1vISSION
4 ►1.) 26 -ILDEPARTMENT OF ENVIRONNENi, HEALTH, 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 LO
complete application and mail to address on the back page. CD
—r
Type 5A7/5QM Wells
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER. QUALITY
DATE. /0- 2.0 , 19 97
Please type or print clearly,
A. SYSTEM CLASSIFICATION Does the proposed system re -circulate only potable
water without any additives such as corrosion inhibitors or antifreezes in continuous
piping which isolates the fluid from the environment?
YES _ If yes, do not complete this form. A form GW-57 CL. (Notification
Of Intent To Construct A Closed -Loop Geothermal -Water -Only
Injection Well System), should be completed.
N3 If no, then continue completing this form.
B. PERMIT APP
LICANT
Name: -e.ge0.
Address: c2/ rtf
City: Zea
County: (
Zip code: ,0 7 S u 7
i eiephor e: 12-6 ► a 3- 3
C PROPERTY -OWNER (if different from applicant)
Name:,2
Address: c /fp 4 a. - .
City: Z 1 f C Zip code: 077537
County: le.r� Telephone: Zb `3 Q - 3
D. STATUS OF APPLICANT
Private: Imo"
State:
Federal: Commercial:
Public: Nztive American Lands:
E. FACILITY (SITE) DATA (Fill out ONLY 1 the Status of Owner is Federal, State. Public
or Commercial).
Name of Business or Facility:
GW-57 HP (March 1997) Page 1 of 4

Address: _______________________ _
City: ___________ _ Zip code: ________ _
County: ________ _ Telephone: __________ _
Contact Person: ______ _
Standard Industrial Code(s) which describe commercial facility: _______ _
F. BEAT PUMP CONTRACTOR DATA
Name: Ir/-~ ~
Address: _______________________ _
City:~~//,/.~. Zipcode:_·:-.----Councy:.~
Telephone: C/L<?-,39-C770 ContactPerson: (;.Mte, -;i/~
G. INJECTION PROCEDURE (Briefly describe how the ~ well(s) will be
~!-?&:~~ ~ :""~
H. WELL USE Will the injection well(s) also be used as the supply well(s) for
either of the following?
YES V
YES __
(a) The injection operation? NO __ --=-
NO i-,---(b) Your personal consumption?
I. CONSTRUCTION DATA (CHECK ONE)
(1)
(2)
EXISTING WELL(S) being proposed for use as an injection well(s).
Attach a copy of Form GW-1 (Well ~onstruction Record) and furnish items 1~6.
If Form GW-1 is not available, furnish the data to the best of your knowledge.
,__-PROPOSED WELL(S) to be constructed for use as an injection
well(s). Furnish items 1-6 as PROPOSED construction specifications. Submit
Form GW-1 after construction., ,
Well Drilling Contractor's Name: ~ 64ef'/~;Bc .
NC Driller Registration number: .-~~~~9'.'; ..... st'~---------
Date to be constructed:5-/?-97 Number of borings: _ ___._/ __ _
Approximate depth of each boring: zl45 feet
(3) Well casing: Is the well(s) cased?
(a) YES ~ If yes, then provide casing information below.
Casing type: Galvanized steel_ Black steel _ Plastic V
· Other (specify) ________ _
Casing depth: from -J-/ ft. (reference to land surface) to l/:7
ii Casing extends above ground inches
(b) N)
GW-57 HP (March 1997) Page 2 of 4
used.)
( 4) Grout (material surrounding well casing and/ or piping):
(a) Grout type: Cement v{Bentonite_; Other (specify) _____ _
(b) Grouted surf ace and grout depth (reference to land surface):
_ around closed-loop piping; from. ___ to ___ ft.
~und well casing; fr~m O to 2D ft.
(5) Screens (if applicable):
(a) Depth: From ___ to ___ feet below ground surface
(6) 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. Will there be a faucet on:
(a) the influent line? yes~-(b) on the effluent line?yes V no __
N01E: THE WELL DRILLING CONTRACTOR CA.'\J' SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFOlli'v1ATION IS UNAVAILABLE BY OTHER MEANS.
J. PROPOSED OPERATING DATA
(a) Injection rate: Average (daily) --3 e:allons per minute (gpm)
(b) Injection volume: Average (daily) {. 'itJO e:allons per day (gpd)
(c) Injection pressure: Average (daily) /0 (psi) ~ ·
(d) Injection temperature: Annual Average 80 ° F. "'-·
K. INJECTION FLUID DATA
(1) Fluid Source. If underground, from what depth , formation and type of
rock/sediment unit will the fluid be drawn(e.g., granite, limestone, sand).
Depth: 55 Formation: &~ Rockunic _____ _
(a) SOURCE WELL CONSTRUCTION INFOR.\1ATION (if different from injection well).
