WI0100023_GEO THERMAL_20120510

Na
NCDEN�
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P. E.
Governor Director
May 10, 2012
Johannes and Martha Pena
667 Keener Road
Murphy, NC 28906
Subject: Rescission of Injection Well Permit W10100423
Dear Mr. and Mrs. Penz:
Dee Freeman
Secretary
On May 4, 2012, we received notification that your water supply well is no longer being used for
geothermal heating/cooling purposes. In accordance with this status change and your request for
permit rescission, your permit is rescinded and the well can no longer be used for injection. Our
Asheville Regional Office staff may wish to verify that the well is no longer being used for injection.
If you wish to conduct future injection operations you must first apply for and receive a new injection
well permit. Operating an injection well without a valid permit could result in a civil penalty of up to
$25,000 per day.
If you have any questions please contact me at [e-mail] or 919-807-6412, or our
Asheville regional Office staff at 828-296-4500.
cc: Landon Davidson —Asheville Regional Office
W10100023 Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleo h, North Carolina 27604
Phone: [phone] FAX: A9.867-649B
Internet www.nmaterquali€y.polweblwolaos
Best Regards,
Thomas 5lusser, L.G.
Underground Injection Contra] Program Manager
NanethCaroI'
latmr'lalllf
An Equal Opportunity 1 Afrirmative Ado Employar

State of Nortli Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: 1, �rl L o r d_C)o
Permittee Name: -J0 H A N C79 e,- M A A TH A F E N. z
Address: t,97 Kagw e- Xao pf My&F>Nj7 N[ Z83oG --
Please check the selection which most closely describes the current status of your injection well system:
] r_l Well(s) still used for injection activities, or may he in the future,
2) 19 Well(s) not used for injection but is/are used for water supply or other purposes.
3) ❑ Injection discontinued and: a) ❑ Well(s) temporarily abandoned
b) ❑ Wells) pennanentIy abandoned
c) ❑ Wells) not abandoned
4) ❑ Injection well(s) never constructed
Current Use of Well.
If you checked (2), describe the wet use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information. _
r' f�i iV [.{ �: i 17 r\ ! j F WU % S �7 �S' 1 L� �N C� i i4>2 r1 L Y ❑ F '
r �
sA"_LL�'�Epz an ; VAS _ y0 t
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description ofhow the well
was sealed and the type ofmaterial used to fill the well f permunendy 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 ofthe
permit. Do you wish to rescind the permit?
it Yes Ll No
Certification:
" i hereby certify, under penalty of law, that I have persanal iy examined and am familiar with the inroi-mation submitted
in this docurnent, and that to the best of my knowledge the information is true, accurate, and complete."
S ignature
2 7-�
Date
RECENED10ENFlDW0
Revised 5/05 GWIUIC- iB
p{qWler Pr4teC1V� 56s:lifln

i
Permit Number WIOI00023
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
facility
Facility Name
Johannes and Martha Penz SFR
Location Address
667 Keener Rd
Murphy NC 28906
Owner
Central Files: AP5 SWP
06/15/09
Permit Tracking Slip
Status
Project Type
Active
Renewal
Version
Permit Classification
2.00
Individual
Permit Contact Affiliation
Johannes Penz
667 Keener Rd
Murphy
TIC 28906
MajorlMinor Region
Minor Asheville
County
Cherokee
Facility Contact Affiliation
Owner Name Owner Type
Individual
Johannes Penz Owner Affiliation
Johannes Penz
667 Keener Rd
Murphy NC 28906
DateelEvents
Scheduled
Ong Issue App Received Draft Initiated Issuance public Notice Issue Effective Expiration
11/23/04 02/19/09 06/02109 06/02/09 05/31/14
Regulated Activities Requested/Received Events
Heat Pump Injection RO staff report requested 02126/09
Additional information requested 02/26/09
RO staff report received 05/06/09
Additional information received 05/06/09
outfalll NULL
Waterbody Name 5trearn Index Number Current Class
Subbasin

Central Files: APS SWP
05/28/09
Permit Number WIOI00023 Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
miichaei.rogers
Coastal SW Rule
Permitted Flow
Status Project Type
In review Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Johannes Penz
667 Keener Rd
Murphy NC 28906
Facility
Facility Name Major/Minor Region
Johannes and Martha Penz SFR Minor Asheville
Location Address County
667 Keener Rd Cherokee
Murphy NC 28906 Facility Contact Affiliation
Owner
Owner Name Owner Type
Individual
Johannes
Penz
Owner Affiliation
Johannes Penz
667 Keener Rd
Murphy NC
28906
��[eILfiCl�s
Scheduled
ONg Issue App Received Draft Initiated Issuance
11 /22104 02/19/09
Public Notice Effective
tzPTORRegulated
Ex1 tiIn
Activities
Regut<s_ d1R fir Lved EvgW&
Heat Pump injection
RO staff report requested
02/26/09
Additional informalion requested
02/26/09
RO stall report received
05/06/09
Additional information reovivad
05/06/09
Outfall NULL
Waterbody Name 5trearn Index Number Currant Class Subbasin

LFIX
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Govemor Director
June 2- 2009
Johannes and. Martha Penz
667 keener Road
Murphy, NC 28906
Re: Issuance of Injection Well Permit
Permit No. WIOIO0023
Issued to Johannes and Martha Penz
Cherokee County
Dear Mr. and Mrs. Penz:
Dee Freeman
Secretary
In accordance with your application received February 19, 2009, I am forwarding Permit No. WI0100023 for
the operation of a 5A7 geothermal underground injection control (UIC) well heat pump system located at 667
Keener Road, Murphy, NC 28906. This permit shall be effective from the date of issuance until May 31. 2014,
and shall be subject to the conditions and limitations stated therein.
Also attached is a summary of the laboratory sampling results from water samples collected from your
geothermal well on March 9, 2009.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application
to renew the permit four months prior to its expiration date. As indicated in the permit, this permit is not
transferable to any person without prior notice to, and approval by, the Director of the Division of Water
Quality. If you have any questions regarding your permit or the Underground Injection Control Program please
call me at [phone].
Best Regards,
Michael Rogers, En ironmental Specialist
cc: Landon Davidson — Asheville Regional Office
Central Office File — WI0100023
Cherokee County Environmental Health Dept.
Attachment(s)
AQUIFER PROTECTION SECTION
1636 Mail Service Cen(err Raleigh, Norlh GaroUria 27699-1636
Location: 2728 CapbISou leuard, Raleigh. North Carolina 27604
phone: �19.733-3221 t FAY 1 949-715-0588: FAX 2' 919-715-6048 I Customer Service? 1-877.623-5746
tntemet: www.rirwalemunlgym
An Equal �pportanitp %Atfifmalive Acdon Frmoloyer
One
NorthCarolina
Naturally

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
Johannes and Martina Pent
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C ,0209(c)(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 667 Keener Road, Murphy, NC28906, and will be constructed and operated in
accordance with the application dated February 19, 2009, and in conformity with the specifications and
supporting data submitted, all of which are filed with the Department of Environment and Natural Resources
and are considered a part of this permit.
This permit is for operation 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 May 31, 2014, and shall be
subject to the specified conditions and limitations set forth in Parts 1 through IX hereof.
Permit issued this the �2 day of _j��—t , 2009.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
2

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S, 87-94.
2, This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the: entrance to each well
must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during construction and use,
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section — UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section — Asheville Regional Office
2090 US Hwy 70
Swannanoa, NC 28778
[phone]
GW-1 s must be submitted within 30 days of completion of well construction. Copies of the GWA
form(s) shall be retained on -site and available for inspection.
9_ Well construction records must also be submitted for any existing water supply wells on -site as well as a
site map showing any water supply wells on adjacent properties as specified in NCAC .0211(d)(1)(1)),
PART II — OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the: event there is a desire for the facility to change ownership, or there is a

name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction, Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
PART III — PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
1 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 REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
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.
?. 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.
4

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 Office, telephone number (828) 9-96-4500, 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 he required by the Director.
PART Vli - PERWT 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 2C .0213(h)(1), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer he used for any purpose, the
Permitted 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 he 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.
5

(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel -packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(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 Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART IX— OPERATION AND USE SPECIAL CONDITIONS
None,

LABORATORY ANALYTICAL RESULTS
5A7 GEOTHERMAL UNDERGROUND INJECTION CONTROL (UIC) WELL
PERMIT NO.; WI 0100023
PERMITTEE: Johannes and Martha Pena
SAMPLE COLLECTED DATE: 319109
Collform, total
Coliform, fecal
PH
Total Dissolved Solids
Chloride, Cl
Sulfate
Ammonia, NH3
TKN
1 CFUI100mi
1 CFUI100ml
units
m IL
m IL
m L
m L
m IL
MCL =1
MCL = 1
MCL - 6.5-8.5
MCL = 500
MCL = 250
MCL = 250
MCL = nss
MCL = nss
Influent
not dectected
not detected
na
23
<1
4.1
na
na
Effluent
not dectected
not detected
na
7
<1
3.9
na
na
NO2 + NO3 as N
Phosphorus
Nitrate
WOW
Silver, Ag
Aluminum, Al
Arsenic, As
Barium, Ba
m IL
m IL
m IL
m IL
IL
pWL
pg1L
IL
MCL = 10
MCL = nss
MCL = 10
MCL = 1
MCL =17.5
MCL = nss
MCL = 50
MCL = 2000
Influent
0.05
na
0.05
<.01
na
<50
na
a10
Effluent
0.05
na
0.05
<.01
na
<50
na
<10
Calcium, Ca
Cadmium, Cd
Chromium, Cr
Copper, Cu
Iran, Fe
Mercu , HU
Potassium, K
Magnesium, M
m IL
pq1L
L
OIL
L
m IL
m IL
MCL = nss
MCL =1.75
MCL = 50
MCL =1000
MCL = 300
MCL =1.05
MCL = nss
MCL = nss
Influent
2.5
<1
<10
41
<50
na
0.34
2.1
Effluent
2.5
a 1
<10
55
<50
na
0.35
2.1
Manganese, Mn
Flouride, F
Sodium, Na
Nickel, NI
Lead, Pb
Selenium, 5e
Zino, Zn
pji#L
m IL
pUlL
p IL
L
gIL
m IL
MCL = 50
MCL = trss
MCL = 100
MCL =15
MCL = 50
MCL =1050
MCL = 2
C0.4
Influent
<10
4.3
<10
c10
<5
<10
Effluent
<10
4.3
<10
<10
<5
<10
E0.4
MCL = Maximum Contamination Level per NCAC 2L .0200 (GA Standards)
nss - na state standard
na = not analyzed
'The IAarelorysample matrix interfered wish the ability to to make any accurate deterrminallan; Estimated

A I'
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 511109
To; Aquifer Protection Central Office
Central Office Reviewer:
Regional Login No:
County: Cherokee
Permittee: W10106023
Project Name; Penz 5A7 well
Application No.:
I. GENERAL INF0BAL4T10N
1. This application is (check all thalappty): _New X Renewal
X Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ EvaporationlInfiltration Lagoon
❑ Land Application of Residuals X Attachment R included ❑ 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
—Closed-loop Groundwater Reinediation X Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? X Yes or ❑ No.
a. Date of site visit: 319109
b. Person contacted and contact information: Johannes and Martha Penz 828-837-6496
c. Site visit conducted by: Julie Vann
d. Inspection Report Attached: _X_ Yes No.
?. Is the following information entered into the BIMS record for this application correct?
X Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities: NIA
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 Inlection_Sites:
iIf multiple sites either indicate which sites the information applies to, copy and paste anew section into the
document for each site, or attach additional pages for each site)
a. Loc:ation(s): 667 Keener Road, Mur phi NC
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
If NEW AND MAJOR MODIFICATION APPLICATIONS NIA
Description Of Waste[sIAnd Facilities
I. Please attach completed rating sheet. Facility Classification: residential
FORM: Pena 1)IC staff rpt-doc

AQUIFER PROTECTION REGIONAL STAFF REPORT
2. Arc the new treatment facilities adequate for the type of waste and disposal system?
❑ Yes ❑ No X N/A. -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 X NIA. If no, please explain:
4. Does the application (maps, plans, etc.) represent the actual site (property Iines, wells, surface drainage)?
5. X Yes ❑ No ❑ NIA. If no, please explain:
b. Is the proposed residuals management plan adequate and/or acceptable to the Division. ❑ Yes ❑ No
X NIA. If no, please explain:
7. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
❑ Yes ❑ No X NIA. If no, please explain:
8. Are the new treatment facilities or any new disposal sites located in a 104-year floodplain?
❑ Yes X No — N/A. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measureslspecial conditions in Part IV:
9, Are there any buffer conflicts (new treatment facilities or new disposal sites)? ❑ Yes or X No. If yes,
please attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit:
10. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? ❑ Yes ❑ No X 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;
11. For residuals, will seasonal or other restrictions be required? ❑ Yes ❑ No X NIA. If yes, attach list of
sites with restrictions (Certification B).
III. RENEWAL AND MODIFICA TIONAPPLICA TIONS (mve previous section for new or major modfykation
systems) N/A
IV. BUECTION 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.)
Descrintilon Of Well(a) And Facilities —New, Renewal, And Modification
l . Type of injection system:
❑ Heatinglcooling water return flow (SA7)
X Closed -loop heat pump system (5QM)
FORM: Perm UIC staff rpt.doc 2

