WI0100083_GEO THERMAL_20120517

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NCQENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P, E.
Governor Director
May 17, 2012
Thomas and Sharon Gray
84 Soaring Eagle Drive
Franklin, NC 28734
Subject: Notification of Rule Revisions Affecting
Closed -Loop Geothermal Injection Well Permit Holders
Permit Number: WI0100083
Dear Mr. and Mrs. Gray:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed -loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards — Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed -loop geothermal injection well(s) have become
"permitted by role." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http:llt)ortal.ncdenr.org/web/wg/aps.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636 One
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604 NqfthCarolina
Phone: [phone] FAX: 91 M07-6496
Internet: www rtmaterauality,org Naturally
An Equal Opportunity l Affirmative Action Employer

01-31-2012 15:10 TARHEEL WATER TREATMENT 828-369-0740
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1817 Mail Service Corrbr, Astelah. NC 27029-101, Phone : IE1E18074M raww 9014
RECEIVED 01-31-'12-14,36 FROM- 8283690740 TO- NC DENR P&5 P0011002

` - Central Files: AP5 5wP
03/29/10
Permit Numbe'. WIO'I00083 Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (50M)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
FaciiitN
Status Project Type
Active New Project
Version Permit Classification
1.00 individual
Permit Contact Affiliation
Christy McClure
Contact Driller Well
3494 Georgia Rd
Franklin NC 28734
Facility dame Major/Minor Region
Thomas and Sharon Gray SFR Minor Asheville
Location Address County
84 Soaring Eagle Dr Macon
Franklin NC 28734 Facility Contact Affiilation
Owner Name Owner Type
Individual
Thomas James Gray Owner Affiliation
Thomas James Gray
Owner
PO Box 1447
Franklin NC 28744
Scheduled
Orig Issue App Received Oran Initiated Issuance Public Notice Issue Effective Expiration
03/24/10 02/18/10 03/24/10 03/24/10 02/28/15
Reriuiated Activities _ _ _ _ _ Rerauested/Received Events
Heat Pump Injection RO staff report requested 03/05/10
RO staff report received 03/11/10
Outfall I�t! --
Waterbody Name Stream Index Number Current Class Subbasln

Permit Number WIOI00083
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (50M)
Primary Reviewer
michael.rogers
Coastal 5W Rule
Permitted flow
Contra] Files: APS SWP-
03/17/10
Permit Tracking Slip
Statue
Project Type
In review
New Project
Version
Permit Classification
Individual
Permit Contact Affiliation
Christy McClure
Contact Driller Well
3494 Georgia Rd
Franklin
NC 28734
�ac.i►it•
Facility Name MajoriMinor Region
Thomas and Sharon Gray SFR Minor Asheville
Location Address County
84 Soaring Eagle ❑r Macon
Franklin NC 28734 Facility Contact Affiliation
r
Owner Name
Owner Type
Individual
Thomas James Gray
Owner Affillatlon
Thomas James Gray
Owner
PO Box 1447
Franklin NC
28744
Scheduled
Orig Issue App Received Draft Initisted issuance
Public Notice )aayie Effective
-
Ex iratidn02/18/10
Reculated Activities
Re--uested/Received events
_
Heat Pump injection
RO staff report requested
03/05/10
FtO staff report received
03/11110
Outfali
Waterbody Name
Stream Index Number Current Class Subbasin