Attach a copy of Fonn GW-1 (Well Construction Record). If Form GW-1 is not
available, provide the data in part I of this application to the best of your
knowledge.
(2) Chemical Analysis of Source Water. The follO\ving chemical characteristics
fv1UST accompany this appiication:
pH ~. 0 I ; Total hardness l 1. \ ppm (parts per million or mg/1);
Iron~ ppm; Chloride /0.-S' ppm; Nitrate • 0 8 / ppm;
Coliform bacteria ,46cu,,,,,:;;c:: coums /lO0ml
NOTE: Assistance in determi1:ffig these values may be obtained by contacting: your local or county
health official, a commercial wate:-testing laboratory, your well drilling contractor, or the
regional Hydrogeologist, NC Dept. of Em'ironment, Health, and Natural Resources.
L. INJECTION-RELATED EQUIPNIENT
Attach a diagram showing 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).
GW-57 HP (March 1997) Page 3 of 4
M. LOCATION OF WELL(S) Attach two maps
(1) Include a site map (can be drawn) showing: 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 ground-source
heat pump well system; include buildings, property lines, surf ace water bodies,
any other potential sources of groundwater contamination. Label all features
clearly and include a north arrow to indicate orientation.
(2) Include a topographic map of the area extending one mile from the property
boundaries and indicate the facilitis location and map name.
N. PERMIT LIST: Attach a list of all permits or construction approvals, received or
applied for by the applicant that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
0. 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. t am aware that there are significant penalties, including the possibility of
fines and imprisonment, for ~ubmitting false infonnation. · 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 o~-
Permit." · . . --fl~~-=-· -'--"""'----"-q--"--.---'~"---"--'..cc......==----=----
(Sirnature of Owner or Authorized A!!ent)
Please supply a letter signed by the owner -~ -
authorizing the above agent, if authorized agent is signer. ~ rv,.J~-E' .&~'-
·P. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other
. property rights in the well being constructed. A well is real property and its
construction on land rests ownership in the 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 construct an injection well(s) as outlined
in this application and that it shall be the responsibility of the applicant to
ensure that the iajection well(s) conform to the Well Cons~= -" [? .
(Title 15A NCAC 5.ubchapter 2C .0200) (R~ 9 . /~
GW-57 HP (March 1997)
. : {~ignature of Property Owner if Different From Applicant)
Please return the c'ompleted Applicatio~ package to:
Underground Injection Control Program
Groundwater Section
North Carolina DEBNR-DWQ
PO. Box 29578
Raleigh, NC 27626-0578
(telephone: [phone])
Page 4 of 4
a
COON I 1
QUAD NU
WAKE
DIVISION OF WATER QUALITY
Chemistry LaharRlory Report / Ground Water Quality
SAAII'LE PRIOitrr►•
�R01.1T1NE D1_MIDRGENCY
•
REPURT:1O RHO Rcgkona1O17ice CHAIN OF CUSTODY
COLLECTORS} GREER
DATE 11/12/97 E SAMPLE TYPE
TIME -
PURPOSE ()ohm : All_ WILLIAAI BEAN
Locao k n or Site
LABORATORY ANALYSIS
80D 310
me.
COD High 340
mg/L
COD Law 535
mg/.
Caliform. MF Fecal 31616
/ 100m1
X
Carom M1 Total 31504
s 1
r100m1
FOC
rstg/l
Turbitily
NTL1
Residue., Suspended 530
mg/1.
Teal Suspended solids
mWL
p11
units
A1kalin+lr to p1115
mg/L
AILalinit so p1! 9.3
mgoL
Carbonate
mflL
bicarbonate
mviL
Carbon dioxide.
mat L
X
Chloride
3
urg'i.
Chromium Ilex 10.12
ug:L
Color 1sur10
au.
Cyanide 720
mg•L
COP I M1 ENTS
Description nlsamplingpninl
Sampling Mellnnl:
Remmks:
2
Dias. Solids 70300
mg/L
Fluoride 951
mgfl.
N
1 hardness: natal 900
12
mg/L
Hardness: lnon-carbl 902
mg/L
Phenols 32730
ug/L
Specific Coed 95
uMhos/cla2
Sulfate
-
mg/L
Sulfide 745
1,110.
MBAS
mg/L
Oil and Grease
mg/L
Silica
mg/L
boron
Formaldehyde
m91L
X
N113 as N6I0
<0.01
mg/L
X
TKNasTt625
0.1
mg&L
X
NO2 +NO3 ns n 630
<001
mgiL
F. -room as P 665
mgil-
PO4
role
Ag-Sil1cr 46566
ug/L
M-Aluminum 46557
uglL
As -Arsenic 46551
ugil,
1!a-Barium 46555
ug/f.
