WI0700183_GEO THERMAL_20200522

ROY COOPER
Governor
MICHAELS. REGAN
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
March 10, 2020
Louis & Brenda Spry
2500 Riddick Rd.
Elizabeth City, NC 27909
Subject: Permit Rescission
UIC Permit No. WI0700175
Geothermal Heating/Cooling Water Return Well
Pasquotank County
Dear Mrs. and Mrs. Spry:
Reference is made to your request for rescission of the subject Geothermal Heating/Cooling Water
Return Well Permit located at the above referenced address. Staff from the Washington Regional
Office has agreed that a permit is no longer required. Therefore, in accordance with your request,
Underground Injection Control (UIC) Permit WI0700175 is rescinded, effective immediately. If
in the future, you wish to operate a Geothermal Heating/Cooling Water Return Well injection
system, you must first apply for and receive a new permit.
If it would be helpful to discuss this matter further, please do not hesitate to call Shristi Shrestha
at [phone].
cc: Washington Regional Office -WQROS
Sincerely,
)#z-
Rick Bolich
Chief, Groundwater Resources Section
NCDEQ Division of Water Resources
Central Files -Permit No. WI0700175
Pasquotank County Environmental Health Dept.
North Carolina Department of Environmental Quality I Division of water Resources
512 North Salisbury Street I 1636 Mail Service Center I Raleigh, North Carolina 27699-1636
919.707.9000
WELL ABANDONMENT RECORD
1, Well Caatragoe Irforsmdian:
Loy i t F, SAY 4 es �; C. 1�R. Lr iigV �,lY�
,d
❑�
wen cvftso rug (orwellowoar9 gy a onhilberFvpMv)
No Well Cewewcsa CettfON&Ot+temda Jl�} ��`
aMPMY Name r
2. Welk Contv'pct1*M lPonsl M:
Urrall4awc ale MU ranatrWibn pvndrr o e- U1G
I Wen tan (ehcdc MAI tug):
water ftp* welt:
UAgritmtaM
L7mmkipaYPu &
©t iaAcrmal (HubWLW 6 Sawy)
ORasidomfial Water &Wly (ni &)
p
ORadders2W wafer &vplr (dwed)
Mrization
Nso-Water Sapp17' Wtfi:
OMMAOring
OR=vcry
lrtjecom ■:
ClAquircrRobbow
OChuncidwaW on
l3Agmdrr storago and Re —ay
OlAWW Burier
t7A*Wor Test
13stormwaux Drainage
12Bxpesimpat8l Technology
CiSwbxsdcam Control
1713ooQeama1 (Cloud Loop)
CTnw=
CKieathanret Gn ltsmm
ter rain Uwa 7
4, Date well(s) abandoned:
Sae. Won tocatloo.
FacMfytowec Noose F-MY OU RMPh ID)
SQ ) � y yGKf P- ,Al4 ( 1r 1(12
suss Add=4 QM and 2*
tp S&aia — - -
Coanay hand idaotf gwioa Nc,
SL LNIH I mod degree:
(WWOS 60K aloe LWLM g is tai66e0)
7s. For CAnpc*beMVT ar Coed -Lapp Gc+ &auW Weiss haven tba rune
weal conamctivnhlcplh, only 1 Ci W 30 is ocv&& 1Amts MTAL NU11M13 t of
wells abs:xioocd:_ ,
7b. Apprsr3moabe ralseae of water rtemd:im Ia wsH * j
FOR WAnM RUPMY WFddB ONLY:
7e. Tn* of disiafcebat awed•
7d. Amoaat of didnfecQmt asod:
le. Sn1Feg asaterisla and (+Lett all that M*Y-
is Not Cmtenf &W , R BcWonse Chaps ar-BdIets
O $sad Cement Chem
11 Dry My
O Caerlele GUM
0 Da cwl mpc
O spoc"hy erml
O arard
o Be icnite slaery
O O®ta (tin under 7g)
7c Far eselt waft tar adcMd cbmi , pmvide:mains of eaaieaiale need:
7rr Praride a Grid daa#ptioa of the alpantlimannt prvcadnre:
Flle 0,1 7-0 -cap -I }I crnA,,-T.
�C
L Catffleatlonn
orl7anLlod w � w4ts owecr tae�
$Y + $ t Y l Ow the ­U(s) xaa (WO-) abmsdarcd in
aaaordawv vM )SA hFG4C 0,?C .0100 or X .A3M Weft GansdW4nn ids
and dW a Copy ofibbrrxard)anr bear p►flvddai to She wettow er.
9. &lie diatom or adtlMkod wet! de oft
Yea may we the back ar ilds page to pioviac addidomd well site doWls or well
W ab=dnamst deWIL Yea moy" xawb D&Ub Cal pages if nc u ary.
(c 31+159 UC1TOF US'fA11..4 OF WIRLUtSl 13s; KG AR &ti82E1 MAL lNffRUCT1OM
XmwhwelfcDaMagamnaopr44frowdizde For emltokbocc merman-mresgpp6pweMs
anyW& Ac amen msardsrer/essfabmadraneeaC year am srbau melons. 10a_ Fer AR 99eOe: Submit this form wi&ia 34 days of oampledan of Fall
dery Well Mo. }� abmdonma�f to the %Buwiag:
db TOM well depth: (nl • 1 '� ) Dirrkion of Wabw Remarees, D&rm2dm Pr xmdng thdi,
n { 161711 O Swvkc Ceasiu, Rdelpt, NC 2763�197
' lr
JU N r 2018 `8 10b. E Injection WA-, In addition In seadiog the farm to Iffie eadd=% m 10s
6e BorrbalO diameter ia) �l;a�+'� also submit am vopy of this form within 34 days of c ormIchon of well
3{t(prt."s3'a£ f Ve �:fc} is abrmdnammttothe founwiag:
6d. Water level below gmand ro:fwee: ) f iAdon of WaterRrsauren Ueaderg aW tmjaflaa Control Pmgrata,
1636 Mail Strvlee Center. Raie4A NC 27699L-1636
6r Oster aalag length (if L-umm): -- tg) 10a For wptsr-SMIT & iyit Ia addition to raudkS the form to the
addmu(ea) above, ads eiubcmt am Cory oftbis form within ail days of enmpWou
of well abandoameat to the eotmty bealth department of the county where
6f. Inner cadalpftblog kngtis (if Imo m): 1R) abandoned.
r
6g• screra Isogib (if knows): _ -- - fM)

WELL ABANDONMENT REC Far
InletmlUse ONLY:
1. Well contractor larorraatioa:
! �, '17-5 S& 1 � C, - JUL 4u f ff;;7r. For Geoprobe/DPT or Cloned -Loop Geotherto l Wegs Miring the same
Well Contracter Name for well owngr parsousUy abaadouLrs weld on hjvl v progeny) "a ell oonstrtsetitsnldeptk only I OW-30 is nailed. Indicate TOTAL NUMBER of
Jr-- wells abandmod:_
NC We II Cantractar Catificadoo Number
Cca IDY Naa:c
wr%; ...
2. Weil Conatracdoo Permit 9.
flrr all qppffcahfe rrlironsrrarnvn prnWrr I?_e. UIC, Ccmrty, &M 7 arinace, dc.) I(Amvm
3. Well roe (check well
Water Supply Well:
❑Agricultural ❑MuniciRallilublic
❑Crcatlrestnsl (i-lculiog/Cooling Supply) ❑Residential water Supply (single)
01ndustrixl/Commetesal 0 Rcsidmdai Water Supply (abated)
❑JrriAatio'n
Non -Water Supply Weu
❑Aquifer kcchsrge
DAquifer Storage end Recovery
❑Aquifer Test
❑Experimental Torlinalogy
❑Oeothmnal (Closed Loop)
OGronmdwaur Remodiatioo
❑SAlittity Harrier
❑Sturmwaler Drainage
❑Suhsidcncc Control
C}TM=
d. Date well¢) abandoned. 1yj! 6
sa. Well lacatlon:
Fsciiit owner Name -- -
%. Approximate volume of water teauslidag In rre11{a): (Y•i.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of d1dafeetanl vaa1:
7d. Amon of of dlsinfratxot sued:
7e. Sealing material! aced (check all that apply):
0 Neat Cement Grout 4 $erstonite chips or Pellets
0 Sand Ccmeat Grout
1:3 Dry Clay
© ConcMe Grrnst
❑ Grill Cutting
❑ Specialty Grout
13 Gravel
* Sermonise SIurry
❑ Other (crptain under 7g)
7f. For et& material tetocted ttsavt, provide amamat of tamterkh need.
7g. Provide a brief description of the abandonment precedere:
&.0Ij L] isPz►1T
CU 1 &C.
Facility UM (if applicable) 8. C-ertiliatlon:
Sao � f C Y r . C. a
Physical Adddreaa, City, and 4 S 6auae of Cert fled W f or Well Owacr Dote
By a(grsksg Mir joint!, 1 harey t:err fy that the Wil ft) xar OVIeTe') abwrsdwted In
County Parcel Idatdficadou No. (PIN) acconftRce with f 3A WA 02C .0100 or 2C.0200 Well Cnnrtrucriotr SVandordr
and Chet a copy of ehir reconi has beets providad to the well pruner:
$h i,rtltnde end bagitnde is degrrulminntesraeoaods or dettmal degrees
(ifwed field~ one IMAMS is suiNclent) 9. Site dlagrant or addltlonal well details:
fJ W You may use the hack of Ws page to provide additional well aite dclauls or well
abandonment details. You may also attach additioaal pages if necessary.
Q=TRVCTIO tN PETAIM OF 1 ELUS) P&NQ A13AMQUil
Attach"11Ca,<strWWnMOM(.1)tr--Wi frir. Fars►rk§,tcbj*rtarw+wwwah7n"[y+ )h
ONLY with thr tamee ,our}}urnicftPWeha4dyoernen{ yor can menure farm_ a
60. well [I)#-. Ul 1 � ,ISO � I � ,,,„ C y � � ! .
64. Tote wel3 depth. (FL) AN ! N tjr 2018
I6s. FQr AIJ Vft: Submit this farm within 30 days of completion of well
aboadonmeat to the following:
Division of Water Remurm, Informodoa Procrsting Uoil.
1617 Mill Service Ctnler, Rrleigh. NC 276"-1617
10b. Fff_1nlgdoa Wtiltt in addition to sending the form to the address in 1Wa
6c. Prarehole diameter: �L [io.),r&rrri91i0i1 P:+_ �•+?=•'t'ti -1r•1 above, also subtrut one copy of this form within 3a days of eompldion of well
o'Vv(v1)0'-'7 abandonment tog; the foliawii
6d. Water level below greand rnrftce: (R)
r
6e. Outer casing leagtb (if lotown): Y R.)
6C raper cadogltuhing length (if known): (f -)
g. Sereen length (if lmowa): �( & 00
Divislon of water PAnuurrca, Underground InjaFl4en Control Program,
1636 Hall Servlct Center, Ratellb, NC 27699-1636
lac. For Water Supply & InIecdoa Wells: In addidDo to sending ibc farm to the
addresses) above, also aubrnit one copy of this form within 10 days of completion
of well abandomnew to the county heatth department of the county Atcrc
abandoned -
fi

North Carolina Department of Environmental Quality-Division .of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application ___ Renewal* __ Modification __ Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Sections A thru E , and M (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. ______ (leave blank if New Application)
A. CURRENT WELL USE & OWNERSIDP STATUS (Leave Blank if New Well/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as O Geothermal Well O Drinking Water Supply Well D Other Water Supply Use-Indicate use (i.e., irrigation, etc.) ________ _
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? D YES ~ NO
If yes, indicate New Owner's contact information:
Name(s) ___________________________ _
Mailing Address: ____________________________ _
City: __________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: _____________ E_m_a_i_l _A_d_dr_e_.s_s._: __________ _
B. STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence L_ Business/Organization __
Government: State Municipal __ County__ Federal
C. WELL OWNER(S)/PERMIT APPLICANT -For single family residences, list all persons listed on the
property deed. For all others, list name ofbusiness/a ency and name of person and title with delegated authority
to sign: LO J sl l:f'~ 1
. ,. e DA {!.;, S'/JR
Mailing Address: @ S'ao P-.. 10V I c. K. 12 I),
City: [ltzfi h Erh CJ(t;,. State:ne,ZipCode: :;;?f;,1 County: IAs 4u BTfl,r1k
Day Tele No.: /-;) ~';.>-]3, S"°-15' S'~ Cell No.:
EMAIL Address: Fax No.:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 1
D. WELL OPERA TOR (if different from well owner) -For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
to sign: ____________________________ _
Mailing Address:--------------------------------
City: ____________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: ---------------=E=m=a=il"""A=d=dr=es=s=.: ___________ _
E. PHYSICAL LOCATION OF WELL(S) SITE
( 1) Parcel Identification Number (PIN) of well site: ..l 2 3 0 j.J / 6 7 Db J 7 ~ County: p4~9 u ff J:+ wK..
(2) Physical Address (if different than mailing address): ________________ _
City: _____________ County _________ 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. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: ___________________________ _
NC HVAC Contractor License No.: ________________________ _
Company Name: _______________________________ _
Contact Person~: _______________ EMAIL Address: ___________ _
Address: _________________________________ _
City: __________ Zip Code: ____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ----------------
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _
YES ___ _
NO ___ _
NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS -As specified in ISA NCAC 02C .0224 (d ):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15ANCAC 02C .0107 .
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107 , except that:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page2
(a) For screen and gravel-packed wells, the entire length ofcasing 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
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
____ *EXISTING WELLS ____ PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(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 .0107C0(8)
(f) 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 15A 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 ISA 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 Permit Application Rev. 4-15-2016 Page3
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded frow the applicable county GIS website. Typically, the property can he searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic lanks, other
wells, etc. can then be drawn In by hand Also, a `layer' cart be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .02 i I (el 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 thepersou(s) lasted on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf:
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. 1 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 ofProperty Own I�licant
Print or Type Full Name and Title
i
... ; ; Signature of Property Owne Applic nt
Print or Type Full Name an Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - L]IC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water return Well Permit Application Rev. 4-15-2016 Page 4

ROY COOPER
Governor
M1CHML S. REGAN
seaw*ty
LINDA CULPEPPER
Dimcmr
NORTH CAROLINA
EftVh"mm"tadquality
February 10, 2020
CERTIFIED MAIL # 7018 0040 0001 1449 5555
RETURN RECEIPT REQUESTED
Louis & Brenda Spry
2500 Riddick Rd.
Elizabeth City, NC 27909
Subject_ Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0700175
Pasquotank County
Dear Mx. & Mrs. Spry:
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state, Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on April 24, 2015, and expires on April 30, 2020. 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 Beiny- 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
h :11 oital.ncd=.or weblw la sl rol ermit-a lications.
If Your Geothermal Water Return Well is NO LONGER Beim Used for Iniection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C,
Section .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.
E�y North Carolina Depart"wnt of Envirimmental Quality I DIvWon of Water Resources
`� 512 North Salisbury 5treet 1 1636 Mail Service Center I Rairlgiy Noah Carolina 27699-1636
r 919.707.900D

If There has been a Change of Ownership of the Property:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application_
This fonrris not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email at shristi.shresth@C,,i).ncdenr.go�.
Regards,
019A'a
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington- Regional Office — WQROS w/o enclosures
Central Files - Permit No. W10700175 w/o enclosures

N.S.P�stal Service"
CERTIFIED ■ ■
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b ° Louis & Brenda Spry
s
d3 2500 Riddick Rd.
Seal Tn --I
Elizabeth City, NC 27909
ra Sire�sr'arr�rl�f i
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�liy, �raie: err
w Complete items 1, 2, and.3. A. Signaturo
■ Print your name and address on the reverse x
so that we Can return the card to you. 1 r
i Attach this card to the back of the mailpiece, B R®°�"� by ��''�"
or on the fwd if span permits.
1 nrtic[a Addressed to:
L--ujs & Brenda Spry
,2500 Riddick Rd.
. Elizabeth City, NC 27909
uimnnu 111111111111111111111111111111111111111
018 0040 0001 1449 6665
E3 Agent
Date of Delivery
E). is delivery address different from item 17 ❑. Yes
If YES, enter delivery address below: ❑ No
3 Service Type
Priority Mail ESpressW
RAd ult Signatum
eglstered Mai ITµ
Aduh Signature Restricted Delivery
Registered Mall Restricted
13 Certified Mail®
* Certified Mau Restricted Wivery
0 Collect on Delivery
* Collect on Deilvery Restrkted DaRvery
I7 Insured Mail
13 Insured Mall Restricted Delivery
_(over $500,
nrery .
13 Return �calpt far
Merchandise
13 Signature Omfirmatlonrb
Cl signairae6onfirmatfOn
Restricted Delivery
Ps Form 3811, July 201 a PSN 7530-02-000-49053 Domesto Return Receipt

ROY COOPER
rove m ar
M]CHAEL S, REGAN
Uffesary
LINDA CULPEPPEk
vok-r /
NORTH CAROLINA
FiiV00"MMrai Quaily
February 10, 2020
CERTIFIED MAIL # 7018 0040 0001 1449 6665
RETURN RECEIPT REQUESTED
Louis & Brenda Spry
2500 Riddick Rd.
Elizabeth City, NC 27909
Subject: Notice of Expiration (NOE j
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0700175
Pasquotank County
Dear Mx. & Mrs. Spry:
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on April 24, 2015, and expires on April 30, 2020. 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 Seine Used for Inieetion:
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 :Ilu ortaLiicdenr.gW,Zweb/wglans/gw pro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Beine Used for Njection:
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.
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If There has been a Change of Ownership of the Property_:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email at shristi.shrestha(&ncdenr.Wv.
Regards,
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington- Regional Office — WQROS w/o enclosures
Central Files - Permit No. W10700175 w/o enclosures

