WI0300051_GEO THERMAL_20160602

PAT MCCRORY
Govemor
DONALD R. VAN DER VAART
S<Cl'l//to,y
Water Resources
ENVIRONMENTAL QUALITY
S. JAY ZIMMERMAN
Anne Holden
124 Tall Oak Drive
Mooresville, NC 28117
Subject: Pennit Rescission
UIC Permit No. WI0300051
June 2, 2016
Geothennal Heating/Cooling Water Return Well
Iredell County
Dear Ms. Holden:
Director
Reference is made to your request for rescission of the subject Geothermal Heating/Cooling Water Retum
Well Permit located at the above referenced address: Stajifrom the Mooresville Regional Office has
agreed that a permit is no longer required. Therefore, in accordance with your request, Underground
Injection Control (VIC) Permit WI030005 l is rescinded, effective immediately.
Since the geothermal injection is inactive and you do not plan on using the well for any other
purposes; the well should be temporarily or permanently abandoned by a NC certified weU driller
according to 15A NCAC .0100 and/or .0200. Please coordinate with Ed Watson with the
Mooresville Regional Office (704-663-1699) to abandon the well.
If in the future, you wish to operate a Geothermal Heating/Cooling Water R~turn Well injection system,
you must first apply for and.receive a new permit. Operating a geothermal heat pump injection system
without a valid permit may result in the assessment of civil penalties and/or the use of other enforcement
mechanisms available to the state.
If it would be helpful to discuss this matter further, please do not hesitate to call Michael Rogers
at [phone].
Attachment(s)
cc: Mooresvil)e Regional Office -WQROS
Central Files -Permit No. Wl030005 l
Iredell County Environmental Health Dept.
Sincerely,
{r it:!:!~ De Division of Water Resources
Sta1c of North Carolina f En\·ironmentaJ Quality j Water Resources
161 I M•il servic• Center I Ralei~h,.North Carolina 27699-1611
9 19 707 9000
Rogers, Michael
From : Pitner, Andrew
Sent:
To:
Thursday, June 02, 2016 10:00 AM
Watson, Edward M; Rogers, Michael
Subject: RE: Permit WI0.300051 Holden Residence
I agree too.
A
From: Watson, Edward M
Sent: Th u rsday, June 02, 2016 9:53 AM
To: Rogers, Michael <michael.roger [e-mail]>
Cc: Pitner, Andrew <[e-mail]>
Subject: RE: Permit WI0300051 Ho lden Residence
Mike,
I am in agreement with the permit rescission. The system is no longer i n existence
Ed
From: Roge-rs, Michael
Sent: Thursday, June 02, 2016 9:51 AM
To: Watson, Edward M <[e-mail]>
Cc: Pitne r, Andrew <andrew.p itner(ii'ncdenr.5ov>
Subject: RE: Permit WI0300051 Holden Residence
Mr. Pitner-
I received the permit rescission request from Anne Holden 5/31/2016. Do you approve the rescission?
Thanks.
From : Watson, Edward M
Sent: Friday; May 13, 2016 5:04 PM
To: Rogers, Michael <michael.ro11:ers @. ncdenr.rnv>
Cc: Pitner, Andrew <andrew.p [e-mail]>
Subject: Permit W1030005·1 Holden Residence
Mike,
Attached is. the lab results for t he Anne Holden residence.
We can use this toward the Geothermal permit rescission for the system that has been bypassed.
Best Regards,
~d
~Edward Watson
Hydrogeologist
Wa-ter Quality Regional Operations Section
Division of Water Re sources
1
North Carolina Department of Environmental Quality
704 235 2198 Office
704 235 6040 Fax
[e-mail]
610 E. Center Ave.
Suite 301
Mooresville, NC 28115
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
2
Rogers, Michael
from: Watson, Edward M
Sent:
To:
Thursday, June 02, 2016 9:53 AM
Rogers , Michael
Cc: Pitner, Andrew
Subject: RE: Permit WI0300051 Holden Residence
Mike,
I am in agreement with the permit rescission. The system is no longer in existence.
Ed
From: Rogers, M ichael
Sent: Thursday, June 02, 2016 9:51 AM
To: Watson, Edward M <[e-mail]>
Cc: Pitner, Andrew <[e-mail]>
Subject: RE: Permit WI0300051 Holden Residence
M r . Pitner-
I received the permit resc issio n request from Anne Holden 5/31/2016. Do you approve the resci ssion?
Thanks.
From : Watson, Edward M
Sent: Friday, May 13, 2016 5:04 PM
To:·Rogers, Michael <michael,ro>Z ers .a ncdenr.~ov>
Cc: Pitner, Andrew <[e-mail]>
Subject: Permit W I0300051 Holden Residence
Mike,
Attached is the lab re sults for the Anne Holden residence ;
We can use this toward the Geothermal permit rescission for the system that has been bypas~ed .
Best Regards,
Ed
Edward Watson
Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources
North Carolina Department of Environmental Quality
704 235 2198 Office
704 235 6040 Fax
[e-mail]
6·10 E. Center Ave.
Suite 301
1
Mooresville, NC 28115
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
2
Roge rs, Michael
I
From:
Se nt:
To:
Cc:
Subject:
Attachme nts:
M ike ,
Watson, Edward M
Friday, May 13, 2016 5:04 PM
Rogers, Michael
Pitner, And rew
Permit WI0300051 Hold en Residence
DOC051316WI0300051-05132016.pdf
Attached is the lab results for the Anne Holden residence.
We can use this toward the Geothermal permit rescission for the system that has been bypassed.
Best Regards,
Ed
Edward W atson
Hydrogeologist
Water Quality Regi o nal Operations Section
Division of Water Resources
North Carolina Department of Environmental Quality
704 235 2198 Office
704 235 6040 Fax
edward.watsont@ ncdenr.go v
610 E. Center Ave.
Suite 301
Mooresville, NC 28115
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
PAT MCCRORY
Govemc,r
DONALD R . VAN DER VAART
, &crstary
.Water Res.ources
ENVIRONMl!tfTAL OUALl'l'.Y
S. JAY ZIMMERMAN
Mrs. Anne Holden
124 Tall Oak Drive
Mooresville, NC 28115
Dear Ms. Holden:
May 16, 2016
RE: Underground Injection Control (UIC) Sampling
Results·
Wl0300051 Holden SA7 Geothermal U!C
Mooresville, Iredell County
Permit Rescission Request
Dt,..,,a,·
On April 21, 2016, staff from the Mooresville Regional Office {MRO} of the Division of Water
Resources sampled the water supply well at y~ur residence for the purpose of water quality. During our
visit, we discovered your ,geothf!rmal well had been 'bypassed and was no longer in service. As a result, a
permit•rescission of the geothermal underground injection well heat pump has bee·n initiated.
The samples were analyzed _by the_·Division of Water quality (DWQ) lab for metals, nitrates and other
inorganic constituents. Thi:! results indic;:ate, at the time· of sampling:
1) The water supply well tested negative for total and Fecal Coliform Bacteria.
2} Total Nitrates were measured to be within groundwater standards.
3) No exceedances of metals wer~ detected.·
4) TotaJ Dissolved Solids are within gro.undwater standards.
ff you have ·not already done so, please submit the permit rescission form to Mr .. Michael Rodger at our
central office in Raleigh . A complete copy of the DWQ lab results is.e~tlosed for your.review: The MRO
will forward the lab results to the .central office in Raleigh as part of the permit rescission process.
Should ,you .have arw questions;· plea~e feel free to co~tact n:,e at [phone]. ext. 2198 or by email at
edward.watson@ncdern:gov.
flfipc
Edward Watson
Hydrogeologist
Water _Quality RegionaH)perations Se.ct/on
Division of Water-~esources
Enclosures: 05-2.1-16 ·sam·ple results, definitions of laboratory sVmbols,
Cc: Michael Rogers, UIC, Raleigh (email)·
Sblte of North Carolina I Envi~eoLtl Quality I Wm:r R.c:touroes I Ww:r Qualify ~oual Operatioas
MO<RIVille Rogional Offiec 1610 Etlst Center :A\lellue, Smte 301 I Mooruvill~. ~ortlt. Carolin~ 28! IS"
704663 !699
LDc,.0e11ce1·
Gour!¥
Rcig)o0,
Rt-(er'J:!~n
Em&geooy
C.O~ V~o
North O'lr.olliia:Di"isio:ti:ofWaterResources Water. Sdiences Section Labo·ta.tary Results
RONAtp,5110 ANNE HOl.DEN.HQU>EN
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BesUttl 11.ruli Method An~ysi~•
~ Ao.atvte Name_ fQL Q'ualirier: _Ret'er§iJce Date '\l,illoated ~Y
I.AB
Sample: temper.arure at:.receipf1 by lab· 1·,9 ·c· ·4122/16 MSWIFT
MIC
Coliform. MF P'eeflJ itl MUfd. 1 1'B2Qt CF!:1/1~1 ~"lll";1.2,2 D-1:!)1l7 4/22/16 ~TAFFQRO1
CQfjfonn, MFT9tal in J/ql!l9 i 1~2Q'I 'Gft.J/100mi SM 1;12_?2 S:-1_99f. ll.1~2/16' ESTA,f.FgRD!
NUT
Nitrate as N In. liquid O.D2, Q.95 ·m9{Ltas N EPA,353.ZR6V 2 -5/2/16 CGREEN
Nitrtfe as:1:<1 In liquid 13.01 0.01 ·.U l!Jg/1:.ai.·N EPA 353:2 REV2 4/22/fl, . CGREEN
NOZf.Nct:{ as f-J in llquid P.0.2 .o.&.5 Tl\9'L-as N EPA'..3~.'2 RE\1·2-4/2~16 .CGllBEN
WET
aronikl~ 0;4 O'A ,\J' fl:lg/L EPA 300,o r~ i 4/21M 'G'GREEN
Ch.(orj~e 1!() 1.8 .mlJI!,, EPi\,30_q!Pm~:f 11WM ;q;,-REl;N ---•---
FJU~ride· -DA P,-4 lJ mQ/L; EPJ\::a0(i.0:rev-2.~ 4/22116 C'GREl:)'l
SUffute 2..-0 4-::1 IJ)g/1. EPA:300.0,rev2. f 4122/11) CG~EE,:J
Tota1 Dlssolved.Sotias :iri liquid: 11Z: ~8 ma,'L Slil i2S40 C 1!i9T 4/25i16 'CGREEN
Mtr
7,¥;0:.~ Ag by. JCPM.S 1,~Q t»~ ~~ EPA~OQ/a A:'3116 ESTAFl'O~D.1
f 42~S 1"1P¥ ICP. 50 so _ll' u~ll'.-,ai'A~Q0;'7.' -5131.16 .ESTAFF~/W1
7440,aa.2. A~•~Y· IGPM~ 2;6 ~·:ou urj([. ~.fl.20())8 ~1/i ESTAF.li'.QR01
T,440!3$-a ~1'! !:iylGP 1Q. ~.2 ug/l EPP.~®.7 6Mi6 ~I\FF,ORD1
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!440~-S. ~d.l?Y.)CPMS (')~ -MQI.I \Jg/I.._ J;il>A-2,Qq'8: ~~16 ®Ai=fO~P.1
7440A7,'3 CrbylCPMS }:o $;0,V . •u_g/i:. EPA20'C1,8 5ll/16 ~~OROf
l440'5lk8 C.u by fOPMS -~-0 t r '4llit. 6PMl00.8· 5/µ16 ~TAFFOR!:11
1"1l9'8!Hl Fe'by!C.P 50 S'Otf VJJ(L EPA:200.7 51311!1 ESTAf.Fotm.'I
"*-09,,7 ~.b.y {GP 0 .1 0 1.7 ,ffig/L EPA:200,7-513/16 EST1\FFORD'1
1A39'Q!µj ~gbyTGP n:.10-4:0 ~c EPA..2QO;r 5/3116 esmFFoRo,,
1~ Mn:by lGf" 1D 101'.I ill9fl EPA.2.0&,7' 5/3/:16 ESTAFFOR01
7l{-4Q-13.·S f'JabyJPP U.'10. a:2 ~b'(t.. E'.PA·.2.00'.7 5/3116 ESTAFi'ORCH
7,44.'0-.02--0 Nibyl_QPMS 2 .0 2.0 U .vg/£: E?A~.B 0;~6 6STAf-F.0fU!)~
1•i4!!:~1 Pb b¥ JC.PM$, ';2;(} 2.0.LI -~/I!, EPA2P0,8 5(;!/tB ESWFOR01
j'-782,:4~-2 Se~YJ.QPMS f,o 1..v:u ·\l!J({. EPA.'200:1:! 6/atf8 ESl;A,i;FQRI)!!