Ca -Calcium 46552
mg/L
X
Cd-Cedium 46559
<2,0
ug/L
X
Ct-Chromium 46560
c2S
ng/L
X
Cu- Copper 1042
23
ug/L
X
Fe- Iron 1045
540
ug/L
lig• Al vestry 71900
tie,
K-rnukssium 46555
mg/L.
Ma- hlugnesium 927
nag/L
X
Aln-Atnngnriesr 1055
120
ug/L
Na- Sodium 929
mg/L
X
Ni-Nickel
<10
ug/L
X
Pb-Lead 46564
<1 D
Vt.
Se -Selenium
ug/L
X
Zn Zinc46567
26
ug/L
Lab Number 7(;2439
1]mc Received 11/12/97
Time Received 13;20
Received 1ly : IIMW
Released By 175
Daly wp :Fled 1/5/911
013am:ch lorine Pesticides
Organophosphnrns Pesticides
Nitrogen Pesticides
Acid herbicides
X
Sendvolatkkcs
TPII-Diesel Range
V01eli1e Ol9nllics iVOA bank)
TPII-Gasoline Runge
TPH-BTEX Gasoline Range

GROUNDWATER FIELD/LAB FORM
County__ _
Quad No_ .. Serial No.
Lat. Long.
Report To: ARO, FRO, MRO, CEDWaRO, WiFiO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other: _
Shipped by: Bj , Courier, Hand Del., I _ V IF
SAMPLE.TYPE SAMPLE PRIORITY
2. Water ❑ Routine
D Soli ❑ Emergency
0 Other
❑ Chain of Custody
Collector(s): Date
FIELD ANALYSE
pH400 Spec. Cond.94
Temp.14 °C Odor
Appearance --
Field Analysis By:
LABORATORY ANALYSES
Time �r j
at 2a° C
BOD, 310
n19/1
COD High 340
mgll
COD Low 335
mg/1
Colilorm: ME Fece131616
/1.00m1
JColi1orm:
ME Total 31504
/100ml
TOC 680
mg/1
Turbidity 76
NTU
Residue., Suspended 530
mg/1
pH 403
units
Alkalinity to pH 4.5 4 t0
mgll
Alkalinity la pH 5.3 415
mgll
Carbonate 445
mgfl
Bicarbonate 440
mq/1
Carbon dioxide 405
mg/I
L.
Chloride 940
mg/1
Chromium: Hex 1032
ugl1
Color: True 80
CU
Cyanide 720
sng/I
Purpose:
Baseliqs. Complalrrl Qrtt liance. US I, Pesticide Study, Federal Trusl,(lt1C17-) 6-1 I !._
rcre of
Owner .1 r' • [ I II,"riF �� >�
Location or site -2—_,‘ W e 7` a ra I,u ii r4* .) z 6-444.71v 46 - 7 a57
Description al sampling point __-__I,‘" c-I/ i e
Sampling Method Sample Interval eIr_+-f a /1 1
Remarks
Norlh Carolina
Department of Environment, Health, and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
7
Lab Number F.' 7 ' I
Dale F{ecei ed 1.'7Ii/1-7 Time / 0
Rec`d by: t.4,1 From: Bus, Courier,(115fd if4
Other: — - -- Data Entry By: - - Ck:
Date Reported:
Diss. Solids 70300
>;lourido 951
moll
mt11I
Hardness* Total 900 mn l
Hardness (non-carbl 902 mull
Phenols 3273Q uo/!
Suecific_Cand.95 - iMhvs rjr_
Sulfate 945 moll
Sulfide 745 rr1y1!
all and Grease
mgll
NH, as 610
1-15.N as N 675
NO2. # NO, as N 630
P: Total as P 665
moll
Inuit
moll
mg/1
(Pu .lie[, etc.}
(}pumping lime. a tempp.. 6110
A_g - Silver 46566
Al - Aluminum 46557
As - Arsenic 46551
Ba - Barium 46558
Ca
Calcium 46552
Cd - Cadmium} 46559
Cr - Chromiuin 46550
„Cu - Copper 46562
Fe - Iron 46563
Hg - Mercury 71900
K - Potassium 46555
,Mg - Magnesium 46554
Mn - Manganese 46565
Na - Sodium 46556
- Nickel
Pb - Lead 46564
Se - Selenium
Zn - Zinc 46567
moll
ugll
ugll
uyll
uglt
ugll
mgll
mg/1
ugli
mull
ugjl
ugf1
ug/1
uql!
