WI0300030_Complete File - Historical_20191108

Central Files: APS _ SWP _
11/8/2019
Permit Number W10300030
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
Active Renewal
Permit Type
Version Permit Classification
Injection Heating/Cooling Water Return Well
_ 4.00 Individual
Primary Reviewer
Permit Contact Affiliation
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Gregory and Elizabeth 011ish SFR
Location Address
136 Perennial Dr
Mooresville NC 28117
Owner
Major/Minor Region
Minor Mooresville
County
Iredell
Facility Contact Affiliation
Owner Name Owner Type
Individual
Gregory 011ish Owner Affiliation
Gregory 011ish
136 Perennial Dr
Dates/Events Mooresville NC 28117
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
8/6/1991 11/7/2019 11 /7/2019 10/31/2024
Regulated Activities Requested /Received Events
Heat Pump Injection Administrative amendment request received 9/16/19
RO staff report requested 9/20/19
RO staff report received " 10/15/19
Outfall
Waterbody Name Streamindex Number Current Class Subbasin

Permit Number W10300030
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
1
Central Files: APS _ SWP _
11 /7/2019
Permit Tracking Slip
Status Project Type
In review Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Facility Name Major/Minor Region
Gregory and Elizabeth 011ish SFR Minor Mooresville
Location Address 1 County
136 Perennial Dr Iredell
Facility Contact Affiliation
Mooresville NC 28117
r
Owner 4
Owner Name Owner Type
Individual
Gregory 011ish Owner Affiliation
Gregory 011ish
136 Perennial Dr
Dates/Events Mooresville NC 28117
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
8/6/1991
Regulated Activities Requested /Received Events
Heat Pump Injection Administrative amendment request received 9116119
RO staff report requested 9/20/19
RO staff report received 10/15/19
O utfa II
Waterbody Name
Streamindex Number Current Class Subbasin

ROY COOPER
Governor
NCHAEL S. REGAN
Secretary
UNDA CULPEPPER
DUector
Gregory & Elizabeth 011ish
136 Perennial Dr.
Mooresville, NC 28117
NORTH CAROLINA
EnvtronmerindQuaW
November 7, 2019
Re: Issuance of Injection Well Permit
Permit No. WI0300030
Geothermal Heating/ Water Return Well
PIN# 4646094556, Iredell County
Dear Mr. and Mrs. 011ish:
In accordance with your permit renewal application received September 16, 2019, I am forwarding
Permit No. WI0300030 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
October 31, 2024 and shall be subject to the conditions and limitations stated therein.
Please Note:
• Samples from the influent and effluent sampling ports of your geothermal well system
were collected on October 14, 2019. 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, I 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,
,J (�./ % /
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
® Ew 512 North Salisbury Street 1 1636 Mail Service Center I Raleigh, North_ Carolina 27699-1636
919.707.9000

cc: Cory Basinger- Edward Watson, Mooresville Regional Office
Central Office File, WI0300030
Iredell County Environmental Health Department

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
Gregory & Elizabeth 011ish
Iredell County
FOR THE CONTINUED OPERATION OF ONE (1) 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 136 Perennial Dr., Mooresville, NC 28117,
and will be constructed and operated in accordance with the application received September 16, 2019, and
conformity 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 be effective, unless revoked, from November 7, 2019, until October 31, 2024, and shall be
subject to the specified conditions and limitations stated therein.
Permit issued this the 7th day of No. tuber 7, 2019.
For Linda Culpepper
Director; Division of Water Resources
By Authority of the Environmental Management Commission.
Permit #W10300030 Geothermal Heating/Cooling Water Return Well Pagel of 5
ver. 8-8-2018

PART I — PERMIT 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 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 .0211(a)].
3. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data [15A NCAC 02C .0211(1)].
4. This permit is not transferable without prior notice 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 .0211(q)].
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
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 [I 5A 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 if bentonite is to -be used [15A NCAC 02C .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 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 .01070)(2)].
Permit #WI0300030 Geothermal Heating/Cooling Water Return Well Page 2 of 5
ver. 8-8-2018

