WI0700107_GEO THERMAL_20120523

Beverly Eaves Perdue
Governor
•~A s..,,~~=
N(DENR:,~
North Carolina Department-of Environment andNatural Resources
Division -ofWater ·aualitf~~-
Charles Wakild, P. E.
Director
May 23, 2012
Edward Latta
301 Neuse Drive
Chocowinity, NC 27817
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0700107
Dear Mr. Latta:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http ://portal.ncdenr.org/web/wq/ap s.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P .G.
Hydtogeologist
cc: UIC Pennit File
AQUIFER PROTECTION SECTION
1636 Mail Seivice Center, Raleigh, North Carolina 27699-1636
Location : 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterquality.org
Ari Equal Opporiunily \ Af:irrnative Action Employer
NCZf rth Carolina
.Natural/11
Permit Number WI0700107
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facili
Facility Name
Edward Latta SFR
Location Address
301 Neuse Dr
Chocowinity
Owner
Owner Name
Edward
Dates/Events
NC 27817
Latta
Scheduled
Orig Issue
09/21/07
App Received Draft Initiated Issuance
04/13/12
Central Files: APS_ SWP_
05/01/12
Permit Tracking Slip
Status
Active
Version
2.00
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Beaufort
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Edward Latta
301 Neuse Dr
Chocowinity NC 27817
Public Notice Issue
04/27/12
Effective
04/27/12
Expiration
03/31/17
Regulated Activities Req uested/Received Events
-----------------------
Heat Pump Injection RO staff report received
RO staff report requested
Outfall NULL
Waterbody Name Stream Index Number Current Class
04/20/12
04/20/12
Subbasin
Permit Number WI0700107
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Edward Latta SFR
Location Address
301 Neuse Dr
Chocowinity
Owner
Owner Name
Edward
Dates/Events
NC 27817
Latta
Scheduled
Orig Issue
09/21/07
App Received Draft Initiated Issuance
04/13/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
04/23/12
Permit Tracking Slip
Status
In re'(iew
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Beaufort
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Edward Latta
301 Neuse Dr
Chocowinity
Public Notice Issue
NC
Effective
Re guested/Received Events
RO staff report received
RO staff report requested
27817
Expiration
04/20/12
04/20/12
Waterbody Name Stream Index Number Current Class Subbasin
AWA -----.,...,.,; _I,. Jt,,.
~cb""'""""EN-R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Charles Wakild, P.E.
Director
April 27, 2012
Edward and Ordella Latta
301 Neuse Dr.
Chocowinity, NC 27817
Ref: Issuance oflnjection Well Permit WI0700107
Issued to Edward and Ordella Latta
Chocowinity, Beaufort County
Dear Mr. and Mrs. Latta:
Dee Freeman
Secretary
In accordance with the application received on April 13, 2012, I am forwarding pennit number WI0700107 for the
continued operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system located at the above
referenced address. This pennit shall be effective from the date of issuance until March 31, 2017, and shall be subject to
the conditions and limitations stated therein.
Also, please pay special attention to Part V.2. The Permittee shall retain all records of repairs, pressure tests,
maintenance, and other activities needed to maintain normal operating conditions.
In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an application
to renew the permit 120 days prior to its expiration date. This permit is not transferable to any person without prior notice
to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or [e-mail] if you have any questions about your permit.
cc: David May, Washington Regional Office
WI0700107 Permit File
Beaufort County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: [phone] \ FAX: 919-807•6496
Internet: www.ncwaterguality.org
An Equal Opportunily \ Affirmative Action Employer
;~~r,c;.-----
Michael Rogers, P.G. (NC & FL)
NOI!S.1-.c· li. 01u1 . aro na :Vaturatlu ·
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, arid Regulations
PERMISSION IS HEREBY GRANTED TO
Edward and Ordella Latta
FOR THE OPERATION OF 10 (TEN) TYPE SQM INJECTION WELL(S), defined in Title 15A North
Carolina Administrative Code 2C .0209( e )(3)(F), for the purpose of operating a vertical closed-loop
geothermal-mixed-fluid heat pump system. This system is located at 301 Neuse Drive, Chocowinity, Beaufort
County, NC 27817, and will be constructed and operated in accordance with the application received April 13
2012, and in conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for operation of~ injection well and 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 March 31, 2017, and shall be
subject to the specified conditions and limitations set forth in Parts I through VII hereof.
Permit issued this the 26th day of April 2012.
{Jtt,a-J. ~
Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission.
WI0700107 UIC/5QM-M.F. Renewal
Version 1/2010
Page 1 of4
PART I-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. In the event that there are multiple wells with separate clusters; one well identification tag per 'cluster' of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
PART II-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance ofthis permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART III -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
WI0700107 UIC/5QM-M.F. Renewal
Version 1/2010
Page 2 of4
PART IV -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit; and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reaspnable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for. collecting any necessary and appropriate samples associated with the
injection facility activities.
PART V -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water . Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall retain all records of repairs, pressure tests, maintenance, and other activities
needed to maintain normal operating conditions.
3; The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Washington Regional Office, telephone number 252-946-6481, 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;
4. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
5. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VI -PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
WI0700107 UIC/5QM-M.F. Renewal
Version 1/2010
Page 3 of4
PART VII-CHANGE OF WELL STATUS
I. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to ISA NCAC 2C .0213(h)(l), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel-packed wells in which the .casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part VII (1) and (2) (G) shall be submitted to:
WI0700107
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/5QM-M.F. Renewal
Version 1/2010
Page 4 of4
Ro gers, Michael
From:
Sent:
To:
Cc:
Subject:
Michael,
May, David
Friday, April 20, 2012 4:51 PM
Rogers, Michael
Clark, Allen
RE : WI0700107 Latta
Our office doesn't wish to perform a pre-permitting site inspection.
Thanks
David
David May, Regional Aquifer Protection Supervisor Division of Water Quality
Aquifer Protection Section
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
E-mail: david.ma v@ ncdenr.gov
http://portal.ncdenr.org/web/wg/
E-mail correspondence to and from this address may be subject to the North
Carolina Public Records Law and may be disclosed to third parties.
-----Original Message-----
From: Rogers, Michael
Sent: Friday, April 20, 2012 4:46 PM
To: May, David
Subject: FW: WI0700107 Latta
Please find attached a SQM residential renewal application. Please let me know
if you wish to conduct a pre-permitting inspection or not.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line 919-807-6406
htt p ://portal.ncdenr.org/web /wq/a ps /gwpro /p ermit-a pp lications#geothermA pp s
1
E-mail correspondence to and from this address may be subject to the North
Carolina Public Records Law and may be disclosed to third parties
-----Original Message-----
From: Michael Rogers [mailto:[e-mail] ]
Sent: Friday, April 20, 2012 12:42 PM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0'' (Aficio 2075).
Scan Date: 04.20.2012 12:42:19 (-0400)
Queries to: robin.markha m@ ncdenr.gov
2
MA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Edward T. Latta
Ordella R. Latta
301 Neuse Drive
Chocowinity, NC 27817
Dear Mr. and Mrs. Latta:
Charles Wakild, P.E. Dee Freeman
Secretary Director
April 13, 2012
Subject: Acknowledgement of
Application No. WI0700107
Edward Latta SFR
Injection Mixed Fluid GSHP
Well (SQM) System
Beaufort County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on April 13, 2012. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Washington Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
· efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
Sincerely,
forQm~A.~
Groundwater Protection Unit Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Permit File WI0700107
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
Internet: www.ncwaterouality.org
An Equal Opportunity \Alllnnative Action Employer
N%rthCarolina ·A1.····t··.····.~~··.·· · ·· · 'h "Uff/f rg · · · ·u i n,: "~ · · : : : . : . : : ... : ... :.
--. WWA9 rVP- ■ 9 0 qw—"
Pr
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP MIXED -FLUID GEOTHERMAL MECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system
(check one) New Application /Renewal* Modification
* For renewals complete Parts A-C and the signature page.
lnt or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 201■A_ ROE ' 1m�rp,,l!nnmm
PERMIT NO. WrD7DQ L O T (leave blank if New Application)'uCrrtvlJW{,
A. STATUS OF APPLICANT (choose one) APR '� 201Z
Non -Government: Individual Residence Business/Organization Aquifer Protealon SeOon
Government: State Municipal County Federal
B. PERMIT APPLICANT — For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business. or agency:
Mailing Address: v�
City: 1U State: AIIII Code: d 7 1 7 County: * u f f`
Day Tele No.: o Cell No_:
EMAIL Address: 19"rd 14,6154cUe V1sAJX.Fax No.:
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 11F1_7J � County:
(2) Physical Address (if different than mailing address):
City:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No —
Company Name:
Contact Person:
Address:
State: NC Zip Code:
EMAIL Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
GPUMC SQM Permit Application (Revised 112V2011) Page 1