AQUIFER PROTECTION REGIONAL STAFF REPORT
❑ Ire situ remediation (51)
❑ Closed -loop groundwater remediation effluent injection (5U"Nan-Discharge")
❑ Other (Specify:
1 Does system use same well for water source and injection? X Yes ❑ No
1 Are there any potential pollution sources that may affect injection? ❑ Yes X No
What is/are the pollution source(s)?
What is the distance of the injection weIl(s) from the pollution source(s)? n!a
4. What is the minimuin distance of proposed injection wells from the property boundary? 25 feet
5. Quality of drainage at site: X Good ❑ Adequate ❑ Poor
G. Flooding potential of site: X 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. X NA .
Attach map of existing monitoring well network if applicable. If No, explain and recommend any changes to
the groundwater monitoring program;
9, Does the map presented represent the actual site (property lines, wells, surface drainage)? X Yes or ❑ No.
If no or no map, please atrach a sketch of the site, Show property boundaries, buildings, wells, potential
pollution sources, roads, approximate scale, and north arrow,
lneeetion 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)?
❑ Yes X No ❑ Not Applicable, If yes, explain:
2. For closed -loop heat pomp systems, has system lost pressure or required Snake -up fluid since permit issuance
or last inspection? ❑ Yes ❑ No X N/A. If yes, explain:
3. For renewal or modification of groundwater remediation permits (of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident?-❑ Yes ❑ No, X NA. If yes, explain:
Drilling contractor: N/A
4. Complete and attach Well Construction Data Sheet, NIA
FORM: Pena UlC staff rpt.doc 3

AQUIFER PROTECTION REGIONAL STAFF REPORT
V. E M UATION AND RECOAIMENDATIONS
1. Provide any additional narrative regarding your review of the application, There was a hieher concentration of
caper in the effluent than the influent. However, the concentrations in both influent and effluent is below the 2L
threshold
?. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuancelrenewal of this permit? ❑ Yes X No, If yes, please explain
briefly.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
a
I
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 perrnit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
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;
8. X Issue; ❑ Deny. If deny, please state reasons:
.. 9. Signature of report preparer(s): 1 ; • A01.1
Signature of APS regional supervisor G
Date: Foy +4aw a4 /A.YV V
FORM: Penz UIC staff rpt.doe 4

INJECTION FACILITY INSPECTION REPORT -FORM B (CON1•INUED)
WELL CONSTRUCTION
1
Date constructed 9 /.14
Drilling contractor: Name
Address
Registration number
Total depth of well Total depth of source well 1
(rf applicable)
Inspection point Measurement Meets rninimum standards Comments
Yes No
Casing
Depth
Diameter
Height (A,L.S.)
Grout
DepVi
Screens
Depth(s)
Lengths)
I.Q. Plate
1_�1--v- &111
�t 1
Static water level r W Ceh�L{�d
Well yield w;=:� . -
i-
Enclosure �¢
Enclosure floor
(concrete)
Sampling port l/
E4.sff�
Water tight pipe eziitiry JC
Well enclosure'eiatry,;:-
Vent
Functioning of Treat pump system (Delervibie front 1he owner if heat pomp f me4ow properly)

North Carolina Department of Environment and [Natural Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSP +' CTION REPORT - FORM B
11
INJECTION WELL PERMIT INO. WI 0 f 000� DATE _� [A5 _
NAME OFOWNER Q Z-
ADDRESS OF OWNER
(Shvell road or lot andstrbdiulsion, county, taiw+) LOCATION OF INJEC'rIOIN WELL (and source well(s), if applicable) a4 p k, tl
(Street/road or lot andsubdivision , county, tosm, ifdierent Man osvner's address, priers description oflocation on site)
Potential pollution source _mat_ _ Distance from well _ Z-_
Potential pollution source '� Distance from well
Potential pollution source Distance from well
Minimum distance of well from property boundary
Quality of drainage at site _od._ Flooding potential of site JOW
(good, adequa te, poor ) (high, moderate, low)
DRAW SKETCH OF SITE (Show property boundaries, buildings, tivells, polentialpolludon sources, roads, approximate scale, and
worth arrow)
ACV
DESCRIBE INJECTION SYSTEM(verllcal'clasedrirop, uncased.borehole well; •sepgt'ate source, well and
it jecdoii well; cbn i►ladort. source and injaetion well; or other rlescrfptiwi,ets'appllcabtej_ •; �,. ~',',:':,:
At
41,4 .•

-�
D r,f Q LaGorato of Section Results
County:
CHEROKEE ,
Sample ID
Ae41666
Rlrer Basin
-
1
F V4A�
PC Number#
9G0321
Report To
AROAP
�.''
41
date Received:
01/1172009
VAHH
Time Received:
09:76
Collectcr.
.1
AN
22
�r�=
L-+6w'orksLoginiD
SMATHIS
Reglow
AARO
f�
fCLO
-
Sample Matrix
GRr7_U_Hr]WATER
Date Reported:
411s109
Loc, Type:
WATER SUPPLY
4
r
RsportGenerated:
ad115Ro09
J i
i
Emergency Yes1No
s `
Y.WMD
We.
Das.er.: MN_7
Oa
f� ( /j
Location ID-
1P02OW10100023-INF
Collect pate:
0310917009 CallertTrne.: 11.40
Sample Depth
Sample ❑uaiifters and Comments ;J ., y .? ; _.r�.
Routine Qualifiers
Far a mare detailed description of these qualifier codes refer to www.dwgIab.org under Staff Acuess
A -Value re parted is the averaDe of two or more determinations
N3-Estimated concentration is c POL and >MDL
B1 -Ca untaWe membranes with <20 Wonles; Estimated
HE -No establlOed P0L
a2- Counts from all filters were zero.
P-Elevated PC due to marix interference andlor sample diWtwn
l3� Caun[etsie membranocwith more Than 00 arSO cdanies; Estimated
84F0lers Nava counts of both �60 or 60 and c 20; Estimated 01-bolding time exceeded prior ba receipt at lab.
R2- Hold1ng 5me exceeded following receipt by lab
SS. -Too many mtontes were present tva numerous In caurtt (THTC)
P(2L- Practical Quantitation Limit-svt jectto change due m insvument sansiti"
JP- Reported value Tailed ID meet QC criteria tar either prcciswn ar acwracy; Estimated
J3-The sample matrix interTered wish >he abiifty to make any acwrata determination: EstrrnarrII U-Sam*s analyzed for thiscampound but not detected
J6•The: lab anary Os was From an unpreserved or improperly rhemtaplly preserved sample: Estimated %i- Sample not analyzed for this compound
NS-The component has peen tentatively Wended based on mesa spectra[ library aearch and has an estirneted value
LAB
Labor;tpry Secoorraa 1623 Mail Serrlce Center, Raleigh, NC 27899.1623 1919) 733-3908 Page 1 of 3

WC DWQ, Laboratory Sectuin _ResuCts Sample ID B41666
Lnration ID: 1POZOW10IM23. NF Collect Rafe: 0300912009
Loa Descr-, PENZ called Tone:: 11:40
Malt ID
CAS 0 Anah" Name
POL
Result
Guallfler
urllbr
ArrslystfData
Approved By 1Dals
Sernpta larr4--M at teal g by Ish
1.7
IC
DSA,UNDERS
SMATHIS
Method Relererces
391 Vw
3111oe
1MT
hmchm"llftgfaphy
TITLE
MOIL
AWILLIAMS
CGREEN
Method RerarwKe EPA 300.0
3117*9 •
3MM9
Ctdodde
1.0
1.0
U
MG&
AWIL,LIAMS
CGREFIN
1,4elhod Refsrarm EPA 3MO
W17MO
MGM
FhrO m
0.4
0d
U
ROIL
AWILUAMS
COWEN
MoodRderanrp EPA300.0
Y17R9
3r20A9
SUIN"
ZO
4.1
MOO
AWILLIAMS
CGREEN
Method Reference EPA MMO
3117109
%r2=9
NUT
NO2tNM w N In i<gtid
au
0.05
MAIL as N
MA kAYI
CGREEN
Malhad Rerereace L000.1074A-1-
-
V12%
3119I09
NI7a19 R9 N In"
0.02
Q.DS
r1g&an M
MOIIE=RMAN
CGREEN
Meerod Rolm I", Lacha11074*1s
Niew
3nums
NMU as N In liquid
0.01
0.01
u
ROIL as H
G13ELK
CGREEN
Method Retaranca La&%d107-0a7{
3AIM9
911em
74786-80-5 Al by1CP 50 50 u UG& PCOWHIER ESTAFFORD
Method Refefw%a EPA 270.7 3rMw 4115109
744MS-3 Ba try ECP 10 10 u IWL PGAUTHIER ESTAFFORD
Malhad Refeence EPA 200.7 3119N9 4115109
7440-70-2
Ce by 1CP
0.10
25
ffQ L
PGAUTHIER
ESTAFFORD
Muhod MOM.
EPA200.7
f
311=9
4115M
744943-8
Cd b?ICPMS
1.0
1.0 u
WEI&
SGOSS
ESTAFFORD
Meltwd Rafefence
EPA 200.5
3►20109
4115MO
744947 7
Or by ICPAIS
10
10 u
WEI&
SGOSS
ESTAFFORD
MWM Refarence
EPA 200.8
MOM
4r1SM
744¢60.8
Cu by 1CPM6
2.0
41
UO1L
SGOSS
ESTAFFORD
Mehod Rare,a a
EPA 200.a
arwmo
4113i09
7439- m
Fe by ICP
58
00 u
q&
PGAUTHIER
ESTAFFORD
Melhud Refererm
EPA 2M.7
312M
4115109
7"0-09.7
KhyICP
0.10
0.34
_
MG&
PG4LRHiER
ESTAFFORD
Melhod Refem=
EPA2M.7
3r19R7A
4l15=
7439•S54
Mg by iCP
0.10
2.1
MOIL
PGAUTHIER
ESTAFFOR13
VMCMd Rmrararrca
EPA 200.7
3m&"
4MSM
Laboratory Sectlon» 162E Mail Service Canter, Raleigh, NC 27091-1823 1912) 737-3WS Page 2 of 3

5VC DWQ Labor1t01?y Section �Rpsu is Semple ID
AS41666
Locatlotl ID: 1P020 MI000234NF CcledDale:
03l09m09
L". Dearr.: PENZ CoMdTirw-
11,40
Vlait IA
CAS 0
Analyes Mane
POL
Rasutl
Chia" 4'
u"m
AhelywMata
Approved 0y IDate
7439-98-5Mn
by JCP
1D
16
u
UO&
PGAUTHIER
ESTAFFORD
MVMMRerermra
EPA=7
arem
4M810a
7440.2M
No by ICP
0.10
4.3
MIWL
PGAUTHIER
ESTAFFORD
MOMMRafarN=
EPA2DM7
`f�
3m2w
4118108
7440-02-0
HI by ICPM3
10
10
u
4L
SGOSS
ESTAFFORD
McUmdF%W-
EPA210.a
3f1511t19
471d09
743"2.1
Pb by ICPM
10
10
u
4L
SGMS
ESTAFFORD
MON" Rsh"f=
EPA 200.E
30M
UISM
7782-49.2
Be by ICPMS
5.0
&0
li
WL
SGCSS
ESTAFFORD
Method FWOA M
EPA 200.8
3rn=
wism
744""
Ill by ICPMS
10
10
u
u9&
SO955
ESTAFFORD
MuChod Rafe w
EPA200.8
3r2QM0
4l15M
Laboratory Saollonaa 1623 Mal Serrlee Cmftr, R.e1e19h, NC 271199-1623 [phone] Page 3 013

County;
CHEROKEE
River Basin
a--
- -- -^-_ .. - - -- — _
D� VIA r,�?
Report To
pn
AROA P
Collector:
Region:
ARC)
�7r,ry
A9
MAR 13 2AUU
MAR
Sampe A5atr6r:
GR NbWA
Loc. Type:
WATE�R�SUPPPPk
Emergency YesRVu
ir;. _ � 7r �7-�,�;._,- ? � !?!C�'
CCC yeslNo
Visiif E7
m —L&. denar.:
PENZ.1N
Sample ID:
A941633
PC Number 0
ARO
Date Received.
0310512009
Time Recalved;
15:00
Labworkc Loginl❑
KJIMISON
Date Reported:
W23109
Repon Generated: 03123121709
Location 10: 1P02MG1000213-MF I Colect Date: 03 N12NS I Collect timer: 11.40 I sample Depth
Sample QuaIifters and Commends ,
Routine Qualifiers
For a more detailed description of these qualifier codes refer to www,dwgIah.org under Staff Access
A -Value reported is the average of two or more deteeminations
S}-CountaWe membranes with c20 colonies; EatRnaLed
92- Counts hem all fillers were tern.
B3-CounwhW membranes with more than fig ar80 colonies: Estimated
Ba-Fitters have counts at both �60 or 90 and < 20: Estimated
as -Too many coloNea were present; too nurnamus to count (TNTC)
.i2- Rap"d value Tailed to meet QC criteria for either prwWon araccuracy; Estimred
A -The sample matrix interfered with the abdry to rake any accuratedeterminatiow. EsKmate 6
A -The lab analysis war, lrom an unpreserved or improperly chemically preserved sample; Esttma1 6
N1-The Campo nenthas been tentativdy iden%fled based on mass spectral library search and has an estimated value
ARC
qc 3laq I Ci
M-Estimated concentration is < PQL and y M D L
NE-Na established PQL
P-Elevate d PQL due to matrix interference andlor sample dilution
Q1-Haiding time exceeded peer to receipt at lab,
02- Holding time exceeded lollowi:tg receipt by lab
PQL- Practical puantttotlon Limn suh}est to dlarrge due b tnstrumant aenaiGyily —
U- Samples analyzed for this compound but not detected .
XI- Sample net analyzed lcr this compound
�J ILA �CE y
� t
Laboratory Sectlon» 1623 Mali Servlce Cenw, Ratelgh, NC 27690-1623 (9191 733-3008
! a L )6 R 2 a 20o9
L
lP+R l v r CUfi tl 1"; SEC i i0N

