WI0500334_GEO THERMAL_20160626

Permit Number WI0500334
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.sh~stha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Elbert Smailes SFR
Location Address
11206 Governors Dr
Chapel Hill
Owner
Owner Name
Elbert
Dates/Events
NC
Orig Issue
3/15/2011
App Received
3/23/2016
Qegulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27517
Smailes
Draft Initiated
Scheduled
Issuance Public Notice
Central Files : APS SWP
8/26/2016
Permit Tracking Slip
Status
Active
Project Type
Renewal
Version
2 .00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Steve Bowman
Contractor Heat Pump
145 Technical Ct
Gamer
Owner Type
Individual
Owner Affiljation
Elbert Smailes
11206 Governors Dr
Chapel Hill
Region
Raleigh
County
Chatham
NC
NC
Issue
8/25/2016
Effective
8/25/2016
27529
27517
Expiration
7/31/2021
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
3/23/16
8/22/16
Subbasin
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Water Resources
ENVIRONMENTAL QUALITY
Elbert Smailes
11206 Governors Dr.
Chapel Hill, NC 27517
Re: Issuance of Injection Well Permit
Permit No. WJ0500334
August 23, 2016
Geothermal Heating/Cooling Water Return Well
Chatham County
Dear Mr. Smailes:
Secretary
S. JAY ZIMMERMAN
Director
In accordance with your permit renewal application received March 23, 2016, I am forwarding Permit
No. WI0500334 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 July 31, 2021,
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 June 16, 2016. Laboratory analytical results have been forwarded to
you by RRO on August 2, 2016.
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,
Shristi Shrestha
Underground Injection Control (UIC)-Hydrogeologist
Division of Water Resources, NCDEQ
Water Quality Regional Operations Section
State of North Carolina I Environmental Quality I Water Resources
1611 Mail scrvi.;.: C.oilL.;r i fu1ki11h, Nonh Co.ruliua .27699-1611
919 707 9000
cc: Danny Smith & Rick Bolich, Raleigh Regional Office
Central Office File, WI0500334
Chatham County Environmental Health Department
Page 2 of2
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Elbert Smailes
FOR THE CONTINUED OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defined in Title 15A North Carolina Administrative Code 02C .0224(a), which will be used
for the injection of heat pump effluent. The injection well(s) located at 11206 Governors Dr., Chapel Hill,
Chatham County, NC 27517 will be operated in accordance with the application submitted March 23, 2016, 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 July 31, 2021, and shall be subject
to the specified conditions and limitations set forth in this permit.
Permit issued this the 25th day of August 2016.
L S. Jay Zimmerman, P.G.
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Perms[ 4\7410500334
Zr1C/5A7
ver. 11/15/2015
Page 1 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
he ~mhmitted, including any supporting materials as may he appropriate, at least ~O days prior to the date nf
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 [ISA 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 ISA 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 detennine 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 [ISA 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)].
Pt:rniit I./-WI0500334 UIC/5A7
ver . 11/15/2015
Pagl! 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 Ill-OPERATION AND USE CONDITIONS
l. 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 02C .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 02C .0206].
PART IV -INSPECTIONS [15A NCAC 02C .021 l(k)]
1. Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation of credentials, enter and inspect any property, premises, or place on or related to the
injection facility at any reasonable time for the purpose of determining compliance with this permit, may
inspect or copy any records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwater, surface water, or injection fluids.
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 [ISA 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 ISA . NCAC 02L [ISA NCAC 02C
.0224(f)(l )].
3. The Permittee shall report any monitoring or other information that indicates noncompliance with a specific
permit condition, that a contaminant may cause a violation of applicable groundwater quality standards, or
that a malfunction of the injection system may cause the injected fluids to migrate outside the approved
injection zone or area. As specified in rule 15A NCAC 02C .021 I(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 m~de within five days of the occurrence and submitted to the addresses
in Item #5 below.
Permit #WI0500334 UIC/5A7
ver. 11/15/2015
Page 3 of 5
(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(t)(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 .0l 13(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 .0l 13(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 .011 l(b)(l)(A), (B), and (C).
Pt:rmil #WI0500334 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 sources of drinking water.
(F) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15ANCAC 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 #WI0500334 UIC/5A7
ver. 11/15/2015
Page 5 of 5
WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
Permit No. WI0500334
Date: 08/02/2016
To: Michael Rogers _,....--
Central Office Reviewer
County: Chatham
Permittee/Applicant: Elbert Smailes
Facility Name: Smailes Geothermal Well
L GENERAL INFORMATION
1. This application is (check all that apply): D New ~ Renewal
D Minor Modification O Major Modification
a. Date of Inspection: 06/15/2016
b. Person contacted and contact information: Jack Smailes , (919 ) 240-5885
c. Site visit conducted by: Laura Robertson. Steve Bowman (Bowman Mechanical Services)
d. Inspection Report Printed from BIMS attached: D Yes [8] No
e. Physical Address of Site including zip code: 11206 Governors Drive, Chapel Hill, NC 27517
f. Driving Directions if rural site and/or no physical address:
g. Latitude: 35.841125 Longitude: -79.050674
Source of Lat/Long & accuracy (i.e., Google Earth, GPS, etc.): Goo gle Earth
IL DESCRIPTION OF INJECTION WELL(S) AND FACILITY
1. Type of injection system:
[8J Geothermal Heating/Cooling Water Return
0 In situ Groundwater Remediation
0 Non-Discharge Groundwater Remediation
0 Other (Specify: )
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system:
RECEIVED/NGDEQ/OWR
AUG ·o 4 2016
Water Quality Regional
Operations Section
Were samples collected from Influent/Effluent sampling ports? ~ Yes D No.
Provide well construction information from well tag: No well tag was visible: construction records
indicate that the well is 900 feet in total depth.
b. Does existing or proposed system use same well for water source and injection? 0 Yes [8J No
If No, please provide source/supply well construction info (i.e., depth, date drilled, well contractor,
etc.) and attached map and sketch location of supply well in relation to injection well and any other
features in Section IV of this Staff Report.
3. Are there any potential pollution sources that may affect injection? 0 Yes ~ No
What is/are the pollution source(s)? ________________________ _
What is the distance of the injection well(s) from the pollution source(s)? ___________ _
4. What is the minimum distance of proposed injection wells from the property boundary? ______ _
5. Quality of drainage at site: ~ Good O Adequate O Poor
6. Flooding potential of site: [8J Low D Moderate D High
Rev. 6/1/2015 Page 1
WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
7. For Groundwater Remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D 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)? D Yes 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.
9. For Non-Discharge groundwater remediation systems only:
a. Are the treatment facilities adequate for the type of waste and disposal system? D Yes D No O 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 and/or Professional Engineer? D Yes D No O N/ A. If no, please explain: __
III. EVALUATION AND RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? D Yes IZ! No. If yes, explain. __
2. 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
D Deny. If Deny, please state reasons: __
0 Hold pending receipt and review of additional information by regional office
D Issue upon receipt of needed additional information
r8J Issue C }
5. Signature ofreport preparer(s): _.............~ ......... ~~L ~~.__..,_~___..~______,~~-0'1(J-~~ /t,._._ /~ ~-
Signature ofWQROS Regional Supervisor: ---~-"'4-~--..-~-----..;.,C!/,_~_,;j,_,_,_'Lf-~/-~......,,:; {~---
Date: i-Z-lu
Rev. 6/1/2015 Page 2
WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
IV. ADDITIONAL REGIONAL STAFF REVIEW COMMENTS/ATTACHMENTS (If Needed)
A water sample could not be collected from the effluent port on April 12, 2016, which was a function of the
spigot fitting. Steve Bowman met me on site on June 15, 2016, and was able to remove the spring within the
spigot so that I could collect a sample from the effluent port. He said the entire spigot would be changed before
the next inspection.
Betty is deceased as of 5/25/14, and should be removed from the permit. Elbert (Jack) should be the primary.
Rev. 6/1/2015 Page 3
Writer Resources
ENVIRONME 4tAL QUALITY
August 2, 2016
Jack Smailes
11206 Governors Drive
Chapel Hill, NC 27517
Subject: Geothermal Well Sampling Results
UIC Permit No. WI0500334
11206 Governors Drive
Chapel Hill NC — Chatham County
Dear Mr. Smailes
PAT MCCRORY
DONALD R. VAN DER VAART
S. JAY ZIMMERMAN
1;re'i'!ar
Groundwater sampling was conducted at the geothermal well on your propertyon June 15,
2016, thanks to the assistance of Mr. Steve Bowman. We are forwarding herewith e laboratory
reports dated August 1, 2016, issued for the following analyses in the influent and effluent samples:
fecal and total conform. bacteria, chloride, fluoride, sulfate, total dissolved solids, nitrate -nitrite as
N, and metals,
The laboratory results indicate that total coliform bacteria and several metals were detected
in the groundwater samples collected on June 15, 2016. Coliform bacteria were above the 15A
NCAC 02L .0202 groundwater standard of 1 CFU per 100mL during the June 15 sampling event.
To remove these bacteria, DWR recommends shocking the well with chlorine.
For all analytes tested, the results of the influent and effluent samples are very similar in
concentrations. All metals that were detected in the samples on June 15, 2016 were below the 15A
NCAC 02L .0202 groundwater standards in both samples. Your permit application renewal is
currently processing and will be mailed to you separately.
Please find the attached laboratory results. Feel free to contact me with any questions.
Sincerely,
•l 1 1,-�lx't
Laura Robertson, L.G.
Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ
Enclosure
cc: RRO-WQROS Files
Chatham County Environmental Health
State of North Caroinei I Environmental Quality I Water Resources
1628 Mail Service Center I Raleigh, North Camaro 27699.1628
919 741 4200

WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
Permit No. WI0500334
Date: 05/11/2016
To; Michael Rogers
Central Office Reviewer
County: Chatham
Permittee/ Applicant: Elbert Smailes
Facility Name: Smailes Geothermal Well
L GENERAL INFORMATION
1. This application is (check all that apply): D New [8J Renewal .
D Minor Modification D Major Modification
a. Date of Inspection: 04/12/2016
b. Person contacted and contact information: Jack Smailes. [phone]
c. Site visit conducted by: Laura Robertson, Shristi Shrestha. & Erin Deck
d. Inspection Report Printed from BIMS attached: [8J Yes D No
e. Physical Address of Site including zip code: 11206 Governors Drive. Chapel Hill, NC 27517
f. Driving Directions if rural site and/or no physical address:
g. Latitude: 35.841125 Longitude: -79.050674
Source of Lat/Long & accuracy (i.e., Google Earth, GPS, etc.): Goo gle Earth
IL DESCRIPTION OF INJECTION WELL (S ) AND FACILITY
1. Type of injection system:
[8J Geothermal Heating/Cooling Water Return
□ In situ Groundwater Remediation
D Non-Discharge Groundwater Remediation
D Other (Specify: )
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system:
RECEIVED/NCDEQ/DWR
MAY 13 2016
Water Quality Regional
Operations Section
Were samples collected from Influent/Effluent sampling ports? D Yes [8J No.
Provide well construction information from well tag: No well tag was visible: construction records
indicate that the well is 900 feet in total depth.
b. Does existing or proposed system use same well for water source and injection? D Yes [8J No
If No, please provide source/supply well construction info (i.e., depth, date drilled, well contractor,
etc.) and attached map and sketch location of supply well in relation to injection well and any other
features in Section IV of this Staff Report.
3. Are ther~ any potential pollution sources that may affect injection? D Yes [8J No
What is/are the pollution source(s)? ________________________ _
What is the distance of the injection well(s) from the pollution source(s)? ___________ _
4. What is the minimum distance of proposed injection wells from the property boundary? ______ _
5. Quality of drainage at site: [8J Good D Adequate D Poor
6. Flooding potential of site: [8J Low D Moderate D 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 map, 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
1. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, explain.
2. 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:
▪ Hold pending receipt and review of additional information by regional office
❑ Issue upon receipt of needed additional information
❑ Issue
5. Signature of report preparer(s): VaSt4.1...
Signature of WQROS Regional Supervisor:
Date: s� t 1.1 Lo
Rev. 6/ 1 /2015 Page 2