KT
Ai
NCDETR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Qoleen H. Sullins
Governor Director
March 24, 2010
Thotuas and Sharon Gray
P.O. Box 1447
Franklin, NC 28744
Subject: Issuance of Injection Well Permit
Permit No. WI0100093
Issued to Thomas and Sharon Grab
Macon County
Dear Mr. and Mrs. Gray:
Dee Freeman
Secretary
In accordance with your application received February 1 S. 2010. 1 am forwardsng Permit No. WIa100083
for the construction and operation of a vertical -closed -loop geothermal mixed -fluid heat pump injection
well system to be located at 54 Soaring Ea41c Dr., Frai*Jin, NC 28734. This permit shall be effective
from the date of issuance until February 28, 2015, and shall be subject to the conditions and limitations
stated therein.
Please pay special attention to Part VII.2 of the permit and submit,copies of the Well Construction
Completion form (OW-1) after construction. Please submit all data within 30 calendar days of
completion of installation of geothermal well(s) to the following address:
Aquifer Protection Section (APS)
[underground Injection Control "C) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
Additionally-, your MC system is subject to inspection by the APS. Per special Condition Part 11.4 it, the
event that there will be multiple wells with separate clusters, one well identification tag per `cluster' of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
Finally, please pay attention to special condition 11.5. The well(s) must at a minimum be grouted
with bentonite grout from land surface to 5 to 10 feet into competent bedrock.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit three months prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director OFthe
Division of Water Quality. If you have any questions regarding your permit or the Underground Injection
Control Program please call me at [phone]

Sincerely,
Michael Rogers, P.G. (NC R FL)
Environmental Specialist
cc; Lancin» Raid zon — AghP�illt Rea anal Office
Central Office File —' 10100083
Macnn County Environmental Health Dept.
Christy McClure - Tar Heel NN'ater Treatment. Inc.
Attachment(s)

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 HERESY GRANTED TO
Thomas and- Sharon Gray
FOR THE CONSTRUCTION AND OPERATION OF 2 TYPE 5QM INJECTION WELLS), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3}(F); for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at 84 Soaring Eagle Dr., Franklin, Macon
County, NC 28734, and will be constructed and operated in accordance with the application received February
18, 2010, and in conformity with the specifications and supporting data submitted, all of which are Bled with
the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation of an injection well and sball be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until February 28, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 24"' day of March 2010.
IcColeen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #W10100083 UIC/s4M Page 1 of 5
ver. 03/2010

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94,
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers,
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II — WELL CONSTRUCTION SPECIAL CONDITIONS
]. At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number (Q)9ti 715-6166, and the Aslieville Regional Office Aquifer Protection Section Staff, telephone
number (8281 2.96-4500,
?. The location of each of the systertt manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation corners) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
_ . Boreholes shall not connect separate :aquifers nr zones that have di izerenwes in water G1ualit� t e.g.. skiallar.
surficial aquifers, saprolite. fractui-ed bedrock. etc. f as specified in 15A NCAC 2C..0213(dK8)(C1.
4. One well identification tag per grouping or `cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
5. The wells inust at a minimum be grouted with bentonite grout from land surface to 5 Io 101 feet into
competent bedrock. r
PART 11II — 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.
?. 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 maybe appropriate, at least 30 days prior to the date of the change.
Permit #W10100083 WC/5aM Page 2 of S
ver. 03/2010

3. The,issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
PART IV — PERFORMANCE STANDARDS
1, The injection facility shall be effectively maintained and operated. at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
?. 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.
1 The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V — OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number [phone]. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
PART V1- 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.
?. Division representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in MC.G.S. 87-94.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
Permit #W10100083 UIC/SQM Page 3 of 5
per. 03/2010

PART VII - MONITORING AND REPORTING REQUIREMENTS
l , All required documentation shall be submitted to:
Aquifer Protection Section - UIC Program Aquifer Protection Section
DENR - Division of Water Quality Asiievill: Regional Office
1636 Mail Service Center and 2090 US Hi4ahv-aN 7Cr
Raleigh, NC 27699-1636 Swannanoa_LNC
Ph# 919-715-3221 ( 828 ) 296-450U
1 A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Asbcvillc Regional Office within 30 days of completion
of well construction. Copies of the GW-1 forni(s) shall also be given to the Permittee and retained on site
to be made available for inspection.
3. A copy of the site map updated with manifold locations required in Part I1.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the .kheville Regional Office within 30
days of completion of well construction.
4. 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 scbedule shall be followed.
5. 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:
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of ani
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.
7, In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director,
PART VIII - PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permir 120 days prior to its expiration date.
Permit #W10100083 UIC/5QM Page 4 of 5
ver. 03/201 Q