74,4,0~ ZnbYJCt='MS ·10 t1 )!9/)., EPA.~,6 pl'3l'f(, .6$TAf'FORDl
-WSS:Chemliri,yl,a1,orat"?°"> 16251\fil.!rS•nilc. Cent.,; Rafelgh, NC 2'1899-1'623 .(9.'9) ~l9D8-
"fl!oi O~~cl~' ~-•Q' d~s not)1~!cai~ ~m]i!~;\s JJ'.)ely/e. tre.r:~at 11\tl':l\";1.M&~J! n9 t;tlet~'8f-QT'e~v.e.the:POL.
Pa~e.1 o{1
:A
B
'BB
C
G
Definition
Valuen:portMisthe 1111:111D (averege)of~ ormoR1 dot'ormmatiolll: This codo lsto be uscdif1b.e .ull8'(!ftwo ormo~
disaeti: and separe 111Dplos ue ·llVen,pd. 1bmc SIDlplcs shall hllftl bean jll'O(IIIS5ed mtd lllll1yz.ed indepandently (e.g. fio1d
dnpBcatcs, _diffcmot dllulions of tho llltlDt sample). Tlfis code is not ftlquin,d for BOD, .collto.rm or acute/chronic metals
l'llp(lJ1ing eince aver~ multiple resullS fur 1llese p~ i.8 fmldammtal to !h09e motbod.! or JIW1ller of':n,porting.
1. The ICpOrted value is an a~age, whe:e at Ieut one ~suit is qullificd with a. "U''. Tho PQL is used lbr the qualified
m.lWll's) 1o caloulal= the.a.,_e.
Resulta based upon· colony count!! outside the accep1ablc rao;e and ahollld be ust>d with caution. This code applies lo
microbiologuia] tests IIDd specifically to 111embl'Jll1e ~ (MF) colony coWll!s. lt la to 1,e used if !es., than 10096 semple wa.s
analyzed 1111d the coloJJ,Y count fa genmted from a plale in which 1he number of colonies extieeds the ideal ranges indioati,ci by
the method. 1'htae ideal nmges are defined In the method as:
Fec:Q/ coliform or Enttrt,co(%Z/!I bactvla~.10-60 co/ordes To/al colffo,m l;ar:teria; 20-80 cofomes
1. Count:1bll: membranes with leS3 than 20 co Jonie 1. Rt:portcd value is estimated oris II total. of the counts on all fi.1~
zq,orted plll: I 00 ml.
2. Counts from all filtm ware zero, The va111e reported is hued on 1be llUml>er of colonies per 100 ml that would have
been reported' If there had been one ooloey on_ the tilter re~enting the largest filtratfrul volume (reported as a less
thaJl "<" Vallie), , ' .
3. Countable IIIIIBlbranca with more 1han 60 or 80 cok>niea. !he value l'CpOrted .is calcuJed 1ISing 1he count from the
smalleit volmoe filleted sad reported as a &realer dum ">" value.
4. Filters have coun1a of both >60 or SQ and <20. Reported value is estimated or is a total of the coimts on all filters
~poried pa 100 ml. • . . ,
S. Too many colonies were present; too llllmUOUs to count ('INTC), 1NTC is generally de~ BS> 150 ooloniu. 1ha
numeric valoe represents the maximum number of 001mts typfoaJ.ty accepted on a filter membrane (60. for fecal or
cntcrococcus and 80 fur to1al), ,nultiplicd by 100 IJld then divided by the smallest filtnltion vclume anelp.w.. Thi8
number is l'CpOrted tS a greater than value.
6. Bstimelz:d--Value. Bhnlc: l'lODhirnination evident ,
. 7. Many non-ooliib1ID or non-enterococcos colo:oii,s or io~g non-coliform or 11DIH1n1at1coccw growth piescnt !n
thiswmpeti!M aifmlian, tJ;e reposted value tllll)' unde:-"f'CJlfflllcof actwsl dtmjj;y.
~: A "B" value sh.all be actompani;d by justification fur its uso de!loted by the 11U111bcra listed above (e,g., Bl, B2, etc.).
Not.e : A "n" !lbould be used fur mil;i11diillmcs.
11m code 'applies to most probable 011m ber (MPN) microbiologioal tc.sta.
1. , No ~!ls orfubes pve a. positive rce.ctioll. Value based upon llte approprimi MPN Index 111\.d reported 11.'1 a less 1hllll
"<'' value.
2. All wells or to bes ge.ve poai1i.ve reaotions. Value baaed upon the MPN lnd.ex lllli n:ported as a gmitor 1hm ">" value .
.!'i2ft: A .''bi," vatue ll!all !Se ilfcbmjSam!d 15yjtmf&1limrf0ritnnrde!lnte'.d1ly the nlltilben ™ l!bove (e.g., BBl, B.,...,
etc.),
Total rcsidwil. chlodne Wll.!I pre.sent in sample upon i:eoeip1 in 11:ie ~ty; value is atimated. G=rally applies 1il ~enide.
r,henol. NH3 TKN. COlifullll; ll1li orirmies. •
A ~ qualily contJOl 1ailure oOQll[t'e(! during biocl>emic1ll oxygen demand (BOD) mely&is. The san:tple n:sults should be
used with caution. ·
1. The cti&S01\1'11d oxygen (DO) depletion ofUJ.e dllutiou v.u blank oicceedod 0.2mg/L.
2. The baoterial ,oed oontro).s did not meet the re~111ellt ofa DO depletion of at least 2.0 ~ and/or a DO residual
of at least 1.0 mg/L.
l. No AIIIJIIC dilution met the ceq~ofa DO depletion o£4t leut2.0mg/L mid/or &DO~dual ofstkast L.0
mg/L.
4. Evidence of1X>Jticity was pre,ent Thi! is generally olmracte:tir.ed by a signi.ficentincrta1e, in~ BOD Vlililc as the
. .smJI>k con.001drauou decroases. 1lu: n,pomd value is calculated from 1h.e highest dilution repte81!11(iDg the mnximum
Joadi!ig pot=utial.ud should be CODl!idet'edan estrmaeed value.
.S. lb~ ,1uoo-'1:f ghlta.mic acid slalldard c:nieeded. the 111D.ge of 198 * 30.S mg/I..
6; 1lu: cal.cmlll!cd seed oorrcttion cxoeeded the ran,ge of 0.6 to 1.0 DJ&IL.
7. !all ihan 1 mg/L DO remained fur. all ctilutioJIS art The n:poited value is BO ati.mated giule:r • value and is
calculini,d file the _dilntiou using the leastemollllt of sample. ·
8. Oxygen usage is lC&1 than 2 mg/L for e:11 dllutiOllll set. lhe reported value is sn eltimated lesa tllan value and is
caJculatcd fur the dihrtion using 1he most amount.of samplt;.
9. The DO depktlon of1he dilution Wl!fer blank Fl)dllced aneptive valua.
Nn te: A "G" value shall be aooom1>imiod by iustifica:ti011 fur its use dcooted by tbe n 1mb= lisll:d above (e.11.~ Gt G2 etc.J.
Eatlmated value; valuem.yuotbe accute. 'lbisoodeisto beuaed ill tbefollowioginsllln~:
l. Surroge recovery 1uJln liave been eXIJtC&d.
:l.. The reported. value failed to Jl)eet 1be cstsbllsbed qnality ocmttol critetil for eitht'II! precision OI'. accuracy.
3. lhe SllmOlc matrix inti:rli:Jed with the abilitv to IIJllke any accura~ dc21?Dmon. I
J
M
N
Q
p
s
u
V
x-
y
z
4.
5.
6.
7.
8.
9,
10,
11.
12.
The dllla is questionable because of impropm laborar.ory or .field protocols (e.g., composite smnple was coileclM·
instead of grab, plaBtio ins!ead of e:).a8.'I coilllli.rm, enc.).
Tc:mpe;aturc limits execede(f(sampl" fro.zmi en >6°C) during tranBPoct or not verifiable (e.&,, llO remper:a1u:re blenlc
provided); oon,reportllbl.e fur NPDES oomplisnoe monit.oring ..
Toe laboratory mal.ysii;, was from an unpiucrvcd or improperly cbeniically preserved sample. 'Lbe data may net be
IICCtlllte. •
1hi5 qualifier is used tt> idcnlily e.nalyte cooomttBtion exceeding the upper cah'bral.ion range of che analytical
ins1rument/method. Toe reported v•hte should be CODlliderw estimaled.
Te.mpsralllre limitt; txeeeded (samples iroull or >6"C) during Slorllge; tho data ma.y .not be 11Ccurate.
'I.be reported valne 18 dotmmined by a one--poillt eatimation ~r than against a regre~'$ioo equation. The esti.lnaled
oooceo.tration is Jw t:ban 1be labomtozy practical quauti!atiO!l limit and ~r than the; labora:lory method detection
limit.
UuidllU!ifiad _peu.; estinnted value,
The repom:d value is detemiliied by a one-point esli.nulti-ou rether than 11gainst a regression equation. The esfunaiut
oonce.otrstion Is less th.an the laboratocy ptY>ctica.l quantitation limit 1md gieater th8.ll the irutrumcnt noise level This
rode is used WP"" an MDL has not been eslabfished for lhe analyte in question,
The c:alibmion veruicafioll did not meet the calibration eooepnm_ce criterion for field parameter!,
Note: A "1" value shall be accompanied by justification for its use denoted by the11umbcrs listed above (e.g., JJ, n , etc..). A "J'
value shall not be used if another code anolies re.,, N V Ml.
S!!lllple 1111d duplicate results are "out of c:oatrol". The sample is .non-homogeuous (e.g., VOA soil). The reported valne it the
lnwter vlllue of duPlicllle anal vaee oh Sarnole.
Pre=ptive evidence ofprese.ilce of material; estimated value . This code is to be ll3Cd_ if:
1. 1he component has been tentatively identified based on mass spi,cl:ral Ubnuy Sel!rCb.
;2. There is an indioation '!bat the imalyte is present but quality control requirements for confirroation were not met {ie~
prestru:e of analyte was .not confinned by altwtate procedures).
3. This code aluill ho u~ed If the level is 1oo low to ptmnit at~ quantification, but the e&timal:ed cance.nb'ation is
less tfuni the laboratory practical quantitatlon llmit and greater Then the liiboratn.ry method detection limit This code
is not~ used for fTl(}tf analyses.'