NC OWQ. Laboratory Section results Sample ID A647&33
Lomkn 10: 1P02t1' 01000213-tNF Collect. oaw OSl11WGM
Lae. Moor— PENZ4NF Called Time:: 71 a4
visit Id
CRS A Artalyle Mama
POL Result qualifier
Unks
AradystMew
Approved By 10aw
rRp a�hmpereMe at reo5lpt by teb
4.1
IC
KAfMMON
SMATFAS
MMOd Refwanos
3mm
3MIM9
CoMm 4 MF Facgd In fiquld
1 1 02
CPUI1DOrW
KJIMISQN
CGREEM
Alslhed Ram APHASEZ262Mh
3mm
W12=
UWarm,htFTdalInOquid
1 i 82
CFUrlOOnd
KJIMISON
COREEN
Method Raftroms AFHA92M-20tt+
MA9
3F1209
Total DWs*#ed Sonde In 11mdd
12 23
M91L
K HMISON
CGREEN
MMhad Raterence APHA254CC-1RTH
3113me
9F am
Laboratory Section» 1923 Mats Seryice Camara Retelgh, NC 27690.16M [phone] Page 2 of 2

County:
CHERCKEE
RNer Basin
Report To
ARDAP
Celledor;
J VANN
Region:
ARQ
Sample Mat+ix'
GRQUNDWATER
Loc. Type:
WATEE SUPPLY
Emergency YeslNo
COO YeWNo
LocaSon1D- 1P020VA0100023-EFF
WC.-OU.-D Laboraton,.tection ,)
`b'Ar�9
APR
M
' y i� • .. i y� -
VIUMD
l ac, Descr PENZ-Er
Called Dale' 03109/2099 CaReot Tie;; 72:05
Sample ID;
PQ Number4
Ante Received:
Time RecaNed:
Labworks LoglnlD
Dale Reparled:
Report Generated:
LP
Sample Dep1h
Sample qualifiers and Comments
AB41895
200320
03/11/2009
09.15
SMATHIS
4115109
04/15/2009
_q III j 09
Routine Qualifiers
For a more detailed description of these qualifier God es refer to www,dwgIab.org under Staff Access
ANWua re parted is the average or two or more determinations
iV3-Estlmatad concentration Is < PdL and 7MDL
B1-Cc Lmtable membranes with <20 colonies; Estimated
N E-No established PQL
B2- Counts from ail Mlera were zero.
63- Covntable membranes with more than 60 or 80 colonies; Estimated P-Elevated PQL due to matrix interference andlor sample d�ution
134-Filtiers have taunts of both >60 of 80 and < 20; Estimated D1-Holding time exceeded prior to receipt at lab.
SS -Toe many colonies we re present; too numamus to count tTNTC1 02- Holding time exrteded following recelpt by lab
PQL- Practical Quamitatlon Limivsubject M change dua to instrument senAvity
,12• Reported slue faded to mass QC criteria for either precision or accuracy; Estimated Li -Samples analyzed for this compound but not detec d
J3-Tha sample matrix Interfered with the ability to make any Accurate determination; Estimated
JbThe lab artaty6ie was from an unpreeerved nr improperly zhemkaiiy preserved semptta; Eeiimared 7(1- Sample not analyzed fo• this cum patrnd
NI -The component has Nen tantaMly Identified based on mass Spectral tibrary searrh and has an es imated Value
LAB
iadorstoty Secdorpa 16231tiali Service Cerrtfr, Raleigh, NC VOS&1623 [phone] Page 1 of 3

Sampl
NC (DWQ Laboratory Section *jufts C49ed ID AMI2009
Laca6en ID: �Pa�ovrfaso�ox�-EFP can�z o9w: aaramogs
Lor— Do=.- PENi•EFF Catlett Time:: 42:05
MSS ID
I CAS A AnA to Nang PQL Remilt ❑uaEEfler Chas AnafyWDatq Approved By Mate
Mound Reference
Wilke
3111A9
WET
Ian ChMflub praphy
TTT1.E,
RAIL
A► ALLIAMS
CGREEN
Mabod Rcleronoe
IPA 300.0
31171C9
W2=9
ChbrKe
1.0 1.0 u
MVL
AWILLIAMS
CGREEN
Metlnd Reference
EPA U0.0
Y17M
3r10109
R#MWO
0A CA U
ROL
AN4ILILL4MS
CGREEN
Marhod Refewce
EPA 3DMO
3f17109
s 20"
Suftm
2.0 39
M&
AWILLIAMS
CGREEN
Meftd Reference
EPA 3=0
3r17109
3ROM
N Q2+NC3 95 N f0 PALM
0.02 0.0$ rrg& es N
MAJAYI
CGREEN
Merhdd Rerdfenca Lac1D-107-04-1t
3112r09
3119)09
Nkrets ae N En "
0.02 DM5 mgA. n9 N
MOVERMAN
CGREEN
vmu d Rwerence Ledfa1107- 4 I-c
3119109
N1209
NArbe ee N In IIRM
0.01 0.01 u rrg& ea N
GBE=L K
CGREEN
MET
Mearod ResersKm Lachar107-G&-1-C 311L09 3 ISM9
742"C-5 N dy1CP 50 50 u VIL PGWJTHLER ESTAFFORD
MoftdReferaow
EPA2W.7
3rmw
4115M
744W8:3
Be by ICP
10
10
u
ODIL
PGAUT HIER
ESTAFFORD
Melhod Reference
fPAM7
3MGM
4M6109
7440-70.2
CS by ICP
0.10
25
mp+L
PGAUTHIER
ESTAFFORD
MeuwdRefemnes
fPA�00.7
3119109
411409
7440-43-9
CA by ICPUS
1.0
1 A
U
upfL
$Goss
ESTAFFORD
Mahod R@rarerm
EPA2Da.8
3R0109
4mme
7440-47-3
"ICPMS
10
10
U
UA
SGOSS
ESTAFFORD
Maftd Rehr Inca
E:PA2M8
3ROM
4MSM9
7440-5M
Cu by ICPMS
2.0
55
UDL
SGOSS
ESTAFFORD
MRftd Reference
EPA 2002
31211%
4MBM
7439-8"
Fe ry ICP
50
5a
u
UDL
POAUTHIER
ESTAFFORD
Method R04ranu
EPA 2D0,7
ar.009
4ASA9
7440-09-7
K by ICP
0.10
0.35
mwL
PGAUTHIER
ESTAFFDRD
Method RiOdence
EPA-2D0,7
3fIT09
015M9
7439-95-4
MgV/1EP
0.10
2.1
mQ&
POAUTHiER
ESTAFFORD
MsVxd Rereramm
EPA 20D.7
3f19+09
4MZ109
Labormory Sac6arraa 1622 Nall Service Unter. Rs"h, NC 276MIG22 19191 T33 7905 Page 2 ar 3

NC DWQ, Laboratory Section Results Sample 1° AB41665
LOMIlerr In: 1P020N(MO0025� CaRedDarbw 0 MSM09
Loc. Deser.: PEMZ-EFF Collect T1me:: 12:05
draft 10 -
CAS 0
AnWyw Mama
POL
Result
Clualrfirr
U11ft
MaWDetc
Approved By/Data
7429-90-5
WbVJCP
10
10
U
UWL
PGAUTHIER
ESTAfFORD
McMW Rpererm
EPA200.7
3FZM
015M
T440.23-6
No by KF
0.10
42
MWL
PGAUTHrER
ESTAFFORD
MedmdReverence
EPA200.7
w1wM
Ar1610a
7440-02-0
N by ICAAMS
10
10
U
UWL
SGOSS
ESTAFFDRD
Method ReSeWM
EPA 200.H
32M
AMW9
7439-92.1
Pb by 1CPU3
10
10
U
t10IL
SGOSS
ESTPFFORD
FAaMWRetera=
EPA2WA
]Q&M
4MMS
TF62-46-2
BA by ICPUG
5.0
U
U
uVL
SGOSS
EST►FFORO
ManodRekranoe
EPA2a0.6
3r25D9
{r1610B
7440 M
In by 1CPMB -
10
10
U
trp1L
SGOSS
ESTAFFQRD
Mvftd Raft
EPA2DM8
390%
AM&W
Laboratory 9ec6arla3-- 1923 Mall Service CarAw, Raleigh, MC 276WI5ZS 19191 T33 3900 Paige 3 of 3

County:
River Basin
CHERCKEE
, p
RaportTo
AROAP
�1
Region:
AR❑
Sample Matrix:
GROUNMAJER
Loc. Type:
WATER SUPPLY
Emergency YesINO
-- -- - - - _._—._.....-_-
_�
Ct7C YesrNo
Vlsitl❑
Loc. Descr.t PEN2-EFI'
sample tp:
AB41634
PO Number #
ARQ
Oats Reverend:
03l0912009
Tlrne ReraNed:
16:DO
LabwarksLoginlD
KAM1sON
Data Reported:
3/2WO9
Report Generated: OM312009
aZ� 11�
Location 10: 1P02OW10100023-EFF 1 Collect Date: 030094009 [Collect Time:: 12:06 I Sample Depth
Sample Qualifiers and Comments
Routine Qualifiers
For a more detailed description of these qualifier codes refer to www.dwglab.org under Staff Actress
i
A -Value reported is the average of two or more determinations
NI-Esthnasad caRcerttration is � PaL and rMDL
91-Countable membranes with �2o colonies; Estimated
NE-Noeslahlishad PaL
52- Counts treat all fllters were zero.
P-Elevated PO due to mao-x intt:rierencs andlar Sample dpluiion
B3- Countable membranes with more Than 60 or Bo coion�es: Estimated
84-Fillers have founts of both a60 or a and K 20; Estimated 01-Holding tens exceeded prior to receipt at ]ab-
85-Too many colonies were present; ton numerous To court. (TNTC) 42. Holding time exceeded lollowing receipt by lab
PQL- Practical Quentitatlon Llmit-subject to change due to instrument senslUvIty
J2- Reported value failed to meet QC crile62 for eldler precision or acwracy, EsIJ mated
LJ- Samples analyzed for This compound but notdetected
J3-The sample metrU Interfered north the ability to make any accurate determination; Estimated
?[I -Sample not analysed for this compound }'---.
J6-Tha lab analysis was "in an unpreservad or improperly rhemically preserved sample; Estimates! Z C - F
Ntifi IJba component has been tentatively ;de based on mass speoiral library seam and has an estimated value
ARO
rI� rr 2 6 20
Lw °�a 1
�: �:'l try • n -
Laboratory Section— 1623 Mali Service Center, Raleigh, NC 276911.162] (919) 733-390fs �—`�9��1�EC _�.y�:

sempe In p�41S34
NC` fD'VQ Ladnfatory Section Jesuits
LoesGctlln: iPO2dW1a1114023-EFF C(Awtoate: a9@9IZ009
Loc. Crier- PENT-EFF CdNeet Tlme:: 12.05 `
Visit 113
f CAS F AAMyto Kama PQL Result Quaefler Units ArnalyallCate Approved By ICata
A vhA Rete ce
39M
Wilms
Ocida L MF Fecal In 4qutd 1
1 112 CFLA10Gr1E
KAMiSON
CGREEN
K%Umd Rderonca APKAZ2Z2DQM
3nm
3012M
Cafflum NIFTatel in Iquld 1
1 92 CFLW10W
KJIMISON
CGREEN
MOW Reference APHA5222&2mh
3mm
3112f09
TOW CLIWKed Soffdi In BgYld 12
7 M9&
KAWSQN
CGREEN
Menpd Rmfunff= APK&2540r-I9M
3113M
=3m
Laboratory Soctlon» 1923 Mall Service Cantor, 92109h, NC 275994623 1219) 733-3900 Page 2 of 2

Rogers, Michael
From: Vann, Julie
Sent: Wednesday, May 06, 2009 10:46 AM
To: Rogers, Michael
Subject: staff report and sample results for W 10100023
Attachments: pent staff rpt odd pages.pdf; pent staff rpt even pages.pdf; penz lab results.pdf
Good morning, Mike;
attached are the files containing the UIC field staff report, inspection form, and lab results for the Penz 5A 7 permit
renewal in Cherokee County. I only got the lab results last week; hence the delay. The original report was double sided,
so 1 ended up scanning the even pages then the add pages.._ so rry about that.
Julie
Julie Vann
North Carolina Dept. of Natural and Environmental Resources
Aquifer Protection Section
2090 US Highway 70
Swan nanoa, NC 28778
Phone: [phone]
Fax: [phone]
iulie.vann ncdenr. ov
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.

permit WIO1OOO23
Subject: permit WI0I00023
From: Julie Vann <[e-mail]>
Date: Mon, 09 Mar 2009 17:36:44 -0400
To: Michael Rogers <[e-mail]>
HI, Mike;
Today I sampled the 5A7 well owned by the Penz family in Cherokee County as
part of the permit renewal request. All went well. They have re -plumbed the
wellhead so as to have an easily accessible influent and effluent sampling valve.
Since they will be leaving for most of the summer fairly soon, they would like
you to email the letter of reissuance to them (and the sampling results). Would
you be willing to do that? their email is John Martha penz(OL-Iotmail.com.
Please let me know if you cannot do it via email so I can work with them to find
another way of getting the info to them in a timely manner (they will be
forwarding mail but not in the usual sense, it seems ... it will be stockpiled for a
while).
Julie
1 of 1 3/30/2009 11:56 AM