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCB's
ernivolatlle Organics
TPH - Diesel Flange
Volatile Organics (VOA bottle)
TPH - Gasoline Range
TPH - BTEX Gasollre Range
7
Lab Comments:
GW-54 REv. 7f95 For Dissolved Analysis - submit filtered sample and write "DIS" in No

REPORTED BY
CHECKED BY
REVIEWED BY
SAMPLE TYPE:
WATER
EHNRIDWO. LABORATORY
SEMI -VOLATILE ANALYTICAL REPORT
ANALYSIS RESULTS
LAB NO. 702439
SUPERVISOR`
DATE
ENTERED BY
DATE
-R
SEMIVOLATILES
TARGET COMPOUND]
TQL DETECTED.
us/1- ugt1
CAS4 SEM1VOLATILES
TARi5ET<DoMPOUN0
VOL DE1'EC1'ED
62-53-3
108-95-2
111-44-4
95-57-8
541-73-1
106-46-7
100-51-6
95.50.1
95-48-7
108.60.1
106.44-5
621-64-7
67-72-1
98.95.3
78-59-1
88.75.5
105-67-9
65.85.0
111-91-1
120-83-2
120-82-1
91.20-3
106-47-8
87-68-3
59.50.7
91-57-6
77.47.4
88.08-2
45-95-4
91-58-7
88- 74.4
131-11-3
208-96-8
ANILINE
PHENOL
1'JlSI2-CHLOROETHYLI ETHER
2-CHLOROPHENOL
1,3-DICHLOROBENZENE
1, 4-DICHLQRQBENZENE
BENZYL ALCOHOL
1,2-D1CHLOROBENZENE
2-METHYL PHENOL
13ISI2•CHLDRDISOPROPYLI ETHER
4-METHYL PHENOL
N-NI TROSO-D I•N-PRQPYLAMINE
HEXACHLOROETHANE
NITROBENZENE
ISOPH0RONE
2-NITRO PHENOL
2.4.01METHYL PHENOL
BENZOIC ACID
BISI2-CHLOROETHOXY? METHANE
2.4-DICHLORO PHENOL
1,2, 4-TRICHLOROBENZENE
NAPHTHALENE
4-CHLOROANILINE
HEXACHLOR0BUTADIENE
4-CHLORO-3-METHYL PHENOL
2-METHYL NAPHTHALENE
HEXACHLOROCYCLOPENTADIENE
2,4,6-TRICHLORO PHENOL
2,4,5-TRICHLORO PHENOL
2-CHLORO NAPHTHALENE
2-NITROANILINE
DIMETHYL PHTHALATE
ACEN APHTHYLENE
1 ❑ U 606-20-2
10 U 99-09-2
10 U 83-32.9
10 U 51-28-5
10 U 100.02-7
10 U 132-64-9
20 U 121-14-2
10 U 84-66-2
10 U 700E-72.3
10 U 86-73.7
10 U 100-01-6
10 U 534.52.1
10 U 86=30-6
10 U 101-55-3
10 U 118-74-1
10 U 87.8E-5
10 U 85-01-8
50 U 120-12-7
1 ❑ U 84-74-2
10 U 206-44-0
10 U 129-00-0
10 U 85-68-7
20 U 91.94.1
10 U 56-55-3
20 U 218-01-9
10 U 117-81-7
10 U 117-84-0
10 U 205-99-2
10 U 207-08-9
10 U 50-32-8
50 U 193-39-5
10 U 53-70-3
10 U 191-24-2
2,6-DINITROTOLUENE
3-NITROANILINE
ACENAPHTHENE
2,4-D1NITRO PHENOL
4-NITRO PHENOL
❑IRENZOFURAN
2, 4-DINITROTOLUENE
DIETHYL PHTHALATE
4-CHLOROPHENYL PHENYL ETHER
FLUORENE
4-NITROANILINE
4.6-DINITRO.2-METHYL PHENOL
N-NITRO 5 DD I PH ENYLA MINE
4-BROMOPI-IENYL PHENYL ETHER
HEXACI-fLOROBENZENE
PENTACHLORO PHENOL
PHENANTHRENE
ANT HRACENE
DI-N-BUTYL PHTHALATE
FLUORANTHENE
PYRENE
BUTYLBENZYL PHTHALATE
3, 3'- D 1C HL0 RQ B EN ZIDIN E
BENZDIA/ANTHRACENE
CHRYSENE
BISI2-ETHYLHEXYLI PHTHALATE
DI-N-OCTYL PHTHALATE
BEN ZO I61 F LU O RANTH E N E
BENZOIKI FLUORANTHEN E
BENZOIA}PYRSNE
INDENO{1, 2,3-CDI PYRENE
❑IBENZOIA.HIANTHRACENE
BENZO(G,H,IIPERYLENE
10
50
10
50
50
1❑
10
10
10
10
50
50
10
10
10
50
10
10
10
10
10
10
20
10
10
10
10
10
10
10
10
10
10
l7

SEMIVOLATILE ORGANICS REPORT - DWD LAB PAGE 2 LAB NO. 7G2439
Ottt r;Setiti V:otOtile ca:ixlpeuridi-rttat c r
NO RASEINEUTRAL Ofi ACID EXTRACTABLE ORGANICS
DETECTED BY GC/MS.