-4 . This code shail be ll9ed ifth.elevd is100 low tXJ pc.rm.it a=ste qu.antilication, but the at!mated concentration is
bs than the l&borelory practical quantilation limit and greatv than 1he imtrumetrt noiae levol, TrJs code is used
when an MDLluzs not been estabtlshedfor the analyte ill que;ittoh.
5 . The COIJlPOnent has been tentatively identified based Oil a retention time standard.
Holding time exceeded. These CO~«:$ sh2ll be used If 1he value .is derived from a sample tbiq was received, prepined and/or
enalyu.d after the approved holding time ~striciions for sample Jlreparetion and snalysu. The value does not mest NPDBS
requirements .
1. Holding time exceeded prior to rc~ipt by lab .
2 J:l'nJA;nn t-im .. exceeded followinir rei;eiP,(~I.~"--_---·-------------------f------
Elevated PQL• due-to matr:ix intcrfi:tcmce end/or 5a1DPle dilutia.n.
Not enough sawp]e provided 'to _prepare and/or &1alyz.e a md.hod•required mab;ix spike (MS) aod/or mnrix spike duplicate
fMSD).
lndicatcs thet the IIDalyte was analyzed fur but not detected above the.reported practical qL>Ultitation ii.mit•s The DllUlber valoe
rcoomcl witb the "U" QUll.liffot is =I to the labora!O!)''s practical ouanlitarion limit".
IndiCl!te:J the anelyte was dcttoted in both tho sample and the e.ssociated blenk. Note: The value in the blank shall not be
snbi?acted from the assoCl.lllcd smnpl.cs.
I . The analyte was detected in both the sample 8Ild the rru:thod blank
2. The aos.J ytr was detected in both the sample and 1he field blllllk
Sample not analyz.cd fur this constil'Jcnt Th.is code is to be Ulled if
l. Ssmple not screOlled for this compound
2. Sampled. bul ar.ialysiB lost or not perfurmed-~cl.d tl!!ot.
3. &lmpled, but analysis lost or not perro.r:mcd ~lab error.
Noil:: an •x• value shall be accoropacied by ju.stiti.calfon for rts u,e bv the numbers listed.
Elevated PQL" due to insufficient Sll!llJ?le size _
The sample analysis/resul.is iire not reportecl due to:
I. Inability to ane.\y.l.e tbe sample.
2. Quc!fions conceming data reliability .
~ presence or absence oft!ie a.nalyte CftllllOt be -vcdfi11d.
Sli;,IA',;,;,.."' Definitions listed below
MDL A Miithod De1ection Lim.it (MDL) b defined as 1hc millimum ooncentzation of a subsiaDoe that cu be meamtred and ~m:d
with 99 peltOllt oonfidcnc;e that1he tnic val~ ls gn:mr ttim zero and is detcmJJned In accordance with -4() CPR Part 136,
Appendix. B.
-ML MiDi:mmn ~ls m ll8ed in ,ow, BP A methods. A Minimllln Lm,l (ML) ia !ht lowest levcl It which the entire analytical
sy~m-must give a ~le sigml &11d aocep'llble oa.libration point fur tho 111.alyte. It ls equivalentto lhe concentntlon of
the lowest calibratkm standard. ~ that all ~d -~oifiod sample wcigb.1S, volumes, and o1eamlp procedlll'IIS ha~
been employed. Tho ML is wc:alllled by. muhiplymg tho MDL by 3 .18 and roundl:Dg th& ~to lhD Dm'tlst factor of 10
multiple{!.c:., I, 2, or 5), For ex:aplt, MDL= 1.4 IIJS"L; ML-1.4 mg/Lx.3,18-_4.4SroU11dedtothi: nearcstlil.clorof10
multiple (i.e., 5) '"' S .0 mglL
*PQL Toe Piaelical Qwmtitatio.n Limit (PQL) la defined as lb!! lowest co110entrl¢ion that am be reliably achieved within speci&d
limil3 ofpicdsion end accMII:)' durinpmlUlle labonitory oporatiog ·oonditio!lll, PQLs IIRl s-.ibjectivdy set at some multiple of
tn,lcal MDLs for':reagent water (generally 3 to 10 times the MDL depending upon the _piram.eter or ana!yn: and based o;i the
enalyst's be8t profi!l!Sionaljudgemllllf, the quality and age of tho ~t 1111d the naturcJ of the samples) rather than expllcttly
delennlncd. PQLs mey be oommelty cbosao within these guidelines to simplify dalt n::parti.ng and, where appliC&.ble, e
generally equal to the concentration of the loWffl non-zero stllndm! in the cal:ibratian. QU!'Ve, PQ.Ls are adjusted:.fuf ,11111pl11
size, d!IU!ion. and% rnofstme. For pma,aeters 1bal are not amanable to MDL Btudiea, th'tl'QL may be de&84by the aamplo
volume end buret graduatiom fur tiln.tionB or by minimum measurcmenl valu=1 set by-1he method fur method-dofmed
p~ (e.g., BOD require.'! aminimmn DO depletion of2.0 m~. fecal oolifonn roqu.im a. minimum plato count of:ZO
c:fti, total rruBpended residue require! a minimum weight gain of2.S mg. ell:.). Additionally, ao111& EPA methods _pmscn'be
~um Levels (MLs) and the lab IIllJY set the PQ_L eqwil to this method-silted ML. Dettnnina.tlon ofPQL js fully desorlbed
in. flu: l.a.horetory's onalytical S1audaid Open'ling P.roccdum (SQP) document.
06/lSf.2015
North Carolina Department of Environmental Quality-Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S) ,,
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application ___ R.enewal* __ Modification _X_permit Rescission Request*
~For Permit Renewals or Rescission Request, complete Pages I and 4 (signature page) only
Prlnt or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: May 18
Application)
,2016 __ PERMIT NO._ Wl030005 l _____ Oeave blank if New
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as O Geothermal Well D Drinking Water Supply Well
D Other Water Supply Use-Indicate use (i.e., irrigation, etc.) ________ _
b. Terminate Use: lfthe well is no longer being used as a geothermal inj Wi:i~~E.O'.,NAl~
rescind the permit, check the box below. If abandoned, attach a copy o'fiheWeh~\i~~otilii!'d/
Record (GW-30). MAY 3 1 2016
~ Yes, I wish to rescind the permit Water Quality Regional
Operations Section
2. Current Ownership Status
Has there been a change of ownership since permit last issued? 0 YES ~ NO
If yes, indicate New Owner's contact information:
Name(s) Anne Holden
Mailing Address: 124 Tall Oak Drive
City: Mooresville _________ State:_NC __ Zip Code:281 l 7 ______ County~
/
lreJJ¢11
Day Tele No.: [phone] ___________ --'E=m=ail=A~dd=r=es=s.,_,_.: ____ _
B. STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence _X_ Business/Organization __
Government: State Municipal__ County __ Federal
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 1
L. SITE MAP-As specified in LSA NCAC 02C .0224( b )( 41, attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the_ injection well(s). The site map shall
include the follo,Wing:
(1 )1 All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a )(2) located with.in 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained a.ttd downloaded from the applicable county GIS website. Typically, the property can be searched by
owner """'e or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
-,vells, etc. can then be drawn In by hand. Also, a 'layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .02 l l(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the person(s) listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty oflaw, that I have personally examined and am familiar with the infonnation
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment.
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Pennit."
Print or Type Full Name and Title
Signature ofProperty Owner/Applicant
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Geothermal Water Return Well Permit Application Rev. 3-1 -2016 Page 4
C. WELL OWNER(S)/PERMIT APPLICANT -For single family residences, list all persons listed on the
property deed. For all others, list name of business/agency and name of person and title with delegated authority
to sign:.., _______________________________ _
l\-1:ailing Address: ____________________________ _
City: ____________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
D. WELL OPERATOR (if different from well owner)-For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
to sign: __________________________ _
Mailing Address: ____________________________ _
City: ____________ State: __ Zip Code: ______ County:. _____ _
Day Tele No.: ______________ E=m=aH~A=d=dr~e=ss=·=-----------
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: _________ County: ____ _
(2) Physical Address (if different than mailing address): ______________ _
City: ____________ County _________ Zip Code: ____ _
F WELL DR.ILLER INFORMATION
Well Drilling Contractor's Name: _______________________ _
NC Well Drilling Contractor Certification No.: ____________________ ,
Company Name: _____________________________ _
Contact Person~: -------------~EMAlL Address: __________ _
Address: _______________________________ _
City: _________ Zip Code: ____ State: __ County: ________ _
Office Tele No.: ________ Cell No.: Fax No.:. _______ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HV AC Contractor's Name: _________________________ _
NC HVAC Contractor License No.: ______________________ _
Company Name: _____________________________ _
Contact Person~: -------------~EMAIL Address: __________ _
Address: _______________________________ _
City: _________ Zip Code: ____ State: __ County: ________ _
Office Tele No.: Cell No.: _________ Fax No.: ______ _
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
G<:othennal Water Return Well Permit Application Rev. 3-1-2016 Page2
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
l. , WELL CONSTRUCTION REQUIREMENTS -As specified in ISA NCAC 02C .0224<d ):
( l) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of ISA NCAC 02C .0107. except that:
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from ' the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
1 *EXISTING WELLS ---~PROPOSED WELLS
* For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, lllld diameter
(c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per l5ANCAC 02C .0107t/J(8 J
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below 1and surface
K. OPERATINGDATA
(1) Injection Rate:
(2) Injection Vo~ume:
(3)
(4)
Injection Pressure:
Injection Temperature:
Average ( daily) __ ..Qgallons per minute (gpm).
Average ( daily) · gallons per day (gpd).
Average (daily) pounds/square inch (psi).
Average (January) ° F, Average (July) __ 0 F.
Geothermal Water Return Well Pennit Application Rev. 3-1-2016 Page3
Submit two copies of the completed application package to:
Division of Water Resources -UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Ce.nter
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Penn.it Application Rev. 3-1-2016 Page 5
GEOTHERMAL HEATING/COOLING WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxes. Fill in depths b elow land surface (BLS) and
details of well construction on the blank lines provided. Use additional sheets as needed.
O o e o -Hole Well D esign
D Proposed D Existing
D Injection; D Supply;
D Dual Purpose
Screened Well Design
D Proposed D Existing
D Injection; D Supply;
D Dual Purpose
Record Depths Below
Land Surface (BLS)
1on Lines Provided
l
Bottom of casing
(Ft. BLS)
Total Depth
(Ft BLS)
r-----(Ft.)
Return or Supply Line
Casing
.,.. _______ Grout -------~
WELL DETAILS
Casing Material: _______ _
Casing Diameter (in.):
Grout Type: _________ _
Grout Depth (BLS): ______ _
Top ofBentonite Seal (if present): __ _
Bottom of Bentonite Seal. _____ _
Screen Material: ________ _
Sere.en Slot Size (in.): ______ _
Sand/Gravel Pack
Material Type: ________ _
--Bedrock
Bentonite Seal
(if present)
r------(Ft.)
Record Depths Below
Land Surface (BLS) on
Lines Provided
1
(Ft.BLS )
(Ft BLS)
Bottom of casing
(Ft. BLS)
(rotal Depth
Ft. BLS)
NC Certified Well Driller Name: _______________ Certification No.: _____ _
J\,,,,I;. , .,.
Ac,•.j
:~ea~-~~ Lal 35.566661 Long. 80 919812 ,..AnaJyze Bacteria samples regardleaa of hold time ... ~-c. ,.lf1,o .. ~'"d'l"!-.zr,.!,.t11 -tl,~~ --
.
