WI0100008_GEO THERMAL_20160901

j�ECEJVEDINC0E0WR
WaWrResources J U N a 2 2016
EA1V3ROi1MEWTAL gUALlTY
Water Quality Regional
pperationS SectionJune 1, 2016
Robert and Marguerite Randall
226 Dogwood Dr.
Mount Holly, NC 28120
PAT MCCRORY
Govenror
DONALD R. VAN DER VAART
Re: Geothermal Heating/Cooling Water Return Well Analytical Results
Permit No. WI0100008
Henderson County
Dear Mr. and Mrs. Randall:
secretapy
S. JAY ZIMMERMAN
D+reclor
On April 13, 2016, I collected geothermal system influent (Location ID: I P045WI01 000081NF)
and effluent (Location ID: I PO4 5WI0 1 00008EFF) samples from your well located at 44
Whiteside Trail, Hendersonville, North Carolina. The water samples were collected as part of
the permit renewal process for injection well permit WI0100008.
Analytical results for both the influent and effluent samples were all below the North Carolina
Administrative Code (NCAC) Title 15A 02L .0202 groundwater standards. A copy of the
analytical results is attached.
If you have any questions regarding the results please contact me at [phone].
Sincerely,
Andrew Moore
Environmental Specialist
Water Quality Regional Operations Section
Asheville Regional Office
Attachment: Laboratory Analytical Results
cc: ARO File
Michael Rogers, DWR Central Office
State of North CEffolma J Environmental Quality I Water Resources
2090 U-S. Hvey. 70 J Swamanoa, North Carolina 28778
8292964500

AC27989 North Carolina Division of Water Resources Water Sciences Section Laboratory Results
Loc. Weer-
g4 WHTTESIDE TRAIL
County:
HENDERSOH
Collector:
A MOORE MOD
Region:
MQ
Report To
AN Lacatlon ID:
1Ptt48WIU1048081NIF
River Basin
FRB
Called Date:
044131ZOI Priority
GROUNDWATER
Emergency
Collect Time;
agig Sample Matrix:
GROUNDWATER
COC Yea/Ho
Sample Depth
HA Loc. Type:
INFL.UEN
Final Regort
Sample ID:
AC2798�
PO Number 0
ARO
Date Reoaived:
eA V2016
Time Received:
1111:20
Lahworks LoginiD
�!S 1 R
Delivery Method
HanddOggvered
Final Report Dew
U27111
Reparz Print Data:
09QUADIG
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
Result) jnl Method Anal sis
CA$ # Anal Name Pam{._L aiifier Reference Date Va1idaW by
ARO
Alkalintty4.5
1.0
44,
mglL w CaCO3 APHA23208-20th
4119/15
ESTAFFORDI
Afkalinity8.3
1,0
1 U
rr#Las CaCO3 APHA2320B-20th
411 W1 6
ESTAFFORDI
Bicarbonate
1.0
44
mglLas CaCO3 APHA2320B-20th
4119116
ESTAFFORDI
Carbonate
1.0
1 U
mg/L as CaCO3 APHA2320B-20th
4119116
ESTAFFORDI
pl- Alkalinity
7.7
mglL as CaCO3 APHA23208-20th
4119115
ESTAFFORDI
Conform, MF Fecal in liquid
1
; g2
CFUIT00ml APHA9222D-201h
411WI0
ESTAFFORDI
Coliform, MF Total in liquid
1
182
CFU1100rrH APHAB222B-29th
4/13/10
ESTAFFORDI
Sample temperature at receipt by tab 2.2 T V13110 RAYR❑
Total DisscAved Solids in liquid 12 66 mg/L APhiA2540C-10TI-I 4f14118 ESTArFORD1
WS8 Chemistry Laboratorpo 1523 Mail Service Center. Raleigh, NC 27699-1623 [phone]
"Not Deteded" or "U" does not IndIcate the sample is analyte free but that the analyte Is not defected at or above the PI] L
Page 1 of 1

2BO40 North Carolina Division of Water Resources Water Sciences Section Laboratorti Results
: Deser.: 44 WHITESIDE TRAIL
linty. HENDERSON
Collector:
A MOORE
Vlsdio
410n. ARO
Repon To
ARO
Locaf�an 10,
i P0415IN10100000
ee+ Basin FtB
Collect Rate:
0 1�11
Priority
COMPLIANCE
e'gency
CONeet Time:
09:1s
Sample Matrix.
GROUNDWATER
iC YeslNo
Sample Depth
Loc. Type:
INFLUENT
Final Retort
Sample ID:
AC26040
PO Number #
IfiGnI00
Date Received:
04J1412016
Time Received:
0 0-0
Labworks LoginlD
M§WIFT
Oetivery Method
NC Grier
Final Report Date.
NJ16
Report Prim Date:
03V2036
If this report is labeled preliminary report, the results have not been validated. ❑o not use for Regulatory purposes
Result! nits Method Analysis
CAS # Analyte Na_rTte PQ-I, Qualifier Reference Date Al4a!ad 5Y
LAB
Sample temperature at receipt by lab
2.2
°C
4/14/18
MSWIF7
NUT
Nitrate as N in liquid 0.02
0.02 U
mg1L as N
EPA 353,2 REV 2 512116
CGREEN
Nitrite as N in liquid 0,01
0.01 U
mglLas N
EPA353.2 REV 2 4114116
CGREEN
NO2+NO3 as N in liquid 0.02
0.02 U
mg1L as N
EPA 353.2 REV 2 4/27116
CGREEN
WET
Bromide 0,4 0.4 U mg1L EPA 300.0 rev2.1 4114116 CGREEN
Chloride 1.0 1.0 U mGIL EPA 300.0 rev2.1 4114116 CGREEN
Fluoride 0.4 0.71 mWL EPA 300.0 rav2 1 4114JIS CGREEN
Sulfate 2,0 2.4 mg1L EPA 300.0 rev2.1 4114116 CGREEN
MET
R6-90-5
Al by ICP
50
$0 U
uglL
EPA200,7
41221tS
ESTAFFORDS
440-38.2
As by ICPMS
2.0
2.0 U
ug1L
EPA 200.8
4126118
ESTAFFOR131
44¢70-2
Ca by ICP
0.10
10
mg1L
EPA20o.7
412211E
ESTAFFORD1
440-07-3
Cr by ICPMS
5.0
5.0 U
ua/L
EPA 2018
412811e
ESTAFFORDI
440-50-8
Cu by ICPMS
2.0
30
ug1L
EPA 200.8
412611t3
ESTAFFORD1
1439-89-6
Fe by ICP
50
5o U
uglL
EPA200,7
4=16
ESTAFFORDI
'4-10.04'7
K by ICP
0.10
1.1
mglL
EPA 200.7
4122J16
ESTAFFORD1
'439-854
Mg by JCP
0,14
0.92
mglL
EPAXV
4122116
ESTAFFORDI
1439-96.5
Mn by ICP
10
10 U
uglL
EPA200.7
41Me
ESTAFFORDI
' 440-23-5
No by ICP
0.14
7.3
mG1L
EPA zao.7
4122116
ESTAFFOROI
7440.02-D
Ni by ICPMS
2.0
2.0 U
aglL
EPA 200,8
40116
ESTAFFOR01
7439-92-1
Pb by ICPMS
2.0
245
ug&
EPA200A
412011e
ESTAFFORDI
7,140-86-6
Zn by ICPMS
10
42
ugIL
EPA 200,8
4126116
ESTAFFORDI
WSS Chemistry Laboratoryaa 1023 Mail Service Car0hr. Raleigh, NC 27699-1623 (919) 1334909
"Mat Detected" or "U" does not Indicate the sample is anaiyte free but that the anaiyte is not detected at or above the PO L,
Page 1 of 1

AC27990 North Carolina Division of Water Resources Water Sciences Section Lahoraton- Results
Loc. Dew.-
44 WHITEWDE
TRAIL
County-
HFNOERBDN
ColWor.
Region
ARD
Report To
River Basin
ERA
Collect Date:
£mergwW
Collect Time:
CDC YeWNo
Sample Depth
A M $M Vlsitl0
MQ Lorellon ID: jMWMQIQQQQOFFF
04PU02016 Priority GROLII1DVIfA ELR
09:30 Sample Matrix: CagoUNDWATER
NA Lye. Type: EFFLUENT
Final Report
Sample ID-
ACZ7990
PO Number#
ARO
Date Received:
W1312016
Tune Received:
It'22
Labwork3 Loginfa
K.AM6SDNZ
Delivery Method
Hand delivered
Final Report Data:
&27116
Report Print Date:
0541112016
If this report is labeled preliminary repor4 the resufts have not been validated. Do not use for Regulatory purpose&
Resuld Units Method Analysis
CAS # Analvte Name P[�L ualifi r Reference Date Validated �+
ARD
Alkalinity4.5
1.13
44
mg1L as CaCW APHA23298-20rh
4119116
ESTAFFORD1
Alkelinity&3
1.0
1 U
mglL as CaCO3 APHA2320&20th
4119115
ESTAFFORD1
Bicarbonate
1.0
44
m01L as CaCO3 APHA232013-200
4119118
ESTAFFORDI
Carbonate
1.0
1 U
mg IL as CaCO3 APHA23209-2oth
4119/16
ESTAFFORDI
pH_Alkalinity
i'.7
mg/Las CaCO3 APHA232013-20th
4119115
ESTAFFORDI
Coliform, MF Fecal in liquid
1
1 82
CF1.1I100ml APHA9222D-2Dth
4113✓18
ESTAFFORDI
Coliform, MF Total in liquid
1
1 02
CFU1100m1 APHA92M-20th
4113116
ESTAFFORDI
Sample temperature at receipt by lab 2.2 °C 4113/16 RBYRD
Total Dissolved Solids in liquid 12 276 mglL APHA254OC-18TH 4114110 ESTAFFORDI
WSS Chemistry Labaratorpa 1623 Mail service Center, Raleigh, HC 27699-1923 [phone]
"Not Dawab!W' or" Li" does not indicate the sample is analyte hoe but that the analyte Is not detected at or above the POL.
Page 1 of 1

G16039 North Carolina Division of Water Resources Water Sciences Section Laboratory Results
oe. Debor.. dd WHITESIDE TRAIL
vunty: HENDERSON
Collector;
A MOORE
Visdld
egw: ag
Report To
AA O
Location 10:
1131)"WID100
ver Basin FRB
Collect Date:
001340116
Priority
COMPLIANCE
rnergency
Collect Time;
09;10
Sample Matrix:
QRggyp ATER
0C YeslNo
Semple Depth
L= Type'
EFFLU T
Final Report
Sample ID:
AC28039
PO Number #
16G0099
Date Received
0w1412pjs
Time Received:
098.
Labworks Logini0
MSYNFT
Delivery Melhad
NC Ccuder
FInai Report Date:
d19116
Report Print Dale,
QW3111agif
ff this report is labeled preliminary report, the rlesutts have not been validated. Do not use for Regulatory purposes.
Result/ Units Method Analysis
CASH Anafyte_Name PQL Qualfifier Reference bate Vaiidaled by
Sample temperature at receipt by lab
LAB
2.2 °C
NUT
4114116 MSWIFT
Nitrate as N in liquid
4.02
0.02 mg& as N EPA 353.2 REV 2 512/16 CGREEN
Nitrite as N in liquid
0.01
0.01 U mg1L as N EPA 353.2 REV 2 4114M CGREEN
NO2+NO3 as N in liquid
0.02
0.02 m.WL as N EPA 353.2 REV 2 4127116 CGREEN
WET
Bromide 0.4 0.4 U MgA- EPA 300,0 rev2.1 4M4116 CGREEN
Chloride
1.0
1.0 U
mg1L
EPA 300.0 rev21
4/14/16
CGREEN
Fluoride
0.4
0.73
mg1L
EPA 300.0 revr2.1
4114116
CGREEN
Sulfete
2.0
2.5
mg1L
EPA 30.0 rev2.1
4114116
CGREEN
MET
1429-90-5 Al by ICP
50
s0 U
ug1L
EPA 200.7
4122116
ESTAFFORDI
7440-3&2 As by ICPMS
2.0
2.0 U
uglL
EPA 200.8
4126118
ESTAFFOR01
1440-70.2 Ca by ICP
0.10
10
mg1L
EPA 200.7
4122116
ESTAFFORDI
1440-47-3
Cr by ICPMS
5.0
5.0 U
uglL
EPA 200.6
4126/16
ESTAFFOR01
7440.50-8
Cu by ICPMS
2.0
13
uglL
EPA200.8
4128/16
ESTAFFORDI
7439-69-6
Fe by ICP
50
50 U
uglL
EPA 2007
4122116
ESTAFFORDI
7440-09-7
K by 1CP
0.10
1.1
mg1L
EPA 200.7
4122116
ESTAFFOR01
7430-95-4
Mg by ICP
0.10
0.94
mg1L
EPA 200.7
4122116
ESTAFFORDI
?439M-5
Mn by ICP
10
10 U
uglL
EPA 200.7
4r2VI6
ESTAFFORD1
7440-23-5
Na by ICP
0.10
7.5
aVL
EPA 200.7
4122116
ESTAFFOR01
'440.02-0
Ni by ICPMS
2.0
10 U
ug1L
EPA200.8
4/28116
ESTAFFORDI
7439-9Z1
Pb by ICPMS
2.0
2.0 U
ug1L
EPA200.8
4128?16
ESTAFFORDI
7440-66$
Zn by ICPMS
10
IOU
ug1L
EPA200.8
4126116
ESTAFFORD7
WSS Chemistry Laboratory>> `16Z3 Mali Sanrice Center, Raleigh, NC 27699-16M [phone]
'Nat Detected" or "U' does not Indicate the sample is analyte Free but that the analyte is not detected at or above the POL.
Page 1 of 1

Pi)rrnit Number W10100008
Program Category
Ground Water
Permlt Type
Injection HeatinglCooling Water Return Welt
Primary Reviewer
shdsti.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Robert and Marguerite Randall SFR
Location Address
44 Whiteside Trt
Hendersonville
Owner
Owner Name
Robert
NC 28792
Randall
Central Files: APS _ SWP _
4/14/2016
Permit Tracking Slip
Status Project Type
In review Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
MajorlMinor Region
Minor Asheville
County
Henderson
Facility Contact Affiliation
Owner Type
Individual
Owner Alf illation
Robert Randall
226 Dogwood Dr
CatesiEvents Mount Holly NC 28120
Scheduled
Oft Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
3119/2001 2/16/2016
Regulated Activities Requested iReceived Event` -
Heat Pump Injection RD staff report requested 211°!16
RO staff report received 4113116
Outfall
Waterbody Name Streamindex Humber Current Class Subbasin

Water Resources
EMVIQ014MENTAL QUALtTV
April 22, 2016
Robert and Marguerite Randall
226 Dogwood Dr.
Mt, Holly NC 28120
Re: Issuance of Injection Well Permit
Permit No. WI0100008
Geothermal Heating/Cooling Water Return Well
Henderson County
Dear Mr. and Mrs. Randall:
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secrerary
S. JAY ZIMMERMAN
!wean"
In accordance with your permit renewal application request received February 16, 2016, I am
forwarding Permit No. WI0100008 for the continued operation of geothermal heating/cooling water
return well(s) located at 44 Whiteside Trail, Hendersonville NC 28792. This permit shall be effective
from date of issuance until March 31, 2021, and shall be subject to the conditions and limitations stated
therein.
Please Note:
■ Samples from the influent and effluent sampling parts of your geothermal well system
were collected on April 13, 2016. 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,
Shristi Shrestha
Underground Injection Control (UIC) - Hydrogeologist
Division of Water Resources, NCDEQ
Water Quality Regional Operations Section
Smle of Nordi Cgrolina [ EnvimnmeaW Quality ! Water Rewurcrc
1611 Mail cemks Coto I Raleigh, Nonh Cwolina 27699-1611
919 707 WO

Page 2 of 2
cc: Landon Davidson and Andrew Moore, Asheville Regional Office
Central Office File, WI01 00008
Henderson County Environmental Health Department

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Robert and Marguerite Randall
FOR THE CONTINUED OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defined in Title 15A North Carolina Administrative Code 02C .0224(a), which will be used
for the injection of heat pump effluent. The injection well(s) located at 44 Whiteside Trail, Hendersonville,
Henderson County NC 28792 will be operated in accordance with the application submitted February 16, 2016
and conformity with the specifications and supporting data received, all of which are tiled with the Department
of Environmental Quality and are considered a part of this permit.
This permit is for continued operation of an injection well shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until March 31, 2021, and shall be
subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 22"d day of April 2016.
S. lay Zimmerman, P.G.
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Permit 4WI0100008 UIC15A7 Page I of
ver, 11/15/2015

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 [I 5A 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 and approval. In the event there is a desire for the facility
to change ownership, or there is a name change of the Pennittee, 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)].
5. 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 [ 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 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 [ 15A NCAC 02C
.0224(d)(2)5(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.
[15A NCAC _0225(g)(8)1.
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 [I5A NCAC 02C .0224(d)(4)].
5. Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal as defined in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .0107(j)(2)].
Permit #W10100008 UIC15A7 Page 2 of'5
ver. 11115/2015

7. A completed Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 of this
permit.
PART III -- OPERATION AND USE CONDITIONS
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 rides of 15A NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C .02110)].
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 ofthe injection facility [15A NCAC 02C .0206].
PART IV — INSPECTIONS [15A NCAC 02C .0211(k)]
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
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 monitoring or other information that indicates noncompliance with a specific
permit condition, that a contaminant may cause a violation of applicable groundwater quality standards, or
that a malfunction of the injection system may cause the injected fluids to migrate outside the approved
injection zone or area. As specified in rule 15A NCAC 02C .021 l(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 Asheville Regional Office, telephone number 828-296-4500.
(B) Written notification shall be made within five days of the occurrence and submitted to the addresses
in Item #5 below.
Permit #WI0100008 U105A7 Page 3 of 5
ver. 11/ 15/2015

(C) The written notification shall contain a description of the noncompliance and its cause; the period of
noncompliance, including dates and times; if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and any steps taken or planned to reduce, eliminate, and
prevent reoccurrence of the noncompliance_
4. The Permittee shall record the number and location of the wells with the register of deeds in the county in
which the facility is located. [15A NCAC 02C .0224(f)(3)],
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
U1C Program Staff Water Quality Regional Operations Section
Division of Water Resources and DWR Asheville Regional Office
1636 Mail Service Center 2090 U.S. Highway 70
Raleigh, NC 27699-1636 Swannanoa, NC 28778
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]
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 permanently abandon that injection well in accordance with the procedures specified in 15A
NCAC 02C .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
such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected prior to sealing in accordance with role 15A
NCAC 02C .0111(b)(1)(A),(B), and (C).
Permit #WI0100008 UIC15A7 Page 4 of 5
per. 1 1 / 15/2015

(D) Each well shall be completely -milled 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) la those cases when a subsurface cavity has been created as a result of the injection
operations, each well shall be abandoned in such a manner that will prevent the movement
of fluids into or between underground sources of drinking water.
(F) The Permittee shall submit a Well Abandonment Record (Form GW-34) as specified in
15A NCAC 2C .4224(f)(4) within 34 days of completion of abandonment.
S. The written documentation requirod in Part VII (4)(F) shall be submitted to the addresses specified in Part
V.5 above
Permit #W101 aoob8 LTIC15A7 Page 5 of 5
ver. 11/15/2015

Shrestha, Shristi R
From:
Moore, Andrew W
Sent:
Wednesday, April 13, 2016 2:43 PM
To:
Shrestha, Shristi R; Rogers, Michael
Subject:
RE: W10100008
Attachments:
W10100008 Staff Repo rt_04132016.pdf
Shristi,
See attached staff report for the subject facility. I will not plan on sending the original unless you notify me otherwise.
I collected influent and effluent water samples today as well. I will copy you on the results letter once the analytical
data are received.
Thanks,
Andrew
From: Shrestha, Shristi R
Sent: Monday, March 21, 2016 11:40 AM
To: Rogers, Michael <[e-mail]>; Moore, Andrew W <[e-mail]>
Subject: RE: W10100008
It's done.
Thank you,
Shristi
From: Rogers, Michael.
Sent: Monday, March 21, 2016 11:17 AM
To: Moore, Andrew W <andrew_w.moorco ncdenr. r+>; Shrestha, Shristi R Eshristi.shrestha? ncdenr.tiav>
Subject: RE: W10100008
We'll wait on you sampling and inspecting the system and sending the staff report before re -issuing the
permit. However, we won't wait on the lab results.
Shristi- Put in BIMS the time delay as an Additional Information Request for the owners being out of the country
From: Moore, Andrew W
Sent: Monday, March 21, 2016 9:33 AM
To: Shrestha, Shristi R <shristi.shrestha z, ncdenrTov>
Cc: Rogers, Michael <rnichael.roters ,± itcdenr. �ov>
Subject: RE: WIOI00008 _
Shristi,
Mr. and Mrs. Randall are not available until April 13"'. If I perform the site inspection and sampling at that time,
would that give you enough time to complete the perrni[ renewal?
One other option would he for me to perform the site inspection prior to the 13"' with no one present at the residence,
then return to perform the sampling. However, from a ti me perspective, I would prefer to perform the inspection and
sampling at the same time.
Let me know if completing and submitting the staff report on the 13`r' will give you enough time to complete the
permit renewal.