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 .02110)].
1 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 including those actions
that may be required, such as the repair, modification, or abandonment of the injection facility [ 15A NCAC
02C .0206].
PART IV — INSPECTIONS [I 5A NCAC 02C .0211(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 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)(1)].
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(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 Mooresville Regional Office, telephone number 704-663-1699;
Permit #WI0300030 Geothermal Heating/Cooling Water Return Well Page 3 of 5
ver. 8-8-2018

(B) Written notification shall be made within 5 (five) days of the occurrence and submitted to the
addresses in Item #5 below; and
(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(f)(3)].
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
UIC Program Staff Water Quality Regional Operations Section
Division of Water Resources And DWR Mooresville Regional Office
1636 Mail Service Center 610 East Center Ave.
Raleigh, NC 27699-1636 Mooresville, NC 28115
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 insure freedom from
obstructions that may interfere with sealing operations;
Permit #WI0300030 Geothermal Heating/Cooling Water Return Well Page 4 of 5
ver. 8-8-2018

(C) Each well shall be thoroughly disinfected, prior to sealing, in accordance with rule 15A
NCAC 02C .01I l(b)(1)(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; and
(F) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0224(f)(4) within 30 days of completion of abandonment to the addresses
specified in Part V.5 above.
Permit #WI0300030 Geothermal Heating/Cooling Water Return Well Page 5 of 5
ver. 8-8-2018

Permit No. WI0300030
Date: 10/14/2019 , County: Iredell
To: Michael Rogers' (Central Office UIC Permitting) _
Permittee/Applicant: (Owner)_Gregory, and Elizabeth 011ish
Central Office Reviewer' Facility Name: 011ish Residence
L GENERAL INFORMATION,
1. Thisapplicationis (check all that apply): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification.
a. Date of Inspection:' 10/14/2019
b. Person contacted and contact information: Greg 011ish [phone]
c. Site visit conducted by: Edward Watson and Maria Schulte
d. Inspection Report Printed from BIMS -attached: ❑ Yes ®No.
e. 'Physical Address of Site including zip code: 136 Perennial -Dr., Mooresville, NC 28117
- L Driving Directions if rural site and/or no physical address:
g. Latitude: Longitude:
Source of Lat./Long & Accuracy-(i.e., Google Earth, GPS, etc.): GCS WGS-1984 to nearest 10 seconds.
II. DESCRIPTION OF INJECTION WELL AND FACILITY
1. -Type of _injection- system:
® Geothermal Heating/Cooling Water Return
❑ In situ Groundwater Remediation
❑ Non -Discharge Groundwater Remediation
❑ -Other (Specify:
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system only:
Were samples collected from Influent/Effluent sampling ports? ® Yes ❑ No.
Provide well construction information from well tag: Well Depth -300 ft., well dia. 6 inches, casing
depth 119 ft., Static water LVL 40 ft., well construction date 12-06-1996.,, Well Registration # 462.
b. Does existing or proposed system use same well for water source and injection? ® Yes ❑ No
If No, please provide source/supply well construction info (i.e., depth; date -drilled, well contractor,
etc.) and attached map and sketch location of supply well in relation to injection well and any other
-features in Section IV of this Staff Report.
-3.- This is also -a Water Supply Well for the residence.-
4: Quality -of drainage at site: ❑ Good ® Adequate ❑ Poor
5. Flooding potential of site: ® Low ❑ Moderate ❑ High
6. Does the map included in the Application reasonably represent the actual site (property lines, wells, surface
drainage)? ® Yes ❑ No. If No, or no map, please attach a sketch of the site. Show property boundaries,
buildings, wells, potential pollution sources, roads, approximate scale, and north arrow.

III. E VAL UA TION AND RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? Yes - ® No. If Yes; explain.
2. List any items that you would like WQROS Central Office to obtain through -an additional information request.
Make sure that you provide a reason.for each item:
3. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
4. -Recommendation
- 0 Deny. If Deny, please state reasons:
El Hold pending receipt and review of additional information by Regional Office .
❑ Issue upon receipt of needed additional information
® Issue
5. Signature of Report Preparer(s): - Edward Watson 10/15/2019
Doeuftned by:
E
+•d�►cw H Put." 10.14".19 "
Signature of WQROS Regional Supervisor: F181FB69APD84A3.. Date:
IV. ADDITIONAL REGIONAL STAFF REVIEW COMMENTS/ATTACHMENTS. fttional / If Needed) :
Well Water samples have been submitted to the Water Quality lab in Raleigh. The samples should arrive at the
lab on 10115/2010. Results will be reported to the well owner with a couv to -CO -when the analyses are
completed.

WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: September 20, 2019
To: Cory Basinger- Andrew Pitner
From: Shristi Shrestha, WQROS — Animal Feeding Operations and Groundwater Protection Branch
'Telephone: [phone] Fax: [phone] E-Mail. [e-mail]
Permit Number: W10300030
A. Applicant: Gregory & Elizabeth 011ish
B. Facility Name:
C. 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.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a completed WOROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer:
COMMENTS:
NOTES:
Date:
FORM: WQROS-ARR ver. 092614 Page 1 of 1

ROY COOPER
Governor
1ACHAEL S. REGAN
secretary
LINDA CULPEPPER
Director
Gregory & Elizabeth 011ish
136 Perennial Dr.
Mooresville NC 28117
NORTH CAROLINA
Envtronmenhd Quality
September 20, 2019
RE: Acknowledgement of Application No. WI0300030
Geothermal Heating/Cooling Water Return Well
Iredell County
Dear Mr. & Mrs. 011ish:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt
of your permit application and supporting documentation received on September 16, 2019.
Your application package has been assigned the number listed above, and the primary
reviewer is Shristi Shrestha
Central and Mooresville Regional Office staff will perform a detailed review of the
provided application, and may contact you with a request for additional information. To
ensure maximum efficiency in processing permit applications, the Water Quality Regional
'Operations Section (WQROS) requests your assistance in providing a timely and complete
response to any additional information requests.
Please note that processing standard review permit applications may take as long
as 60 to 90 days- after receipt of a complete application. If you have any questions, please
contact Shristi Shrestha at 919-107-3662 or email at [e-mail].
Sincerely,
W�-
For Debra J. Watts, Supervisor
Animal Feeding Operations &
Groundwater Protection Branch Division
of Water Resources
®North Carolina Department•of Environmental Quality I Division of Water Resources
_ 512 North Salisbury Street 1 1636 Mail Service Center I Raleigh, North Carolina 27699-1636
��� /� 919.707.9000

cc: Mooresville Regional Office, WQROS
Permit File WI0300030

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
NORTH CAROLINA
Eytt &vnmetW QaaUty
July 27, 2019
CERTIFIED MAIL # 7017 0190 0000 1635 3344
RETURN RECEIPT REQUESTED
Gregory & Elizabeth 011ish
136 Perennial Dr.
Mooresville NC 28117
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0300030
Iredell County
Dear Mr. & Mrs. 011ish:
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 July 18, 2014, and expires on September 30, 2019. Per permit ' conditions and
requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior to expiration of the permit if you wish to continue operating the injection well
on your property.
If Your Geothermal Water Return Well is Still Currently Beim Used for Iniection:
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
htty.//portal.ncdenr.or web/wq/aps/g2Mro/permit-applications.
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Parf 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,
D
� North Carolina Department of Environmental Quality I Division of Water Resources
—' 512 North Salisbury Street 1 1636 Mail Service Center I Raleigh, North Carolina 27699-1636
919.707.9000

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.
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 [e-mail].
Regards,
0 6
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Mooresville- Regional Office — WQROS w/o enclosures
Central Files - Permit No. WI0300030 w/o enclosures

North Carolina Department of Environmental Quality —Division of Wat s�oii ecxr--QiDWR
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTIONS�VF a L6S)0'9
In Accordance With the Provisions of 15A NCAC 02C .0224
Regional p
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(g���ons Sea
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: ,5 �.h— �a-1c.� , 20 19 - - PERMIT NO.�J�'� �p(leave blank if New Application)
A. - :CURB+T„�WELL.USE,&�O�W,NERSH�IPSTATUS `(I:eave Blank if New Well./Permit Application)
1. Current Use'of Well
a. I wish to continue to use the well as [Geothermal Well [Drinking Water Supply Well
0 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? E]YES [fNO
If yes, indicate New Owner's contact information:
Name(s)
Mailing Address:
City: State: Zip Code: - County:
Day Tele No.: Email Address.:
B. ff N US-0C—PLICANT (choose. one) /
Non -Government: Individual Residence V Business/Organization
Government: State Municipal County Federal
C.WEI;IJ 2W yER(S)/PERMIT APPI,IUANIFI 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:
Mailing Address:
City: lL" - State: 64(- Zip
Day Tele No.: b5Q.) 853 — y0rN-3 X 37CA
EMAIL Address: Gii SaL'��� � Fax No.:
_County:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 1