ROY COOPER
Governor
MICHAELS. REGAN
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
May 22, 2020
Stephen & Marilyn Durci
2206 Corral Circle
Trent Woods, NC 28562
Re: Issuance of Injection Well Permit
Permit No. WI0700183
Geothermal Heating/Cooling Water Return Well
Craven County
Dear Mr. and Mrs. Durci:
~ SWRED
In accordance with your permit renewal application received May 8, 2020, I am forwarding Permit
No. WI0700183 for the continued operation of geothermal heating/cooling water return well(s)
located at the above referenced address. This permit shall become effective on June 1, 2020 (i.e.,
the day after the expiration date of the existing permit), which may differ from the date of this
letter until May 31, 2025 and shall be subject to the specified conditions and limitations stated
therein.
Please Note:
• Samples from the influent and effluent sampling ports of your geothermal well system will
be collected at a later date when the DWR laboratory resumes normal operations.
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
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street I 1636 Mall Service Center I Raleigh. North Carolina 27699-1636
919.707.9000
cc: David May-Robert Tankard-Randy Sipe, Washington Regional Office
Central Office File, WI0700183
Craven County Environmental Health Department
NORTH CAROLINA
ENVIRONMENT AL 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
Stephen & Marilyn Durci
· Craven County
FOR THE CONTINUED OPERATION OF TWO (2) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defined in Title 15A North Carolina Administrative Code 2C .0224, which will be used for
the injection of heat pump effluent. This injection well is located at 2206 Corral Circle, Trent Woods, NC 28562,
and will be constructed and operated in accordance with the application received May 8, 2020, and confomiity
with the specifications and supporting data, all of which are filed with the Department of Environmental Quality.
This permit is for continued operation of an 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 become effective on June 1, 2020 (i.e., the day after the expiration date of the existing permit),
which may differ from the issuance date below until May 31, 2025 and shall be subject to the specified conditions
and limitations stated therein.
Permit issued this the 22nd day of May, 2020.
~
For S. Daniel Smith
Director, Division of Water Resources
Permit WI0700183
By Authority of the Environmental Management Commission.
Permit #WI0700183 Geothermal Heating/Cooling Water Return Well
ver. 3-24-2020
Page 1 of5
PART I -PERMIT GENERAL CONDITIONS
1. The Pennittee 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 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 .0224(b)].
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 .021 l(e)].
4. This permit is not transferable without prior notice to, and approval. In the event there is a desire for the
facility to change ownership, or there is a name change of the Permittee, a formal permit amendment request
must be submitted, including any supporting materials as may be appropriate, at least 30 days prior to the
date of the change [15A NCAC 02C .021 l(o)].
5. The issuance of this permit shall not relieve the Permittee of the responsibility of complying \}'ith any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met [15A NCAC 02C .0203].
PART II-WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed in accordance
with requirements of rule 15A NCAC 02C .0107.
2. Any injection well shall be constructed in accordance with requirements of rule 15A NCAC 02C .0107
except that the entire length of the casing shall be grouted in such a way that there is no interconnection of
aquifers or zones having differences in water quality that would result in degradation of any aquifer or zone.
For screened wells, grout shall be emplaced from the top of the gravel pack to the land surface. For open-
end wells, the casing shall be grouted from the bottom of the casing to the land surface [15A NCAC 02C
.0224(d)(2), (3)].
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing conditions
ifbentonite is to be used [15A NCAC 02C .0225(h)(8)].
4. The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [15A NCAC 02C .0224(d)(4)].
5. Each injection 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 geothermal injection well shall have permanently affixed an identification plate according to [15A
NCAC 02C .0107(j)(2)].
Permit #WI0700183 Geothermal Heating/Cooling Water Return Well
ver. 3-24-2020
Page 2 of5
7. A copy of the Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 of this
permit within 30 days after completion.
PART III-OPERATION AND USE CONDITIONS
1. The Permittee shall comply with the conditions of this permit and properly operate and maintain the
injection facility in compliance with the conditions of this permit and rules of 15A NCAC 02C .0200, even
if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C .021 l(i)].
2. The issuance of this permit shall not relieve the Peimittee 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 including those actions
that maybe required, such as the repair, modification, or abandonment of the injection facility [15A NCAC
02C .0206].
PART IV -INSPECTIONS [15A NCAC 02C .021 l(j)]
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 and appropriate samples associated with the injection
facility's activities.
PART V -MONITORING AND REPORTING REQUIREMENTS
1. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on-site and available for inspection [15A NCAC
02C .0224(f)(2), (4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State and
compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
. 0224( f)(l)].
3. The Permittee shall report any report any monitoring or other information that indicates noncompliance
with a specific permit condition, that a contaminant may cause the injected fluids to migrate outside the
approved injection zone or area. As specified in rule 15A NCAC 02C .0211 (p ), 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 Washington Regional Of:l;ice, telephone number 252-946-6481.
Permit #WI0700183 Geothermal Heating/Cooling Water Return Well
. ver. 3-24-2020
Page 3 of5
(B) Written notification shall be made within 5 (five) days of the occurrence and submitted to the
addresses in Item #5 below.
(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
the facility is located [15A NCAC 02C .0224(±)(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 Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
PART VI-PERMIT RENEWAL [15A NCAC 02C .0224(c)].
As required by rule, and application for permit renewal shall be made at least 120 days prior to the expiration of
this permit. This permit condition does not apply if the Permittee chooses to discontinue operation of the well
for injection of effluent from the geothermal heating and cooling system associated with this permit.
PART VII-CHANGE OF WELL STATUS [15A NCAC 02C .0240].
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complying with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to rule
15A NCAC 02C .0113(b) in order to prevent the well from deteriorating and acting as a source or conduit
of contamination, which is prohibited by General Statute 87-88(c).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well
seal that cannot be removed without the use of hand or power tools.
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0113(b), which include, but are not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if any
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 ensure freedom from
obstructions that may interfere with sealing operations.
Permit#WI0700183 Geothermal Heating/Ceioling Water Return Well
ver. 3-24-2020
Page 4 of5
(C) Each well shall be thoroughly disinfected, prior to sealing, in accordance with rule I SA NCAC
02C .011 l(b)(l)(A), (B), and (C).
(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 Pennittee shall submit a Well Abandonment Record (Form GW-30) as specified in 15A
NCAC 2C .0224(£)(4) within 30 days of completion of abandonment to the addresses specified
in Part V.5 above.
Permit#WI0700183 Geothermal Heating/Cooling Water Return Well
ver. 3-24-2020
Page 5 of5
ROY COOPER
Governor
MICHAELS. REGAN
Secretary
S. DANIEL SMITH NORTH CAROLINA
Environmental Quality Director
Stephen & Marilyn Durci
2206 Corral Circle
Trent Woods, NC 28562
May 11, 2020
RE: Acknowledgement of Application No. WI0700183
Geothermal Heating/Cooling Water Return Well
Craven County
Dear Mr. & Mrs. Durci:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt
of your permit application and supporting documentation received on May 8, 2020. Your
application package has been assigned the number listed above, and the primary reviewer
is Shristi Shrestha
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 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
contactShristi Shrestha at 919-707-3662 or email at [e-mail].
cc: Washington Regional Office, WQROS
Permit File WI0700183
Sincerely,
For Rick Bolich, Chief
Ground Water Resources Section,
NCDEQ Division of Water Resources
North Carolina Dc.-partment of Environmc.-ntal Quality I Division of Water Resources
512 North Salisbury Street I 1636 Mail Service Center I Raleigh, North Carolina 27699-1636
919.707.9000
North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS)
4 S IU2a
In Accordance With the Provisions of 15A NCAC 02C- .002
flE01D OTHERMAL HEATING/COOLING WATER RETURN WELL S
ntral
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 Sections A thru E. and M (signature page) only
Print or Type Information and Mail to the address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 'i Q . 20 Z Q PERMIT NO.-WJJ7t�61! 613(leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as M Geothermal Well ❑ Drinking Water Supply Well
Other Water Supply Ilse- Indicate use (i.e., irrigation, etc.) W 4-Ve r �: r n-s _ �'� �I s
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 E] NO
If yes, indicate New Owner's contact information:
Name(s)
Mailing Address:
City:
Day Tele No.:
State: Zip Code:
B. STATUS OF APPLICANT (choose one)
Nan -Government: Individual Residence X
Government: State Municipal
Emai I Address.:
County:
Business/Organization
County Federal
C. WELL OWNER(S)IPERMIT APPLICANT — For single family residences, list all persons listed on the
property deed. For all others, list name of business/agency and name of person and title with delegated authority
to sign: ,7-t � 2 k, a , r= _e A rt I , ny
Mailing Address: 2104.
City: rr —u t Id., -. � ; _ State: /VC Zip Code: Z ,� 7 � ..Z County: � P'r4 v L &f
Day Tele No,: ? 5- 2- .,a S — T3 6 7 Cell No.:
EMAIL Address. -Cl ut'c-! -.S mod' j — rarkFax No.:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page I

D. WELL OPERATOR (if different from well owner) -For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
to sign: A/4 .N Q_
Mailing Address:--------------------------------
City: ____________ State: __ Zip Code:'-______ County: _____ _
Day Tele No.: Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: __________ County : _____ _
(2) Physical Address (if different than mailing address): -~/--f~_._.u~~ m~~~~-----------
City: ____________ County _________ 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)
HVAC Contractor's Name: ___________________________ _
NC HVAC Contractor License No.: ________________________ _
Company Name:,_ ______________________________ _
Contact Person __ : _______________ EMAIL Address:. ___________ _
Address: _________________________________ _
City: __________ Zip Code: _____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ----------------
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS -As specified in 15A NCAC 02C .0224(d ):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107 .
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107 , except that:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 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
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
----~*EXISTING WELLS ____ PROPOSED WELLS
* For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(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 .0107rf)(8 )
(f) 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 OPERATING DATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP -As specified in 15A 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 Permit Application Rev. 4-15-2016 Page3
NOTE. In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from lire applicable county GIS websht-, Typically, the property can be searched by
owner name or address. The loco don of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc, can then be drawn in by hand. Also, a `layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021.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 person(s) listed on the properly 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 ain 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."
f
A.4
lib re of perry Owner/Applicant
Print or Type Full Name and Title
-L L_� • Af ��
Sigridiure of Noperty Owner/Applicant
Hart t- n s re-[
Print or Type vll Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Retum Well Permit Application Rev. 4-15-2016 Page 4

If There has been a Change of Ownership of the Property;
If there has been a change of ownership of the property, an "Injection Well. Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the_ Vplicable forms 30 da• s before the expiration of the permit ma% 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.shrestharu!nedenr.aV.
Regards,
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington- Regional Office — WQROS w/o enclosures
Central Files - Permit No. W10700183 w/o enclosures

ROY COOPER
Covrrnar
MICHAEL S. REGAN
Secretary
S. DANIEL SMITH
0[tecmr
NORTH CAROLiNA
Environmental QUO14
April 20, 2020
CERTIFIED MAIL # 7017 0190 00001635 3436
RETURN RECEIPT REQUESTED
Stephen & Marilyn Durci
2206 Corral Cir
New Bern, NC 28562
Subject: Notice of Expiration (NOE)
Geothermal Water Retum/Open-Loop Injection Well
Permit No. W10700183
Craven County
Dear Mr. & Mrs. Durci:
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on June 30, 2015, and expires on May 31, 2020. 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 Beinp_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 'Dells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
htto:llnortal. ncdenr. orgLweblwAlansluxnrolpenrut-nlications.
If Your Geothermal Water Return Well is NO LONGER Being Used for Iniec"on:
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
North Carolina Ucgarlmeni oPEnvironmentaI Quakry i DNision of Water Resources
512 North Salisbury Street 11ta36 Mail Service Center Raleigh.rtorth Carolina 27h49-1636

If There has been a Change of Ownership of the Property:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms 30 days before the expiration of the pen -nit 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('u�nodenr. oy.
Regards,
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington- Regional Office — WQROS w/o enclosures
Central Files - Permit No. WI0700183 w/o enclosures

.............. .,._ ---------r-----------.. ----------"-·---. ..,
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of l 5A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groW1dwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application X Renewal* __ Modification __ Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Sections A thru E . and M (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE:.4-f)C 1· 1 3 0 ,20 2. O PERMIT NO. W //;7 0618"'3 (leave blank if New Application)
A. CURRENT WELL TJSE & OWNERSHIP STATUS (Leave Blank if New Weil/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well ~slD Ge~the~~1 ~ ell D D_rinking Water Supply Well J.. 00. Other Water Supply Use-Indicate use (1.e., lfilgation, etc.) tr../ 1':}+e r-9 r--A-S-S -t-f 1 A~"'"" :J
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-3(1°;.
0 Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? D YES ~ N6
If yes, indicate New Owner's contact information:
Narne(s) _____________________________ _
Mailing Address: ____________________________ _
City: ----------~State: __ Zip Code: _______ Coum_r: _____ _
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence X Business/OrganizauO;'.;
Government: State Municipal __ County__ Federal
C. WELL OWNER(S)/PERMIT APPLICANT -For single family residences, list al'l persons listed on the
property deed. For all others, list name of business/agency and name of person and title with delegated authority
to sign: s+.si ()h e & 1-:-fnA r tl tr{ N D vi. cci
Mailing Addres~ 2.1 0 G C. o ,~r 4 I I C:t r c f -
City: '1r12.JJ ± \;1£,.:i ,J-s State: ,NC.Zip Code: '28 5°C 'L County: Cr-r.1. v ~""
Day Tele No.: 2.. 5~ Z.. ._ l:. ~ 3 -ff g 6 7 Cell No.:
EMAIL Address: 'S ±ev ·<-d 1.A-r-c..t. ~ s iA.-& .k...-r l wk-Fax No.:
''lfe-r
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page I
D. WELL OPERATOR (if different from well owner) -For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
to sign: A/4 .N' <L.
Mailing Address: ______________________________ _
City: ____________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site:. __________ County: _____ _
(2) Physical Address (if different than mailing address): -~h~fa-m~'<-~----------
-city: _--_.-_-___________ -Coiinty_---_,, _______ .. _______ Zip Code: ____ _
F WELL DRILLER INFORMATION
Well Dri11ing 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 drillei:;)
HVAC Contractor's Name: __________________________ _
NC HVAC Contractor License No.: _______________________ _
Company Name: ______________________________ _
---Contact Person~: ______________ ---~~EMAIL Address: __________ _
Address:---------------------------------
City: _________ Zip Code: ____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ----------------
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
"tl) The injection operation? YES ____ NO .-
(2) Personal consumption? YES ____ NO ___ _
I. WELL CONSTRUCTION REQum.EMENTS-As specified in ISA NCAC 02C .0224 (d ):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothennal Water Return Well Permit Application Rev. 4-15-2016 Page2
~~--·----
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 i.r\iection.
J. WELL CONSTRUCTION SPECIFICATIONS
K.
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
---~*EXISTING WELLS ____ PROPOSED WELLS
* For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
( 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{f)(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 surf~
OPERATING DATA
---uy~ -.-----.,-._••,.•-----
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 15A 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 Permit Application Rev. 4-15-2016 Pagel
NOTE. In most cases are aerial photograph of the property parcel showing property lines and strucwres can be
oblained and downloaded from the applicable county GIS webshe-Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, ere- can then he drawn in by hand Also, a Paver' care be selected showing topographic contours or elevation
dada
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C...021111 e) requires that al! 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 person(s) listed on the twooem deed -
If an authorized agent is signing on behalf of the applicant; then supply a letter signed by the
._appheantt that names and authorizes their agent to sieuu this amllication on their bebalE
"I hereby cergfy, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete, 1 am aware that there are significant penalties, including the possibility of floes 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."
! na re of Property Owner/Applicant
Print or Type Full Name and Title
Sign tore of Property Owner/Applicant
-�. VmLor. Type 1=tnll Name and Titk--- --
Signature of Authorized Agent, if any
Print or Type Full Name and Title
7]
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
16336 Mail Service Center
Raleigh, NC 276"-1636
Telephone [phone]
Geothermal Water Return Welt Permit Application Rev_ 4-15-2016 Page 4

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.
'Mis form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
I=TIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the an llicable forms 30 days before the expiration of the permit 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.shre &cdenr.g_ov_.
Regards,
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington- Regional Office - WQROS w/o enclosures
Central Files - Permit No. W10700183 w/o enclosures

ROY COOPER
:governor
MICHAEL S. REGAN
Serrerory
S. DANIEL SMITH
Director
NORTH CAROUNA
£nWronrrrenral Qualify
April 20, 2020
CERTIFIED MAIL # 7017 0190 0000 1635 3436
RETURN RECEIPT REQUESTED
Stephen & Marilyn Durci
2206 Corral Cir
New Bern, NC 28562
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. W10700183
Craven County
Dear Mr. & Mrs. Durch
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on June 30, 2015, and expires on May 31, 2020. Per permit conditions and requirements
per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120 calendar days
prior to expiration of the permit if you wish to continue operating the injection well on your
property.
If Your Geothermal Water Return Well is Still Currently Being Used for 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://Vortal.ncdenr.oW,,/web/w/Us/izyMro/t)en-nit-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.
.�_ North Garolna ❑epartmentof Enviranmental quality Ptvi5wri of Water Rrsourres
512 North Sal;sLury Start 1 1&36 MJ61 Service Center F[elelgh, North Carolirpa 276"?1636
100.7074000

If There has been a Change of Ownershim of the Pronerh•:
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
[TIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms 34 days before the expiration of the permit 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.shresft4Zcdenr.Vv_.
Regards,
01(Ar60Q
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington- Regional Office — WQRDS w/o enclosures
Central Files - Permit No. W10700183 w/o enclosures

Central Flles: AP5 SwP
02/17/10
Permit Number W10800183
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
Active New Project
Permit Type
Version Permit Classification
Injection Water Only GSHP Well System (5QW)
1.00 Individual
Primary Reviewer
Permit Contact Affiliation
michael.rogers
Jim Cornette
Coastal SW Rule
PC Box 882
Hampstead NC 28443
Permitted Flow
Facility
Facility Name
Thomas Hyatt SFR
Location Address
2221 Tattersalls Dr
Wilmington
Owner
Owner Name
Thomas
NC 28403
Hyatt
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance
02/17/10 02/03110
_ egec uiated Activities
Heat Pump Injection
Private residence, single family
Outfal# NULL
Major/Minor Region
Minor Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Thomas Hyatt
Owner
2221 Tattersalls Dr
Wilmington NC 28403
Public Notice Issue Effective Expiration
Waterbody Name Stream Index Number
02/17/10 02/17/10
Current Class Subbasin

ALEIX�
HCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality?
Beverly Eaves Perdue Coleen H. Sullins
+governor director
2/17/2010
Thomas Hyatt
Anne Hyatt
2221 Tattersalls Drive
Wilmington, NC 28403
Subject; Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W14800183
2771 Tattersalls Drive
Wilmington, NC 28403
Dear Mr. & Mrs. Hyatt:
Dee Freeman
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
02/03/2010, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed -loop geothermal water-
on]y injection well system for the operation of a ground -source heat pump located at 2221 Tattersalls Drive, Wilmington,
New Hanover County, NC 28403. This system is deemed permitted by rule (North Carolina Administrative Code Title
15A, Subchapter 2C, Section _0211(u)(2))_
However, it is recommended that you contact the New Hanover County Health Department, as they may have additional
construction or permitting requirements for this type of system. If you modify your system at any time, including the
addition of antifreeze, corrosion inhibitors, or any other substances to the circulating fluid, you must contact the APS to
verify compliance with applicable rules,
Thank you for submitting this notification. If you have any questions please call me at [phone],
Sine ely, I' J
I�6
�
for Micha&kogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Wilmington Regional Office - APS
.LPS C'cntrti Fie_ - Vcri u %u. '%'1tt9UuT83
New Hanover County Health Dept.
Jun Cornette (Applied Resource Management, P.C_, P.O. Box 882, Hampstead, NC 28443)
Nate Carr (O"Brien Heating and Air, 3308 Enterprise Drive. Wilmington, NC 28405)
AOU CER Pr Oi EU)ON SECTU.'
1c35 Mail Service Cvlt2T, Ra wah. North arc"aa 2769u•i63G
iombii. 2728 Capital WJerard. Raleigh. Norte Card1.1 27EN Or
Prioae: 91c 733.3221 l FA 1: 9'9-715.G6W PAX 2: 919-715.6048 `, Cunoniei 5erv:;:e. V7-623-67(18 N C]I'th Carol Ana
Intemet. WWW.ncwatetuuaifi+.or_
F,Yatwra111
A� >:qu�; ;ppor«er.., + A.�r+-)r i,u5 »� �,�� cmdOyer �

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL. RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL(S)
In Accordance with the provisions ofNCAC Title 15A: 02CA200, please
complete this notifcarion and mail to address on the back page (please Print or LTinformation).
DATE: December 23, 2009
Well Type Confiirriration: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes X Continue completing this form.
No Do Not complete this form. Complete other UTC application forms for installing
either a SA.7 well (2pen-loop well iniectin potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors),
A. PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state tiame of
entity and a representative wlauthority for signature): Thomas and Anne Hvatl
B.
(1)
(2)
Mailing Address: 2221 Tattersalls Drive
City; _ WilmingtonState: NC Zip Code: 29403 County: New Hanover
Home/Office Tole No.: 910- 620-3625 Cell No.:
Email Address: Website:
Physical Address of Well Site (if different than above):
City:
Home/Office Tele No.:
State: Zip Code:
Cell No.:
County;
AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: ENTAIL Address:
Address:
City; State: Zip Code:
Office Tefe No,:
County:
Website Address of Company, if any: RaCENED I DFJdR r IDWQ
AquifEr ion Section
❑PUIUIC SQW Notiticalion of Iment Fonts (Revised 8/2008) FEB 0 3 z010 Page I

. .
C. WELL DRILLER INFORMA TlON
Company Name: A pp lied Resource Mana gement. P.C.
WeU Driller Contractor's Name: ....,H'"""'""'. M=·=ic=h=a=el~S=a=g=e ________________ _
NC Contractor Certification No.: 2531-A
Contact Person __ : -=-J=im=--"C~o=rn=e=tt=e __________ -=E~M=A-=-I=L"""'A--'-=dd=11=e=ss=:"""J""'im""'--'A'-'-"-R=M=@._a=b=e=lls=o""u=th=.n=e"""t __
Address: ___ P~.O~·~B....,o=x....,8-=-8=2 _________________________ _
City: Ham pstead Zip Code: 28443 County: ---=-P-=-e=nd~e=r ________ _
Office Tele No.: 9I0-270-2919 Cell No.: 910-512-4890
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: O'Brien Heatin g and Air
Contact Person.,_: ---=-N--'-'a:=te=---C=ar=r ________ -=E=MA=--==IL:..:..:A=d=d.._re=ss=:-=-N..:a=te=®=o=br""'"ie=n=s=erv"-'-"ic=e=.c=o=ma:..._ __
Address: ----=3'"'"30=8,c....=E=nt=e_,_,,rp=r=is=e -=D=r-=--iv=e _______________________ _
City: Wilmin gt on Zip Code: 28405 County: New Hanover
Office Tele No.: 910-799-6611 Cell No.: -----------
E. STATUS OF APPLICANT
Private: _lL__ Federal: Commercial:
State: Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p geothennal system. Water onl y. Grouted alon g the loo p's entirety .
G. WELL CONSTRUCTION DATA
(I) Proposed date to be constructed: __ 2/""1-=-0/""'2""0-=-I-=-0 _____ Number of borings: __ 6 __ _
Approximate depth of each boring (feet): __ =20~0=-'------
(2) Type of tubing to be used (copper, PVC, etc): __ ,_,_H=D~P=E __________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes QI (b.) No below)
(a) Yes if yes, then provide casing information below
Type: _galvanized steel __ black steel_plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ .inches
(b) No X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement __ Bentonite Other (specify) Thermex
(b) Grout placement: Pumping __ Pressure Other __
(c) Grout depth of tubing (reference to land surface): from 0 to 200 (feet)
Jf well has casing, indicate grout depth: from to (feet)
GPU/lJIC 5QW Notification oflntent Form (Revised 8/2008) Page2
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipingitubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
1. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Inciudc a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of grou ndwater contamination and the orientation of and distances between the proposed wells) and
any existing well(s) or waste disposal facilities such as septic tanks or drain Fields located within 200 feet of
the geothermal heat pump well system, Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams. and/or highway inrersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
rceorded legal property deed.
1 hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I bellevo 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 construe.[, 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."
Si nature of Property Ow er/Applicant
vIn r
Print or Type Full Name and till
Signature of Property Owner! pplicant
Print or Type Full Name Ad title
Signature of Authorized Agent, if any
Print or Type Full Flame and tftie
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]S
CGPUlUIC SQW Notification of intent Form (Revised 8r?608) pnge 3

it
q r
_.,.o
(U
0
p
Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
2. Well locations are approximate and will be a minimum of 20' apart and 25' from the building.
3. Adapted from Google Earth and New Hanover County GlS Map, November 2009.
TITLE: SITE MAP FIGURE:
had Fo9our-ce Manument Pc 2221 TATFLRSALLS DRIVE
7 P.O. 10078U, Hampsteca, NMM443 JOB: SCALE: DATE: DRAWN BY;
j910} 2702419 FAX [phone] Hyatt 1 " - 100' 12/23/09 �NH

it
1!�
• � 1 r ter � �
Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
2. Well locations are approximate and will be a minimum of 20' apart and 25' from the building.
3. Adapted from Google Earth and New Hanover County GIS Map, November 2009.
TITLE: SITE MAP FIGURE:
G ,lied Kroource Management f C 2221 TATTERSALLS DRIVE
Box Hampstead, 4 JOB: SCALE: DATE: DRAWN BY:
P.O. I z�a-29�e FAx 2�n-24as Hyatt 1 " - 100' 12/23/09 DNH

N '
Approximate Property Lines
Note: Adapted from Google Earth and New Hanover County GI5 Map, November 2009.
TITLE: SITE VICINITY MAP FIGURE:
F.rdfcd Kccourcc Manaaement ?G 2221 TATTERSALLS DRIVE
BOX 862, Hampstead NC 284T= JOB: SCALE: DATE: DRAWN BY:
[910) 270-2919 FAX [phone] Hyatt 1" - rv--400' 12/23/09 DNH L

40
aye �
- + DOS%d L
rCD
S,s
' 1 Aj
H
57
CD
of
OP (ID
Approximate Property Lines
Note: Adapted from Google Earth and New Hanover County GIS Map, November 2009.
TITLE: SITE VICINITY MAP FIGURE:
died Kceoume Management PC 2221 TATTERSALLS DRIVE
x 552, HampsleacJ,JOB: SCALE: DATE: DRAWN BY:2
(916] 2702919 FAX [phone] Hyatt 1 " =-•-400' 12/23/09 DNH

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL(S)
In Accordance with the provisions ofNCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or~ information).
DATE: December 23 . 2009
Well Type Confirmation: Does the proposed system circulate potable water onl (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loo p)?
Yes X Continue completing this form.
No ___ Do Not complete this form. Complete other UIC application forms for installing
either a SA 7 well ( open-loop well injecting potable water into the aquifer) or a SQM well ( closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): ---'T=-=h=o=m=a=s----=a=n=d_c_A=nn=e-=-H=--y=a=tt ________ _
(1) Mailing Address: ___ 2_22_1_T_att_e_rs~a_ll_s_D_r_iv_e ____________ _
City: Wilmin gt on State: NC Zip Code: 28403 County: New Hanover
Home/Office Tele No.: 910-620-3625 Cell No.:
Email Address: _________ -'W~eb=-=s=it~e~: _____________ _
(2) Physical Address of Well Site (if different than above): _______________ _
City: __________ State: __ Zip Code: ______ County: _____ _
Home/Office Tele No.: -------------"C=-=e=ll'""N-'-o=._,_: __________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:--------------------------------
Contact Person._,_: -----------------=E=MA=-==IL=-=A=d=dr=-=e=ss=: ___________ _
Address:----------------------------------
City: _________ State: __ Zip Code: County: ________ _
Office Tele No.: Cell No.:
Website Address of Company, if any: _____________ R-hE....,CmE ..... IVED I DENR / DWQ
Aquifer Protection Section
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) FEB O 3 2010 Page I
C. WELL DRILLER INFORMATION
Company Name: A pp lied Resource Manru?ement, P.C.
Well Driller Contractor's Name: --'H~. M~ic=h=a=el~S=ag---""e ________________ _
NC Contractor Certification No.: --~2~5~3 ~1-~A~--------------------
Contact Person: Jim Cornette EMAIL Address: Jim ARM@ bellsouth.net
Address: P.O. Box 882
City: Ham pstead Zip Code: 28443 County: ---=P--=e=n=de=r~--------
Office Tele No.: 910-270-2919 Cell No .: 910-512-4890
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: O'Brien Heating and Air
Contact Person.-'-: --=N-'-'a=te=---=C=arr=------------=E=MA.:.=..::=IL=...::..;A=d=d=re=s=s:'""N""'a=t=e®~t =o=b=ri=en=s=e=-crvc:.ic=e=.c=o=m=----
Address: 3308 Enterp rise Drive
City: Wilmingt on Zip Code: 28405 County: ----=N~e~w~H=an=o~v--'e=r ______ _
Office Tele No.: 910-799-6611
E. STATUS OF APPLICANT
Private: __x_
State:
Federal:
Municipal: __
Cell No.: __________ _
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p geothermal system. Water onl y. Grouted along the loo p's entirety.
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: __ 2-/1~0_/2~0--=1 __ 0 _____ Number of borings: __ 6 __ _
Approximate depth of each boring (feet): ___ 2~0~0' ______ _
(2) Type of tubing to be used (copper, PVC, etc): --~H=D=-=P-=E=---------------
(3) Well casing. Is the well(s) cased? (check either (a.) Yes Qr (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: ___galvanized steel __ black steel__plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite Other (specify) Thermex
(b) Grout placement: Pumping__ Pressure Other
(c) Grout depth of tubing (reference to land surface): from O to 200 (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Fonn (Revised 8/2008) Page 2
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing 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
information.
I. LOCATION OF W ELL(S)
Attach two copies of maps showing the following information:
(1) include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system, Label all features clearly and include a north arrow-
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note; This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"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 infortation, 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
ail related appurtenances in accordance with the approved specifications and conditions of the Permit."
� r
Sienature of Property Ow er/Applicant
/77
Print or Type Full Name and titly'
r 4
-L, - Signature of Property Owner) pplicant
l n n<- -?!y y ,- 7 —
Print or Type Full Name aSid title
Signature of Authorized Agent, if any
Print or Type pull Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
OPUMIC 5QW No[ificatiun of Intent Form (fzvised W2008) Page 3

New Hanover County
Page 1 of 1
New Hanover County
Profile
sales
Residential
Commercial
Misc. Improvements
Permits
Land
Values
Agncaftral
Skala
Full Legal
Exemptions
Sub-parcel(s) Info
❑riginai Parcel Info
Parcel Map
I CONTACT US I HELP
NHC Tax Home n Keglster or Afleds iFome
Home Property Records
Owner Address Parcel iD Advanced
PARED: RUGO 15-0 02-036 -000
HYATT T140MAS E ANNE P 2221 TATTERSALLS OR CURRENT RECORD
Last 618 Dap Update. 7-Oct- 0
Data Copyright New Hanover County [Disclaimer] [Privacy Panty] Last updated: 28 Dac 2009
7 Site Design Copyright 1999-2005 Akanda Group LLC. All rights reserved.
http://etax.nhcgov.com/Forms/MapDatalet.aspx?slndex=d&idx=7&LMparent=20 1 / 11 /2010

. New Hanover County
PARID: R06015-002-036-000
HYATT THOMAS E ANNE P
Parcel
Alt ID
Address
Unit
City
Zip Code
Neighborhood
Class
Land Use Code
Living Units
Acres
Zoning
Legal
Legal Description
Tax District
Owners
Owner
City
State
Country
Zip
312611.65.7765.000
2221 TATTERSALLS DR
WILMINGTON
1440
RES-Residential
958-Unused Land
1
.5051
R-15-RESIDENTIAL DISTRICT
LOT 21 PH 2 GLEN MEADE EXTENSION
WM
HYATT THOMAS E ANNE P
WILMINGTON
NC
28403
THE DATA IS FROM 2009
Page 1 of 1
2221 TATTERSALLS DR
http://etax.nhcgov.com/Forms/PrintDatalet.aspx?pin=R06015-002-036-000&gsp=PROFIL... 1/11/2010
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Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
L�211
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
2. Well locations are approximate and will be a minimum of 20' ❑part and 25' from the building.
3. Adapted from Google Earth and New Hanover County GIS Map, November 2009.
TITLE: SITE MAP FIGURE:
:lied Kcoourcc Mana ncrit f C — 2221 TATTERSALLS DRIVE
am a JOB: SCALE: DATE: DRAWN BY:
At41Q) 27D 2914 FAX [phone] Hyatl 1" =---100' 12/23/09 DNH

I F
AW
Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
2. Well locations are approximate and will be a minimum of 20' apart and 25' from the building.
3. Adapted from Google Earth and New Hanover County GIs Map, November 2009.
TITLE: SITE MAP FIGURE:
r-, lied Rcirouroe Mma:-;ement PC 2221 TATTERSALLS DRIVE
RU x r am ea JOB; SCALE: DATE: DRAWN BY:
7 [phone] FAX [phone] Hyatt 1 -_ —1 00' 12/23/09 DNH

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Approximate Property Lines
Note: Adapted from Google Earth and New Hanover County GIS Map, November 2009.
TITLE: SITE VICINITY MAP FIGURE:
At
fled Ke5aurce Manaaement PC 2221 TATTERSALLS DRIVE
Box am JOB: SCALE: DATE; DRAWN BY:
91�j 270-2919 FAX [phone] Hyatt 1 " =---400' 1 12/23/09 DNH 2

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Approximate Property Lines
1
Note: Adapted from Google Earth and New Hanover County GIS Map, November 2009.
TITLE: SITE VICINITY MAP FIGURE:
rlied P 5ource Maria:�ement PC 2221 TATTERSALLS DRIVE
t'.V. COX tS82, riOfi1F?SiBQG, lVl, 1,544.3 JOB: SCALE: SATE: BRAWN BY:
(910] 2702919 FAX [phone] Hyatt 1 " --400' 12/23/09 DNH

NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
June 30, 2015
Stephen and Marilyn Durci
2206 Corral Circle
New Bern, NC 28562
Re: Issuance of Injection Well Permit
Permit No. W10700183
Geothermal Heating/Cooling Water Return Well
Craven County
Dear Mr, and Mrs. Durci :
Donald R. van der Vaart
Secretary
In accordance with your permit renewal application received April 21, 2015, 1 am forwarding Permit
No. WI0700183 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
May 31, 2020, and shall be subject to the conditions and limitations stated therein,
Please Dote:
• Samples from the influent and effluent sampling ports of your geothermal well system
were collected on May 26, 2015. Laboratory analytical results will be forwarded to you
when it becomes available.
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,
P`l
Michael Rogers, P.C. (NC & FL)
Hydrogeologist
Division of Water Resources, NCDENR
Water Quality Regional Operations Section
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Phone:[phone] Intemet: Np:llwww.wwater.org
An Equal QpparWOy 4 Adfirmove Aadon Employer — Made in part by recyded paper

• Stephen and Marilyn Durci
cc: David May and Robert Tankard, Washington Regional Office
Central Office Eile, WI0700183
Craven County Environmental Health Department
Page 2 of2
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
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
Stephen and Marilyn Durci
FOR THE CONTINUED OPERATION OF 1 (ONE) 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 2206 Corral Circle, New Bern,
Craven County, NC 28562 will be operated in accordance with the application submitted April 21, 2015, and
conformity with the specifications and supporting data, 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 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 May 31, 2020, and shall be
subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 30th day of June 2015.
\I\ S.JayZimmerman,P.G.
\ , Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Permit #WI0700183 UIC/5A7
ver. 04/15/2015
Page 1 of5
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 .021l(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 (l)].
4. This permit is not transferable without prior notice and approval. In the event there is a desire for the
facility to change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted, including any supporting materials as may be appropriate, at least 30 days
prior to the date of the change [ISA NCAC 02C .021 l(q)].
5. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met [15A NCAC 02C .0203].
PART II-WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed m
accordance with the requirements of rule 15A NCAC 02C .0107 except as required in Item #2 below.
2. Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC 02C
.0107 except that the entire length of the casing ·shall be grouted in such a way that there is no
interconnection of aquifers or zones having differences in water quality that would result in degradation of
any aquifer or zone. For screened wells, grout shall be emplaced from the top of the gravel pack to the
land surface. For open-end wells, the casing shall be grouted from the bottom of the casing to the land
surface [15ANCAC 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 1,500iiiilligrams per liter. In areas where elevated chlonde levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing
conditions. [15A NCAC .0225(g)(8)].
4. The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is · operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [15A NCAC 02C .0224(d)(4)].
5. Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal as defined in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [ISA NCAC 02C .0107(j)(2)].
Permit #WI0700183 UIC/5A7
ver. 04/15/2015
Page 2 of5
7. A completed Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 of this -
pennit.
PART III-OPERATION AND USE CONDITIONS
1. The Permittee shall comply · with the conditions of this permit and properly operate and maintain the
injection facility in compliance with the conditions of this permit and the rules of 15A NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C
.0211 (i)].
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 [ 15A NCAC
02C .0224(t)(2), (4)].
2. .Monitoring of any well may be required to ensure protection of the groundwater resources of the State
and compliance with the grom1dwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
.0224(t){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 .021l(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 Washington Regional Office, telephone number 252-946-6481.
Pennit#WI0700183 UIC/5A7
ver. 04/15/2015
Page 3 of5
(B)
(C)
Written notification shall be made within five days of the occurrence and submitted to the
addresses in Item #5 below.
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(±)(3)].
5. All forms, reports, or monitoring results require_d by this permit shal~ be submitted to:
UIC Program Staff
Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Water QualityRegional Operations Section
DWR Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
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 f.or temporarily or permanently abandoning a well are tlie same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complying with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to
rule 15A NCAC 02C .0113(b) in order to prevent the well'from deteriorating and acting as a source or
conduit of contamination, which is prohibited by General Statute 87-88(c).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well
seal that cannot be removed without the use of hand or power tools.
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose,
the Permittee shall permanently abandon that injection well in accordance with the procedures specified in
15A NCAC 02C .Ol 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.
Permit #WI0700183 UIC/5A7
ver. 04/15/2015
Page 4 of5
Permit Number
Program Category
Ground Water
Permit Type
WI0700183
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted F"iow
Facility
Facility Name
Stephen and Marilyn Durci SFR
Location Address
2206 Corral Cir
New Bern NC
Owner
Owner Name
Stephen R
Dates/Events
Orig Issue
8/18/2010
App Received
4/21/2015
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
28562
Durci
Draft Initiated
Scheduled
Issuance Public Notice
Central Files : APS SWP
6/25/2015
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Stephen R. Durci
2206 Corral Cir
New Bern
Issue
NC
Effective
28562
Expiration
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
4/22/15
6/2/15
.Subbasin
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: 5/29/15 Permittee(s): Stephen & Marrilyn Durci
Permit No.: WI0700183
To: APS Central Office County: Craven
Central Office Reviewer: Michael RogersProject Name: Inj. Heating/Cooling Return Well
Regional Login No: __ _
I. GENERAL INFORMATION
1. This application is (check all that apply): 0 SFR Waste Irrigation System [ZJ UIC Well(s)
D New IZJ Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse O Recycle O High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
0 Attachment B included
D Surface Disposal
D 503 regulated O 503 exempt
D Closed-loop Groundwater Remediation IZJ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IZJ Yes or D No.
a. Date of site visit: 5/26/15
b. Person contacted and contact information: Ste phen Durci
c. Site visit conducted by: R. Sipe
d. Inspection Report Attached: IZJ Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
IZJ Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For SFR Treatment Facilities:
a. Location: NA
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude: __ Method Used (GPS, Google™, etc.); __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For UIC Injection Sites:
( If multi ple sites either indicate which sites the infonnation ap plies to . co pv and paste a new section into the
document for each site . or attach additional pa ges for each site l
a. Location(s): no change since permit was issued.
b. Driving Directions: __
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude: __
APS-GPU Regional Staff Report (Sept 09)
RECEJVED!DENR!DWJ
Method Used (GPS, Google™, etc.); ----j/jN () ~
2 2015
Water Quality .
Operations 8Reg_1ona1 ect,on
Page I of 4 Pages
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description of Well(s) and Facilities -New, Renewal, and Modification
1. Type of injection system:
cg] Heating/cooling water return flow (SA 7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5L/"Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes cg] No
3. Are there any potential pollution sources that may affect injection? D Yes ~ No
What is/are the pollution source(s)? --~·-W~h=a~t =is-'t~he~d=is=ta=n~c~e~o~f =tl~1e~in ..... ie~c~ti~o--'-'n-'w-'--e~l=l(~s ,_) f=r~o =m~t=h=e"""p""'o=ll=u~ti~on
source(s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 25 ft.
5. Quality of drainage at site: D Good ~ Adequate D Poor
6. Flooding potential of site: ~ Low D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable . If No, explain and recommend any changes to the
groundwater monitoring program: NA
8. Does the map presented representthe actual site (property lines, wells, surface drainage)?~ Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow. See attached ma12
Injection Well Permit Renewal and Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes ~ No. If es . ex lain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If ves. explain: NA
3. For renewal or modification of groundwater remediation permits (of any type). will
continued/additional/modified injections have an adverse impact on mil!.ration of the plume or management of
the contamination incident? D Yes D No. If, es. explain: NA
APS-GPU Regional Staff Report (Sept 09) Page 2 of 4 Pages
AQUIFER PROTECTION SECTION-GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
4. Drilling Contractor: Name: Jason Morton -Morton Drillin g
Address: 117 Turners Dai rv Rd.
Morehead Ci rv. NC 28557
NC Certification number: 2453-A
5. Complete and attach NEW Injection Facility Inspection Report, if applicable
V. EVALUATION AND RECOMMENDATIONS
l. Provide any additional narrative regarding your review of the Application:
2. Attach new Injection Facility Inspection Form, if applicable
3. Do you foresee any problems with issuance/renewal of this permit? 0 Yes 0 No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
APS-GPU Regional Staff Report (Sept 09) Page 3 of 4 Pages
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
8, Signature of report Preparers): _
Signature of APS re Tonal supervisor:
Date:
WI, ADDITIONAL INFORMATION AND SITE MAP 6aetch ot site showiffg, !rouse and waste arri ration
si-stem, sprat or drip field, location of well(s), and/or other relevant information- SHOW NORTH ARROI0
APS-GPU Regional Staff Report (Sept 09) page 4 of 4 Pages