State of North Carolina
Department of Environment
and Natural Resources
Division of,Water•Quality
Beverly Eaves Perdue, Governor
Dee Freeman, Secretary
Coleen Sullins, Director
Division of Water Quality
Aquifer Protection Section
Location: 2728 Capital Blvd.
Raleigh, NC 27604
Mailing Address: 1636 Mail Service Center
Raleigh, N.C. 27699-1636
FAX: [phone]
[phone]
Date: 4 C- 1 .
I FAX TO: LAW D0,,/ I FAX NUMBER: I
FROM: / c&S
PHONE:
NO. OF PAGES INCLUDING THIS SHEET:
Al9 COP ;` 7D C-U /",/ ev�crc--e
t � I
If you receive this fax by mistake call: Aquifer Protection Section @ 919-733-3221

AOUTFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: Februar � 26. 2009
To: ® Landon Davidson, ARO-APS ❑ David May, WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Charlie Stchinan, WiRO-APS
❑ Andrew Pitner, MRO-APS ❑ Sherri Knight, W-SRO-APS
❑ Jay Zimmerman; RRO-APS
From: Michael Rovers Groundwater Protection Unit
Telephone: [phone] Fax. [phone]
F.-Mail: Michael.Ro�,,ers(trncmaiI.net
A. Permit Number: WI 0100023
B. Owner: Johannes and Martha Penz
C. Facility/Operation:
❑ Proposed © Existing ❑ Facility ❑ Operation
D. Application:
1. Permit T),pe: ❑ Animal ❑ SFR-Surface Irrigation❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Remediation (ND)
UIC — 5A7 Geothermal well
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
Z. Project Type: ❑ New ❑ Major Mod. ❑ Minor Mod. ® Renewal ❑ Renewal wl Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
NOTE: Permittees have requested the site be inspected and Permit re -issued b� end of March as
they will be unavailable for most of the rest of the scar. Please expedite inst}ection if possible._
TFANKS.
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 applicable.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO.*
Remember that you will be responsible for coordinating site visits and 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 SLIP 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:
Date:
FORM: APSARR 07106 Page 1 of 1

��
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
February 24, 2009
Johannes Penz
Martha Penz
667 Keener Rd,
Murphy, NC 28906
Subject. Acknowledgement of Application No. WID 100023
Penz, Johannes & Martha - SFR
Injection Heating/Cooling Water Return Well (5A7)
Cherokee
Dear Mr. and Mrs. Pena:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on February 19, 2009. This application package has been assigned the number listed above and will be reviewed
by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the ]division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time., processing permit applications can take as long as 60 - 90 days after receipt of a complete
application,
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at [e-mail]. If the
reviewer is unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To
review our new organizational chart, go to hitj,Jlh'�o.enr.state.nc.us/documents/dwLprgchart.11d F.
PLEASE REFER TO THE ABOVE APPLICATION NUMMER WHEN MAKING INQUIRIES ON THLS PROJECT.
sincer y,
m-,�-
3for Debra J. atts
Supervisor
cc: Asheville Regional Office, Aquifer Protection Section
Permit Application File WIOI00023
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Ralel h, North Carolina 27699-1636
Lot Wn; 2728 Capital Boulevard, Raleigh, North Camiina 77604
Phone: [phone] l FAX 1: 919-715-0588; FAX 2: 919-715-iD48I Custorner Service' 1-877-62M749
lnlemet www.nctvatemualbt !2
An Equal Opportunity t Affirmelive AcWn Employer
Na Carolina
Naturally

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL: RESOURCES (NCDENR) .
APPLICATION FOR PERART TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 5-A7 WELLS)
New Permit Application OR � Z ewal (check one)
DATE: FE-8 _ IS 2tl-03
P$RMIT NO. (leave blok if NEW. permit application)
A. PROPERTY-OWNER(SyAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): JO HAV LACKS P E N Z t% nd
_1..,__ __gam _—LEA R T�J A PE -NZ - - - -
(1) Mailing Address: 667 k e7F-N E-R R.
city: Ad U R P !, y State:. L zip code:_ 2. g? 40 4 county: N MOK -eF
HomelOffce Tele No.: <fJ 7 - 6 4 Q &-- Cell No.:
EMAIL Address: f f Co W a$ tl . ►'l C P CA
(2) Physical Address of Site (if different than above): Cl t++,%C-
City: ' State - Zip Code: County:
Homc/Office Tale No.. Cell No.:
EMAIL Address:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit. Applicant dacgnot own the subject property,
attach a letter from the property owner autborizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAEL Address:
Address:
City: State: Zip Code: County:
Office Tele No.: - Cell No.:
Website Address of Company, if any:
RECEIVED l DENR ! BWQ
C;PUUC SA7 Weil Permit Appbeatian (Revised 41200T) Aqt if of Pmf-riji)n '. GPL n Page 1
FEB T 9 20U9

C. WELL DRILLER INFORMATION
Company Name: CH ER- O k e e WELL DiZ I L L IN&Well Drilling Contractor's Name: - � I J__L f
NC Contractor Certification No.: J !
Contact Person_ CY415 .DICK Y EMAIL Address.
Address: M -_H_W Y Y W es T -- - -
City: _ ILt u R PK Y, f! C zip code: 219 D C County: CH ERK.0 K E E-
Office Tele No. _ 2413 T- 9O0 d Cell No.:
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Warne: W O OP &&I R L6 C'F_ [ C
Contact Person- (JA &N . _ LJ � UR&I-EMAIL Add Sa -
Address: 14 t_ 9_1= k K.S 1P Ir C l 1Z C L_e
city. HAya V (L LF. R1C Zip Code: Z4ffQ1V County:
Cl-
Office Tele No.: 3d9 13 6 Cell No.:
E. STATUS OF APPLICANT
Private: V", Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
WPTL WAIL is use.) ED& yerar Pump To Hr1coOL HOUSE.
PART of wATm is K-gra"crzNsra TP Weu Agp P kT _"RA1Ar .
G. WELL USE Will the injection welI(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES T NO
(2) Personal consumption? YES , NO
H. WELL CONSTRUCTION DATA (Skin to Section I if this is a Permit RENEWALI
PROPOSED Wells) to be constructed for use as an injection well- Provide the data in (1)
through (7) below as PROPOSED construction specifications. Submit Form OW-1 after
construction.
EXISTING Wcll(s) being proposed for use as an injection well. Provide the data in (1) through
(7) below to the best of your knowledge. Attach a copy of Fora GW-1 (Well Construction
Record) if available.
(1) Date to be constructed: Number of borings: _
Approximate depth of each bo ing (feet):
(2) Well casing. Is the weil(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES If yes, then provide the easing information below.
Type: Galvanized stee]__ Black steel Plastic Other (specify)
Casing thickness: diameter (inches): depth: from to ft. (reference to land surface)
Casing extends above ground inches
GFU/MC SA7 Well Pe mit Appiicadon (Revised 9l2007) Page 2

(b) NO
(3) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite Other (specify) —
(b) Grouted surface and grout depth (reference to land surface):
Around closed -loop piping; from to (feet).
Around well casing; from to (feet).
(4) Weil(s) Screen Information
Depth of Screen: From to feet below land surface
(5) N.C. State Regulations (Title 15A NCAC 2C .0200) require the Penmittee to make provisions for
monitoring wellhead water quality and processes. A faucet on both Influent (groundwater entering heat
pump) and Effluent (water being injected back into the: well) lines is required. Will there be a faucet on:
(a) Influent line? Yes No (b) FEluent line? Yes,__Na
(6) Source Well Construction Information (if the water source well is a different well than the injection well)
Attach a copy of Form GW-1 (Well Construction Record). If Form GW=1 is not available, provide the
following data:
Groundwater Source. From what depth, formation, and type of rocklsediment units will the groundwater
be withdrawn`! (e.g. granite, limestone, sand, etc.)
- Depth: Formation: Rock/sediment unit:
MOTE: THE wELL DRILLING CoNTRAcrOR CAN SUPPLY THE DATA FOR EirHER E}IIS Ncy OR PROPosm WELLS tF
THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
L OPERATING DATA wNei4 kewr Pump t 9
(1) Injection rate: Average (daily) allons per minute (gpm). U SGP
#-(2) Injection Volume: Average (daily) gallons per day (gpd). ONLY (di NTM11A"
NOR
(3) Injection Pressure: Average (daily) -EQ- pmm&square inch (psi),
(4) Injection Temperature: Average (January) a F, Average (July) ° F.
1-1 -%r PUMP 13 L4 t" "our JS TO 1 $40 WA IPAX IN tVIAJV t t SUP-& 47R
J. ]INJECTION -RELATED EQU P1V ENT
Attach a diagram showing the: engineering layout or proposed modification of the injection equipment and exterior
pipinghabing associated with the injection operation. The manufacMm's brochure may provide supplementary
information.
R. LOCATION OF WKWS)
Attach two copies of maps showing. the following• information:
(1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing wells) or waste, disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothermal heat pump well system. Label all features clearly and melt* a north mrM.
(2) include a topographic map of the. area extending one mile from the property boundaries and
indicate the facility's location and the map name.
GPUAAC 3A? Well Permit Application (Revised 91=7) ' Page 3

L. CERTIFICATION
Nate: This Permit Application must be signed by grh person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and alll attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
Signature of Property OwnerlApplic
�JOHA A IJ E-S FEIV_ Z-- -
Print or Type Full Name
Signat re of Property OwnerlAp t
Print or Type Fail Name
Signature of Authorized Agent, if any
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mall Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5A7 Wet! Permit Application (Revised 912007) Pagc 4

6 6 7" j;4 "^Atr
r-r -,
to
YV
000,

7
,�d N� 1# -.-
M-Y
Ile
i W!��'w .�it ���� ■a��.' _
Ap
rol.4A., l0l j ft
u
� �#1 r �■� .� rr tl�

667 Keener Road
Murpky,N.c. 2,1906
ter Flo w bia,� ram
M.

North Carolina DENR-DWQ
Aquifer Protection Section
L]IC Program
1.636 Mail Service Center
Raleigh, NC 27699-1636
[phone]
17.1-L'1 ;-;
Johannes and Martha Penz
667 Keener Road
Murphy, NC 28906
Dear Mr. Rogers,
This permit application fnr renewal will be due later this year. Because we are planning a
longer absence from our home with occasional short returns we would like to ask you to
` �7)av �s next�ection done o � � arc ice'! tF�a is possrbT � - -
Our house is very well insulated and it therefore requires only limited times of heating in
winter and cooling in summer. We heat the house mainly with wood. The only return
water flow is through our geothermal Trane heat pump.
Tbank you for your consideration in handling this soon.
Best regards,
Johannes and Martha Pena
RECEIVED 1 DENR i DWO
Aquitar Prmtecfion Sadon
FEB 19 2009

May 9, 2005
Martha and Johannes Penz
667 Keener Road
Murphy, NC 218906
Ref: Receipt of Corrective Action
Sampling Spigot Installation
Dear Illy. and Mrs. Pena:
r
Michacl F. Easley, Governor
William U. Ross Jr., Secretary
Narth Carolina Departmeni of Environmil rind Natural Resources
Alan W. Klimek, Y.E. pimctor
Division of Water Quality
On May 4, 2005 the Underground Injection Control Program received your documentation of corrective
action associated with the Notice of Regulatory Requirement issued on March 30, 2005. Thank you very
much For submitting a copy of the invoice for the installation of the required sampling spigots. Your prompt
reply and cooperation with our request are greatly appreciated.
Please contact nie at 919-715-6166 or Evan Kane at 919-715-6182 if you have any questions about the
Underground Injection Control Program or injection well rules and regulations.
Best Regards,
10:0� &AA -PA -
Thomas Slusser
Hydrogeological Technician Il
UIC Program
Cc: Landon Davidson, Asheville Regional Office
CO-UIC- Files
Ncui�hCarub na
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1630 Phone [phone] Cuslorner ScrVice
Internet: http:Ph 2o.enr.stale. nc.us 2728 Capital Boulevard Raleigh, NC 27004 Fax [phone]
Fax [phone]
An Equal OpportunityJAffirmative Action Employer— 5D% Recycled110°% Pos( Consumer Paper

Johannes and Martha Penz
667 Keener Road
Murphy, NC ?8906
May 1,
2005
North Carolina Department of
Environment and Nahual Resources
Division of Water Quality
Aquifer Protection Section
P�
1636 Mail Service Center
can
Raleigh, NC 27600-1636
-.4
Dear Mr Kane,
=
a
n
RE: Notice of Regulatory Requirement
v1
Martha and lohannes Pcric
667 Keener Road
r•�
T+
Murphy. NC 23906
Ref: Notice of Regulatory Requirement
N.C. Well Construction Standards
NCAC 15A 2C .0213(r)(4)
Dear Mr. and Mrs. Penz:
The (lndcr;round Injcclion Control (U1C) Program of the Division ul' Wa1cr Quality is responsOle far the
regulation of injcchon well construction and operation activities within the state of North Carolina. On
February 7. 2005 Mr, Ted Minnick of the Asheville Itegional 0fiicc conducted an inspection and samplin- of
your ecolhcrmal heat pttnip systettt. A copy or the water qua iLy test results is included for your recovds.
❑misig Hr. \4iirnic.k's inspection lie observed that sampling spigots were not preseut at the well head ❑f the
utiection Weil. These sanipling ports are required under Tillc 15A_ 5ubehapler 2C, Scow .0213(c)(4) of the
North Cam] ina Administrative Code and are necessary to IdUT111fy the cause or source of any potential ground
water quality Violations associated with your heat pump and to accurately charactcrizc the quality of the heat
pump effluenL that is being rcturncd to the Nell.
In order to otinl�ily with this rule you tt� ust in taiI well head sonifPIin_ s11i ots for the influent anti effluent lines
and submit sujqulrtinu_documentation. of the well heat! repairs within 60 dais of recei it of this letter.
acceptable doculnentat1031 ira:ludes photographs aildior an jilvoicc for the installation of the sampling, spigots.
Fallowing receipt or th is 60cumcotatinn we 111ay ll7spw your in]cC[ion well system to Verify t'arnphaTWV.
Your prompt cooperu6cin with this request will be greatly appreciated. Please contact Thanias Slusser at (919)
715.6166 or nic a( (911)) 715-6182 iF you havc airy gnesriDns re�arding this notice. (tie UIC Program, or
injcctian Well rules and regulations. r
13es1 regards.
Phan D. Kai ic, L.C.
UIC Program Mana-ger
Thank you for informing us of This requirement. A copyif'the invoice For the installation of the sampling
spigots is enclosed.
Sincerely, Martha Penz
r�

CHEROKEE WELL DRILLING
AND PUMP CO., *sic.
P.O. Box 1007, Murphy, NC 28906
Phone: [phone] • Fox: [phone]
)ATE: f r
::USTOMER NAME:-=�'/�� +� � •� 1'_
4DDRESS: 6�6p7
�iTY & STATE 1"f i tg& ./ Nr c2,� 26!(,�,
TELEPHONE NUMBER: 937-- 6IzPrc,
kit work to be paid for upon completion unless prior arrangements were made. if
mysnent is not rwzived by than, a 1.5% INTEREST AND SERVICE CHARGE will be
tdded monthly to past due balances. This charge is equivalent to an interest rate of 19%
,IER ANNUM. Customer agrees that he shall be responsible for reasonableattorney's
,ees and casts should they be incurred to collect the order, and further agrees that the
61us of this contract is Murphy, N.C.
QUA. ITEM SELL CUST.COST
H.P. Submersible Pump
Stages GPM Pump
Ft. ' SCH 80 PVC Threaded DW P"
Ft. - SCH 40 PVC Pipe
Ft, ' SCH PVC Pipe
Ft. " Galvanized Pipe
Water Meter & Base
Ft, Pump Cable
Ft. U.F. Wire
Ft. Safety Rope
Torque Arrestor
" Clamps
" Sla•Lock Stainless Clamps
Hose Bibb 11
t" Lawn hydrant
' PVC Cap
" PVC Coupling
^ PVC Female Adaptor
" PVC Mate Adaptor
' g0° PVC Elbow
"45° PVC Elbow
titI
r - PVC Tree
ILYafPVC Bushing
3,ec
PVC Glue (Site) &ji
PVC Cleaner (size)
o� • /c"]
Teflon Pipe Dope
801b. Sand Mix
Fiberglass Pump House
Fiberglass Well Cover
Concrete Well Tile 8 Lid
6'/0` Welt Cap
H.P. Control Box
Tank
Black Roll Adaptors
" Gate Valve
SUBTOTAL (1)
OUA. ITEM SELL ICUSTCOST
" Ball Valve
'Chock Valve
Pressure Switch
Gauge
Pressure Relief Valve
1/4' Nipple
Box Connectors
Sta-Kons
Vulcanized Tape
Electrical Tape
" x ' Galvanized Bushing
x " Galvanized Bell Redu der
' Galvanized Couplings
Galvanized Adaptor
x " Galvanized Nipple
'Galvanized Elbow
Well Vent
" well Seal
" Tank Tee
silicon Sealer
" x " Galvanized Nipple
x " Galvanized Nipple
` x " Galvanized Bushing
Heat Shrink Kits
" All Threads_
" Galvanized Tee
Galvanized Tee
" Union I
Insulation (amount)
' Boiler Crain
" Dresser Couplings
Lightning Arrestor
Portable Pump Puller Rental
Caulking
�.e- •ram= i.�r�u � �' �t��e,,.�.�►
�-, a.� �
Subtotal 01
Subtotal i1) forwarded 0.1
/'49 OG
Subtotal 0.1
NC State Tax 11
r3"3
Subtotal Oil
Clia —49
Time Out +
Time Back
Hours Manual Labor
1 6 O,CGG
Feet Pump Truck x ¢
_
Feet Trencher
6:/-" Drilled Well @ S Ft.
Steel Casing Charge @ S Ft.
Subtotal
q
Men on job! '
GRAND TOT

■ G; M items 1, 3, and 3. Also complete
Item 4 Ff, Restricted Delivery is desired.
■ Print your name and address on the roverae
so that we can return the card to you,,
■ AWmh this card to the hack of the mallplace,
or on the front if space permits.
t. Article Addressed toc
Martha and Johannes Pent
667 Keener Road
Murphy, NC 28906
A. Signature r
x f Agent
-�j�:Addressee
s. by (Purred Name) C. Date of DeliveN
D. Is deQirery address ditrard from Item t? ❑ Yes
If YES, enter deTlvery address below: ❑ No
3. Service Type
1308rtified Mail ❑ Express Mall
❑ Reg[stered 13 Return Receipt far Merchandise
❑ Insured Mail ❑ C.O.D.
J 4. Restricted Delivery? (Extra Fee) ❑ Yes
x. ► 7002 2410 0002 0272 9412
PS r-orrn 3811. August 2001 Dornestic Return Receipt 2ACPRt oegz WBs f

March 30, 2005
CERTIFIED HAIL
RETURN RECEIPT REQUESTED
7002 2410 0003 0272 9412
Martha and Johannes Pena
667 Keener Road
Murphy, NC 28906
Ref: Notice of Regulatory Requirement
N.C. Well Construction Standards
NCAC I SA 2C .0213(c)(4)
Dear Mr, and Mrs. Penz:
Midrtel F. Easley. Governor
wiIIisrn C. Ross Jr., Seeietary
Ntxtlt Carolina Deparlrnent ul-hn%,ironmcntand Natural 9esnurces
A}un W. Unick, P.E. Qirecror
❑ivislnn of Water Quality
The Underground Injcctlon 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. On
February 7, 2005 Mr. Ted Minnick or the Asheville Regional Office conducted an inspection and sampling of
your geothermal beat pump system. A copy of the water quality test results is included for your records.
During Mr. Minnick's inspection he observed that sampling spigots were not present at the well head of (lie
injection well. These sampling ports are required under Title 15A, SLibchapter 2C, Section ,0213(c)(4) of the
North Carolina Adniinistrative Code and are necessary to identify the cause or source of any potential ground
water quality violations associated with your heat pump and to accurately characterize the quality of the Beat
pump effluent that is being returned to the well.
In order to conirI with this rule .ou must install well head sai-n-Mini: sLi�ots for the influent and effluent lines
and submit _s u 1) )oI_ rtil7L� documentation _of the well mead rg�Liai�r witlzin 60 dwvs of _recJtit of this letter.
Acceptable documentation includes photographs and/or an invoice for the installation of the sampling spigots.
Following receipt of this documentation we may inspect your injection well system to verify compliance.
Your prompt cooperation with this request will he greatly appreciated. Please contact Thomas Slusser at (919)
715-6166 or me at [phone] if you have any questions regarding this notice, the UIC Program, or
injection well rules and regulations.
Best regards,
(L)v
Evan ❑. Kane, L.G.
UIC Program Manager
CG: Landon Davidson, Asheville Regional Office th
CO-UIC Files NonhC arolhia
Naiirrillly
Aquifer Protcetion Section 1630 Mail Service Ccnler Raleigh, NC 27699.1636 Phone (t)19) 73 3-32 21 Custorner Service
Internet: http:/fh2u.etir_sta1e.11c.us 2728 Capital Boulevard Raleigh, NC 27604 Fax [phone].623-6748
rax [phone]
An Equal OpporWnilylAffrmatVe Action Employer — 50% Recydedfl0% Past Consumer Paper

4Fhi r-LLE RO E232997043 T-997 ;'01/93 U--914
p William G Ro9s dr., 5zcretary
North Carolina DGpal MItnt of Environment end Natural Resources
0 Alan W. Klimek, P.E. Director
Division of Water Quality
AQUIFER PROTECTION SECTION
FACSIMILE
TELEPHONE NUMBER
[phone]
(828) 2964681 direct
FAX NUNTBER
(828) 299--7043
TO:
FAX NO:
FROM: H.E. qED + 1►IINNICh, JR- DWQ;_AQUIFER PROTECTION SECTION
DATE: Z 2 C124ML
NUMBER OF PAGES, INCL COVER PAGE:
COMMENTS:
A 70U tA,$ 9CWtn --64- -1 o1 pjcS PEA
fl 1 000 2 3 rp I_ At CAg' xo,�� &W.171 t
_ ,1�a`tr�rarry
Noah Cuelma Division of Water QLISIity — Ash avi11c itcgioaal CITite 2090 U.S. Highway 74 Swanannoa. N.C. 29778 Phone (U.3) 296-4500
FAX [phone]
Cusbrnar Service 1-877•623-6748
Internet: h2a.etinstate.nc,us
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COUNTY :
QUAD NO.
REPOKf'TO
COLLFGTONS)
DATE.
UME:
PURPOSE:
CKEROKEE
ARO
T MINNICK
1—mow---
?2ro
Regional office,
LABORATORY ANALYSIS
BOD 310
mg/L
_
COD Iligh 340
mg/L
COO Low 335
m9n.
Colifonn: MF Fecal 31616
I100071
Coliform: MFToW 3I5N
Iltl[1ml
TOC
m
Turbidty
NTU
Reaidue., Suspended 530
ml.+t
Tau t 5 uspended solid;
m I•
H
units
Alkelinily to p H 4.5
m IL
AlkaliniI% wpH 8.3
mp,IL.
Carbonalc
B ices borure
mg/L
m
Car' ��xide
K 61, iLi
n1
m�0.
Cluontium: Hex 1032
utin
Color. True 80
c. u.
Cyanide 720
mg&
I� 99 / coo 2-3
DIVISION Or WATER QUALITY
Chemisu-y Labormtury Repars 1 Grouad Water Quality
SAM F PRIORITY
E]ROUTINE EMERGENCY
El C H A IN OF CU STODY
EFF
W❑ SAMPLF TYPE `
Owner- Isj7 KRF_NRR. ROAD —j--4 -N qi-r
Locatian or Site:
Deseriplion of sampling point ( -A�fr
Sampling Medtad: kC. My
Remwks:
Lab Number
5G0243
Date Reacivrd :
ZNfM05
Time Rea:ivM
9:00 AM
Received By
DS
ReteAsrd By :
!e
Date mpmod :
31t-U2005
Or anochtndne Pesticides
Orplicilifl Pesticides
Nitroran Pesbcidnc
Acid Herbicides
S emi V41Ati lea
TPH-Diesal Ran e
Volatile Organics {VOA bottle]
1P1I-Gasoline Rar.Sc
TPH-B'fF.X Gasoline Range
COMMENTS : � .1 d 03, 3 id /
00,
Diss. Solids 70300 m IL
Fluoride 951 mg/L
Hardness- total 900 mglf.
Hardness: {non-carh)901 mbA.
Phenols 32730 uSIL
5 ecific Cond. 95 umho0cm2
Sulfalc mglL
Sul Fide 745 rtio&
MRAS mg/L
Oil and Grease !L
Silica mg/L
Raton
F4mnidchyde mYR.
NH3 as N 610 mgIL
TKN as N 625 m IL
K
NO2 +NO3 as n 630 0.05 m
P: Tote; as P M5 m rL
Pea mglL
Nitrate (NO, u N) 620 mall,
Nitrite (NO3 as Ny 615 MIL
r
Y1�V
[V
�fT1
—e21
m�
rcn
SU24S