COMMENTS:
TOL- Target Ouantitation Limit- Subject to
change due to instrument sensitivity
T- Tentatively identified, estimated concentration
E- Estimated Value
U- Samples analyzed for this compound but not detected
N- Sample not analyzed for this compound
D- Detected below quantitation limit
H- Holding time exceeded

COUNTY {MAKE
QUAD NO.
REPORT TO PRO
COLLECTORIS) GREER
DATE: I1112/97
TIME:
PURPOSE:
LABORATORY ANALYSIS
DIVISION OF WATER QUAL! k
Chemistry Laboratory Report (Ground Water Quality
SAMPLE PRIORITY
ROUTINEEMERG ENCY
Regional Office CIIAMN Or CUSTODY
SAh1PLE TYPE
no] 310
mg/L
COD I1igh 340
mg/L
COD Low 335
ng/L
Coliform: h1F Fetal 31616
/I00m1
y(
Califarre; &IF Tom] 31504
e1
/100tid
LOC
mg4
Tinbilih
NTLI
Residue.. Suspended 530
mg/L
Taal Suspended solids
mg/L
p11
,nits
Ali rdinih :opt! 4 5
mg• L
Alkalinity rop111J
mg,1.
Carbonate
ntgL
Bicarbonate
ma•i_
Carbon dioxide
lmut
X
Chloride
4
mgt.
Chromium: Ilex 1032
ug/L.
Color: True g0
e.u-
Cyanide 720
mat
:Om MErin
Outer- MR. WILLIAMS DEAN
Local ion or Site:
Description of sampling point
Sampling Mcthod-
Remarks.
1
Diss. Solids 70300
mg/L
Fluoride 951
mg/L
I larderss: total 900
32
mg/L
I Inrdncss: lnnn-carb) 902
ntg/L
Phenols 32730
ug/L
Specific Cond. 95
uMhoskm2
5111fatc
mg/L
Sulfide 745
mg/L
hIBAS
mg/L
Oil and Chem
me.
Silica
mgtT.
Boron
Formaldehyde
nylll..
NI13asN610
.0.01
mgll.
X
IEli asN62_5
0,1
mglt.
NO2 +NO3 as n 030
40.01
mg/L
P: Total as P 665
mglL
PO -I
InglL
Ag-Silver 46565
ug/L
CAI -Aluminum 46557
ug/L
As -Arsenic 4655 t
ug/L
DwOarium 46555
ug/L
Ca -Calcium 46552
mfyL.
X
Cd-Cacum 46559
42.0
ug/L
X
�Cr-Chramium46560
A25
ug/L
X
Cu- Capper 1042
34
ug/L
X
Ft- Iron 1045
2400
ug/L
I Ig- Mercury 71900
ug/L
1:-lru:usiunt 46555
mg/I.
1tIg- itlagnesiun, 927
mg/L,
X
Mn-Mmganese 1055
130
ug/L
Na- Sodium 929
mg/I.
X
Ni-Nichef
410
uglL
X
Pb-Lead 46564
410
ug/L
Se -Selenium
ug/L
X
Zn Zinc 46567
25
uglL
Lab Number • 7G2438
Dale Rozeivcd . 11113/9-1
Time Received ! 120 Phi
Received Ily • I IMW
Released By DS
Dale mantled I15/95
Orgenochrerine Pesticides
Qrganophospherus Pesticides
■
Nitrogen Pesticides
■
■
Acid herbicides
Semi vain: des
■
TPH-Diesel Runge
Volatile Organics I VOA bwlkl
TPIS-Gasoline Munn.
fPH-B.1'L•.'( Uasoline Ronne
1
70zaa1++av

..