f
WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
IV. ADDITIONAL REGIONAL STAFF REVIEW COMMENTS/ATTACHMENTS a/Needed)
A water sample could not be collected from the effluent port, which is either a function of the valve or the
spigot. The system seems to be functioning efficiently, but the valve could not be removed. The flow seems to
be under tremendous pressure.
I will plan to collect a sample when a maintenance contractor is on site in case pipe fittings must be removed or
refitted in order to collect a sample.
Betty is deceased as of 5/25/14, and should be removed from the permit. Elbert (Jack) should be the primary.
Rev. 6/1/2015 Page3
Com p liance Ins pection Re port
Permit: WI0500334
SOC:
Effective: 03/15/11
Effective:
Expiration: 02/29/16 Owner: Elbert Jackson Smailes
Expiration: Facility: Elbert & Betty Smailes SFR
11206 Governors Dr County: Chatham
Region: Raleigh
Contact Person: Glen A Darch
Directions to Facility:
Chapel Hill NC 27517
Title: Phone: [phone]
From Raleigh take l-40Wto exit lake NC 54S ~0.2mi turn L, take Farrington Rd ~2.0mi turn L, take Farrington Mill Rd ~3.7mi turn R,
take Mt. Caramel Chrurch Rd -0.6mi turn L, take Governors Drive ~1.7mi, the property is on the Rt
System Classiflcations:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 04/12/2016 Entry Time: 09:00AM
Primary Inspector: Laura Robertson
Secondary lnspector(s):
Erin M Deck
Shristi Shrestha
Certification: Phone:
Exit Time: 11 :ODAM
Phone: [phone]
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well
Facility Status:
Question Areas :
■ Wells
D Compliant
(See attachment summary)
■ Not Compliant
■ System Operations
RECE\VED/NCDEQ/DWR
MAY 13 2016
water Que\ity Regional
O,::;.;;raijuns S8:.;tk.1r1
Page: 1
Permit: WI0500334
Inspection Date: 04/12/2016
Inspection Summary:
Owner -Facility: Elbert Jackson Smailes
Inspection Type : Compliance Evaluation Reason for Visit: Routine
The well system is only used for geothermal purposes; the home is supplied with municipal water. A water sample was
collected at the influent, but could not be collected from the effluent port, which is either a function of the valve or the spigot.
The system seems to be functioning efficiently, but the valve could not be removed and the homeowner was very disinclined
to have us unscrew any fittings, and adamant that we not cause any problems with the well infrastructure. The flow seems
to be under tremendous pressure. I will plan to collect a sample while the maintenance contractor is on site in case pipe
fittings must be removed or refitted in order to collect a sample. The next contractor visit will be sometime in October or
November 2016.
Betty is deceased as of 5/25/14, and should be removed from the permit.
Page: 2
Pennit: W10500334
Inspection Date: 04/12/2016
S ystem 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)
Owner-Facility: Elbert Jackson Smailes
Inspection Type : Compliance Evaluation
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
Reason for Visit: Routine
Yes No NA NE
□■□□
■□□□
□■□□
■□□□
■□□□
Comment: The system seems to be functionin g correctl y , however. an effluent sam ole could not be
collected due to either the functionin g of the valve or the s pigot. This will be attem pted ag ain in
coordination with the maintenance contractor visit in the fall.
Page: 3
ND
Water Resources
ENVIRONMENTAL aUAL MT
May 11,2016
CERTIFIED MAIL# 7014 3490 0001 8820 9846
RETURN RECEIPT IQTTESTED
Jack Smailes
11206 Governors Drive
Chapel Hill, NC 27517
Subject:
Notice of Deficiency
NOD-2016-PC-0155
Permit No. WI0500334
Geothermal Heating/Cooling Water Return Well System
Chatham County
Dear Mr. Smailes:
PAT MCCRORY
GO Vet/0 fn.
DONALD R. VAN DER VAART
Srrrrfa+ p
S. JAY ZIMMERMAN
(Erecter'
REGENEGINCDEQJDWNR
MAY 132016
Water Quality Regional
❑aerations Section
On April 12, 2016, staff of the NC Division of Water Resources (DWR) inspected the subject
geothermal well system. The purpose of the visit was to conduct a compliance inspection in
support of a permit renewal application.
The following items were determined to be deficient at the time of the inspection. (Also please
refer to the attached inspection report):
1. 15A NCAC 02C .0224 (d) Well Construction (4), which states,
"The injection well system shall be constructed such that a sampling tap or other collection
equipment approved by the Director provides a functional sources of water when the
system is operational. Such equipment shall provide the means to collect a water sample
immediately after emerging water from the supply well and immediately prior to injection
into the return well."
An influent and effluent groundwater sample is required to be collected at each renewal
inspection. An effluent sample was not able to be collected at the time of the April 12,
2016 inspection because the effluent sample port valve was inoperable. Please repair or
replace the geothermal well effluent sample port, and contact this office to re -schedule
the compliance sampling of the effluent.
You are required to take corrective measures regarding Item 1 above on or before June 12, 2016.
Please send a letter to our office upon completion of the above. Please inform our office if there
are extenuating circumstances that preclude compliance with the permit's conditions, or if there
are any ways that we may be of assistance to help you bring this system into compliance. Failure
to comply with the State's rules and correct the noted deficiencies by June 12, 2016, may result in
the assessment of civil penalties and/or the use of other enforcement mechanisms available to the
State.
State of North Carolina I Environmental Quality i Water Resources
1628 Mail Service Canter Raleigh, North Carolina 27699-1628
919 791 4200

Mr. Jack Smailes
WI0500334
May 11, 2016
Page 2 of2
If you have any questions concerning this Notice of Deficiency or the necessary corrective
measures, you may contact Laura Robertson via email at [e-mail] or at (919)
791-4200.
Sincerely,
ik' L.G., Assistant Regional Supervisor
Division of Water Resources,
Water Quality Regional Operations Section
cc: RRO-WQROS Files
Michael Rogers, WQROS Central Files
Chatham County Environmental Health Dept.
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: March 23, 2016
To: Danny Smith — Rick Boiich
From: Michael Rogers, WQROS — Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
A. Permit Number: WI0500334
B. Applicant:. Elbert Smailes =(J4(4c}
C. Facility Name:
D. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
❑ 1 would like to accompany you on a site visit.
5
tott
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a completed WOROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above_
RO-W QROS Reviewer:) Date:
COMMENTS:
NOTES:. Please check with Shristi to see if she would want to go out during the site
inspection. Please record all well construction indicated on the well tag Thanks_
FORM: WQR0S-A RR ver. 092614
Page 1 of 1

WATER Q UALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: March 23, 2016
To: Danny Smith -Rick Bolich
From: Michael Rogers, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
A. Permit Number: WIOS00334 ·
B. Applicant: Elbert Smailes
C. Facility Name:
D. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
D I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action . Within 30 calendar days, please return a com pleted W QROS Staff
Report.
When you receive this request form , please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: Date: -------------------------
COMMENTS:
NOTES: Please check with Shristi to see if she would want to g o out durin g the site
ins pection . Please record all well construction indicated on the well ta g. Thanks .
FORM: WQROS-ARR ver. 092614 Page I of l
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
March 23, 2016
Elbert Smailes
11206 Governors Dr.
Chapel Hill, NC 27517
RE: Acknowledgement of Application No. WI0500334
Geothermal Heating/Cooling Water Return Well
Chatham County
Dear Mr. Smailes:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on March 23, 2016. Your application
package has been assigned the number listed above, and the primary reviewer is Michael Rogers.
Central and Raleigh Regional Office staff will perfom1 a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Water Quality Regional Operations Section
(WQROS) requests your assistance in providing a timely and complete response to any additional
information requests.
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application . If you have any questions, please contact Michael
Rogers at 919-807-6412 or [e-mail].
cc: Raleigh Regional Office, WQROS
Permit File WJ0500334
Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
Slate ofNonh Carolina I Environmental Quality t Water Resources
1611 Mail service Center ! Raleigh , Nonh Carolina 27699-1611
91.9 707 9000
Director
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RES 'NCDEcticiWR
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTIOI WELLS
2016
In Accordance With the Provisions of 15A NCAC D2C .0224
W Qualtry
GEOTHERMAL HEATINGICOOLING WATER RETURN WELLS) "'�'
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: ,20 PERMIT NO. tht)50033V(leave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave Blank if New Application)
1. Current Use of Well r
a. Continue to use as f/ 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 the Well 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:
Name(s) (.47.76, e/, f 't/4i)
Mailing Addr s: d/:� I r/ �,- IQ e-r-DS e
City: C 1 P/ /'4' _ State: ode:Zip Code: ,2j S% 7 County:, (119.
Day Tele No.: /! •2€ ,SF . Email Address.:.%E•5 #d02- 6651.G %2
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
ail othe , listame of,entity an name of person delegated authority to sign:
/,ems/ �: -$
Mailing Address: d ' d .s
City: e' .0/7 StateA. Zip Code: 01-I J County: C I eA
Day Tele No.: ` Sets"-- Cell No.:
EMAIL Address: .�fMf�. 3 9Dz f iJi.�+I e & 'ax No.:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 1

D. WELL OPERATOR (if different from well owner) -For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the business
or agency: ______________________________ _
Mailing Address:---------------------------------
City: _____________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: Email Address .:
E. LOCATION OF WELL SITE-Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: __________ County: _____ _
(2) Physical Address (if different than mailing address): _________________ _
City: ________________ State: NC Zip Code: _________ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.: _____________________ _
Company Name: ________________________________ _
Contact Person"-: _______________ EMAIL Address: ___________ _
Address:------------------------------------
City: __________ Zip Code: State: __ County:
Office Tele No.: Cell No.: Fax No.: -----------------
G. HV AC CONTRACTOR INFORMATION (if different than driller)
H.
HVAC Contractor's Name: ____________________________ _
NC HV AC Contractor License No.: _________________________ _
Company Name: ________________________________ _
Contact Person~: _______________ EMAIL Address: ___________ _
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?
(l)
(2)
The injection operation?
Personal consumption?
YES __ _ NO ___ _
YES ----NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS -As specified in 15A NCAC 02C .0224(d ):
(1)
(2)
The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page2
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(I) Specify the number and type of wells to be used for the geothermal heating/cooling system:
I *EXISTING WELLS ____ PROPOSED WELLS
*For existing wells, please attach a copy of th e Well Construction R ecord (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 lorg as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(0(8 )
(t) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATINGDATA
(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.
L. SITE MAP-As specified in ISA NCAC 02C .0224 (b )(4 ). attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells , surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107 (a)(2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Penn it Application (Revised Jan 20 I 5) Page3
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicublc county GIS website. Typically, the property can be searched by
owner name or address. The locution of the wells in relation to property boundaries, houses, septic ranks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
1 SA NCAC 02C .0211(e) 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 all the personisllisted 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 ou their behalf.
"I hereby certify, under penalty of law, that 1 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. 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 Owner/Applicant
4/4rr. •% s
Print or Type Full Name
Signature of Property Owner/Applicant
Print or'fype Full Name
Signature of Authorized Agent, if any
Print or Type Full. Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Warer Return Well Permit Application (Revised Jan 2015) Page 4