North Carolina Department of Environment and Natural Resources
Division of Water Quality -Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700183
DATE OF INSPECTION: 5/26/15
INSPECTOR: __ R;;..;;;.;_. S=-'--'-i p.;_;;e ______ _
NAME OF PERMITTEE(S) Ste phen & Marilyn Durci
MAILING ADDRESS OF PERMITTEE 2206 Corral Circle, New Bern, NC 28562
PHYSICAL ADDRESS OF SITE (if different than above) Same as above
PERSON MET WITH ON-SITE Ste phen Durci; TELE NO. [phone]
WELL(S) STATUS:
_X_Existing and operating Class V Well
__ Existing well proposed to be converted to Class V well
__ Proposed/not constructed
LAT/LONG OF WELL(S) 35.084286N, 77.077454W
Appx . distance of well to property boundaries: _25 feet ________________ _
Appx. distance of well from foundation of house/structure: _60 feet ___________ _
Appx. distance of well from septic tank/field (if present): _None present _________ _
Appx . distance of well to other well(s) (if present): _20 feet to supply well _______ _
Appx . distance to other sources of pollution: _None _________________ _
Flooding Potential of Site: _high __ moderate _X_low
Comments: Both inj., and supply wells appear to be in good condition consistent with findings of prior inspection
and operating
adequately . ____________________________________ _
Injecti on Fac ili ty ln sp. Report (Rev . Sept 200 9) Page I of 3 P ages
See Attached Map
DRAW SKETCH OF SITE ABOVE (Show property boundaries, buildings, other wells, septic tanksldrain fields, other
potential pollution sources, roads, approximate scale, and NORTH arrow)
IASf
4,-ft'o,o ilqw-'w
Q . T+' 'h :S(ret1
Draw Schematic of well above showing TD, casing depth, grout, etc.
Injection Facility Insp. Report (Rev. Sept 2,009)
Page 2 of 3 Pages

Well Construction Information
Date Constructed: 9/16/2010 --------
Well Contracting Company: _Morton Drilling, _____________ _
Well Driller Name: Jason Morton ----------------
NC Well Cert. No.: 2453-A ----
Address:_117 Turners Dairy Rd., Morehead City, NC 28557 _______ _
Telephone No.: [phone] ______ ; Cell No.: _________ _
Email Address: -----------
Proposed Depth ofWell(s): _70 _______ _
Total Depth: _70 ___ _ Total Depth of Source Well, ifpresent:_Unk __
Casing:
Depth: 50 feet; Diameter: _4 inches_; Type (gav. steel, PVC, etc.): _PVC_; Stick Up: _12+ inches __ ft
Grout:
Depth: 20 feet; Type (cement, bentonite, etc.):_Bentonite; Placement (pumping, press. etc.): _pumped.
WelJ ID Plate Present (Y or N): _Y_; Heat Pump ID plate present (Y or N): _Y __
Influent spigot (Y orN): _Y __ ; Effluent spigot (Y orN): __ Y __
Well Sampled? (Y or N): __ Y_; If Yes, Lab Sample ID numbers: Supply well (Inf) & Inj . well (Eff)_
Static Water Level: 3 feet ---
In_jection Information (if applicable):
Injection Rate: GPM -------
Injection Pressure: PSI
Injection Volume: GPD
Temperature-Summer: P0
Temperature-Winter: P 0
Comments/Notes_Both inj., and supply wells appear to be in good condition consistent with findings of prior
inspection and operating
adequately. _____________________________________ _
Injection Facility lnsp, Report (Rev, Sept 2009) Page 3 of 3 Pages
Com pliance Ins pection Re port
Permit: WI0700183
SOC:
Effective: 08/18/10
Effective:
Expiration: 07/31/15 Owner: Stephen R Durci
Expiration: Facility: Stephen and Marilyn Durci SFR 5A7
2206 Corral Cir County: Craven
Region: Washington
Contact Person: John Taylor
Directions to Facility:
New Bern NC 28562
Title: Phone: [phone]
From Hwy 70 in New Bern, take Country Club Road south. Take right turn onto Steeplechase Drive, then left onto Horse Shoe Bend,
cross Hunt Master Road onto Corral Circle. Durci residence, fourth house on right, 2206 Corral Circle. Well in back yard.
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 05/26/2015 Entry Time: 10:00AM Exit Time: 10:45AM
Primary Inspector: Dwight R Sipe Phone:
Secondary lnspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well
Facility Status: ■ Compliant D Not Compliant
Question Areas:
Other
(See attachment summary)
Page:
Permit: WI0700183
Inspection Date: 05/26/2015
Inspection Summary:
Owner -Facility: Stephen R Durci
Inspection Type: Compliance Evaluation Reason for Visit: Routine
As part of the renewal process for Permit# WI0700183 R. Sipe w/ WQROS WaRO inspected and sampled two (2) wells (1
supply well and 1 injection well) which are associated with the UIC geothermal heat pump system under Permit#
WI0700183. The wells were found to be in good condition and operating adequately. The location and construction of the
wells are consistent with the findings of the previous inspection in Oct. 2010. They are considered in compliance with
Permit# WI0700183.
Page: 2
Permit: WI0700183
Inspection Date: 05 /26/2015
Other
Comment:
Owner -Facility: Stephen R Durci
Inspection Type : Compliance Evaluation Reason for Visit: Routine
Yes No NA NE
Page : 3
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: April 2Z 2015
To: WaRO-WQROS: David May / Robert Tankard
From: Michael Rogers, WQROS ---- Animal Feeding Operations and Groundwater Protection Branch
Telephone. [phone] Fax. [phone] E-Marl. [e-mail]
A. Permit Number: W10700183
B. Anulicant: Stephen and Marilyn lurch
C. Facility, Nance:
D. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
❑ I would like to accompany you on a site visit.
RECEIVED/NCDENRJDW
APR 27 2015
W'xjr QUaiKy FlegiorW
Draratans Section
Waal?,11121on HeglonW Offf*
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 yoar name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office Groundwater Protection Branca contact
person listed above_ _
Date: l7-
-� - --_ _s
RU-WQROS Reviewer: y � � �
CONEVIENTS:
MOTES:
FORM: WQROS-ARR ver. 092614 Page 1 of 1

WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE QUEST FORM
Date: April 22, 2015
To: WaRO-WQROS: David May/ Robert Tankard
From: Michael Rogers, WQROS -Animal Feeding Operations and Groundwater Protection Branch
A.
B.
C.
D.
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0700183
Applicant: Stephen and Marilyn Durci
Facilitv Name:
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-WOROSReviewer: __________________ Date: _____ _
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 092614 Page 1 of 1
NA NCDEMR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Stephen and Marilyn Durci
2206 Corral Circle
New Bern, NC 28562
April 22, 2015
RE: Acknowledgement of Application No. WI0700183
Geothennal Heating/Cooling Water Return Well
Craven County
Dear Mr. and Mrs. Durci:
Donald R. van der Vaart
Secretary
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
.permit application and supporting documentation received on April 21, 2015. 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 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 [phone] or [e-mail].
cc: Washington Regional Office, WQROS
Permit File WI0700183
Sincerely,
I ~f?~~--
IJ:YoebraJ. Watts, Sup:rv:7
Animal Feeding Operations & Groundwater
Protection Branch ,
Division of Water Resources
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Phone: [phone] I Internet: http://www.ncwater.org
An Equal Opportunity \ Affirmative Action Employer -Made in part by recycled paper
NORIB CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL{S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application X Renewal* __ Modification __ Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete PaQ.es 1 and 4 (signature page) only
Print or Type Jriformation and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 4 ,I } 4 / } s--,20 / ~ PERMIT NO. ~ ~ '0~ ~eave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS ()eave blank if New Application)
1. Current Use of Well
a. Continue to use as X Geothermal Well __ Drinking Water Supply ___X_ Other Water
Supply L.A. ~ rs + F' lcH.v e.r f
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the pennit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
D Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since _permit last issued? D YES ~NO
If yes, indicate new owner's contact information:
Name(s)
Mailing Address: ___________________ _
City: ___________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: -------------~E=mail ~A=d~d~re~s=s~.=------
STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence X Business/Organization __
Government: State Municipal __ County__ Federal
WELL OWNER(S)/PERMIT APPLICANT-For individual residences , list owner(s) on property deed . For
all ot,hers, list name of entity and, name of person delegated authority to sign: R-ECEIVED/DENR/DWR
~6"'·~ -1 P, &¼A1tJ D\A(C, . rn~,.. 'r' G ~~;_ 21 zo15 ~2-Z~e--R
City: ~11..,, L31!.,f-=:..,,.__ ____ StateN_(_Zip Code: ZBS-" 2 V,Ja \&~Iliilli~.1W'2.AJ
Day T~le No.: 2 £'2 .-"3 g .,.. £8l 7 Cell No.: Operation"~ . ._,..,,.,.,
EMAIL Address: s dv..,cc ~~.t,,' !.u,_kl!-,_h .... ,➔±~F_ax~N~o~.:~-------------
Geothermal Water Return Well Pe rmit 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 INFORJ.".IATION (if different than driller)
H.
HVAC Contractor's Name: ____________________________ _
NC HVAC 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?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS -As specified in 15A NCAC 02C .0224@ :
(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 J 5A NCAC 02C .0107, except that:
Geothermal Water Return Well Pennit 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
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
____ *EXISTING WELLS PROPOSED WELLS ------
* For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifkations:
(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 pmhibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(0(8 )
(f) 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 15A NCAC 02C .0224{ b )( 4 l, 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 drain field , waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential s ources of contamination listed in 15A NCAC 02C .0107(a )(?) 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)
Gcot hcnnal Water Return Well Permit A pplication (l{cvi,cd Jan ~O 15) Page 3
NOTE. • Inmost cases an aerial photograph of the properly parcel showing property litres and structures can be
obtained and downloaded from the applicable county GIS webs ite. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc, can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data
1VL CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021 He requires that all permit applications shall be signed as follows:
L 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 ail others: by all the person(s)_listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that i have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fixes 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."
ti
Signature fT Property Owner) pplicant
Print or � Pe Cull Naive
$ignat ire o PAperty Owner/Applicant
Print or Type Ful 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)
L636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Applieatian (Revised ]an 2015) Page 4

Nos
NOMA
A.- -
.YA
ROCISE�NR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
June 24, 2015
Stephen and Marilyn Durci
2206 Corral Circle
New Bern, North Carolina 28562
SUBJECT- Groundwater Sampling Results
UiC Permit No, W10700183
Issued to Stephen and Marilyn Durci
New Bern, Craven County, North Carolina
Dear Mr. and Mrs. Durci;
Donald R. van der Vaart
Secretary
i(ECEADPDENR DWR
3UN 2 6 Z015
Water nudity
perlls $ection
Staff from the Washington Regional Office of the Water Quality Regional Operations Section collected
samples of the influent (supply well) and effluent (injection well) from your geothermal heat pump system on
May 26 31, 2015. The samples were analyzed for metals, nutrients, and other inorganic constituents by the
Division of Water Resources laboratory. A summary table of the analytical results, as well as the laboratory
reports, field sampling forms; and definitions of laboratory data qualifiers are attached to this letter. The
following two constituents were detected above state groundwater standards in both samples from your
system;
Parameter knits NC Groundwater Results
Standard
Iron ug/L 340 1000 {supply well -influent}
1000 (injection well-effluenti
pH Standard Units 1 6.5 to 8.5 6.0 (supply well -influent)
6.0 (injection well -effluent
The exact source of these exceedances is unknown; however, Iron and pH exceedances in
groundwater are often due to naturally occurring conditions. These exceedances should not affect the use of
the wells for your geothermal heat pump system; however, it is recommended before using the water from
these wells for personal consumption that you consult with the Craven County Environmental Health Department.
If you have any questions regarding the sampling results or your permit, please feel free to contact me at
[phone].
Sincerely,
I
*44
`� `-
t-
Dwight Randy Sipe, P.G., Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources, NCDENR
Attachment
cc: YMichael Rogers - DWR Groundwater Protection Unit, Central Office
Craven County Environmental Health Department
WaRO
Division of Water Resources - VVater Quality Regional Operations Section - Washington Regional Office
943 Washington Square Mall, Washington, NC 27889
Phone: [phone] Fax: [phone] Internet: vnNvi.notlenr.gov
Aa Equal ❑pporWrirly 1 Affirmative ACM rt Employer —Made in part by recycled paper

Parameter Fecal Coliform
units CFU/100ml
NC MCL and/or EPA Standard NCGWS=< 1
Influent Sample Results < 1
Effluent Sample Results < 1
Parameter Nitrate
units mg/Las N
NC MCL and/or EPA Standard NCGWS= 10
EPA PDWS = 10
Influent Sample Results <0 .02
Effluent Sample Results <0 .02
Parameter Chromium, Cr
units f.19/L
NC MCL and/or EPA Standard NC GWS= 10
EPA PDWS = 100
Influent Sample Results <10
Effluent Sample Results <10
Parameter Sodium, Na
units mg/L
NC MCL and/or EPA Standard NS
Influent Sample Results 40
Effluent Sample Results 40
NC DIVISION OF WATER RESOURCES
LABORATORY ANALYTICAL RESULTS
GEOTHERMAL UNDERGROUND INJECTION CONTROL (UIC)WELL
PERMIT NO .: WI0700183
PERMITTEE(S): Stephen and Marilyn Durci
SAMPLE COLLECTION DATE : 5/26/2015
Total Coliform Total Dissolved So l id s Chloride, Cl
CFU/100ml mg/L mg/L
NC GWS = 1 NC GWS= 500 NCGWS =250
EPASDWS = 500 EPA SDWS = 250
< 1 374 24
< 1 380 24
Hardness as CaC03
Nitrite (by Calculation}* Aluminum, Al
mg/Las N mg/L as CaC03 fJg/L
NC GWS=1 NS NS
EPAPDWS = 1 EPA SOWS= 50 to 200
<0 .01 263 <50
<0 .01 288 <50
.Copper, Cu Iron, Fe Potassium, ·K
fJg/L fJg/L mg/L
NC GWS .= 1000 NC GWS= 300 NS
EPA SOWS= 1000; PDWS = 1300 EPA SDWS = 300
10 1000 1.4
17 1000 1.4
Nickel, Ni Lead, Pb Zinc, Zn
µg/L f.19/L µg/L
NC GWS = 100 NCGWS= 15 NC GWS = 1000
EPA PDWS= 15 EPA SOWS= 5000
<2 .0 <2.0 <10
<2 .0 <2.0 18
Fluoride, FL
mg/L
NCGWS=2
EPA PDWS = 4.0
<0.4
<0.4
Arsenic, As
fJg/L
NCGWS=10
EPAPDWS= 10
<2.0
<2 .0
Magnesium, Mg
mg/L
NS
3.1
3.1
pH (field)
ur:iits
NC GWS = 6.5-8.5
EPA SOWS = 6.5 to 8.5
6.0
6.0
NC GWS. = North Carolina Groundwater Standard per 15A NCAC 2L .0200 • Calculation performed by WaRO
EPA PDWS = Environmental Protection Agency Primary Drinking Water Standards
EPA SOWS = Environmental Protection Agency Secondary Drinking Water Standards
NS = No Standard
Sulfate, S04
mg/L
NC GWS = 250
EPA SDWS = 250
34
34
Calcium, Ca
mg/L
NS
100
110
Manganese, Mn
µg/L
NCGWS = 50
EPASDWS=50
34
34
s
North Carolina Divislol, of Wamr Resources
Water Sample Collection & Submittal Form
Central Laboratory CWaterSciences 5ectionj
visit ID:
(opcianafJ
Ir �.11
lD
Lob Use Only:
-------------- -----,
_ Laboratory
sample nlumher., r
.7 / c 1
Location Description.�uG- 't r 4 L a k9 �� . C oLr%!1(
tacation Ccde: j _ ]T 07 0
v�
Dare Received:
n
County: C V'C Y ►
Callector. {
Priority:
❑Ambient
❑Routine
wCompliance
❑ COC
❑Emergenoy
❑0A
Water Matrix.
❑ Surface
f Ground
❑ Waste -
❑ Blank
❑5alution
Location Types
❑RtverJScream []take
❑Estuary ❑Cana!
❑Stormwater
❑Monitoring Well ❑wafer Supply
❑Effluent ❑Iniluent
❑Field Blank
[]Trip clank
❑Filter Blank j� Jn �'
lap V� Y""
�iher; 5►tdo ly
L
?(me Received:
IJtt1lRRegion: �
{based ancwmiyl L'7.)
❑WRQ�Ce: r � Tl] �''1
larosencvr+ame} VJ+.! � S+ LJ
Received0y. INK
River Basin: (
Aate_ I� r /
❑State Courier
DeAvery Merhad: []Hand Delivery
❑other:
Notes-
Time: --
!!
Chlorinated ❑be -chlorinated in Field
Sampling Grate ICa mposile
Method- {]Sher:
Temperature('Cj
an Arrival:
Oissolyed analysis' I?nler "DtS"
❑ Filtered in Field inchedrbwxs for parxmelers
sample Depth:
Caliector•'s Commeuts: S A lAti� E C a e C. 1� if if+' �'1 ! C� 5 1t $" vl `- -: F
Mierablology Parameters:
MaA5 (surfaWsn%) mg/t
Nletals Parameters:
Tin (5n) ftg/L
Acidity, as CaCO3, zo pN 4.5/8.3 4n8]t
Oil and Grease, ITEM, Total Recoverable mg/t,
Aluminum (All }rg/L
Titanium (TO IFJL
Aikallnity, as CaCO3, to pH 4-518.3 mg/L
Phenols. Total Recoverable pg/L
Antimony (Sb) Vg/L
vanadium (VI pg/L
BOO: ftchemicalOrygen Remand, 5.day mg/L
Residue; Total iTolo15o11d5) mg/L
Ar5aoIC (A5) Vel.
Zinc (In) µg/L
c800• Carbonaceous 130D, 5-day mg/L
Residue- Volatile/Fixed, Total mg/L
Barium (gal p&/L
Colitorm- Fecal MF /100ml
Residue: Suspended (SvwendedSands) mg/L
Beryllium (Be) (rg/L
Boron (5). Total µg/L
Colilorm: Total MF /100mi
Residue: VolatilelFixed. Suspended mg/L
Cadmium (Cd) pg/L
Mercury 1531, low-level iWL
Coliform- Tube Fecal 1100m1
TD5 - Tatal Dissolved Solids rn L
Calcium (Ca) mg&
Gotitorm: 1ubeTntal J10omt
Silica mg/L
Chromium (Cr), Twai µB/L
❑rganics Parameters;
Speriiir Conductance, at 7.5 °C drnhMjCM
Sulfide mg/L
Cobalt (co) pg/L
Acid herbicides
TOC - Total Organic Carbon mg/L
Tannin & Ligmn rng/L
_
Copper icuj µSIL
Organochlonne Pestindes
TurbLduy NTLI
Iron (Fe) 09/1-
Organomtrogen Pesticides
Other Parameters;
Lead (Pb) yg/L
organophosphoc us Pesticides
Wet Chemistry Parameters:
pH s.u.
Lithium (Ll) Ng/L
PCBs (polychlorinated bighenyis)
Bromide rng/L
Hardness, Total as CZC03 - by thratfan sng1L
Magnesium (nag) rngIL
Chior}de mg/L
Mang2ne5e (Mn) pg/L
Semi -Volatile Organics (SNAs)
Fluoride mg/L
Mercuryftj Pg/L
TPH Diesel Range
Sulfate mgll.
Nutrients Parameters:
Molybdenum (nMoI flg/L
Chlorophyll a pg/L
Ammonia as N (NH3-N) mg/L
Nickel (Nil pg/L
Volatile Organics IVOAI
Color: ADMI c.u.
Nitrate-Nttrite as N (NO3+w02-N) mg/L
X
Potassium JK} rngIL
Color: Platinum Cobah C.U.
Total Kjeldahl Nitrogen as N (TKN) mg1L
seicrv.um Ise) pg/L
TPH Gasoline Range
COD: Chemical Oxygen Demand mg/L
Total Phosphorus as P (TP) rng/L
Sriver lAg) pg/L
Cyanide, Total mgJL
N[En te as N (NO2-N) mg/L
Sodium (Na) mglL
Biological_
Formaldehyde mg/L
Nurat e as N tw03-N calculated) mg/L
Strontium jSr) t,g/L
Phytopla n ktort / Algae
Hexavalent Chromium (Cr6+) mg/L
Orthdphosplrate as P (P041 mg/L
Thallium (TO }Ig/L
LAB COMMENTS :
Field Paromete rsrppriaPwg: Water -remP ('Q; PH (s.u.)r 11" i1 Dissolved Oxygen (ppm)- Conductivity (pn)hos/cm): SafiniW (Ppt);
Revision; 2106/20i5