rs */" t
. 9"0"60 ► r onah amrM
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:
Contact Person: EMA 1 L Address:
Address:
F.
City:
Office Tele No.:
Zip Code: State:
WELL CONSTRUCTION DATA
Cell No.:
County:
Fax No.:
(1) Number of borings to be constructed*: Depth of each boring (feet):
* If existing water supply wells will be used their provide the information in item (4) below.
(2) Chemical additives to be used: R-22
Propylene glycol
Ethanol
Other (other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc):
(4) Well casing_ If the well(s) will use casing then provide the bTee (steel, PVC, plastic, etc.), diameter, depth,
and extent of casing appearing above ground:
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite** Other (specify)
*'` By selecting bentonite grout, a variance is hereby requested to 15 A NCAC 2C .0213(d)(1)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from to (feet)
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clear]-, and include a north arrow.
(1)
(2)
Attach a site -specific map showing the locations of the following:
* Proposed injection wells
* Surface water bodies
* Buildings
* Water supply wells
* Property boundaries
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
Attach a topographic map of the area extending 114 mile from the injection well site that indicates the
facility's location and the map name.
NOTE. In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded front the applicable county GIS websile Typically, lire property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5QM Permit Application (Revised 1/24/201 l)
Page 2

s
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
I. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner {which means all_persons listed on the propert-, deed}.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct. operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Signature of Property Owner/Applicant
W4Yd I . 14 19�- &4.-
Print or Type Full Name
Signature of Property Owner/Applicant
0-<agry1,k_ 0 /s4 6f4—
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telcphone [phone]
RECEIMIDENRIDWQ
APR 13
Aquifer Protectory Section
GPUIMCr 5QM Permit Application (Revised IJ24/2011) Page 3

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: W I d -7 O i O 7 ---
Permittee Name: A'6o!"l ?Z
Address:
Please check the selection which most closely describes the current status of your injection well system:
1) ITL/Weli(s) still used for injection activities, or may be in the future.
2) ❑ Wells) not used for injection but is/are used for water supply or other purposes.
3) ❑ Injection discontinued and: a) r Well(s) temporarily abandoned
b) ❑ Well(s) permanently abandoned
c) ❑ Well(s) not abandoned
4) ❑ Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description ofhow the well
was sealed and the type of material used to f ll the well if permanently abandoned):
Permit Rescission:
If you checked (2), (3), or (4) and will not use a well for injection on this site in the future, you should request rescission of the
permit. Do you wish to rescind the permit?
❑ Yes ❑ No
Certification:
"i hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
-z&66t= ,, / a". 0?0/0�
mgnature Date
RECEVEDIDEONG
APR 13 1012
Revised 5105 GWIUIC-68
MOW Protection Section

fi
A�
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Ouality
Beverly Eaves Perdue Charles Wakild, P. E.
Governor Director
March 30, 2012
Edward Latta
301 Neuse Drive
Chocowinity, !'IC. 27817
Subject: Notice of Expiration (NOE)
5QM Geothermal Injection Well
Permit No. W10700107
Beaufort County
Dear Mr, Latta:
Dee Freeman
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Quality (DWQ) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for
the underground injection well system located on your property at 301 Neuse Drive in
Chvcowinity, NC, which was issued to you on September 21, 2007, and expires on August 31,
2012, is soon due for renewal. If you wish to keep this permit and Operate the injection well
system, the permit must be renewed and issued in your name_
If Your Injection Well is Currentiv Inactive:
If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed under NCAC Title 15A, Subchapter
2C, Section _021 4. When each well is plugged and abandoned, the well abandonment record
(Form GW-30) must be submitted to our office to certify that the abandonment was properly
conducted.
If there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form roust also be submitted. The GW-30 and Name/Ownership
Change forms can be found at htiw loortal.ncdenr.nrgvweb/wq/at}slLy_ v-forms.
If Your Injection Well is Currently Active:
If the injection well system is still active and you wish to renew your permit, the renewal
application must be submitted within 120 calendar days of the expiration of your permit.
According to our records, you must submit your permit renewal by Ma► 3.2012.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636 011C
Location: W N. Salisbury St., Raleigh, North Carolina 27694 North Carolina
Phone:[phone] FAX: 9iMO7-6496 -9 i1 , ry
Irnternet: www.ncWatgrauaHty.Uru
An Equal Oppo6rwty l AYmathre AMOrl Erhployer