PAT MCCRORY
•
Governor
DONALD R. VAN DER VAART
Secretary
Water Resources S. SAY ZIMMERMAN
ENVIRONMENTAL QUALITY
Director
March 16, 2016
CERTIFIED MAIL # 7014 1200 0001 3432 8688
RETURN RECEIPT REQUESTED
Elbert & Betty Smailes
11206 Governors Dr.
Chapel Hill
NC 27517
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0500334
Chatham County
Dear Mr. and Mrs. Smailes:
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 11206 Governors Dr. Chapel Hill,
NC 27517 was issued on March 15, 2011, and expires on February 29, 2016_ Per permit conditions
and requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least
120 calendar days prior to expiration of the permit if you wish to continue operating the injection
well on your property.
If Your Geothermal Water Return Well is Still Currentiv Being Used for Injection:
In order to comply with the regulatory requirements fisted under North Carolina Administrative
Code (NCAC) Title 1 SA, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate injection. Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http:llportal.ncdenr.org/web/wq/aps/gwpro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Being Used for Injection:
If the well is no longer being used for injection, you do not have to renew your penult. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.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.
State of North Carolina j Environmental Quality 1 Water Resources
1511 Mali service Center j Raleigh, North Carolina 27699-1611
919 707 9000

Page 2 of2
If There has been a Change of Ownership of the Pro pertv :
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
UICProgram
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.shrestha@ncdenr.2:ov.
Regards,
c;.~·
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Raleigh-Regional Office -WQROS w/o enclosures
Central Files -Permit No. WI0500334 w/o enclosures
7014 120E1 0001 3432 8688
U.S. Postal Service
CERTIFIED MAIL, RECEIPT
(Domestic Mail Only; No Insurance Coverage Provided)
For delivery information visit our web site at www.usps.coma
Postage
Certified Fee
Return Receipt Fee
(Endorsement Required)
Restricted Delivery Fee
(Endorsement Required)
Total Po
Serrire Elbert & betty Smailes
11206 Governors Dr.
.............. Chapel Hill, NC 27517
,51n tre_sicktk,
CEIMMAziaxasais
Postmark
Here
c ilea
SENDER: COMPLETE THIS SECTION
■ 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 rnaiipiece,
or on the front if space permits.
1. Article Addressed to:
Elbert & betty Smailes
11206 Governors Dr.
Chapel Hill, NC 27517
Slsristi Shrestha
COMPLETE THIS SECTION ON DELIVERY
Ci Agent
el wise
C. Date of De}iv=.
D. Is delivery address different from item 1? ❑ Yes
if YES, enter delivery address below-.. ❑ Ho
3. Service Type
o Certified Mahe 0 Priority Mall Express'"
❑ Registered 0 Return Receipt for Merchandise
0 Insured Mail 0 Collect on Delivery
4. Restricted Delivery? (Extra Fee) 0 Yes
2. Article Number
(Transfer from service labe'
• PS Form 381 1 ,July 2013
71114 1200 0001 3432 8688
Domestic Return Receipt

Water Resources
ENVIRONMENTAL QUALITY
February 22, 2016
CERTIFIED MAIL # 7014 1200 0001 3432 8671
RETURN RECEIPT REQUESTED
Elbert & Betty Smailes
6 Grey Widgeon Rd
Hilton Head Island, NC 29928
PAT MCCRORY
Oovenwir
DONALD R. VAN DER VAART
Sea dary
S. JAY ZIMMERMAN
E1ireclar
Subject: Notice of Expiration (NOE)
Geothermal Water ReturnlOpen-Loop Injection Well
Permit No, WI0500334
Chatham County
Dear Mr_ and Mrs. Smailes:
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 11206 Governors Dr, Chapel Hill,
NC 27517 was issued on March 15, 2011, and expires on February 29, 2016. Per permit conditions
and requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least
120 calendar days prior to expiration of the permit if you wish to continue operating the injection
well on your property.
If Your Geothermal Water Return Well is Still Currently Beim, Used for Injection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http:llportal. ncdenr_orglweblwglap slgwprolperrni t-applications.
If Your Geothermal Water Return Well is NO LONGER Being Used for Injection:
If the well is no Longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.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.
Slate of North Carolina I Environmental Quality 1 Water Resources
1611 Mail service Center I Raleigh, North Carolina 27699-1611
919 70790tkl

Page 2 of 2
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/Owncrship 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 Prograrn
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.shresthaiu ncdenr. uov.
Regards.
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Raleigh- Regional Office — WQROS w/o enclosures
Central Files - Permit No. WI0500334 w/o enclosures

NC
Water Resources
ENVIRONMENTAL QUALITY
February 22, 2016
CERTIFIED MAIL # 7014 1200 0001 3432 8671
RETURN RECEIPT REQUESTED
Elbert & Betty Smailes
6 Grey Widgeon Rd
Hilton Head Island, NC 29928
PAT MCCRORY
Goyearwr
DONALD R. VAN DER. VAART
Subject: Notice of Expiration (NOE)
Geothermal Water ReturnlOpen-Loop Injection Well
Permit No. WI0500334
Chatham County
Dear Mr. and Mrs. Smailes:
Secretory
S. JAY ZIMMERMAN
aireclar
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 11206 Governors Dr, Chapel Hill,
NC 27517 was issued on March 15, 2011, and expires on February 29, 2016. Per permit conditions
and requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least
120 calendar days prior to expiration of the permit if you wish to continue operating the injection
well on your property.
If Your Geothermal Water Return Well is Still Currentl► Beim Used for Infection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http:llportal.ncdenr.orgfweblwglapslgwprolpermit-applications.
If Your Geothermal Water Return Well is NO LONGER Beim Used for Injection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.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.
State of North Carolina I Environmental Quality I Water Resources
161 I Mail service Center i Raleigh; North Carotins 27699-1611
919 707 9000

Page 2 of2
If There has been a Chan ge of Ownershi p of the Pro pe rtv :
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh , NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email at [e-mail].
~~·
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Raleigh-Regional Office -WQROS w/o enclosures
Central Files -Permit No. WI0500334 w/o enclosures
,
!
ru
rn
U.S. Postal SerViCeTM
CERTIFIED MAIL,,, RECEIPT
Domestic Mali Only; No Insurance Coverage Provided)
or delivery information Visit our website at www.usps.com�
Postage
Certified Fee
r9
1=1 Return Receipt Fee
C7 (Endorsersent Required)
▪ Restricted ❑eEvery Fee
C7 (Endorsement Required)
Postmark
Here
Pc" Elbert Sr Betty Smailes
sar:tro 6 Grey Widgeon Rd
- Stre, ,3 pt
▪ or Poetsax Hilton Head Island, NC 29928
City, state,
P5 Farm lam, August 2006
SENtYER: 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 mailpiece,
or on the front if space permits.
1 . ArticleAddreasad to:
Elbert & Betty Smailes
6 Grey Widgeon Rd
Hilton Head Island, NC 29928
Shristi Shrestha
1111111111111 11111 11 I III III II III 11111111111111
9590 9403 0730 5196 3155 88
See Reverse for instructions
COMPLETE THIS SECTION ON DELIVERY
A. Signature
x
B. Recalved by (Printed Name)
0 Agent
❑ Addressee
iC. Date of Delivery
D. Is deitvery address different from item 1? ❑ Yes
if YES, enter delivery address below: 0 No
• Grlir•Ja {lirirnhar (Tmnst'er./Yem service 18befi
7014 1200 0001 3432 81.71
PS Fcrm 3811, April 2015 PSN 7530-02-000-8053
3. Service Type ❑ Priority Meil EpressO
L1 Adult Signature D Registered M'aiPv
0 Adult Signature Restricted Delivery R Registered Mall Res4iWed
0 Certif!ed Matte Delivery
0 Certified Mall Restricted Delivery 0 Return Receipt for
0 Collect on Delivery Merchandise
0 Collect on Delivery Restricted Delivery 0 signature Confrme tton*t
'sured Mail 0 Signature ConfirmWien
muted Mail Restricted Delivery Restricted Dellvory
'over$500)
Domestic Fietum Receipt

PAT MCCRORY
DONALD 3t. VAN DER. VAART
Water Resources
tti VtR(NMIP TAL 3UALrV
May 11,2016
CERTIFIED MAIL# 7014 3490 0001 8820 9846
RETURN RECEIPT REQUESTED
Jack Smailes
1124E Governors Drive
Chapel Hill, NC 27517
Subject, Notice of Deficiency
NOD-2016-PC-0155
Permit No. VTr05003+:1
Geothermal Heating/Cooling Water Return Well System
Chatham County
Dear Mr. Smailes:
S. JAY ZT'MMERM.AN
On April 12, 2016, staff of the NC Division of Water Resources (DWR) inspected the subject
geothermal well system_ The purpose of the visit was to conduct a compliance inspection in
support of a permit renewal application_
The following items were determined to be deficient at the time of the inspection. (Also please
refer to the attached inspection report):
1. 15A NCAC 02C .0224 (d) Well Construction (4), which states,
"The injection well system shall be constructed such that a sampling tap or other collection
equipment approved by the Director provides a functional sources of water when the
system is operational. Such equipment shall provide the means to collect a water sample
immediately after emerging water from the supply well and immediately prior to injection
into the return well."
An influent and effluent groundwater sample is required to be collected at each renewal
inspection.. An effluent sample was not able to be collected at the time of the April 12,
2016 inspection because the effluent sample port valve was inoperable. Please repair or
replace the geothermal well effluent sample port, and contact this office to re -schedule
the compliance sampling of the effluent.
You are required to take corrective measures regardin Item 1 above on or before June 12, 2016.
Please send a letter to our office upon completion of the above. Please inform our office if there
are extenuating circumstances that preclude compliance with the permit's conditions, or if there
are any ways that we may be of assistance to help you bring this system into compliance. Failure
to coinply with the State's rules and correct the noted deficiencies by June 12, 2016,.may result in
the assessment of civil penalties and/or the use of other enforcement mechanisms available to the
State.
$la lc cf North Ern' irontr ehtot t'loahr}•; %Fuer ktEburcer
it:IS Mail S r ics Center ! Raleigh, Chrnli;ra 27699.162S
4i474142O