CGUNTY ; CH>ZROK6.E
QUAD NO:
J�C
DTVISION OF WATER QUALITY
Ciremlatry Baer fiery Report ! Ground Wasm Quality
SAMPLE MIURR1+
%ROLMWFEMERGENCY
REPORT TO : ARO Rzglorml Orfim CHAIN OF CUSMIDY
COL-ECTOR(S) : T MINNICK INP
DATE: zaam ►Y� SAMPLETYPE
TMmE+
PURPOSE: i� LAC fwf?Wr#,JM' Ownu: rtN Fxirit RDAs
Location or Sim:
0-cripliott Of unv"eg paim .2 . i
Sampling Merhwi . _1
Reroui *.
LABORATORY ANALYSIS
ROD 310 [pttll-
COn High 340 m
COO Law 335 na
Califums: MF Foal 31636 I100nd
Co]iN= MF Tb W 31504 1100m1
TOC msA
,Dews Km
Residue., Suapcndcd 530 m
Tom[ Suapeadcd solids mgRL
pH uedes
Alicatinity to PH 4.5 rtlpjl.
A[Wwity to pff 83 TMAJ
Cwbarutm w
Birarhomm Fne-
x
r n dioxide mgfL
da I FOWL
Chra—: H. 1032 ug&
Calm True 80 c u.
Cyanide 7Z0 mgfL
clirKMElvrs
disc SoUds 70300 mp,IL
Fluoride 951
t•Iarducn: WW 9l1O FaWL
lfardoass: (non -cub) 902 mg&
Phenols 32M
.Spe6fbC Card. 95 umhoa/cm2
Stdtam nttli.
Sulfide 745
MBAS TELL
Oil sad Grease m 1.
Simcr mwi
Bnron
n MgLfL
NH3 as N 610 mg&
T'KN as N 625 mgR.
%
NO2 *NO3 as n 630 8.03 m94.
P: Tani as P 665
PO4
Nittue (NO, as N) 620 m9fL
Nitrite (NO, as N) 6l5 MVL
C"� of 00023
A-Silver46566
URIC
Xt
AI-Alual mm 46557
&OU kiWL
Ar-Arsenic 46551
URIC
Ba-Barium 46558
ur
X
Ca•CAkium 4052
3.2 m
Cd-Cadium 46559
ni
It
Cs -Chromium 46560
25U u
X
Cu-CopM 1042
42
x
Fe- beer 1045
50U u
Fi - MErcary 71%0
uvi-
$
K-Pdnssuun46555
0A1
X
Mg- Magnesium 977
2.3
]i
Mn-M cxc 1055
IOU uVL
X
Na- Sadiltm 9N
SA mg&
x
N1i-NkkcJ
IOU MV%
x
Pbiaad 46564
IOU UgIL
ScSeknium
uwL
7t
Zn_?AM 46567
34 u ri
Lal: Number
5G0242
Dasc Retired
21W280
Tlma Romived :
9M AM
Received By
OS
Rrl=m!d By :
IC
U+Un rcportw _
-VIda0Q5
Qrgaaachlnrine Pesticides
Op.plpb,. Pesticides
NinnRear Pndddes
Acid HerNaidss i
CO
Lam;
s3am

r: -r
m
I
C+7
r�
a
m
In
I
V]
�Ir
B
O'1
CV
00
N
W
++f� �- y North CarvlErra
GROUNDWATER FIELDILAB FORM! (��f.' L {,11 _ Q � QG!d�� ❑epaflmenf of Ersvirnnm en ar►d Na luret rZosDurces
- -- -- -- -- - - -- DIVISION OF WATER QUALITY-URaU1g0VVATFR sr-f-
�!� PLC D F'g SAhfPLE EanRy Y 1
i
CouMy__ _ �� s_wafer im Rouline Lab Number
Quad Ho _ Serial No. ❑Soil ❑ Emergency J� Date Received__?`7'-�� Time: J�7
Lai._❑other Reed By: S Fmrn I3us, Cour[er, 11a QeK;1
❑ Cfla{ l of Custody ocher:
Report 7 H RO, MO. RRO, WaRO, WiRO, Data E B 5
WSRO, Kinston FO, Fad. -r ntsl Central Off., C1her. ep Y _ -:2 - -� - - -
-�-�.� Gate Rap�ried=? � 5��6 _ - --
S1uned b�: Bus, Caurinrnd Uei:?p11�er: _ _ Purpose= _
ColiBrfor[s} f ;, fu ifs - -- - Dal ^ Time_ i0v-,� 8 5ellne, Complaint OMPITOMT LUST, P vcide Slud , Federal Trust, Other'
lrCr� QaQI
FELE) ANALYSES 7(honer
iA 4C0- - _ ter, Spec. Cand.s4_ at 25eC Location or -Ae
Temp,lo _ _ f 3 _ "C Odor - Description of sampling pgir� - =Lrz4'
Appearance _ _ _ _ _ Sampling Melhad ��;r��(� � Sample Interval_
Field Analysis By: -_ -- _ _ - _ - -- T - - _ Remarks TAU. bA 47F _a r--- - - - --- - LABORATORY ANALYSES {c��:nqun aU1mr�.,ax.3
BC}i7 3f6 mWI Ms. Selds 70wo 'sV �*��� 1r� � Ag-Saver 46 66��f � �R 7rlarmCfil[xine F'BsllddRa � ~~
- -
COO i Cqh 340
irIU&
COD Low 335
mgrL-
-
V.,
-
Cdifwm_htF Feral Ziq M
I100m1
L
T
Cailrarrrr My 7oia131Sa4
iSnamr
TOG W
sng7L
iurWI Fy 76
H TU
Residue. Suspended 53(t
MV&
L�l
PI i 403 _v.
hliwlin[[y to pl i 4_5 4 }0
W
-
—
Allrallrr4y io pli 8_3 415
4c
Carbanale 445
a"
t3iearponatn A4U ____
_
{{
-Cnrt)nn cFloxida i[15 —
j
C"rnrida. 9",
-
— ` -
Ch+merturm Flex f032 —
0
Coloa- True So
Cyanide T20
ri
Lab Comff}{Dnts----
00 _
� �U11-54 nr±G
LC7
m
t
00 �
N
1
N
Ruaride 951
rngrL
I iaalmrss: Total 9011
ring!&
liardneaa [no)i-cart); 902
MWL
Phermis 32730
UW1
SpecfllcCvnd.95
LAZDTlcm
Suiale 9A5
�— nyglll,
sulrxie 745
1. mglL -
04 4na Grease rrm7+L
mgrL�
Nl Ir®s N Gfo
Y mg/L-�
-
TKN as H 625 T�
mgrL
T{p� « NQ, as H 6311 -
mg(L
P- rolal as P 665
�u�+L
R T
N1[rak (Alm, ae N) 620
CU
NittIte {N% as N) 615
Far f]Issahed Antalyais�ubrrit 1&red serrlple arrd mile'US' In bkx:%.
mylL
mgrL
mgr[
`rng3t
- zrgrL
nrgrt
AI-Alurnkrum 46551
As-Amanie 48551
Da-SaMom 4855E
Ca-Calr;3lmt 46552 _
Gd-Cadmium 4&550
Cr-Chremfurn A6559
_ uprL
_Organ_ o�hos�orusFrs[kidea_
Nlri os : n PgsAkfes
Acid Herbicides
PCBs
T uglL
��r k
marl
Gy-Copys8rd6567
�ti
Ft 4ron 46563 _ _
_ JO
I Hg-fdlerrury 7f900
f ud;,
It-Pat85Aiu m 45555
mg✓L
lAg•kiagrim sluro4B5S4
A{rrf larganese 46565
- LrLyr�
HaStidfirm 45555—
Ni-flickei
�+L
Pb•L ead 4 6554
Se StienTum
�� 1
in-2inc 4656?
n
Semh�olBllSe fl�an'1[s� ��-
TPFI-olasel
TPHH-Ua line Ftany� _ —
7AH-BiEX Gasoline Ranue —
x �— z -P �•—
Ternpsralufe nn arrive!; 0, LD

m
m
C'+7
Q
R�
Wo th Carolina
GROUNDWATER FiELDILAB FORM L'Te' D 1 cavZ 3 Depadmsntof Environmert( and Nniumt Re,;ources
❑IV1S1ON OF WATER OLJA ITY-GR1ai]f+if)WATER SECTIC)�J
0 T RAMP E �RIURITY
Cotmty _-- R ! water f Routine IT 'e�
(: ) Lab Number .4 �I � Li3 L � —
I
Quad No _ _ Serial No_ �i ❑ 5ai1 Q Emergency -
I � 17aie Received J-�'T�-1 Time: I S~r� i
Let. i Lang.' '�C��' - ;�� 0 Other Rec'd 8 - 7>rA, _ __ _-�
y, Fram:Bns. Caurler,;Cand i3iL-'
11 ❑ Chain of Cuslady �y Other,
Report 1 AR .SRO, MR0, RRO, WaRG, WiRC, - = - ---- - - - - -_ - 's Data Entry By:_ -T/A-� Ck: I'sks
INSRO, Kinston FQ. Fed. 7 Fenlral OIL, Other: Date Reported: ,7-DS-05
Shipped by, Btis. Courie. and 0 ., Other. Purpose:
Caflerfor{sj: r1��n�:71r(' Ua1eG'� e; S;_Tuna I Z �_ _ Baseline, Complaint.} omplial� ' LUST, Pasticide Sludy, Federal Trust, Other.
FIELD ANALYSES Owner J.
7 C•4`�z
- -- - r-
pN Spec. Cond g4 at 25°C Location or Site. C_ =? - ch; '_ fit? 'L/14 -far-
TenTp-10 _ _-� _"C Odor T Description ofsamping pain ---
Appearance T _ _ _ _ Sampfing Method_ _._ 1-t �,�_ - Sample Interval - - --
Field analysis 8y: _ , _ �- - - - - --- - - Remarks -
LAB RATORY ANALYSES �tPureringbrae,air ir.sp.,Nr.I
801D310
T^ mg1l
Disq Solids 7030a—
M
C013 r4gh a40
mWL
Puer'de 951
d
CUQ Low 335
mpl1.
1-lardnesc Totar 900
M
}� C.610m : W Fspcvd 31616
1 f aLYr,f
Hardness {qan-Carh19Q2�
C%j
Ccdriorm: MF Total315a4
rlaorrd
Phenols 32730
Speumc Cond. 95
00
_ T QC 690
rngAt
Solrale 445
7tilbidiTy 76 NTU
RvQs up. Suspended 530
_ m¢iLL
Saluda 745
CD
f7C
ts3
_---- --_--
-
_ OII- and Greastp
nit 403-
r�
AikiWinlly to pi 14.6 416
IRI}
n gft
in:lylnnH8.34T5
rmWL
x
I G2rdanaIe 445
- -
- - - srglL
f _ N1i, at.N 510 - - -
+ 6kait;onare 440 - -
"Inh
7XN as N 54
Cp,hon dioxide dos
-�
mWL
--
140a ■ N0j as N 539
C141urhre9So ~J--
^ ^
rnWL,-.
- f
P: Total as P 665 --
1 Chrorrilum: Iles 1U32
uglt
Wrrrle (NO 3as NV W
C:Q£
f _ Color: Prue 80
c'li
Wile (NO as N} 616
f
rL
Cyanide r20
mgOL W
-- - - ,
Lab Comments
13,
� mgrL
rnnrt
rng1L
wg+i
wKins(Cm
nog!!.
rag+L
- --- mglL
mgrL
mg&
T mgrL
mWL
mgrL
d Gtll-5¢ F1EV. TID3 For bissal�d Jkra sk guhrr�i filw.d sample EmRt w lls -DW In block.
Ln
m
�I
ca
lV
CV
m
Rg-Silver d8566 l >s
Ai Alrfrrdrtum 4f 557 uoL
As-AHseAM 40531 q
Be-Badurn 46551B- u
Ca-Calr;um 465552 k
_
—
Cd-Cadmium 46559 ugk_
Cr-Chromium 48559
C,r-Ccpper4b'S62 u�,L
Fe-twn 4b583, `L .
RQ.V'eK- of%tg,ep •.�VlL
K-Potasslum 46.%6
Mg_hlagr7gsivrrl 46554 L
�
m-Ma+paneso 46565
Na- Sod i urn 4 6556 - -� mu4
NI- uickM
Pb-l.esd 46554�
Se•Se*hurn
7rrLc46567 .,
HeMddes
__I Serrllralaille Or2anks _ _ _ _ T _ _ jj
TPH_Degel Rsore
_ ''Io1gSHe pr janlcs [V(2A bo5ltei_ --_ -- _ - _ I
_T Tf!�-Ggsurh)e RanUa - --
TP1.1-6TEX GgaalTne Ram— —
LAP Li5E ONLY
TnVaretuis on arrival: J D

02-08-'05
07:34
Q�
FROM-NCUFNR A5HEVILLE RO 8282997043 T-921 P01183 U-837
TELEPHONE N[UNMR
(828) 2%-4500
[phone] Direct
WOW R Easy, Oa wwar
womam O, Roo Jr., Saxntary
North Csroiinq Departmrnt of En► Uftmmt and NAhE sl Rc oumas
AOUIPER PROTECTION SECTION
FACSIMILE
FAX NCTMBER
[phone]
Alan W. YJim *, P.E. Direr w
Division of Wata Quaiiry
TO:ti
S �5c JSz . 1 C� to
- - - ----
FAX NO: _ �'1��_ 71S - ofa
FROM: A.E. {'FFpJ_NIINNIC , DWQ, AQUYnR PROTECTION SECTYDN
NUMBER OF PAOEB, INCL COVER PAGE:
COM ZNTS:
a�Cr- &VAfry, � c -�_ _s" ►►'+ _ 7a !*,? �a�' cad.
Arty o L*lover C.,f tc
ta=yo
North CanoftR bivWcm of Water QLwlitq - Aahm'U RLTional OdPim 244 M.S. Wrmy 70 Swarmmoa, N,C. 28770 1'hma (W 296.M
FAX [phone]
Customer Service 14177-623-674&
lnterriei: h2omr.state.na.ue
An Eaud 4pporti */ARfm on Acdm Psnployer - 50% Regcled110% Past Comer Paper

4%1
North Caroli.._ Department or F,nvironment and N:. .rat Resources
Division of Water Quality - Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT- FORM B
INJECTION WELL PER -MIT NO. WIOI00023 DATE Udrj 61- / e�
NAME OF OWNER MARTHA & JOHANNES PENZ 7
ADDRESS OF OWNER & !
TE:.jwyk?7-(44�
(Streeff road or lot and subdivision, county, town.)
LOCATION OF INJECTION WELL (and source well(s), if applicable) _
*9 . 1 ,t,-oc Zexjc 7 sW aP
L
rp Wt trs{ rrOrsr 'A ►ee kL'" er aJ'a )
(Street/ road or lot and subdivision , county, town, if diffierew than owner's address, plus description of location on site)
Potential pollution source Sa_ r c T,Wk / 4kEx
Distance from well
Potential pollution source ro r .V_h4-rrn..(
Distance from well
_]T'
i 3j'
_
>
Potential pollution source
Distance from well
v
_
� ,
rn
Minimtim distance of well from property boundary
1
W--
l7t]
Quality of drainage at site ( Qor) Flooding potential of site
bui
- r
(good, adequate, pool)
(high, moderate, low)
rU
—i ce
�_
GPS DATA: Latitude: 3S0 r`3-3!JPr Longitude:
4W M,7" vr/
c-n
vy
- '17ti
DRAW SIKETCII OF SITE (ShowIn-op erty ljou)reta i-ies, buildings, wells, po ten tial p o llu tio n sources, roads, approximatescale, crud
north arrowj
'
i
LD
vA a s v ,
WU
c
-- EFFcr1err,r. Z Af106 i.) A;
�w�rnl rJ G�Aei� af" kre,
DESCRIBE INJ ' C'TION S TEVI ryer cal closed loop, uncased borehole or cased water well; separate source tivell and
injection well. �,( nibination source and injection well, or outer description as applicable)
INJECTION FACILITY INSPFCT[ON la PORT -DORM B (CONTINUED)
Ver. 7/04 GWITAC-2