In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subcbapter 2C, Section 0211, you must submit one of the following
enclosed forms:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for Injection with
Geothermal Heat Pump System for Type 5QM Wells) if the injection well system on
your property is still active.
-GR-
B. Status of hgection Well System if the injection well system is inactive or has been
temporarily or permanently abandoned.
Please submit the appropriate forms to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
httu://,Portal.ncdenr.org/web/wg/apslgwpro/permit-applications#geotherTnApps.
Thank you in advance for your cooperation and timely response. If you have any questions,
please contact me by phone at [phone] or by email at eric.g.smithr&_ncdenr.gay.
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Washington Regional Office - APS w/o enclosures
APS Central Files - Permit No. W10700107 w/o enclosures
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Nxechanieal Integrity Test Record
(For 5QM Geothermal Heat Pump Injection Well System)
i_ ,
Owner/Pennittee Name:
Facility Address: -;r I
_Permit Number. WI L 7 0
Home Phone: 71 r `1 Cell Phone:
Heat Pump Contiactor Name:y 1 P- IZO Cq Lr�'
Oce Phone: _ _i a-- Q� L Cell li Phone: -
Tester Name: U:d it t fir° j5 __Signature: i
DateofTest: I -
7?
Any additional loop testing add to bank of this form
Lu t
Other T Methods and Results:
This Form must be filled out and signed by the tester.
prior to the initiation of the operation of the facility.
Raleigh, NC 2769,9 or by fax: [phone].
Mechanical Integrity Test Form 1 112007
The record must be received by Aquifer Protection Section 24 hours
You can send the form by mail: LTIC Pragram, Mail Service Center 1636,

r_· -
(
(
J

i ncorporat
g e e y a o
Mr. Michael Rogers,
Please find the following Mechanical Integrity Test Records and triangulation maps for the following
projects. I will be sending you another packet of the remaining 07 and 08 projects at my soonest
convenience. Thank you for your patience and help on this matter.
• WIO0800137
• WlO500157
• WIO500161
• WIO500162
• WO500169
• WlO700107
• WlO700096
• WIO500143
• WIO700093
• WIO700095
• WIO500185 -not included on permit list.
Best Regards,
/2: ~ /f' /1 '1 1/1 ~
/;C //1/./
Anna Jeffreys
Administrative Assistant
Home Energy Inc.
RECEIVED/ DENR / oyva
Aquifer Protection Section
JAN 2 9 2009
: ~ E Third Street· \.Nendeii, NC 2759 • 919-366-0261
[e-mail]
ri i — me, ; � d—�
Permit No.
W10400082
W100800137
W10500145
W10800140
W10500157
W10100086
W14700105
W10500161
WI0500162
W10500163
W10500166
W10500169
W10700107
W10800150
W10500171
W10500170
W10700094
WI0800136
Wf0500139
W10800135
W10700096
W10500143
W10700093
W10700095
W10500173
W10500174
List of Issued Permits to Home Energy, Inc.
Name
Braden
Panigutti
Clark
Beianger
S. Martin
Combs
Chen-illo
Stein i! r�
Lauer w�
Blachowicz
Maloney
Latta
Duan
ENT Audiology
Griffin
Harris
Jefferson
Esstck
Wilson
Stafarx'
Kahn
Young
Turner
Bell
Wilson Community College
]c�- ar i I I
-fir �il.irw�
U}
November 20, 2007
Heat Pump Gontractor
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Date Permit issues!
11 /20/2006
11/22/2006
10/9/2006
2/13/2007
3/9/2007
411812007
5/17/2007
6/27/2007
716/2007
8/2012007
8M 712007
10/12/2007
9/21/2007
9/20/2007
9/20/2007
10/11/2007
7/3012006
9/12/2006
1/6/2006
9/12/2006
9/22/2006
8/4/2006
7/3/2006
9/22/2006
not permitted as of 11/20/07
11120/2007
RECEIVED 1 ❑ENR 1 DWD
Aquifpr Protection Section
.JAN 2 9 2009

0� W A 'QQG y" tJ 7� 7 Michael F. Easley, Governor
� William G. Ross Jr., Secretary
.. 7 North Cambna Department of Environment and Napual Resources
QColeen Sullins. Director
Division of Water Quality
November 27, 2007
Monte Jefferson
Home Energy, Inc.
PO Box 238
Wendell, NC 27591
Subject: Geothermal Well installation Data
Dear Mr. Jefferson:
In review of our records concerning closed -loop geothermal mixed -fluid injection well systems,
classified as 5QM type permits, we have found the following records have not been submitted
for permits where your company is listed as the heat pump installers:
• Well Construction Record (G W-1)
• Triangulation Data
• Well ID plate installation date
• Mechanical Integrity Pressure testing data (if available)
In order to assist your clients (those who hold 5QM permits) in meeting the condition of their
permits. Home Energy, Inc. (specifically Brad Scheel) has agreed to provide the above
inforination no later than December 27, 2007. For future reference, as we discussed November
14, 2007, we recommend you provide this information to your clients as soon as construction is
complete to assist them in meeting the condition of their permits. Also, please remember their
permits require there to keep this information on -site as well.
To assist you, we have attached a list of permits where you are listed as the heat pump installer.
We have also attached a form to fill out the results of your mechanical integrity tests. Thank you
in advance for your woperation and timely response. If you have any questions regarding this
letter, please call me at [phone] or Michael Rogers at [phone].
Sincerely,
Debra J. Watts
Environmental Supervisor
Groundwater Protection Unit
Attachments)
cc: APS Central Files (copy to each permit file on attached list)
Aquifer Prot action section 1636 Mail service Center
intent: www-lagwatyclighty.0r Ucation: 2728 Capital Boulevard
An Equal Opportur?!t AMrmaWe Acllon Ernptoyer- 50% Recycledil0% PW Consumer Paper
Dn..
NattbCam ina
Naturallil
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