Mr. Jack Smailes
WI0500334
May 11, 2016
Page 2 of2
If you have any questions concerning this Notice of Deficiency or the necessary corrective
measures, you may contact Laura Robertson via email at [e-mail] or at (919)
791-4200.
cc: RRO-WQROS Files
Sincerely,
/ ' , I
j;~
Rick Boifch, L.G., Assistant Regional Supervisor
Division of\Vater Resources,
"\Vater Quality Regional Operations Section
,. .
Michael Rogers , WQROS Central Files
Chatham County Environmental Health Dept.
03/20/2012 07:13 FAX
4I 003
R&!iIIIENT!AL WELL CONSTRUCTION awo
North Carolina Department of Emvimnrnebt end Natural Reanuoras- Divbir oof W
wail. CONTRACTOR CERTIFICATION N 3900
1. WML. CONTRACTOR:
wee Contecmr(IndIvIdla0 Norte
S3len A DetchWell Dn ina _
Wei Caul emr Carr len'r Name
IMO Bald Rljp Hill Rd
Street Addreer
CRy or Town Stall ap Cards
t 919) 558-5959
Aram media Fliers muter
2. WELL INFORMATION:
WEU. corlSTRUCTION PERMIT ' -1'30 3 3t 1
OTHER ASSOC4ATEO PHtIYIT1. i.)
NTS WELL ID re► ar k
3. WELL uee Pax*Applicable fire* Reit:Iambi Water Supery
G
GATE DRILLED `I I !- -i
TIME camikerm AM 0 PM pd
4. WILL LDGAflO* II j j
cn 1 r ►eretL q�,COLiNTr C 1 M
1 ettova LoverYIN
mvr Ne m litortem, Gonawa*. SulnIsiike. Lair No. Perms ZIP CAI
-
TOPOGRAPHIC 1 iANO SETTING: (deck approve la Tod
tslops civeoetl coy tomes C101hs
tAT T DC 6 35 0° ' 'IS - OMS OR o0
LGNCO WUC ' A' `�� . 01 -OW OR 7UIRc0130{M OD
Ladtunadengisde no : PS [(ropop ptio mu"
11ooadan ofwell mustbn airiziwit an a U969 fepo moll eraiidea +ed
Ws tam gaol oft GPS)
IL WELL OWNER
1IaDi
t31rw Aam*ea
cny
�we4ry o/ 'fir
Cha 1 14.11
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4t91 l!4)-
Area cods Phone number
d. WELL DETAILS:
i. TOTAL QMMTH:
Stele Zip Cade
b. DORS Mali PJPLACE IDII$'11NO wsu.? YES to NO 0
WATER LEVEL Beraw Tap of Ceairq JT.
(UN •+• if Above Top of cam)
rL TOP OF LINO Is ' 1 FT. Above Land Surftso
'Top of using terminated eVor below land surface retry require
a variance In eccadance wtt,1aA NCAC 2G .0118.
a WAD team) 5o METHOD OF MyrA)r_Rotoiv _
f. DIEINs3Ci1ON: Typ'e�� . amount 1Ib-
Qualiiy
o. WATER ZONES (UM:
Top " Spew
'NIA& eaterm Ica i
reIRS1) Bottom 4t0
T. CAIRO; want e
talk -'►_Boo _-
Top
Top _ I3oAom
Inldoeema/
Wrerthe NW:MA I
Top ► F I eotmen 43 Ft
Top
Tnre BOSOM_ FL
6. GROUT: Depth
TOp 0 Eitmamilel
Too _ Iloldlru
e. scecirr- Gaper
Top Bonaire__ FL
Too minor a
top R-
10. B*I lD GRAVEL PACK
DOPOI
Top 9oMcrlr_ FL
Top Scream R.
Top Ft
11. DRILLING LOG
Tap Boom
1
1
12. REMARKS:
,'ekt4
Method
DOuf
stet sea, tee`riar
In. In.
►n In.
Formation Desedpaon
day
tdoal
t DO HERESY CERTIFY THAT TH
ACCORDANCE M TN 16A NCAC
STAND/MRANDTHATAC•• ■
PR, a_=r ■ THE 3. ■
11P / if., 41
- c r e - CERTtF ■
Jet A . �.
PRI NAME of • a •,:: ' . 1 : • VC FUIMG THE WW.
Submit within 30 day, of completion to: oi►rialon o! Mktg Duality - Information
1617 Men Service Center, Raleigh, NC 27890.181, Phone: [phone]
WELL wnS CONSTRUCTED IN
WELL CONSTRUCTION
F THIS RECORD HAS BEEN
4Szkt'1
ccN TRACTOR DATE
Ferrn GW-1 d
Rev. 2100
RECEIVED 03 -20— ` 12 o5: 5S- FiRect
TO- NC DENR P&S
P003I005

ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Oaken H. Sullins Dee Freeman
Governor Director Secretary
November 21, 2011
Mr. and Mrs, Smailes
11206 Governors Drive
Chapel Hill, NC 27517
Subject: Permit No. WI 0500334
1.1IC-5A7 Geothermal Well
Chatham County
Dear Mr. & Mrs. Smailes,
Enclosed please find the analytical results of the well water which was sampled on October 7, 2011. The
analytical data indicate that all the parameters are in compliance with Groundwater Standards and the
subject well is in compliance with the permit conditions.
If you have any questions, please contact me at [phone].
Cc: RRO-APS Files
The Central Office-APS Files
Aquifer Protection Section
1628 Mail Service Center. Raleigh, North Carolina 27699-1628
Location! 3800 Barrett Dr., Raleigh, North Carolina 27609
Phone: [phone]FAX. [phone] Customer Service: I-877-623-6718
Internet www.nc..water ivalii' .or:
An Equal Opportunity 1 Affirmative Action Employer
Sincerely,
Lin McCartney
Environmental Senior Tech
NorthCarolina
Naturally

ATA
NCDENR
BECEVED I Until`linig
Fup'vRoiF rt iriNI .;r• i :T iO
NOV 8 2 2bt1
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
November 21, 2011
Mr. and Mrs. Smailes
11206 Governors Drive
Chapel Hill, NC 27517
Dear Mr. & Mrs. Smailes,
Dee Freeman
Secretary
Subject: Permit No. WI 0500334
UIC-5A7 Geothermal Well
Chatham County
Enclosed please find the analytical results of the well water which was sampled on October 7, 2011. The
analytical data indicate that all the parameters are in compliance with. Groundwater Standards and the
subject well is in compliance with the permit conditions.
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
I628 Mail Service Center, Raleigh, North Carolina 27699-1628
Location: 3800 Barrett Dr., Raleigh, North Carolina 27609
Phone: [phone] PAX 919-5714718 \Customer Service: 1-877-623-6748
Internet VA.AY.ncwatertjualim.al
An Equal Opportunity \ Affirmative Action Employer
North Carolina
Naturally

`11(C' cDT1,10 LaJioraton, Section 'Results
County: CHATHAM
River Basin
Report To RROAP
Collector: L MCCARTNEY
Region: RRO -
Sample Matrix: WASTEWATER
Loc. Type: INFLUENT
Emergency Yes/No
COC Yes/No
Sample• ID:
PO Number #
Date Received:
Time Received:
RECEIVED (OE Labworks LoginlD
Aoliir;p PRf]TF:" Report Generated:
r• Date -Reported:
140V 2 L «tl
VisitlD
Loc. Descr.: ELBERT SMAILES 11206 GOVERNERS DR CHAPEL HILL, NC
AB77326
11G0894
10l1312011
12:20
DLEAVITT
12/30/99
11 /0712011
7.I(
Location ID: 5P019W10500334-INF
Collect Date: 10/13/2011
Collect Time:. 11:00
Sample Depth
CAS # Analyte Name
LAB
Sample temperature at receipt by lab
PQL
Result/
Qualifier
3.3
Units
Method Analysis Validated by
Reference Date
10/13/11 DLEAVITT
M1C
Coliform, MF Fecal in liquid
1 1 82
CFUI100m1 APHA9222D-20th 10/13/11 CGREEN
Coliform, MF Total in liquid
1 1 B2
CFU1100m1 APHA9222B-20th 10/13/11 CGREEN
WET
Ion Chromatography _TITLE_
mg/L EPA 300.0 - 10/24/11 MOVERMAN
Chloride
1 5.1
rnglL EPA 300.0 10/24/11 MOVERMAN
Fluoride
0.4 0.9
mg/L EPA 340.0 10/24/11 MOVERMAN
Sulfate
2 2.0 U
mg/L EPA 300.0 10/24/11 MOVERMAN
Total Dissolved Solids in liquid 12 167
mg/L APHA2540C-18TH : 10/19/11 MOVERMAN
NUT
NO2+NO3 as N in liquid
0.02 0.02 U
rng/L as N Lac10-107-04-1-c 10/13/11 CGREEN
MET
7429-90-5 Ai by ICP
50 50 U ug/L EPA 200.7 10/18/11 ESTAFFORDI
7440-70-2 Ca by 1CP
0.1 36
mg/L EPA 200.7 10/17/11 ESTAFFORDI
7440-47-3 Cr by ICPMS
10 10 U uglL EPA 200.8 . 10/18/11 ESTAFFORDI
7440-50-8 Cu by ICPMS
2 6.4
ug/L EPA 200.8 10/18/11 ESTAFFORD1
7439-89-6 Fe by ICP
50 50 U ug/L EPA 200.7 10/18/11 ESTAFFORD1
7440-09-7 K by ICP
0.1 0.53
mg/L EPA 200.7 10/17/11 ESTAFFORDI
7439-95-4 Mg by ICP
0.1 8.8
mg/L EPA 200.7 10/17/11 ESTAFFORD1
7439-96.5 Mn by ICP
10 65 ug/L
EPA 200,7 10/18/11 ESTAFFORDI
7440-23-5 Na by ICP
0.1 18
mg/L EPA 200.7 10/17/11 ESTAFFORDI
7440-02-0 Ni by furnace
2
2.0 tJ ug/L EPA 200.9 10/18l11 ESTAFFORD1
7439-92-1 Pb by ICPMS 2
2.0 U ug/L EPA 200.8 10/18/11 ESTAFFORDI
7440-66-6 Zn by ICPMS 10 59
ug/L EPA 200.8 10/18/11 ESTAFFORD1
Laboratory Section>> 1623 Mail Service Center, Ralerigh NC-27696 1623 [phone]
Fcr a dalailed 6eaeriplien or the quatifer codaB refer la
Page 1 of 1