D. FELL -OPERA -TOR -(if -different from -well -owner-) z 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.: Email Address.:
E. PHYSIC'ALEOC-ATION,.OF-WELL(S� SITE
— u � i
(1) Parcel Identification Number (PIN) of well site:Lk(A(y09Lk ALP County: T—VUEe = i
(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) The injection operation? YES NO
(2) Personal consumption? 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 62C .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 Page 2

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
M. CERTIFICATION (to�be signed- as required below or by that person's authorized agent)
15A NCAC 02C .0211(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or -sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal.executive officer
or ranking publicly elected official;
4. - for all others: by all the persons) listed on the proppM deed.,
If an authorized agent is signing on behalf of the applicant, then -supply -a - letter signed by the
applicant that names and authorizes their agent to sign -this application on their behalf.
"I hereby certify, under penalty of law, that I have'personally examined and am familiar with the information
submitted in this document and all attachments thereto and that,, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate -and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, 'and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
�ignature-i . y`.Owrier/Applicant
Print or T , __ Full ame and Title ; /
3
Signatureo£Property'+OwnerlApplicarit�
6- zQlc.- i
PorType<Full`�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 Return Well Permit Application Rev. 415-2016 Page 4

J.
(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.
WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
j- *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 1 SAWCAC 02C. 010 7(fi(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)Z_'W,0 gallons per day (gpd).
(3) Injection Pressure: Average (daily)-b-5 pounds/square inch (psi).
(4) Injection Temperature: - Average (January) _° F, Average -(July) bb ° 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 Page 3

-Pfllll�

❑ Return Receipt (hardcopy) $
❑ Return Receipt (electronic) $ Postmark
❑ Certified Mail Restricted Delivery $ Here
❑Adult Signature Required $
❑Adult Signature Restricted Delivery $

Certified Mail service provides the following benefits:
■ A receipt (this portion of the Certified Mail label).
for an electronic return receipt, see a retail
■ A unique Identifier for your mailpiece.
associate for assistance. To receive a duplicate
■ Electronic verification of delivery or attempted
return receipt for no additional fee, present this
delivery.
USPS®-postmarked Certified Mail receipt to the
■ A record of delivery (including the recipient's
retail associate.
signature) that is retained by the Postal Service-
Restricted delivery service, which provides
for a specified period.
delivery to the addressee specified by name, or
to the addressee's authorized agent.
Important Reminders.
Adult signature service, which requires the
■ You may purchase Certified Mail service with
signee to be at least 21 years of age (not
First Class Mail®, First -Class Package Service®,
available at retail).
or Priority Mail® seryice.
- Adult signature restricted delivery service, which
°'Certified Mail service is notavailable for
requires the signee to be at least 21 years of age
international mail.
and provides delivery to the addressee specified
■ Insurance coverage is notavailable for purchase
by name, or to the addressee's authorized agent
with Certified Mail service. However, the purchase
(not available at retail).
of Certified Mail service does not change the
■ To ensure that your Certified Mail receipt is
Insurance coverage automatically included with
accepted as legal proof of mailing, it should bear a
certain Priority Mail items.
USPS postmark. If you would like a postmark on
■ For an additional fee, and with a proper
this Certified Mail receipt, please present your -
endorsement on the mailpiece, you may request
Certified Mail item at a Post Office- for
the following services:
postmarking. If you don't need a postmark on this
- Return receipt service, which provides a record
Certified Mail receipt, detach the;barcoded portion
of delivery (including the recipient's signature).
of this label, affix it to the mailpiece,apply
You Gan request A hardcopy return receipt or an
appropriate postage, and deposit the mailpiece.
electronic version. For a hardcopy return receipt,
complete PS Form 3811, Domestic Return .
Receipt; attach PS Form 3811 to your mailpiece;
'IMPOiIiiii save this receipt for your records.
Ps Form 3800, April 2015 (Reverse) PSN 75s0-0&000.9047