AC19519 NC ®W<l( Water Sciences Section-Cfiemistry La6oratory <R.§su{ts
County:
River Basin
Report To
CRAVEN
NEUSE
WARO
Collector: R SIPE
Region: WARO
Sample Matrix : GROUNDWATER
Loe : Type : WATER SUPPLY
Emergency Yes/No
COG Yes/No
/ Location ID: WI0700183
DWR
Division of Water Resources
Final Report
VisitlD
Loe. Descr.: 2206 CORRAL CIRCLE
/ Collect Date : 05/26/2015
Samp le ID:
PO Number#
Date Received:
Time Received:
Labworks LoginlD
Final Report Date :
Report Print Date:
/ Collect Time: 09:50
AC19519
15G0229
05/_27/2015
08:10
TASCENZO1
6/16/15
06/16/2015
/ Sample Depth
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
CAS#
LAB
MIC
WET
NUT
MET
Anal yte Name
Sample temperature at receipt by lab
Coliform, MF Fecal in liquid
Coliform, MF Total in liquid
Ion Chromatography
Fluoride
Chloride
Bromide
Sulfate
Total Dissolved Solids in liquid
N02+N03 as N in liquid
Nitrate as N in liquid
Nitrite as N in liquid
7429-90-5 Al by ICP
7440-38-2 As by ICPMS
7440-70-2 Ca by ICP
7440-47-3 Cr by ICPMS
7440-50-8 Cu by ICPMS
7439-89-6 Fe by ICP
7440-09-7 K by ICP
7439-95-4 Mg by ICP
7439-96-5 Mn by ICP
7440-23-5 Na by ICP
7440-02-o Ni by furnace
7439-92-1 Pb by ICPMS
7440-66-6 Zn by ICPMS
PQL
0.4
1.0
0.4
2.0
12
0.02
0.02
0.01
50
2.0
0.10
10
2.0
50
0.10
0.10
10
0.10
2.0
2.0
10
Result/
Qualifier
2.2
Units
·c
Method
Reference
Analysis Validated by
Date
5/27/15 MSWIFT
1 82Q1 CFU/100ml APHA9222D-201h 5/27/15 ESJAFFORD1
1 82Q1 CFU/100ml APHA9222B-20th 5/27/15 ESTAFFORD1
_TITLE_ mg/L EPA 300.0 rev2.1 5/28/15 CGREEN
mg/L EPA300.0 rev2.1 5/28/15 CGREEN
24 mg/L EPA3000 rev2 .1 5/28/15 CGREEN
0.4 U mg/L EPA 300 .0 rev2.1 5/28/15 CGREEN
34 mg/L EPA 300.0 rev2 .1 5/28/15 CGREEN
374 mg/L SM 2540 C-1997 5/27/15 CGREEN
0.02U mg/Las N EPA 353.2 REV 2 5/27/15 CGREEN
0.02 U mg/Las N EPA 353.2 REV 2 5/29/15 CGREEN
0.01 U mg/Las N EPA 353.2 REV 2 5/28/15 CGREEN
50 U ug/L EPA 200 .7 6/3/15 ESTAFFORD1
2.0 U ug/L EPA200.8 6/3/15 ESTAFFORD1
100 mg/L EPA200.7 6/3/15 ESTAFFORD1
10 U ug/L EPA200.8 6/3/15 ESTAFFORD1
10 ug/L EPA200 .8 6/3/15 ESTAFFORD1
1000 ug/L EPA200 .7 6/3/15 ESTAFFORD1
1.4 mg/L EPA200 .7 6/3/15 ESTAFFORD1
3.1 mg/L EPA200.7 6/3/15 ESTAFFORD1
34 ug/L EPA200.7 6/3/15 ESTAFFORD1
40 mg/L EPA 200 .7 6/3/15 ESTAFFORD1
2.0 U ug/L EPA200.9 6/3/15 ESTAFFORD1
2.0 U ug/L EPA200.8 6/3/15 ESTAFFORD1
10 U ug/L EPA200.8 6/3/15 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
Fora detailed descriotion of the oualifier codes referto <httu://oortal.ncdenr.orn:/web/wa/oos/methods-and-oals>
Page 1 of 1
se C) ­7 � C>
Z_
North Carolina Division of Water Resources
Central Laboratory (Water Sciences Secdon) Water Sample Collection Su biuitW Form
Visit II)J":,
top�ankr
h q,$ Use. On Iw
Locki'm Otscriptlan Lp.,t C
Laxatfqn Code. -
CaIlecfor.
Dwq A:��
115
06AM
Priority: •Walier7
ElAmblera
[3AUtlne
Nrmpllance
❑ CDC
F ] Efner,,.c,
E]QA
StrFa Ce
[KGround
El waste
E1181a.k
OSolution
❑River trMam E]Laku
ElEstuary Ocanal
❑0Stprrnwater
11monitorIng well E]Iuvatef Supply
OEffluent Llinfl vent
E]Ileld Blank
a6p Blank
❑niteriVar[k
e or I je7P, IIIA I
MOther-
&Irt
Lin
red A,
PWR izegip-
("agrounty) �j A
17
- River-Bosin:
--A
LiState Courier
00 L)�4and Delivery
LjOther
Note.s.,
MaFinaled
❑FjDe-cMorinated in Field
Dissolved anatysin,•
❑ Filtered in Field i=-Foer'018'
dM*,bwV.S for "ra-13te-
5amp ny Grab UCOMPOaXe
Viijuw'. t5"
01her
re A
e
,coliect-'s Co--ts.- - A V"%p 1E_ C-b 0 A -
'Microbiolop Parametirs.-
MBAS (surfactants) mElL
- 'Metals Pa��qj�*6:
Tin (Srij
Addlty, as CaCO3, to pH 4SI8-3 mg/L
Oil and Grease, HEFA, Total Recoverable rn#)L
><TAluminum
W) pg/L
Titanium (Ti} WL
Alkalinity, as CaCO3,;u pH 4.518.3 -fit
Phenols, Total Recoverable JJZIL
Antimony (Sbj pg/L
Vanadium M WL
BOO: Uachenftal oxygen Demand, 5-lay mg/L
Residue; Total (-rptal Solids) mg/L
Arswilt (As) p8/L
�;<,ZhL
(Zn) ItglL
cBOD: CarbOn2MOUS BOD. 5-day MEA
Residue; Volatile/Fixed, Total mg/L
Barium tBal pg/L
Boron (81-Totaj VeL
Cojjform_, Fecal MF 1100MI
_Aesmve_ Suspended (Suspended—solds)mg/L
Beryllium (U) PKIL
Cc lito rm : Total MF /100ml
Residue! Volatile/Fixed, Suspended mg/L
cacirnlum(od) pg/L
Niercury 2531, low-level ng/L
Coliform'. Tube Fecal 1100mi
TD5 -Total Cki=lved Solids M&IL
'5<—.7cedum
(Ca} rngIL
Cc rftrm. Tube Total 1100ml
silica - mVL
Chromium Ph Total pg/L
Dcp rtiIEi._Pih;rh1ffiiri .,- 4-.,
Specific Conductance, at 25 'C_ uMhMIrm
Sulfide mg/L
><
Cobalt (CO) pg/L
Acid Herbicides
TOC - I otai OrEaruc Carbon mg[L
Tannin & Ugnin mg/L
Copper (Cu) pg/L
Oqanochlwine Pesticides
Turbidity NTU
Iran (Fe) pg/L
Orpnonitrogen Pesticides
_1 .. . .
lead (pbl pa/L
Organophospho rus Pesticides
Wet Chemistry P4f4meters-','
PH s. U.
Uthlum (U) pg/L
PCBs (poiychlariciated biphenytO
Bromide mg/L
Hardness, Total as CzLQ3 - by titration rr;
MaCrinsFurn (Mg) nngIL
Chloride MgjI
Manganese (Mn) pg/L
Semi-Volazlie Organics (SIVAsI
Fluoride mg/L
Mercury (Hg) pg/L
TPH Diesel Range
Sulfate mg/L
NzmieptipaqmeW`4
Molybdenum PAO
Chbrophyll a pg/L
Ammonia as N (NH3-N) mg/L
Nickel (Nil pg/L
Volatile Organics (VOA)
Color,. ALDIM I 'L.U.
Nitrate -Nitrite as N (NO3 NO2-N) mg/L
Potassium (K) mgIL
I
Color: Platinum Cobalt E.U.
To w I Kle Idahl Nitrup nas N [TKN) mgtL
Selenium (Se) pg/L
TPH GaWwe Range
COD- Vkesbca4 Owygwi Demand mg/L
Total Phosphorus as P (TF) Mall.
Silver (Ag) pg/L
Cyanide, Total mg/L
Nitrite as IN (NO2—NI ..vt
Sodium (Na) Mg/L
ajqlojipk
Formaldehyde MCIL
Nitrate as N (NO3 A Calculated} m9A
Strontium (Sri P&Jpg/Loptankton
:I Algae
Hexavalent Chromium jCr6+j mg/L
Ontiophu5 phate as F1 (PO4) Z—LiH
Thallium (TQ lig/L
TR
LAO COMMENTS:
Revision 7/Ofi1�[TL5