Andrew
From: Shrestha, Shristi R
Sent: Monday, March 21, 201E 8:59 AM
To: Moore, Andrew W -,andrew.w.moore , f acderinuo_v_>
Cc: Rogers, Michael <mzichael_rouers ,, izcrlenr.+wQv>
Subject: RE! WIDIO0008
Thank you for letting us know.
shristi
From: Moore, Andrew W
Sent: Monday, March 21, 2016 8:38 AM
To: Shrestha. Shrish R <shristi,shrestha , nedenr. ,ova
Cc: Rogers, Michael <michael.iogars c7 ncdenr,�ou>
Subject: W1010OW8
Shristi,
The ARO received a request for a WQROS Staff Report as part of the permit renewal for the subject pernut. The
pern-iittees do not live in the residence where the iiliection well is located and they have been unable, tuitil this week,
to travel to the residence in order for me to conduct the inspection and collect the intluent and effluent samples. They
were planning on traveling to the home this Wednesday so that I could conduct the ulspeetion. However, wish the
holiday Friday, I cannot get the sainples to the laboratory before the laboratory restrictions go into effect.
I am waiting to hear back from the permittees as to when they can travel to the residence so that I can conduct the
inspection and collect the requisite influent and effluent samples. I'll keep you informed of the schedule,
Andrew W. Moore, P.G.
Environmental Specialist — Ashevilte Regional Office
Water Quality Regiona! Operations Section
NCDEQ — Division of Water Resources
828 296 4684 office
email: And rew.W. Moore,-Lncdenr.cov
2090 U.S. Hwy. 70
Swannanoa, N.C. 28778
—`="Nuthmy Compares
Email correspondence to and from 0is address is subject to the
North Carolina Joblic records Law and may be disclosed to third parties.

r
WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
Permit No, W10100008
Date: April 13, 2016 County: Henderson
To: Sliristi Shrestlm PermitteelApplieant: Robert Randall
Central Office Reviewer Facility Name: Robert and Marguerite Randall SFR
I. GENERAL INFORMATION
1. This application is (check wI thw ggiy): ❑ New 0 Renewal
❑ Minor Modification ❑ Major Modification
a. Date of Inspection: 4/13MI6
b. Person contacted and contact information: Robert and Marguerite Randall (704-8274347)
e. Site visit conducted by: Andrew Moore
d, Inspection Report Printed from RIMS attached: ❑ Yes ® No.
e. Physical Address of Site including zip code: 44 Whiteside Trail, Hendersonville, NC 28792
f. Driving Directions if rural site and/or no physical address:
g. Latitude: 35.4424 Longitude; 8Z346996
Source of LaVLoug & accuracy (i.e., Google Earth, GPS, etc.): Earth
H. DESCRLPTION OFINJECTION WELL(S1,4N))FACILITY
1. Type of injection system:
® Geothermal Heating/Cooling Water Return.
❑ In situ Groundwater Remediation
❑ lion -Discharge Groundwater Remediation
❑ Other (Specify:
2. For Geothermal Water Return Well(s) only
3.
4.
5.
6.
a. For exis in geethermtil system:
Were samples collected from Intluent/Efflucat sampling ports? Z Yes [__1 No.
Provide well construction information from well tag; Drilled 1]6 5!'99: Depth. 405': Casing Depth 94':
Yield 20� aim
b. Dues existing or ptoposed system use same well for water source and injection? ® Yes E] No
If No, please provide sourWsupply 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 aay other
features in SectEnrt IV of this Staff Report.
Are there any potential pollution sources that may affect injection? E] Yes ® No
What islare the pollution sources)?
What is the distance of the injection well(s) from the pollution source(s)?
What is the minimum distance of proposed injection wells from the property boundary?
Quality of drainage at site; ® Grad ❑ Adequate ❑ Poor
Flooding potential of site: SLOW ❑ Moderate ❑ High
Rev. 6l112415 Page I

WQ-ROS REGIONAL STAFF REPORT FOR
❑IC Program Support
7 For Groundwater Retnediation systems, is the proposed and/or eaisfing groundwater monitoring program
(number of wellsr frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. If No,
attach map of existing monitoring well network if applicable and recommend any changes to the groundwater -
monitoring program.
8. Does the map included in the Application reasonably represent the actual site (property lines, wells, surface
drainage)? ❑ Yes ❑ No. If No, or no map, please attach a sketch of the site. Show property boundaries,
buildings, wells. potential pollution sources, roads, approximate scale, and north arrow.
9. For Non -Discharge groundwater remediation systems only:
a. Are the treatment facilities adequate for the type of waste and disposal system? ❑ Yes ❑ No ❑ N/A.
If no, please explain:
b. Are the site conditions (soils, topography, depth to water table, etc.) consistent with what was reported by
the soil scientist and/or Professional Engineer? ❑ Yes ❑ No ❑ N/A. If no, please explain:
1H.. EVALUATION AND RECOMMENDA77aNS
1. Do you foresee any problems with issuance/renewal of this permit`( ❑ Yes jZc No. If yes, explain.
2. List any items that you would like WQRO8 Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item
Reason
3. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that yoir provide a reason for each special condition:
Condition
4. R.econamendation
Reason
❑ Deny. If Deny, please state reasons,
❑ Hold pending receipt and review of additional information by regional offec
❑ issue upon receipt, of needed additional information
® Issue
S. Signature of report preparer(s):
Signature of GVQROS Regional Supervisor:
Rev, 6/1/2415 Page 2
I
I
I

WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
Datv:
IV. ADDITIONAL REGIONAL STAFFREVIEW COM,,VN�MVA7TACE ENTS [If!Ve4*dJ
Rev_ 6/1/2015 [ Page 3

To; Shrestha, Shristi R <shristi.shrestha ' ncdenr.rov>
Cc: Rogers, Michael <michae1.ro�-ers--ncdenr.ov>
Subject: W10100008
S h risti,
The ARC) received a request for a WQROS Staff Report as part of the permit renewal forth e subject permit. The
perm ittees do not live in the residence where the injection well is located and they have been unable, until this week,
to travel to the residence in arder for me to conduct the inspection and collect the influent and effluent samples. They
were planning an traveling to the home this Wednesday so that I could conduct the inspection. However, with the
holiday Friday, I cannot get the samples to the laboratory before the laboratory restrictions go into effect.
I am waiting to hear back from the perm ittees as to when they can travel to the residence so that I can conduct the
inspection and collect the requisite influent and effluent samples. I'll keep you informed of the schedule.
Andrew W. Moore. P.G.
Environmental Specialist — Asheville Regional Office
Water Quality Regional Operations Section
NCDEQ — Division of Water Resources
828 296 4684 office
email: Andrew.W.Moor&Ci)ncdenr,nov
2090 U.S. Hwy. 70
Swannanoa, N.C. 28778
Email corresponefence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

Shrestha. Shristi R
From:
Shrestha, Shristi R
Sent:
Monday, March 21, 2016 11:40 AM
To:
Rogers, Michael; Moore, Andrew W
Subject:
RE: WI0100008
It's done.
Thank you,
Shristi
From: Rogers, Michael
Sent: Monday, March 21, 2016 11:17 AM
To: Moore, Andrew W earidrew,w,moo [e-mail]>; Shrestha, Shristi R <shristi,[e-mail]>
Subject: RE: W10100008
We'll wait on you sampling and inspecting the system and sending the staff report before re -issuing the
permit. However, we want wait on the lab results.
Shristi- Put in RIMS the time delay as an Additional Information Request for the owners being out of the country
From: Moore, Andrew W
Sent: Monday, March 21, 2016 9:33 AM
To: Shrestha, Shristi R rshristi,shrestha �F ngdenr.rov>
Cc: Rogers, Michael rmichael.ror:ers a ncdenr._r.ov�
Subject: RE: W10100008
Shristi,
Mr, and Mrs. Randall are not available until April 13` If I perform the site inspection and sampling at thattime, would
that give you enough time to complete the permit renewal?
One other option would be for me to perform the site inspection prior to the 13''' with no one present at the
residence, then return to perform the sampling. However, from a time perspective, I would prefer to perform the
inspection and sampling at the same time.
Let me Yvow if completing and submitting the staff report on the 13" will give you enough time to complete the
permit renewal.
Andrew
From: Shrestha, Shristi R
Sent: Monday, March 21, 2016 8:59 AM
To: Moore, Andrew W <andrew.w.moorei.+,ncdenr.rov>
Cc: Rogers, Michael rmichael. ro�erSL `ncdenr,-ova
Subject: RE: WIOI00008
Thank you for letting us know
Shristi
From: Moore, Andrew W

WATER iUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: February 19, 2016
To; Landon Davidson- Andrew Moore
From: Shristi Shrestha, WQROS — Animal Feeding Operations and Groundwater Protection Branch
Telephone. [phone] Fax: [phone] E-Mail: [e-mail]
rcdenr.gov
Permit Number•: W10100008
A. Applicant: Robert & Marguerite Randall
B. Facility Name:
C. APPdica_tion:
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.
❑IVISSaz of Vval�a Rascu cis
V?aYAr 7++2iI'1 RI_JInr,a1 0Eliris
Attached, you will find ail information submitted in support of the above -referenced application for your
review, comment, and/or action, Within 30 calendar days, please return a comijeted Wt yROS 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
fisted above.
RO-Wi ROS Reviewer: &_L uz Date: ?/S 2o4
COMMENTS:
NOTES
ram.
'�j1�3 �aolf+ . � �
/r�.r 7�ir�Fr-p*-w�
{Gfa� � a-•// kC
,1 e­r tom' '-+ "" po aJc enl. C
f
-71, 10.. . i �
MAR 0 8 NIS
wales Oua ty
FORM: WQROS-ARR ver. 092614 "laaal operatlarms6clian Page l of 1

WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: February 19, 2016
To: Landon Davidson- Andrew Moore
From: Shristi Shrestha, WQROS -- Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E Mail. [e-mail]
Permit Number: W10100 08
A. Applicanrt: Robert & Marguerite Randall
B. Facilit► Name:
C. Application:
Permit Type. Geothemiai Heating/CooIing Water Return Well
Project Type: Renewal
E. Comments/Other Information-
-
I would Iike 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 W(IROS Staff
R. eyort•
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-WORDS Reviewer: Date:
COMMENTS:
NOTES
FORM: WQROS-AFAR ver. 092614 Page 1 of 1

K!
Water Resources
ENVIRONMENTAL OVALITY
PAT MCCRORY
Guvemal
❑ONAL❑ R. VAN DER VAARZ
S. JAY ZIMMERMAN
Orrecun-
February 19, 2016
Robert & Marguerite Randall
226 Dogwood Drive
Mount I lolly NC 28120
RE: Acknowledgement of Application No. W10100008
Geothermal Heating/Cooling Water Return Well
Gaston County
Dear Mr, and Mrs. Randall:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on February 16, 2016. Your application
package has been assigned the number listed above, and the primary reviewer is Shristi Shrestha.
Regarding your question about permit renewal in 5 years, according to the permit the owner
is required to send in a renewal request at least 120 days prior to expiration date. However, we may
as a courtesy send you a renewal notification.
Central and Asheville Regional Office staff will perform a detailed review ❑fthe 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 919-807-6406 or email at Shristi.shrestha@ncdenr,gov.
Sincerely, OIL
Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
cc: Asheville Regional Office, WQROS
Permit File WI01t)0008
State of North Carol tsia Ellwvsimental Qualiry I Wafer Resource;
1611 Mod service Center I F AWh gli, Ncinh Carof:sla 27699-1611

e
1
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NC:AC: 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 TH I- FOLLOWING:
New Application _,�Renewal* Modification Permit Rescission Request's
*For Pennit Renewals or Rescission Request, complete Pa yes 1 and 4 (signature page) only
Print or 7} Irrfor ration and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 20-Z62— PERMIT NO.t.L 61660C g heave blank if New Application}
A. CURRENT WELL. USE AND OWNERSHIP STATUS (leave Blank if New Application)
B.
C.
1. Current Use of Well
a. Continue to use as
Supply
/ Geothermal Well / Drinking Water Supply f% Other Water
b. TenT►inate Csc: If Lbe 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 copyRYWG�O�tcnt
Record (GW-30).
❑ Yes, I wish to rescind the permit FEB 16 2018
Water quality
Z. Current Ownership Status Regional Qperaaons Section
Has therebeen a change of ownership since permit last issued? ❑ YES A NO
If yes, indicate new owner's contact information:
Name(s)
Mailing Address:
City:
State: Zap Code: County:
Day Tele No.: Emafl Address_=
STATUS OF APPLICANT (choose one)
Nan -Government: Individual Residence L' Business/Organization
Government: State Municipal County Federal
WELL OWNERS)/PERMIT APPLICANT - For individual residences, list owner(s) on properly deed. For
al', others, list name of entity and name ot'person delegated authority to sign:
Mailing Address: 2
City: ,�_Ir ._ �'; ; cr �� State { Zip Code: / C1 County:( -� 5 7
�. -
Day Tele No.: r _ 47 - 7 %' Cell No.: `�C�
EMAIL Address: ,L2 6 F i� .4. vet- Fax No_: _- - -
Geothermal Water Return Well Pcrmit Application (Revised Jan 2015) Page 1

0
E
WELL ❑PER V1 OR (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.:
LOCATION OF WELL SITE - Where the injection wells are physically located: f9-/t! lee -rSG,, 3-3�"1�d - y �-
W
(i ) Parcel Identification Number (PIN) of well site: (j `:.7)11 } E 7 County:. Y +kA
(2) Physical Address (if different than mailing address):
City: hI , ]- 1 c�i' 7, _� . 1 �� f ���� State: NC Gip Code: I !
F WELL DRILLER INFORMATION
Well Drilling Contractors Name:
i
NC Well Drilling Contractor Certification No.: •. , _;
Company Name:
r
Contact Person: EMAIL Address:
,f •
Address:
City: Apr Flip Code: - Stte:�,4 L County:
1
Office Tele No.: .r , j '- iYG Cell No.: Fax No.: �• '
G. IIV AC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: A
NC HVAC Contractor License No.:
Company Name;
Contact Person: L1 EMAIL Address:
Address: , `f �. /z+ r .
City: �- r Zip Cade: State: �l(�Cntinty: f ��� r
1 -
Office Tele No.: {'?" ri' f�. `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 r,/ 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 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 (Revisud Jan 2015) Page 2

(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 rrom 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/coohng system:
]f *F-{ISTiNG WELLS PROPOSED WELLS
*For exisling wells, please attach u coP), of the Well Constrnsction Record (Farm Gr-1 ) iil'uuailable.
(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
II 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 groats are prohlbiled for sealing water -bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(tif 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 Iand surface
K, OPERATING DATA
(1) Injection Date; Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) 1.3Y gallons per day (gpd).
(3) Injection Pressure: Average (daily) �/O_ pounds/square inch (psi).
(4) Injection Temperature: Average (January) -- ° F, Average (July) (_7 F.
L. SITE MAP— As specified in 15A NCAC 02C .0224tbt0 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 held, waste
application area, and repair area located within 250 feet of the injection wcll(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .01OTa)L2 i located within 250
feet of the proposed injection weli(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection weli(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 (Reviseel3an 2015) Pad

NOTE; In+ rrrost cases an aerial photograph of the property+ parcel showing properly lines and structures can be
obtained anti downloaded from the upplicahle county, GIS websile. Typicully, the property, can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic funks, other
wells, etc. can then he drawn in by hand. Also, a `layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (Io be signed as required below or by that person's authorized agent)
1.5A NCAC 02C .02111 e) requires that all penAt applications shall be signed as, follows:
1 _ for a corporation: by a responsible corporate officer;
2. fora partnership or sole proprictorship: by a general partner or the proprietor, respectively,
3_ for a municipality or a state, Cederal, or other public abency: by either a principal executive officer
or rariluuug publicly elected official;
4. for all others: by al] the persons s t listed on the1'ro ?,,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 ant 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."
Af,af� � 1L�eti1a��.N
Signature of Property OwncrlApplicant
'q0 h"rzt r
Print or Type Full Name
Signature,of Property 0wnerlApplicant
Print or T,► wa Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Subunit t►vo copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
1036 Mail Service Center
Raleigh., NC 27699-1636
'Telephone [phone]
Ceothcrnial Water Return Well Permit Application (Revised Jan 2015) Page 4

-- .--......b........ as - ..a+v Wj"Wn►tl1 .7tlLRIQH
P.O. Box 29535 - gaieigh, N.G. 27626-GS35
Phone [phone]
WELL. CONSTRUCTION RECORD
..+. .n rnrc Lx Vi�ILs.r V_J'f U V
OUAD, NO. !SERIAL NO. -�
Lat RD
Minor Baoln
Basin Code.
r'"LLING CONTRACTOR Fgrguson r s Snell Dril l i rig Co. I "Mums C"L __—_ fvrmr111 Lm
0 Z-19 STATE WELL CONSTRUCTION
13RILLER REGISTRATION NUMBER: 54'"�� ,��PERMIT NUMBER: L;-rc-
1, WELL LOCATION: Show sketch of the loc:adon IiAR "i 1
Neeres, Town: Renders onviIle County Hp-n , rsan _
(Road. Cornmutfty. or SubdivWon and Lot Na,j
DEPTIA DRILLING LOG
2. OWNER Bob Randall
From To Fonrnadon Desarlption
ADDRESS 226 Dorrwoad Dr-
0-84 Dirt
1Slreet of Route No.)
8 4— 4 0 0 Bedroct
Mount Holly, NC 28120
City o►Towp State Zip Code
3. DATE DRILLED 6-15.-99- USE OF WELL norm
1. TOTAL DEPTH 400
L CUTTINGS COLLECTED YES ❑ NO®
i. DOES WELL REPLACE EXISTING WELL? YES Q NOn
v
STATIC WATER LEVEL Below Top of Casing: 6 5 -- Ff.
(Ilse '+' R Above Tap of Casing)
TOP OF CASING IS 1 - FT. Above Land Surface"
L
Castng Terminated aVor below rend surleca Is Ilrtget unless a varlenea is Issued
1 --
In eceardance wllh 15A NCAC IC .0119
YIELD (gpm): 2 Q METHOD OF TEST P i a
=:
0. WATER ZONES (depth):
CHLORINATION: Type HTH Amount 68
—CD
II additional space is needed luau bacl�lforrw"
e- CASING:
Ls
WallTidakness
LOCATION SKETCH
Depth clameter or WelghtfFL Material
(Show direction and distance from at feast two Slate
From— To 84 Ft.6.25 2 76 _12I.�PMrgn8
Roads} or other map reference poinls)
From Tv Ft.
From Ton Fl.
I. GROUT:
De th Material Method
From 0 To�0 FLcement Poui2ed
From Ton FL
. SCREEN:
Depth Olameter Slot Size Material
From —To—Ft. In. —in..
From —To—Ft— In, —in.
From To Ft. in. In.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
Lace Falls Subdivision
Lot 4W59
off Wash Freeman Rd.
REMARKS:
=Fl.%! 9 Tl IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC aCr WELL
7N❑ THAT A COPY OF THIS RECORD HAS BEEN PROVIDED Tfl THE WELL OWNER

HENOERSON COUXW DEPARTMENT OF PUBLIC HEALTH
aPERATI.ONS, PERMIT
98
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PAT MCCRORY
Gomerow-
DONALD R. VAN DER VAART
Water Resources
ENVIRONMENTAL QUALITY
February 5, 2016
CERTIFIED MAIL # 7014 1200 0001 3432 8626
RETURN RECEIPT REQUESTED
Robert & Marguerite Randall
226 Dogwood Dr
Mount Holly, 28120
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. W10100008
Henderson County
Dear Mr. and Mrs. Randall:
s'ecrewry
S_ JAY ZIMMERMAN
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 pen -nit for the
geothermal injection well system located on your property at the above referenced address was
issued on February 11, 2011, and expired on January 31, 2016. Per permit conditions and
requirements per 15A NCAC 2C .0224(c), the renewal application must be Submitted at least 120
calendar days prior to expiration of the permit if you wish to continue operating the injection well
on your property. According to our records, the permit renewal application is now past due.
Please submit your renewal application (attached) as soon as possible if you wish to continue using
the well for injection.
If Your Geothermal Water Return Well_is 5dll 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://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Beim Used for Infection:
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
9fait ofNorth Carolina Envirmmeiim] Quabtv', Waicr Resources
1611 Mail service Gemar j Raleigh, North Cam kna 27699.1 tit l
9197079000

Page 2 of 2
.0240. When the well is plugged and abandoned, a well abandonment record (Font 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 Prvpertr,-:
If there has been a change of ownership of the property, an "Injection Well Permit
NamelOwnership Change" Farm must also be submitted in addition to the renewal application.
This farm 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 farms 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 a ncdenngov.
Regards.
V�
Shrish Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Asheville - Regional Office — WQROS w/o enclosures
Central Files - Permit No, W I0100008 w/o enclosures

(Domestic•Coverage
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:=-n� Robert & Marguerite
a '-.'lretir,xpr- 226 Dogwood Drive
r• :,.Po Sax f' Mount Holly r NC 28120
iy siaio, .
Shristi Shresth❑
1e �
■ Complete items 1, 2, and 3.
r Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
Robert & Marguerite Rand -ill
226 Doglvood Drive
Mount Holly, NC 28120
shristi Shrestha
B. Received by PnInted Atamej C. Gate of 1�9livery
0. Is detivery address di[farent from item i7 ❑ Yes
If YES, enter delivery address below- © No
Service Ty�
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PS Farm 3811, Apol 2015 PSN 7530-02-0Uo-9053
domestic Retum Receipt

North Carolina
Beverly Eaves Perdue
Governor
Robert and Marguerite Randall
226 Dogwood Dr.
Mount Holly. NC 28120
MCDENR
Department of Environment and Natural Resources
Division of Water 4uaii[
Colsen H. Sullms
Director
February 1 I, 2011
Re: Issuance of Injectiou Well Permit
Permit No. WI0100008
Issued to Robert and Ma guerite Randall
Henderson County
Dear Mr. and Mrs. Randall-.
Dee Freeman
Secreiary
In accordance with your application received DeQ.ember 10., 2010, 1 am forwarding Permit No. WICK 100008' fvr
the operation of a 5A7 geothermal underground injection control (U1C) well beat pump system located at 44
Whiteside Trail, Hendersonville. Henderson County- NC 29792, This permit shall be effective from the date of
issuance until January ;1, 2016, and shall be subject to the conditions and limitations stated therein.
Please contact Landon Davidson with the Asheville Regional Office at [phone] by April 1, 2011, to
make arrangetrients to inspect and collect groundwater samples from your geothermal well system.
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
Quality, If you have any questions regarding your perrnit or the Underground Injection Control Program please
call me at [phone].
Best Regards,
Michael Rogers, P.G, (NC & FL)
Envirunttrental 5peeial is t
cc: -1andun Davidson, tls'nev311e Reglona; Office
Central Office File WIOI00008
Hcriderson County Environmental Health Dept.
AQUIFER PRGrECT[ON SZC7ION
1636 sail 5ervrce Center, Raieph. North Carolina 27699•t636
Location: 2728 Capital Boulevard, Raleigh, Norm Carolina 27604
Phone: [phone] FAX [phone]. FAX 2, 919.715.6048 ti Customer Serves 1.8i 023-5746
Internet. www.nanatercualitv.org
Ar.. Equal uppar. dniry I Affirm arive :T:oi� EmfiiowYer
North Carolina
,�A771lTL��lf

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Robert and Marguerite Randall
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title ] 5A North Carolina
Administrative Code 2C .6269(e)[3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 44 Whiteside Trail. Hendersonville, Henderson County- NC 2F,792. and will be
constructed and operated in accordance with the application Decernber 10. ?U 10, and in 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 operation of an inj ection 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 3 anuary 31. 2016, and shall be .
subject to the specified conditions and limitations set forth in Parts I through VII1 hereof.
Permit issued this the 11 cr day of February 2011.
O'"n H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
WlO [: of)("v

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
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 (1 SA 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.
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 — U_ IC Staff
1636 Mail Senice Center
Raleigh, NC 27699-1636
Mrs]
Aquifer Protection Section — Asl cville Regional Office
2090 US Hiuh�vav 70
Su,annanoa 4NC 28779
[phone]
GW-ls must be submitted within 30 days of completion of well construction. Copies ofthe GW-1
form(s) shall be retained on -site and available for inspection_
PART II — OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature. volume of materials and rate of infection, 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 Permi#tee, 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.
wilA O"h 1f,,

The issuance of this permit shall not relieve the Permittee of the responsibility of Complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. 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
PART III — PERFORMANCE STANDARDS
I. The injection facility shall be effectively maintained and- operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility,
?. 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 IV — OPERATIONS AND MAINTENANCE REQ IRENIENTS
I. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
PART V - 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 VI — MONITORING AND REPORTING REQUIREMENTS
L Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Ditirision of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
?. The Permittee shall report by telephone, within 48 hours of the occurrence or frst knowledge of the
occurrence, to the Asheville Regional Office, telephone number (8?81 296-4500, 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 VII — PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART VIII — 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 ?C .0213(h)(1), Well
Construction Standards.
?. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC ?C
.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.
wI{jjilfo • 4

(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 mariner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
grins and conditions of the perrait.
(G) The Permittee shall submit a Welt Abandonment Record (Form GW-30) as specified in
1 S A NCA C 2 C.0213(h)(1) within 30 days of completion of abandomnent.
3. The written documentation required in Part Vlll (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
mi—lizs(1116„ ;

Rogers, Michael
From: Stepp, Jonathan
Sent: Tuesday, February 01, 2011 2:09 PM
TO: r7onargilAirhaal
Cc: Davidson, Landon
Subject: FW : W IOI00008
Attachments: v,' 10100008-5A7. pdt
Jonathan Stepp — lonathan.5te;ipiL ncdenr.cov
North Carolina Dept. of Environment and Natural Resources
AshevMe Regional Office
Division of Water Quality - Aquifer Protection Section
2090 U.S. 70 Highway
Swannanaa, NC 28779
Tel: [phone]
Fax: [phone]
Notice: E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and
therefore may be disclosed to third parties.
From: Stepp, Jonathan
Sent: Tuesday, February 01, 2011 2:02 PM
To: Rogers, Michael
Cc: Davidson, Landon
Subject: WI0100008
M ichael,
Please find the regional staff report attached, also note that I was not able to collect water samples from this one due
the owner's medical condition (plan to sample in April).
Thanks,
Jonathan
Jonathan Ste pp—Jonathan.Stevr- 7 ncdenr.i,!ov
North Carolina Dept. of Environment and Natural Resources
Asheville Regional Office
Division of Water Quality - Aquifer Protection Section
2090 U.S. 70 Highway
Swannanaa, NC 28778
Tel: [phone]
Fax: [phone]
Notice: E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and
therefore may be disclosed to third parties.