List of Issued Permits to Home Energy, Inc.
Permit No. Name Heat Pump Contractor Date Permit Issued
WI0400082 Braden Monte Jefferson 11/20/2006
WI00800137 Panigutti Monte Jefferson 11/22/2006
WI0500145 Clark Monte Jefferson 10/9/2006
WI0800140 Belanger Monte Jefferson 2/13/2007
WI0500157 S. Martin Monte Jefferson 3/9/2007
WI0100086 Combs Monte Jefferson 4/18/2007
WI0700105 Cherrillo Monte Jefferson 5/17/2007
WI0500161 Stein Monte Jefferson 6/27/2007
WI0500162 Lauer Monte Jefferson 7/6/2007
WI0500163 Blachowicz Monte Jefferson 8/20/2007
WI0500166 Manning Monte Jefferson 8/17/2007
WI0500169 Maloney Monte Jefferson 10/12/2007
WI0700107 Latta Monte Jefferson 9/21/2007
WI0800150 Duan Monte Jefferson 9/20/2007
WI0500171 ENT Audiology Monte Jefferson 9/20/2007
WI0500170 Griffin Monte Jefferson 10/11/2007
WI0700094 Harris Monte Jefferson 7/30/2006
WI0800136 Jefferson Monte Jefferson 9/12/2006
WI0500139 Essick Monte Jefferson 1/6/2006
WI0800135 Wilson Monte Jefferson 9/12/2006
WI0700096 Stolar Monte Jefferson 9/22/2006
WI0500143 Kahn Monte Jefferson 8/4/2006
WI0700093 Young Monte Jefferson 7/3/2006
WI0700095 Turner Monte Jefferson 9/22/2006
WI0500173 Bell Monte Jefferson not permitted as of 11 /20/07
WI0500174 Wilson Community College Monte Jefferson 11/20/2007
November 20, 2007
Mechanical Integrity Test Record
(For SQM Geothermal Heat Pump Injection Well System)
Owner/Permittee Name: Permit Number: WI '-------------------'-'-'"--------
Facility Address: _______________________________ _
Home Phone: Cell Phone:
Heat Pump Contractor Name: ___________________________ _
Office Phone: Cell Phone: -----------------~~~~~------------
Tester Name: _______________ Signature: _______________ _
Date of Test: --------
Loop Initial Pressure (p si) Final Pressure (p si) Duration (minutes)
1
2
3
4
5
6 .
7
8
9
10
11
12
13
14
15
Any additional loop testing add to back of this form
Comments:
Pass (Yes or No)
----------------------------------
Other Test Methods and Results:
This form must be filled out and signed by the tester. The record must be received by Aquifer Protection Section 24 hours
prior to the initiation of the operation of the facility. You can send the form by mail:-UIC Program, Mail Service Center 1636,
Raleigh, NC 27699 or by fax: [phone].
Mechanical Integrity Test Form 11/2007
Permit Number W10700107
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Permitted Flow
Facility
Facility Name
Edward Latta SFR
Location Address
301 Neuse ❑r
Chocowinily
Owner
Owner Name
Edward
Dates/Events
NC 27817
Central Files. APS SwP
09/21/07
Permit Tracking Slip
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
MajorlMinor Region
Minor Washington
County
Beaufort
Facility Contact Affiliation
Owner Type
}ndlvidual
Latta Owner Affiliation
Edward Latta
301 Neuse Dr
Chocowinity NC 27817
Scheduled
Orig Issue App Received Draft initiated Issuance
08/29/07
Reciulated Activities
Neat Pump Injection
Outfall MILL_
Waterbody Name
Public Notice Issue Effective Expirati n
9b1I0.7 /Iola
Requested/Received Events
RO staff report requested 09/05107
RO staff report received 09/20/07
Stream Index Number Current Class subbasin

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Directer
Division of Water Quality
September 21, 2007
Edward Latta
301 Neuse Drive
Chocowinity, NC 27817
Re: Issuance of Injection Well Permit
Permit No. W10700107
Issued to Edward Latta
Dear Mr. Latta:
In accordance with your application received August 29,1-007,1 am forwarding Permit No.
W10700107 for the operation of a vertical closed -loop geothermal mixed -fluid heat pump
injection well system to be located at 301 Neuse Drive, Chocowinity, NC 27817, This permit
shall be effective from the date of issuance until August 31, 2012, and shall be subject to the
conditions and limitations stated therein.
Pay special attention to the well construction standards in Parts II and V of your permit.
You must notify this office (Raleigh Central Office) and. the Washington Regional Office at least
forty-eight (48) hours prior to constructing the system, and forty-eight (48) hours prior to
initiation of the operation of the system,
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit
an application to renew the permit three months prior to its expiration date, As indicated in the
permit, this permit is not transferable to any person without prior notice to, and approval by, the
Director of the Division of Water Quality, If you have any questions regarding your permit or
the Underground Injection Control Program please call Mr. Qu Qi at [phone] or me at
[phone].
Best Regards,
9
7 r'
Michael Rogers
Environmental Specialist
cc: David May -- Washington Regional Office
Central Office File — WI0700107
Monte Jefferson — Home Energy, Inc.
Attaclunent(s)
Nx Carolina
Naturally
Aquifer Protection Secrion 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone: [phone]
Internet: htW_Ilwww.ncwai=ualitv.cn 2729 Capital Boulevard Raleigh, NC 27604 Fax 1; (919) 7r5-0588
Fax 2; [phone]
An Equal opportunftylAffrrmative Action Employer- 50% Recyded/1WD Post Consumer Paper Cusnomrr Service; [phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other
applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
EDWA" LATTA
FOR THE CONSTRUCTION AND OPERATION OF 10 TYPE 5QM INJECTION WELLS,
defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of
operating a "direct expansion" type vertical closed -loop geothermal -mixed -fluid heat pump
system. This system is located at 301 Neuse Drive, Chocowinity, Beaufort County, North
Carolina, and will be constructed and operated in accordance with the application received
August 29, 2007, and in conformity with the specifications and supporting data submitted, all of
which are filed with the Department of Environment and Natural. Resources and are considered a
part of this permit.
This permit is for Construction and Operation only and does not waive any provisions of the
Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an
injection well shall be in compliance with Title 15A North Carolina Administrative Code 2C
.0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well construction and
use.
This permit shall be effective, unless revoked, from the date of its issuance until August 31, 2012
and shall be subject to the specified conditions and limitations set forth in Parts 1 through EK
hereof:
Permit issued this the 2 �A day of +?A-► b 007.
(3:2�en__
l
Coleen H. Sullins Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0700107 Page 2