AC19520 WC <D<W<l{, Water Sciences Section-Cfiemistry £a6oratory <R..esufts
County : CRAVEN Sample ID: AC19520
River Basin NEUSE DWR PO Number# 15G0230
Report To WARO Date Received : 05/27/2015
Collector: R SIPE
Time Received: 08:10
Region : WARO Division of Water Resources
Labworks LoginlD TASCENZO1
Sample Matrix: GROUNDWATER
Final Report Date: 6/16/15
Loe. Type: MONITORING WELL Final Re p ort Report Print Date: 06/16/2015
Emergency Yes/No Visit lD
COC Yes/No
Loe. D_escr.: 2206 CORRAL CIRCLE
I Location ID: Wl0700183 I Collect Date: 05/26/2015 I Collect Time: 10:00 I Sample Depth I
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
CAS# Anal yte Name POL Result/ Units Method Analysis Validated by Qualifier Reference Date
LAB
Sample temperature at receipt by lab 2.2 ·c 5/27/15 MSWIFT
MIC
Coliform, MF Fecal in liquid 1 1 B2Q1 CFU/100ml APHA9222D-20th 5/27/15 ESTAFFORD 1
Coliform, MF Total in liquid 1 1 B2Q1 CFU/100ml APHA9222B-20th 5/27/15 ESTAFFORD1
WET
Ion Chromatography TITLE mg/L EPA 300.0 rev2.1 5/28/15 CGREEN --
Fluoride 0.4 0.4U mg/L EPA 300 .0 rev2.1 5/28/15 CGREEN
Chloride 1.0 24 mg/L EPA 300 .0 rev2.1 5/28/15 CGREEN
Bromide 0.4 0.4 U mg/L EPA 300 .0 rev2.1 5/28/15 CGREEN
Sulfate 2.0 34 mg/L EPA 300 .0 rev2.1 5/28/15 CGREEN
Total Dissolved Solids in liquid 12 380 mg/L SM 2540 C-1997 5/27/15 CGREEN
NUT
NO2+NO3 as N in liquid 0.02 0.02 U mg/Las N EPA 353 .2 REV 2 5/27/15 CGREEN
Nitrate as N in liquid 0.02 0.02 U mg/Las N EPA 353 .2 REV 2 5/29/15 CGREEN
Nitrite as N in liquid 0.01 0.01 U mg/Las N EPA 353.2 REV 2 5/28/15 CGREEN
MET
7429-90-5 Al by ICP 50 50 U ug/L EPA 200 .7 6/3/15 ESTAFFORD1
7440-38~2 As by ICPMS 2.0 2.0 U ug/L EPA200.8 6/3/15 ESTAFFORD1
7440-70-2 Ca by ICP 0.10 110 mg/L EPA 200 .7 6/3/15 ESTAFFORD1
7440-47-3 Cr by ICPMS 10 10 U ug/L EPA200.8 6/3/15 ESTAFFORD1
7440-50-8 Cu by ICPMS 2.0 17 ug/L EPA200.8 6/3/15 ESTAFFORD1
7439-89-6 Fe by ICP 50 1000 ug/L EPA200.7 6/3/15 ESTAFFORD1
7440-09-7 K by ICP 0.10 1.4 mg/L EPA200.7 6/3/15 ESTAFFORD1
7439-95-4 Mg by ICP 0.10 3 .1 mg/L EPA200.7 6/.3/15 ESTAFFORD1
7439-96-5 Mn by ICP 10 34 ug/L EPA200.7 6/3/15 ESTAFFORD1
7440-23-5 Na by ICP 0.10 40 mg/L EPA200 .7 6/3/15 ESTAFFORD1
7440-02-0 Ni by furnace 2.0 2.0 U ug/L EPA200.9 6/3/15 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0 2.0 U ug/L EPA200.8 6/3/15 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 18 ug/L EPA200.8 6/3/15 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
Fora detailed description of the aualifiercodes refer to <htto://oortal.ncdenr.orn/web/wa/oos/methods-and-oals>
Page 1 of 1
Sy mbol
A
B
BB
C
G
J
Definition
Value reported is the mean (average) of two or more determinations. This code is to be used if the results of two or more discrete
and separate samples are averaged. These samples shall have been processed and analyzed independently (e .g., field duplicates,
different dilutions of the same sample). This code is not required for BOD or colifonn reporting since averaging multiple
dilutions for these parameters is fundamental to those methods .
Results based upon colony counts outside the acceptable range and should be used with caution. This code applies to
microbiological tests and specifically to membrane filter (MF) colony counts. It is to be used if less than 100% sample was
analyzed and the . colony count is generated from a plate in which the number of colonies exceeds the ideal ranges indicated by
the method. These ideal ranges are defined in the method as:
Fecal coliform or Enterococcus bacteria: 20-60 colonies Total coliform bacteria: 20-80 colonies
I. Countable membranes with less than 20 colonies. Reported value is estimated or is a total of the counts on all filters
reported per I 00 ml.
2 . Counts from all filters were zero. The value reported is based on the number of colonies per 100 ml that would have
been reported if there had been one colony on the filter representing the largest filtration volume (reported as a less
than "<" value).
3. Countable membranes with more than 60 or 80 colonies. The value reported is calculated using the count from the
smallest volume filtered and reported as a greater than ">" value.
4. Filters have· counts of both >60 or 80 and <20. Reported value is estimated or is a total of the counts on all filters
reported per 100 ml.
5. Too many colonies were present; too numerous to count (TNTC). TNTC is generally defined as > 150 colonies. The
numeric value represents the maximum number of counts typically accepted on a filter membrane (60 for fecal or
enterococcus and 80 for total), multiplied by 100 and then divided by the smallest filtration volume analyzed. This
number is reported as a greater than value .
6. Estimated Value. Blank contamination evident.
7. Many non-coliform or non-enterococcus colon ies or interfering non-colifonn or non-enterococcus growth present. In
this competitive situation, the reported value may under-represent actual density .
Note: A "B" value shall be accompanied by justification for its use denoted by the numbers listed above (e.g., B 1, B2, etc.).
Note: A "J2" should be used for s pikin l'. failures.
This code applies to most probable number (MPN) microbiological tests.
1. No wells or tubes gave a positive reaction . Value based upon the appropriate MPN Index and reported as a less than
"<" value .
2. All wells or tubes gave positive reactions. Value based upon the MPN Index and reported as a greater than">" value.
Note: A "BB" value shall be accom panied by justification for its use denoted by the numbers listed above (e .j!., BBi , 882, etc.).
Total residual chlorine was present in sample upon receipt in the laboratory; value is estimated . Generally applies to cyanide,
phenol, NH3, TKN, coliform, and organics.
A single quality control failure occu1Ted during biochem ical oxygen demand (BOD) analysis. The sample results should be used
with caution. ·
I. The dissolved oxygen (DO) depletion of the dilution water blank ·exceeded 0.2 mg/L .
2. The bacterial seed controls did not meet the requirement of a DO depletion of at least 2.0 mg/Land/or a DO residual of
at least 1.0 mg/L.
3. No sample dilution met the requirement of a DO depletion of at least 2.0 mg/L and/or a DO residual of at least 1.0
mg/L .
4. Evidence of toxicity was present. This is generally characterized by a significant increase in the BOD value as the
sample concentration decreases . The reported value is calculated from the highest dilution representing the maximum
loading potential and should be considered an estimated value.
5. The glucose/ glutamic acid standard exceeded the range of 198 ± 30.5 mg/L.
6. The calculated seed correction exceeded the 1·ange of0.6 to 1.0 mg/L.
7. Less than 1 mg/L DO remained for all dilutions set. The reported value is an cstimnted greater than value and is
calculated for the dilution using the least amount of sample.
8. Oxygen usage is less than 2 mg/L for all dilutions set. The repotted value is an estimated less than value and is
calculated for the dilution using the most amount of sample.
9. The DO depletion of the dilution water blank produced a negative value.
Note: A "G" value shall be accom panied by justification for its use denoted by the numbers listed above (e .g ., GI, G2 , etc .).
Estimated value; value may not be accurate. This code is to be used in the following instances :
l. Surrogate recovery limits have been exceeded.
2. The repo1ted value failed to meet the established quality control criteria for either precision or accuracy.
3. The sample matrix interfered with the ability to make any accurate detennination.
4. The data is questionable because of improper laboratory or field protocols (e .g., composite sample was collected
instead of grab, plastic instead of glass container, etc.).
5. Temperature limits exceeded (samples frozen or >6°C) during transport or not verifiable (e.g., no temperature blank
orovided ): non-re portable for NPDES com pliance monitorin g .
J 6. The laboratory analysis was from an unpreserved or improperly chemically preserved sample. The data may not be
accurate .
7. This qualifier is used to identify analyte concentration exceeding the upper calibration range of the analytical
instrument/method . The reported value should be considered estimated.
8. Temperature limits exceeded (samples frozen or >6°C) during storage, the data may not be accurate.
9. The reported value is determined by a one-point estimation rather than against a regression equation . The estimated
concentration is less than the laboratory practical quantitation limit and greater than the laboratory method detection
limit.
10. Unidentified peak; estimated value.
11. The reported value is determined by a one-point estimation rather than against a regression equation. The estimated
concentration is less than the laboratory practical quantitation limit and greater than the instrument noise level. This
code is used when an MDL has not been estabfishedfor the anaiyte in question.
12. The calibration verification did not meet the calibration acceptance criterion for field parameters.
Note: A "J" value shall be accompanied by justification for its use denoted by the numbers listed above (e.g., JI, J2, etc .). A "J"
value shall not be used if another code a pplies (e .g., N, V, M).
M Sample and duplicate resu]ts are "out of control". The sample is non-homogenous (e.g., VOA soil). The reported value is the
lower value of du p licate analyses of a sam ple.
N Presumptive evidence of presence of material; estimated value. TI1is code is to be used if:
l. The component has been tentatively identified based on mass spectral library search .
2. There is an indication that the analyte is present, but quality control requirements for confirmation were not met (i.e.,
presence of analyte was not con finned by alternate procedures).
3. This code shall be used if the level is too low to pennit accurate quantification, but the estimated concentration is less
than the laboratory practical quantitation limit and greater than the laborat6ry method detection limit. This code is not
routinely used for most analyses.
4. This code shall be used if the level is too low to permit accurate quantification, but the estimated concentration is less
than the laboratory practical quantitation limit and greater than the instrument noise level. This code is used when an
MDL has not been established/or the analyte in question.
5 . The component has been tentatively identified based on a retention time standard .
Q Holding time exceeded. These codes shall be used if the value is derived from a sample that was received, prepared and/or
analyzed after the approved holding time rest1ictions for sample preparation and analysis . The value does not meet NPDES
requirements.
l. Holding time exceeded prior to receipt by lab.
2 . Holding time exceeded following receipt by lab.
p Elevated PQL* due to matrix interference and/or sample dilution.
s Not enough sample provided to prepare and/or analyze a method-required matrix spike (MS) and/or matrix spike duplicate
(MSD).
u Indicates that the analyte was analyzed for but not detected above the reported practical quantitation limit*. The numbe\' value
reported with the "U" qualifier is equal to the laboratory's practical quantitation limit*.
X Sample not analyzed for this constituent. This code is to be used if:
I. Sample not screened for this compound.
2. Sampled, but analysis lost or not perfonned-field en·or.
3. San1pled, but analysis lost or not performed-lab e1TOr.
Note: an "X" value shall be accom panied bv iustification for its use b v the numbers listed.
V Indicates the analyte was detected in both the sample and the associated method blank. Note : The value in the blank shall not be
subtracted from the associated samples.
y Elevated PQL * due to insufficient san1ple size.
z The sample analysis/results are not reported due to:
I. Inability to analyze the sample.
2. Questions c9nceming data reliability.
The presence or absence of the anal yt e cannot be verified.
*PQL The Practical Quantitation Limit (PQL) is defined and proposed as "the lowest level achievable among laboratories within
specified limits during routine laboratory operation". The PQL is about three to five times the calculated Method Detection Limit
(MDL) and represents a practical and routinely achievable detection limit with a relatively good certainty that any reported value
is reliable".
3/10/2011
E33
AT ORO Tabontanl_Section
Res ftr
County_ CRAVEN
Sample 10:
AS64294
wATsy
River Basle
Ok
�� QG�
PO Number 4
10GO692
Report To WAROAP
t^
?
Date Received'
Time Received:
10TOE 010
08�30
-Collector. A CLARrt
Y
Labworks LoginiD
SMATHIS
Ragian. WARD
Report Generated:
1114110
Sample Mabix, GROUNDWATER
Date Ftaported
1110412010
Lac. Type- WATER SOPPi.Y
Emergency Yes1N0
VisitlD
-y
COG Yes/No
I
Lac. Oescr.: STEl1E [3URCI
Location ID: APS-NSWW-CRAVE-0183
Collect Date; 1010712010
Collect Time: 14:20
Sample Depth
Rawl
Method
Malysis
CAS # Anallte Name
PPCC_L
Units
Validated by
Qualifier
Reference
Date
LAB
Sample temperature
at receipt by lab 1.3
1015110 SMATHIS
WET
Ion Chromatography
TITLE_
mg1L
EPA 300.0
1D/13110
CGREEN
Chloride
1
14
mg1L
EPA 300.0
10/13/10
CGREEN
Fluoride
0.4
0.4 it
mg1L
EPA 300.0
10/13/10
CGREEN
Sulfate
2
21
mg/L
EPA 300.0
1D113110
CGREEN
Total Dissolved Solids in liquid
12
276
mg1L
APHA`640C 18TH
10/14/10
CGREEN
NUT
NH3 as N in liquid
U.02
0.02 U
mg/L as N
I.400-107-06-1-i
1W11/10
CGREEN
Total Kjeldahl N as N in liquid
0.2
0.2 U
mg11- as N
LachatIV-06-2=111
10/13/10
CGREEN
NO2+NO3 as N in liquid
0.02
0.02 U
mg1L as N
Lac10-107-04-1-e
101110
CGREEN
Phosphorus -total as P in liquid
0.02
0.12
mg(L as P
Lac10-115-01-1EF
10/12/10
CGREEN
MET
7429-90-5
Al by ICP
50
50 U
ug?L
EPA 208.7
10/13110
ESTAFFORD1
7440-70-2
Ca by ICP
❑.1
81
mg1L
EPA200.7
1D112110
ESTAFFORDI
7440-47-3
Cr by ICPMS
10
IOU
u91L
EPA 200.8
10/13/10
ESTAFFORDI
7440-50-0
Cu by ICPMS
2
2:0 U
og/L
EPA 200.8
10/13110
ESTAFFORDi
743&69-6
Fe by ICP
50
800
vglL
EPA 200.7
10/13/10
ESTAFFORDI
74413-09-7
K by ICP
0.1
0.80
mg1L
EPA2D0.7
10112/10
ESTAFFORDI
7439-95-4
Mg by ICP
0.1
2.2
mg1L
EPA 2D0.7
10/12/10
ESTAFFORDI
7439.96.5
Mn by ICP
10
29
uglL
EPA200.7
1Gil 3110
ESTAFFORDI
7440-23-5
Na by ICP
0.1
26
mg&
EPA20D,7
101121iD
ESTAFFOROI
7440-02-0
Ni by ICPMS
10
IOU
ug1L
EPA 200.9
10/13/10
ESTAFFORDI
7439-52.1
Pb by ICPMS
10
IOU
ug/L
EPA 200.0
101i3/10
ESTAFFORDI
744"6-6
Zn by ICP
10
260
ug&
EPA 200.7
10/13/10
ESTAFFOR01
Laboratory Sectlon>> 1623 Mao Service Center, RaWig h. NC 2769 9-16 23 [phone]
For 9 detected des7�pllo� of!. a qua 115odes rcier lu holynfJpQgr4@[yuryjrgbrv/��A¢1Y I�IIr�[go'�eq�pe_q [bell Oyatlrfer COI eM cplLil(�dre¢I.na}e p�lj sials
Page 1 of 1

GROUNDWATER FIELD/LAB FORM
SANIFLETYPE j PLC PRIORITY
County • C.1; av en M Waier q§L .Ftoutine
Quad No Serial No. ❑ sal, ❑ Emergency
LaL3" Cis' 63' N Long.- IT-__ �, W ❑ Other
© CFtairt of Custody
Report To: ARO, FRO, MRO, RRO Wa WsRO, - -- -
WSRO, Kinston FO Fed. T►ust, Central Off., Other_
Shipped by: BPS, ouner $-land Del., Mer. Purpose:
Colfector(s), , [Date }0.1.2ol_# Time 2.s �_ Baseline: Complair
FIELD ANALYSES Owner_ iz b1. re 1
PH 40o CIi:� _ Spec. Cond. r. _ Jat 250C Location or Site-7.�31, ( ,
Temp, to °C Odor Description of -sampling point a
Appearance C t c sr Sampling Method G t
Field Analysis Sy:_ - Remark's K kk%V [ ${ q5%,cwV
LABORATORY
ANALYSES
900310 mg1L
COL] High 340 mgn-
COD Low 335 m91L
Conform; kW Fecal 31618 110om1
'Colkwm. AIF ToW 31504 11 90tnl
-rbc 6ao tngn-
T'urhidlty 76 NT U
Residue, Suspended 530 mg1L
pH 403 units
Alkalinity to pH 4.5 410 mg/L,
Awarinity-to pH 8.3 415 mg1L
Carbonate 44S mg/L
Sirarbartaie 440 - - - mg/ -
Carbon dio;do 405 mgJL
Chloride94e mgA-
Ctxnmarn. Hex 7032 ug1L
Color- True 80 CU
Cyanide 720 mg&
Lab Commertfs—
North Carolina
❑eparim enl of Environment and Natural Res aurces
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
]%-0677- gq
Lab Number
Date Received_jlb' ', 10 Time: --- -
Rec'd By: From.Bus, un , Nand Del.,
Other Data Entry Bye Ck:—
Date Reported:
Compiianct. LLIST, Pesticide Study, Federal Trust. Other,
Ica de one)
piss- Solids 70300 mgJL
Ag-Silver 45556
Al-Nurnirwm 46557
FlUpdide 951 Me&
Hardness: Total 900 mglL
As —Arsenic 46551
8kBarium.46558
Hardness (non -tart) 902 mgJL
Phends 32730 ugA
Ca Caitiurn 46552
Cd-Cadmium 46559
Cr-chmrnium 46559
SpedSc Cond. 95 omhoslcm
Sulfa le 945 m911
Salfide i+4'S mg1L
Cu-Copper 46562
Fe -Iron 46S63 3
Hg-Memury71900 �
1FP0tassium 46555 __T
09 and Grease 'r-A
Mg Magnesium 46554
p
Mn-Manganese 46555 5,
NHyasHfilO i ��' $►�SLF m91L
NaSodium46556
K Tbf as F16Z5 �'
Ni r4tckct�—
NO, + t+103 as N 63111�rL y� ; _ mglL
Pb-Lead 45584
So -Selenium At
P. TOfal as P 665 j� pKe [ nglL
Nitrale (NO, as N) 626 mg1L
—
Zn•Zinc 4fi5fi?
Nitrite thox as Nj 815--
G+W-54 REV- 7103 For Ussolved Mal ysis-submitrdlered sample and Write -DIS- 1n block
Sample Intery
IPunprg lime, air Irma.,
Dot BnPehlorine Pesticides
CWganophospborwsP*sUE;idqs
T
Nol"on Pestcides
Acid_H_erhicides
PCBs ~
Serni►nlatile Drganit.s
TPH-Diesel Range
Volatile Oar anus (VOA boWe
TPH-Gasoline Ran_qe y 1
TPH-ErrEX Gasoline Range
W_t,ISF_ ONLY
Temperature on arrival ('C): r

` 17bonlicorySection C
County_ c_RAVr Sample D: AS64293
River 8asln QF wAr�,.?Q J�Av%. PO Number # 10G0921
RepenTo W ROAP O Gy �'L) pate Received: 10108/2010
r time Received: 08:30
Collector. A CLARK y =" '
WARD '�' Labwor"Loginll) SMATWS
Region:
Sample Matrix! GROUNDWATER OWATER ��� ~ Report Generste& 1011010
Date Reported: 1011412010
Lcc. Type: WATER SUPPLY
Emergency YeslNo visillo
COC YeslNo
Loc. Descr.: STEVE DURCT
Location 10: APS-N-SWW-CRAVE-0183 Collee, ❑eta: 10/47/2010 Collect Time; 14:20 Sample Depth
CAS # Analvte Name R�I
Result) Units
Method
An_ _ alysis
Val*dated by
alifi r
Reference
Cate
LAB
Sample temperature of receipt by lab
1.3 °C
1018110
SMATHIS
MIC
Coliform, MF Fecal in liquid 1
1 B2 Q1 CFUI100m1
APHA9222D-20th
1018110
MOVERMAN
Coliform, MF Total in liquid 1
15 Q1 CFU1100ml
APHA92228-20th
101011t7
MOVERMAN
Laboratory Sections 1623 Mail Service Center, Rale 19h. NC 27699.1623 [phone]
For a pCls NO pCacr,Wlon al Inv gvaUfar r:ouv9 rvlar W tyy��7p4fJ91.nrprnr R'9LY±ASb`IR7A�!f.°'.41!!�1 L^5l'A•4`k€ �?.]i.. �-r i k2 •:hNnlYoebrVmQry,d r SMraAecNyryg—
Page 1 of 1

Department of Environment and Natural Resources
GROUNDWATER FIELDILAB FORM
Location code_AY:i -N— SAMPLE TYPE
County [t n.'4(1-1 _ water
{quad No Serial No. � soil
LaLi'S' OS ►J Long. �' 0� 3$ Other
DIVISION OF WATER QUALITY-GROLINOWATER SECTION
SAMPLE PRIORITY j,,�
� Routine Lab N unlb ' l "!J
Emergency'' �U�n Date Received Time s�
Rer d ElyFrom:Bus, r Line , Hand Del.,
Chain of Custody ❑ther;
Unm
Report To ARO, FRO, MRO, RRO, aR WiRO, Data Entry B : Ck:
WSRO, Kinston FO Fed_ Trust, Central Off„ Other; Date Reported:
Shipped by,: us, ourier Hand Del., Other Purpose.
CoiiectorWl , ��_ Date f d �Z�ifl Time `P crrnBaseline Complaint, _omp ance LUST, Pesticide Study, Federal Trust. Other;
FIELD ANALYSES Owner cards one)
pH log_ra-�.._, ._ Spec_ Cand.94 at 25°C Location or Site 'mod •t t a -
Terep.lo °C Odor_ _ Description of sampling point
Appearance_ Cif _ Sampling Method -;t eb Sample Interval
Field Analysis By, Remarks 5 a-1pUS c2r�`
BOO 310
COD High 340 -
COD Low 335 --
Colilnrm: MF Fecai 31616
Cohlorm' MF Total31504
Toc 680
Turllidity 76
Residue, Total Suspended 530
I PH 403 --- -
VAlkalirlty to pH 4.5 410
Alkalinity l0 pH 8,3 415
Carbonate 445
L. Bicarbonate 440
mg1L
mglL
mg1L
►100m1
!1 oam[
mglL
NTU
mg1L
Diss. Solids 74300
mg1L
Fluoride 951
mgfL
Hardness: Total 900-
mg1L
Hardness (non -Garb) 902
mglL
Phenols 32730 - - -
ugll
Specific Cand, 95
pMhoslCm
Sulfate 945
mgfL
Sulfide 745
mgfL
Oil and Grease mgfL
NH3 as N 610 mgiL
TKN as N 625 - - mgtL
Carbon dioxide 405 mglL NO2 + NOa as N 630 mglt
k Chloride 940 --mgfL P' Total as P 665 -- mg1L
Chrormium: Hex 1032 ug1L Nitrate (NQ3 as N) 620 mgfL
units
mg1L
mgfL
moll
mgrL
Ag-StIver 46586
uV
AI -Aluminum 46557
u�iL
As -Arsenic 46551
uylL
Sa-Barium 46558
—
u,11L
Ca -Calcium 46552
mctlL
Cd-Cadmium 46559 —
- -
us L
Cr-Chromium 46559
uciL
Cu-Copper 46582 J
uyll -
Fe -Iron 4G563
u j/L
Kg -Mercury 71900
ualL
K-Potassium 4655S
m�lL
Mg -Magnesium 46554
moll
Mn-Manganese 46565
t
Na-Sodium 46558
m,JL
Ni-Nickel
Pb-Lead 46584
uu1L
Se-seienium -
ua1L
Zn-Zinc 46557
ua1L
tPumping time, air tamp.. etc )
❑rganxhiorine Pesticides
Dr-a�_n WlsphosusPeslicides
Nitrogen Pesticides
Acid Herbicides
PCBs
semivolatila omanirs
TPH-Diesel Ran,e
- LVolatile Oryanias rVOA_bott_le`
TPH-Gasefine_Range
TPH-BTEX Gasoline Range
Cater True av
CU
Nitrite (NO2 as N) 615 mgfL
LAB 175E ONLY
Cyanide 720
mg1L
—
{L
Temperature art arrival (°C):
Lab Comments
C}W-54 REV• 7l03 For Dissolved
Filtered sample and write "DIS in block-