N o r t h C a r o'.I I n a
"GROUNDWATER FIELD/LAB FORM Department of Environment, Health,i and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
County W«-4 SAMPLE TYPE SAMPLE PRIORITY Lab Number/&--~ 1/-: 5.:_?S'
Quad No Serial No. ~ Water D Routine Date Reci;ved 7'2/lic Z Time I 3 ;;;;__c:; Soll D Emergency 0 Lat. Long. D Other Rec'd by:}JJtl//1
From: Bus, Courier, ~a~
Other:
Report To: ARO, FRO, MRO,<a:B.<,1)vaRO, WiRO, D Chain of Custody Data Entry By: Ck:
WSRO, Kinston FO, Fed. Trust, Central Off., Other: ________ _ Dale Reported: ______________ _
Shipped by: Bus Courier, Hand Del., QI1Jw~P2--k'----,---------
-,,,, -., / Purpose:
Collector(s): · Date ·~ i Z. L£Xime -::..._.c~-=----· · -; ·--· · y, Federal Trust, ~--U~/----'L=·---
FI ELD ANALY E /' Owner -.:C....:.-'-'C-'-''----j~e......./,'--L.L...J.:..L:...~L-----'=..-,,:--=-----J,....-'--'-'---1...t....L.J.~-------------
p H ,IQ O _____ Spec. Cond.94 ____ at 25° C Location or site _ __.,=-_L___.k::, __ ~,:___-~'-LJ.:......L:.L.£l'--~~~L--~=--......... -·z""'-"'~=---LDL.-'-~,£_.C......,>""'·-_,~~7
Ternp.10 _____ 0 c Odor _______ Description of sampling point --"'-'i:,.£-1-'-"--':,C-.~=-=~£....:CL-....---------------=-----,++---
Appearance ________________ Sampling Method --------,~r,..Pu-mc-t-a=i1er-._,
81
-.c.) ________ Sample Interval ·-::C-/\I w ~1-f
Field Analysis By: ______________ Remarks ___________ ~ __ u ____ ;..,.:;5,=-.....J="'------------------
LABORATORY ANALYSES (pumpingllme,alrtemp.elc .) . 6-~ i,,•.:l z. 0
f-BOD, 310 mgtl Diss. Solids 70300 mo/I Ao -Silver 46566 uo/1 Organochlorine Peslicides
COD High 340 mg/I Ylouride 95 t mo/I Al -Aluminum 46557 uo/1 Organophosphorus Pesticides
COD low 335 mg/I v Hardness: Total 900 mg/I As -Arsenic 46551 uo/1 Nitrogen Pesticides
Colilorrn: MF Fecal 31616 /1-00ml
✓ Coliform: MF Total 31504 1100ml
Hardness {non-car b l 902 mg/I Ba -Barium 46558 UQ /1 Acid Herbicides
PhenQIS 32730 ug/1 Ca -Calcium 46552 mall PCB's
TOC 680 mg/I Sgei;;ific CQnd. ~:i uMhoslcm 2 I/ Cd -Cadmium 46559 ug/1
Turbidity 76 NTU --Sulfate 945 ma/I v Cr -Chromium 46560 ua/I --
--Residue ., Suspended 530 mg/I V Sullide 745 mo/I Cu -Copµer 46562 U!,J/1 / --V Fe -Iron 46563 ug/1 V Semivolatile Organics
--OIi and Grease mg/I Hg -Mercury 71900 ug/1 TPH -Diesel Range
pH 403 units K -Potassium 46555 mg/I
Alkalinily lo pH 4.5 410 mg/I Ma -Maanesium 46554 mu/I
Alkalinity lo pH 8.3 415 mg/I , V Mn -Manaanese 46565 uo/1
Carbonate 445 mg/I v -NH. as N 610 ma/I Na -Sodium 46556 mq/1 Volatile Organics (VOA bottle)
Bicarbonate 440 mq/1 V )!'KIi.i <>c: N A?.:; moll I/ .. Ni-Nickel 11 n /f TPH -Gasoline Ranae
., Carbon dioxide 405 mg/I ✓ NO. + NO. as N 630 mo/I V Pb -lead 46564 UQ/1 TPi-1 -BTEX Gasollre Range --✓ Chloride 940 mg/I P: Total as P 665 mo/I ,Se -Selenium UQ/I /
Chromium: Hex 1032 ug/I L/ Zn -Zinc 46567 ua/1 l---,,
Color: True ao cu J --
Cyanide 720 mg/I ,/
Lab Comments: --------------------------------------------------------
GW-54 REV . 7/9f For Dissolved Analysis -submit filtered sample and write "DIS" in blc
REPORTED BY
CHECKED 8Y
REVIEWED BY
SAMPLE TYPE:
WATER
EHNRIDWQ LABORATORY
SEMI -VOLATILE ANALYTICAL REPORT
ANALYSIS RESULTS
LAB NO. 7G2438
SUPERVISORrtiy_
DATE7
ENTERED BY
DATE
TL1L DETECTED
u9iL.. u t ....