AQUIFER PROTECTION SECTION — GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: 02/02/201.1 Pernlittee(s):
Permit No.: WIOIO0008
To: APS Central Office County: Henderson
Central Office Reviewer: Michael Rogers Project Name: 5A7 Renewal
Regional Login No:
1. GENERAL EVFOR41A�Ita?Y
1. This application is (chcsk ali that apply): ❑ SFR Waste Irrigation System ® i.IIC Well(s)
❑ New Z Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop GroundwaterRemediation ❑ Other Injection Well§ (including in situ remediatioa)
Was a site visit conducted in order to prepare this report? E Yes or ❑ No.
a. Date of site visit: 01 /31/2011,
b. Person contacted and contact information: D&Raridall t 7f]4-8274347?
c. Site visit conducted by: Jonathan Stem
d. Inspection Report Attached: 2 Yes or [] No.
2. Is the following information entered into the-BLMS record for this application correct?
® Yes or [] No. If no, please complete the following or indicate that it is correct on the current application.
For SFR Treatment Facilities:
a Locati ui i.
h. Driving Directions:
c. USGS Quadrangle Map name and number:
d_ Latitude- Longitude: Method Used (GPS. Gooftler4, etc.};
e. Regulated Activities 1 Type of Wcstas (a.g., subdivision, food processing_ municipaI wastewater):
For UIC In*tion Sites:
If.tnultipfe sites either indicate which siwsthe infvrrrtation a��lies to. cove and haste a new section into the
document for each site: or attach additional_ tjages for each situ
a. Locatidn(s): dne% We- Henderson count
b. Driving Directions: US 64 Last to left qn St. Paula Rd. to Left on Beehive Rd, to teft_�n V1'�t_ers Rd. to
Rif t a�� OI%Ctear Creek rf't on Waste freeman Rd. to Leff on La.ural Creek Dr. to s lathRiaht on
Marshall Ride rd. to ?°a Rust on iteside Trail
c. USGS Quadrangle Map name and number:
d. Latitude: 35. 2$' 32.75" Longitude: 8Z 1W 49.53" Method Used (GPS, Googlerm, etc.); GnogIe Earth
APS-GPU Regional Staff Repart (Sept D9) Page 1 of 6 Pages

AQUIFER PROTECTION SECTION -- GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
II IVEWANDMAIMA
LODIFICATIONAPPLICATIOM this section not heeded for renewals or ►ninor
► o(j1 cutionS tikin to ne"section)
Desetiption of Waste System and Facilities
1. Please attach completed rating sheet. Facility Classification:
?. Are the new treaunent facilities adequatc For the type of waste and disposal system?
❑ Yes ❑ No ❑ NIA. Ifno, please explain:
a. Are the new site conditions (sails, topography, depth to water table, etc) consistent with when was reported by
the soil scientist and/or Professional Engineer? ❑ Yes ❑ No ❑ NIA. if no, please explain:
4. does the application (maps, plans, etc.) represent the actual site (property lines. wells, surface drainage)? ❑
Yes ❑ No ❑ NIA, If'no. please explain:
S. is the proposed residuals management plan adequate and/or acceptable to the .Division. ❑ Yes ❑ No ❑
NIA, if no. please rxplain:
U. Are the proposed application rates for new sites (bydraul is or nutrient) acceptable?
❑ Yes ❑ No ❑ .NIA. I.f no, please explain:
7. Are the new treatment facilities or any new disposal sites Imited in a l00-year floodplain:'
❑ Yes ❑ No ❑ NIA. if ves, please attach a reap showing areas of I00-bear flood plain and please explai11
and recommend any mitigative measures/special conditions in Part IV;
8. Are there any hulTer conflicts (new treatment facilities or new disposal sites)? ❑ Yes or ❑ No. Lf y'es, please
attach a snap showing conflict areas or attach any new maps you have received from the applicant to he
incorporated into the permit:
9. Is proposed and/or existutg groundwater monitoring prograni (number of wells, frequency of monitoring.
monitoring parameters, etc.) adequate? ❑ Yes ❑ No ❑ NIA. Attach map of existing monitoring well
network if applicable, Indicate the review And compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program:
10. For residuals, will seasonal or other restrictions be regiiited? ❑ Yes ❑ No ❑ NYA .if yes, attach list of sites
with restrictions (Certification 13?)
1 . RENEW L AND MORITICA TIONAP L C ONS /use rePiaua section for new or r eo i i rttlurr
s •slemr
Description of Waste System and Facilities
L Are there appropriately certified ORCs for the facilities" ❑ Yes or ❑ No.
Operator in Cl3arge: Certificatc #:
Backup- Operator in Charge: Certifi at'e #:
AP5-GPU Regional Staff Report (Sept 09) Page 2 of 6 Pages

AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
2, is the design, maintenance and operation (e.g, adequate aeration, sludge ,Nesting. sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? ❑ Yes or ❑ No
If tto, please explain:
3. Are the site conditions tsoils, topography, depth to wnter table, etc) maintained appropriately and adequateia
ass imdal-ing the waste" ❑ Yes or ❑ No_ If no, please explain:
4. Has the site changed in any way that may affect permit (drainage added..new wells inside the compliance
bounclarv, new development, ctc.)? if yes: please explain:
5. is the residuals rnemageinent plan for the facility adequate and/or acceptable to die Division?
❑ Yes or❑ No. If no, please explain
G. Are the existing, applic:atioft rates (hydraulic or nutrient] still acceptable? ❑ Yes or ❑ No. if no, please
expinin:
7. is the existing groundwater monitoring program (number of wells, fiVgUCttcy of monitoring, rnnnitating
parameters, etc.) a&XJI.Late? ❑ Yes ❑ No ❑ N/A. Attacb reap of existing manitoringe well network if
applicable. Indicate the review and comph nce Boundaries. if No, explain and recommend any flanges to the
i'
groundwater monitoring prvgranv
I'
8. Will seasonal or other restrictions be required for added sites'? ❑ Yes ❑ No ❑ N/A U'ves. atmoh List: of sites
} H•ith t'eStjetiUns (C erfl iCatiori B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)`? ❑ Yes oT ❑ No. If -yes, please "irtach a
mrip $lrowirtg conflict areas or attach any new maps you have received. from die applicant to be incorporated
into the perinic
10. 1s the description of the facilities, type and/or volume o{ waste(s) cis written in the existing perltiit correct" ❑
Yes or ❑ No. If no, please explain:
I 1 Were monitoring Hells properly constructed and located? ❑ Yes or ❑ No ❑ N/A. If no, please explain:
11 Has a review 0I'd ll set!'-rtronik3ring data been conducted ([iW, NDMR, and NDAR as applicab10? C Yes or
❑ No ❑ NIA. Please swri.marize arty findings restiItiiig from this rev)ew:
13. Check ail that apply: ❑ No corttplia-nce issues: ❑ Notice(s) of viokition within the last permit cycle; [M
Current enforcement action(s) ❑ Currently under SUC; ❑ Cutrently under JOC, ❑ Currently under
inoratorium. If any items checked, please explain and ameb any documents that may help ciaril}�
answer/comments (such as NOV. NOD eta): _
4, Have ail compliance dates/conditions to the existing pannit, (SUC. JOC, etc.) been complied with? ❑ Yes
❑ No ❑ Not Determined ❑ N/A.. It no. please explaili--
IS. Are there any issues rebated to cornplianceJenforcemew (.bat should be itsulved hefore issuirig this permit? ❑
Yes or ❑ No ❑ N/A. f f yes, plewse explain:
APS-GPU Regional Staff Report (Sept 09) Page 3 of 6 Pages

AQUIFER PROTECTION SECTION — GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
IV. EVECTION WELL PERMITAPPLICATIONS {Complete these two sections for all systems that use injection
wells, including closed -loop grmmdwater remediation effluent injection wells, in situ remediadon injection wells, and heat
pump injection wells.)
Description of We[](s) and Facilities — New, Renewal, and Modification
I. Type of injection system:
® Heatinglcooling water return flow (5A7)
❑ Closed -loop heat pump system (5QM15QW)
❑ In situ remediation (5 f)
❑ Closed -loop groundwater rernediation effluent injection (512" Non -Discharge")
❑ Other (Specify:
2. Does system use same well for water source and injection? ® Yes ❑ No
3. Are there any potential pollution sources that may affect injection? ❑ Yes ® No
What is/are the pollution sources)? What is the distance of the _iniectio w-elli sAfrom the pollution
sourpe(s)? -f3.
4. What is the minimum distance of proposed injection wells from the property boundary? ! t
5. Quality of drainage at site: ® Good ❑ Adequate ❑ Poor
6. Flooding potential of site: ® Low ❑ Moderate ❑ High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program:
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? ® Yes or ❑ No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
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)? Pending April sampling
❑ Yes ❑ No.
2. For closed -loop beat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? ❑ Yes ❑ No, Imo_ explain:
3. For renewal_or modifioatian of groundwater remediaiion permits (of amre), will
continu ad i LLm?difed injep!iQm ha au adverse impact on migt9ion of the plume or D=gggm nt of
incident? ❑ Yes ❑ No. If ves. explain:
APS-GPU regional 5%ff Report (Sept 49) Page 4 of 6 Veges

i
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
4. Drilling Contractor: Name: FMILISon Well & Pump CO.
Address: 2731 New Leicester Hiahwa,
Leicester. NC 28749
ITC Certification number: WI 2825 1 from apolication)l 2029 + gurreno
S. Complete and attach NEW Injection Facility Inspection Report, if applicable
V EVALUATlONAAD RECOMMENDATIONS
I. Provide any additional narrative regarding your review of the Application: Mr. Randall was unable to meet me
on site for the inspection, therefore I was unable to collect water samples and will need to collect them in April
after Mr. Randall has had adequate time to recover from an operation.
2. Attach new Injectian Facility Inspection Form, if applicable
3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes Z 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
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:
Mr. Randall shall Call ARO upon his return to ARO staff needs to collect water samples from
Henderson county to schedule an appointment, the system.
somctime in April 2011.
APS-CPC] Regional Staff Report (Sept D9)
Page 5 of 6 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 Preparerk):
Signature of APS regional supervisor:
Date: 02Z "P0_C 1
P7 44D ITIONAL INFOR 4TZON ND MTE M4P fflktchof site sitowireg house and waste Orieatiox
system snrm- nr driP �elr -location of PwMrs), And/or other releya W Infortlarrtinn- SfIDF� PVDI�THAkROl3�
See attached
APS-GPU Regional Staff Report (Sept 09) Page 6 of 6 Pages

R
a
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AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: Januar 62011
To: ® Landon Davidson, ARG-APS
❑ David May, WaRG-APS
❑ Art Barnhardt, FRG-APS
❑ Charlie Stehman, WiRO-APS
❑ Andrew Pitner, MRG-APS
❑ Sherri Knight, W-SRO-APS
❑ Tay Zimmerman, RRG-APS
From: Michael Rowers Groundwater Protection Unit
Telephone: 1919f 715_fi166 Fax: (919f 715-0588
EP Mail. Michael.Ro:.}ers,o ncmail.net
A. Permit Number: WI 0100008
B. Owner: Robert and Pliarguerite Randall
C. Faciltty/Operation:
❑ Proposed ® Existing ❑ Facility ❑ Operation
D. Application:
L Permit Type: ❑
Animal ❑
SFR-Surface Irrigation❑
Reuse
❑ H-R infiltration
❑
Recycle ❑
III:' Lagoon ❑ GW Remediation
(ND)
®
U1C —s.7 well
For Residuals: ❑ Land App.
❑ D&M
❑
Surface Disposal
❑ 503
❑ 503 Exempt
❑
Animal
Z Project Type: ❑
New ❑ Major -Mod. ❑ Minor Mod. ®
Renewal
❑ Renewal w1 Mod.
E. Comments/Other Information: ❑
NOTE: Since this is a renewal, please submit groundwater analytical data along with staff report with
any recommendations or comments. I will enter an Add Info into BIMS so that it will not show up late on
vour Dart.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within, please take the following actions:
® Return a Completed APSARR Form and attach laboratory analytical results, if applicablc.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RG.*
Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer:
FORM: APSARR 07/06 Page 1 of 1
Date:

HCDGNR
North Carolina Dwartment of Environment and Natural Resources
Division of Water Quality
Beverly --aves Perdue Coleen H. Sullins
Govemor Director
January 4, 2011
Robert F. Randall
Marguerite T. Randall
226 Dogwood Drive
Mt Holly, NC 28120
Subject: Acknowledgement of Application No. W10100008
Randall, Mr. & Mrs. Robert F. - SFR
Injection Keating/Cooling Water Return Well (5A7)
Henderson
Dear Mr. & Mrs. Randall:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on December 10, 2010. This application package has been assigned the number listed above and will be reviewed
by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely, and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications cats take as long as 64 - 90 days after receipt of a complete
application.
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at michaei.rogersCjTcdenr.gov. if the
reviewer is unavailable, you may leave a message, and they will respond promptly.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAK NG INQUIRIES ON THIS PROJECT.
Sincerely,
Owjk
A-e?oc�
for Debra J. Watts
Supervisor
cc: Asheville Regional Office, Aquifer Protection Section
Permit Application File W10100008
4QUIFER pP,UTECT0N S=_CTIDN
1636 Wail Service Centsr. P,a:e h. Hamm Cara+na 27E99-1536
LQMVIP. 2728 C,aprtai 3ouevar., RaieO Nom raroiina 276C+4
Phone' 919-733-3221 I FAY 1 919_715-i] FAX [phone] Customer Scrv+ce 1-577-n23-c74E
kntema3 www.rrcwatemaatly.orq
Af, E.r JA CILLI-eRlll IV . 0-00ZME h,1!,,!1 JTPIDV
Pia rthCarolina

Am-vio,-
ROADWAY!-L-�
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Cam L D.69
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRICT -AND/OR USE A WELL FOR INJECTION
WITH A GEOTHERMAL HEAT PUMP SYSTEM
TYPE 5A7 "OPEN LOOP" INJECTION V ELU S )
(check one) New Permit Application Renewal Modification
DATE: 11 — U'1 20
P ERMIT NO.: Wl O Ld 0 0 6 Y (leave blank if NEW permit application)
A, PROPER VY 0NVNER/PI RMIT APPLICANT
Name of each owner listed on property deed. For a business or government agency, state name of entity and
name of person delegated authority to sign application on behalf of the business/agency: � Y
[ 1 j Mailing Address: _ _ ' �_� G1
City: i'_' - C Zi �•_ State Zip Code: County:
-'F3nrnel [lice Tele No.: 4 -�9'� Cell No.:
Fax No. Email Address:- , � }' /`' r � � � ! �� F � e' 71�� , ,�e, X 7-"
(2) Physical Address of Well Site (it -different th abovei:
I
City: r_ art {." f State: �i L`�ip Code:.-1 rZ.J County:�fe
HomelOffice Tele No.: j ti �T, _ Cell No.: r'� � ' f 0, 9C3
Fax No. r 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 owner/permit 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: E W Addres_s_—---
Address:
City:
State: Zip Code: County:
Office Tele No.: Fax N-0. CgUNo.:
Website Address of Company, if any.
REGEIUED I DEHR) DW4
Aquifer Protection SedOn
Type 5A7 injection Well Per ni! Appikation (Rrv. August 2009) DEC 1 0 2019 Page I of 4

D. WELL DRILLER INFORMATION
Company Name:
Well Drilling Contractor's Name:
NC Contractor Certification No.: r� � Contact Person:,---," y t' F -
Company W ebsite: W W W . �` J = `' 7 Say' ` 4 L ��� " r E'� ail Address
Address:
City: % r C 7"r State: Zip Code:
j rr �� , County
Office Tele No.: r� , �'.?, i � Fax Na.: �'"`�. '� Cell No.:
E. HEAT PUMP CONTRACTOR INFORMATION (if different than Driller)
/t �
Company Name: I H 1 1' 1� e_-- Contact Person: C
Company W ebsite: 1L' W W . Email Address:
Address:
Iff '
City: A-C �� 3 — . State: A- L Zip Code: County: r_ ••- , f �r r
Office Tele No.: � �,`�0 r ,�p Fax No. Cell No.
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
�`?f' 1 rrr 1'[-r- � ���� — f 1F_ '•�' f _=fir G �/� ��r'C' .G-ri��, l: I �'tiL � f, �:s ''
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES V NO
(2) Personal consumption? YES a/ NO
H. WELL CONSTRUCTION DATA
PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(7) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
—EXISTING Wells) 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- i) if available.
(1) Well Construction Bate: Nuinber of borings: (J�
Depth of each boring (feet): YfC', I
(2) Well casing- LS the well(s) cased?
(a) YES V If yes, then provide the casing information below.
Type: Galvanized steel Black steel Plastic r/ Other (specify)
Casing thickness: diameter (inches): depth: from - t- to feet (relative to land surface)
Casing extends above ground '� ?_ inches
(b) NO
(3) Grout material surrounding well casing:
(a) Grout type: Cement Bentoiiitc* Other (specify)
*By setocting bentonite grout, a variance is hereby requested to 13A NCAC 2C .0213(dX 1)(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from to feet
Type 5 A 7 injection Well Permit Application (Rev. August 2004) Pace 2 of 4

(4) Well Screen or Open Borehoie depth (relative to land surface): from to feet
(5) N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead processes. A faucet on both lafluent (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 tine? Yes :fir 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: Formation; Rock/sediment unit:
NOTE' THE WELL DRri.LTNG OR FEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
WFORINATION 1S OTHERWISE UNAVAILABLE.
I. OPERATING DATA
J.
K-
(1)
Injection Rate
(2)
Injection Volume:
(3)
Injection Pressure:
(4)
Injection Temperarw-e:
INJECTIOTMi-RELATED EQUIPMENT
Average (daily) .gy _gallons per minute (gpm).�5^y,�
Average (daily) ,�3fY gallons per day (gpd).
Average (daily) ' O pounds/square inch (psi). a l,01,J19h&P 'GrdPro�'=
Average (January) . s ° F, Average (July) (0 ! ° F_
Attach a schematic diagram or cross-section of the well construction that shows xhe total depth, length of casing,
extent of grout. stickup. location of influent/effluent saimpling ports, etc. If this is a modification, show the
engineering layout or proposed modification of the injection equipment and exterior pipmgltubing associated with
the injection operation. The manufacturer's brochure may provide supplementary information if needed.
LOCATION OF WELL(S)
(1) Attach a site map (cart be drawn) showing; houses and other structures, property lines, surface water bodies,
potential sources of groundwater contaminatiou. and the orientation of and distances between the proposed
injection weli(s) and any other existing well(s) or waste disposal facilities such as septic ranks 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 Yhuwing property lines and structures can be
obtained and downloaded from the applicable coam), GI.S website. Typically, the property can be searched by owner
mime or address. The location of the ",ells in relation to property boundaries, hauspr, septic tanks', other wells, etc.
can then be drawn in by hand Also, o 'layer' can be selected showing topographic co►rrours or elevation data.
Type SA7 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 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 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 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 iintnediately responsible for
obtaining said information, f 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."
r
Signa'lure of Property Owner Applicant f
Print or Type Full Nance
pA[fh P Ottdion
Signature of Property Owner/Applicant
Print or T4e Full Name
Signature of Authorized Agent, if any
Print or Type Fall Name
Submit TWO signed copies of the completed application package and all attachments to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Type 5A7 Injection Well Permit Application (Rev, August 2009) Page 4 of 4

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: ' T , 1 r, (; C` 0 Z
Permittee Name:. l± �'� % �':; �� P r Fr P�
Address:
Please check the selection which most closely describes the current status of your injection well system:
1) J( Well(s) still used for injection activities, or may be in the future.
2) C Well(s) not used for injection but is/are used for water supply or other purposes.
3) ❑ Injection discontinued and: a) ❑ Weil(s) temporarily abandoned
b) ❑ W ell(s) permanently abandoned
c) ❑ Wel(s) not abandoned
4) ❑ Injection well(s) never constructed
Curren_ t Use of Well
If you checked (2), describe the well use [potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description ofhow the well
was seated and the t)pc vl'naalerial used to.f11 the well Ifpermanendy ahandonedj:
Permit Rescission:
If you checked (2). (3), or (4) and will not use a well for injection on this site in the future, you should request rescission of the
permit. Do you wish to rescind the permit?
❑ Yes ❑ No
Certification:
" l hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted
in this document, and that to the hest of my knowledge the information is true, accurate, and complete."
Signature Date
RECEivED I aENR 1 p WQ
Aqueer P"0100 Seciian
Etc
Revised 5105 GWlUIC-58

HAN.09RSgN.CgUMTV DEPORTMENT OF PUBLIC HEALTH
OPERaT1,01YS, P.IF-
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VALID ONLY FOR USE A.S- E$CRIBED ABOVE
PJ. W.ING. NOT TO SCALE
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System Type j0JA-L
Min System Review Frequency
issued By
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RECEIVED 1 DENR J DWQ .
Aquifer Protection Section
DEC 10 2010

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AqUifer ProtpCtion Section
f)Ff_ 10 ufo