North Carolina
~ROUNDWATER FIELD/LAB FORMP'lf/u er1-r Department of Environment and Natural Resources
I DIVISION OF WATER QUALITY-GROUNDWATER SECTION
Location code K DO/C1 \,\/J 0 5 00 33-"I,.... SAMPLE TYPE SAMPLE PRIORITY
0 /!& oi°r~ A~1·1-3 ZCo Ch; -fh c.) ff1 ~Water □ Routine County Lab Number
Quad No Serial No. 0 Soil □ Emergency Date Received / 0 · 13 · / I Time; /2~
Lat. Long. 0 Other
D Chain of Custody
Rec'd By: ~ From:Bus, ~~ier H~
· ARO FRO MRO R WaRO WiRO
Other:·
. . Report To. :(!§@ L,..,(/ u c:.., J Data Entry By. _____ _
WSRO, Kinston FO, Fed. Trust, Central Off., Other: Date Reported:
Shipped by: B\JS, Courier, .'Band Del.) Other: Purpose;q--fYl -------------
Collector(s): L Vh l( c,,_c\ ½ e 1 Date l <:J -1.:5 -II Time I l 0 0 'B'aseline, Complaint,§ lianc ' LUST, Pesticide Study, Federal Trust, Other:
FIELD ANALYSES . r Owner Gi bet s ma.., e'5, (circleone) -----
pH 400 2. U Spec. Cond.94 3 D O at 25°C Location or Site I 2 ~ Cc.,\/ e n , rs C"h · IN,· 1/G ::.. '}~ -J 7
Temp.10 i q . ~C Odor J:J o .i., Q_. Description of sampling point:-,-w~·~~~i~/-~J-f-'-'e~c,..._c~·'_1 --------::---:--:----,---------
Appearance C --L e .. e~-1".'.: , Sampling Method-.-__ C½_r-_~ ... _b __ ~=~~~-----Sample Interval _______ _
Field Analysis By: z n jr: l c. '{ I·;,., < I Remarks ·z.~,-t Ju ¼ r· I Pumo. baller. elc. I
LABORATORY ANALYSES '
Ck. ____ _
(Pumping lime, air temp .• etc.)
BOD 310 mg/l y.._ Diss. Solids 70300 mgll Ag-Silver 46566 ug/L OrQ anochlorine Pesticides
COD High 340 mg/L Fluoride 951 mg/L X Al-Aluminum 46557 uo/L Oroanoohosohorus Pesticides
COD Low335 mg/L ~ Hardness: Total 900 mg/L As-Arsenic 46551 ug/l Nitrooen Pesticides
)( Coliform: MF Fecal 31616 1100ml Hardness (non-carb) 902 mg/L Ba-Barium 46558 UQ/l Acid Herbicides
'7-Coliform: MF Total 31504 1100ml Phenols 32730 ug/1 ·y Ca-Calcium 46552 mQ/l PCBs
TOC680 mg/L Specific Cond. 95 µMhos/cm Cd-Cadmium 46559 uo/L
Turbidity 76 NTU Sulfate.945 mg!L )I Cr-Chromium 46559 uQ/L
Residue, Total Suspended 530 mg/L Sulfide 745 mg!L X Cu-Copper 46562 UA/l
·,J.._ Fe-Iron 46563 uo/L Semivolatile Organics
Oil and Grease mg/L Hg-Mercury 71900 ug/l TPH-Diesel RanQe
pH403 units ·,( K-Potassium 46555 mg/l
Alkalinity lo pH 4.5 410 mg/l )( Mg-Magnesium 46554 m!l/l
Alkalinity to pH 8.3 415 mg/L ')I.. Mn-Manganese 46565 uo/L Volatile Oroanics /'VOA bottle )
Carbonate 445 mg/L NH3 as N 610 mgll 'I-Na-Sodium 46556 mA/l TPH-Gasoline Ran 11e
Bicarbonate 440 mg/l TKN as N 625 mgll 'f. Ni-Nickel ug/l TPH-BTEX Gasoline Ranoe
Carbon dioxide 405 mg/L '-I--NO, + N03 as N 630 mg/L "i Pb-lead 46564 UQIL •.. ,._ Chloride 940 mg/L P: Total as P 665 mg/l Se-Selenium UQ/l
Chromium: Hex 1032 ug/L Nitrate (NO,as N) 620 mg/l y.:_ Zn-Zinc 46567 uo/L
Color: True BO cu
Cyanide 720 mg/L
Nitrite (N02 as N) 615 mg/l LAB USE ONLY J,J Temperature on arrival (°C):
Lab Comments _____________________________________________________________ _
GW-54 REV. 4/06 For Dissolved Analysis-submit filtered sample and write "DIS" in block.
'VC D t20 L it ora torn Section {Results
County' CHATHAM Sample ID: AB77321
River Basin pF W ATE-R PO Number # 1160895
Report To RROAP O G Date Received: 10/1 3/2011
a r- Time Received: 12:20
Collector: L MCCARTNEY p r
Region: RRO ��
Latnvorics LoginlD DLEAVJTT
~�
Report Generated: 12/30/99
Sample Matrix: WASTEWATER
Loc. Type: EFFLUENTDate Reported: . 11/07/2011
Emergency Yes/No VisitID
COC Yes/No MA, I
) 1/7 !
Loc. Descr.: ELBERT SMAILES 11206 GOVERNER$ DR CHAPEL HILL, NC
Location ID: 5P019WI0500334-EFF
Collect Date: 10/1312011
Collect Time: 11:30
Sample Depth
CAS # Analyte Name
LAB
PQL
Result/
Qualifier
Sample temperature at receipt by lab 3.3
Units
Method Analysis Validated by
Reference Date
°C 10/13/11 DLEAVITT
MIC
Coliform, MF Fecal in liquid 1 1 B2 CFU1100m1 APHA9222D-20th 10/13/11 CGREEN
Coliform, MF Total in liquid 1 1 B2 CFU1100m1 APHA9222B-20Ih 10/13/11 CGREEN
WET
Ion Chromatography
TITLE rng/L EPA 300.0 10/24/11 MOVERMAN
Chloride
1 5.1
mg/L EPA 300.0 10/24/11 MOVERMAN
Fluoride
0.4 0.9 rng/L EPA 300.0 10/24/11 MOVERMAN
Sulfate 2 2.0 U mg/L EPA 300.0. 10/24/11 MOVERMAN
Total Dissolved Solids in liquid 12 164 mg/L APHA2540C-18TH 10/19/11 MOVERMAN
NUT
NQ2+Nd3 as N in liquid
0.02 0.02 U
rng/L as N Lac10-107-04-1-c 10/13/11 CGREEN
MET
7429-90-5 Al by ICP 50 50 U ug/L
EPA 200.7 10/18/11 ESTAFFORDI
7440-70-2 Ca by ICP
0.1 37
mg/L EPA 200,7 10/17111 ESTAFFORDI
7440-47-3 Cr by ICPMS
1 Q 10 U ug/L EPA 200.8 10/16/11 ESTAFFORD1
7440-50-8 Cu by ICPMS
2 19
ug/L
EPA 200.8 10/18/11 ESTAFFORD1
7439-89-6 Fe by ICP
50 50 U ug/L
EPA 200.7 10/18/11 ESTAFFORDI
7440-09-7 K by ICP
0.1 0.51
mg/L EPA 200.7 10/17/11 ESTAFFORD1
7439-95-4 Mg by ICP
0.1 8.9 rng/L EPA 200.7 10/17/11 ESTAFFORD1
7439-96-5 Mr) by ICP
10 65 ug/L
EPA 200.7 10/18/11 ESTAFFORD1
7440-23-5 Na by ICP
0.1 18
mg/L EPA 200.7 10/17/11 ESTAFFORD1
7440-02-0 Ni by furnace
2
2.0 U ug/L
EPA 200.9 10/18/11 ESTAFFORD1
7439-92-1 Pb by ICPMS 2 2.0 Li ug/L
EPA 200.8 10/18/11 ESTAFFORD1
7440-66-6 Zn by ICPMS
10 46
ug/L EPA 200.8 10/18/11 ESTAFFORD1
17)
•
L
ilpi+lt ra!'ra:4 ultir:e
Laboratory Section» 1623 Mail Service Center. Raleigh, NC 27699-1623 [phone]
Fora detailed aesa•plion of the quaker daaas refer to
Page 1 of 1

GROUNDWATER FIELD/LAB FORM
Location code ,i ' e2t9. 4 (.2,` i.)C' :Sly - GR.
County C f h d ill
Quad No Serial No.
Lat, Long.
Report To: ARO, FRO, MRO RR❑ aRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other.
Shipped by: Bus, Courier, Fund Del Other: Furpose. yY1
Collectors : !— it �
FIELD ANALYSES O }'+Qrc)- S I39 r Irrrcia one)
SAMPLE TYPE
X) Water
❑ Soil
❑ Other
0 Chain of Custody
SAMPLE PRIORITY
❑ Routine
O Emergency
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALFTY-GROUNDWATER SECTION
r� u a K g_PMa Z-7
Lab Number
pH 400
Ternp.to • 14- °C
Appearance ( (c e
Field Analysis By: L.. _)J I
LABORATORY ANALYSES
SOD 310
Date Received to -13 .1r Tirne: 1•2O
Rec'd By: From:Bus, Courier, and Del.
Other:
�—�
err �,� f -Data Entry Sy: Ck:
T Date Reported:
Date I -13 -111 Time J) D. Baseline, Complaint, Cbmp anc LUST, Pesticide Study, Federal Trust, Other:
Owner - ra-jJ
Spec. Cond.q :� 0 r , at 25°C Location or Site j Q EL,L� +:? V r:r G) Y 5 I-7).r • C I :{',pi I )-J r`i j •; C
Odor , } r, y1 a Description of sampling point W ie t H
Sampling Method T b Sample Interval
`CG-Y e y Remarks
COD HIgt1340
COD Low 335
Coliform- MF Feeat 31516
Coliform: MF Total 31504
TOC 680
Turbidity 79
Residue, Total Suspended 530
pH 403
Alkalinity to pH 4.5 410
Alkalinity to pH 8.3 415
Carbonate 445
Bicarbonate 440
Carbon dioxide 405
Chloride 940
Chromium, Hex 1032
Color. True 80
Cyanide 720
mg11
mg/L
mg1L
1100ml
1100m1
mglL
NTU
mglL
units
m9f1-
mg/L
mg&
mg1L
mg1L
mg1L
CU
mg+L
j4 Diss. Solids 70300
Fluoride 951
mg1L
ic Hardness: Total 900
Hardness (non-carb) 902
mg&
mg/L
Phenols 32730
ugA
Specific Cond. 95
UMhoslcm
Sulfate 945
Mg/L
Sulfide 745
mglt.
Oil and Grease
mglL
+scene. ea+urr. ent;
/PumpIns Imre, eirlemp., alc.t
AgSilver 46565
ug+L
x
xY
x
AI -Aluminum 46557
As -Arsenic 46551
Ba-Barium 46558
Ca -Callum 48552
Cd-Cadmium 46559
Cr-Chromium 46559
Cu•Copper48562
Fe -Iron 46563
Ng -Mercury 71900
K-Potassium 46555
ugtL
ug1L
u9+L
mglt
ugh.
ug/L
ug/L
ugfL
rg&
Mg -Magnesium 46554
NH3asN610
TKN as N 625
NO2 • HO, as N 630
mg&
mg/L
P: Total as P 655
mg!L
Nitrate (NO, as N) 020
mglL
Mn-Manganese 46565
Na-Sodium 46556
Ni-Nicker
Pb-Lead 46564
SeSelenlum
ug&L
mg&L
ug/L
ugIL
OrOanOchtorine Pesticides
Oryanophosphonis Pesticides
Nitrogen Pesticides
Acid Herbicides
PCB
Sernivolatile Organics
TPH-Diesel Range
Volatile O_Nantts (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
Zn-Zinc 40507 ugrL
Nitrite (NO; as N) 615
mg&L
LAB USE ONLY
Temperature en arrival (°C):
Lab Comments
GW54 REV 4106 For Dissolved Analysis -submit filtered sample and write'D1S- in Mock.

ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Bcveriy Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
November 21, 2011
MEMORANDUM
To: Michael Rogers, The Central Office, APS
Through: Jay Zimmerman
From: Lin McCartney
Subject: Analytical Result Report- W10500334, Elbert Smailes,
Geothermal 5A7 Well
Chatham County
Ar.luiier Protection Srctiatt
1028 Mail Service Center, Raleigh_ North Carotin* 27699-T62S
Locution: 3800 Barrett Dr., Raleigh, North Carolina 27609
Phone. 919.791 •42130 t FAX. [phone] C isatmner Ser vsee_ 1-S77-623.674?i
Irrreriser: www ttcwaterquality,nrq
Air Equal Opportunity I Atnnrcalive Action Ernlduye,
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Permit Number WI0500334
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Elbert & Betty Smailes SFR
Location Address
11206 Governors Dr
Chapel Hill
Owner
Owner Name
Elbert
Dates/Eve nts
NC 27517
Jackso Smailes
n
Scheduled
Orig Issue
03/15/11
App Received Draft Initiated Issuance
01/07/11
Re ci ulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
03/23/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Glen A. Darch
13109,Bold Run Hill Rd
Wake Forest
Major/Minor
Minor
Region
Raleigh
County
NC
· Chatham
Facility Contact Affiliation
Steve Bowman
145 Technical Ct
Garner
Owner Type
Individual
Owner Affiliation
Elbert Jackson Smailes
6 Grey Widgeon Rd
Hilton Head Island
NC
SC
Public Notice Issue
03/15/11
Effective
03/15/11
Re g uestedfReceived Events
RO staff report requested
RO staff report received
27587
27529
29928
Expiration
02/29/16
02/14/11
02/17/11
Waterbody Name Stream Index Number Current Class Subbasin
A7A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Qoieen H. Sullins Dee Freeman
Governor Director Secretary
March 15. 2011
Elbert and Betty Smailes
6 Grey Widgeon Rd.
Hilton Head Island, SC 2992S
Re: issuance of Injection Well Permit
Permit No. WI0500334
Issued to -lhcrt and Betty Smaiies
Chatham County
Dear Mr. and Ms. Smailes:
In accordance with your application received January 7. 20..1,1 am forwarding Permit No. WI0500334 for the
construction and operation of a 5A7 geothermal underground injection control (UEC) well heat pump system located at the
above referenced address. This permit shall be effective from the date of issuance until February 29. 2016, and shall be
subject to the conditions and limitations stated therein.
Please pay special attention to the permit conditions Part II 1 and 2 which require you to notify the Raleigh
Regional Office at 919-791-4200 so that site visits can be arranged during construction and to collect groundwater
samples from the influent and effluent sampling spigots prior to start up.
In order to continue uninterrupted legal use of this well for the stated purpose. you should submit arr application to renew
the permit 120 days prior to its expiration date. As indicated in the permit, this permit is not•trainsferable 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 (919) 715-616E.
Best Regards,
John McCray
Environmental Specialist
cc: jay Zimmerman — Raleigh Regional Office
Central Office File — WI050033'
Chatham County Environmental Health Dept.
Attachment Permit WI0500334
ACiUIEER PROTECTION SECTION
1638 Mail Service Center, Rater;. Norm Carolina 27699.163G
timber: 2728 Capita! Boulevare. Ralegn. Norl,i Carolina 2760
Phone' 919.733.3221 i FA; 1 919-71 -O 8. FAY. 2: 915-715-8O48 Customer Servce: i-877 =• 1-67R&
Inlernet. www.ncuaterquaIity.oro
r xman Emninw-
sane
N orth Carolina
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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
Elbert and Betty Smailes
FOR THE CONSTRUCTION AND OPERATION OF 1 TYPE SA7 INJECTION WELL, defined in Title lSA 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 11206 Governor's Drive, Chapel Hill, Orange County, NC 27517, and will be constructed and
operated in accordance with the application received January 7, 2011, and in conformity with the specifications and
supporting data submitted, all of which are filed with the Department of Environment and Natural Resources and are
considered a part of this permit.
This permit is for Construction and Operation of an injection well shall be in compliance with Title 1 SA 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 29: 2016, and shall be subject to
the specified conditions and limitations set forth in Parts I thr~:mgli IX he.reof
:tr-.
Permit issued this the \ ~ day of ~J..i-, 2011. ---~--
~_')-v~
)d'--Coleen H. Sullins, Director
\ Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0500334 UIC/SA7 Page 1 of 5
. ver. 03/2orn
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified in
Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with conditions
of this permit constitutes a violation of the North Carolina Well Construction Act and is grounds for enforcement
action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of this
permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into the
gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well shall be
permanently labeled with a warning that it is for injection purposes and the entrance to each well must be secured
with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C .0213(g).
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section -UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628-
Ph# 919-791-4200
GW-ls must be submitted within 30 days of completion of well construction. Copies of the GW-1 form(s) shall be
retained on-site and available for inspection.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing each injection well, the Permittee shall notify the Aquifer
Protection Section-Underground lnj ection Control (UIC), Central Office staff, telephone number [phone]
and the Raleigh Regional Office Aquifer Protection Section (APS) Staff, telephone number [phone].
2. Within 30 days of injection well completion, Permittee must contact the Raleigh Regional Office APS Staff in
order to have samples collected at the source well and injection well.
3. Continued operation of the injection system will be contingent upon the effluent not impacting groundwater quality .
The water quality of the effluent cannot be that of a lower quality than the influent, which results in a degrading of
water quality of the aquifer.
4. The injection well system must be constructed with sampling ports so that system influent and effluent may be
sampled.
5. The injection well must be constructed to a depth such that it is injecting water into the same aquifer that the source
well is drawing from.
Permit #WI0500334 UIC/5A7 Page 2 of 5
ver . 03/2010
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as described in the
application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of Water
Quality (Director). In the event there is a desire for the facility to change ownership, or there is a name change of
the Permittee, a formal permit amendment request must be submitted to the Director, including any supporting
materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall I].Ot 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 requireito comply with the terms and .conditions of this permit even if compliance requires
a reduction or eliminati~JJ 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 Aquifer Protection 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 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.
Permit #WI0S00334 UIC/SA7 Page 2 of 5
ver. 03/2010
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 iajection 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 Pemiittee shall report by telephone, within 48 hours of the occurrence or first know ledge of the occurrence, to
the Raleigh Regional Office, telephone number [phone], any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper injection
operations , such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of an y 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 eventthat the permitted facility fails to perform satisfactorily, the Permittee shall take such immediate action
as may be required by the Director.
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection well. Such a
change would include the discontinued use of a well for injection. If a well is taken completely out of service
temporarily, the Permittee must install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well Construction Standards.
2 . When operations have ceased at the facility and a well will no longer be used for any purpose, the Permittee shall
abandon that injection well in accordance with the procedures specified in 15A NCAC 2C .0214, including but not
limited to the following :
(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.
Permit #WI0500334 UIC/SA7 Page 3 of 5
ver. 0 3/2010
(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 ofabandc:mment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Permit #WI0500334
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/SA7
ver. 03/2010
Page 4 of 5
Permit Number WI0500334
Central Files: APS SWP
03/15/11
Permit Tracking Slip
Program Category
Ground Water
Permit Type
injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Faciljt
Facility Name
Elbert & Betty Smailes SFR
Location Address
11206 Governors Dr
Chapel Hill NC 27517
'wner
Status Project Type
in review New Project
Version
Permit Classification
Individual
Permit Contact Affiliation
Glen A. Darch
13109 Bold Run Hill Rd
Wake Forest NC 27587
Major/Minor
Minor
Region
Raleigh
County
Chatham
Facility Contact Affiliation
Steve Bowman
145 Technical Ct
Gamer NC 27529
Owner Name
Elbert Jackso Smailes
n
Dates -vew
Orig Issue App Received Draft Initiated
01/07/11
Reoulate:: Activities
Heat Pump Injection
❑utfall r•;IJ+.I
Scheduled
Issuance
Owner Type
Individual
Owner Affiliation
Elbert Jackson Smailes
6 Grey Widgeon Rd
Hilton Head Island SC 29928
Pubiic Notice Issue
P7:e rtil, sTE d/Re orr
RO staff report requested
RO staff report received
Effective
Expiration
02/14/11
02/17/11
Waterbody Name Stream Index Number Current Class Subbasin

Permit: WI0500334
SOC:
County: Chatham
Region: Raleigh
Effective:
Effective:
Contact Person: Glen A □arch
Directions to Facility:
-
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 02/16/2011
Primary Inspector: Lin McCartney
Secondary IAspector(s):
Reason.for Inspection: Routine
Compliance Inspection Report
Expiration:
Expiration:
Title:
Owner: Elbert Jackson Smailes
Facility: Elbert & Betty Smailes SFR
11206 Governors Dr
Chapel Hill NC 27517
Phone: [phone]
Certification: Phone:
Entry Time: 12 :30 PM Exit Time: 01 :30 PM
Phone: [phone]
Ext.4243
Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well (5A7)
Facllity Status: D Compliant O Not Compliant
Question Areas:
■Other
(See attachment summary)
Page: 1
Permit: WI0500334
Inspection Date: 02/16/2011
Inspection Summary:
Owner -Facility: Elbert Jackson Smailes
Inspection Type: Compliance Evaluation Reason for Visit: Routine
We recommend that the Central Office proceed to issue the applicant a permit for geothermal well operations, so that the
contractor could start construction. However, before the geothermal well begins operations, the permittee shall notify the
Raleigh Regional Office, so that a follow-up inspection and sampling of the well water can be performed.
Other
Comment:
Yes No NA NE
Page : 2
AQUIFERPROTECTION REGIONAL STAFF REPORT
Date: 02-17-2011
To: Aquifer Protection Central Office
Central Office Reviewer: John McCrav
Regional Login No: __ ._
I. GENERALINFORMATJON
I. This application is (checkallthatapptyJ: ~ New D Renewal
County: Chatham
Permittee: Elbert Smailes
Project Name: UIC-SA 7
Application No.: WI0500334
D Minor Modification D M~jor Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/lnfilh·ation Lagoon
D Land Application of Residuals D Attac hment B included D 503 regulated D 503 exempt
D Distribution of Residuals · D Surface Disposal
D Closed-loop Groundwater Remediation ~ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ~Yes or O No.
a. Date of site visit: 02-16-2011
b . Person contacted and contact information: Elbert and Betty Smailes, 843-715-2254
c. Site visit conducted by: Lin McCartnev
d. Inspection Report Attached:~ Yes or D No.
2. ls the following information entered into the BIMS record for this application correct?
~ 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): __
For Dis posal and Iniection Sites:
(If multi ple sites either indicate which sites the information a pp lies to .. co m and paste a new section into the
document for each site . or attach additional pa ues for each site )
a. Location(s): 11206 Governors Drive. Chapel Hill, NC 27517
b . Driving Directions: Take US-I S for 11.6 miles , merge onto US-64 W via Exit 98 B for 12 miles , tum
right onto Farrington Rd., Farrington rd becomes Farrington Point Rd., Farrington Point Rd becomes Mt.
Carmel Church Rd, tum left onto Governors Dr. for 2.6 miles , 11206 Governor Dr is ori the right.
c . USGS Quadrangle Map name and number: __
d . Latitude: 35-50-37 Longitude : 79-02-49
II. NEW AND MAJOR MOD/FICA TJON APPLICATIONS (this sectio11 not needed for renewals or mi11or
modifications. skip to next section)
Description OfWaste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
FORM: staff report-Smailes .doc
AQUIFER PROTECTION REGIONAL STAFF REPORT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No D NIA. 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 NIA. lfno, 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. Ifno, please explain:~
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No0
NIA. Ifno, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D N/A. lfno, please explain: __
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No D N/A. If yes, please attach a map showing areas of JOO-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? 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 pennit: __
9. Is proposed and/or·existing groundwater monitoring program (number of wells, frequency of monitoring,
monit,,1ing parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitorin? well
n,·twork 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 ( Certification B?)
III. RENEWAL AND MODIFIC4TION APPLICATIONS (use previous section fo r new or maior modification
systems)
Description OfWastc(S) And Facilities
1. Are there appropriately certified ORCs for the facilities'? D Yes or D No.
Operator in Charge: __ Certi;icate #: __
backup-Operator in Charge: __ Certificate #: __
2. Is the design, maintenance and operation ( e.g. adequ:ite 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. Ifno, please explain:
FORM: staffreport-Smailes.doc 2
• 1 Formatted
Formatted
AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Has the site changed in any way that may affect permit (drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain:--.-
5. Is the residuals management plan for the facility adequate and/or acceptable to.the Division?
D Yr:s or D No. Ifno, 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? DY es D No D N/ A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatmen_t facilities or 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 pennit: __
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. lfno, please explain: ____ _
11. Were monitoring wells properly constructed and located? D Yes or D No D N/A. If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as ~pplicable)? 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 pennit cycle; D
Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently under
Il)oratorium. 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: staffreport-Smaiies.doc 3
AQUIFER PROTECTION REGIONAL STAFF REPORT
TV. 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 .)
Descri ption OfWell(S} And Facilities -New. Renewal, And Modification
1. Type of injection system:
IZI Heating/cooling water return flow (SA 7)
0 Closed-loop heat pump system (SQM/SQW)
0 in situ remediation (51)
0 Closed-loop groundwater remediation effluent injection (SLf'Non-Discharge")
0 Other (Specify: __j
2 . Does system use same well for water source and injection'.' D Yes
3 . Are there any potential pollution sources that may affect injection? [8J Yes
What is/are the pollution source(s)? Sanitan Sewer Line. What is the distanc e of th e in jection _wel lj s ) from the
pollution sourcet s l? 50 ft.
4 . What is the minimum distance of proposed injection wells from the property boundary? I 00 ft.
5. Quality of drainage at site: 1Z1 Good D Adequate D Poor
6. Flooding potential of site: IZI Low O 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'.' 0 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 reprnsent the actual site (property lines, wells, surface drainage)? IZI Yes or O 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.
In jection Well Permit Renewal And Modification Onlv:
l . For heat pump systems, are there any abnonnalities in heat pump or injection well operation ( e.g. turbid water,
failure to assimilate injected fluid , poor heating/cooling)?
D Yes 1Z1 No. If ves . ex plain :
2. For closed-loop heat pump system s, has system lost pressure or required make-up fluid since pennit issuance
or last inspection? D Yes D No . If ves . ex plain:
3. For renewal or modification of g roundwater remediation nennits ( of an v typ e ). will
continued/additional/modified in jections have an adverse im pact on rni eration of the plume or manal!ement of
the contamination incident? Yes D No. lf ves. ex plain:
FORM : staffreport-Smailes.doc 4
AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Drilling contractor: Name: Glen Darch
Address: 13109 Bold Run Hill Road. Wake Forest. NC 27587
Certification number: 3900 A
5. Complete and attach Well Consti:uction Data Sheet.
V. EVALUATION AND RECOMMENDATIONS
I. 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 l;gJ 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 pennit when issued. Make sure
that you provide a reason for each conditi~n: •
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
FORM: staffreport-Smailes.doc 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 pennit by regional office; D Issue upon receipt of needed additional information; ~
Issue; D Deny. If deny, please state reasons: __
8. Signature·,1freport preparer(s): _____________________ _
Signature of APS regional supervisor: ___________________ _
Date: ______ _
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
We recommend that the Central Office proceed to issue the applicant a permit for
tr eothermal well o perations . so that the contractor could start construction. However.
before the geothermal well beu:ins o perations . the permittee shall notifv the Ralei gh
Remona! Office . so that a follow-u p inspection and samplinf! of the well water can be
performed.
FORM: staff report-Smailes.doc 6
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CHATHAM COUNTY, NC
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Property Map
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The. data prev;ied an drk map are prepared tor Me hrentory of real property found vet in
CnaIharn County. NC and are compicd from recorded plats deeds, and other public records
and data. This data is for Irlrormeional purpoeee only orrd should net be wbatluled
F a hue flit search, property appraisal. surveyor rpr n.ii,ig vw,i*c dori.
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Owner Address:
Owner City:
Owner Address:
Owner State:
Owner Zip:
Description:
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11206 GOVERNORS DR
CHAPEL HILL
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NC
27517
N2-81-632
Deed Book:
Deed Page:
Plat Book::
Plat Page:
Deed Acres:
Physical Address:
Improvement Value:
Land Value:
Fire District:
Township Code:
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One Inch = 1536 Feet