10
50
10
50
50
10
10
10
10
10
50
50
10
10
10
50
10
10
10
10
10
10
20
10
10
10
10
10
10
10
10
10
10
GAS,'
62-53-3
108-95-2
111.44-4
96.57-8
541-73-1
106.4E-7
100-51.6
95-50-1
95.46.7
109.60.1
106-44-5
621 54.7
67-72-1
98.95-3
78-59-1
88-75-5
105-67.9
65-85-0
111-91-1
120-83-2
120-82-1
91-20-3
106.47-8
87-68-3
59-50-7
91-57-6
77-47-4
,88 08.2
95.95.4
91-58-7
88-74.4
131-11-3
205.96-8
sEMIVOLArILES
TARGET COMPOUND
ANILINE
PHENOL
BI512•CHLOROETHYLI ETHER
2-CHLOROPHENOL
1,3-DICHLOROBENZENE
1,4-DICHLOROBENZENE
BENZYL ALCOHOL
1.2-DICHLOROBENZENE
2-METHYL PHENOL
BISI2-CHLOROISOPROPYLI ETHER
4-METHYL PHENOL
N•NIT R050-01-N-PROPYLAMINE
HEXACHLOROETHANE
N1TR0BENZENE
ISOPHORDNE
2-NITRO PHENOL
2,4-DIMETHYL PHENOL
BENZOIC ACID
BISI2-CI-ILOROETHOXYI METHANE
2,4.DICHLORQ PHENOL
1, 2.4-TRICHLOROBENZENE
NAPHTHALENE
4-CHLOROANILINE
HEXACHLOROBUTADIENE
4-CHL0R0-3-METHYL PHENOL
2-METHYL NAPHTHALENE
HEXACHLOROCYCLOPENTADIENE
2,4.6-TRICHLORO PHENOL
2,4,6-TR$CHLORO PHENOL
2-CHLORO NAPHTHALENE
2-NIT ROANILINE
DIMETHYL PHTHALATE
ACENAPH1HYLENE
TOL DETECTED
tiq►L
10 U 606-20-2
10 U 99-09-2
10 U 83-32-9
10 U 51-28-6
10 U 100-02-7
10 U 132.84-9
20 U 121-14-2
10 _ U 84-66-2
10 U 7005-72-3
10 U 86-73-7
10 U 100-01-6
10 U 534-52-1
10 0 86-30-6
10 U 101-55-3
10 U 118-74-1
10 U 87-66-5
10 U 85.01-8
50 U 120-12-7
10 U 84-74-2
10 U 206-44-0
10 U 129-00.0
10 U 85-68-7
20 U 91-94-1
10 U 56-55-3
TO U 218-01-9
10 U 117-81-7
10 U 117.84-0
10 U 205-99-2
10 U 207-05.9
10 U 50-32-8
50 U 193-39-6
10 U 53-70-3
10 U 191-24-2
CASH SEMIVO1ATIL1?S
TARGET COMPOUND
2, 6-DINITRQTOLUENE
3-NITROANILINE
ACENAPHTHENE
2,4-OINITRO PHENOL
4-NITRO PHENOL
DIBENZOFURAN
2,4-DINITROTOLUENE
DIETHYL PHTHALATE
4-CHLOROPHENYL PHENYL ETHER
FLUORENE
4-NITROANILINE
4,6-DINITRO-2-METHYL PHENOL
N-NITROSODIPHENY LAMINE
4-9ROMOPHENYL PHENYL ETHER
HEXACHLOROBENZENE
PENTACHLORO PHENOL
PHENANTH RENE
ANTHRACENE
DI-N-BUTYL PHTHALATE
FLUORANTHENE
PYRENE
BUTYLBENZYL PHTHALATE
3,3'-DICHLOROBENZIDINE
BENZO(A)ANTHRACENE
CHRYSENE
51512-ETHYLHEXYLI PHTHALATE
DI-N-OCTYL PHTHALATE
BEN Z0IB}FLUORANTHENE
BEN ZOIKIFLUORANTHENE
B£NZOIA)PYRENE
INDEN2{1, 2,3-CDWYRENE
DIBENZOIA,HIANTHRACENE
BENZOIG,H,IMPERYLENE

SEMIVOLATILE ORGANICS REPORT - DWG LAB PAGE 2
:24�;kiTias#ik._ :
NO BASE/NEUTRAL OR ACID EXTRACTABLE ORGANICS
DETECTED BY GC/MS.
COMMENTS:
LAB NO. 7G243B
TOL- Target Quantitatton Limit- Subject to
change due to instrument sensitivity
T- Tentatively Identified, estimated concentration
E- Estimated Value
U- Samples analyzed for this compound but not detected
N- Sample not analyzed for this compound
D- Detected below quantitation limit
H- Holding time exceeded

INJECTION
WELL CONSTRUCTION
Date constructed
FACILI"
INSPECTION REPORT ---,FM S (CONTINUED)
Drilling contractor:
+9 Lt31 -o/6"
yi, 1-#3.-7/67
Total depth of well
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
(concreted)
Sampling port
(labelled)
Name C 4,} /3 1
• [.de. // z--G t ;"y C.-
Address 7-0 cJ / al4.1 4 11:) i2' i r/e-
Registration number
Total depth of source well S ,,e9- ,6r
Water tight pipe entry
Well enclosure entry
Vent
Fuunctioning of heat pump
7
(if applicable)
Measurement Meets minimum standards Comments
Yes No
C'%
o
System (Oetern7ine from theowner if heat pump functions proper7y.)