Tin (Sn) IJg/L
Aadity, as caco3, to pH 4 5/8 3 mg/l Oil and Grease, HEM, Total Recoverable mg/L .....,_X-+-A_lu_m_1_nu_m ___ (Al_) __________ µ_g/_L_
0
___________ _
Alkalinity, as CIC03, to pff 4 S/8 3 mg/I. · Phenols, Total Recoverable µg/L Antimony (Sb) l,lg/l
Tltllmum (T1) µg/L
Vanad1umM IJg/L
900• Blocherma,I Ocysen Demand, 5-day mg/L Rl!Sldue• Total (Total Soltd.s) mg/L X Arsenic (As) JJg/L X Zmc (Zn) µg/L
c800-carbonaceous BOO, 5-<lay mg/I. Residue Volatde/FU<ed, Total mg/L X Ban um (Bal 1,1g/L
X COlll'orm• Fecal MF /100ml Res1due,Suspended(Su.spendedSof1ds) mg/l Berylhum(Be) µg/l Boron (BJ, Total µg/L
JC Coliform Total MF /100ml Residue V0Jat1li=/F1xed, Suspended mg/L X Cadmium (Cd) IJg/L Mercury 1631. low-level ng/L
Coltfom, Tube Fecal /100ml X TDS -Total DISSOived Sohds mg/L X Calaum (Ci) mall
Coliform• Tube Total /lOOml S1hca mg/l X Olrom1um (Cr), Total µg/L ~:<-'l'..Olpniis_,a . . :., (.,.;·,.,;,,n ;'; ._: ~\
Speaf1c Conductance, at 25 °C umhos/cm Sulfide mg/L Cobalt (C~l µg/L Acid Herb1c1des
TOC-Total O(8iln1c carbon mg/l Tanmn & Llgntn mg/L )( Copper (CU) IJg/L Organochlonne Pestlodes .
Turbidity NTU X Iron (Fe} µg/l Organonrtrogen Pest1C1des
X lead (Pb) tJg/L Organophosphorus PestJCJdes
PCBs (oolyehlorinmd b1phenyJs)
Bromide mg/L X Hardness, Total as caco3 • by titration mg/L X Magnesium (Mg} r Contain, '1,___m-'1g/-il_O•-+-------------i
x 01forlde mJ!/t X Manganese (Mn) 1:1 _ µg/L Sem1-Volatde Organics (BNAs)
x Ffuonde • mg/l Mercury (Hg) -, 1,1g/L TPH Diesel Range
i--::x+s=u,.;.;fa.;.::te;.;;._ _________ _:.;mg/l~;......i1-::.i~.Jr,i:-::1, ~Ni.11:Qeii~. "':"l'T, .~ts--=~-: • ...,_ •=-ete~·rs"'"'· ::r.::~c::~'.':"'."."'•,:f-:::~-;-.,:::f_:--: •• ~-==r"~=-::f,.--:~.~-~;--:-,:--:it-:-J•it--+M::-.-:oly-:-b-:de:...:n""'u:a:.m-;:{M:-:-o-:-)--; SUlfunt Acid -, ......... IJ .. g/l"---o------1-------"--------◄
!--=-'c.+:Ch=lo:.;.rop:...hyl_J_a __________ fJ_,g/=,.L-ft-"'-.;.:.;--Am--m"--on-ia""'a:...s ... N""(N-H3-~N"")---'""""';;_'----'---'---'-m--g/-;L'-'-tt--:-X-:--t-N:-:-1""'.ck .... el:-:(:-:-N1.,..) -----'-----; .SA-52S2920 IJ8/L
Color. ADMI c u X N1trate-Nrt:nte as N (N03+N02-N) mg/I. X PotaSS1um (K) , EXP: 09/09!16 mg/L
1--....:Co=lo:.;.r:.;.P.;;;Jatl.:..:n:..:..u_m_C_o_b_al-t _______ ..;.c..;.u_, ~i,....:.;;+1i-o'-ta-'J K..;..Je....,1-da_h.,..l N_ftr_o_g,_e_n_as_N_(TK-,--N-')-----m-'gf=-:L--ll·....;;X-'--t-,-Se""'le--n-1u_m_(:-c:Se-;)-----; W3rPIA011 ... _µ_.pj..,.L--tl~-+-TP-H-G-as_o_ltn_e_R_a-ng-e--------1
Volatlle Organics (VOA)
COD: 011tm1cal Oxygen Demand mg/I. Total Phosphorus as P (TP) mg/L X Sliver (Ag) See 11\SOS 1 __ 1J81-=-L--1
1
___ ........ _____ ....,.... __ ...,... __ __
CVanide, Total mg/I. X Nitrite as N {NO2·N) mg/l X Sodium (Na) J mg/l •• ::: , Bloloifcal: -~ ._-: ... -, :. ,;.;._ ·: '~ ; l
0
, "
Formaldehyde mg/l X Nltrilte as N (N03-N calculated) mg/L Strontium (Sr) -·-__-µg/L Phyti,plankton / Algae
Hexavalent 01rom1um (Cr6+} rrl¥,/L Ofthophosphate as P (P04) mg/L Thallium {TI) tJg/L
lA8 COMMENTS:
Revision: 06 2015
l.oc;D..,_ct,:
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WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
!!!!£: April 19, .2016
To: Corey Basinger -Andrew Pitner
E!:!!m: Shristi Shrestha, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone:-919-807-6406 Fax: [phone] E-Mail: [e-mail]
PermitNumber:WI0300051
A.
B.
C.
Applicant: Anne Holden
Facilin Name:
Application:
Permit Type: Geothennal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
_· I would like to accompany you on a site visit.
Attached. you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within ~ calendar days. please return a completed WOROS Staff
Report.
When you receive this request form, please write your n ame and dates in the spaces below, make a copy of
this sheet, and return it to th'e appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROSReviewer: __________________ Date: ____ _
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 092614 Page 1 ofl
NORTH CAROLINA DEPARTMENT OF ENVJRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 0 2C .0224
GEOTHERMAL BEA TING/COOLING WATER RETURN WELL(S)
These well{s) inj ect groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application ___ Renewal* ✓ Modification __ Permit Rescission Request*
•For Permit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. lllegible Applications Will Be Returned As Incomplete.
DATE: _______ __,20 __ PERMIT NO. wIO 3 OO~S'I {leaveblankifNew Application)
A . CURRENT WELL USE AND OWNERSHIP STAT US (JeaveBlankifNew Application)
1. Current Use of Well
a. Continue to use as __ Geothermal Well __ Drinking Water Supply Other Water
Supply
b. Terminate Use: If the well is no longer b eing used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
REC~
0 Yes, I wish to rescind the permit
APR 18 2016
2. Current Ownership Status
Has there been a change of ownership since permit last issu ed ? 0 YES n N ~ Ou■llty
~Ions! Ope,ratlona Section
If yes, indicate new owner's contact information:
Naine(s) ______________________________ _
M ailing Address: ___________________________ _
City: __________ State: __ Zip Code: ______ County:. ____ _
Day Tele-No.: Email Address.:
B. ST A.({_US OF APPLICANT (c hoose one)
Non-Government: Individual Residence ✓ Business/Organization __
Government: State Municipal __ County__ Federal
C. WELL OWNER{S)/PERMlT APPLJCAN11 -For individual residences, list owner(s) on property deed. For
all others, list name of entity and name of person delegated authority to s ign: __________ _
Mailing Address: 7j H '1 e Ho Id (~(1
City: /1 oc,re;:5 V ,1 ( 1-e State:~Zip Code: e tr II 7 County: 1r12 de 1/
;.> '
Day Tele No.: '103/-66.Z,-3 7 3 D Cel.1--No.: r 2
EMAIL ~ss: Fax No.:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page I
D. WELL OPERA TOR (if different from well owne r ) -For individual res idences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated a uthority to s ign on behalf of the bus iness
or agency: _____________________________ _
Mailing Address:--------------------------------
City: ____________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: Email Address.:
E . LOCATION OF WELL SITE -Where the injection w ells are phys ically loca ted:
(1)
(2)
Parcel Identification Number (PIN) of well site: __________ County: _____ _
Phys ical Address (if different than ma iling address): ________________ _
C ity: ________________ State: NC Zip Code: _________ _
F WELL DRILLE R INFORMATION
Wet! D rilling Contractor's Name: _________________________ _
NC Well Drilling Co ntractor Certification No.: ____________________ _
Company Name: _______________________________ _
Contact Person.~: _______________ EMAIL Address: ___________ _
Address: __________________________________ _
Cit y: __________ Zip Code: _____ S tate: __ County: _________ _
Office T ele No.: ________ Cell No.: Fax No.: ________ _
G. HV AC C ONTRACTOR INFORMATION (if different than d1iller)
HVAC Contractor's Name: ___________________________ _
NC HV AC Contractor License No.: ________________________ _
Company Name: _______________________________ _
Contact Person~: _______________ .EMAIL Address: ___________ _
Address: ________________________________ _
City: __________ Zip C ode: _____ State : __ CoW1ty: _________ _
Office Tele No.: Cell No.: Fax No.: ----------------
H. WELL US E Will the inj ection well (s) a lso be used as the su pply well(s) for the following?
(I )
(2)
The injection operati on?
Personal oonsw n ption?
YES ___ _ NO ___ _
YES __ _ NO ___ _
l. WELL CON STRU CTION REQUTREMENT S -As specified in 15A NCAC 02C .0224(.dl:
(1) The water supply well sh all be constructe d in accordance with the water supply well r equirements of
15A NCAC 02C .0107.
(2) If a separate weU is used to inject the heat pump efflue nt, then the injection well sh all be con structed
in accordance with the water supply well requirements of I SA NCAC 02C .0107, except that:
Geothermal Water Return Well Permir Application (Revised Jan 2015) Pagc2
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen. the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
K.
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
____ *.EXISTING WELLS ____ PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW~l) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothennal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Bach diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
(c) Casing depth b elow land surface
(d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(Q(8J
(t) Length of well screen or opeo borehole and depth b elow land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
OPERATING DATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
{3) Injection Pressure. Average (daily) pounds/square inch (psi).
(4) Injection Temp erature: Average (January) ° F, Average (July)_° F
L. SITE MAP -As specified in 15ANCAC 02C .0224(b)(4), a ttach a site-spe cific map that is scaled or otherwise
accurately iudicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells, surface water bodies, and septic systems inclu ding drainfield. waste
application•area, and r ep air area located within 250 feet of the injection w e ll(s),
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a)(2) located within 250
feet of the pr oposed injection well(s).
(3) Property boun daries located within 2.S0 feet of the parcel on which the proposed injection well(s) are
to be located.
( 4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
G«>thermal Water Return Well Pennit Application (Revised Jan 20 15) Page3
NOTE: In most cases an aerial photograph of tire property parcel slwwi11.g property li11es and s tructures can be
obtaine d and downloatled from th e applicable cou11ty GJS website. Typically, tire property can be searched by
ow11er 11am e or address. Th e locatio11 of the wells in refotion to property boundaries, /1011 ses, septic tanks, o ther
wells, etc. ca11 then be drawn iii by hand. Also, a 'layer' can he selected s howiilg topographic contours or elevation
data
M. CERTIFICATION (to be signed as required b elow or by that person's authorized agent)
15A NCAC 02C .0211 ( e ) requires that all pennit ap plications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnershi p or sole proprietorship: by a general partner or the proprietor, respectivel y;
3. for a municipality or a state, federal, or other publi c agency: by either a principal executive office1·
or ranking publicly elected official ;
4. for all others: by all the p erson(sl listed on the propert y deed.
lf an authorized agent is signing on behalf of the applicant, then supply a Jetter signed by the
applicant that names and authorizes their agent to sig n this application on their behalf.