WELL CONSTRUCTION
Date constructed IWVW-10
Drilling contractor- N'ame
J o� Ahltc►r� � • ��,,,1 kkct ■ �
�D 1.�G
Address
irLC-4
-
�.�a�icy�r�rGc _NC Z -1 zC
Certification number
"Total depth of well 3Z2-'
Total depth
of source well �Q•��
(if rrp�liccrble,
Inspection point
iiMeasurement Meets minimum standards
Comments
Yes No
Casing
Depth
Diameter
(o•IZ� "__
She Z1
Hcight (A.L,S.)
.
Grout
Depth
+7
fit/ r
'�
04- 7a 3'
Screens
Depth(s)
Length(s)
rl
L.D. Plate
Static water level
r
Well yield
�� P►+�
`�
(eve el
Enclosure►L�cc-
Enclosure floor (concrete)
A/
Sampling port (labeled)
►�
Water tight pipe entry
►�
Well enclosure entr►
•�
Vent
lAinetioning r�o�--f� beat pump sy tem, if applicable (Deterazipie trnr?a the osuner if hear piwip�irnctrons properlv.)
�unlc� rGnrr.�4 pI�n"y
INSPECTOR office fV7
f
WITNESS O�sife-4 Address
WITNESS Address
Ver. 7/04 GWIUIC-2

DIYI5ION OF WATER QUALITY
AQUIFER PROTECTION SECTION
November 23, 2004
MEMORANDUM
To: Landon Davidson
Asheville Regional Office
From: Thomas SIusser-z j5
Central Office
Re: Issuance of a New Water -source Heat Pump Injection Well Permit (Type 5A7):
Permit Number W10100023 has been issued to Johannes and lnattha Penr in Murphy, Cherokee
County, to construct and operate a well for a water -source heat pump injection well system. This
permit is valid through November 30, 2009.
Please inspect and sample the injection well once the injection "yell system is constructed and
operational, and submit the attached post -construction fonn (Form B) to the UIC Program
Central Office staff.
The Underground Injection Control Program greatly appreciates the assistance of you and your
staff in getting this permit issued. If you have any questions regarding this memo or the UIC
Program, please contact me at (919) 715-61 bG or Evan Kane at [phone].
cc: CO-UIC Files
Eiictosmes

November 23, 2004
Martha and Johannes Penz
667 Keener Road
Murphy, NC 28906
Dear Mr. acid Mrs. Penz:
Michael F. CuSltiy, C+ownior
William C Rass Jr., Seeroary
North Carolina Department of EnVIF0aMen t and Natural Resource
Alan W- Klimek, P.E. Director
Division a caster Quality
In accordance with your application submitted July 15, 2004, the Division of Water Quality's Underground
Injection Control (UIC) Program is forwarding Permit No. WIOI00023 for the construction and operation of a
geothermal heat pump injection system at 667 Keener Road, Murphy, North Carolina, in Cherokee County.
This permit shall be effective from the date of issuance until November 30, 2009, and shall be subject to the
conditions and limitations stated therein. Please read your permit carefully to make sure you thoroughly
understated its requirements your and responsibilities.
Post -construction inspection and sampling of this geothermal heat pump system is necessary to complete the
permitting process. You must contact the Division of Water Quality's Asheville Regional Office at (828) 296-
4500 to schedule the post -construction inspection once the injection 'well system becomes operational. Please
note, if the sample results exceed groundwater duality standards, it is the well owner's responsibility to take
corrective action as stated in Title 15A Subchapter 2C, Section ,0206.
Please contact ire at [phone] or Evan Kane at [phone] if you have any questions regarding )0Ltr
pem-iit, the UIC Program, or injection rules and regulations.
Best regards,
Thou-ias Siusser
Hydrogeological Technician If
Underground Injection Control Program
Attachnient
Cc: Landon Davidson, Asheville Regional Office
CO-UIC Fifes
tis, 111C.110 nia
aX1,11r1vill/
Aµuiter Prntectiun SeOtov 1636 hlnii Service Center Raleigh, NC 27099.1636 Plioru [phone] Cttsiumo ScrJreL!
Imer'nct h tpWo2o.enr.slate.ne,us 2728 Capilal Boo lewd Raleigh, NC 27604 Nx [phone] 1-877-(�23-04X
l arc (919) 715-WAS
An Equal OpportumlylAIflrma!ive Aclron Employer — 50% RecyolPdl10% Post Consumer Paper

DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
November 23, 2004
MEMORANDUM
To: Debra Watts - -- -
Through: Evan Kane
From: Thomas Slusser ASS it-23-- `!
Re: Issuance of a New Water -source Heat Pump Injection Well Permit (Type 5A7):
I recommend that the attached permit to construct and operate a Type 5 A 7 injection well associated
with a geothermal heat pump system be issued to Johannes and Martha Penz in Murphy, Cherokee
County. In July 2004 Ted Minnick of the Asheville Regional Office inspected the facility and
submitted the pre -construction form (Form A), which indicates that the well had been previously
drilled and that the site is satisfactory and ready for construction. The lateness of this permit
issuance is entirely my fault as I overlooked the fact that all of the necessary documentation had been
received in order to issue the permit.
cc: CO -MC Files
Enclosures

�►C�] :i� �l �.�3i1�I�it1
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RAI.EIGH, 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
JOHANNES and MARTHA PENZ
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5A7 INJECTION WELL, defined in
Title 15A North Carolina Administrative Code 2C .0209(e)(3)(A), which will be used for the
injection of heat pump effluent. This injection well will be located at 667 Keener Road, Murphy, in
Cherokee County, North Carolina, and will be operated in accordance with the application submitted
July 15, 2004 and in conformity with the specifications and supporting data submitted, all of which
are filed with the Department ❑I Environment and Natural Resources and are considered a part of
this permit.
This permit is for Constniction 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 pen -nit shall be effective, unless revoked, from the date of its issuance until November 30, 2009
and shall be subject to the specified conditions and Iimitations set forth in Parts I through X hereof
>R )
Permit issued this the ;13 day of f\00+rf-Qkr , 2004.
-,D:��L4�
Ted J._ Bush, Jr_, Chief
Aquifer Protection Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit Na. WI0100023 PAGE l OF 6
G W MC- 5 per. 7/04

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
l . The Pennittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200), Any noncompliance with conditions of this pemlit constitutes a violation ofthe 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 -
Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constricted in such a manner that water from land surface
cannot migrate into the gravel pack or well screen.
S. Each injection well shall be secured to reasonably insure against unauthorized access and use.
Each well shall be permanently labeled with a warn 1ng 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 daring
construction and use.
Each injection well shall have permancntly affixed an identification plate.
A completed Well Construction Record (Form GW-1) must be submitted for each injection
well to, DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1 G36 Mail
Service Center, Raleigh, NC 27699-1636. within 30 days of completion of well construction.
PART I1 - WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (49) hours prior to constructing each injection well, the Permittee shall
notify the Aquifer Protection Section -Underground Injection Control (UIC), Central Office
staff, telephone number [phone] and the Asheville Regional Office Aquifer Protection
Scction Staff, telephone number [phone]
PART III - OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the app11cat ion and other supporting data.
Pemn t No. W10100023 PAGE 2 OF G
GWXIC-5 ver. 7/04

2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to change
ownership, or there is a name change of the Permittee, a formal permit amendment request
must be submitted to the Director, including any supporting materials as may be appropriate, at
least 30 days prior to the date of the change.
The issuance of this permit shall not relieve the Permittee ofthe responsibility of complying
with any and all statutes, rules, regulations, or ordinances that may be imposed by other local,
state, and federal agencies that have jurisdiction. Furthermore, the issuance of this permit does
not imply that all regulatory requirements have been met.
PART IV - 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. Inthe 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 shal I 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 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.
At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section -Underground
Injection Control (UIC), Central Office staff, telephone number [phone]. Notification
is required so that Division staff can inspect or otherwise review the injection facility and
determine if it is in compliance with permit conditions.
Permit No. WIQ 100023 PAGE 3 OF 6
GWIUIC-5 per. 7/04

PART VI - INSPECTIONS
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 pem-iit, and may obtain samples of groundwater, surface water,
or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided for in
N.C.G.S, 87-90-
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VII - MONITORING AND REPORTING REQUIRE, MENTS
I . Any monitoring (including groundwater, surface water, or soil samp]ing) 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 [phone], any of
the following:
(A) Any occurrence at the injection facility that results in any unusual
operating circumstances;
(S) 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.
Permit No. W10100023 PAGE 4 OF G
G W/LJIC-5 per. 7/04

PART YIII - PERMIT RENEWAL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
PART IX - CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an
injection well. Such a change would include the discontinuation of 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 it trust 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 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 that extends to the bottom of the well
and is raised as the well is filled.
(E) In the case of gravel -packed wells in which the casing and screens have not
been removed, the casing shall be perforated opposite the gravel pack, at
intervals not exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner that
will prevent the movement of Fluids into or between underground sources of
drinking water and in accordance with the terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as
specified in 15A NCAC 2C .0213(h)(1) within 30 days of completion of
abandonment.
Permit No. WIOI00023 PAGE 5 OF 5
GWAJIC-5 Yen 7/04

3. The written documentation required in Part IX (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 X - OPERATION AND USE SPECIAL CONDITIONS
None
Permit No. WI0100023 PAGE 6 QF 6
G WIUIC-5 ver. 7/04

Page I of 2
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTION
I111]04Z1]1"0111!'101M
INJECTION WELL PERMIT NO. WI
NAME OF OWNER a-iV�
ADDRESS OF OWNER 467 rp_�cv- 4 oJ
mu"Ifr . nip 21ro
DATE _ "�� a%
-? 37- 6¢ gf.
'V'e I re-9
(nreeil road or lot and subdivision, county, town)
LOCATION OF PROPOSED INJECTION WELL (and source well($), if applicable)
(3treetl road or lot and subdivision, county, town, ijd gerent than owner's address, plus description of location on site)
Potential pollution source S -Rric 7Anf ,ArPia-b Distance from well CO
Potential pollution source #;�;10+77b ! ^ Distance from well S '
Potential pollution source
Distance from well
Minimum distance of proposed well from property boundary ;1 "0
Quality of drainage at site 67" W Flooding potential of site 6
(good,adequatepooa) (high,modcrate,low)
DRAW SKETCH OF SITE
(Show property boundaries, buildings, wells, potential pollution sourres, roads, approximate scale, and north arrow.)
r
r"
GWIMC-1
28, 2001

Page 2 of 2
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cant.)
CPS Data:
Latitude: 3S° C' • 3/91
3S b 57-5'3
COMMENTS
Longitude: g4 o 00 • 779
INSPECTOR -
Office gPsR 140
WITNESS pvj9€x-
Address
WITNESS
Address
- e V, 0 ram. 'tJY3
GWILT[C-1 March 28, 2001

North Carollna
r]epartment of Environment and Naturai ' ources
Division of Water Duality �y _
Groundwater Section
Well Location: MLW-F r C
(Town, Community, Subdivision and Lot No.)
Owner: -JC -ffrS /"�Wo
Address. 66 1-' c t Iv C 14+�J
- - i
�. WeU jConstructian
Well Contractor M 4
,.►Vame
Contractor Cerlificaioq #
Permit Required ? (YIN) k/
L c ti - DWance Rr m. ...................
Water light Sewage/waste collection..
Waste disposal (septic tank drain field)
Other Pall. Source {c�_�deranl j
Other Poll. Source { ]
Qa�lng
Type.....................................................
Qeplh......... ......................... ..................
WeighUthickness..................................
Height(A.L.S.)......................................
Other ( ]
Drilling FluidsJAdditiyes
Type.....................................................
Grou
Type.....................................................
Thickness.............................................
Depth.....................................................
Other (-
Screens
Screened interval .... ............................
Other [
Deve)cement.........................................
Total Suspended solids .:......................
Turbidity...............................................
Settleable Solids ....................................
I.Q. Plate
Well Contractor ........... •................ .........
AbandonaLent......................................
Temporary......._. ...................................
permanent
GW-36 Rev. 112000
S
Date 0 2- J?.10
WELL TYPE L&
County_
Road/Street i;�cIa'-
Quad No.
Serial No.
Lat. 55"C7 3 • d" Long.
"-/W-
Check Items
Measured
Meets Min. Standards Remarks
Yes No
►- {Permit No.
.............
� R
iS-0
_ (circle anu)
Plastic r.'.arban Gatv, Slain. St. ❑(her
F4 t
Al I-
1
Applies to wells constructed alter December i, 1992
U-nFit lint ARVPn:GPl