A �
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MCD84R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor C)Irector
November 17, 2010
Robert Randall
226 Dogwood Drive
Mount Holly, NC 28120
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WI0100008
Henderson County
Dear Mr, Randall:
Gee Freeman
SecrEtary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Quality (DWQ) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for
the underground injection well system, which was issued to you on April 11, 2006, and expires
on April 30, 2011, has not been renewed. If you wish to keep this permit and operate the
injection well system, the permit must he renewed and issued in your name.
If Your Injection Well is CurrentIN Inactive:
If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed under NCAC Title 15A, Subchapter
2C, Section .0214. When each well is plugged and abandoned, the well abandonment record
(Form GW-30) must be submitted to our office to certify that the abandonment was properly
conducted.
If there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form must also be submitted. The GW-30 and Name/Ownership
Change forms can be found at hti,-:llaortal.ncdenr.orJweb/wtilatisl- +nrolrenortin ,-forms.
If Your Infection Well is CurrentlN Active:
If the injection well system is still active and you wish to renew your permit, the renewal
application must be submitted within 120 calendar days of the expiration of your permit_
According to our records, you must submit your permit renewal by December 31. 2010.
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raleigh, Nonh Carolina 27's99-163E
Lacabor,:2728 Capital Boulevard. Raieigti, Nortn Carolina 27604 Oriy t. Phone. [phone] 'k FAY f. 919415-CH8. FAX 2. 919L715•50481 Custorner Service; 1-67r-523-o748 N�iLll �aT��II7
Internet www.ncwale u li .arc Ar, RLia OT)Dom nrtr'. Afnrmaiiue"c.n Fmntwe- Naturally
"�
> aturall y

In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit one of the following
enclosed forms:
A. Application .for Permit (renewal) to Construct andlor Use a Well(s) for Injection with
Geothermal Heat Purnp System for 7_vpe 5A7 Well(s) if the injection well system on your
property is still active.
01
B. Status of Injection Well System if the injection well system is inactive or has been
temporarily or permanently abandoned.
Please submit the appropriate forms to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-163 6
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
httl, :!lli2 o . en r. state. n e. u s lap s1;1+u1 fo rms.h tm .
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 erica.smith amncdenr.gov.
Sincerely,
i
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Asheville Regional Office - APS w/o enclosures
APS Central Files - Permit No. Wlal00008 m-/ o enclosures

April 12, 2006
Marguerite and Robert Randall
226 Dogwood Drip e
Mount Holly, NC 2-Sl20
Ref: Injection Permit Issvrince
Permit # W 10100008
Dear Mr. and Mrs. Randall:
MichacI F. Casley. Governor
William G. Ross Jr., Scc%nary
North Carolina Departmerit of Environment and Naiul-�l Re SOUWcj
Alai) W. Klimek, P.F.. Dileci-)r
division of Warer Quality
In accordance with your application submitted January 6, 2006, the Division of Water Quality's
Underground Injection Control (UIC} Program is forwarding Pen -nit No. WI0100008 for the
operation of a geothermal heat pump injection system at 44 Whiteside Trail in Hendersonville,
North Carolina. "Phis permit shall be effective from the date of issuance until April 30, 2011 and
shall be subject to the conditions and limitations stated therein. Please read your permit carefully
to inake Sure you thorottahly tuiderstand its requirements your and responsibilities.
Please contact me al [phone] if you have any questions regarding YOU permit, the UIC
Program, or injection rules and re;uintions. y
Best regards,
Thomas S l usser
Hydro geological Technician 11
UIC Program
k.I1CIOSIit'L'
cc: Landan Davidson, Asheville Regional Office
CO-t►IC Files
AtloR6 11rlHCCtkNI Sccl1Un 11130 &I:rsl SCI"Vl['C L'mwt Ra Icigh, NC 2701)-I(66
Internil: httlla .'%%tcZUFQu�lin nr, 27]k(-s13ltaI IWUIV'V11f-d Raleigh, NC 27604
An Equal Opponunit Iftrma6e Actiori Employar- 50% Recycledl10% Post Consurner Paper
o Nlthi'nrnlina
.1ntrrrrt!!Y
Telephon;. [phone]
Ira" 1: (911)) 715-05tSH
Fax 2: (919) 715.600
Coswinc'r servwe: (377) 623-674,4

DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
April 3, 2006
MEMORANDUM
r �" a
TO: Debra Watts 1
THROUGH: Evaaz Kane
FROM: Thomas Slusser
RE: Issuance of Injection Permit WIO 100008
I recommend that injection pemtxt WI0100009 be issued to Marguerite and Robert Randall for the
injection of heat pump effluent. Ted Minnick of the Asheville Regional Office inspected and
sampled the injection well system on February 28, 2006. Laboratory test results do not indicate
any parameters exceed the 2L groundwater quality standards. Mr. Minnick and Landon Davidson
of the Asheville Regional Office recommend issuance of this permit without reservation. Please
let me know if you have any questions or concerns about issuing this permit.

f►C� '�ii iil�ll��7�►�1
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
' : r< ��II:�I�:ial!]Z�1'.7�1�[!],[!]-�:1��ll;�l►��11�1�1
In accordance with the Provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other
applicable laws, Risles, and Regulations
PERMISSION IS HEREBY GRANTED TO
MARGUERITE AND ROBERT RANDALL
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title t 5A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat purnp effluent.
This injection well is located at 44 Whiteside Trail, Hendersonville, Henderson County, North
Carolina, and will be operated in accordance with the application submitted January b, 2006, and in
confon-nity 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 pen -nit is for Operation only and does not waive any provisions of the Water Use Act or any
other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be in
compliance with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and any other
Laws, RLr1es, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issrranee Until April 30, 201 1 and
shall be subject to the specified conditions and limitations set forth in Pans 1 throu;ll IX hereof,
Permit issued this the _i duty of � � , 2006.
�1 Alan W. Klimek, Director
Division of Watcr Quality
By Authority of the Environmental Management Commission.
Permit No. W 10 100008 PAGE 1 OF 3
GWIUIC-5 per. 7/05

PART I -1VELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee roust comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (l5A NCAC 2C
.0200). Any noncompliance with conditions of this peen-iit 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.
This pemiit shall become voidable unless the facility is constructed in accordance with the
conditions of this pemiit, the approved plaits 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 infection well sllall be secured to reasonably insure against unauthorized access and use.
Each well shall be pernlanctltly labeled tivith a warning tllat it is for injections purposes and the
entrance to each well must be secured with a locking cap.
G. Each injection well shall be afforded reasonable protection against damage daring construction
and use.
7. Each injection well shall have permanently affixed an identification plate.
8. A completed Well Construction Record (Form G W - I ) most be submitted for each injection
well to, DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1636 Mail
Service Center, Raleigh, NC 27699-1636, within 34 days of completion of well construction.
PART II - OPERATION AND USE GENERAL CONDITIONS
1, This pemlit 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 Pemiittee, a formal perrnit amendment request
ill ust be submitted to tllc Director, including any supporting materials as maybe appropriate, at
least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Pemiittec of the responsibility of eornpiyilig
with any and all statutes, rules, regtilatiolts, 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.
Permit No, WI4100008 PAGE 7 OF 5
GW"C-5 ver_ 7105

PART III - PERFORMANCE STANDARDS
The injeciion facility shall be effectively maintained and operated at all times so that there is
no contamination of groundwater which will redder it tmsatisfactory for rionnal 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
Per-mittee shall tale immediate corrective actions including those actions that maybe rcquired
by the Division of Water Quality such as the repair, modification, or abandonment of the
injection facility.
?. The Perm ittec shall he required to comply with the terns and conditions ofthis permit even if
compliance requires a redaction or elimination of the permitted activity.
3. The issuance of this }permit shall not relieve the Perlmittee oftbe responsibility for damages to
stirface or groundwater resulting from the operation of this facility.
FARTIV - OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
?. The Perniittee must notify [lie 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.
J. At ]cast forty-el.lit (48) hotn-S Prinr to the initiation of the operation of the: facility for
injection, the Pesrillittee must noti fy by telephone the Agtrifer Protection Section -Underground
Injection Control (UIC ), Central Dff-ice staff, telephone number(919) 715-6166. Notification
is required so that ❑ivision staff can inspect or otherwise review the injection facility and
determine if it is in compliance with penult conditions.
PART V - INSPECTIONS
1. Any dilly atithorizcd officer, employee, or representative ofthe 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 deterinining
compliance with this permit, may inspect or copy any records that must be maintained under
the terms and conditions of this permit, and nay obtain samples of groundwater, surface water,
or iitjcction fluids.
1 Department representatives shall have reasonable access for purposes of Inspection,
observation, and sampltn- associated with irljcctlon 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.
Permit No. W 10100008 PAGE 3 OF 5
GWIUIC-5 ver. 7105

PART VI -]MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by
the Division of Water Quality to insure surface and ground water protection, will be
established and an acceptable sampling reporting schedule shall be followed,
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge
of the occurrence, to the Asheville regional Dffice, telephone number [phone], any of
the following:
(A) Any occurrence at the injection facility which results in any unusual operating
circumstances;
(B) Any failure due to known or unknown reasons, that residers the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
3. Where the Permittee becomes aware of all omission of any rele�•aizt Facts in a permit
application, or ofany incorrect information submitted in said application or in any report to the
Director, the relevant and correct facts or Information shall be promptly suhtnitted to the
Director by the Permittee.
4. In the event that the permitted facility Fails to perform satisfactorily, the Penmittee shall take
such immediate action as may be required by the Director
PART VII - PERMITRENEWAL
The Permittee shalt, at least 120 days prior to the expiration of this permit, request an
extension.
PART Vlll - CHANGE OF WELL STATUS
I. The Permittee shall provide written noti lication within 15 days of ally change of status of all
injection well. Such a change would Include the discontinuation ofuse of well for in'ection.
If a Nvell is taken cotzipletely out of service temporarily, tiie 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)(1), Well Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose,
the Permittee shall abandon that injection well in accordance with the procedures specs fled 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
Permit No. WI0100008 PAGE 4 OF 5
G WIU IC-5 vc r. 7105

contribute to, the contamination ofan underground source oFdrin1dng water.
. (13) The entire depth oFeach well shall be sounded before it is scaled to insure:
freedom from obstructions that may interfere with sealing operations,
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
detennines 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 oFgraveI-packed wells iji which the casing and screens Have not
been removed, the casing shall be perforated opposite the gravel pack, at
intervals not exceeding 10 Feel, and grout injected throul-li the perforatioils
.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each %velI shall be ahandoned in such a manncr that
will prevent the movement of Fluids into or between Lill dergror1nd sources of
drinking wetter and in accordance with the terms and conditions of the permit.
(G) Tlie Permittee shall subunit a WcII Abandonment Record (Form GW-30) as
specified in 15A NCAC 2C .0213(h)(1) within 30 days of completion of
abandonment.
3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
Aquifer• Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART IBC - OPERATION AND USE SPECIAL CONDITIONS
Norte
Perini No. W1010OOOS PAGE 5 OF 5
GW/UIC-5 ver. 7/05

' NC Division of Waterlr',jality Laboratory Section Resul+c
Loc. Descr.: ROB ERT RAN DALL CIC Wl0100008
Location ID: 01HEV ANDALI 02280601
County: HENDERSON Sample ID:
River Basin
Report To AROAP
Region:
ARO
Collector;
T MINNIGK
Sample Matrix
d W .'uWAT>=�?
Lac, Type:
WATER SUPPLY
Sample Depth
Collect Date:
02J2612006
Collect Time::
12:30
RECEIVED
I
MAR 8 24flh
Asneville RegionalOffice
.a.tirli�
PO Number P
Visitl D
Date Recaived;
Time Received:
Labwo*s LoginlD
Date Reported'
ABO1731
6GO324
0310212006
08:50
JWA
0312212006
nalyte Name
POL
Result
Clualtfler
Units
Approved By
LAB
Sample temperature at receipt by tab
0.4
°C
JGOODWiN
MET
�I by ICE'
50
50
U
ugrL
RBYRD
:.a by 1CP
010
7A
mg1L
RBYRD
Cr by ICPMS
25
25
U
ug/L
RBYRD
Cu by ICPMS
2.0
33
ug1L
RBYRD
re by ICP
50
50
U
ugrL
RBYRD
K by iCP
0.10
1.1
mg/L
RBYRD
Mg by 1CP
0,10
0.66
mg/L
RBYRD
4n by ICPMS
10
10
U
ug/L
RBYRD
Na by ICP
0.10
6.6
mg/L
RBYRD
Ni by ICPMS
10
10
U
uglL
RBYRD
r'b by ICPMS
10
10
U
uglL
RBYRD
'n by ICP
1 D
21
ug[L
RBYRD
NUT
Niterate as N in liquid
0.01
0.04
mg/L as N
CGREEN
Nitrite as N in liquid
0.01
0.01
U,01
mg1L as N
CGREEN
NO2+NO3 as N in liquid
0.02
0.04
mg1L as N
CGREEN
'NET
Chloride in liquid
5
1
Li
mg1L
CGREEN
Total Dissolved Solids in liquid
10
76
mglL
CGREEN
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 2759E-1623 {919j 733-3908
Pang 1 of 'I

COUNTY-
HENDERSON
(QUA D NO•
REPORT TO :
AW0
Regiono1O11iec
CQI1-EC7GR(S)
7- ImmNICK
DATC:
212x12006
PURPOSE:
COMPL AFNCF
Owner -
Location or S i [c:
Descroian of mopling
Sampling Mdho&
Remarks:
LABORATORY ANALYSTS
�_
`
13OD 3l0 mg(L
COLS 11i h 340 m
A
COD Low 335 m
ColifaawM_F_Feca111696 1100m1
Colifmm: MF Tom131504 1100ml
_
ITdc _ mgR
I
Turbidity NTL1
Residue-, Sua mood 530 m
Tonal Suspended solids m_&A
H units
Alkalinity en pH d 5 m
Alkalini to pli 8.3 T m�
, C w wnaic mgtL
Bicarbonate m L
Carbon dioxide In
X ride Ill m/L
xmi+rn: Ilex 1032 u
Cokm True 90 c-u-
Cyanidc 720 mgA.
COMMENTS
DIVISION OF WATER QUALITY
Chews Iry LaburaCory Reporl 1 Ground Waver Qualby
SAMPLE PRIORITY
EjROUTTNF []EMFRGFNCY
❑ CHAIN OF CUSTODY
!NF
Ej SAMPLE TYPE
ROBERT RA N DA L L 111C W10100008
X
Piss. Solids 10300
76
mr_/L
Fluonde 951
m L
l iac d aess: lord i0i]
mglL
I lardncss' [nOn-carp] 902
m
Pher+oIs 32730
u
Ispecific Cond- 95
umhoslcm2
Suilaw
mgrt.
SuIrMe 745
M6A5
m
M.
_
OiT and Grease
m L-
Silica
Boron
mg/L
f Prnmaldchydc
-8/L
NH3 as N 614
InWL
TKN as N 625
FFL99
X
M02 +NO3 es n 630
D-04
WIWL
P: ToW its P 665
PO4
my
MO -
Nitrate (NO3 as N) 620
0.04
mglL
X
Nitrite (NO; as N)615
4.O1U•01
mg/L
Ag-Sliver 46566
u,_IL
X
Al-Alutninvm-1057
50LJ u
As -Arsenic 465 51
B:)-Barium 46558
uo-
ug)L
X
Ca -Calcium a6552
7A m t
Cd-Cadmium 46559
u L
X
Cr-Chromium 46560
25U ue1L
X
Cu- Coppas 1042
33 OVL
X
Fe- Iron 1045
5OU u L
Hg-1ulemury 7I900
_ uWL
X
K-Potassium46555
1-1 mg1L
X
Mq-Ma ncsium927
0.$6_mIL,
X
Mn-Mari anezu 1055
IOU u L
X
Na- Sodium 929
6-6 m0L
X
X
Ni-Nicicl
SOU u
Ph -Lead 46544
10U u L
Se-Selenlum
ag/L
X
7n-Zinc 46367
_
21 qJL
Lab Number :
AH01731
flare Received
MV2046
Time litccived :
8:50 AM
Received By
DSS
`J`
I
f cicascd Hy
jsw
paleirponcd
3l2212006
Urepnuchiorint Pes[icides
Organ hasphnrus_Peslicides
Nism cn Pes[icirles
Acid Herbicides
Semivnlaliles
TPH•Die3el Paige
Vdl6iiLC❑ anics(VpAhmtic)
TPH-(-,mnline Range
TPIi-BTEX Gasoline Range
f�A
C
CD
inP7
^-e
Go
a�
_
m 0
r1.a
m
IQ 0
con
i7
CD
ABnt73r

GROUNDWATER FIELD/LAB FORM
Location code__ Cl' =
County
Quad Na Serial No.
Lat. j S"G 16 r S--( "' Long. L2-' 1d' 41,4
..
North Caraiina
Department of Environment and Natural Resources
o c W-Z 01©Ck`Jtj DIVISION OF WATER QUALITY -GROUNDWATER SECTION
-SA MPLETYPE SAMPLE PRIORITY '- 7 N 1 11 A
Water 51 Routine _ Lab Numbert��a�
❑ Soil ❑ Emergency Date Revel- d T,,,�.- �4
❑ otherRec`d $y:iFrom:Bu Cou ' Hand Del.,
❑ Chain of Custody Other:
Report Tom Data try By. Ck',, ,
WSRO, Kinston FO, Fed. Trust, Central Off., Other, date Reported:
Shipped by: Bus curie Hand i?el., Other- _ Purpose:
Collector{s}:y��.v.rC R= ❑ate�C-Cry Time vI.�'J Baseline, Complaint, arnpiianc LUST, Pesticide Study, Federal Trust, Other:
ANALYSES Owner 4?; r✓+n(il tG��9°"Bfr'9cYi3?7-+ I e 7+rs1477-$O
pH 4aa 7. Spec. Cond-94 at 25°C Location or Site^
Temp.lo-.. 1 L °C Odor Description of sampling. point
F�i-Appearance_ Sampling Method _�_t 7►LI `� Sample Interval
Field Analysis By:_ Remarks_
LABORATORY ANALYSES (Pumping time. air temp., eic)
T sac 310 - � -9l- Dtss. Sotids 70300 M04-
COO High 340 _ mgA- ��� Fluoride 951 _ — _ mg1L
COU !ow 33 5 mgrL Hardness'Total Sao _mg1L
Colirorm: MF Fecal 31616 MDamt j Hardness (non -cart) 902 mg1L
Coliforrn: MF Totaf 31504 1109mf Phenols 32730--f
Ug1I
TCC 580 mg1L Spectfe Cond. 95 uMhoslcm
Turbidity 76 NTIJ L Sulfate 945 mgrL
Residue, Suspended 530 mg1L Sulfide 745 mglL
i
LT
f�_ Oil and cream MOILpH 403 units
Alkalinity to pH 4.5 410 mg1L
Alkalinity to PH 8.3 415 mglL
Carbonate 445 mg/L NHa as N 610 mgiL
Bicarbonate 440 rngnL TKN as N 625 mgA-
Carbon diowde 405 mg1L NO2 + NOa as N 030 - mgrL
Chloride 940^ mp1L P: Total as P 685 - - mg1L--
Chromium: Hex 1032 uglL NRreta (NC3as N) 620 _mg/L
Color: True 80 CU , MUM (NO, as N) 615 mg1L
Cyanide 720 mgAL T -
Lab Comments
y'ar •+t�A+�r'1�ss. .�� •7 c.'a ' � 4. 1Lrna�1
GVV-54 REV, 7103 For ❑lssolved Anatysis-submiI filtered sample and write'DIS' in block
Ag-Silver 46585 uq&
Al -Aluminum 46557 — _uglt.
As -Arsenic 46551 ur:1L
Ba-Sarfum 46558 ug1t._
Ca-Caldum 45552
Cd-Cadmium 46559
,i
X Cr-Chromium 46558
X Cu-Copper46562 ug/L
Fe -iron 46663 w/L
Hg-Mercury 71900 gJL
v' K-Potassium 46555 moll
} - Mg -Magnesium 46554 L
m IL
1i11n Manganese 46565 u 1L
NoSodiurn 46558 mUAL
N-tdicket tx"IL
Pb-Lead 45564 ug/L
Se -Selenium I '
Zn-Zinc 48567
!
Organechlorine Pe:
DrganoP-h�horus
Niirog_en Pesticides
Acid Herbicides
PCBs
Pesticides
sernivoldtfle Qr anics
TPH-Giese! Range ` f
Volatile Or
pnics NOA
TPH-Gasoline Range
TPH-BTEX Gawfiine R;
i
LAB 115E ONLY
Temperature on arrival (°C):
RECEIVED
MAR 23 79ro
Asheville Regional Office
A, Uifer 0-Ctection

NC Division of Water r• tality Laboratory Section ResuIf,-.
Loc. Descr.:
ROBERT RAN DALL UIC Wf0100008
Location ID:
01HERANDALL02280602
County.
HENDERSON
River Basin
Report To AROAP
Region:
WARD
Collector:
T MINNICK
Sample Matnx:
GROUND'rYA T ER
Loc. Type-
EFFLUENT
Sample Depth
Corlett Date:
0212812OD6
Collect Time::
12:45
RECEIVED
MAID 2 8 2006 �
Asheville Regional Office
L. - - guifer Protection
Sample ID:
PO Number #
Usitio
Date Received:
Time Received;
Labworks LoginiD
Date Reporled:
AUD1730
6G0323
D310212006
08:50
JWA
03/22/2006
nalyte Name PQL Result Qua liner Units Appro►red By
L.AI3
Sample temperature at receipt by lab
0.4
°C
JGOODWIN
MET
At by ICP
50
50
U
ug1L
RBYRD
Ca by iCP
0.10
7.4
mglL
RBYRD
:r by ICPMS
25
25
U
ug1L
RBYRD
tsu by ICPMS
2.0
36
uglL
RBYRD
Fe by ICP
50
50
U
ug1L
RBYRD
K by ICP
0.10
1.1
mg1L
RBYRD
Nig by ICP
0.10
0.67
mg/L
RBYRD
Mn by lCPMS
10
10
U
ug1
RBYRD
No by ICP
0.10
6.6
mg1L
RBYRD
'Ji by ICPMS
-10
10
U
ug1L
RBYRD
Ph by ICPMS
10
10
U
uglL
RBYRD
=n by ICP
10
16
ug1L
RBYRD
NUT
Nitrate as N in liquid
0.01
0.04
mg/L as N
CGREEN
J�trite as N in liquid
0.01
0.01
U,Q1
mg/L as N
CGREEN
NO2+NO3 as N in liquid
0.02
0.04
mg1L as N
CGREEN
WET
Chloride in liquid
5
1
U,J3
mg1L
CGREEN
}otal Dissolved Solids in liquid
10
74
mg1L
CGREEN
Laboratory Section>> 1923 Mail Service Center, Raleigh, NC 27699-1623 j919j 733-39DB
Pane 1 of 1