l7
INSPECTOR C ]
WITNESS
Office
Address
WITNESS
Address
JULY , 1994

North Carolina Depa ient of Environment, Health, an 4atural Resources
Division of Environmental Management - Groundwater Section
INJECTION
FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WI
NAME OF OWNER 16. 1. C IL), / /1 jn-•)
ADDRESS OF OWNER _/ 1
DATE
La) sf a A-, . ri oAlf)t/L
� G-t r /..) .fr/ AI . 7 ; �-7
(Street/ road or lot and suddivision, county, town)
L TION OF INJECTION WELL (and source well(s) if applicable) 3-0 I 5-17,y
0 / 0 / frr 41 7 P cY . le-
(Stroet/ road or lot and suddivisior , county,
Potential pollution source
town, if different than owner's address, plus description of location on site)
Potential pollution source
Potential pollution source
Minimum distance of well from property boundary
Quality of drainage at site
(good, adequate, poor)
Distance
Distance
Distance
from
from
from
well
well
well
Flooding potential of site
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells,
scale, and north arrow.)
DESCRIBE Itm
injection well; tion source and injection we7
(high,moderate,low)
potential pollution sources, roads, approximate
closed loop, uncased borehole or cased water7; separate source well and
or other description as applicable)

AM ak±
Oaf da-61
cA 3e4F4
w. GyaOo", Ave.
utdl-! j 1
D D O❑
11
Coca _
Ma i� qMy

05/06/1997 Oh: 23 919-251 `443 ENV HEALTH WCDi]H PAGE 62
* N, ;OR WASTEWATER sr s t cm 4't.ern r nun. r n PC
WAKE COUNTY ENVIRONMENTAL HEALTH WELL AND SEWAGC SITE, LOCATION PERMIT
No PER(S) FOR INSTRUCT ON, LvcATION OR RELOCATION ACTIVITY- SIMLI. SE ISSUED
UNIX AN AIrT URITATAON FOR WASTEWATER awn! Catrn UG7]i0N HA.S MEN ISSUED -
pin # g?c. e79A0e12,3.97rvleot
Improvement Pern t
Tax Map No. Parcel No. Well Permit No. D
/
Zoning ! 0� 4.e Township Zee i _
QwnerlCornractof�Date: r
LocationfAddreerc "-A..3rj j- r4 4 4/ Ere. t e` g"-e
S.R.
Subdivision Name:
Lot No.
Section or Block No.
Preliminary Layout
r 'ailhat7141iyizigit
OM, rxcr<
sEE ATTACHED PLAT PLAN FOR WASTEWATER
DISPOSAL SITE.
SEE CONSTRUCTION AUTHORIZATioN FOR
WASTEWATER SYSTEM DESIGN.
` war �Gryy'�,� . ' r.l �J(7`
Sewage System Specifications
Repair [ 1 Original Permit No. -
Garbage Dispoelal Unit Yes 1 - 10 [ ]
House 1 ] Nubile ► ] Business I
islo. of a Loa Area
S1re-01 Tank
9a-
Wastewater: Sewage [ ] Industrial [ ] Dt' mefte:
Dale: Installed By:
Final layout
1
.1 1
} c f aft_e.
Nitriticafion Line
e 4-
�r
Depth o1 Stone: 12" [ 1 Max Depth of ttlaxh .: _ in.
Ricer and Bete Required [ 1 = bed [ ]
er Permit void if we with zoning regulatiotrs
+rep
ar ;Idea
elkt
Approved By:
We System
Individual [�" Sent-Filie [ I Public 13
New [V Replacement [ ] Ftepeiir [ 1
Fee Paid: Yes [,r" No [ ]
Construction Compliance Yes No
Site Approved I 1 1 1
Welt dead APPetwed I 3 [ I
Grouting Approved 1 ] [ 1
Date Inspected Sanita►raI7
Bacteriological Results
Initial Sample: _ Dante:
` Re -Sample #1 _ dare:
' Re -Sample 42 Date
* Re -chlorination as required [ ] Yee [ 1 No
*Fees for all raserr7ples
All checks payabic to Wake County
Fib inspection
Required Slab
Chlorinated
Required Certifioate
Variance (Explain)
WCHD R.D. Affixed
Sample Collected
Comments
Well Installed Fly: _ -
D $ m F# d Sanaarian
This report is based err part an information provided t y the homeowner or hisTher representative( in the applIcatlon submitted frir this
permit. The sanitarian is not respOnsbte fvr trice or mizlading Information contained in the application. The sanitarian is also not
responsible for e:oor+ooaled conditions on the property or for statements in Ns report that may have resulted from false or misleading
statements provided to him iri the application. Neither Wake County nor the sanitarian warrants that the septic tank system will oolltinue to
function satistaetorily in the future or that the water supply wig remain potable.
DOPY TO ENVIRONMENTAL HEALTH
azs 5.4rds,ar