[ r
County:
CRAVEN
Sample
Sample 10:
A1364292
*A
River Basin
�p 1QQ
�y
PO Number #
10G0690
Report To
WAROAP
Q
7
Data Reeeheed:
Time Received-
10108/2010
08:30
Co4fectar.
CA LARX
❑
Lahworks LoginlD
SMATHIS
Region,
WARO
Report Generated:
1114110
Sample Matrix
GROUNDWATER
Date Reported:
1110412011)
Lac, Type-
WATER SUPPLY
Emergency YeslNv
VlsitiD
II r l
COC YesING
Lac. [Mnr.; STEVE DURCi
Location tD:
APS-N-1 WW-CRAVE-0163
Correct Date: 1010712010
Collect Tirre 15:25
Sample Depth
CAS #
LAB
Analyte name
Sample temperature at receipt by lab
St
Result)
Qualifier
1.3
Units
`C
Method
Reference
Analysis
Date
101800
Vauda[nd
SMATt-�S
WET
Inn Chromatography
_TITLE_
mgl+-
EPA 300.D
10/13110
GGREEN
Chloride
1
15
mg1L
EPA 300.0
10/13/10
CGREEN
Fluoride
0.4
0.4 U
mglL
EPA300.0
10M3110
CGREEN
Sulfate
2
24
mglL
EPA 300,0
10/13/10
CGREEN
Total Dissolved Solids in liquid
12
288
m.g1L
APHA254OC-19TH
10/14/10
CGREEN
NUT
NH3 as I in liquid
0.02
0.02 U
mg(- as N
LaC10-107-D8-1-4
10/11/10
CGREEN
Total Ijeldahl N as N in liquid
0.2
0,2 a
mglL as N
Lachat107-66.2-14
10/13110
CGREEN
N42+NO3 as N in liquid
0.02
0.02 U
mg)L as N
LactD-107-D4-1-c
IWI1110
CGREEN
Phosphorus total as P in liquid
0.02
0.12
mglL as P
Lac10-115-0IAEF
10/12/10
CGREEN
MET
7429-90-5
Al by ICP
5D
130
uglL
EPA 200.7
10/13/10
ESTAFFCRDI
7440-70-2
Ca by ICP
0.1
85
mglL
EPA200,7
10/12/10
ESTAFFORDI
7440-47-3
Cr by ICPMS
10
10 U
ug&
EPA 2003
10113Ma
ESTAFFORDI
7440-SD-8
Cu by ICPMS
2
13
ug1L
EPA200L
10113MO
ESTAFFORDI
7434- "
Fe by ICP
50
1000
ugk
EPA 200.7
10/13/10
ESTAFFORDI
7440-09-7
K by ICP
0.1
0.85
mglL
EPA200.7
I0112110
ESTAFFORD1
7439-95-4
Mg by ICP
0.1
2.4
tn9fL
EPA 200.7
10112/10
ESTAFFORDI
7439-S&-5
Mn by ICP
10
32
ug&
EPA 200_7
113/13/10
ESTAFFORDI
7440.23-5
Na by ICP
0A
29
m%1L
EPA 200.7
10/12/10
ESTAFFORDI
7440.02-0
Ni by ICPMS
10
10 N
uglL
EPA 200.6
10/13/10
ESTAFFORDI
7439.92-1
Pb by ICPMS
10
10 U
uglL
EPA200-8
10/13/10
ESTAFFORDI
7440.66-6
Zn by ICP
10
22
uglL
EPA 200,7
10/13/10
ESTAFFOR01
Laboratory SecUoiP> 16Z3 Mail Service Center, Raleigh, NC 27699-ISM [phone]
Fnr a ❑etaoled desrrpgw of the quaff ler Wdes reFef Ie gr,,nrtal.ntdm-mjnrah, Aahlmalan �rt it ass e[a ❑o Ell r pv5 ehtli X, an nodenra,jwgv-..i.a.4W - ragechgs�ist+
Page 1 of 1

GROUNDWATER FIELDILAB FORM
North Carolina
❑eparlment of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Location code ' N i WyV—�[ sky- ���� 5AMPLETYPE SAMPLE PRIORITY 1 0 l o`_ qu
1r
County •C( A, , l� wales �Cl .Routine Lab Number IU "
❑ sail ❑ Emergency 1Kaht r�
Quad No Serial Na. Date Received � (}' i' 1D Time'
Lat 35'' 45 N Long. . 04 � W ❑ awol ReCd By: From -,Bus, Dune, Hand Del..
❑ Chain of Custody Other-,
Report To: ARO, FRO,. MRO, RR Wa WIRO, - -- Data Entry By- Ck:
WSRO, Kinston FO ed. Trust, Centr Off., Other, Date Reported: --
5tupped hy: Sus, owner Hand Dd., Other: Purpose:
Colwor(s): c Date O- - time Baseline, Complain Compliar►c LUST, Pesticrt3e Study, Federal Trust, Other-_.—
FIEW ANALYSES owner S+Zif - Dmcl
PH 400� .C7 Spec. Cond.•" __ at 25'C Location or Site­?�20-tt a r c Zvi 4rn -
Temp-ta "C Odor _ _ Description of.sam Ing point
Appearance Sampling Method Tt -D Sample interval
Field Ariaiysis 6y- - - Remarks m Ir��15 t a>'r v, --%
LABORATORY' ANALYSES �+ pin9 ffi„e. a r itirtP.. �G}
_
BOD 310 mglL
OisS. Solids70360 mgfL
GOO High 340 mglL
FluvridR 951 mg&
COD Low 335 MB&
Hardness; olal goo rnglL
Cdiform: MF Fecal 31619 11 ooml
Hardness (non-carb) 902 mg1L
'Coiihmn: MF Total 31504 1100rni
Nends 32730 U94
TOC 690 T mg1L
Specift Cond. 95 uMhoslcm
T0(Sdity76 Mill
Sulfate 945 mgA-
Residue. Suspended 530 mg)L
Sulfide 74S mg1L
pH 403
Alkafinfty to PH 4.6 410
WiWinity, (a pH 8.3 415
Carbonate 445
l3karhvnate 440
Carbon dioxide 405
Chloride 940
Chromiun: Hex 1032
Color, True all
`Cyanide 720
Comments
- _ I I I OA and Grease
Units
mg1L
mgR,
mg1L
myL
mglL
ug1L
Cu
N141as1`4610 i�ti' •j �Lyt
TKN as N 625
NO, as N 630
P. Totai as P 665�C�y � y
Nitrate (N%as I 62I
Nitrite (No, as N) 815
' GW-54 REV. W03 . For [Yusolved Anafysis•subrrit filtered sample and write'Vl5' In blots
mglL
mgiL
mg1L
mgll
mglL
mpll �4
mail
Ag-Silvrr 46596
L
N-Nu ninum 46557
U
A.0,Menic 46551
e
—
Ba-Barium 46559
—
Ca -Calcium 45552
Col -Cadmium 46559
u
Cr-Chromium 46559
e, u
Cu-Copper46562
Fe -iron 46563
u
fag-1rlw"ry71900
_
1FPolpssium 46555—--�--(
rr
Mg -Magnesium 46554
Mn-Manganese 46565
Na-Sodium 46556
T n
W-Nickel
u;
Pb-Lead 45564
u;
Se Sefenirsrn •
u
Zn-zinc 46567 ,,J
e.
O�rc gnac#dorina PesGrSdes
•Or arlOPilosphdrus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCBs
Semivolatile Organics
TPH-❑'seat Range - —
Volatile Organics (VDA Cottle) —
TPH-Gasoline Range
TPH-BTEX Gasoline Ran e
LAB USE g(vU-
Temperature on arrival ('C)- {

V' tL7`�r ��[I�1 jiPtr�1'L+.SCt lr �t '-I 1dL
County:
CRAVEN
Sample ID:
AB64291
River Basin
p���ArR
rq PO Number 0
10Go689
Report To
WAR AP
D Qy
� �
9' fiats Received-
Time ReceivedCollector.ACIJIR1i
10108/2010
Collector.
Region:.
WART
�-� �
4�r_
1 Labworks LoginlO
SMATHIS
Report
1 Report Generated:
10/14/10
Sample Mairbr.
GROUNDWATER
Reported:
1011412015]
Loc. Type:
WATER SUPPLY
Emergency Yes/No
Vis416
CDC Yas±No
Loc. ❑escr,: STEVE DURCI
Location ID:
APS-N•IWW-CRAVE-0183
Collect Date: 10107/2010
Colect Time: 18:25
Sample Depth
CAS It Analvte Name PQL
Result/
Method
Units
Analysis
Validaled by
[qualifier
Reference
Date
LAB
Sample temperature at receipt by lab
-
1.3
°C
1018110
SMATrtts
—�
MIC
Coliform, MF Fecal in liquid 1
2 Q1
CFU1100ml APHA92220-20th
1018110
MQVERMAN
Col-Iform, MF Total in liquid 1
5 Q1
CFL1100ml APNA9222B-20th
1=110
MOVERMAN
Laboratory Section>a 1623 Main Serviru Canter, Raleigh, NG 2T699.1823 19191133,3"8
For a doinb5d desfirolan of lee 11w IRer codas rarer to t$IR-,(1nn_dal n5 , ':Q!p[Y}.ryf {gr]Jp(�Wm�roner,Legg°{y-i�aIa—%,ILfo� .n0a��hla.•G.e�llsituu�ar p !�r�7 p la re4e�.esa, .
Page 11 of 1

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Location code. _v j ' - L� - L�C 4- Q� SAMPLE TYPE SAMPLE PRIORITY i r � qq f
County C k QX A." _4 K Water � La € N u er� U � hwq'i 4
�• Routine ❑ p r� El Emergency ��� J Quad No Serial No_ soil � Date Recei�ed���O Time: D Lat. S5-5 Long-"�� °6�3W❑ Other Rec'd ey- HP From: Bus, rourier Hand Del.,
❑ Chain of Custody Other:
Report To: ARO, FRO, MRO, RRO, aRO IRO, Data Entry By: Ck:
WSRO, Kinston FO, Fed, Trust, Central Off_, Other_ Date Reported_ _
Shipped by: Bus, ourie Hand Del., Other. � _ _ Purpose-
Cviiector�s}:� . C r Dateh -'7 -2- --Time 3�.5 Yr. Baseline, Complaint, Compliance, LUST, Pesticide Study, Federal Trust, Other,
FIELD ANALYSTS Owner �-�ei L i LN [crcleane]
pH�Spec- Cvnd.y4 at 25°C Location or Site p _� C tii _ L 5
Temp. to °C Odor Description of sampling point i_�__ �� ���_ _mil, lr_t �•�
Appearance Sampling Method 1,orab _ _ _ Sample Interval
Field
LABORATORY
Analysis By:
ANALYSES
Remarks w'
Diss, Solids 70300 mg1L
X.
FOOD 310 rnglL
COD High 340 mglL
COD Low 335 mglL
Fluoride 951 mg1L
Hardness:Total 9o0 mg/L
Hardness (non-carb) 902� mg1L
Colirorm: MF Fecal 31516 1100m1
Cdiform: MFTotal 31504 1100MI
To c 66o mglL
IX —
Phenols 32730 ugll
Specifir-Cond, 95 pMhosfcm
Turbidity 76 _ NTL I
Residue. Total Suspended 530 mglL
Sulfate 945 mg/1-
Sulfide 745 m911-
Oil and Grease mglL
pH 403 - units
Alkalinity to pH 4.5 410 mglL
Alkalinity to pH 8.3 415 mg1L
NH3 as N 610 mglL
TKN as N 625 -- "IL
NOz + NO,, as N 630 mglL
Lab
Carbonate 445 rriSft
Bicarbonate 440 mg1L
Carbon dioxide 405 mglL.
Chloride 94r1 nxyL
Chromium- Hex 1032 ug1L
Color: True 8o Cu
Cyanide 720 mgn-
P: Total as P 8S5 rnglL
I
Nitrate (NO,, as N) 520 mglL
Nitrite (NOS as N) 615 rrn11L
Comments
GVJ-S-0 REV, 710 For Dissolved Analysis -submit fikered sample and write 'DIS' in black
(Purliping time, air iemy- etc,)
Ag-Silver 45566
u IL
Al -Aluminum 46557
u4fL
_
As -Arsenic 46551
Ba-Barlum46558
uf.UL
--uq1L
ca-Calcium 46552
m;lL
Cd•Cadmlurn 46559
Cr-Chromium 45559
ur�IL
lu&
CJV-Copper 48562
u L
Fe -Iran 46563
uglt-
Hg-Mercury 71900
unlL
K-Potassium 46555
ling -Magnesium 46554
mglL
m rL
Mn-Manganese 46565 _
Na-Sodium 46556
uulL
mg1L
Ni-Nickel
ui1L
—
Pb-Lead 46564
u L
Se -Selenium _
Zn-inc 46557
WIL
Will.
Omanochldrine Pesticides
Onranophosphorus Pesticides
Nitro}en Pesticides — -
A6d Herbicides
PCes
Semtvoiatile bar anics —
TPH-Diesel Ranae -
Volatile Organics iVGA bot9e;
TPH-Gasoline Ran
LAB USE ONLY
Temperalure an arrival (*G): .
tltltlt3l

Permit Number WI0700183
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
Stephen and Marilyn Durci SFR 5A7
Location Address
2206 Corral Cir
New Bern
Owner
Owner Name
Stephen
Dates/Events
NC 28562
R Durci
Orig Issue
08/18/10
App Received Draft Initiated
07/14/10
Scheduled
Issuance
Central Flies: APS_ SWP_
09/01/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
John Taylor
Driller Well
2030 Taylor Rd
Chocowinity
Major/Minor
Minor
NC
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Stephen R. Durci
2206 Corral Cir
New Bern
Public Notice Issue
08/18/10
NC
Effective
08/18/10
27817
28562
Expiration
07/31/15
_R_e_g_u_la_t_e_d_A_c_t_iv_it_ie_s _______________ Reouested/Received Events
Heat Pump Injection RO staff report requested
RO staff report received
Outfall NULL
Waterbody Name Stream Index Number Current Class
07/27/10
08/02/10
Subbasin
Permit Number WI0700183
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
john .mccray
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Stephen and Marilyn Durci SFR 5A7
Location Address
2206 Corral Cir
New Bern
Owner
Owner Name
Stephen
Dates /Events::
NC 28562.
R Durci
Scheduled
Orig Issue App Received Draft Initiated Issuance
07/14/10
Reaulated Activities
Heat Pump Injection
Outfall r,'U:...L
Central Files : APS_ SWP_
08/18/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
John Taylor
Driller Well
2030 Taylor Rd
Chocowinity NC
Major/Minor
Minor
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
lndi:vidual
Owner Affiliation
Stephen R. Durci
2206 Corral Cir
New Bern NC
Public Notice Issue ·Effective
~\\1\o
R ea uested /Rece ived Eve nts
RO staff report requested
RO staff report received
27817
28562
Expir~tion -w~ I,$
07/27/10
08/02/10
Waterbody Name Stream Index Number Current Class Subbasin
F
WEX
"Y`=��
NC®ENR
North Carolina Department of Environment and Natura
Divislon of Water Quality
Beverly Eaves Perdue 0oleen H. Sullins
Governor Director
4u-ust 1 S. 2010
Stephen and Marilyn Durci
2206 Corral Circle
New Bern, NC 28562
Re: Issuance of Injection Well Permit
Permit No. W10700183
Issued to Stephen and Marilyn Ilurei
Craven County
1VT;7M3i'� 5118illy0�la
Resources
Dee Freeman
Secretary
In accordance with your application received July 14, 2010,1 am forwarding Permit No. W107001S3 for the construction
and operation of a 5A7 geothermal underground injection control (UIC) well heat pump system located at the above
referenced address. This permit shall be effective from the date of issuance until July 31, 2015. and shall be subject to the
conditions and limitations stated therein.
Please pay special attention to the permit conditions Part H 1 and 2 which require you to notify the Washington
Regional Office at 252-946-6481 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 an application to renew
the permit four 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 me at [phone].
Best Regards,
John McCray21
Environmental Specialist
CC: David May - Washington Regional Office
Central Office File - W10700183
Craven County Environmental Health Dept.
Attachment: W10700183
AWIFER PROTECTION SECTION
1636 Mail Service Center. Rater h, North Carolina 27699-1636
Location- 2728 Capital Saulevare, Raleigh. North C;arohria 27604
Phone: [phone] FAX 17 9T9 7i5-0588, FAX 2:919-715-6948 (Customer Service: 1-877.623-6745
Internet. www r%wateruualp.om
An Egual Gpportumy % Affina�,veAction EMVLyer
One
NorthCarolina
,NW rally