DIVISION OF WATER QUALITY
Chcmislry Labotnrory Report 1 Gmund Water Quality
COUNTY HRNDERSON SAMPLE PRIORITY
QUAD NO_ IKOUTINFEMERGENCY
U-PORT TO :
AM)
T Regional Ot7Cr � CHAIN OF CUSTODY
COLLECTOR(S)
: T MINNICK
EFF
DATE:
2129r2006
0 SAMPLE TYPE
TIME:
PURPOSE:
COMPL.AfNcrR
Owner: R[IIIERT R i,N0kL�L UIC WL0IMOOR
—
Locad on or S i le:
DCSCiIpI 01P bf =nlPf ng POW
Sampliog Method-.
Itcmarks:
LABORATORY ANALYSIS
HOD 310 mglL
COD High 340 _ inWL
COD Low 335 mg/L
Coiifom: MF Fccnl 31616 I100ml
Califoml: MF Taml31M4 1100rrtl
--
70C rn I
Turbldiry N7I1
Residue.. SusLcmJerl53A mWf
Total Suspended solids m
pll units
Ik�linity w pH4-5 m IL
jiA�
A lkal intly to p H 8.3 mjVL
Carbonate m L
Ricarborlam m
Carbon dioxide mwL
k •.ride 1il,J3 m !.
-•�hrom ium: Hex 1032 u (1.
Color: True $11 c 1.
Cyanide73OJ_ mglL
-
COMMENTS:
Diss. Solids 70301)
74
mWL
X
X
X
X
X
X
7L
X
X
X
A -Silver 46566
Fluoride 951 mg/L
AI -Aluminum 46557
Hardness E)MI900 M&IL
As-Atuflic 46551
Hardness: {non -carp) 902 Ln
Ba-Bariam 46558
Phenols 32730 tiVL
Ca -Calcium M552
Cd.Cadmium 45559
Cr-Cltromiuni 46550
Specific Cand.95 umhaskm2
Sulfale
_m
Sulfide 745 mglL
Co- Copper 1042
MBAS m rL
Oil and Grease mglL
Silica T11
Fe- iron 1045
li - Mercury 71900
K-Parassium46555
Scan
Mg� Magnuwm 977
Fommldch de m:
Mn-Man ancsc 1055
NH3 w N 610 mg,L
Na- Sodium 029
TKN as y 025 rnWL
Ni-Nir):cl
Tl02 +NO3 as n 630
0-04
mgVL
X
Ph -Lead 46564
A: Total as P 665
m L
X�
Sc-Selmum_
7�r-Zinc 46567
PO4 lnzq.
Nilmte (NO, as N) 620
004
malt.
Nitrite (NUS asN) 615
0.0IU,01
mpjL
tt�
5olf ugll..
7-4 n
It
25U u
36 u
SOU u
1�I nn
0,67 n
IOU u
0.6 n
IOU u
IOU u
L.
16 L
Iah!Jumbcr A001730
pain Received
3l21I006
Time Received
8'50 AM
R`e%ci By
r DS
`e�'-ved
Released By—
]SW
Date reported!
312212006
inc Pesticides
N
aCD
_}
�
0
CD
phoms Pesticides
Otl4crltkides
lcide5
Semivolaliles
TPH-Diesel Ranee
VolatiicOrganics (VOA bottle)
TPH-Gmn1inc Ran a
TPH•BTEX Gasoline Range
m
rn
m
m
a
,vennae

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural G0= 6 j occr DIViSiON OF WATER QUALITY-GROUNOWATER SECTION
Location code C.°�. SAMPLE TYPE SAMPLE PRIORITY i
County—rill �%tii T Water Routine Lab Number )323
4 El Soil ❑ Emergency� �
Quad No Serial No. ��r� Date Recei ed 3-2--t 6 Time < _
Lat. 5_5'° 26'32. G'' Long e us ` 4114 �` _ ❑ Other Rec'd By: U� From:Bus ouri Hand Del.,
ILEl Chairs of Custody Other
Report Ta FRO, MRO, RRO, WaRO, VITRO, -- - Data Entry By: Ck:
WSRO, Kinston FO, Fed. Trust, Central Off„ Other. 3 Date Reported:
Shipped by., Bus ourie�rHand Del., Other: __ Pu ose: �` ,_ lr.,�,.+
Coilector(s): , ,�,.�,_�iC_ Date�,-",4' Time i?4-� Baseline, Com Laint m Iianc�,�LUST, Pesticide Study, Federal Trust, Other: `- �
FIELD ANALYSES Owner �- +'�.- ;�j(j-G icv�taonmy 7 � r� `— 4-34zze ('7Wd7'--C)69C+
pH 400 7+42-- Spec. Cond.94 at 25°C Location or Siie——
Temp.sq t#LL—°C Odor Description of sampling p�Yinf
Appearance Sampling Method r���1E rJ Sample interval
Field Analysis By: Remarks elimD, ial'�a'
LABORATORY ANALYSES (Pumping time, air amp., etc.)
11300310
-
mg&
iI COD High 340 mg/
I COD Low 335 mglL
i Coliform: MF Fecal 31618 ti00mi
I Coliforrn: MF Total 31504 110Dve
7nC 580
mglL
Turbidity 75 - _
Residue, Suspended 530
NTU
mglL
f pH 403
Alkalinity to pH 4.5 410
Alkalinity to pH 8.3 415
Carbonate 445
Bicarbonate 440
Carton dioxide 405
Chloride 940 --'
h ium: Hex i032
Color: True 80
Cyanide 720
Lab Comments
units
mglL
rnglL
mg1L
MOIL
MqAMgm-
uWL
-
Cu
mg1L J
Dlss. Solids 70300 mg/L
Fluoride 951 m$1L
Hardness: Tota1900 M91L
kardness (non-oarb) 902 MOIL
I
Phenols 32T30 ugll
Speclfle Cond. 95 uMhoslrm
Sulfate 945 mg1L
Sulfide 746 mglL
Oil and Grease mglL
NHs as N 010 mg1L
TKN as N 625 mg1L
NO2+ NO,, as N 630 mg1L
I
P: Total as P 665 MOIL
Nitrate (11%as N) 620 M4L
FNitrite
(NO2 as N) 516 mg1L
Cc! } r 4. t NY i- +tic
GW-54 REV. 7103 For Dissolved Analysis -submit filtered sample and write 'DIS' in block.
Ag Silver 46566 _ ugll-
AI-Aluminum 48557 ! IL
As -Arsenic 46551 u IL
Ba-Batium 46558 !L
Ca -Calcium 48652
Cd-Cadmium 46559 L
Cr-Chromium 46M w1L
(_
7(
Cu-Copper 46562 u IL
�Fe-hen 46563 - uq&
i�'
#-Hg-Mercury 71900 tx L
K-POUSSI im 4s555 n1nIL
}}} Mgadagneslum 46554 mn[ IL
}4
_
. i�4�ganese 46565 IL
h
Na-Sodium 46558 m IL
Ni-Nickel unIL
Pb-Lead 46564 _ IL
Se Sefeniurtt IL
'rL
Zn-71nC465S7 uglL
Organcehlorine Pesticides
Chganoprmphorus Pesticides
Nitro en Pesticides _
Acid Herbicides
PCSs�
Sem�atile Organics
TPH-Diesel Ranee
Volatile Organics NOA bode)
TPH-Gasollne Range
TPH-BTEX Gasoline Rar!Ue
LAB USE ONLY
Temperature an an-ivai (OC): _
RECEIVED
OR 096
{
Asheville Regina} Office
A uifer Protection

03-13-'06 09:04 FROM-NCDENB ASHEVILLE RO
8282997043 T-745 P01/03 U-373
\NATER
Q
Ma ��ri i
�r
TELEPHONE EMBER
(828) 296-43D0
(828) 2964681 Direct
Mtehaal F. Ea Ley, Governor
William Cs. Rosa Ir., Semwuy
North Camiina Depgrrmont of Envirmmont aW Natural Resources
AQUIFER PROTECTION SECTION
FACSEMLE
Juan W. YJiraok P.E. Iluieawr
nivi tt of Water Qnality
FAX BER
[phone]
TO:
—7_A4ws
ss 0
G ,I Aut. tk—
FAX No:
oS-yf
FROM:
ffK. CMD)MMCK.
M. DWO,A
E T C-nO QN
DATE: 6 &Z-4
N UMIB )[t OF PAGES, YNd COVER PAGE:
COMMENTS:
1 h(drA1,4'.S - A& 14r3 .etc `s {q►- U_Z C curd / qWo f
ele-SF/snI s C -k
North Carolina DiiWsion of Water quelny — AshoMa kc&nsl OMm 2000 U.S. Ntghwy 70 Swunaeooa, N.C. 28779 Phone [phone]DO
FAX (829) 2W7043
Customer 5arvics 4-877-023.6748
Intarnst h2memstate.mus
An Egzwf Action Emp - 5A Rwyd 00% Poe! Omm mer Paper

GROUNDWATER FIELDMB FORM
t, TC WX 6 f d oao 97
North Carolina
Depaftwwt of EnvircmMent and Notrad Resaurcm
M
[l-
M
1
a
M
09
04
M
w
In
N
F
A
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cr.
M.
N
cc
Ki
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09
CO
t5
I
C1'1
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C,
m
Locadon
County —
Quad No Serial No.
Lat. Long.
-0 wafer CK Routine
© SA ❑ Emergency
❑ 4lfw
❑ Chain afcuswy
Report TaRO, MRO, RRO, WsRO,1d1+'Rt O,
WSRO, Kinston FO, Fed. Trust Central Off., Other:
Shipped by, Bus.�CJouft;. nd , Other:
C011ector[s): ' ► A4—, ;;i+ Tien
FIELD ANALYSES
off A,v Spec- Cond.a4 tad 250C
Te°C 06or
Appearance
Field Analysis By:
LABORATORY ANALYSES `
BOB 310 MWL
COD Kinh 340 OWL
CAD Lear 333 in&
Cckbrm: MF Feael 316% r -3 noornl
CoUb m: OAFToFaFS16D[ ticaml
'roc sea nwL
Towdky 75 NTU
ftseldu% 5ulpended 530 M901L
PH 403 units
APo dmhy 10 pH 4-5 410 MWL
Alkainity m pH 8.3 4t6 MWL
Canc�nate 445 mglL
skarbMats 440' MWL
Caftn d6axkft4W mWL
Cry wo 24D m91L
chmmil Hex 1032 adl-
Coku: True s7 Cu
Cyanlde 720 mp1L
Lab
Purpose:
-v[s Baseline,
-- --T - - -
IF
Lab Number Ao � ii� 1
Dale Recetvfed Time: 1100
Reed By: From: Bus, Courier,
other.
Data Erdry By_ /K S_ Ck: 3A'L5
Date Reported:
PesWde Study, Federal Trust, Order: 01 C
Location or Site !1�_ rcr f�r.,r,S�s�cs�„�rrr4 Z3"Mz.
Description of sampling point,k;Fe e1C.,�•�T- - -
SamplkV Method i L{Weep Sample Interval
Remarks �-%jM s"s^ter---�--�-
(PI tww strEal w' ea)
Dls& Some 70300 'OWL
Ag-Mac AIMS L
Frwode 93i mot
Al-Ahueinum 48557 LwL
Hardne=ToWWo mWL
As4kraenbz48551 L
Hatdnese.4nowevb) 9G2 mWL
e,a4Mdum 41t558 L
Phsttnfis 52730 tw
CaCalcWm 48552 rvWL
Specific CorxL 95 Whadem
Cd-GadniWal 48558 u
Scirete 945 mWL
i
Cr-Chramium 0559 ` L
SrAlyde 745 mplL
Co-CoWer 46562 &&L
Fa-kan 4M3 ucVL
Oil and 13nme mtpL
"a-wrcwy 71900 u L
l4PaGssivam 4LiEC�
Mg6Mapnesfum 45W4 L
bin lAanperrese 45M WIL
HFIf as N 810
r68tiSadlum 483M IWL
UN as N 625 MI&
IVFNkW . L
1402 + N% as N 6w mp1L.
PbUsd 49584
?: Talet as P W5 mgiVL
so-setenrum
Nhts (N%ae X) 82D rng1L
7n-Zna 46587 —
pitribe {Nqx ss N) �t5 myL
GW-51 REV.71M For 0L'4*%dM*sft14l0brrd1Uned saffq* and wft'al5 in b1cdL
T.
1i;;.MICai
Temperature oft arrival IBC): D D

M
n
M
I
Ln
n
1
f
GROUNDWATER UNDWATER FIELD/LAB FORM
L acatioe coded 01
CountyCued No No Sedal No.
Let. Long.
Lj i C AlL 6/ dwo
SAME TYPE SAMPLE e310R
®, wmer I.ourtlM
0 salt ❑ E-rneraenal
El other
�Chain of Custody
Report T RO �FRa,113R0, RRO, WaRO, MO,
WSRO, Khston FO, Fed. Trust, Central Of., Other.
Shipped by. Sus. Caurierl {Fe , Other Rurpose:
Colledtor(s): -I—A4, D^ZeMN�� _ Time
FIELD ANALYSES Owner��
North Carolina
Depo trnent of Enviromnenrt arld Nakual Resources
DIVISION OF WATER QUAMY-GROUNMATER SECTION
it
Lab Number A o[, 0 i �1 3
Bate ReGemell Time: IfeVC
Reed BY:'T". S From. -Bus, Couri and
Other
Data Entry Byr._ jn-S Ck 3 ms
Date Reported.
amp' i UST. Pesticide Study, Federal Trust, Other: L)�,
�... _ _
PH xn _ Spar. Corrd ae at 250C Location or Site I ! — !� � c 'S ,rl. G -Ar
-TA.."' .0 ,0 °C Odor Description of sampling pointlee4 r" 7;v"
Appearance Sampfi g Method Ifcl s.;jrb Sample. Intetvai
Raid Analysis 13y: Remarks
LABORATORY ANALYSES (R•ealrgvm. •v.,.IG)
m
e—
En
vn
cu
N
M
a0 a sic
COD Hkh No
COD Low 335
CcRiom7: !AF i ecaf 31818
Cnllfomr tdF TOM 31504
TOC Sea
Tarbid'ity 76
Resldu% Smomded 530
M
m
o-i
m
w
m
I
M
I
M
m
PH 403
Alit MRI In pH 4.6 410
Alk2eini4y to pH 8.3 416
Carbends 445
Gkaf7 &W 440-
Cartm ftmide 406
Ctderkde 240
ChrvmiWe: ilex 1032
Color TneeEO
GyMide 720
Lab
moat
mglL
MWL
fi0amf
floamt
rng1L
NTU
flv&
urlfL9
MOIL
mq&
MWL
Cif
mrpt
Ores. Sofid970300 Y4f Irlg -
Fluoride $51 mWL
HardrAss: Tnfat No MVL
lfawness (man-mb) 902 rgplL
1'diURMS 22730 y w
SFeeftCcad.95 010oe10M
Sulfate 945 mglL
Sulfide 745 MO&
of and Grasse molt
iVF#sas N Bl D moll.
f
TKN as N 625 nnplL
N(h4 NGa as N 530 alS&
P_ Total as P 655 mWL
NOaes" 620mA%
as N) 015 m®fl-
F
GW4 4 REV. TM3 For IDisaolved AWob-mbmil: bared Sample and wdle'Dw in most
►tpSiWar 4656F} q
AIhIunNUm 48657
As•AtseNc 465S1
8"wium46WS L
f,e-Caldum 46W2 MWL
Cd-Ceditm 45558
Cr-ChrcmKun 44W9 L
Cu-Capper 4SE62 +L
Fa4ron 46%3 L
Hg,Vs wry 71900 L
R.lk/awk m 49555 MNA
mourn 4A55A
Un-Iidmigame 441565 UWL
Na-SodkmI4e556 m
NI -Nickel u L
Pb-Lead 4V;64 L
ss$ebenlum L
I.n•2inn 46667 Uwt
or2a —
ofgfnahwhanm Pasec"
Nkropa PasWdea
Acid Herioocfdes
PCfs
se„wlatile organim
TPH-05esd Ra e
Vb1dlB n6z /0A
7PH-Gasollne flan
TMBTEX Gaaagm Range
L60 USE ONLY
Temperature on antral M:

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department orFn►+irontnent and Natural Resources
Alan W. Klimek, P1. ❑imtor
Division of Water Quality
AQUIFER PROTECTION SECTION
Febmary 28, 2006
MEMORANDUM
TO: Thomas Slusser
Groundwater Protection [knit
THROUGH: G. Landon Davidso �
APS Regional Supervisor
FROM: H.E. Minnick,
Ashevilltept-
APS, al Office
SUBJFICT: Inspection/Sampling of UIC Permit #WI 0100008
Henderson County
An inspection and sampling of the well system for permit renewal of Robert Randall was
conducted on this date. Attached are the results of that inspection, including the APSSRR. As soon as
the lab results are received, they will also be submitted.
Please call me if you have any questions at [phone].
r�s
i+>n c hcarolina
Naturrr!!y
North Carolina Division of Water Quality - Asheville Regional Office 2090 U.S. Highway 70 Swannanoa, NC 28778 Phone [phone]
Aquitler Protection Section FAX {82V 299-7043
Customcr Service 1.877-62;-6748
Internet. h2o.enr.Slate.nc.us
An Equal Opp onun4/Affirmative Action Employer - 50% Recydadl10% Post Consumer Paper

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: �M128
To: Aquifer Protection Section Central Office
Central Office Reviewer:
Regional Login No:
County:
Permittee:_L' 41,644
Project Name:
Application No.: VWr o t 00008
L GENER4L INFORMATION
i. This application is (check all that apply): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 563 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation ❑ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
a. Date of site visit: ��Y
b, Person contacted and contact information: )ZAF4- u, dw^Ir7.L ej--tG (704) 477-06J16
c_ Site visit conducted by: A"OSI,4
d. Inspection Report Attached: ® Yes or ❑ No.
2. is the following information entered into the BIMS record for this application correct?
®,Yes or ❑ No. if no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
e. Regulated Activities 1 Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For Disposal and Injection Sites -
(If multiple_sites either indicate which sites the information arnlies to, con -. and paste_a new section into the
document for each site. or attach additional pa'es for each site]
a. Location(s): Q%1cYJicr.G
b. Driving Directions: WJ
c. L'SGS Quadrangle Map name and number:
d. Latitude: � M C32.6 " Longitude: ?702,0 *49 4 "
H. NE WAND liL4JOR HODIFICATIONAPPLICr# TIONS (this section not needed for renewals or inin,, r
modifications. skirl to nex-fsection)
Deserivtion Of Wastei S] And Facilities
r� -
1. Please attach completed rating sheet. Facility Classification: _
2. Are the new treatment facilities adequate for the type of waste and disposal system? '
FORM: Doc4.doc

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
❑ Yes ❑ No ❑ NIA. If no, please explain:
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? ❑ Yes ❑ No ❑ N/A. If no, please explain:
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? ❑
Yes ❑ No ❑ NIA_ If no, please explain:
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. ❑ Yes ❑ No ❑
NIA. If no, please explain:
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
❑ Yes ❑ No ❑ NIA. If no, please explain:
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
❑ Yes ❑ No ❑ N/A. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV:
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? ❑ Yes or ❑ No, If yes, please
attach a snap showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit:
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? ❑ Yes ❑ No ❑ N/A. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program:
10. For residuals, will seasonal or other restrictions be required? ❑ Yes ❑ No ❑ NIA If yes, attach list of sites
with restrictions (Certification B?)
III. RENEWAL AND MODIMCATIONAPPLICATIONS (use grevious section Lor new or mWor modification
s stems
Description Of Waste S And Facillities
1. Are there appropriately certified ORCs for the facilities? ® Yes or ❑ No.
Operator in Charge: &Wi, Certificate #:
Backup- Operator in Charge: Certificate #:
2. Is the design, maintenance and operation (e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? ❑ Yes or ❑ No.
If no, please explain: ^(I A
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? ❑'Yes or ❑ No. If no, please explain: ► /,A
FORM: Doc4.doc 2

}
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
4, Has the site changed in any way that may affect permit (drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain: A&
5. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
❑ Yes or ❑ No. If no, please explain: NIA
6. Are the existing application rates (hydraulic or nutrient) still acceptable? ❑ Yes or ❑ No. If no, please
explain: N/A
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? 5j Yes ❑ No ❑ NIA. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program:
S. Will seasonal or other restrictions be required for added sites? ❑ Yes j4 No ❑ NIA If yes, attach list of sites
with restrictions (Certification 13?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? ❑ Yes or [Z No. If yes, please attach a
map showing conflict areas or attach any new maps you have received from the applicant to he incorporated
into the permit:
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? 19
Yes or ❑ No. If no, please explain:
IL Were M°�g�Nells properly constructed and located? [A Yes or ❑ No ❑ NIA. If no, please explain:
12. Has a review of all self -monitoring data been conducted (GW, NDNIR, and NDAR as applicable)? ❑ Yes or
❑ No W/A. Please summarize any findings resulting from this review: A
13. Check all that apply: ®. No compliance issues; ❑ Notice(s) of violation within the last permit cycle; ❑
Current enforcement action(s) ❑ Currently under SOC; ❑ Currently under ]OC; ❑ Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc):
14. Have all compliance dates/conditions in the existing permit, (SOC, 3OC, etc.) been complied with? t, Yes
❑ No ❑ Not Determined ❑ NIA., If no, please explain:
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? ❑
Yes or PKNo ❑ NIA. If yes, please explain:
FORM: DocCdoc 3

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMITAPPLICATIONS (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:
g Heating/cooling water return flow (5A7)
❑ Closed -loop heat pump system (5QM15QW)
❑ In situ remediation (51)
❑ Closed -loop groundwater remediation effluent injection (5L1"Non-Discharge")
❑ Other (Specify:
2. Does system use same well for water source and injection? ® Yes ❑ No
3. Are there any potential pollution sources that may affect injection? ❑ Yes ZNo
What is/are the pollution source(s)? A-kAX._ What is the distance of the injection weIl(s) from the pollution
source r-AA— t�.
4. What is the minimum distance of proposed injection wells from the property boundary? fl-
y. Quality of drainage at site: ® Good ❑ Adequate ❑ Poor
6. Flooding potential of site: ERLow ❑ Moderate ❑ High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program:
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? ® Yes or ❑ No, If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow. (gh— A-*M "7 A4,4 t0 ' ±`'' 170
lniection Well Permit Renewal And Modification Onit:
1, For heat pump systems, are there any abnormalities in Beat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating(cooling)?
❑ Yes XNo. If yes, explain:
2. For closed -loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? ❑ Yes ❑ No. If `•es. explain:
3. For renewal or m dLf ti of Mundwater remediation Vermits. (of anN ry Ve 1. will
continued/additionallmodifted iniections have an adverse impact on migration of the plume or mapg11ement of
the contamination incident? ❑ Yes ❑ No. If ves,eexplain:
4. Drilling contractor: Name: � [JS4n1
FORM: DoAdoc 4

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address: ZY29 PIEW Lit /41�jy
�fCtz� r ArC 7F74-F
ft=7�410�aber; V41 I-!],� WL'� ►-�
5. Complete and attach Well Construction Data Shut.
(0(
rr.4e-G14,-Aj
FORM: DocCdoc

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVAL [IA T'ION AND RECOMMENDATIONS
t. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuanceirenewal of this permit? ❑ Yes allo. 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:
S. 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
r"f-r-
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
Afe rfe
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 regional supervisor: ' L 1� _ �`�r�t` ob
Date: QZZf
ADDITIONAL REGIONAL ST-4FFREY7EJ-VITE111S
FORM: Doc4.doc 6