4. Prior to installation, all tubing to be placed in boreholes ("loops") shall be checked for leaks
by pressurizing the loop to a gage pressure of at least 350 pounds per square inch (psig),
immersing the loop in water and · examining it for leaks. Loops with leaks shall not be
installed.
5. Prior to installation, each loop shall be visually inspected for damage such as kinks~ dents,
and scrapes. Each loop shall be checked to verify that the nitrogen charge applied to the loop
by the manufacturer before shipping is still present at a pressure of at least 300 psig. The
loop · manufacturer shall be notified in the event of damage or pressure loss, and the
manufacturer's instructions shall then be followed. The nitrogen charge may be released
only when the loop is installed and ready to be connected to the manifold.
· 6. Boreholes shall be large enough to allow insertion of the loop plus a tremie pipe for grouting.
7. After insertion of the tubing into the boreholes, an approved grout (as defined in Title 15A
North Carolina Administrative Code 2C .0100) shall be pumped via tremie pipe into the
annular space of each borehole so as to completely fill it from bottom to top.
8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material
shall have a galvanic potential as close as practicable to that ofthe tubing material.
9. Dry nitrogen shall be circulated through the tubing during brazing to prevent oxidation.
10. After installation and prior to operation of the system, a mechanical integrity test shall be
conducted by pressurizing the injection well system to 400 psig with dry nitrogen and
monitoring for leaks using an ultrasonic or other leak detector of equal sensitivity and
monitoring pressure in the system for at least 2 hours. Alternatively, an equivalent vacuum
test is acceptable. Any pressure fluctuation other than that due to thermal expansion and
contraction of the testing medium shall be considered a failed mechanical integrity test. Any
leaks shall be located and repaired prior to charging the system with refrigerant. A copy of
the p ost-installation pressure or vacuum test record (initial pressure readin g, final pressure
reading, and the duration of the test) shall be submitted to the Aquifer Protection Section.
The test records must be received b v the Aquifer Protection Section at least twenty-four (24 )
hours prior to the initiation of the o p eration of the facili ty for in jection.
11. The location of each of the system manifolds shall be recorded by triangulation from two
permanent features on the site (e.g., building foundation comers). The Permittee shall retain a
copy of the triangulation records. The Pennittee shall also submit a copy of the ·triangulation
records to the Aquifer Protection Section within 30 days of completion of well construction.
12. The written documentation required in Part II. para!rraphs (1 0) and (11) shall be submitted to:
Permit No. WI0700107
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Page4
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 not be located in an area generally subject to flooding. Areas that
are generally subject to flooding include those with concave slope, alluvial or colluvial
soils, gullies, depressions, and drainage ways.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each injection well shall have permanently affixed an identification plate.
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection
well to: DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1636
Mail Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well
construction.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. Prior to constructing the injection well system, the Permittee or his agent shall test the pH of
the soil at a depth of three feet at the planned well location. If the resulting soil pH is less
than 6 standard units or greater than 11 standard units, the well system shall be equipped with
a compatible cathodic protection system. All testing results shall be kept on site available for
inspection.
2. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the
Aquifer Protection Section's Underground Injection Control (UIC) Program Central Office
staff, telephone number [phone] and the Washington Regional Office Aquifer
Protection Section Staff, telephone number [phone].
3. All underground tubing shall be refrigeration grade copper tubing.
Pennit No . WI0700107 Page 3
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.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be _made. for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed
necessary by the Division of Water Quality to insure surface and ground· water protection,
will be established and an acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone,. within 48 hours of the occurrence or first
knowledge of the occurrence, to the Washington Regional Office, telephone number (252)
948-3939, 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;
( C) Any loss of refrigerant in the system, regardless of the ?rigin of the loss;
(D) Any recharging of the refrigerant system.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in. said application or in any report to the
Director, the relevant and correct facts or information shall be promptly submitted to the
Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
Permit No. WI0700107 Page 6
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 not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations,. or ordinances, which may be
imposed by other local, state, and federal agencies, which have jurisdiction. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater that 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 oe required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQIDREMENTS
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 (24) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section's
Underground Injection Control (UIC) Program 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.
Permit No. WI0700107 Page 5
(G) 1'he Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in ISA NCAC 2C .0213(h)(l) within 30 days of completion
of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
PermitNo. WI0700107
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Page8
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 90 days prior to the expiration of this permit, request an
extension.
PART IX -CHANGE OF WELL STATUS
1. The Pennittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) 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.
Permit No. WI0700107 Page 7
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: September 13.2007 County: Beaufort
To: Aquifer Protection Section Central Office Permittee: Lalta
Central Office Reviewer: Micheal Ro,2ers Project Name: Edward Lalta UIC
Regional Login No: Application No.: WI070 En
wept, cot aN}i
L GENERAL INFORMATION
1. This application is (check all that apply)' ® New ❑ Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagool
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation ❑ Other Injection Wells (including in .situ remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
Gn
a. Date of site visit: September 1.1.2007
b_ Person contacted and contact information: Mr. Monte Jefferson t 919.366.02611
c. Site visit conducted by: Allen H. Clark and Will Hart
d. inspection Report Attached: ® Yes or ❑ No. N
c
2. Is the following information entered into the BM record for this application correct? Lr
N Yes or ❑ No. if no, please complete the following or indicate that it is correct on the current application.
IL NE WAND MAJOR MODIFICATIONAPPLICATIONS (this section not needed for renewals ornrinar
modifications, skip to next section)
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification,
2. Are the new treatment facilities adequate for the type of waste and disposal system?
❑ Yes ❑ No ® NIA. If no, please explain:
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? ❑ Yes ❑ No ❑ NIA. If no, please explain:
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)'? ❑
Yes ® No ❑ NIA. If no, please explain; -
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. ❑ Yes ❑ No
N/A. If no, please explain: _
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
❑ Yes ❑ No ®N/A. If no, please explain:
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
FORM: Latta APS Staff Report i