• 110 Adams Street Cary, NC 27513
Phone: [phone] Fax: [phone] www.BrightleafCo.com
Brightleaf Development Company, LLC.
Enclosed are two copies of the Type 5A 7 well permit. Please let me know if you need anything
else or have any questions.
Best,
Shane Malloy
Project Manager
Brightleaf Development 2---4
919-465-0322 (office) X z;
919-291-2253 (cell)
919-465-0890 (fax)
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145 Technical Court 6 Garner, NC 27529 • [phone] • Fax [phone]
FAX COVER SHEET
SEND TO A/C. �/y Li `?0,-tm-cgAr
Attention
Fax #
From
Date
Phone*
Urgent Reply ASAP Phase Comment Please Review
Total pages, including cover 1�-
9 G
Far Your lnformetia--..
Comments
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PARCEL # 68240
OWNER Governors Club Lot (132
Leptrld
Existing Well
Roads
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s
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StrearniRiver 5 25_e n fax
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DATE-
RECEIvED 1 DEW 1 DWQ
Aquifer Protection Section
JAN 48 2011

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01/06/2011 18:23 9197799294
911 Address
RECEIVED I DENR I D.'\4 -
Aquifer Protection Se or!
CHATHAM COUNTY ENVIRONMENTAL HEALTH
80 EAST STREET • P.C. BOX 130 • PITfSBDRO, NC 27312-0130
Phone [phone] . F'ex 919-542-8288
WELL. PERMIT'
JAN 0 B- 204
WELL SAMPLING REQUIRED WI77'IIN 30 DAYS OF CERTIFICATE OF COMPLETION.
TIiI$ PERMIL XPtRES FIVE YEARS FROM AATFS OF ISSUE.
OWNER "S'd1h4 Lc_ 5 ADDRes5 / .
Directions la she 15. iL! 1 p. " zer. 1,1 S',r " lo( -"" } Ci- 1 t..{ry CIA v-t0A.
Ropiaceni0 Wee
WELL TO SERVE
Residence'
Sketch of Well Site:
As Bulk:
MAINTAIN 100' FROM ALL SEPTIC AREAS, 50' FROM ANY
BUILDING FOUNDATION & 10' FROM ANY PROPERTY LINE.
Galvanized steel casing required: YES NO T1
Dater!
WELL CONSTRUCTION
Dist2noa from nearest property line .
Distance from source of pollution , .
Total depth of wail fr. GPM
Water Bearing Zones: - Depth Pt.
Casing Depth: , Porn^ tp
Static Water Level G v d
Casing Type:
Oats Drilled Cartifrctstion# - Contractor Name ,cv 1 : .
Address
Phone_
Ft, Ft. Ft. • :
Ft i iarneler
PVC Steel Thickness r
Delve Shoe I
Coupling ' Height of casing above ground Hose Hihb i2" Inch-
ch C[aarencd i .;_:;. r
Pr�obfame in eating (seeing' Yes Ei ii No !m_ .] Explain
I ! Grout Type, Neat SendiCesnent 1i C
oncrete ...7. Annular space width
Water in Annular space Yea Hop Method at Grout: PurnplPressure l� PouredEl
No. Baps of Portland Cement
Weight oft beg iba. Depth From to
Weil ID Plate L 1 Chlorination I j pump ID Plate Li OW1 form L.7
tiliitLER LOG
DEPTH
From
To
FORiskrio I DESCRIPTION
I hereby certify that the above information Is sorroet sett
that this waif was constructed p
in accardence witxfr 4•
Chatham County Wei! Rules,
Sige<mfcre vrebarracrar — Oita .1
Weil Grata InsPer, d by
Permit Issued by f L,. y—sr- 3�' ,,A.)-- .� r 1: � gala 6; I S r
axe
Certificate of Gurrtplaban -,
Sampled by_
Data,
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i-01-1995 0:01AM FROM P.2
NORTH CAROLINAA
DFPAR1ME T OF ENViRONMENT AND NATURAL RESOURCES
APPLICATION FOR. PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WIN AGEOTHXRMAL HEAT PUMP SYSTEM
TYPE 5A7 "OPEN LOOP" INJECTION WELLS)
(check one) Ncw Permit Application Renewal Mo tion
.„Tpz fi 13 20
PERMIT NO.: WI tlerec Mink if NEW permit application)
A. PROPERTY AFTLICANT
Name of each earner listed on property deed. For a business or (government agency, state name of eldfly and
name of Pelson debated authority to sign application an behalf of the
(1)
Mailing A5Idrem ' 4 4•4)
City: .+ Marl ZIP Cads fg), Cindy: Aber f• r1-
Hom lice Tele No.: S—/ ram,$~/ Cell No.:
Fax No. Email Address:
(j PSysical Address °MWdi Ste (if differ= than above): f! G Qv/Wife.; b r
( /ilr .. _ _ Sea= Ak Zip Cade r 7 County: ataTii$1.41
Homti0f5ce Tele No.: CCn
Fax No. Email Address:
S. 9RRT'Y OWNERSHIP DOCUMENTATION
Provide legal docume traU o of paperty ownership, such as a comma, dead. article of inc,orpraatian, etc. and
a PLAT map showing the property. This information may be obtained from minty Register of Deeds or GIS
w ebsite.
C. AUTRICRULD AGPNr. fp ANY
If the property owrtiedpermit applicaatt wants in authorize someone else to sign the permit on their bdhail then
attach a letter from the property ownerlpeJmTt applicant specifying and asdhorixirrg their agent (well
&Vier, beat pomp fir, cx other type of contraciariagent) to ago this application ix' their behalf.
Company Name:
Carte Person: Email Adb.Av.
Address:
City: SIM= rip Codes — Caa>•t�r,
Of`fa a Te k Na: Fax No. CallNo.z
Were Adehess ofemininity, if soy:
Type Ski *alien Wei! Permit A rgtheitim (Rcr_ Almoet2199) Pace r of 4