"I hereby certify, under penal ty of law, that I have personally examined and am familiar with the infonnati on
submitted in this document and a ll attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtain ing said information , I believe that the information is true, accur ate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. l 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
Pennit."
Sign ature of Property Owner/Applicant
Print or Type full Name
SigJ1atme of Property O wner/ Applicant
Ptinl or Type r,'ull Nam~
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geotherma1 Water Return Well Perm.it Application (Revised Jan 2015) Page4
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Qm: April 19, 2016
To: . Corey Basinger -Andrew Pitner
From: Shristi Sbrestha, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mall: Shnsti [e-mail]
Permit Number: WI03000S1
A. Applicant: Anne Holden
B. Facility Name:
C. A pplication:
Permit Type: Geothermal Heating/Co o ling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
__ I would like to accompany you on a site visit..
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. W ithin 30 calendar days, please return a com pleted W OROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: __________________ Date: ____ _
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 0 92614 Page 1 o f l
PAT MCCRORY
Go~mor
DONALD R . VAN DER VAART
Secrt#ary
Water Resources
ENVIRONMENTAi. QUALITY S . JAY ZIMMERMAN
April 19, 2 01~
Anne Holden
124 Tall Oak Dr.
Mooresville, NC 28117
RE: Acknowledgement of Application No. WI030005 l
Geothermal Heating/Cooling Water Return Well
Iredell County
Dear Ms. Holden:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on April 13, 2016. Your application
package has been assigned the number listed above, and the primary reviewer is Shristi Shrestha
Central and Mooresville R egional Office staff will perform a detailed review of the
provided application, and ipay contact you with a request for additional information. To ensure
maximum efficiency in processing permit applications, the Water Quality Regional Operations
Section (WQROS) requests your assistance in providing a · timely and complete response to any
additional information requests.
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of~ complete application. If you have any questions, please contact Shristi
Shrestha at 919-8_07 -6406 or email at [e-mail] .
cc: Mooresville Regional Office, WQROS
Penn.it F ile Wl0 300051
.Jr Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
Di vision of Water Resources
State of North C-aroliM I Enviroomental Quality I Wa~r ResO\lfCCS
161 J Mail service Center I Raleigl\ North Ca.rolina 27699-1 61l
919 707 9000
Director
P AT M C CRORY
Govenu,r
R!!C'ENEOMcol:0,'0WR
D ONALD R . VA N D E R VAART
Secretary
Water Resources
ENIIIRONMENTAl QUALITY
APR 18 2016 S . JAY Z IMMERMA N
Weter Ouan11
Roglanal 000t8don, .5ecl/Of1.
. March 29, :t016
CERTIFIBD MAIL # 7014 1200 000134326578
RETURN RECEIPT REQUESTED
Anne Holden
124 Tall Oak Dr.
Mooresville, NC 28117
Subject: Notice ofExpiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0300051
Iredell <;:aunty
Dear Ms. Holden:
Director
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina , and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above-referenced operating permit for the
geothennal injection well system located on your property at the above referenced address was
issued on May 11 , 2011 , and expires on April 30, 2016. Per permit conditions and requirements
per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120 calendar days
prior to expiration of the permit if you wish to continue operating the injection well on your
property.
If Your Geothermal Water Return Well is Still Currentlv Being Used for lniection:
In order to complY, with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells -Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http://portal.ncdenr.org/web/wq/aps/gwpro/pennit-applications.
HYour Geothermal Water Return Well is NO LONGER Being Used for Injection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.0240. When the well i s plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
State of No~ Carolina I Environmcntnl Quality I Water Resources
1611 Mafl service Center I Raleigh, Nortl1 Carolina 27699-16 11
919 707 9000
P:ige'2 of2
If There has been a Change of Ownership of the Property:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change'' Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
fo1ms to:
Division of Water Resour ces
UIC Program
1636 MaH Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email at [e-mail].
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Mooresville-Regional Office -WQROS w /o enclosures
Central Files -Permit No. WI0300051 w /o enclosures
U.S. Postal Service rn
CERTIFIED MAILTM RECEIPT
IQ
('-
Lil
..u
(Domestic Mail Only; No Insurance Coverage Provided)
~ ..__ _____ -._....;::____:;_~__:_--=;::...___.::~..::.::.___,:;=--..-1
::r m
....
Postage $
t---------1
c,,r11ne<1 Fee
C Retum Receipt Fee
C (Endorsement Required)
CJ i---------1
Restrlcled Dellveiy Fee
C (EndO/Sement Required)
CJ t---------1
ru
.-'I Total P Anne H olden
::r nt O 12 4 Tall Oak Drive
Postmark
Here
8 ~~ef:.\ Mooresville, North Carolina 28117
I'-orPOB,
City.Sta,
PS Form 3800, Augusl 2000 ---Set Reverse for Instructions
SENDER: COMPLETE THIS SECTION
■ Complet, Items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mallp!ece.
or on the front If space pennlts.
B. Received by (Prlnted Name) c. Date pf Oellvery
1. Article Addressed to: D. Is dellWry address dlffenlnt from Item 1? □ Yes
If YES, enter dellvery address below: □ No
Anne Holden
124 Tall Oak Drive
Mooresville, No1th Carolina 2.811 7
1111111111111111111111111111110 111111 1111 1111
9590 9403 0730 5196 3155 64
3. Servtce 'fype
□ Adl.llt Slgnali.ue
□ Adult Slgnalln Rellvloted Oellvery
□ Certffled-Malle
□ Car1ffled Mall Reetrloted Oellvery
□Pr1ClllyMalll:Xpreaal8
0Reglslftd~f11'
O~Ma11Ree!J1ctedl
O~fQI' □ CoAec« on Oellvely -_-• ....,_.__--.... ---..._-"""----fmm--~--/abe/J--------, □ Collect on OellvelyRestr1cted[)el-.,iry
7014 1200 □001 3432 b578 ... ·--=~:lRealrloledDellvely
11'$SOO)
0 Slgn«!ure Conf\,natjonlll
□ Signature Col1fltmallon
Aeatrlcted Dellvery
PS Fonn 3811, Aprll 2015 PSN 7630-02-000·8053 ~ Return Receipt
PAT MCCRORY
Governor
DONA LD R. V A N DER VAART
Secretary
Water Resources
EMvlRONMIElffAL QUALITY
S . J A Y ZIMMERMAN
March 29, 2016
CERTIFIED MAIL# 7014 1200 0001 3432 6578
RETIJRN RECEIPT REQUESTED
Anne Holden
124 Tall Oak Dr.
Mooresville, NC 28117
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI030005 l
Iredell County
Dear Ms. Holden:
Director
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources· (DWR) is entrusted to protect the groundwater quality and resources of the State ·of
North Carolina, and is responsible for the regulation of injection well coµstruction and operation
activities within the state. Ow-records indicate that the above-referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on May 1 1, 2011, and expires on April 30, 2016. Per permit conditions and requirements
per ISA NCAC 2C .0224(c), the renewal application must be submitted at least 120 calendar days
prior to expiration of the permit if you wish to continue operating the injection well on your
property.
If Your Geothermal Water Return Well is Still Currently Being Used for Injection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subcliapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Pennit to C onstruct or Operate Injection Wells -Geothennal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http:/ /portal .ncdenr.orglweb/wq/ aps/ gwpro/permit-applications.
HYour Geothermal Water Return Well is NO LONGER Being Used for Iniection:
If the well is no longer being used for injection; you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well , irrigation well, inactive, plugged and
abandoned, etc.): If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title I SA, Subchapter 2C, Section
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonm~t was properly conducted.
State of North Carolina I Environmen!AI Qua lity I Water Re.•ources
16 11 Mai l ser,,[ce Center I Raleigh,, North Carolina 27699-1611
919 707 9000
Page2 of2
If There has been a Change of Ownership of the Property:
lf there has been a change of ownership of the property, an ''Injection Well Permit
Name/Ownership Ch ange" Form must also be s ubmitted in addition to the ren ewal application.
This form i s not enclosed but can be foun d at the website listed above. P lease submit the applicable
forms·to;
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may resul t in the assessment o f civi l
penalties in accordance with North Carolina General S tatute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact m e b y phone at
(9 19) 807-6406 or by email at shristi.shrestha@ ncdenr.gov.
Regar~ . ~ -~
Shristi Shrestha
Hyd.rogeologi st
D ivision of W ater R esources
Water Quality Regional Operations Section
Enclosures
cc: Mooresvme-Regional Office -WQROS w/o enc losures
Central Files -Permit No. WI0300051 w /o enclos ures
Permit Number WI0300051
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Anne Holden $FR 5A7
Location Address
124 Tall Oak Dr
Mooresville
owner
Owner Name
Anne
Dates/Events
NC
Orig Issue
02/10/01
App Received
03/30/11
28117
Holden
Draft Initiated
05/07/11
Scheduled
Issuance
Central Flies: APS_ SWP_
05/10/11
Permit Tracking Slip
Status
In draft
Version
Project Type
Renewal
Permit Classification
Individual
Permit Contact Afflliatlon
Major/Minor
Minor
Region
Mooresville
County
Iredell
Facility Contact Affillatlon
Owner Type
Individual
Owner Affiliation
Anne Holden
124 Tall Oak Dr
Mooresville NC 28117
Public Notice Issue Effective Expiration
t::::l I I II I
ReQulated Activities Rea uested/~eceived Events --c...-....;;~...;;..;;..~;;..;;.;;_;-'-"'-.;;..;;_---------------
~,~{ll,o
Heat Pump Injection Additional Information requested
Outfall
Waterbody Name
Addltfonal Information received
RO staff report requested
RO staff report received
Stream Index Numbe r Current Class
03/15/11
04/01/11
04/07/11
05/10/11
Subbasin
1W -~r,
NCD~EN~R
North Carolina Department of Environmen t and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Anne Holden
124 Tall Oak Dr.
Mooresville, NC 28117
Coleen H. Sullins
Director
May 11 , 201 1
Dee Freeman
Secretary
Re: Issuance of Injection Well Permit
PermitNo, WI0300051
Issued to Anne Bolden
Iredell County
Dear Ms. Holden:
In accordance with your application received March 30, 2011, I am forwarding Permit No. WI0300051
for the continued operation of a 5A7 geothermal underground injection control (UIC) well heat pump
system located at the above referenced address. This permit shall be effective from the date of issuance
until April 30, 2016, and shall be subject to the conditions and limitations stated therein.
Regional Office staff collected water samples from your geothermal well on May 4, 2011. Laboratory
analytical results will be sent to you once they are completed along with any explanation that may be
necessary. Also during the visit Regional Office Staff explained the need to repair the water supply
well pipe vent. Proper maintenance of the facility is required in Part IV .1 of the permit.
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 D ivision of Water Quality.
If you have any questions regarding your permit or the Underground Injection Control Program please call me at
[phone].
cc: Andrew Pitner -Mooresville Regional Office
Central Office File -WI030005 l
ltedeU County Environmental Health Dept.