.PART LK — 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, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(1 ).
Notification shall be submitted to the addresses given in Part VII.1 of this permit.
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 copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C ,0213(h)(1) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VH.1 of this permit.
Permit M1010ao83 UIC/5QM Page 5 of 5
ver.03/2010

Rogers, Michael
From: Davidson, Landon
Sent: Thursday, March 11, 2010 1:45 PM
To: Rogers, Michael
Subject: geothermal applications
Attachments: image003.png
Michael -
I'm good with both WIOI00083 and 84. Please process.
Landon
P5 --the well schematics were acceptable in regard to grout placement
C. Lander, D'avidsor-., P.G.
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web pone: ht[,r:Jlh2o.enrstate_nt_usZaaw_html
This e-mail contains a public record which is subject to disclosure to third
parties and the public pursuant North Corotina's Public Records Law. N.0
Gen. Stat. §132-1, et seq. This a -mail may'cantain materials prepared
during or in anticipation of a legal proceeding us port of preparation for that
legal proceeding, in which case third party or public access to it is subject to
N,C. Gen. Stet. §132-1.9 and may be denied until the conclusion of the legai
proceeding, including the cornpietion of all appeals and post judgment
proceedings, or, in the case where no legalproceeding has been commenced,
upon the expiration of ail applicable statutes of limitations and periads of
repose.

-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: 1.636 Mail Service Center
Raleigh, N.C. 27699-1636
FAX: [phone]
[phone]
Date: -7/� f Q
FROM: Al n
PHONE:
NO. OF PAGES INCLUDING THIS SHEET:
r�� s d14
FAX NUMBER:
4f " rkm
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If you receive this fax by mistake call: Aquifer Protection Section @ 919-733-3221

TRANSMISSION VERIFICATION REPORT
TIME : 03/02/2010 01:03
NAME : NCDE$NRIWATER QUAL
FAX : [phone]
TEL : [phone]
DATE,TIME
03102 00:5B
FAX NO./NAME
918282947043
DURATION
B: 05: 24
PAGE(S)
14
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RESMODE
STD DARD
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
March 3, 2010
Thomas J. Gray
Sharon H. Gray
P.O. Box 1447
Franklin, NC 28744
Subject; Acknowledgement of Application No. WIOI 00083
Thomas James Gray SFR
Injection Mixed Fluid GSHP Well System (5QM)
Macon
Dear Mr. and Mrs. Gray:
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 18, 2414. 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 fiscal action by the
Division, Please also note at this time, processing permit applications can take as long as bO - 90 days after receipt of a complete
application,
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at michael,[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 hti,11112❑.enr.state.nc-us/docuroents/dwA-� orachart.ndf.
PLEASE REFER TO THE ABOVE APPLICATION NU34BER'WHEN MAKING INQUIRMS ON THIS PROJECT.
Since
fvr Debra J. is
Supervisor
cc: Asheville Regional office, Aquifer Protection Section
Christy McClure (Tarheel Water Treatment, Inc., 3494 Georgia Rd., Franklin, NC 28734)
Bruce Auld (Andrews Auld Heating a Cooling, Inc., 3348 Old Murphy Rd., Franklin, NC 28734)
Permit Application file'�':'1uJv$s
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raleigh, North Carolina 27699-1636
LOcation: 2728 Capital Boulevard. Raleo. Norris Carolina 27604
Phone: 919.73M221 1 FAX 1: 919-715-0588: FAX [phone] Gustormr Service: 1-877-623.6748
intemet: www.ncwateraualitv.ore
An ERuar Opporlrrmry t Afhrnahve Ad& Fmplayer
nt
NnrthCarolina
Nawrallay