North Carolina
17priartment of Environment and Natural Res rces
Divlslon of Water ❑uailty ' Orin wr 01600or
Groundwater Section
Well Location: iFZA(FYV.-,.W, Date _ Z006 , n�Zt
[Town, Community, � Subdivision and Lot No.] WELL TYPE_
owner: r 7t1 ds'C County—
Road/Street — 049+ Sit 1A
Address: Si LA�Fw Fs4idlr Quad Na,
Serial No.
C A,li�n�l. a y�11(L Zj1b Lat.i fib' 3Z. 6" l.ano. An
Well Contractor _ h@WGF'gW
N ante
ijnw#w
r ,
Penmit Required ? (Y/N)
Lgr,atign - Diratance From• ...................
Water Tight Sewage/waste collection..
Waste disposal (septic tank drain field)
Other Poll. Source ]
Other Poll. Source { ]
casi
Type.....................................................
Deplh....................................................
Weightlthickness..................................
Height(A.l_.S.) ......................................
Other ( ] .
Drill-_4n4 Fluids/Additive
Type.....................................................
Grout
Type.................... ...........................
Thickness .............................................
Depth........ -............................................
Other {] .
Screens
Screened inlervat.................................
Other
Develgpt n.....................................
Total Suspended solids .:......................
Turbidity...............................................
Settleable Solids..............................
......
I.Q. Plate
Well Contractor .....................................
And mat - .....................................
Temporary............................................
Permanent ............................................
GW•36 Rev. 11200C]
Constructio,n ,
;jq 1
Check Items
Measured
Meets Min. Slandards
Yes No
Remarks
(Permit No_ (fl'C 1AW aldd00j j
.............
t�
(circle one)
Sastic arbon Gal'v. Slain. St. oilier
sia z►
ffijA
N A
k
'
Q re 3'
I
r
1�
{
o4
=t
f
2. i
:.,
Applies to wells constructed after December 1, 1992
Wont on RRVpr.SR1

WellTest ...............................................
fluration ................................................
Freque3tcy/A�cut2cy ormeasurements
Other ( 604 — .1ww
o swL fofer.dpV.........................................
Chiorination..........................................
"Othdf (' ' 7 . , F ..) .
Uttn..............................................
Fieoarts................................................
Construction (CW-i) ............................
Abandonment (gW-,30) .......................
Well head Cornoletion
Access port .................................... .......
Hose bib ...........................
Pitless Adaptor .................................--..
Pitless Adaptor Unit .............................
Suction line ...........................................
Tee(}et} ................................... ......... ---
Valved ilaw...........................................
Vent.......... -•.............._...........................
Water tight pipe entry ...........................
Wellentry .............................................
❑ate W-etl �:anstrycted (R !� �%
7—br�r
Check Items
Measured
Maels Agin. Slandaras Rema-rk1
Yes I No
.r
I
YX
Applies to wells constructed alter December 1, 1992
- I Pump Installation
Pump Installation Contractor-
Name Address Reg, ri
P_tJMP �OPITF3A r7CR l,R. PLACJE-F iSEMT 7 (Y/N) ors pate Pump1Ritalted
Vidlalians noted attributable to the pump installation contractor are as -,follows:
(1j +
(2)
INSPECTOR
Wilness(esa
(If Available)
office
Name I Address Type
Name Address Type

Compliance Inspection Report
Perrnit: W10100008 Effective: 03119/01 Expiration: 03/31/06 Owner:
SOC: Effective: Expiration: Facility: Randall, Mr. & Mrs. Robert F. - SFR
County: Henderson Lace Falls PropertVot 59
Region: Asheville 226 Dogwood Dr Ma+C
❑❑ Mount Holly NC 28120
3
Contact Person: 4'W-"' m."Vix- Phone: (UIL) 7# f-477. p6?o
Directions to Facility: -T G f -ro CKo i49, io (.4 E +ors ,] dya� CkW AF�ar- a.,f s.- fcd.2, srpadci 4
L"A-r O 4 S-C v f 9 r&f AA- 42,- Q. A err 59 1 r9l?l 4"icx'r,•.,r 4 ,
4e4- L cofof - fi R-.e n,.v �,rIf I'rrr,,oe W , j sr ► "c cr+r /s-{ ('or 44)
Primary ORC: Certification: Phone:
Secondary ORC(s):
On -Site Representative(s): � _ 4jWA— 124,►aA*G4_
Related Permits:
Inspection Date: 02J2012006 Entry Time: 12:00 PM Exit Time: 01:00 PM
Primary Inspector: Harold E Minnick
Secondary lnspector(sj: H G,- 14+-h4� A,41Aol-D
Phone: [phone]
Reason for inspection: Routine■ Awm+r AnvFWAL Inspection Type, Compliance Sampling
Permit Inspectlan Type: Injection Heating/Cooling Water Return Wefl (SA7)
FacilityStatus: X Compliant ❑ Not Compliant
Question Areas:
Wells
(See attachment summary)
Page: 1

Permit: W0100008
Inspection Data: 02=2005
Inspection Sumrnary:
Owner -Facility: &J.9r A4rJs34LL
Inspection Type: Compliance Sampling
i�,'c• e• U+'Cid,Ir�1.!
Reason for Via it: Routina
Page: 2

Permit: W10100008 Owner - Facility:
Inspection Data: 0212MOO6 tnspecton Type; Cwnpliance Sampling Reason for Visit: Routine
CONVO05799
Location Yes No NA NE
Distance from septic tank & drainfield (feet)
Distance from other waste disposal/collection (feet)
Comment
Distance from other pollution source (feet) a ZS` jL
Comment
Is well location subject to flooding? ■ ❑ El
Minimum distance to property boundary (ft)
Comment.
Casin Yes No NA NE
Type PVC
Depth (ft b.l.$) (decimal range, e.g. 15.5 to 25.5 ft)
WeighVthickness
Height (A.L.S) �,�r
X
Comment:
Grout
You
No
MA NE
Type
7C
Thickness
Depth (Decimal range, e.g. 15.5 to 25.5 ft) a - 2f-) '
Comment:
ID Plate
Yes
No
NA NE
ID Plate present & properly completed?
1W
0
0 0
Well Contractor indicated on ID Plate?
0
0
Comment:
Wellhead Com 1p eiion
Yes
No
NA NE
Access port present?
0C1
Cl
Spigot present?
6
❑
❑ ❑
Page: 3

Permit: Wi0100006 Owner -Facility:
Inspection Hate: 02/26/2006 Inspection Type: Compliance Sampling
Comment:
Suction Line meets standards?
Tee {jet) meets standards?
If naturally flowing well, is flaw valved?
Vent meets standards?
Watertight pipe entry meets standards?
Well Entry meets standards?
Pitless adaptor (if used) meets standards?
Well enclosure meets standards?
Infuent (water source) sampling part present and labeled?
Effluent (injected fluid) sampling port present and labeled?
Fume Installation
Pump Contractor ID plate present?
Date pump installed 41W
Pump installation violations, if any n1eWC-
Comment:
GW•1W Construction Record
Well construction/abandonment record submitted?
Comment:
Reason for Via It: Routine
Yes No NA NE
■❑on
Yes No NA NE
■❑❑❑
Page: 4

North Carolina . Department of i=nvironmr ' Health, and Natural Resources
Division of Environmental Manage( I • G►oundmatar Section
P.O. Box 29535 - Raleigh, N.C. 27825-0535
Phone [phone]
WELL. CONSTRUCTION RECORD
-- FOR QFFlC£ Use oNL� LJ a] 4 Q
❑UAD. NO. BERIAL NO.
/
Miner 9min
Basin coda
r"LLING CONTRACTORFexguaon 1 s Well Drill_i_ ng co. Deader Ent, OW-1 Ent.
STATE WELL CONST"t" lull
DRILLER REGISTRATION NUMBER:_ _541 _ _ PERMIT NUMBER: UTr-14JL 0100W
1. WELL LOCATION: Show sketch of the location below)
Nearest town: Henge r sonvi Ile � - County:
(Road. Communtly, or Subdivision and lot No.)
2. OWNER Bob Randall
ADDRESS _22E Dogwood Dr.
(street or Route No.)
_Mount Holly, NC_ 28120 _ -
City or Town State Zip Coda
DEPTH
From To
0-84
84-400
DRILLING LOG
Formation Descdplion
Dirt
HedTock
3. DATE DRILLED Fi 1 _5.-_9 Q USE OF WELL nom .
4. TOTAL DEPTH 4 D 0
5. CUTTINGS COLLECTED YES ❑ NO®S.
DOES WELL REPLACE EXISTING WELL? YES [] NOQ
�
7. STATIC WATER LEVEL Below Top of Casing: 65 - FT.
(Use '+' if Above Top of Casing)
8. TOP OF CASING 1S 1 FT. Above Land Surface"-;
Casing Terminated Wor below lend surface Is Illegal unless a varlence to Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):20 METHOD OF TEST _ R i
14. WATER ZONES (depth):='
CHLORINATION: Type HTH Amount 68
If additional space is needed use bacl�lforrM _
.e. CASING.
LOCATION SKETCH
Wall Thickness
Depth Diameter or WelahtlFt. Material
(Show direction and distance from at least two State
From 0 To 84 FtA,2—z 16-125 Pv(----qnR
Roads, or other rnap reference points)
From To Ft.
From To ' Ft_
13. GROUT:
Depth
Material
Method
From 0
T020
Ftcement
soured
From —To
Ft.
14. SCREEN:
Depth
Diameter Slot Size
Material
From
To
Ft 1n.
In.
From
To
Ft. In.
In.
From
To
Ft. Irl.
In.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Lace Falls Subdivision
Lot #59
of f Wash Freeman Rd. (im)
YELL WAS CONSTRUCTED IN ACCORDANCE WITH t 5A NCAC 2C, WELL
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATUR OF CONTRACTOR OR AGENT DATE
Submit original to DMslon of Environmental Management and copy to Wei owner.

Ar 1UIFER PROTECTION SECTION '-
APPLICATION REVIEW REQUEST FORM ; J�rJ � � �06
Date: ,Ianuar, 9 2006
To: ® Landon Davidson, ARO-APS ❑ David May, WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Charlie Stehman, WiRO-APS
❑ Andrew Pitner, MRO-APS ❑ Sherri Knight, WSRO-APS
❑ Jay Zimmerman, RRO-APS
Fart: Thomas Slusser, , Groundwater Protection Unit
Telephone: i 919� 715-6166 - Fax: (919 } 715-0588
E-/Mail: [e-mail]
A. Permit Number: WIOI00008
B. Owner: ROBERT RANDALL
C. Facility/Operation: RESIDENCE
❑ Proposed Z Existing ® Facility ❑ Operation
1). Application:
I. Permit Type: ❑ Animal ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ VE Lagoon ❑ GW Remediation (ND)
❑ UIC - (5A7) open loop geothermal
For Residtials: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type: ❑ New ❑ Major Mod. ❑ Minor Mod. Z Renewal ❑ Renewal wl Mod.
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 take the following actions:
❑C Return a Completed Form APSSRR.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO*.
" Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer;
FORM: APSARR 09/04 Page I of 1
Date:

i NORTH CAROLINA I
DEPARTMEN'G JF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY, AQUIFER PROTECTION SECTION
STATUS OF INJECTION WELL SYSTEM
Permit Number: f L� � ICJ Q I 0 0,J 0 (101' e c.)� '6t1.s - W 101.0Doe
?)
Permittee Name.,- . Q kid y I�"� •�I"� /Qf �Q ��
Address: t . r . �►'1 Pi" Well &Wo`e5j
Please check the selection which most =ely describes theJcurrent status flour injection well.
In addition, please provide the requested information.
1) _Z Well is still used for injection activities.
2) _ Well is not used for injection but is used for water supply or other purposes.
3) Injection discontinued and: a} Well temporarily abandoned
b} Well permanently abandoned RECEIVED I DENRI DWO
c) Well not abandoned AQUIFER PIROTECT'IQHSECpON
4) Injection well never constructed JAN D 6 2006
If you checked (2), describe the well use (potable water supply, irrigation, etc), including pumping rate and other
relevant information.
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (include a description of
how the well was sealed and the type of material used to fill the well if permanently abandoned):
Certification: (For well abandonment)
"I hereby certify, under penalty of law, that I am personally responsible for the proper abandonment of any
injection well as required in Title 15A NCAC 2C .0214 Criteria and Standards Applicable to Injection Weals."
Signature
Date
Certification: (For information verification)
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document, and that to the best of my knowledge the information is true, accurate, and complete."
Signature Date
_e, .3 / ~e.5�
r
Revised 5105 GWIUIC-68

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RENEWAL APPLICATION FOR PERMIT TO USE WELL FOR INJECTION WITH A
FEAT PUMP SYSTEM
Type 5A7 and 5QM Wells
In accordance with the provisions of NCAC Title 15A: 02C.0200
complete application and mail to address on the hack page.
TO: DIRECTOR, NORTH CAROLINA DIVISION! OF WATER QUALITY
DATE. � [ ;�l t? G - J f , 20 0 .�
A. PERMIT APPLICANT
Permit Number: +,r�1r' !f {WIO#####1#!, listed at the bonom of each page of your permit}
Name: _I.j, i { . r /' 4 , fir
Address:
City: �f '! �+ _ State: Ii'fZip code:��
[.�/ � �� J` 1 - L'�J� � ►`ICL` �` .�� i7 �,[i � i't � � � j{ C ■.CJ�r �� :� i ��. %•�Q !
B. PROPERTY OWNER (if diffircut from applicant) �[ p
Name: ���r1V1 [fj! e---,
C.
D.
Address:
City: State: Zip code:
County: 'Telephone:
STATUS OF APPLICANT
Private: wo" Federal: Commercial: State: Public:
Native American Lands:
FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Public or Commercial).
Name of Business or Facility:
Address:
City:
County:
Contact Person:
State: Zip code:
Telephone:
Standard Industrial Code(s) which descnbe commercial facility:
Revised 5105 GW/UIC-57 HPR Page] of3

C. 1NJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
_Al
F. WELL USE ls(are) the injection well(s) also used as the supply well(s) for either of the following?
(1) The injection operation? YES r% NO
(2) Your personal consumption? YE5 e� NO
G. CONSTRUCTION DATA
(1) Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection permit.
(2)
NC. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make provisions far
nionitodug well head processes. A faucet on both influent (groundwater entering heat pomp) and
effluent (water being injected into the well) lines is required. Is there a faucet on:
(a) the influent line?
YES :-� NO
(b) on the effluent line?
YES NO
H. CURRENT
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 per square inch (psi }
(4)
Injection temperature:
Annual Average •�°� r�_
I.
J. LOCATION OF WELL(S) Attach a map
Include a site map (can be drawn) showing: the orientation of and distances between the injection wells) and any
existing we11(s) or waste disposal facilities such as septic tanks or drain fields located .within 1000 feet of the
ground -source heat pump well system; include buildings, property lines, surface water bodies, any other potential
sources of groundwater contamuration. Label all features clearly and include a north arrow to indicate
orientation.
K PERMIT LIST: Attach a list of all permits or construction approvals, received or applied for by the applicant
that are related to the site. Examples include-
(1) Hazardous Waste Management program pemtits under RCRA
(2) NC Division of Water Quality Nan -Discharge permits
(3) Sewage Treatment and Disposal Permits
L. OTHER MODIFICATIONS: Indicate any other modifications to the injection well system (equipment, fluid,
operation, etc.) that have occurred since the issuance of the previous injection perntit and have not been noted
elsewhere on this application.
Revised 5l05 GW/UIC-57 HPR Page 2 of 3

M. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am farxuliar with the information
submitted in this document and all attachmenrs thereto and that, based on my inquiry of those individuals
immediately responsible for obtainhig said inFannation, I believe that the information is true, accurate and
complete.. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment, for
submirting false information. I agree to operate, maintain, repair, and if applicable, abandon the injection well
and all related appurtenances in accordance with the approved specifications and conditions of the Permit."
(Signature of Well Owner or Authorized Agent)
If author•,rzed agent is acting on hehalfof the ivell owner.
please supply a letter signed by the owner
authorizing the above agent.
N. CONSENT OF PROPERTY OWNER {Owner means any persnn who ]toads the fee or other property rights in the
well(s). A well is real property and its construction on land rests ownership in the land owner in the absence of
contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby Consents to allow the
applicant to operate an injection well(s) as outlined in this application and that it shall be the responsibility of the
applicant to ensure that the injection well(s) confonn to the Well Construction Standards {Title 13A NCAC
Subchapter 2C:.0200)
(Signature of Property Owner if Different From Applicant)
Please return the completed Application package to:
UYC Program
Aquifer Protection Section
North Carolina DEINR-DWQ
1636 Mail Service Center
Raleigh, IBC 27699-1636
Telephone: [phone]
revised 905 GWIUIC-57 HPR Page 3 of

AENDERSON COUNTY DEPARTMENT OF PUBLIC HEALTH
OPERATIONS PERJNIT
r6L,1 L,,q C t E Date - �+✓
dkog Contractor
- Tank Instailer _ 6 V P ! ■
Develapment Lhl�'6�
�J r
oe: f�y t TL.9--r4'D fZ r] -To cs�o
z T — eft �r-lw t/flj AD rf-� s 08 ❑ �
,4 ❑ Mobile Nome ❑
_,�drooms 3 _ Design Flow GP❑
Ac-
-'s Signature
VALID ONLY FOR USE AS-f' ESCRIBEO ABOVE
DRAWING NOT TO SCALE
t .Lq`r
f'rW 6M&,dr
0P Nu J,jU
RC No.
17 1% CJ
I No.
_
W! No.
OL 92;7-s
Water Suppty. ❑ Community
❑ Sharec
;?� Individual
❑ City
Talc Size
�1G7100
Gal.
❑rainfieid
752-0 F62
Sq. Ft.
Stone Depth t Z Inches
System Type CCr3 �LE7Tfo► PVL
Min. System Review Frequency
Issued Ry'�r% r
Environmenlal Health ,Pecialis(

�Y Pon?" -surr (1110 urttg PeprimEirf of Public 7 rT 'U4 (j 7
Telaphone 1&47 SPARTANBURG HIGHWAY-j ��-
828_692-4228 HENDERSONVILLE, NORTH CAROLINA 28792
WELL CERTIFICATE OF COMPLETION
f�}7 r�7 r Jtf �IJ1 1 r PERMIT WC M 3081
OwneryrBuilder mr, ;"� 6 r111'1s�L-_Ki 1+•�11 ��f� +-�- 7-0 -
Mailing Address of Applicant 2 2 G D%' wood Tgj M r , f10 L L"I i� r Phone rd �1�- f J J `
Pin No. r� SSubdivision/ParkLAC L- r� L- L Lot #
Location 1 !_ t:'' rid[�1TLAN+ ';VA!, C dSS MILLS (�-A- TQ 00 CL-EAP OPFEK
10 ug I-) rres t : *A I z . rf 96-F OF OH
Type �� 1 Size tD ! Depth �7 nL� Casing Depth`? - - —
Grout �L� C' Yield GQ f -Contractor/Driller r. F&U `s n1\1
ION tSS���P r3p,5ET) LIN
A
L
gr-PTI c-
TD
MAR
Date Issued Environmental yHealth Specialist
Permit Received By �'� Ircr�-� j 1 Ewl 5- ltirr �•~

RETURN RECEIPT j E )U"QZTED
7002 2410 0003 0274 8987 '
Mr. & Mrs. Robert Randall
2?6 Doi wood Drive
1Mount 1lolly, NC 2812U
Ref: Notification of Expiration
North Carolina Well Construction Standards
,Applicilble to injection Wells - Subenapter 2C
['IC Perinit No. W10100008 Issued to Mr. & Mrs. Randall
Deg it Mr. & Mrs. Randall;
RECEIVED J DENR j DWO
AQUIFER PROTECTION SECTION
The Underground Injection Control (UIC) Program of the Division of Water Quality is responsible for
the regulation of injection well construction and operation activities within the state of North Carolina.
Our records show that the operating permit referenced above for the injection well on your property will
expire on March 31, 2006. In addition, our records d❑ not indicate that the well has been abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative Code
(NCAC) Title 15A, Subchapter 2C, Section .0211, you must take one of the following actions. -
A. Submit the form RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM (form GW/TJIC-57 HPR) if the injection well on your property is still
active;
B. Submit the form STATUS of INJECTION WELL SYSTEM (form GW/UTC-68) if the injection well is
inactive or has been temporarily or permanently abandoned.
If the well is no longer being used for any purpose, it must be permanently abandoned according to the
regulatory requirements listed under NCAC Title I5A, Subchapter 2C, Section .0214. If the injection
well is to be permanently abandoned, a well abandonment record must be submitted to our office to
certify that the abandonment was properly conducted,
Naturally
Aquilzr Protection SeCtlon 1636 Mail Service Center Raleigh, NC 27699.1636 Phone [phone] Customer serveer
hiicrnel: 11[4p:llh2o enr.stile. n;..Lis 2728 Capital Boulevard Ralc4h, NC 27604 Fax [phone]
Fax [phone]
An Eg4al ❑ppommty/Aliirmetive Action Employer— 50% Recycled110% Post Consumer Paper

Michael F. 12:451cy, Governur
William G. Ross 3r., Secsclary
Norili CarWina Departmeni of Enviranmeni and Nalural ftcsaurces
Alan W. Klimek, F.F. Diruclor
Division of Woscr QIioIiry
'Ar' :2"
January 6, 2006
Marguerite and Robert Randall
226 Dogwood Drive
Mount Holly, NC 28120
Ref: Receipt of Injection Permit Renewal Application
Injection Permit WIOI00008
Dear Mr. acid Mrs. Randall_
Your renewal application for a permit to use a well for the injection of geothermal heat pump effluent has
been received and is currently incomplete. No city naive was given for the location of the injection well
location; the only information subnnitted was 44 Whiteside Trail, Henderson County. Please submit this
information within 30 days of the date of this letter or your application will be returned to you.
Please contact me at 919-715-6166 or Evan Dane at 919-715-6182 if you have any questions regarding this
letter or the Underground Injection Control Program -
Best Regards,
r �
Thomas Slusser
Hydrogeological Technician II
UIC Program
cc_ CO-UIC Files
Landon Davidson. Asheville Regional Office.
N"
ei scarolinaa
, aA" aI
Aquifer Protection Seclion 1636 Mail Service Center RDleigh, NC 2 7699 -1636 Phane [phone] Cuslorner Service
Internet: http:lfh2a.enr.s1atc.nc.us 2728 Capital Boulevard Raleigh. NC 27604 Fax [phone]•623-6748
Fax [phone]
An Equal QpportunilylAffirmative Action Employer— 50°% Recyclecill0°% Past Consumer Paper