.t\ttachment(s):
Permit
AQUIFER PR OTECTION SECTION
1636 Mail Seiv1ce Center, Raleigh, Nor1h Carolina 27699-1636
Location: 2728 Capllal Boulevard , Raleigh, North Carolina 27604
Best Regards,
~ 1'/, -£_£1 /r,~ /:: -~ · John R. McCray
Environmental Specialist
Phone: [phone] \FAX 1: 919-715-0588: FAX2: 919'-715-6048 \Customer Service: 1..877-623.6748
Internet: www.ncwateroualltv .or: ifthCarolina
v vt1fll.rall!f Ali E11u~1 Ofl\lOflUni\y Affinnanve i<c:tllln EmnJoyer
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
1n 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
Anne Holden
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 124 Tall Oak Dr, Mooresville, Iredell County, NC 28117, and will be operated in
accordance with the application received March 30, 2011, 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, Rule~ and Regulations
pertaining to well construction and use.
This permit shall be effective, unless revok~ from the date of its issuance until April 30, 2016. and shall be
subject to the specified conditions and limitations set forth in Parts I through VIIl hereof.
Permit issued this the 11th day of May, 2011.
~Coleen H. Sullins, Director \j Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #Wl0300051 UIC/SA7
ver. 03/2010
Page 1 of 5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this pennit 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 provjded 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 w ith a warning that it is for injection purposes and the entrance to each well
must be sealed with a water-tight cap or well seal, as defined in G.S. 87-85(16).
6. Each injection well shall be afforded reasonable protection against damage during consWction and u se.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
PART II -OPERATION AND USE GENERAL CONDITIONS
1. This permit i s 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 b~ appropriate, at least 30 days prior to the date of the change.
3. The issuance of this penni.t shall not relieve tbe Pennittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4 . Continued operation of the injection system will b e contingent upon the effiuent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
Permit ltWI0300051 UIC/5A7 Page 2 of S
ver. 03/2010
PART ill -PEltFORMANCE 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.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART 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.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N .C.G.S . 87-90.
3. Provisions .shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART VI-MONITORING AND REPORTING REQUIREMENTS
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.
Permit #WI03000Sl UIC/SA7 Page 3 of 5
ver. 03/2010
2 . The Pennittee shall report by telephone, witrun 48 hours of the occurrence or first knowledge of the
occurrence, to the Mooresville Regional Office, telephone number (704 ) 603-1699, any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIl -PERMIT RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Pennittee shall
submit an application to renew the permit 120 days prior to its expiration date.
PART VIII-CHANGE OF WELL STATUS
1 . The Permittee shall provide written notification witrun 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a wen 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 n o longer be used for any purpose, the
Permittee shall abandon that injection well in accordance w ith the procedures specified in 1 SA NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may b e 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 i s sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected , prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water,
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well i s
filled.
Permit #WI0300051 UIC/SA7 Page 4 of 5
ver. 03/2010
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casi.ng 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
15ANCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
Permlt #W10300051
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/SA7
ver. 03/2010
Page 5 of 5
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 0S/06/11
To: Aquifer Protection Central Office
Central Office Reviewer: John McCrav
Regional Login No: __ _
1. GENERAL INFORMATION
l. This application is (c.heokallthatepply): D New [81 Renewal
County: Iredell
Permittee: Anne Holden
Project Name:
Application No.: Wl0300051
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals D Attachment B included D 503 regulated D 503 e,-empt
D Distribution of Residuals D Surface Disposal
D Closed-loop Groundwater Remediation 181 UIC Injection Wells (5A7) GeoThermal
Was a site visit conducted in order to prepare this report? 181 Yes or D No.
a. Date of site visit: 05/04/201 1
b. Person contacted and contact information: Anne Holden 704-662-3530
c. Site visit conducted by: Maria Schutte
d. Inspection Report Attached: D Yes or fZI No.
2. ls the following information entered into the BlMS record for this application correct?
181 Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location: BIMS info u pdated by MRO: sin,ele well for extraction and injection
b. Driving Directions: __
c. USGS Quadrangle Map name and number: __
d . Latitude: Longitude: __
e. Regulated Activities / Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
IL & m -deleted
NIA thisfacility
IV. INJECTION WELL PERMIT APPIJCATJONS (Complete these two sections for all systems that use injection
wells , including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells .)
Description OfWell(S) And Facilities-New. Renewal. And Modification
1. Type of injection system:
181 Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation (SI)
FORM: APRSR040929-WI0300051-Holden-5A7-May 2011 1
AQUIFER PROTECTION REGIONAL STAFF REPORT
D Closed-loop groundwater remediation effluent injection (5L/"Non-Discharge'')
D Other (Specify:___}
2 . Does system use same well for water source and injection? IX1 Yes O No
3. Are there any potential pollution sources that may affect injection? 0 Yes cgJ No
What is/are the pollution source(s)?
4. What is the minimum distance of proposed injection wells from the property boundary? ~56..fi:
5. Quality of drainage at site: IX1 Good D Adequate D Poor
6. Flooding potential of site: lxJ Low D Moderate D High
7 . For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc .) adequate? D Yes [8J No. Attach
map of ex.is ting monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: No monitorin g program has been established for sv stem. The MRO suggests
a recommended annual s amplin g schedule for coliform and metals be arranged throueh Iredell Env ironmental
Health t not a permit requirement thouwl.
8. Does the map presented represent the actual site (property lines, wells , surface drainage)? D Yes or [8J No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, w ells, potential pollution
sources, roads, approximate scale, and north arrow. No maps included with the renewal app lication. But the
MRO file contains site maps and drawimrn from previous inspections and the orieinal a pplication.
Injection Well Permit Renewal And Modification Onl v:
1. For heat pump systems, are there any abnormalities in heat pwnp or injection well operation (e.g. turbid water,
failure to assimilate injected fluid , poor heating/cooling)?
D Yes ~ No. If ves. explain: Mrs. Holden supplied the following as h er contact names for system
maintenance: Neel's Heating and A/C Inc. 704-663-2276 (Repair)
and Lindsa•• HTG & AIC (Chuck) 704-347-1847 anstaller)
2. For closed-loop heat pump systems, has system lost pressure or required mak:e--up fluid since permit issuance
or last inspection? D Yes D No. If yes. exp lain:
3 . For renewal or modification of groundwater remediation petmits fof anv type ), will
continued/additional/modified injections have an adverse imp act on migration of the plume or management of
the contamination incident?□ Yes □No. Ifv es, explain:
4. Drilling contractor: Name: B&K Well DrillinQ
Addres s : 132 Mount Mourne Loop
Moores ville, NC 28117
704-892-4696
Certification number: 1451
FORM; APRSR040929-WI03000 51-Holden-5A7-May 2011 2
AQUIFER PROTECTION REGIONAL STAFF REPORT
5. Complete and attach Well Construction Data Sheet. -n/a
V. EY ALUATION AND RECOMME"NDATIONS
1. Provide any additional narrative regarding your review of the application: There are two wells on the pro perty.
The well furthest from the house is the water supplv well. Based on visual inspection and file review. it
appears that return flow can be directed to either well or, via floor drain. to a stream leading to Lake Nonnan.
At the time of this site visit an effluent sample could not be collected at either well. Either the flow was not
directed to either one of the wells or the spigots were not operational. A total of three samples were collected.
An influent sample was collected from the water supplv well. Two more samples were collected from the "in"
and "out" lines at the heat pump. Mrs. Holden savs she knows little about the s vstem. but has not had anv
problems. She believe s a well pump was replaced a year or so a go. The pump tag on the supplv well was
illelrible. The vent pipe on the water supply well is broken and allows o pen access through the well head. The
MRO pointed this out to Mrs. Holden and explained the need to repair it. The MRO recommends noting this in
the cover letter with her permit. The MRO recommends issuing the permit renewal and will follow-up upon
receipt of the sample results.
2. Attach Well Construction Data Sheet -if needed information is available
3. Do you foresee any problems with issuance/renewal of this pennit? D Yes l8J No. If yes, please explain
briefly.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issu ed. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7. Recommendation: 0 H old, pending receipt and review of additional infonnation by regional office; D Hold,
pending review of draft permit by regional office; 0 Issue upon receipt of needed additional information;
[8J Issue; D Deny. If deny, please stat e reasons:
FORM: APRSR040929-WI0300051-Holden-5A 7-May 2011 3
AQUIFER PROTECTION REGIONAL STAFF REPORT
8. Signature ofreport preparer(s): -~M~ana~· ~S~c=hu=tt~e _________________ _
Oi;bl!,-UNdti,~-f'IINI" Andrew Pitner :::::-.:.:::-..::::=. Signature of APS regional supervisor: _________________ °'_,.,._,,,_ .... _, ..... _ ..... __
Date: 05 /06/2011
ADDITIONAL REGIONAL STA FF REVIEW ITEMS
FORM: APRSR040929-Wl030005 l -Holden-5A7-May 2011 4
CoonectGIS Feature Report http://iredell.connectgis.comlDownloadFile.ashx?i=_ags_map25966e ...
1 of2
, , l I '\. I '\ ~ -•The maps prepared for this
-. website are generated from
----recorded deeds, plats, and other
public records. Users of these maps are hereby notified that the information provided herein should be verified.
I redell County assumes no legal responsibilities for any of the information contained on this site. Users are advised
that the use of any of this information is at their own risk. All maps on this site were prepared using a 1000' Grid
based upon the North Carolina State Plane Coordinate System from the 1983 North American Datum. The
delinquent real property tax overlay is updated monthly. The information presented is not intended to be used or
relied upon as official notice of tax liens. For additional information regarding delinquent taxes, contact the Iredell
County Tax Collector's Office.
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010 55136 PIN 4626960666. 000
Owner Name HOLDEN ANNE Deed Book 10E
Deed Page 523 Doc Type WB
Deed Date 20100613 Tax Acres 0.713
Lot 22 Plat 21-2
Subdivision POPLAR GROVE Phase
Description POPLAR GROVE PB21-2-2A Township 17
NBH Code 17075 Assessed Value 308150
Sales Year Sales Price
Sale Is Improved Actual Year Build 1999
Number of Bedroom 3 Number of Bath 2
Number of Half Bath 1 Actu~I Heated Area 2183
2 of2 5/6/2011 4:04 PM
Mccray, John
From:
Sent:
To:
Cc:
Subject:
Hi John,
Pitner, Andrew
Thursday, May 05, 2011 2:04 PM
Mccray, John
Schutte, Maria
RE: Staff Report for renewal application for permit Wf0300051
Maria visited the site and collected samples from the system yeste rday. She's out sick today, but I expect we'll get the
staff report back to you, probably no later than ea r ly next week _
Andrew
From: Mccray, John
Sent: Thursday, May 05, 20111:22 PM
To: Pitner, Andrew
S ubject: Staff Report for renewal appllcatfon for permit WI0300051
Mr. Pitner,
1 am writing to see if your office has completed a Staff Report for the renewal of permit WI0300051. I am hoping to get
the renewal issued In the com ing week or two.
Best Regards ,
John McCray
1
AOUIFERPROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: A pril 7.2011
To: □ Landon Davidson, ARO-APS
□ Art Barnhardt., FRO-A.PS
~ Andrew Pitner, MRO-APS
□ Jay Zimmerman, RRO-APS
□ DavidMay, WaRO-APS
0 Charlie Stehman, WiRO-APS
□ Sherri Knight, WSRO-APS
ED!!!!: John McCrav , Groundwater Protection Unit
Telephone: (919} 715-6168 F(IX: [phone]
E-Mail: john.mccrav(a)n cdem. !!ov
A. Permit Number: WI0300051
B. Owner: Anne Holden
C. Facilitv/Operation: Anne Holden SFR 5A7
D Proposed [8J Existing D Facility D Operation
D. Application:
J. Per'!1it Type: D Animal D .Surface Irrigation O Reuse O H -R Infiltration
D Recycle D I/E Lagoon D GW Remediation (ND)
[8J UJC -(SA 7) open loop geothermal __
For Residuals: □ Land App. 0 D&M
D 503 D 503 Exempt
D · Surface Disposal
0 Animal
2. Project Type: D New D Major M9d. D Minor Mod. ~ Renewal D Renewal w/ Mod.
E. Comments/Other Information: 0 1 would like to accompany you on a site visit.
Attached, you will fmd all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
~ Return a Completed Form APSSRR.