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL{S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR.
TYPE 5 M WELL 5
-. New Permit Application OR Renewal (check one)
DATE: O[ ` C 20,D
PERMIT NO. {leave blank if NEW permit application)
A. PROPERTY OWNER(S}/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity rand a representativ
e w/aaAut��hority for signature): "A0 Wfli 5 J� -wes_5 �
(1) Mailing Address • T • a
City: Ff:qrl iC i t A -- State: aZip Code: _D!�Dkft - County: 0� 91^ o n
Home/Of ce Tele No.: tag - .3 9 Q - T 7,35 Cell No.: 40 - 0 `7 ` (c 1 ?0
rouwn. ��T,r=m
(2) Physical Address of Site (if different than above):
City: State:.CL Zip Code; l ___County: C�
Home/Office Tele No.:
EMAIL Address:
Cell No.:
B& AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate llIC well)
Company Name:
Contact Person:
Address:
City:
Office Tele No.:
State:
Website Address of Company, if any:
Zip Code:
EMAIL Address:
County:
Cell No..
C. STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
GPUARC 3QM Well Permit Application (Revised 7/2008)
RECOVED / DENR I DM
Agift Pmte *n Setfion
FEB i 8 tow.,

D. WELL DRILLER IN�MAT
Company
Well Drilling Contractor's Name:
� ll
NC Contractor Certification No.: �1#�.2t-1 A
Contact Person: C�w; J111 f 1 l
8 Address. qL +�
City: _ELaLy k i ln_____` Zip Co
Office Tele No.: S2,S (Qq-b7'/0Cell No.: 8R83_ti_7- &S 1�
E. HEAT PUMP CONTRACTOR INFORMATION (if different dean driller)
Company Name: ljodieos LL _A>X.1���
Contact Person.: EMA Address:
Address:
City. Ruk"_in Zip Code: �L County:
Office Tele No.: 022 3 Iq �1_4;� Cell No.: S�19 371 0' 3L,5
F. INJECTION PROCEDURE (briefly describe how (he injection well(s) will be used)
I
G. WELL CONSTRUCTION DATA (Skin to Section H if this is a Permit RENEWAL]
(1) Proposed date to be constructed: 3 — G 1— 10 Number of borings: O4
I
Approximate depth of each boring (feet):
(2) Chemical additives to be used in closed -loop system (only those chemicals indicated have been approved):
R-22 ropyienc glycol ethanol other (other additives will
need prior approval by NCDENR before use) } f
(3) Type of tubing to be used (copper, PVC, etc); �-j eD4y ma i 00 k F 7 k E r i -C�-
(4) Well casing. is the well(s) cased? (check either (a.) YES or (h.$000w)
(a) YES if yes, then provide casing information such as type (steel, PVC, plastic, etc.), diameter,
depth, and extent of casing appearing above ground: Z�aIb
�i
(5) Grout (material surrounding well casing and/or piping)- 1 �
(a) Grout type: Cement Hentonite !Z Other (specify) q a nt to
(b) Grout depth of tubing (reference to land surface): from to y (feet)
If well has casing, indicate grout depth: from to (feet)
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
inforrnarion.
GPUIMC 5QM Well Permit Appiiccalion (Revised 7/2008) Page 2

L LOCATION OF WELLS]
Attach two copies of maps showing the following information:
(I) Include a site map (can be drawn) showing: buildings, property Lines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 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,
J. POTABLE WATER WELLL(S)
Are there any potable water well(s) on the subject property or adjacent properties? i/ YES NO
If Yes, than indicate location on attached map(s).
K. CERTIFICATION
Note: This Permit Application most be signed by each person appearing on the recorded legal property deed
"1 hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information,) 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 th approved specifications and conditions of the Permit."
3ignaELI a of Prop wner/Applicant
i • 3 • G. �1
Print or Type Full Name
Signature of Property Owner/Applic t
Print or Type Full 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
Agtufer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED I DENR I DVQ
Aquifer Pfaledion Secdon
GPUIUIC 5QM Well Permit Application (Revised 7/2008) Page 3

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