■ Complete Items 1, : A 3. Also complete
Kern 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
IN Attach this card to the back of the mallpiece,
or on the front ifspace permits.
f. Article Addressed to,
Mr. cC Mrs. Robert Randall
226 Dogwood Dime
Mount Holly, NC 28120
A. r—,
ire h
�_ _ x . ❑ Agar x
13 Addressee
ecelvad by (tented Name) e 1Se1� 11 f1 I
D. Is delivery address different Rom Item 1? Ul Yet i
8 YES, girder delivery address Waw: © No
1
I
f
3. Service Type
M Cartifled Mall ❑ Express Mail
❑ Registered ❑ riMm Recelpt for Merchandise
❑ insured mmi © O.O.D. I
4. Restricted t7eEWW ffi�ft ►*e) 0 Yes
7nna aLLl-n nnn7 nm' LU A4A; I
k
PS Form 3811, August 2001 Domestic Return Receipt 2ACPRI-03-Z-OM

of WA rF4 Michael F. Easley, Govemor
of 40 William G. Ross Jr., Secretary
rNorth Carolina Department of Environment and Natural Resources
❑ Alan W. Klimek, P.E. Director
y Division of Water Quality
December 5, 2005
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7002 2410 0003 0274 8987
Mr. & Mrs. Robert Randall
226 Dogwood Drive
Mount Holly, NC 28120
Ref Notification of Expiration
North Carolina Well Construction Standards
Applicable to Injection Wells - Subchapter 2C
U1C Permit No. W10100008 Issued to Mr. & Mrs. Randall
I u3W.1-Muvr,%. ;�TITl:0
The Underground Injection Control (UIC) Program of the Division of Water Quality is responsible for
the regulation of injection well construction and operation activities within the state of Noah Carolina.
Our records show that the operating permit referenced above for the injection well on your property will
expire on March 31, 2006. In addition, our records do not indicate that the well has been abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative Cade
(NCAC) Title 15A, Subchapter 2C, Section .0211, you must take one of the following actions:
A. Submit the farm RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM (form GWIUIC-57 HPR) if the injection well on your property is still
active;
B. Submit the form STATUS of INJECTION WELL SYSTEM (farm GW/UIC-68) if the injection well is
inactive or has been temporarily or permanently abandoned.
If the well 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 .0214. If the injection
well is to be permanently abandoned, a well abandonment record must be submitted to our office to
certify that the abandonment was properly conducted.
I4�hzCaro ina
ur�fly
Aquifer Protection Section 1636 Mail Service Center Raleigh, A'C 27699-1636 Phone [phone] Customer Service
Internet: http:llh2o.enr.state. nc.us 2728 Capital Boulevard Raleigh, NC 27604 Fax [phone]
Fax [phone]
An Equal OpportunitylAfrmative Action Employer — 50% Recyctmdll0% Past Commer Paper

Mr. & Mrs. Robe l Randall
❑eccrnber 5, 2005
Page 2 of Z
Please submit the appropriate form(s) within 30 days of the receipt of this letter. If you have any
questions regarding the permit and injection well rules, or if you would like assistance completing these
forms please contact Thomas Slusser at [phone] or Evan lane at [phone].
Sincerely,
Jesse Wiseman
Processing Assistant
CTTC Program
CC: -" YV %q - nshe�%iue x%.CYIorkU "Iij WIp enclosures
CO-UIC Files w/o enclosures
Enclosures

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
March 20, 2001
MEMORANDUM
To: Landon Davidson, L.G., Groundwater Supervisor
Groundwater Section
Asheville Regional Office
From: Mark Pritzl ple [e-mail]
flydrogeological Technician I1
UIC Group
Groundwater Section
Raleigh Central Office
Re: Issuance of injection well permit type 5A7 (open loop geothermal)
Permit Number WI010000fto use a well for the injection of ground -source heat pump effluent
has been issued to Mr. & Mrs. Randall, in Lace Falls Property, North Carolina. This is a new
permit and the Underground Injection Control Group appreciates Tina Parsons assistance with
the injection well inspection and sampling tasks. Please retain the application and paper
work for the ARO-UIC Files. If you have any questions regarding this permit or the UIC
program, please contact me at [phone] or Meliktu Fanuel at [phone].
cc: CO-UIC Files
Enclosures

February 28, 2001
Mr. & Mrs. Robert F. Randall
226 Dogwood Drive
Mount Holly, NC 28120
Dear Mr. & Mrs. Randall:
Michael F. Easley
Governor
Williams G. Ross Jr„ Secretary
Department of Environment and Natural Resources
Kerr T. Stevens
Division of Water Quality
In accordance with your new application dated November 8, 2000, we are forwarding Permit
No. WIO10000ffor the construction and operation of a geothermal heat pump injection well at
Lace Falls Property, Lot # 59, in Henderson County, North Carolina. A copy of the laboratory
test results of water samples collected on November 20, 2000 is also enclosed,
This permit shall be effective from the date of issuance until March 31, 2006, and shall be
subject to the conditions and limitations stated therein. In order to continue uninterrupted legal
use of this well for the stated purpose, you should submit an application to renew the permit
three months prior to its expiration date on March 31, 2006.
If you have any questions regarding your permit please contact me at [phone] or
Meliktu Fanuel at [phone].
Sincerely,
A& -� 1, 0, d
Mark Pritzl
Hydrogeological Technician 11
Underground Injection Control Program
cc: UIC Files
ARO Files
Enclosures
GIs
gn ERR
Customer Service Division of Water Quality 1 Groundwater Section
1 8DO 623-7748 1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: (919) 715-Q588 Internet: httpJ/gw.ehnr.state.nc.us

MEMORANDUM
R
February 28, 2001
To: Mr. & Mrs. Randall
From: Mark Pritzl tel. [phone]
Re: Groundwater Sampling Results from November 20, 2000
Influent Water Sample
Effluent Water Sample
Coliform, total
<11100ml
Coliform, total
<11100mI
Coliform, fecal
<1/100ml
Coliform, fecal
<11I00m1
Total Dissolved Solids
88 mg/L
Total Dissolved Solids
84 mg/L
NGz- + NO3- as N
0.08 mg/L
NCz + NO3 as N
0.06 mg/L
NH3
0.02 mg/L
NH3
0.01 mg/L
Silver, Ag
<5.0 ug/L
Silver, Ag
<5.0 ug/L
Arsenic, As
<10 ug/L
Arsenic, As
<10 ug/L
Barium, Ba
<10 ug/L
Barium, Ba
<10 ug/L
Calcium, Ca
7.7 mg/L
Calcium, Ca
8.0 mg/L
Cadium, Cd
<2.0 ug/L
Cadium, Cd
<2.0 ug/L
Chromium, Cr
<25 ug/L
Chromium, Cr
<25 ug/L
Copper, Cu
12 ug/L
Copper, Cu
8.9 ug/L
Iron, Fe
130 ug/L
Iron, Fe
88 ug/L
Mercury, Hg
<0,2 ug/L
Mercury, Hg
<0.2 ug/L
Potassium, K
0.99 rng/L
Potassium, K
1.0 mg/L
Magnesium, Mg
0.71 mg/L
Magnesium, Mg
0.72 mg/L
Manganese, Mn
<10 ug/L
Manganese, Mn
<10 ug/L
Sodium, Na
6.3 mg/L
Sodium, Na
6.5 mg, L
Nickel, Ni
<10 ug/L
Nickel, Ni
<10 ugli.
Lead, Pb
<10 ug/L
Lead, Pb
<10 ug(L
Selenium, Se
<5.0 ug/L
Selenium, Se
<5,0 ug/L
Zinc, Zn
200 ug/L
Zinc, Zn
25 ug/L

State Groundwater Quality Standards:
Classifications and Water Quality Standards Applicable To The Groundwater's of North Carolina
(North Carolina Administrative Code Title 15A: 02L.200)
Coliform, total
<11100 m1
Coliform, fecal
<11100 ml
Chloride
<250 mglL
Total Dissolved Solids
<500 mg/L
NO2 + NO3- as N
<10 mgli.
Cadium
<5.0 ug/L
Chromium, Cr
<50 ug/L
Copper, Cu
<1000 ug/L
Iron, Fe
<300 ug/L
Manganese, Mn
<50 ug1L
Nickel, Ni
<100 ug1L
Lead, Pb
<15 ug1L
Zinc, Zn
<2,100 ug1L
Arsenic, As
<50 uglL
Mercury, Hg <1.1 ug/L
Barium, Ba <2000 ug/L
mg/L = milligrams per liter = parts per million
ug/L = micrograms per liter = parts per billion
1000 ug/L = 1 mg/L
ns = not sampled
(1 gra m11,000grarns)11,000grams
(1 gram/ 1,000,000grams)I1,000grams

Initials
Type of Permii/Comments
x1
eat Pum Remediabon Other

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Mr. & Mrs. Randall
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 efflucnt. This system is located at Lace Falls Property, Lot # 59,
in Henderson County, North Carolina, and will be constructed and operated in accordance with
the application dated November 8, 2000, 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 apart of this permit,
This permit is for Construction and Operation only, and does not waive any provisions of the
Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an
injection well shall be in compliance with Title 15A North Carolina Administrative Code 2C
.0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well construction and
use.
This permit shall be effective, unless revoked, from the date of its issuance until March 31, 2006,
and shall be subject to the specified conditions and limitations set forth in Parts I through X
hereof.
Permit issued this the M day of �� � , 2001.
Ted L. Bush, Jr., Assistant Chief
4 Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. W 101 HOOT gj PAGE 1 OF 6

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
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 (i5A 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.
T Each injection well shall have permanently affixed an identification plate.
8. A completed Well Constriction Record (Form GWA) must be submitted for each injection
well to, DENR-Division of Water Quality, Groundwater Section UIC-Staff, 1636 Mail
Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well
construction.
PART lI - WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall
notify the Groundwater Section -Underground Injection Control (MC), Central Office staff,
telephone number [phone].
PART III - OPERATION AND USE GENERAL CONDITIONS
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..
Permit No. WI0100007 PAGE 2 OF 6

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 34 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances which may be
imposed by other local, state, and federal agencies which have jurisdiction. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
PART IV - PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or
abandonment of the injection facility.
2. The Permittee shall be 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
The injection facility shall he properly maintained and operated at all times.
2, The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or
activity not specifically authorized by the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Groundwater Section -Underground
Injection Control (UIC), Central Office staff, telephone number [phone].
Notification is required s❑ that Division staff can inspect or otherwise review the injection
facility and determine if it is in compliance with permit conditions.
Permit No. W10100007 PAGE 3 OF 6

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.
1 Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VII - MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed
necessary by the Division of Water Quality to insure surface and ground water protection,
will be established and an acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Asheville Regional Office, telephone number (828)
251-6208, any of the following:
(A) Any occurrence at the injection facility which results in any unusual
operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
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 Permitter- shall
take such immediate action as may be required by the Director.
Permit No. WI0100007 PAGE 4 OF 6

PART VIII - PERMIT RENEWAL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
PART IBC - 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 well is taken completely out of service temporarily, the Permittee must
install a sanitary sea]. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(1), Well Constntction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel -packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit,
Permit No, W10100007 PAGE 5 QF G

(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(1) within 30 days of completion
of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Groundwater Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X - OPERATION AND USE SPECIAL CONDITIONS
None
Permit No_ W10100007 PAGE 6 OF 6

�
r
c•
C7
L'r-
DIVISION OF WATER QUALITY
Cn
GROUNbWATER SECTION
�G
29 November 2000
'x
x�
{Qr
a
�
rn.a
n
To: Mark Pritzl
UIC Group, CO
(l)
Through; Landon Davidson t
Asheville Region 5upervisor
Fran: Tina Parsons r+°
Hydrogeologist - Asheville Region
Re: UIC Inspection for the Randall
Property, Lot
#59, located at Lace Falls Properties, Henderson
Co.
T have reviewed the UIC Application and visited this site on Noonday 20 November
2000. T have the following comments:
Tn jection system is described as an open loop system utilizing a single well far
bath the intake and effluent for the heat pump. This water source may also be
used as the resident's drinking water and household well.
Applicant needs to provide details and schematics of the heat pump system,
including pipe configuration bath external and internal to the well and well riser,
and a copy of the Well Construction Record (Farm GW-1).
Applicant name on the permit application should be changed to Nor. & Mrs. Robert
Randall.
However, it is the findings of the UIC section that these deficiencies are minor
and d❑ not affect the basic operating system of the heat pump and injection well.
It is therefore our findings that this office has no objection to the request of
the Randall's to hove their utilities turned on.

f
North Carolit.d Department of Environment and Nataral Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WI
NAME OF OWNER: Robert Randall
ADDRESS OF OWNER 226 Dogwood Drive
Mt. Hotly NC 28120
704 827 4347
DATE ; 91 & 00
(Streetl road or lot aW subdivision, county, town)
LOCATION OF INJECTION WELL (and source wells), if applicable:
Lace Falls Properties, Lot #59 in Apple Valley, Henderson County NC
(Streed road or lot and srub&viston , county, town, if differeni than owner's address, plus description of location on site)
Potential pollution source: septic tank Distance from well 50'
Potential pollution source _ _ _ _ Distance from well
Potential pollution source Distance from well
Minimum distance of well from property boundary: 10,
Quality of drainage at site: unknown, no soil tests available (good adequate,poor)
Flooding potential of site: low (htgh,moderate,law)
DRAW SKETCH OF SITE (Show prnperty bounda"es, buiangs, wells, potential pollution sources, roads, approximate scale, and
►wrth arrow.)

S+• 1175 __ ,*
u' iir •� l �� . ,
� ti �' •[.rii; ri.?r'{`�ri,. ��• • • � i � � � i � ' it `
�C f �.•,�; �» , �..: �;.:'��-�'. �.� �.titi _� r :.tea
Henderson County
Map is portion of Bat Cave 7.5' quad
'•s3, it T� �r e I�`� y r� f 1
S.
h.
kI
DESCRIBE INJECTION SYSTEM (vertical closed loop, encased borehole or cased water well; separate source well and
injection well; combination source and injection well; or other description as applicable)
Applicant provided no documentation of the construction of the system or the construction of the well as
required by permit.
INJECTION FACILITY INSPECTION REPORT -FORM B(CONTINUED)
WELL CONSTRUCTION
Date constructed ; Applicant provided no GW-1 form.
Drilling contractor- Ferguson's Well Drilling ?
Address kkw k��.'a ►N,
Registration number W12825 r
Total depth of well _ 400' Total depth of source well
!r { rmn t irreh In i

Total depth of well 4-Abo
? otal depth of source well
+
(if applicable)
Inspection point
Measurement Meets minimum standards
Comments
Yes No
Casing
Depth
7
•
Diameter
t4- r1`7>e.r
Height (A.L.S.)
w 1,Z, htch e.5
Grout
Depth
?
Screens
Depth(s)
Length(s)
I.D. Plate
Static water level
Well yield
?
Enclosure
Enclosure floor
{�
(concrete)
Sampling port
(labeled)
Water tight pipe entry
Well enclosure entry
_
Vent
Functioning of dent pump system (Determine from the owner if heat pump functions properly.)
Lc -tk,Ae..
INSPECTOR Office t Ro
WITNESS
Address
WITNESS Address March 1998

:�.46
j� � f �� a r •$�i� i}•'� rum! �,

f' �'

v . t.

FROM FRK NO.
North CoralinR - Departmenf of Errvitonmenf, Health, snd IValural ho-ioutee9
t]ivielon of Environmental Managernont - Ground-.vator S*ego n
P.O. Box 29535 - Ratelgh, N.C, 27929-0535
Phone (gig) 7a3.3221
WELL CONSTRUCTION RECORD
r ' LING CONtRACTORPer gugon' , Wnll Dr i 11 i n Co
Mar. 09 2001 05:53PM P2
FOR OFFICE Use ONLY
Let __. LOM no
Mirw Bnsbt
0main Cody!
Header Ent- - OW-1 E,
ST�4TE-WELL COIJSTR(lCTm
DRILLER REGISTRATION NUMBER: 541 PEnMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Neamst Tamr Henser sonyi lla Covntyt
(Read, Corrsnletlty, or Sub&y 'ion end Lot Ho j DEPTH
2. OWNER Bob Randall From To
ADDRESS 226 ❑Oawood Dr- _ U -8 4
(Sheet or Route Nu.) 8 4- 4 U U
Mount Holly,, NC 26120 _
City ar Town Slate 7Jp Cade
3. DATE DRILLED 6-1 �-99 USE OF WELL Dow
4. T07AL DEPTH 400
- - --
$, CUTTINGS COLLECTED YES Q NO®
& DOE$ WELL. REPLACE EXISTIN13 WELL? YES [] NOO
7, STATIC WATER LEVEL Ralaw Top of Casing: 65 FT.
(Use '+' If Aba+re Top of CAxine)
8, TOP OF CASING IS i _ FT. Above Land Surface`
4 Cost" Torr„Irojed sVer below fond surface is Iliegol U"49s a variance Is issued
61 ocowdeam with 19A KCAL 30 .01 if
9. YIELD (9pm): 20 METHOD OF TEST R i 9
to. WATER TONES (depth):
,MLORINATION: Type
I2; CASING:
HT H
DRILLING LOG
Fornrsllotl t2ertpdon
Dirt
-Bedrock -
Amount 68 If additional spaeo is needed tons backitrfjam
Wall Tl,leknees
Depth Diameter or Welghu t, fN61081
From 0 To 84 FL5.25.216-'25 P.Vr-_gnR
From To � - -- Ft. From ---..-.--.-.To FL -
13. GROUT:
pe�y1h - Material Methad
From 0 Ta `' 0 FI cernen t poure
From To FL---�-•--
14. SCREEN:
Depth Diameter Slot Size Malerial
From -To_ -_ Ft in.
From To - Fl. ln- ln. �....�
*� Fron1 To . Ft. In. irt.
� 115. SANDIGRAVEL PACK:
Depth Size
Frorn To Ft.
From TO Ft.
18. REMARKS:
Material
LO(;ATt CH_
(show direction and distance from st feast NO SIRIe --
Rases. or other ntap reference Pointe)
Lace Falls Subdivision
Lot. 459
off Wash Frooman Rd.
f DO HEREBY CERTIFY 1HAT THIS WELL WAS CONSTRUCTED try ACCDROANCE WiT1-I t 5A NCAC 2C, wF-LL
CONSTRUCTION 3TARDARDB, AND T14AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL C WNEA.
SlaNATUA� CR CC* TFtACTM OR AGENT DA•YE
f3W-1 AEY. �I arrbrnil origtrad to 0M%6n of tr+rrlronmardA Mjulm nmerd and CO07101" owner.

FROM
FAX No,
Mar. 09 2001 05:52PN PI
,date.% lomm
'j rP3�jj L
............ ....... .. ..................... . .
Forlyusews. Well DC1111op Co.
2829 New Loicotstor Ilwy.
Leicester, HC 20748
FAX flo.1028) 683-2620 TELE too. [phone]

NORTH CAPAMM Mi
GROUNDWATER FIELD/LAB FOAM D" trmd,t of GrWr immicrt and Ndurioi emu-=
DrVX5XON OF WATER gUALM - GROUNDWATER SEC=N
Cauniy f Y SO %A- 2001e Type $MWc PrioriLabLob Number G ❑ i6.3
[�
quad No. Serial Na. {AFoter Routint Date Raceivad 11- a p _ c• o Time � �1 �-
tat. Lang. Soil Emerr—r Rec' d by: From: Bus. Courier o �r
Other Other
Report To: Q (ARO, CO, Other) Chain of Custody Data f: "by -
Shipped by: (Bus, n , HaW Od, Other)
Calleetor(s): ra SCE c Date: t [. tam oc_ Date Reported: 1! - a? - U d .
Time:
Purpose (Baaefine, CamplWnt, Compliance, LUST, Pegicide 5tudy, Federal Trust, Other).
FIELD ANALYSE5 i••i Darter
pH4.M 7. y z Spec Cond.n a7 2ec Loralion or Otte
Temper I� , j oC Odor Descnptlan of sampling point
Appearance Sampling Method 'F• a— y1 • Sampia Inter yai:
Field Anotysie by: 0S Remarks , �} `�j w ,+a. V-,a
LABORATMY ANALYSIS

I
RECL IV EL ./ ng---N
.DIVISION OF WATER QU&Lm
01 JAN 19 P1 kl 2.* 22
.Cl —w-ry "W—L-Y Rq-1 I C--d Wag- Q-5ty
COMM -. ITIMERMN $A -)-,Pi E UPRMY
QUAD ND. LlROITI'ME ENUMGWCY
0 CHAN OF CMMUY REPCWTO ARD
CGUECTCHtp "FAMON
t)A'M- Lia2mm SAMPLETYH
T04E
PURPOSE Owner. WWI ;;. �s
Lamdon or 5ft - N
S-0-g M" 1, RftmLrkL
IABORATORY ANALYSIS
COD mfti 340 mg?L
COD Low 335 ing/L
GDhfoaxXffFwal3I616 lion it
Culdom! WToW 31SU /loond
ITDC MR/I
Turbittiv NM
Remdttry sus -rwded 530 mr, fL
Tolid SUB 03,66 am/L
li aftils
A&dimiW to pH4.5 -r/L
AllmlbLltv 10 PH 93 -4/1.
cArbonau TZ�L
rrZ/L
Cattan dxncWe aig/L
chimille !M/L
chrofflikum- HeK 1032 w,&M
10 CAL
nclibrT
c—== vntjL
'-ODMMENTG
Diu_ So" -AM mr,/L i
Fluoridegm mg/L
Hardnesx!%td900 m&IL
992
Hardnow Lnwwmrb z:ng/L
smuste, mr,/L
mLIL
MAS,
Damoomme m IL
'Saka v— rnrjL
NM SJW�nq 0.01 m&iL
TKN msWiM -rng/L
X
WO-NMAs-fiN 0.06 mj;/L
PO4 mg�L
X •
AgSikver46566' -
C5-0
!%lt
X
AlAlumhwum46557-
140
uf,/ L
X
AsAymmkUffil
<10
ufj L
X
U41mrimm 46M8
<20
Uf/t-
X
Ca,--akrw 46552
80
Mf.'/l
X
Cd-Cadium 46559
<2.0
"t/1-
X
Cr-Chromimm 46560
<25
Uo-
X
CoCpprk-rI042
89
urr/L
X
St- Iron 1045
88 ug/L
X
hg._Memljrv7l9OlD
<4-2
ur,/L
X
K-Pbtanhim 46555
1.0
ME/ L
X
M r. - Nistuln 9v
0-72
mg/L
X
hbvMm?cAnem 12Z
<10
ugjl
X
NiSodium gW
65
M611,
x
Ni-brw;odd
<10
-'-mg/L
x
PbJAd 485W. •
<10
US/I
X
SrSdadvm -
<.5.0
wr,/L
x
Z.-Ziw46567
25
-/L
I Lb Number
YG1916
Date Pmmhped
u=ow
'rime xec6ved
w
Fzodved By
HMW
DS
Dab rcpoltE
mool
A-d FirriKidm
Casalme
S
iw
JAN 10 2091