NORTH CAROLINA
ENVIRONMENT AL 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
Stephen and Marilyn Durci
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North
Carolina Administrative Code 2C .0209( e )(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 2206 Corral Circle, New Bern, Craven County, NC 28562, and will be constructed and
operated in accordance with the application received July 14, 2010, 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 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 , 2015, and shall be subject to the
specified conditions and limitations set forth in Parts 1 through IX hereof.·
Pemtlt issued this the J;~ day of ~ , 2010.
~~4
\£\. Coleen H. Sullins, Director
~ Division of Water Quality
By Authority of the Environmental Management Commission.
WI0700183 1
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 Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
[phone]
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 Injection Control (UIC), Central Office staff, telephone number [phone]
and the Washington Regional Office Aquifer Protection Section (APS) Staff, telephone number [phone].
2. Within 30 days of injection well completion, Permittee must contact the Washington 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.
WI0700183 2
5. The injection well must be constructed to a depth su ch'that it i's iqjecting water into the same aquifer that the source
well is drawing from.
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 Pennittee 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 talce immediate corrective actions including those actions that may be required
by the Division of Water Quality such as the repair, modification, or abandonment oftl:ie injection facility.
2 . The Permittee shall be required to comply with the terms and conditions of this permit even if compliance requires
a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting ·from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any planned
physical alterations or additions in the permitted facility or activity not specifically authorized by the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the Pennittee must
notify by telephone the Aquifer Protection Section-Underground Injection Control (illC), Central Office staff,
telephone number (919) 715-616 8. 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 .
. WI0700183 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 know ledge of the occurrence, to
the Washington 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 any incorrect
information submitted in said application or in any report to the Director, the relevant and correct facts or
information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such immediate action
as may be required by the Director.
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 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.
WI0700183 4
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 prooedures 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 IX (1) and (2) (G) shall be submitted to:
WI0700183
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
Permit Number WI0700183
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
Stephen and Marilyn Durci SFR 5A7
Location Address
2206 Corral Cir
New Bern
Owner Name
Stephen
Dates/Events
NC 28562
R Durci
Scheduled
Orig Issue App Received Draft Initiated Issuance
07/14/10
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
08/18/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
John Taylor
Driller Well
2030 Taylor Rd
Chocowinity NC
Major/Minor
Minor
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Stephen R. Durci
2206 Corral Cir
New Bern NC
Public Notice Issue Effective
Re auested!Rece ·ved Eve ts
RO staff report requested
RO staff report received
27817
28562
Expiration
07/27/10
08/02/10
Waterbody Name Stream Index Number Current Cli3SS Subbasin
.,
AQUIFER PROTECTION SECTION-GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: 07/29/2010
To: APS Central Office
Central Office Reviewer:
Permittee(s): Mr. Steve Durci
Permit No.: WI0700183
County: Craven
Project Name: Durci
Regional Login No: __
I. GENERAL INFORMATION
1. This application is (check all that apply): D SFR Waste Irrigation System ~ UIC Well(s)
~ New D Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals D Attachment 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 D No
a. Date of site visit: 07/08/2010
b. Person contacted and contact information: Mr. Steve Durc i. 2206 Corral Circle ,.New Bern . NC 28562
c . Site visit conducted by : Allen Clark, DWQ/APS Washin gton Re g ional Office
d . Inspection Report Attached :~ Yes or D No.
2. Is the following information entered into the SIMS 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 UIC Injection Sites:
(If multi ple sites either indicate which sites the information a pp lies to , co py and paste a new section into the
document for each site , or attach additional pages for each site )
a . Location(s): 2206 Corral Circle , New Bern , NC 28562
b. Driving Directions: __
c. USGS Quadrangle Map name and number: __
d. Latitude: 35 05 03 N Longitude: -77 04 38 W Method Used; Google Earth
II. NEW AND MAJOR MOD/FICA TION APPL/CATIONS (this section not needed for renewals or minor
modifications. skip to next section) Description of Waste System and Facil ities: NA
Ill. RENEWAL AND MOD/FICA TION APPL/CATIONS (use p revious section for new or major modification
s ystems): NA
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and
heat pump injection wells .)
Description, of Well(s) and Facilities-New, Renewal, and Modification
1. Type of injection system :
C8l Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (5QM/5QW)
APS-GPU Regional Staff Report (S e pt 09)
RECEIVED / DENR / owa
AQUIFFR'PRnTFCTl()N SECTION
AUG O 2 2010
Page I of 3 Pages
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
□ In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5U"Non-Discharge")
D Other (Specify: __J
2. Does system use same well for water source and injection? D Yes [8J No
3. Are there 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 in jection well {s ) from the pollution
source(s )? ft .
4. What is the minimum distance of proposed injection wells from the property boundary? 20 ft.
5. Quality of drainage at site : [8J Good D Adequate D Poor
6. Flooding potential of site: [8J Low D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach map
of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? [8J Yes or D No. If
no or no map, please attach a sketch of the site . Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal and Modification Only: NA
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes D No. If yes . ex plain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit
issuance or last inspection? D Yes D No. If yes , explain:
3. For renewal or modification of groundwater remediation permits (of an y typ e ), will
continued/additional/modified in jections have an adverse im pact on mi gration of the p lume or management of
the contamination incident? D Yes D No. If ves , ex plain:
4. Drilling Contractor: Name: John Taylor . Taylor Well System
Address: 2030 Tay lor Road, Chocowinity , NC 27817
NC Certification number: 2435-A
5. Complete and attach NEW Injection Facility Inspection Report, if applicable
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the Application:
2. Attach new Injection Facility Inspection Form, if applicable
3. Do you foresee any problems with issuance/renewal of this permit? D Yes [8J No . If yes. please explain
briefly. __ .
APS-GPU Regional Staff Report (Sept 09) Page 2 of 3 Pages
AQUIFER PROTECTION SECTION -qROU~DWATER PROTECTION UNIT
REGIONAL STAFF REPORT
4. List any items that you would like APS Central Office to obtain through an additional information request. Make
sure that you provide a reason for each item :
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition :
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued . Make sure that you provide a reason for each special condition:
Condition Reason
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office ; D Issue upon receipt of needed additional information ;
[8J Issue; □ Deny. If deny, please state rea~nr T II I, IL
8. Signature of report Preparer(s): ____ tl/lr ___ ~_._{;{_~~-1!__, "-'--------------
Signature of APS regional supervisor: ----,!~1--'-')u.Cf......,_,1."'",6;...;Y J=a:....:1rJc_,_-'~,.........,~-----------
Date: 0 J ---~9 -3P( iJ
VI. ADDITIONAL INFORMATION AND SITE MAP (Sketch of site showing house and waste irrigation s ystem ,
s pra y or drip field, location of wel/(s ). and/or other relevant information-SHOW NORTH ARROW)
Met on-site with home owner Mr. Steve Durci on July 8, 2010, to conduct a site visit as part of the application
review process to install Type 5A7 injection well. No problems were observed. Purposed well location
measured twenty-five (25) feet from the house. Home owner plans to have both an injection well and supply
well installed. The neighborhood is served by public water and sewage. Other than the house, there are no
known potential pollution sources on this property .
*See Attached Site Map .
APS-GPU Regional Staff Report (Sept 09) Page 3 of 3 Pages
�. Colf all fir.
DRAW SKETCH OF SITE ABOVE (Show property boundaries, buildings, other wells, septic tanksldrain fields, other
potential pollution sources, roads, approximate scale, and NORM arrow)
N� tD IsC CAP,
Draw Schematic of well above showing TD, casing depth, grout, etc.
Injection Facility In Report (Rug, Sept 2009) Page 2 of Pages

WASHINGTON REGIONAL OFFICE - APS SECTION - PHOTOGRAPHIC RECORD
Site Name: Mr. Steve Durci
Permit Numbe W10700183
Site Location 2206 Corral Circle
City 1 County: New Bern ! Craven Count
Photographer.
Photographer:
A. Clark
A. Clark
�•-
Date:
�.
Date:
7/8/2010
:�
•f q ;
718M10
Photo Location:
1
Photo Location:
~
.r
Front Yard
- -
Barnyard
-x': _
Photo Direction:
Photo Direction:
NW
West
J
Comments:
Comments:
Inj. well site
behind fence in
a
Proposed Inj. and
Supply Well at
'+
,- - ' = -•' = - ::�+
backyard
red flags
Photographer:
�,'ti
"'
Photographer. -
A. Clark
. ' �{
L'
T
4*
A. Clark
Date:
-
•
Date:
71812010
,
707010
Photo Location:
Photo Location:
Backyard
- '. -
-
Northside of
home
Photo Direction:
--
Photo Direction:
Comments:
Comments:
Proposed Inj.
--
Proposed Inj. well
and Supply Well
-
=
at measuring tap
at red flags
(not pink flag)

North Carolina Department of Environment and Natural Resources
Division of Water Quality -Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700183
DATE OF INSPECTION: July 8, 2010
INSPECTOR: Allen Clark; W aRO
NAME OF PERMITIEE(S) Steve Durci
MAILING ADDRESS OF PERMITTEE: 2206 Corral Circle, New Bern, NC 28562
PHYSICAL ADDRESS OF SITE (if different than above) ________________ _
PERSON MET WITH ON-SITE: Mr. Steve Durci; Tele no. [phone]
WELL(S) STATUS:
__ Existing and operating Class V Well
__ Existing well proposed to be converted to Class V well
__ Proposed/not constructed
Purposed Injection Well Location: Latitude: 35 Deg., 05 Min ., 03 Sec N ; Longitude: ~77 De g., 04 Min., 38 Sec. W
Appx. distance of well to property boundaries: 25 feet
Appx. distance of well from foundation of house/structure: 25 feet
Appx. distance of well from septic tank/field (if present): NA
Appx. distance of well to other well(s) (if present): The purposed Injection Well will be approximately twenty
(20) feet from the proposed Supply Well.
Appx. distance to other sources of pollution: ___________________ _
Flooding Potential of Site: _high __ moderate X low
Comments: There were no potential problems observed during the site visit.
Injection Facility Insp. Report (Rev . Sept 2009) Page I of3 Pages
Pl!
Wei
N�rl,
DRAW SKETCH OF SITE ABOVE (Show property boundaries, huildings, other wells, septic tanksldrain fields, other
potential pollution sources, roads, approximate scale, and NORTH arrow)
4 Sfve
Draw Schematic of well above showing TD, casing depth, grout, etc.
gay, -
Injection Facility Insp. Report (Rev. Sep t2009) Page 2 of 3 Pages

Well Construction Information
Di te Constructed: Not yet constructed
Well Contracting Company: Taylor Well Sy stem
Well Driller Name: John Taylor
NC Well Cert. No.: 2435-A
Address: 2030 Tavlor Road, Chocowinity. NC 27817
Telephone No.: ~(2_5_2~) 9_4_3_-5~8_4_2 _____ ; Cell No.:
Email Address: -----------
Proposed Depth of Well(s): 70 feet
Total De.pth: TBD Total Depth of Source Well, if present: Not et constructed
Casing:
Depth: TBD Diameter: 4 inch; Type (gav. steel, PVC, etc.): PVC;
Grout:
Depth: Type (cement, bentonite, etc.): Placement (pump, press. etc.):
Well ID Plate Present (Y or N): ; Heat Pump ID plate present (Y or N):
Influent spigot (Y or N): (sample taken from pipe leading into heating unit); Effluent spigot (Y or N):
Well Sampled? (Y or N):
If Yes, Lab Sample ID numbers: _______________ _
Static Water Level: 1.
-Injection Information (if applicable):
Injection Rate:? _____ GPM
Injection Pressure:? _____ PSl
Injection Volume: ? _____ GPD
Temperature-Summer: ? ____ P0
Temperature-Winter: ? ____ P0
Comments/Notes: Met on-site with home owner Steve Durci on July 8. 2010 , to conduct site visit as part of the
a pplication review process to install T yp e 5A7 injection well. No problems were observed. Purp osed in jection
well location is twenty -five (25 ) feet from the house. Pro posed supp ly well location is a pp roximately twenty (20 )
feet from pro posed in jection well. Other than the house . no other potential pollution sources were observed.
Injection Facility Insp. Report (Rev. Sept 2009) Page 3 of 3 P ages
WASHINGTON REGIONAL OFFICE - APS SECTION - PHOTOGRAPHIC RECORD
Site Name: Mr. Steve Durci Permit Numbc Wl0700183
Site Location 2206 Corral Circle City I County: New Bern 1 Craven County
Photographer:
Photographer:
-y+.,d. .•--
A. Clark
A. Clark
'
date:
~•
©die:.:
- Z
7/812010
7/8/2010
4,
Photo Location:
Photo Location:
Frond Yard
Backyard
-_ "' Photo Direction:
'
Photo Direction:
NW
West
Comments:
Comments:
Inj. well site
r Proposed Inj. and
behind fence in
Supply Well at
' .
backyard
red flags
-
Photographer:
�' Photographer:
A. Clark
A. Clark
i
Date:
Date:
7/8/2010
7/8/2010
Photo Location:
Photo Location:
Backyard
�'
'^• - Northside of
f�
home
Photo Direction:
- Photo Direction:SE
Sw
Y
�n
Comments:
Comments:
Proposed Inj.
w- Proposed Inj. well
F
and Supply Well
-� w±- __ at measuring tape
at red flags
[not pink flag]

Craven County Geographic Information System
Craven County does NOT warrant the Information shown m this page and should be used ONLY Fo- tax assessment purposes.
This report was created by Craven County GIS reporting services on 8118/2R10 2:47;25 PM
Parcel ID : 8-075-B -185
Owner: DURCI, STEPHEN RICHARD & MARILYN G
Mailing Address : 2206 CORRAL CIR NEW BERN NC 28562
Property Address : 2206 CORRAL CIR
Description : LT 185 FOX HOLLOW S-5
Lot Description :
Assessed Acreage: 0.470
Deed Reference : 1007-0202
Recorded Survey
Estate Number :
Calculated Acreage: 0.470
Recorded Date : 001982
Land Value : $40,000 Tax Exempt : No
Improvement Value: $126,090 # of Improvements : 1
Total Value : $166,090
City Name : TRENT WOODS Fire tax District
Drainage District : Special District
Land use : RESIDENTIAL - ONE FAMILY UNIT
Recent Sales Information
SALE DATE Sellers Name Buyers Name Sale Type
6/1/1982 DURCI, STEPHEN RICHARD BUILDING SALE
& MARILYN G
List of Improvements to Site
Type of Structure Year Built
RESIDENTIAL CONSTRUCTION
Base Area
Sale Price
$73,000
Value
1980 1689 $126,090

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--
A O IDFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: Julv 27 . 2010
To: D Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS
□ Andrew Pitner, MRO-APS
0 Jay Zimmerman, RRO-APS
IZ! David May, WaRO-APS
□ Charlie Stehman, WiRO-APS
0 Sherri Knight, WSRO-APS
From: John McCray , Grou n dwater Protection Unit
Telephone: [phone] Fax: {919) 715-0588
E-Mail: john.mccray . ,ncdenr.l!ov
A. Permit Number: WI0700183
B. Owner: Step hen and Marilyn Durci
C. Facilitv/O peration: Step hen a.11d Marilvn Durci 5A7 SFR
IZ! Proposed D Existing D Facility D Operation
D. Application:
1. Permit Type: D Animal D Surface Irrigation D Reuse D H-R Infiltration
D Recycle D VE Lagoon D GW Remediation (ND)
IZ! UIC -(5A7) open loop geothermal __
For Residuals: D Land App. D D&M
D 503 D 503 Exempt
D Surface Disposal
D Animal
2. Project Type: IZI New D Major Mod. D Minor Mod. D Renewal D Renewal w/ Mod.
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 take the following actions:
IZ! Return a Completed Form APSSRR.
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, 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: Al(r n Clav 4 '.
/
7-J __ 5(-2or() Dat ~Ut 2 8 2010
FORM: APSARR 02/06 Page 1 of 1
1~~~y~o I D~NR Aqw,a!.-----·-:·;·~-:·--rotect,on S~cHori•", '·" ••. '-.. ~· .
JUL 2 9 2010 .
----
}
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A GEOTHERMAL HEAT PUMW SYSTEM
TYPE 5A7 "OPEN LOOP" INJECTION WELL(S)
(check one) New Permit Application Renewal Modification
DATE: _ J+� ��-201 Q
PERMIT NO.: WI M M & 5 (leave blank if NEW permit application)
A. PROPERTY OWNER/PERMIT APPLICANT
Name of each owner listed on property deed, For a business or government agency, state name of entity and
name of erson delegated authority to sign application on behalf of the businesslagency:
•►4�`, �� to r c i �A.r+ �� � �_ ��ur --
- s
(1) Mailing Address: _ZZ ❑ ' Ca c t a # CL Ig
City: blow &6 "-d State: ALC_ Zip Code: 2 '80-�7 County: Ceit- i eAl
Home/Office Tole No.: 2 SZ Cell No.: _
Fax No. _ Email Address:_ Sj tvc 1 0 5 sc.r t i Auk - Atf
(2) Physical Address of Well Site (if different than above);
City: State: Zip Code, County:
Home/Office Tele No.: Cell No.:
Fax No. Email Address:
B. PROPERTY OWNERSHIP DOCUMENTATION
Provide legal documentation of property ownership, such as a contract, deed, article of incorporation, etc. and
a PLAT map showing the property. This information may be obtained from county Register of Deeds or GIS
website.
C, AUTHORIZED AGENT, IF ANY
If the property owner/permit applicant wants to authorize someone else to sign the permit on their behalf, then
attach a signed letter from the property owneripermit applicant specifying and authorizing their agent (well
driller, heat pump contractor, or other type of contractor/agent) to sign this application on their behalf,
Company Name:
Contact Person:
Address:
City: _ —
State: Zip Code:
Email Address:
County:
Office Tole No.: Fax No. Cell No-
Wobsite Address of Company, if any:
RE aVED I DENR t DWd
A►gtilie► l mjedon Section
Type 5A7 Injection Well Pemnit Application (Rev. August 2009)
Page 1 o1'4

D.
E.
F.
G.
H.
WELL DRILLER INFORMATION
CompanyName: '1A-vloc ~ IL S:~±f'JY'J
Well Drilling Contractm\ Name: ___..,J6 .............. h ...... :~--·~~~-Jla_,_.._;~-----------------
NC Contractor Certification No.: Z 4 3 5 -A Contact Person: #ht,,I µy/o r
Company Website"-: -'W-'---'-W~W'-'-'-. ------------------'E=m=a1=·1-=--A=--=d=d=re=s=s:'--------------
Address: 20 30 1ny/o C Ro Ac{
City: C /1 0 er:., t.,v ~ /\/ ; 4y State: .Nc,Zip Code: '2. 7 8 17 County: flertu.fa d:
Office Tele No.: 252-?4' B -SB1?iax No.: _______ Cell No.: _______ _
HEAT PUMP CONTRACTOR INFORMATION (if different than Driller)
Company Name: G t eerJ ll-./11-L A/<:.. Contact Person: D 1 tJ ka S, ~ ko
Company Website: WWW. Email Address:
Address: ,S::-3 / ,3 J'Yl or-fol\) Rattd
City: New 8.e r /\ I State: N c.. Zip Code: 2 BS6 2. County: Cr fl v-eA..J
Office Tele No.:2S2'-259 -7 9G,. I Fax No. _______ Cell No. ________ _
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
D ro f W-e.1 / \A/A:d::c2r So11ir(~ He14-t PcJm a
J
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES :X NO ___ _
(2) Personal consumption? YES :X -1(, NO ___ _
WELL CONSTRUCTION DATA
~ Lv -4+4!.,.. GI' ,-Ju·
WA"ol,.. <!/l-r~
(1)
__ 'l~_PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (I) through
(7) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
____ EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (7)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
GW-1) if available.
Well Construction Date: __ /:l:~S~f-\~P ___ Number of borings: ___ _
Depth of each boring (feet): __ ,--'-7_,0""---------
(2) Well casing. Is the well(s) cased?
(a) YES ')( If yes, then provide the casing information below.
Type: Galvanized steel __ Black steel __ Plastic__)(_ Other (specify) ______ _
Casing thickness: ____:1_ diameter (inches): 50 }I-depth: from O to SO feet (relative to land surface)
Casing extends above ground / 2.. inches
(b) NO
(3) Grout material surrounding well casing:
(a) Grout type: Cement__ Bentonite* X Other (specify) _______ _
*By selecting bentonite grout, a variance is hereby requested to ISA NCAC 2C ,0213(d)(l)(A), which requires a cement type grout
(b) Depth of grout around well casing (relative to land surface): from .,.-to ± 20 ::theet
Type 5A 7 Injection Well Permit Application (Rev. August 2009) Page 2 of4
(4) • Well Screen or Open Borehole depth (relative to land surface): from __ .-__ to / 0 feet
(5) N.C. State Regulations (Title ISA 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 on:
(a) Influent line? Yes~ No__ (b) Effluent line? Yes_A No __
(6) Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Form GW-1). If Form GW-1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment units will the groundwater be withdrawn? (e .g.
granite, limestone, sand, etc.)
Depth: 5D-7 () ~ f-Formation: I 1 ~.Ls-fo,.,~ Rock/sediment unit: _______ _
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DAT A IF THIS
INFORMATION JS OTHERWISE UNAVAILABLE.
I. OPERATING DATA
(1)
(2)
(3)
(4)
Injection Rate :
Injection Volume:
Injection Pressure:
Injection Temperature:
J. INJECTION-RELATED EQUIPMENT
Average (daily) I Z.gallons per minute (gpm).
Average (daily) C., {)()O gallons per day (gpd).
Average (daily) 4 0 pounds/square inch (psi).
Average (January) ___ ° F, Average (July) __ ° F.
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 information if needed.
K. LOCATION OF WELL(S)
(I) 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 well(s) and any other existing well(s) or waste disposal facilities such as septic tanks or drain fields
located within 1000 feet of the geothermal heat pump well system. Label all features clearly and include a
north arrow.
(2) 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 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.
Ty pe 5A7 Injection Well Permit Application (Rev. August 2009) Page 3 of 4
L. CERTIFICATION (to be signed as required below or by that person-s authorized agent)
NCAC 15A 2C .0211(b) requires that all pen -nit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sale 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.
If an authorized agent is signing on behalf of the applicant, then submit a letter signed by the
applicant that names and authorizes their agent as specified in Part C of this permit application.
"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 wills the approved
specifications and conditions of the Permit."
Signature of Property Owner/Applicant
S+-t h -v-w R- D k rC'1
Print or Type Full Name
Signal re of Prc erty Owner/Applicant ,
Print or Type Fulf Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit TWO signed copies of the completed application package and all attachments to:
UIC Program
Aquifer Protection Section RECEIVED 1 DENR / DWq
North Carolina DENR-D W Q Aquifer Protedicin Spctiorl
1636 Mail Service Center JUL 14 2010
Raleigh, NC 27699-1636
Telephone [phone]
Type 5A7 Injection Well Permit Application (Rev, August 2009) Page 4 of