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WELL DRll.LER INFORMATION
CompanyName: 6/c f) A, llor,k. f&Jt,, 1 J),;I L~
Well Drilling Contractor's Name: -~-=-.:1:...:,-,,_'----'")'----"D~aw.i.'<-L(_,_J""'-~---------------
NC Contractor Certification No.: _3<-}D1.) A Contact Person: ,5AN)r'
Company Website: WWW. Email Address:~,.)( Hd( ,ll 1"'5 i,24 il'-', Cv .. •1,,
Address: 1,3 i<-'113Di~ R1 .1 n l-\,l\ RA':ld
City:~ iuf<d: State:l,j LZipCode: a,,;}S~J County: U)ake
Office Te]e No.: l}1<\ 55"'~ 5e;59 FaxNo.:Y19 55(p, 3'63'1 Cell No.: 11G LJ...3, 3-qq 3 )
HEAT PUMP CONTRACTOR INFORMATION (If different than Driller)
CompanyName:f>,, ... h V\e!Q f1ed-,qo,·ail 5?-"thl:f','.)
Company Website: WWW.
Address: l t\-5 -recbo i"i a I tt
Contact Person: s-±e,it 1,i:.'•,)tl\Ol,
Email Address: b:-..,.)M,h" rn .-dw o,Lt\l @lx>/JSu,Ak /e'
City: fu 1 IY;,," StateiJ .( I Zip Code: aa5JB County: -=-L-.'A_:_· \_Ke:,:_,----
Office Tele No.:"-1 0 ::r ri -J :\5'1 Fax NoJj a =,::,1.,c;aqy Cell No.'71'1 l/J.3:-Bll5
INJECTION PROCEDURE (briefly describe how the injection weU(s) will be used)
)D Dfg , .J-e {\ Ji' t,,AJ L,0 1-M < ~ Wtt:t @" °'f fiJ r h tqt,03 / ('tl1L'j
Wl!LL USE Will 1he injection well(s) also be used as \ supply well(s) fur the following?
(1) Theinjectionoperation? YES NO ___ _
(2) Personal consumption? YES ____ -NO ___ _
WELL CONSTRUCTION DATA
-~X~-'PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(7) be1ow 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 (7)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Fonn
GW-1) if available.
(1) Well Construction Date: _______ Number of borings: --!!'--
Depth of each boring (feet):._::Jo--==0=--'----
(2) Well casing. Is the well(s) cased?
(a) YES _-)(__ If yes, then provide the casing information below.
Type: Galvanized steelX-Black steel __ Plastic __ Other (specify). ______ _
Casing thickness:~ diameter (inches): fu depth: from --\-\ to feet (relative to land surface)
Casing extends above ground ) d-,. inches
(b) NO
(3) Grout material surrounding wen casing:
(a) Grout type: Cement.¼-Bentonite* II Other (specify) ______ _
•By selecting bentonitc grout, a variance is hereby n:quested to 1 SA NC~ ,0213(d)(l )(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from O to J, D feet
Type 5A 7 Injection Well Pennit Application (Rev. August 2009) Page2of4
I.
(4)
(5)
(6)
Well Screen or Open Borehole depth (relative to land surface): from AJ f} to ,14 feet
N.C. State Regulations (Title l5A NCAC 2C .0200) require the Perm.ittee to make provisions for
monitoring wellhead processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Will there be a faucet on:
(a) Influentline? Yes-A-No__ (b) Effiuentline? Yes~No __
Source Well Construction Infonnation. If the water source weU is a different wel] than the injection
well, attach a copy of the well construction record (Fonn GW-1). If Fonn GW-1 is not available, provide
the following data:
From · what depth. formation, and type of rock/sediment W1its will the groundwater be withdrawn? ( e.g.
granite, limestone, sand, etc.)
Depth: _______ Fonnation: _______ Rock/sediment unit. _______ ~
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY TIIB DATA IF TIIlS
INFORMATION IS OTHERWISE UNAVAILABLE.
OPERATING DATA
(I) Injection Rate:
(2) Injection Volume:
(3) Injection Presswe:
(4) Injection Temperature:
Average (daily) JS: gallons per minute (gpm).
Average (dai1y) c/6dl) gallons per day (gpd).
Average (daily) Jo -pmmds/square inch(psi).
Average (January) i6 ° F, Average (July)&° F.
J. INJECTION-RELATED EQUIPMENT
Attach a schematic diagram or cross-section of the well construction that shows the total depth, length of casing,
extent of grout, stickup, location of influent/effluent sampling ports, etc. If this is a modification. show the
engineering layout or proposed modification of the injection equipment and exterior piping/tubing associated with
the injection operation. The manufacturer's brochure may provide supplementary infonnatjon if needed.
K. WCATION OFWELL(S)
(1) Attach a site map ( can be drawn) showing: houses and other stnictures, property lines. surface water bodies,
potential sources of groundwater contamination. and the orientation of and distances between the proposed
injection well(s) and any other existing well(s) or waste disposal faciJities such as septic tanks or drain fields
located within l 000 feet of the geothermal heat pump well system. Label all features clearly and include a
northanow.
(2) Attach a scaled topographic map of the area extending 1/4 mile :from the property boundary that indicates
the facility's location, a north arrow, and the map name.
NOTE: Jn most cases,~· 11 aerial photograph of the property ]Jlll'Cel showing property Ones and structRre:s can be
obtained (llld downloadei from the applicable county GIS website. Typically, the property am be searched by owner
name or address. The I, cation of the wells In relation to property boundaries, houses, septic tanks, other wells, etc.
can tl,en be drawn in by and. Also, a 'layer' can be selected showing topographk contours or elevation data.
Type 5A7 Injection Well Pennit Application (Rev. August 2009) Page3 of4 .
1- 1-1995 0:01 AH HEN P. 3
L. CWIFICAT to a es Resod below tr by imt pasas'a ateareoi swat)
NC AC 1.SA 7C A2 i 10) aiOees tic a0 Pert appi'aadima *WI bra d as folmoc
1. ioraanima= bye Empoosi310 oteTiormic efikeg
2., for a patto amp ar *air peapriecsipe by a Tsai Pears or the prgialvr, rspeotirel r,
3. for a amicipority or II lbdtrol, or [fir Fib& army! by afar a piek'sl asetotira
officer or riot* paha* elected oeie*
4. kw a9 061112C by the wdl awsrr.
Vaolburissel Batt ts *atera uire[Ile sppieaiit, Ow milk* * Mier wiped by Ira
appiraat tre:.asea ■ni atdnoeisa dick avid es speared is hat C crab permit elqpilezdas.
Z rathy madly, =drs pawky of law. bat 1 bare pot weedy araaadraed and as ___ rr#r s iaianowi ow aad:9ied is
deb dogmata and i macbmiats thew ad SO, based es say *airy' et gene iir6iridaafs iioseeaad__1- fur
nbabieg stl Kif vestac 4 I Woes Ow tie ielaaa5ta is tag atm ea aoreplc+ae. fan arm tat Isle ate algt+i5rent
rarebits, Waft dwe seboadlity Orson ad b geb n an t. !brsetemliats &ire kionootik. ' I ewe to oxalis% epaow
!Waft 11104 aid l[appikohl4 abedint d lejeaStos wal! sad ail Mabel apparinrens is ax+ordia = wide Orr ad+paored
speakeekes wad ear llsaofre beret"
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WELL DRil.LER INFORMATION
CompanyName: Gk,n A Darcb. ("Je,/\ J)c, lliq_J
WelJ Drilling Contractor's Name: _G=...,l"-"e .... Q.._L_ .... 1).,La,_,,_,_1 ...... c .... h._,,__ _______________ _
NC Contractor Certification No.: ..... 3.,..A---'---"'trD'--=-._B-<---------==C=o=nta=ct'---"P_,,e=rs=o=n:,._____,.,,5,,µ.::A=t.JML...!.....1. .... i:~------
Email Address:d1t.)e lld<i°/f ,ryi)'lDt:::, C,1)~ Company Website: WWW.
Address: 1.3 I C>':l Bold !<llo t\. ,}\ '2w,d
City: ~ °lY<.d: State:&£ Zip Code: actS~} County: Wake
Office Tele No.: 9 1:l 55~~ i,959 Fax No.A19 59,p , 3'1.3 q Cell No.:<iz9 l.J.J.3-qq 3 )
HEAT PUMP CONTRACTOR INFORMATION (if different than Driller)
Company Name:'&-,:,,JM41'\ '1ecbao,·,a l ~f\f, l.()~ Contact Person: ~ 1301,.~M<Ah
Company Website: WWW. Email Address: O)i,.Yt\lln ~a:hao,c,4 l @J:J JSt>1,il jet
Address: 145 -recho,1al a
City: ta,< O!Y State 1J .(. Zip Code: J.J5d3 County: --=--~_:_______:____:Ke~----
Office Tele No.:'119 ::J].J--a:\5'1 Fax No.1 fl =+h -qaqy CeU No. q,9 llJ.3:-I Y.J...S
INJECTION PROCEDURE (briefly describe how the injection well(s) wi11 be used)
:To or~< J-e l\ :I cu(\) 'S()Ll(' • Wat y'-" 01-f f,)( beCl:\:,oj / o-iot.~
WELL USE Will the injection well(s) also be used as ~ supply well(s) for the following?
(1) The injection operation? YES NO ___ _
(2) Personal consumption? YES ____ NO ___ _
WELL CONSTRUCTION DATA
____ }( __ --'PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(7) below as PROPOSED construction specifications. Submit Fonn GW-1 after construction.
____ EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (7)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
GW-1) ifavailable.
(1) Well Construction Date: _______ Number of borings: _ __,,.______
Depth of each boring (feet): __ "=16=-O=-'----
(2) Well casing. Is the well(s) cased?
(a) YES ~ If yes, then provide the casing information below.
Type: Galvanized steelX-Black steel __ Plastic __ Other (specify) ______ _
Casing thickness:~ diameter (inches): ft, depth: from -+\ to. ___ feet (relative to land surface)
Casing extends above ground I d\ inches
(b) NO
(3) Grout material surrounding well casing:
(a) Grout type: Cement)(_ Bentonite* rl\ Other (specify) ______ _
*By selecting bentonite grout, a variance is hereby .requested to 15A NC~ .0213(d)( l )(A), which requires a cement type grout
(b) Depth of grout around well casing (relative to land surface): from O to :J.,D feet
Type 5A 7 Injection Well Pennit Application (Rev. August 2009) Page2of4
(4) Well Screen or Open Borehole depth (relative to land surface): from AJ/J to ~4 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. Will there be a faucet o~
(a) Influentline? YesL No__ (b) Efiluentline? Yes1l.-No __
(6) Source Well Construction fufonnation. If the water source well is a different we11 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, fonnation, and type of rock/sediment units will the groundwater be withdrawn? ( e.g.
granite, limestone, sand, etc.)
Depth: _______ Fonnation: ______ Rock/sedirnent unit: _______ _
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHERWISE UNAVAILABLE.
I. OPERATING DATA
(1)
(2)
(3)
(4)
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
J. INJECTION-RELATED EQUIPMENT
Average (daily) 6 gallons per minute (gpm).
Average (daily) '/ocflJ gallons per day (gpd).
Average (daily) Jo pounds/square inch (psi).
Average (January) 1/5 ° F, Average (July)62._ ° F.
Attach a schematic diagram or cross-section of the weII construction that shows the total depth, length of casing,
extent of grout, stickup, location of influent/effluent sampling ports, etc. 1f this is a modification, show the
engineering layout or proposed modification of the injection equipment and exterior piping/tubing associated with
the injection operation. The manufacturer's brochure may provide supplementary infonnation if needed.
K. LOCATION OF WELL(S)
(1) Attach a site map (can be drawn) showing: houses and other structures, property lines, surface water bodies,
potential sources of groundwater contamination, and the orientation of and distances between the proposed
injection welI(s) and any other existing well(s) or waste disposal facilities such as septic tanks or drain fields
located within 1000 feet of the geothennal heat pump well system. Label all features clearly and include a
north arrow.
(2) Attach a scaled topographic map of the area extending 1/4 mile from the property boundary that indicates
the facility's location, a north arrow, and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property C{lll be searched by owner
name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other wells, etc.
can tlien be drawn in by hand. Also, a 'layer• can be selected showing topographic contoul"S or elevation data.
Type 5A 7 Injection Well Permit Application (Rev . August 2009) Page 3 of4
1 -01 —1 995 0 : 01 AfvI FROM w. 3
L. CRIMITICATION(10 be signed as required below or by that pe~rson's authariaed age)
NCAC ISA 2C .021 I(b) requires that all permit applications shal be signed as follows:
1. for a oorporatian: by a respoatsfile corporate officer,
2. for a parbscrship os sole proprietorship: by a general partner or the proprietor, respectively:
3. fora mauicipality or a state, federal, or other public agency_ by either a principal executive
officer or ranking publicly eketed official
4. for all others: by the well owner.
Han ■athmfaed mpot is Again on behalf of the apple net, t>rrn serbosit a letter i g.cd by the
apptl ast that noes and arm their neat as apeciird tar Part C of this permit application.
-I hereby certify, tinder penalty of law, that 1 have personally examined and am familiar with the information submitted in
this doCament and ellattachments thereto and that, based on my inquiry of drone individuals immediately responsible for
obtaining said i nfinuietian, r behevc that the information is true, accurate and complete. t am aware that there are significant
per, including tie passibility of fiaaes and imprisonment, for submitting fake information. I agree to construct, opera,
maintain, repair, and tfappfu:ablc, abandon The injection well read all related appsuteerm es in accordance with the approved
s(recif and conditions of the Permit.'
z ofPr
OwneriA Iiva>rai
'i ..r
Print or Type fall Name
Signalize of Authorized Aged, if any
Print .or Type Full Name
Submit TWO signed copies ado completed application pie and all attachments to:
iTXC Program
Aquifer Protection Section
North Carolina DENR DWQ
1636 Mail Service Center
Ramat, NC 276999-1636
Telephone [phone]
Type 3A7 h WdI r+rr:rl A— (Aev. Aawt 2009) paw 4 c 4

1-21 —1 995 0 : 01 AM FROM
L CEA' WJCATION (to be sited as rewired below or by that p 's authorized )
NCAC ISA 2C .021 I(b) requires that all permit applications shall be sited as follows:
1. far a oarparatiou: by a =poasal:3k corporate officer,
2. fora partnership or solo proprietorship: by a general or the: proprietor, respectively:
3. for a nnniicipaiity or a state, federal, or older public agencyagency= by either a principal executive
officer or rank* publicly elegy official
4, for all others` by the Well owner.
1tf as.eatbgr*zd neat is sigaig as beitaltoftire appLica t, thea s■beait a letter signed by the
sit that asaau and authorises tbeiRr neat as specified in Put C of this permit appfiaetia+..
.�1 hereby may, under penalty of taw, that 1 have personally examined and am familiar with the information submitted in
this duce ment ltrd all mats thereto and that used an my inquiry of those individuals' immediately responsible for
obtaining said intimation. r believe that the infunnation is try aocta2te and complete. Nan aware that than are significant
penalties, including the possibility of farm ami imprisonment, for submitting false information.I woe to oarsstru , operate.
maintain, repair, and if applicable, abandon the injection well and all related appurtemmees in accordance with the approved
specifications and :orations of the Permit"
OwnedA
f +•4e4Z-Sei,4- ft s
Print or'type fell Naas
Signature of Andwe ited Agent, if nay
Print .or Type Full Name
Submit TWO signed copies of the completed application parcicage and all attachments to:
UIC Program
Agader Protection Section
North Ca,lolhiz WENR-DWQ
1636 Mail Service Center
Raleigh, NC 276 1636
Telephone [phone]
Tyre 5A7 tat1 wdl ner.rr Alin ro. (ltar. Aagruei 200sq Pala 4 di