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
❑ Yes ❑ No ® NIA. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV:
8_ Are there any buffer conflicts (new treatment facilities or new disposal. sites)? ❑ Yes or ® No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit:
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? ❑ Yes ❑ No ® NIA. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program:
10. For residuals, will seasonal or other restrictions be required? ❑ Yes ❑ No ® NIA If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEWAL AND MODIFICATION APPLICATIONS Luse previous section for new or major madlicution
si-stemy). NIA
IV. INJECTION WELL PERMIT APPLICATIONS {Complete these two sections for all systems that use injection
wells, including closed -loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.}
Description Of Well(Si And Facilities — New. Renewal. And Modification
f. Type of injection system:
❑ Heating/cooling water return flow (5A7)
® Closed -loop heat pump system (5Q1VV5QW)
❑ In situ remediation (51)
❑ Closed -loop groundwater remediation effluent injection (SL/"Non-Discharge')
❑ Other (Specify:
2. Does system use same well for water source and injection? ❑ Yes ® No
.3, Are there any potential pollution sources that may affect injection? ❑ Yes ® No
4, What is the minimum distance of proposed injection wells from the property boundary? 5 ft.
5. Quality of drainage at site: ® Good. ❑ Adequate ❑ Poor
5. Flooding potential of site: ® Low ❑ Moderate ❑ High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: N/A
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? ® Yes or ❑ No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
FORlu: Latta APS Staff Report 2

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet -if needed information is available.
3. Do you foresee any problems with issuance/renewal of this permit? D Yes [8J 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: None
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition: None
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
One well identification tag per "cluster" of wells In compliance with 15A NCAC 2C .0213(g).
shall be permanently affixed to the heating and
cooling unit, in a clearly visable location.
Applicant must submit accurate site drawings Drawings may be required to locate well heads
showing the locations of wells, and other in the future.
pertinent site information, pending installation.
7 . Recommendation: D Hold, pending receipt and review of additional information by regional office; [8J Hold,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information; D
Issue; D Deny. If deny, please state reasons: __
8. Signature ofreport preparer(s): ----~-----~/_f-_-:_t/4_-~----------------
Signature of APS regional supervisor: -.fJl--b""'~~-~-n,~----=---------------
Date: _9~-~r:J_-_01~-
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
It a ppears that the requirements of 15A NCAC 2C .0211 have not been satisfied , namely 2C .021 l(d)(l)(D )(i ),
(E), and (G).
FORM: Lalta APS Staff Report 3
Permit: WI0700107
SOC:
County: Beaufort
Region: Washington
Effective:
Effective:
Contact Person: Edward Lalta
Directions to Facility:
Compliance Inspection Report
Expiration:
Expiration:
Title:
Owner: Edward Lalta
Facility: Edward Lalta SFR
301 Neuse Dr
Chocowinity NC 27817
Phone:
Take Hwy 33 East from Chocowinity, turn left on Old Blount Creek Rd. Take second entrance (on left) to Cypress Landing Subdivision.
StaY. on Potomac Drive until you get to Neuse Drive on the right and Lalta's house is on the left at 301 Neuse Drive.
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 09/11/2007
Primary Inspector: Allen Clark
Secondary lnspector(s):
Will T Hart
Certification: Phone:
Entry Time: 10:30 AM ExitTlme: 11 :15 AM
Phone:
Phone:
Reason for Inspection: Routine Inspection Type: IU Non-Sampling
Permit Inspection Type: Injection Mixed Fluid GSHP Well System (5QM)
Facility Status: ■ Compliant O Not Compliant
Question Areas:
■Wells
(See attachment summary)
Page: 1
Permit: WI0700107
Inspection Date: 09/11/2007
Inspection Summary:
Owner -Facility: Edward Lalla
Inspection Type: IU Non-Sampling
Inspection conducted as part of permit review. No problems observed.
Reason for Visit: Routine
Page: 2
Edw ard Lalta UIC Permit WI0700107 N
Type 5Q M closed loop geothermal +
Cypress Landing, Beaufort County
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AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: September 5, 2007
To: ❑
Landon Davidson, ARO-APS
❑
Art Barnhardt, FRO-APS
❑
Andrew Pitner, MRO-APS
❑
Jay Zimmerman, RRO-APS
From: l lichad floeers . Groundwater Protection Unit
® David May, WaRO-APS
❑ Charlie Stehman, WiRO-APS
❑ Sherri Knight, WSRO-APS
Telephone: t919 M 715-b 1 d6 Fax: [phone]=CEIVtrlyl D NR I OWQ
E-Marl: Michael.Rogers cimcmail.net AOUlF1=R PAf1i r' 1'IDN
A. Permit Number: WI 0700107 SEP 112907
B. Owner: Edward Laita
C. Facility/Operation:
® Proposed ❑ Existing ❑ Facility ❑ Operation
D. Application:
1. Perrnif Type: ❑ Animal ❑ SFR Surface Irrigation❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Remediation (ND)
® UIC - (5QM) closed loop mixed fluid geothermal
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type: ® New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
NOTE: The requested days for the submittal of the staff report [SR) has changed. -Per _the -request of
Debra Watts. the requested dates for the submittal ❑ff_the SR have been changed to 2 weeks for a UIC
report: and 4 weeks for a SFR report. - - -
Attached, you will find all information submitted in support of the above -referenced applicationfor your
review, comment, and/or action. Within 14 calendar days, please take the following actions:
® Return a Completed APSARR Form.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and rev_iews,_as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SDP for additional detail.
When you receive this request form, please write your name and dates in the spac's.bilow'.rnake a- copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: ,AlIy1� C/o--r k )[late: ---7 —0-7
FORM: APSARR 07106
Page l of 1

A QUIFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: Sep tember 5 , 2007
To: D Landon Davidson, ARO-APS
□ Art Barnhardt, FRO-APS
□ Andrew Pitner, MRO-APS
D Jay Zimmerman, RRO-APS
C8J David May, WaRO-APS
□ Charlie Stehman, WiRO-APS
0 Sherri Knight, WSRO-APS
From: Michael Rogers , Groundwater Protection Unit
Telephone: [phone] Fax: (919 ) 715-0588
E-Mail: Michael.Ro gers @ncmail.net
A. Permit Number: WI 0700107
B. Owner: Edward Lalta
C. Facility/Operation: __
C8J Proposed 0 Existing D Facility D Operation
D. Application:
1. Permit Type: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D I/E Lagoon D GW Remediation (ND)
C8J UIC -(SQM) closed loop mixed fluid geothermal __
For Residuals: D Land App. D D&M D Surface Disposal
D 503 D 503 Exempt D Animal
2. Project Type: C8J New D Major Mod. D Minor Mod. D Renewal D Renewal w/Mod.
E. Comments/Other Information: D l would like to accompany you on a site visit.
NOTE: The requested day s for the submittal of the staff rep ort (SR) has changed. Per the re quest of
Debra Watts. the re quested dates for the submittal of the SR have been changed to 2 weeks for a UIC
report. and 4 weeks for a SFR re port.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 14 calendar days, please take the following actions:
C8J Return a Completed APSARR Form.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and · reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer:
FORM: APSARR 07/06 Page 1 of I
WArEq
Michael F. Easley, Governor
�0
William G. toss Jr., Secretary
North Carolina Department of Environment and Natural Resources
p A.
Galaen H. ullinsWater
Qtor
f
Division of Water Quality
lily
August 30, 2007
Edward Lalta
301 Neuse Drive
Chocowinity, NC 27817
Subject: Acknowledgement of Application No. WI0700107
Edward Lalta SFR
Injection Mixed Fluid GSBT Well System (5QM)
Beaufort
Dear Mr. Laita:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on August 29, 2007. This application package has been assigned the number
listed above and will be reviewed by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary.
To ensure the maximum efficiency in processing permit applications, the Division requests your assistance in
providing a timely and complete response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final
action by the Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days
after receipt of a complete application.
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at
michael.rogers rr ncmail.net. If the reviewer is unavailable, you may leave a message, and they will respond
promptly. Also note that the Division has reorganized. To review our new organizational chart, go to
htt://h2o.enr.state.ne.us/documents/dwo orecbart.ndf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING LNQUERIES ON THIS
PROJECT.
Sinc ly,
j❑r Debr r. efts
Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Permit Application File W I0700107
Aquifer Protection Section 1636 Mall Service Center Raleigh, NC 27699-1636
Internet: www.newatemualitv.oro Location: 2728 Capital Boulevard Raleigh, NC 27604
An Equal opportunitylAfirmaM Adon Employer- 50% Recycdedl10% Post Consumer Paper
Telephone:
Fax 1:
Fax 2:
Customer Service:
���, ►Carolina
,Nrli N11111
[phone]
[phone]
[phone]
[phone]

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type 5A7 and 5QM WeRs
In Accordanrc with the provisions ofNCAC Title 15A- 02C.0200
ConVlete application and maul to address on the back page.
TO: DIRECTOR, lip TH CARQLINA DIVISION OF WATER QUALITY
DATE: _. �j 20_ d 7
A SYSTEM CLASSIFICATION Please check column which matches proposed system_
(1) — Type 5A7 wells inject water used to provide heating or coaling for structures.
(2) ' Type 5QM wells contain a subsurface system of continuous piping, that is
isolated From the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes and/or corrosion
inhibitors.
(3) Type 5QW wells contain a subsurface system of continuous piping, that is
isolated from the environment and only circulates potable water. If you selected
this well type, then complete farm_ GW-57 CL, Notification Of Intent To
Construct A Closed -Loop Geothermal -Water Only Injection Well Sp-tem.
B. PERMU APPLIC
Name: �t .
Address:
City: s ' n ' State: Zip Code: County.
Telephone:
C. PROPERTY OWNER (if different from applicant)
Name:
Address:
City: Sate: Zap Code: County:
Telephone:
D.
STATUS OPLICAN'I'
Private:
Federal:
Commercial:
State:
Municipal;
Native American 1.1
C
Mej o_ v ai
F CX- }
�v
Home Energy Inc
P.Q. Box 238
Wendell NC 27591
Revised 5/05 GWIMC-57 HP Page 1 of

E. FACil,ITY (SITE) DATA
F.
G.
H.
L
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility:--~---------------
Address: --A-7 J___!:
City: ('tiJae: ____ County: ______ _
Telephone: _________ Contact Person: ________ _
HEAT PUMP CONTRACTOR DATA _
N._ l~~e ig-1(0•~ ~ •
Address: =0 2 X .r d ~bcee t:
City: \,2e.,d.e L( ) ,,{)L Zip Code: ;>, 759 l County: ~u;:
Telephone: t:1 ,e~ )l:br 02,b I Contact Person: /19o ~ _ --_.c SCv7
INJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.)
{! lo~=~Aloo{t (;r~~t 7:(:,;'~J
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) Theinjectionoperation? A')!' J YES ___ NO __ _
(2) Personal consumption? ✓V /'t YES ___ NO ___ _
CONSTRUCTION DATA ( check one)
(1)
(2)
EXISTING WELL being proposed for use as an injection well. Provide the data in
(1) through (7) below to the best of your knowledge. Attach a copy of Form GW-
1 (Well Construction Record) if available.
PROPOSED WELL to be constructed for use as an injection well. Provide the
data in (1) through (7} below as PROPOSED construction specifications. Submit
FormGW-1 afterconslructi~ _ >-~
Well Drilling Contractor's Name: ~ u \ ol ~d
NC Contractor Certification number: 2,.<' I £s ?-~(
Date to be constructed: ______ Number ofborings: / D
Approximate depth of each boring (feet): 75 s~ h I
(3) Well casing: Is the well(s) cased? tl\..Q
(a) YES If yes, then provide the casing information below.
Type: Galvanized. steel __ Black steel Plastic __ Other (specify) _____ _
Casing depth: From ___ to~~ference to land surface)
Casing extends above ground ___ inches
(b) NO __
Revised 5/05 GW/UIC-57 HP Page 2 of4
(4)
(5)
(6)
(7)
Grout (material sunounding well casing and/or pipinJ)
(a) Grouttype: Cement__ Bentonite_✓_ C Other(specify) ______ _
(b) Gro~ surface and grout depth (reference to land surface):
-~-ar,.1ound closed loop piping; from Top to ,; l f-e'(keQ.
__ around well casing; from __ to __ (feet).
Screens (for Type SA 7 wells) _ A _
(a) Depth: From __ to -A.2~~elow ground surface.
N.C. State Regulations (fitle ISA NC~C C .0200) require the permittee to make provisions
for monitoring wellhead ~J. j fa on both influent (fluid entering beat pump) and
effluent (fluid being injected intD /Yel · is required. Will there be a faucet on:
{a) the influent line? yes __ no (b) the effluent line? yes __ no __
SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well).
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available,
provide the data in part K (1) of this application form to the best of your knowledge.
NOTE: THE WEil.. DRIUJNGCONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS JF TIDS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
J. PROPOSED OPERATING DATA (for Type5A7 wells)
{I)
(2)
(3)
(4)
Injection rate: l IL,, Average (daily) gallons per minute (gpm).
Injection Volume: J 1 JI\ Average (daily) __ gallons per day (gpd).
Injection Pressure: /V Average (daily) pounds/square inch (psi).
Injection Temperature: Average (January) ° F, Average (July) __ ° F.
K. INJECTION FLUID DATA
(1) Fluid source (for Type SA7 wells) If underground, from what depth, formation and type of
rock/sediment unit will the fluid be drawn (e.g., granite, limestone, sand, etc.).
Deptb: _____ Formation: _____ Rock/sediment unit: ____ _
(2) Chemical Analysis of Source Fluid (for Type SQM weDs)
Provide a ~mplete listing of all•?em~ a~ed to the circ ula~ heat transfer fluid: ~ ,_ ;) :? 15-e ~, t3 ~r:Cc--t-e:n o.. S
L. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operatiQD. The manufacturer's brochure may provide supplementary
information.
M. LOCATION OF WELL{S} Attach two maps.
Revised 5/05 GW/UIC-57 HP Page 3 of4
( 1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tar►lcs or
drain fields located within 1000 feet. of the geothermal beat pump well system. Label all
features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
O. CERTII+ICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
informations submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the
information is true, accurate and complete. I am aware that there are significant penalties, including
the possibility of fines and imprisonment, for submitting false information. I agree to construct,
operate, maintain, repair, and if applicable, abandon the injection well and all related appurtenances in
accordance with the approved specifications and Tndi(ions of the Permit."
�
1—
Ifaudiorized
P. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure tha a injection well(s) conforms to the Well
Constriction Standards {Title l SA NCAC 2C .
(Signs Of Pmperty Owner if;_1ffereat Fmm � icant)
Please return two copies of the completed Application package to:
[TIC Program
Aquifer Protection Section
North Carolina DENR DWQ
2636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Reviscd 5ro5 GWXIC-57 HP Page 4 of