- V--
lop
+JOM'CARDLINA
GROU DWATER fIEZA—AB'FORM Mmeparlumst -of bntwm , vvt mW Natml -Resourm
=VMM OF Wgr& QUAU7Y SPD1MWATEk,SECaON
Somple-Type le Prioffft limb NmWw
�L4 Y z� Iql,
m" Serial t4o. r;RaLffine -tote ke"
w .Lot. •Lacs. .7, Emergency E From: Bus�. }land M.
.0rhLr
Report To: A, TLC (ARO CO 01 her) -,Chaim of Custody Data Entry by. Ck
Shipped by: (Bus, Hand Del..0ther)
Date CiO bee kepurtad:
Time: v,
Purpose: (baseline, Complaint, Compliame-LUST, Pesticide Study, FederviTrLwt, Other):
.E= ANALYSES Owner
Location or site
-leaq- 4SELIC) -Z!C Odor
APPUWW= sr,
L49MATMV ANALY-Us
1901), 310mgl
ICOD High 340 4mll
Dlaw 3 5 "A
Coilform. MF Fecal 31616 AOOMI
Colfform-AF Totd31504 /wDrnl
T& 680 - UVA
j7urbidity76 NTU
P,esidur-.-Suspended 53Q M/l.
pH 403 Wft
AlkdiT*"-pH-4.5410
�MWinllyl*,VM 23 415 TF13A
Carbonate 445 rrq/1
BicwbmWB440
Carban45036&405 JrqA
WOA
Otromum. H" 1032 -:w4
Demaiption of somplingipoint
Amapling Method sm"Ple Inh7%mj:
krawrks
I Dils.solids 7'0300 mg
jFlm-;de9-5l . ffs/I
jRardne-sv -Total 900 4v/j
Wardre-ss: tnonwrb) 902 "/1
Whenols32730 U_g/l
Specific cond. 95 Umhos/cm,
15uWatr- 945 7R911
10ii andoFtreaft-1 mg/l
NHr'NUN" A
Tmm"tm -rwl
NQ24WW='N 630 M19A
IP, Tftdas V60 r -ffgA..
A975ilver 465b6 - ug/l
Al-AhimimmA6557 U-9/1
As -Arsenic 46551 UgA
8a-Borium46558 ug/l
Ca-UCkM 46552 "n/j
Cd-Cadmiurn 46559 Ug/l
Cr-Chnxwum46560 UY/I
b)5
Oj- Copper -46562 'U91i
Fe- lr4on46563 L19/1
01
Hg- Mercury 71900 LigIl
1,j
K-Flatessim 465135 WS/I
nt
ft-l4la3w-vum 46-554 IN/I
Mn-Ma gorse 46565
"m-:";Wiurn46556
5r,-5elmum 3r 1Wv
Zn-Zinc46567
u.
L41 CDMAUNM � -
e-I I P

NORTH CAROLINA
GROUNDWATER FIELD/LAB FORM
County�v[R�r�o►�
Quad No. Serial No.
Lot. Long.
Saar ple 3,ypg Sample Priaft
Water Routine
soil Emergency E
Other ff
Demrrerwst of Em*ram mt w d Nahral Pesmroes
DIVISION OF WATER CQUALITY - GROUNDWATER SECTION
��77
roe a�s�
00 0 We Received - a 0 - v D -Time ,� r;
fl, D&A by C_ From• Bus, Courier, a f.
Other
Report To: . (ARO, CO, Other) [Chain of Custody I Data Entry try: nor-- Ck,
Shipped by: [bus, urier'iiond beL, Outer)
Cdiettor(s): c, d r, S ic►�a� Date: 1� . G pate Reported:
Time:
purpose.ELD Baseline' Complaint, Complionee, LUST. Pesticide Study, Federal Trust, Other);
FIANALYSES je&kkaw Owner
PH,w � ` z � , e��� Spec. Cand.q* at 25°C Location or site
Tempiu j ❑ • L °C
Appearance
Odor
Field Ana"is by �ct f SL vt 5
LABORATORY ANALYSIS
Description of sampling paint
Sampling Method f) Sample Interval:
Remarks ^,t.,
I�q hswr *��rc

G
r
iiiCItjI �0 I L!�Hit
;z)�1j,,4Lv JER SECTION
01 .IAH 19 PH 2t 22
WaSION GF W AM QUAMY
C hmirtry ltbor.lcry Peparl I Gr ad Waler (Nmltr
COUNTY: KEND13UM
S�AMM PRBDRITY
QLiAD ND•
[]ROunm Elam CPNxY
REPORfTn ARO
0 AINaFCWMDY
COUECMR(5) : rABSRW
[HF.
DATE LUL22M
El SAMPLE TYPE
PURPOSE
DOD 310 m /L
COD lii h W m IL
= LOW 335 MrZL
Coldorm: MF Fecal 31616 � 100m1
CohfoOn MF Total31i0i 11mml ,
Too m /1
Turbitirs N1'ti
Residue,.r—rr3ed'itU m IL
Total Sasrrtncied minds mrlL
N units
Ally hmw to 4.5 m /L
Alkalbiiiv to pff 83 mg/L.
Carben.tr m IL
ilkarbou.te m i.
Carbon dimide m /L
Chlor66e m /L
Chrcmiu rc Hm 1032 u lL
lor_ Tux 80 cu.
Cs atdde 7w m / L
CON114E NTS
Lzmfian cr Sitc — — —
Lk.itripkz-of tplistEPaint
Swwuns Mcdwd
Remarks:
Dim Sands 70300 m /L
Fluorkle951 m /L
HardraowbAa1900 m /L
Haidsxas: twnr rN 9M m IL
Pkrnuis3273o u ./L
r+ ilicCard-95 umhm crn2
Sulfate -mLIL
Sulfide 745 m L
M$AS m IL
iOU and Grease to /L
50ira m jL
Boron
Ftrrmeldeitrde m JL
NM asN610 U2 mg/L
TKN as N 625 MI. I L
X
NO2+ND3xsn630 0.08 —/L
W. Totai es Pf,65 ' mr/L
pof m •/L
L.b i` mbcr : YG 1915
Date Reached : I11=000
Time Rezired : 9A5
Readved by
�f
Relrised BY
Date separtcd: IM200S
i. as+ocltiori:re Pr�tiodes
( a Fv+r hares Peoiddes
Nitrorm Pesticides
Add Fierbicidea
bottle
�D] �Qi#➢�9� n

DWATER TIELO AS TORM
C�+ Ci[@Y go►�l� '. 5MRke TYP SMDle PrioriTY
CjUW No. Swial No, Water Routine 'E
Lat. Long. Soil Emergency
Other
Report To-. /? o (ARO,.CO, Otter) CMn of Custody
.Shippod � (Bus, Hard Del;:fZther)
_ r
Collecior(s}ic�w�j {�.1c Dec jf.Zo.[
• Tirriv
FrE f ANALYSES
Tempso t3 -
Appe—nsa
Field Analyris br.
-LASMATMY,ANALYSLS
NORTH CAROLINA
1.
bepwtace of Envkawwoxt.and Nattrral.Rcwzxaz
braSMN OF WATER QUAU7Y - Z ROUNDWATEk SECTION
s�.
Purpow (&=Tine, Complaint, Carepliance, LUST, Pesiidde Study, Federal Trust, Othcr): {{ II
Wr� r"7 Owner
5pe Cond"
Odor
�nZ'--' �0?gov % S
rlsyll
COD High 340 "/1
COD Low 335 Mg/1
Co i arm; MF Fecal 31616 0t mi
Coli f orm- MF TQto130304 1100ml
TOC 680 rng/l
Turbidity 76 NTU
Residue., Suspended 530 my11
pH 403 units
Aikwlinity4apH45410 mg/1
AlWinityto pH 8.3-415 mg/1
CzrbmwteA4b mg11
Bicmtomte440 . W911
CarbonAkoadeA05 - -tnq/k
Ckrlaride 940 ' mg/1
Qvvmitm-Hex 1032 ugll
Color: True 80 CV
Cyamde 720 -"/l .-
tld,z59z Location or site
Lab Nnober
Dace Raccivrd
Rued
Other -;
Dota En" by-.
Date Reported:
r,
yc�-m l :�5
❑ Q Time Ir
From: BusrCou and W.
Description of sampling point
Smnpliny Method IF..C"W- -SP:gajg Sample Interval:
Ranmics �e+k ►a7�'1 eY LQ� N_:
Diss_Soiids70300 n9/1
Fluoride 951 mg/1
H Total 900 m91
Hardness, (non-carbI902 "A
Pharos-327 o ugll
Spec= f icCond.95 u os cm
5ukfatc 945 "/1
Sulfide 745 mglE
Oil andi9reetse nv/l
NH4.3 cs N 610 mgl
TKN as N 625 mg/1
NO2-W3 as N 630 mg/1
P Toted o s P 665 mg/1
Aq-Stiver 4656E jJ31i
M-Alumiruun 46557 trg/l
As -Arsenic 46551 tiug I
1
E -Hanum 46558 Yxjl
Cl�'>
Co -Calcium 46552
�S
Cd-Codm+um 46559 ::'091
pAk,
Cr-Chromsum 46560 . t9A
D15
Cu- Copper 46562 :49/1
,s
Fe- Iron 46563 ug
Hq- Mercury 71900 ug
nn
K•Potass um 46555 R911
Mg-1Jagnesitim 46554 n1911
Mn-Manganese 46565 taW'71
�y5
No -Sodium 465 ng
Ni--hkckef ;,�tj� %
nl
M-Laod 46564 f m9►1- _
�,
Se-SrJpuum �ttgiTl+?�;•,
Znr-Lnc 46567
LAB CO"ENTS
Ck
iYY.6s for bWokW Arrlyale -mean foW%d a MW in hlyd< — - -- — -

NORTH CAROLINA
DEPARTMENT OF.ENVIRONMENT AND NATURAL RESOURCES
GENERAL'"PLIC ATION FOR PERMIT TO CONSTRUCT AND/OR USE A
- WELL(S) FOR INJECTION
Class 5 Wekls
' r ` - , Ite Accordant with i i s e the p ravsons of NCAC Title 15A: 02C.0200
:r Complete application and mail to address on the back page.
DIRFICTQR, NORTH CAROLINA DIVISION OF WATER QUALITY
F {:' DATE: '' , 24.
Please type pr prim clearly.
'Ypon completion of this general application, consult the attached guidance document to
'tieterntlne-wh1ch supplement form is required for your Specific injection project.
- 'r_ `A:. " PERMIT_ 'APPLIC AN T
{r,'_.'4�:y_�_ ,.:• _ ;Addres5:',.,' � L r- �li� S� --- ---
City: ,r�`�'L� Zip Code: County ❑ ,�]
Telephoned �� 7 2�7� 7 �� ❑�3 -�
PROPERTY OWNER (if different from applicant)
x_ .r Name: j�.Q�D•. f2tIG_C_ - --
Address' _ _�� tc • -- - - - - - -
1 City; Z_ Zip Code:, County:'
Telephone: rfne 5E2�-? 7 w ".J 'fir 4 •s ` - -
=C, STATUS OF.APPLIC.ANT
Private: c ConVpereial; Fcdcral: State;
r Y County: - M4uucipa1: Native American Lands:
FACILITY (SITEi DATA r
Aw
.,-(Fill out ONLY if the Status is Federal, State, County, Municipal or Commercial).
h _ = -Name aF Business or Facility:
r Address
' City: _ Gip Cade: County:
' TeXe�haneContact Person.• ,
y; G W-57 GEN (Jaa, 2Q4D) ,' Page I o f 5
..A;� 4-
4f.

=[Kip• '•'.1, r: ..•��i:i } •:iM1Y, ,_ ..
�NJECTIChi PROCEDURE {Briefly describe how the injection well(s) will be used.)
01
:. ap•: ..fir; , " '•''E+{' 7 -''.I�� L ;//•_.-1 , I �I�'�I���j����CF �f/f� f
.7'f.+S+' •s a` •,'lt! ' Ji�r%C! •/'77/. ry Lam/„ -]-�f- yti' �'f] L. C%/��y� F E !J/�� �"�'— [•
WELL USE - Will ,tic _injection weli(s)• also be used as the supply well(s) for the
t-
�.Yr . t: following? f
?•}' 'ry rA'.•f.i' fir. "r' • 1 .. I♦I -
J `-.(1) The injection operation? YES NO
YES NO,
-
" CONSTRUCTION DATA (check one)
EXISTING WELL beins proposed for use as an injection well. Provide the
data in (1) through (7) below to the best of your knowledge. Attach a copy
- Re ord) if available.
�'�� :� �_ • •��' '+�': al'Fo GW=I (Weil Construction�: .
�• _ r -.PROPOSED WELL to be constructed for use as an injection wC11. Provide
the data is (1} through (7] below as PROPOSED consiructio _
specifications. Submit Form GW-I after construction. �$A
1 • I! -err VJ i%/rJ 4.C�/C��-•L.� K-r ` • �,
(l}e}1 I]ritiing Contractor s Name:
NC Cvntrarrtor Certification number: .
bate,to be•copstructed:Number of borings:
Apprqxirnatc depth of each horing (feet):
Well casing:
7.
;: `" ';' " .• Galvanized steel Black steel Plastic Other (specify)
ITyFe:
s r'
ng depth, 'From U to ft. (reference to land -surface)
`.r i •6i 'f Casi
g extends above ground inches
asln
J.
tyQP: _ CeMent Bentonite Other (specify)
"�• ,ti 4r- F'' '' :> ' '` Grouted surface and grout depth (reference to land surface):
za•r:,;_;,, j� ,. around closed loop piping; from to (feet).
around well easing; from to _(feet).
E . , S amens
t 1� pepth. From �;.__ to feet below ground swfacer
qf' v '' I •f;
y �+� L GW-51, GEN Qjw- 20W) Page 2 of S
.. "•.rr+rah; ?� r Af. 'r e�'
+' 7• � r`.f �- r :•w, are•,
` •gv.

N,C. State Regulations (Title 15A NCAC 2C .0200) require the permittee to make
provisions for monitoring wellhead processes. A faucet on hate influent (recovered
groundwater) and effluent (fluid being injected into the well lines is generally -
r,• � - 1, • :require � ...s -
=w`;;., w
, • fl : W ill there be a faucet on the influent line? es no
, Will there be a faucet on the effluent line? yes r no
(7)' ,j SOURCE WELL CONSTRUCTION INFORMATION (if different from injection
well Attach aco of Farm GW-1
-� ) PY (Well Construction Record). if Form GW-1 is not
1. a .'. . ;-F available, provide .the data in part G of this application form to the beast of your
',y, y f! V. .? • . r .
s- fir -
knowledge.
NQTE; THE WELL DRILLING CONTRACTOR CAN SUPPLY TFE DATA FOR tcrIilER FX[STING OR
f ..
• '� j; . y; 's .' �'.' .` PROPOSED ►VRr:r-c i$THIS INFORMATIONIS UNAVAILABLE BY O'I%fPR MEAhS.
' Hi".."' PROPOSED OPERATING DATA
:yF ' (l) Injection role: - .5 Average (daily) -��allons per minute (gpm) "t
t i ,
4._ } r'�' .. •• ,.',F' 'fit .., �_. •
r : ' 4(2) . Injection volume: , Average (daily) /_?allons per day (gpd) K
ae " {3), lnjection pressure:' Average (daily} - _ poundslsquare inch (psi)}�ci�Sr��
�. .
L (4) injection, temperature: Average (January) �-2 ° F, Average (]ulY)'Z ° 1�
'(5) '' Hydraulic capacity Of the well: �W C0/"
(6).: - I Expected lifetime of the injection facility: �O t years
47) Give a description of how the above data will be measured�and
. controlled.
• sir ..S*T., r�6•.'��-� IrJ�--I lF%��r%f�e`�5r�'���' �G�di� � FTr���/�l!%�./ f" . G��
V/kly�S 5r t .{ =tr' JL�C%�4 I2f �y'Z. Cif/ J1,
.� _
V YNJECTION-RELAXED E LIPMENT
' Attach, a diagram showing the detailed. plans and specifications of the surface and subsurface
' construetiou details of the system,
-.].-`44!QATION. QF WELUS)
attach a scaled, site specific map showing the location(s) of the following:
the proposed injection well(s);
-(2) -all property boundaries;
(3) < ' ;; the direction - and distance from the injection well or well system to two nearby,
permanent reference paints {such as roads, streams, and highway intersections);
{4) • all buildings within the property boundary,•
any other existing or abandoned wells including water supply and monitoring wells
within the are& of review of the injection well or wells system;
(5) pptentiometric surface showing direction of groundwater movement,
' "_ GW-5:7. CyEN (Jan, 2000) � : - % Page 3 of 5

(7) ; any. existing sources of potential or known groundwater contamination, including
_:, ' waste storage, -treatment or disposal systems within the area of review of the injection
-" f } ,� fr " �'' _ well or well system; and .
4. {$) ail surface water bodies within the area of review of the injection well or well system.
INJECTION 1: LUM DATA
• ' :Inlaid- source, if undergroundf�rom what depth, formation and a of rockls
•_���• �[1}.��.�' P type edimenk
wrr:;, r' j[,,a':• _s''.' �r unit will the fluid be drawn {e.g.; granite, limestone, sand, etc.).
y,, s �H : f , „ .;•; ; Depth:.
Formation'
Rock/sediment unit.•
i. Provide• the chemical, physical, biological and radiological characteristics of the fluid
tQ be injected,
L: 'PERMIT LIST } -
' r' -Attach a list of all permits or construction approvals that are related to the site, including but
not limited to:
'Hazardous Waste Management program permits under RCRA
>(2) .NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
(4) Other, environmental permits required by state or federal law.
114. CERTIFICATION
,41 : , r ; , ` "I hereby certify, under penalty of law, that I have personally examined and am familiar with
;r the information submitted in this document and all attachments thereto and that, based on my
inquiry of those individuals immediately responsible fdr 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
ti :injection, well and all related appurtenances in accordance with the approved specifications
- and condi_txons of the Permit."
tn
Y ..;,,• " '- ' �y" (Signature of Owner or Authorized Agent)
Please supply a letler signed by the owner
authorering the above agent, if authorized agent is signer.
;.
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' i. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other
,"",''"'pprcy riglrt�► in' 'thege , bein'eonstructecl. A well is read property and its. construction an
lard rests owner_ stuip in the lartdo►�vaer i� the absence of contraryag_ eemept in -writing')
k' if the., property is owned by someone •,other than the applicant, the property owner hereby
' ° •• ' ` •' consent§ #o' allow the applicant to constrict each injection well as outlined in this application
and that it shall be the responsibility 'of the applicant to ensure that the injection well(s)
cc�ttfotms ta.the Well Construction Standards (Title 15A NCAC 2C .0200)
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(Signature Of Property 6wner 1f Qifferant From Applicant) I
;:;P}easeE retyrnmtno copes of the completed Application package to
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-,A! UIC Program
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Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
�. '. • G Raleigh,, NC 27699-1635
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Telephony {919} 715-6165
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'� GW-517 GEN'. (Jan,'20W) Page 5 of 5

HENDERSON COUNTY QEI-..ATMENT OF PUBLIC HEALTH OP nf� J iJ
kt''` QpERATloms-PERuir
C+wr>er E' [)ale - I� ' AC No f� 0
Wildrty Contractor ' i No,
�ptic;>'ar�k lnsiatler.:� a� V Q ' ' ► Wl No. C`IJ" rJ
! A! NO: �T [)evelopment f _ Ffrt-�-LS _ Water Supply: 0 Community ❑ Shar
I;ocation t'� ►G V [`1�L- ►`� ] Td �LfJ c 4 r j� individual, ❑ C,ty
F�;o1Yj rJ &i? [r-r Syg ❑ Tank Size r=-rya Gal.
11-*4, � l pGE �ie � ��'��rP� /`tf C_ Drainfleld `�'02� ES? Sq. 'Ft -
Ho use -r• Q ' : Mot)0'Home ' ❑ - Stone Depth i Inches
System Type . �LE�[P,9A- L
No .awrpoms. Design Flow,GRD d _ _ _ Min. System Review Frequency
.ot5ize'.r=. �QfG
issued By, - :v ��-
hvr+er's Signature,�I Environmental Health, Specialist
VALIDL Ml.Y FOH U5f ESCRiBED ABOVE
t' E P_4"INQ NQT TO SCALE,
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i�S'RargO,,Identifcation°,N mbar (PIN): '10-0601-32-1896-55
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Parse[ ad: 9,9,398fi6
ibis Map is prepared rot Flit innniory of real propwy found
•Nlap Sheet -:0603,00 ;Y I rriVhW Uus jut isdicIim, and is compiled from mcurded deeds;
f'• " ' r�r� f « F t : ;'}' PIns, and ocher public records and data, usm of lhq map
.i Deed 8,�ok•�and_ Page. 6331., t 31 - v¢ hereby naliiicd Ihrt Fhc a[urcmcnlioned puh3"Fo primvy :.
?arc�1 rDascriptior�: L#fi0 LACE FALLS SI❑ informslian %vuicm 3hGuid W eonsull d for Ycrirlcal''M of '
Oic infornution contained oa This map. the County VA -Ppi"6
#?ar.�ei Address: SR 592 OFF WASH FREEMAN. R D company auurne rw Ic441 reaponsibiIIty lot Fhc Luf0cmation
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DIVISION OF WATER QUALITY
GROUNDWATER SECTION
November 15, 2000
MEMORANDUM
To: Landon Davidson, L.G.; Groundwater Supervisor
Groundwater Section
Asheville Regional Office
From: Mark Pritzl Of - [e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section, Central Office
Re: Request review of a new injection well permit application for the operation of an open loop
geothermal heat pump system.
The CO-UIC has received an application by Mr. & Mrs. Randall for a new permit for the
construction and operation of an injection well located at Lace Falls Properties, Lot # 59, near
Hendersonville NC. The proposed injection well will be part of an open loop geothermal heat
pump system, therefore a type 5A7 well.
1. Please review the application and submit any comments to CO-UIC. Retain the
application for your UIC file.
2. Please inspect the proposed injection well site to verify that the location and construction
plans submitted in the application are accurate and that the NCAC Title 15A 2C.0200
standards are being complied with, using the enclosed Preconstruction Injection Facility
Inspection Report -Form (A) as appropriate.
Please return any comments immediately upon application review. You are requested to return the
completed Preconstruction Ij jection facility Inspection Report Form (A) to the CO-UIC by
December 15, 2000. If the inspection can not be accomplished by this date, please inform the CO-
UIC. The UIC Group appreciates your assistance in the review and evaluation of this permit
application. Please contact me if you have any questions or comments at [phone].
cc: UIC Files
Enclosures

A`vrj�-UAA
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
November 15, 2000
JAMES B. HUNT JR.
GOVERNOR
Mr. & Mrs. Robert F. Randall
226 Dogwood Drive
BILL HOLMAN Mount Holly, NC 28120
SECRETARY
Dear Mr. & Mrs. Randall:
ENVISION OF WATER QUALITY
KERR T. STEVENS
DIRECTOR Your application for a permit to use a well for the injection of geothermal
heat pump effluent has been received and is under review, A member of the
Groundwater Section's Asheville Regional Office staff wi11 be contacting you to
arrange an inspection of the injection well and collect water samples as part of the
review.
If you have any questions regarding the permit or injection well Hiles please
contact me at [phone].
Sincerely,
Mark Pritzl
Hydrogeological Technician 1I
Underground Injection Control Program
cc: CO-UIC Files
ARO-UIC Files
GROUNDWATER SECTION
1686 MAIL SERVICE CENTER, RALEIG}f, NC 27699.1636 - 2728 CAPITAL, BLVD-, RALEiGH, NC 27604
PHONS 919-733-3221 FAX 919-715•DSBB
AN 99U AL 0PPO R TUN I TY / AFFIRMATIVE ANTI DN EM PLRYER - 50% RECYCLED/10% POST -CON Su M ER PAPER

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11t15i00 17.03
NO.365 901
Mount Holly Branch
24S W. Catawba Ave., Mt. Holly, NC 28120
M 704-827-3581 (phone) 704-827 8S73 (fax)
TO:—.
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FAX NUM3ER: i- / -
FROM!
PHONE NUMBER:
DATE:
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NUMBER or PAGES (INCLUDING COVER):
COMMENTS: �ria — �.� /44� tt�
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!f you experience trarrmiisrion problems, please call 704-827-358J