□-Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO*.
* Remember that you will be responsible for coordinating_ site visits, reviews, as well as additional
infonnation requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification, Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS R eviewer: ------------------
FORM: APSARR 02/06 Page 1 of 1
AVA NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
April 4, 2011
Anne Holden
124 Tall Oak Drive
Mooresvil)e, NC 28117
Subject: Acknowledgement of Application No. WI030005 l
Holden, Ronald -SFR
Injection Heating/Cooling Water Return WeU (5A7)
Iredell
Dear Ms. Holden:
Dae Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on March 30, 2011 . This application package has been assigned the number listed above and will be reviewed by
John McCray.
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 requesfS.
'
Please be aware that the Division's Regional Office, copied below, must provide recommenqations prior to final action by the
Di vision. Please also note at this time, processing p'ermit applications can ta1ce as long as 60 -90 days after receipt of a complete
application. ·
If you have any questions, please contact John McCray at 919-715-6168, or yia e-mail at [e-mail]. If the reviewer is
unavailable, you may leave a message , and they will respond promptly.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
0Lz~A~~
for Debra J. Watts
Supervisor
cc: Mooresville Regional Office. A~fer Protection Section
Permit Application File WI030005 l
AQUIFER PROTECT ION SECTION
1636 Mall Se!Vlce Center, Rale~h. North Carolin.a 27699-1636
Location : 2726 Capital Boulevard, Raleigh, Nortt1 Carolina 27604
Phone: [phone] I FA X 1: 919-715-0588, FAX 2: 919-715-6048 I Custo~r Se/Vice: 1.a77.fi23-674B
Internet: www.ncwaterguahty.org
An Equal Opoo~un,iy Amm,,ttve Ac11on !:ml>IOye,
NirthCarolina
/vaturnll!I
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
-APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A GEOTHERMAL BEAT PUMP SYSTEM
TYPE 5A7 "OPEN LOOP" INJECTION WELL(S}
( check one) __ New Permit Application \/ Renewal Modification
DATE:~?,/ 20 //. ,
PERMIT NO.: WI (, 3 ~ 5 ] (leave blank ifNEW permit application)
A. PROPERTY OWNER/PERMIT APPLICANT
Name of each owner listed on property deed. For a business or government agency, state name of entity and
name of pers n delegated thop ~ to sign application on behalf of the business/agency: ______ _ n, 01ae
(1) MailingAddress: ll't -rau wk J)r:
City: Hooresvl/la, State-N.c_Zip Code:.28117 County: {rede,11
Home/effiee Tele No.: fQtt-"2,-3 £30 Cell No.:
Fax No. ___________ Email Address: _____________ _
(2) Physical Address of Well Site (if different than above): ______________ _
City: -State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: ____________ C=e=ll~N"-'-o=•c=..: _________ _
Fax No. ___________ Email Address: _____________ _
B. PROPERTY OWNERSHIP DOCUMENTATION
Provide legal documentation of property ownership, such as a contract, deed,-article of incorporation, etc. and
a PLAT map showing the property. This information may be obtained from county Register of Deeds or GIS
website.
C. AUTHORIZED AGENT, IF ANY
If the property owner/permit applicant wants to authorize someone else to sign the permit on their behalf, then
attach a signed letter from the property owner/permit applicant specifying and authorizing their agent (well
driller, heat pump contractor, or other type of contractor/agent) to sign this application on their behalf.
Company Name: _____________________________ _
Contact Person."-: ---------------=E=m=ail=· =A=d=dr=e=ss=: __________ _
Address: _______________________________ _
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Fax No. Cell No .:
Website Address of Company, if any: ______________________ _
Type 5A7 ln.iection Well Permit Application (Rev, August 2009) Page I of4
D . WELL DRILLE~FORMATION
CompanyName: ' P 4 K 'We i f D,~/ G~ -:r~.
Well Drilling Contractor's Name: ___ R,......._."""'----------------------;? NC Contractor Certification No.: \ 4 51 Contact Person:
J Company Website . .,__: _,WWC!-'--,_W"-'-'-. -----------------"'E=m=a=il~A:...::.=dd=r=-=e=ss=: ________ _
Address:-----------------------------------
City: __________ State: __ ZipCode: ______ County: ________ _
Office Tele No.: _________ Fax No.: Cell No.: ________ _
E. HEAT PUMP CONTRACTOR INFORMATION (if different than Driller)
Company Name:_JOL::..,..a.A_<-=¥~-""-=fe,;,::::,..,.b....c.·~=+----"-A_._fi_L _----=C=o=nt=a=ct=P~er=s-=-on=: __________ _
Company Website . .,__: ...:..WW::.....:..;._,W.,_'--. _____________ ..,,E=m=a=i'""'I A'-'=d=dre=ss=: ________ _
Address: 7..3..3 2. c.J/d .Sfe..kv, l le. K o:l
City: C "1c.,-. lo He.. State: NC Zip Code: ______ County: _ _.._tv/=--..::::e...:::c. .... L_:__ __ _
Office Tele No.: 7u4 578 &,'7S f Fax No. Cell No. ________ _
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
H.
Zoo\
(1)
(2)
The injection operation?
Personal consumption?
YES ,
YES V
NO ----
NO ----
WELL CONSTRUCTION DATA
~PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
~ (7) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
(1)
____ EXJST,.lliG Well(s) being proposed for use as an injection well. Provide the data in (1) through (7)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Fonn
GW-i) if available.
Well Construction Date: _______ Number of borings : ___ _
.n.,,,,,,' ,,;I ✓~,
Depth of each boring (feet)=--~~----'(14,1~-
(2) Well casing. ls the well(s) cased?
(a) YES ___ If yes, then provide the casing information below.
Type; Galvanized steel __ Black steefi v'c:_ Plastic __ Other (specify) ______ _
Casing thickness:~ diameter (inches): u:> depth: from O to 4i/>' feet (relative to land surface)
Casing extends above ground / C, inches
(b) NO
(3) Grout material surrounding well casing:
(a) Grout type: Cement__ Bentonite* Other (specify) [µ.)Ce,.,ed;
*By selecting bentonite grout, a variance is h ereby requested to 15A NC.AC 2C .0213(dXl XA), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from (J to @ feet
Type 5A 7 injection Well Permit Application (Rev. August 2009) Page2 of4
I.
2
I
(4)
(5)
(6)
Well Screen or Open Borehole depth (relative to land surface): from ____ to ___ feet
N.C. State Regulations (Title ISA NCAC 2C .0200) require the Pennittee to make provisions for
monitoring wellhead processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Will there be a faucet on:
(a) Influentline? Yes ✓ No__ (b} Effluent line? Yes~No~
Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Form GW-1 ). If Form GW-1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment units win the groundwater be withdrawn? (e.g.
granite, limestone, sand, etc.)
Depth: ISO ' Formation: C ~ b 1-k. Rock/sediment unit: 6fl:v1., ie.
NOTE: THE WELL J;)RILLINO OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THJS
INFORMATION !S OTHERWlSE UNAV An..,ABLE.
OPERATING DATA
(I) Injection Rate:
(2) Injection Volume:
(3) Injection Pressure:
(4) Injection Temperature:
Average ( daily) 7 gallons per minute (gpm).
Average (daily)~Doc gallons per day (gpd).
Average (daily) A.,,J,i.Mfpounds/square inch (psi).
Average (January) 4>3 ° F, Average (July~..3 ° F.
J, INJECTION-RELATED EQUIPMENT
Attach a schematic diagram or cross-section of the well construction that shows the total depth, length of casing,
extent of grout, stickup, location of influent/effluent sampling ports, etc. If this is a modification, show the
engineering layout or proposed modification of the injection equipment and exterior piping/tubing associated with
the injection operation. The manufacturer's brochure may provide supplementary information if needed.
K. LOCATION OF WELL(S)
(1) Attach a site map ( can be drawn) -5howing: houses and other structures, property lines,. surface water bodies,
potential sources of groundwater contamination, and the orientation of and distances between the proposed
injection well(s) and any other existing well(s) or waste disposal facilities such as septic tanks or drain fields
located within 1000 feet of the geothermal heat pump well system. Label all features clearly and include a
north arrow.
(2) Attach a scaled topographic map of the area extending 1/4 mile from the property boundary that indicates
the facility's location, a north arrow, and the map name.
NOTE: In most cases, an aerial photograph of the properly parcel showing property lines (!nd structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by owner
name or address. The location of the wells in relation to property bollndaries, ho11ses, septic tanks, other wells, etc.
can then be drawn in by hand. A lso, a 'layer' can be selected showing topographic contours or elevation data.
T-ypc SA 7 Injection Well Permit Application (Rev. August 2009) Page 3 of4
L. CERTIFICATION (to be signed as r equired below or by that person's authorized agent)
NCAC 15A 2C .02ll(b) requires that all permit applications shall be signed as follows:
1 . for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected offici a l ;
4 . for all others: by the well owner. ·
Han autho rize d ag ent i s si g ning on behalf. of the applicant, the n submit a Jetter signed b y the
a pplicant that names and a uthorizes their a gent a s spe cifie d in Part C of this permit application.
"I hereby certify1 under penalty of law, t h at I have personally examined and am fami liar with the information submitted in
this docwnent and all attachments thereto and that, based on my inquiry of those individuals immediately responsible for
obtaining said information, f believe that the information is true, accurate and complete. 1 am aware that ther e are significant
penalties, including the possibility of fines and imprisonment, for submitting false information. l 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 P roperty Owner/Applicant
An1 e.. I--/ old e JJ
t,!AR 8 O 2011 Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Fu ll Name
Submit T W O signed copies of the completed application package and a11 attachments to:
UICProgram
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
T elephone (919) 733-322 1
Type SA 7 injection WeU Permit Appl:cation (Rev. August 2009) Page 4 of4
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Please check the selection which most closely describes the current status of your injection well system:
1) a( Well (s) still used for injection activities, or may be in the future.
2) LJ Well(s) not used for injection bur is/are used for water supply or other purposes.
3) □ Injection discontinued and: a)□ Well(s) temporarily abandoned
b) □ Well(s) permanently abandoned
c) □ Well(s) not abandoned
4) □ Injection well(s) never constructed
Current Use of Well
-If you checked (2), describe the well use (potable water supply, in:igation, monitoring, rte), including pumping rate and other
relevant information.
Well Abandbnment
If you checked (3 )(a) or (3)(b ), describe the method used to abandon the injection well. (Include a description of how the well
was sealed and the type of material used to fill the well if permanently abandoned):
Permit Resci -· :
If you ch ·ed (2), (3), or (4) and will not use a well for injection on.this site in the future, you should request rescission of the
o you wish to rescind· the permit?