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All rights reserved. Use Subject to License/ Capyright
This map is informational only. No representation is made or warranty given as to its content. User assumes all
risk of use. MapQuest and its suppliers assume no responsibility for any loss or delay resulting from such use.
hrip:llwww.rnapquest.eomlmapslprint.adp?mapdata=lgGhLx°/v2S2bMihC 14NxNkV YF6F... 8/2 I /2007

NOTES:
I. THIS HAP IS NOT THE RESULT OF AN ACTUAL FIELD
SURVEY,
R. THIS MAP IS PLOTTFII FROM INFCIRKATI13N FOUrd GN
A PLAT BY McKIM & CREED ERG, TITLED ' A SURVEY
FOR WEYERHAEUSER REAL ESTATE COMPANY,
CYPRESS LANDING SU$DIVISMN, PHASE L SECTION 14
DATES} APRI1. 9, 199$, RECORDED IN PLAT CABINET F
SLIDES 25-9, P-5-10
3. FOR MORE INFORMATI1IN PERTAINING TO THIS LOT, SE
THE ABOVE REFECED PLAT.
IS -
VICINITY MAP (NUT TO SCALE:
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>
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S
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SALE,9 MAP OF
Cy?fW s IANDING�SURD'MoN - P� I. SEC77ON 14
19YE9IAWSM RM WTAM COMPANY
CHOCOWINITY TOWNSHIP - BEAUF'ORT COUNTY - NORTH CAROLINA
Zr = W.
w Iw

Page i of 2
U)58
Site: LOT 386 CYPRESS LANDING
10
� 3
C)
f
385
h;J
N7/
I0
384 4 0
Property Details:
PIN
GPINLONG
NAM E2
ADDR2
STATE
PROP RDAD
ACCT_NEIR
NBR_BLDG
DB_PG
BLDG_VAL i
TOT_VAL
NBHD_DESC
SI18_17ESC f
SALE_PRICE
LAND USE
PROP_DESC
EXMPT PROP
ROAD TYPE
PREVASSESS
15013234 IGPIN 5684-30-1036
5684-30-1036 _ NAME1 LATTA EDWARD T SR
LATTA ORDELLA R ADDR1 301 NEUSE DR
CITY CHOCOW] NITY
NC ZIP 27817
NEUSE DR ACRES 0
863188 MAP SHEET 1568400
1 DATE 6/3/2003
1329/0822 ---][LAND VAL 170000
324007 DEFR VAL 0
394007 _ NBHD CDE G
GOOD ISUB CDE 1179P
CYPRESS LANDING STAMPS 151
PH-1 S
75500 ZONE
DISTRICT 12
LOT 386 CYPRESS MBL 56740094
LANDING
EXMPT AMT 0
P CENSUS BLK
0 11PIN 1 1115013234
http:llwww2.undersys. comiscriptsltestadvlusiwebbpd.dlllusi?formis=ptmap&MouseX=0&.,. 9/21 /2007

Page 2 of2
!GPIN_1 115684-30-1036 II GPINLONG 1 15684-30-1036
YR BUILT 2005 INBR STORY j 1
STYLE !ROOF II IRREGULAR/CATHEDRAL I
!UTILITY ll *ELECTRIC II ROAD _DESC I
!FOUND I lwALL II FACE BRICK I
jsa_FT 115366 II BASEMENT I
BASMNT_PCT j usE_CDE 11 01 I
USE_DESC jSINGLE FAMILY RES IIATTICFNPCT I
ROOF_MATRL 13 II NBR BED 14
HEATING 09 AIR PCT 3
NBR_BATHS 3 FIREPLACE
[GRADE I IEFF YR 11 2005 I
jlNT_WALL 11 6 IIFLOOR 11 12 14 I
NBRHALFBTH 0 jcHIMNEYS I
ATTIC_AREA 0
CONDITION
~ADE I s-I
DISCLAIMER: These maps and info11nalion either In digital or hardcopy fo,mat are provided solely as a public service and they do not meet surveying accuracy standards. Thi s map
data is prepared from the inventory of real property found withi n th is jurtsdiction and is compil ed from recorded deeds, plats, and other public records and data . Users of any maps
generated on this site are hereby notified that the aforementioned public primary info,mation sources should be consulted for verification of the information contained on any maps . The
county of Beaufort assumes no legal responslbllity for the information contained on these maps.
http:/ /www2. undersys.corn/ scripts/testadv/usi webbpd.dll/usi ?formis=ptmap&MouseX =O&... 9/21/2007