9
W�Iljes1.............................................
Duration.......................................... .....
Frequency/Accuracy of measurements
Other { 2� r P+ r i3c0c"' i
Disinfection ...........................................
Chlorination ..........................................
Other { } .
ttn..............................................
Reports................................................
Construction (GW-1) ............................
Abandonment (GW-30)......... ...............
Well -Head Completion
Access part ..........................................
Hosebib ...............................................
Pitless Adaptor .........................--........
Pitless Adaptor Unit ..............................
Suction line ..........................................
Tee{jet) ................................................
Valvedflow ..........................................
Vent......................................................
Water tight pipe entry ...........................
Wellentry ............................................
Zeck Items
Measured
Meets Min. 5tandafds
Yes No
eemarks
w��
1
ram_
II
I
.r
p Applies to yells constructed after December 1, 1992
Dale Well Constructed I GZ-
Pump installation
LAPL4,4
Pump Installation Contractor
Name Address Reg. rV
t
Pt -MP �4MTRA470R I.D. PLATE PRESENT ? (YIN) Date Pump Instatted
Violalions noted attributable to the pump installation contractor are as follows:
(1)
(2)
(3)
INSPECTORf 07 -7
Name Office
WiEness(asl �/ �_rlll_�_ ►— CS)
(If Available) Name Address Type
Name Xddiress Type
i

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
July 16, 2004
MEMORANDUM
To: Landon Davidson, Groundwater Supervisor
Asheville Regional Office
From: Thomas Slusser
Central Office
Re: Request for review of an injection well application, type 5A7 injection well (open -loop
heat pump injection well), submitted by Martha and Johannes Pena, for the construction
and operation of a heat pump injection well system in Murphy, North Carolina.
1. Please review the application and submit any comments to CO-UIC group. Retain the
application for your UIC file.
2. Please inspect the injection well site to verify that the location and construction plans
submitted in the application are accurate and that the NCAC Title I SA 2C.0200 standards
are being complied with, using the enclosed Preconstniction Injection Facility Inspection
Report (Form A) as appropriate.
You are requested to return The Review Comments and the completed Preconstruction
Infection Facility In§Rection Report {Form Al to the CO-UIC by August 9, 2004. If the
inspection and review can not be accomplished by this date, please let me know.
The UIC group appreciates your assistance with this review. If you have any questions regarding
this review or the UIC program, please contact me at [phone].
cc: MUM Filcs
Enclosures

A
'Q�G
Michael F, Easley, Governor
William G. Ross Jr., Secretary
North Carolina Deparnment of Environment and Natural Resources
_��
rAltus
W. Klimek, P. E. Director
Division of Water Quality
❑ -C
Coleen H. Suilins, Deputy Director
Division of Water Quality
July 16, 2004
Martha and Johannes Perrz
667 Keener Road
Murphy, NC 28906
Dear Mr. and Mrs. Penz:
Your application for a permit to construct and operate a Type 5A7 injection well for the injection of
geothermal heat pump effluent has been received and is under review. A member of the Asheville
Regional Office staff will be contacting you to arrange an inspection of the injection well site as part
of the review.
Please contact me at [phone] or Evan Kane at [phone] if you have any questions
regarding the Underground Injection Control Program, permitting, or injection well rules.
cc: CO -MC Files
Sincerely,
Thomas Slusser
Hydrogeological Technician H
Underground Injection Control Program
N. C. Division of Water Quality 1 Groundwater Section
1636 Maii Service Center Raleigh, N.C. 27699-1636 Customer Service
Phone: (9t9)733-3221 Fax: [phone] Internet: http:llgw.ehnr.state.nc.us l�77-673-6749

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
=peSA7. 5QM Wem
In Accordance with the provisions of NCAC Tide 15A: 02C.0200
Compicte application and mail to address on the back page.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: , 2-
A_ SYSTEM CLASSIFICATION Please check column which matches proposed system.
{ 1) 1! Type 5A7 weP inject water used to provide heating or cooling for structures.
(2) Type 5QM wells contain a subsurface system of continuous piping, that is
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate addifives such as antifreezcs and/or con'asior}
inhibitors.
(3) Type 5QW wells contain a subsurface system of continuous piping, that is
isolated from the environment and only circulates potable water. If you selected
this well type, then complete form_GW-57 CL, Notification Of latent To
Construct A Closed -Loop Geothermal -Water Only Injection Well System.
B. PERMIT APPLICANT
Name: JO NAWU .9 I ,99-TNA FENS
Address: 66Z 1<4FEWE-9
City: A' ag P14Y State: hIL Zip Code: 2-S909 County; (:b 7C K1T
Telephone: [phone]
C. PROPERTY OWNER. (if different from applicant)
Name:
Address:
City: _
Telephone:
Sate:
D. STATUS OF APPLICANT
Private: Federal:
State: Municipal:
GW-57 HP (Jan, 2000)
Zip Code. County:
Commercial:
Native American. Lands:
Page I of 4

E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business ar Facility:
Address:
City:
Telephone:
Zip Code: County:
F. HEAT PUMP CONTRACTOR DATA
Contact Person:
Name: _WOO-DA&D LI_EC` P-I C S'EXVICC, WC
Address: Lig CRFE-K S J E- CIRCLE
City: 0AYC, _V 11-4C Zip Code, �8` Q�L County: CLA7"
Telephone: S2,Y-389- 813C:. Contact Person- iJA_kkf-W GJOOPAkQ
G. wiEcTION PROCEDURE (Briefly describe how the injection well(s) will be used.)
Ai! [] a� 2.w. � ea x�-c.t... . ( bC7ir.1 ��'!o lQe urn '3� Abtt `re?{ 4 r►�
J s4ace dsl'Cai.rd ),
H. WELL USE Will the injection weLl(s) also be used as the supply wells) for the following'?
(1) The injection operation? YES ►" NO
(2) Personal consumption? YES NO
1. CONSTR XJNN DATA (check one)
EXISTING WELL being proposed for use as an injection well. Provide the data in
(I j through (7) below to the best of your knowledge. Attach a copy of Form GW-
1 (WellConstruction Record) if available.
PROPOSED WELL to be Constructed for use as an injection well. Provide the
data in (1) through (7) below as PROPOSED construction specifications. Submit
Form GW-1 after construction.
jq
(1) Well Drilling Contractor's Nemc: V[) �r�'u Vim•--_ I �Gb J�
NC Contractor Certification number: to 'S 7
(2) Date to be constructed: —0 Number of borings:
Approximate depth of each boring (feet]: 3 a
(3) Well casing: Is the well(s) cased?
(a) YES —Z if yes, then provide the casing information below.
Type: Galvanized steel Black steel Plastic V-"Qther (specify)
Casing depth: From `t o 1 S t, (reference to land surface)
Casing extends above ground 1-.-.2— inches
(h) NO
GW-57 HP (Jan, 2000) Page 2 of 4

K.
L_
(4) Grout (material surrounding well casing andlor piping):
(a) Grout type: Cement ✓ Bentotute Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
around closed loop piping; from to (feet).
around well casing; from O to 7 (feet)_
(5) Screens (for Type 5A7 wells)
(a) Depth. From to feet below ground surface.
(b) N.C. State Regulations (Title 15A NCAC 2C .0200) require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent (fluid being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? yes 1�no (h} the effluent line? yes no
(7) SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well).
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available,
provide the data in part K (1) of this application form to the best of your knowledge.
NOTE: THE WELL DRRZLNG CONTRACTOR CAN SUPPLY THE DATA FOR ErrFMR EMSTING OR
PROPOSFD WELLS IF THIS P*URMATION IS UNAVAILABLE BY OTHER MEANS.
PROPOSED OPERATING DATA (for Type- SA7 wells)
(1) Injection rate: Average (daily) L � gallons per minute (gpm).
() 3 cdl��sr 4jo 'P� g ( y) ,� g P� y (gP )• m rJe
Z Injection Volume: vera a dail allons da d p f
❑ Ci`f � r Q �.fii
(3) Injection Pressure: Average (daily) 0 poundslsqum inch (psi). prr..sgaee_
(4) Injection Temperature: Average (January) qS ° F, Average (July) 46 9-0 F.
INJECTION FLUID DATA
(1) Fluid source (For Type 5A7 wells) .ff underground, from what depth, formation and type of
rock/sediment unit will the fluid be drawn (e.g_, granite, limestone, sand, etc.).
Depth: Fonuation: Rock/sediment unit:
(2) Chemical Analysis of Source Fluid (for Type 5QM wells)
Provide a complete listing of all chemicals added to the circulating beat transfer fluid:
INJECTION -RELATED EQUIPMENT
Attacb a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufachurr's brochure may provide supplementary
information.
OW-57 UP (;an, 2000) Page 3 of

M. LOCATION OF WELL(S) Attach two maps.
(1) Include a site map (Gan he drawn) showing, buildings, property lines, surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks or
drain fields located within I000 feet of the geothermal heat pump well system. Label all
features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) Hazardous Waste Maaagement program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
O. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the information
is true, accurate and complete. I am aware that there are significant penaltics, including the possibility
of fines and imprisonment, for submitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the injection well and all related appurtenances in accordance with
the approved specifications and conditions of the Permit-"
(Signature of Vell Ownefor Authorized A
!f authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner authorizing the above agent.
P. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed_ A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to constrtct 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) conforms to the Well
Construction Standards (Title 15A NCAC 2C .0200)
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UiC Program
Groupowater Section
North Forolina DENR DWQ
1036 Mail Service Center
Raleigh, NC 276"-1636
Telephone [phone]
GW-57 HP (fan, 2000) Page 4 of 4

WELL CONSTRUCTION )ILCORD
Nm Ill C'moIina - Deluutlrlcnt orEtiviroriment and NalumI Rcxonrccs - Divisirrn of WaIur Qualify - Ciro nlltlwaIur Section
►►T.1.1. CON-1 It,% •'10It IIN1)1VIDUA1.) NAN1F. (print] j �'! Mu<<' r' - -__ CFR11FICATION
►1 V1.1- rrrti l It,►rI Olt c OMI'AN)' NAA1r >A4 _liJ ___'o-1KG PnUNE n dL(T Li Gy '00
S l,► I V 1► I-:1,1, ('OFNS1 RVC:-1 JON 1'l:1tj1YCIF ASSOCIMV0 ► Q PER RlII#
t if appiicablc } (if alllrlivable)
1 WE U9F- (Check Apl)licahle Box): Residenlinl eN1t nicipal/Public ❑ Industrial ❑ Agricultural ❑
NlnniInring ❑ Recovery ❑ 11caI Pump Waler Iojection ❑ ❑I[it r ❑ I i 01Iter. Lisl Use
2. WELL LOCATION.- Tol►ographic/Und Sdtillg
Nearest -l-mvw %)'Z 1+t+Q _k1 j.,_ County OILO lzl vw_ C1Ridge ❑Slopc ❑V,,sllcy '[�Fia,
)�f2 P o-_ . k—_ t S E„J __ T _ Icheek nillim riatc hnsl
1'; Wet Nanc. Numhcrs. Community, Subdivision, Lot No., Zip000 I.atittldellongilude of well lucatioll
1 MVMN R —
Athlress 7 f S it-j01 E
(Sl ra!l nr Houle No ]
!ti11y 1 1'ty N L 10 �yl
or I drn Slab lip Cucfc
Arra Code- Pllonc numb c
a. i]A•rI- Dim.I.ED
5. TOTAL. ❑E PT'li: _ �_��],_
6. DOLS WELL REPLACE- EXISTING WELL? YES ❑ NO 11
7, S'l'A-rIC WAI'EK E,L'Vl:l. Uciovv•l-ol) ofCasiiig- c') 1-1,
IUDC „4 ' If Ahoy lip or Cairlf)
S. I.OP OF CASING IS r FT. Above Land Sttrficc'
of Caslnk SPr11 humeri a11nr t14111R' {eo[i sslr{arc rcgoires a
var{auct• in accurrlanc'e nith 15A NCAC 2C'.0I19.
9. YIELD (gpm)i 1�__ METi10D 0FTEST _4- r ar
10. WATER ZON I:S 0CP1111:
11, I)ISINFI'C_l_I0N_ Type Amoutrt
12. CASING: hall rhickncss
Dehill Dianrcler nt 'cIghVI'l. Nialeriai
I'rnnt +/ To Ft.a6'.21
E=rum To i f. _
From Tv F-I.
11 GROUT: Depth Material 1ct11ot
From
1=rollr T•n Fl.
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IS SANINGRAVEL PACK:
Dcplh Size Materiai
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1.JIIliltlClits15�11St11C gM11CC: EIGPS❑1417ot'Taill tic Map
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DRILLING LOG
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1-n`nnalinJt Ucscriplion
30Q�_m�11-4,,75 3 > _() tz _
LOCATION SKETCH
Shm,• direction and dislancc in miles ftoflt al lead
two St;llc Roads (rl- Cunnly Roads- lllclude lire road
oulnticls ,Intl common road tholes.
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1)O t11:itL=131' -111A f -I I IIS WELT. WAS CONSTRI ICJ I _1) I ACCOR I' %V1111 t 5A NCAC 2C, WILL
UONS1 RUCTION S rANDARDS, AND TiIAT A COPY OF 1-11IS RR'OR1) 11AS 13V1:N Pit OV1DLD 10 -flip WELL O%VNER
S1C;NyTOft Orjf�ERSON CONS-1 RUGH NC;-1111'.. WI;1,1, DATE
Submit I It Itrigiltal to the i]ivisioll of L1'uter Quulily, (kink E►vater See Ilon, 106 A611 Servicr Center - Raleigh, NC
27699-16361'11une No. V)It)l7tt-S221, ►►' Ili tt 30 clays. GIN-1 REV. 0712001

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CW _ community well
PV4 _ private well
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V4 _ V40use
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