□ Yes D No
Certification:
11! hereby certify, under penalty oflaw, that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete. 0
o{b v~ l-~T~
Signature Date
Revised 5/05 GW/UIC--68
"4."Pl"A s.,;,~-~-
NCDENR I
North Carolina Department of En vironment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H, Sullins
Director
March 15, 2011
Anne Holden
124 Tall Oak Drive
Mooresville, NC 28117
Subject: Notice·ofExpiration (NOE)
Dear Ms. Holden:
5A7 Geothermal Injection Well
PermitNo. WI0300051
Iredell County
Dee Freeman
Secretary
As per our phone conversation on March 15, 2011, please complete and return the enclosed form for
renewal of your 5A 7 Geothermal Injection Well system. Your pennit nwnber is listed in the subject
line above. Please complete the form with the information that you know then submit the completed
form to:
Aquifer Protection Section
.Groundwater Protection Unit
UICProgram
1636 Mail Service Center
Raleigh. NC 27699-1636
For your convenience, a self-addressed envelope has been enclosed. The enclosed form is also
available on-line at the DWQ website at http://h2o.enr.state.nc.us/a ps/gpu/forms.htm.
Thank you in advance for your cooperation and timely response. If you have any questions, please
contact me by phone at (919) 7 15-6196 or by email at eric.!.!..smith,@ncdenr.,1 ov.
Sincerely,
£ rlJ, bud.-
Eric G . Smith, P.G.
Hydro geologist
Enclosure
cc: APS Central Files -Permit No. WI0300051 w /o enclosures
AQUIFER PROTECTION SECTION
1636 Mail Service Genter, Raleigh , NOfth Carolina 27699-1636
Location : 2728 Capital Boulevard , Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919•715-6048 I Customer Service: 1.STT-523-6748
lntemel: www.ncwaler'guallty.org
An El!ual Opportunity I AffirmallveA~llon EmplOye:
~rthCarolina
JVaturnll!I
A."if'A NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Qual ity
Beverly Eaves Perdue
Gove rnor
Anne Holden
124 Tall Oak Drive
Mooresville, NC 28 117
Subject: Notice of Expiration (NOE)
Coleen H. Sullins
Director
March 15 , 2011
5A7 Geothermal Injectio11 Well
Permit No. Wl0300051
Iredell County
Dear Ms. Holden:
Dee Freeman
Secretary
As per our phone conversation on March 15, 2011, please complete and retum the enclosed form for
-renewal of your 5A7 Geothermal Injection Well system. Your permit number is listed in the subject
line above. Please complete the form with the information that you know then submit the completed
form to:
Aquifer Protection Section
.Groundwater Protection Un.it
u·1c Program
1636 Mail Service Center
Raleigh, NC 27699-1636
For your ·convenience, a self-addressed' envelope has ·been _ enclosed. The enclosed form is also
available on-l ine at the DWQ website at http://h2o.enr.state.nc.us/aos/!,.rpu/forms.h1m.
Thank you in advance for your cooperation and timely ·response. If you have any questions; please
contact me by phone at [phone] or by email at eric.l!.smithr@.ncdenr.QOV.
Sincerely,
j;;&P,,d-
Eric G. Smith, P.G.
Hydrogeologist
Enclosure
cc: • .L\PS Central Files -Permit No. Wl0300051 w /0 en closures
AQUIFER PROTECTION SECTION
1630 Mail Service Cenlsr, Rale~h, Nor1h Carolina 27699-1636
Location: 2728 Capital BouleVa.ro . Ra leigh. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588: FAX 2: 919,715-6046 I Customer Service: i-877-623-6748
Internet· www.ncwate.rouality.org
An Equal OppO!IUoity I Affi1TI1aijve Aclion Employe,
ifort11carolina
/vaturall!f
NA NCDENR
North Carolin~ Department of Environmen t and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Ronald Holden
124 Tall Oak Drive
Mooresville,·NC 28117
Coleen H. Sullins
Director
March 1 , 2011
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No . Wl0300051
Iredell County
Dear Mr. Holden:
Dee Freeman
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Quality (DWQ) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well CQnstruction and operation
activities within the state. Our records it~dicate that the above~referenced operating permit for
the underground injection well system, which was issued to you on July 3 , 2006, and expires on
July 31, 2011 , is soon due for renewal. If you wish to keep this pennit and operate the injection
well system, the permit must be renewed and issu ed in your name. '
If Your Injection Well is Currentl,· Inactive:
If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed under NCAC Title 15A, Subchapter
2C, Section .0214. When each well is plugged and abandoned, the well abandonment record
(Form· GW-30) must be submitted to our office to certify that the abandonment was properly
conducted.
If there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form must also be submitted. The GW-30 and Name/Ownership
Change form s can be found at httn://rortal.ncdenr.or!.!/w eb/wq/ap s/~rwnro/reportim!-forms.
If Your Injection Well is Currently Active:
If the injection well system is still active and you wish to renew your permit, the renewal
application must be submitted within 120 calendar days of .the expiration of your permit.
According to our records, you must submit your permit renewal b y April 2 . 2011.
AQUIFER PROTSCTION SECTION
1636 Ma,! Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard. Rale1gl1. North Carolina 27604
PhOne; 919-733-322' I FAX 1; 919-715-0588_ FAX 2: 919-715 8048 Customer Service. 1-877-623-6743
Internet www,ncwaierguallty.org
An cqu~I Qpponunlly I Ati1m1allve Action EmllloYer
Non.s.t,.c .. olur arouna Natuzriltv
In o r der to comply with the regul atory requirements listed under North Carolina Administrative
Code (NCAC) Title 1 SA, Subchapter 2C, Section .0211 , you must submit one of the following
enclosed forms:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for lryection with
Geothermal Heat Pump System for Type 5A 7 Well(s) if the injection well system on your
property is still active.
-OR-
B. Status of Injection Well System if the injection well system is inactive or lias been
temporarily or permanently abandoned.
Please submit the appropriate forms to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
, in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application arid a UIC well system status form are attached along with a sel f-addressed envelope.
The above Teferenced forms are also available o n-line at the DWQ website at
h ttp://h2o.enr-.state.nc.us/aps/!.!J1 u/forms .btm.
Thank you in advance for your cooperation and timely r esponse. If you have any questions ,
please contact me by phone at [phone] or b y email at eric.!!.smitb@.ncdenr.rm v.
Sincere1y,
c:·/ d ~ ~ <!J-d7,uvfr'
Eric G. Smith, P .G.
Hydro geologist
Enclosures
cc: Mooresville Regional Office -APS w/o enclosures
APS C entral Fil es -Permit No. W10300 05 I w /o encl os ures
Anne and Ronald Holden
124 Tall Oak Drive
Mooresville, NC 28 117
Ref: Injection Permit Issuan ce
Permit # WI030005 l
Issued to Anne and Ronald Hol den
Dear Mr. and Mrs. Holden:
July 3, 2006
Michael F. Easley, Governor
•. William G. Ross Jr., Secretary
North Catolin,r DepBrttllent of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
In accordance with the application submitted on March 20, 2006, the Division of Water
Quality's Underground Injection, Control (UIC) Program is forwarding permit number
W10300051 for the continued operation of a geothermal heat pump system located at 124 Tall
Oak Drive in Morrisville, Iredell County, NC.
This permit shall be effective from the date of issuance until July 31 , 2011 and shall be subject to
the conditions and limitations stated therein. Please read your permit carefully to make sure you
thoroughly understand its requirements and your responsibilities.
If you have any questions regarding your permit please contact Qu Qi at (919) 715 -6935 or
Debra Watts at (9 19) 715-6699.
cc: Andrew Pitner, Mooresville Regional Office
CO-UIC fi les
Enclosure
Aq uifer Protection Section 1636 Mail Service Center
Internet; http://www.ncwateroualicy.org 2728 Capital Boulevard
Best Regards,
~~
Thomas Slusser, L.G. ,.
Environmental Specialist ill
Raleigh, NC 27699-1 636
Raleigh, NC 27604
Telephone:
Fax 1:
Fax2:
An Equal Opportunity/Affirmative Action Employer-50% Recycled/100/4 Post Consumer Paper Customer Service:
N.?.fthCarolina
/Vlllura/lV
[phone]
(919) 715-0S88
[phone]
[phone]
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 8.7; Article 21 , Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
ANNE and RONALD HOLDEN
FOR THE OPERATION OF A TYPE SA 7 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 124 Tall Oak Drive in Mooresville, Iredell County, North
Carolina, and will be operated in accordance with the application received on March 20, 2006, 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 July 31 , 2011, and
shall be subject to the specified conditions and limitations set forth in Parts I through IIX hereof.
Permit issued this the 3 rJ day of Ju_ f 7 , 2006.
~Ck~
Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
PermitNo. WI03000SJ
GW/UIC-5 ver. 7/05
PAGE 1 OF 5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Pennittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S . 87-94.
2. This pennit 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 reasonabl e protection against damage during
construction and use.
7. Each injection well shall have permanently affixed an identification plate.
PART II .. OPERATION AND USE GENERAL CONDITIONS
1. This pennit 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 pennit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). fn the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a fonnal permit amendment
request must be submitted to the Director, including any supporting material s 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. Furthennore,
the issuance of this permit does not imply that all regulatory requirements have been met.
Permit No. vVI0300051
GW/UIC-5 vcr. 7/05
PAGE2OF5
PART m -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Pennittee shall talce immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility. ·
2. The Permittee shall be required to comply with the tenns 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 Permiuee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART IV -OPERATION AND MAINTENANCE REQUIRE:MENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Pennittee 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 re lated to the injection facility at any reasonable time fo r the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be mac.le for collecting any necessary and appropriate samples associated
with the injection facility activities.
Permit No. WI0300051
GW/UIC-5 ver. 7 /05
PAGE3 OF S
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, wil1 be
established and an acceptable sampling reporting schedule shall be followed .
2 . The Pennittee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Mooresville Regional Office, telephone number (704)
663-1699 , any of the following:
(A) Any occurrence at the iajection facility which results in any unusual
operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
fai lures.
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 coITect facts or information shall be promptly submitted to
the Director by the Permittee.
4. In the event that the permitted facility fails to perfonn satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
PART VII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit,-.request an
extension.
PART IIX -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 that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well Construction
Standards.
Permit No. WI0300051
GW/UIC-5 ver. 7/05
PAGE40F 5
2. When operations have ceased at the facility and a well will no longer be used for any
purpose; the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have
not been remoyed, 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 pennit.
(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 comp letion of
abandonment.
3. The written documentation required in Part IIX (I) and (2) (G) shall be submitted to:
Permit No. WI0300051
GW/UIC-5
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
ver. 7/05
PAGES OFS
NC Division of Water Quality Laboratory 'Section Results
Loe. Descr.: RONALD HOLDEN
Location ID: WI0300051
Sample ID: County: IREDELL AB03130
River Basin PO Number# 6G0702
Report To RROAP RE~IVED / DENR/ DWQ VlsltlD
Region: RRO AQUffl PROTEOOI SECTIO« Date Received: 04/19/2006
Collector: TSLUSSER JUN l 5 2006 Time Received: 09:35 9 ~ Sample Matrix: GROUNDWATER Labworks Loginl D MMA Loe. Type: MONITORING WELL
Date Reported: 05/23/2006 s le.A~ I 0( Sample Depth
Collect Date: 04/18/2006
Collect Time:: 11:30
nalyte Name PQL Result nits Approved By
LAB
Sample tel)1perature at receipt by lab 0.9 •c JGOODWIN
MET
AgbylCPMS 5.0 · l 5.0 u ug/L EST AFFORD
Al by ICP 50 ,j 50 u ug/L ESTAFFORD
Asby ICPMS 5.0 ,5,0 u ug/L ESTAFFORD
Ba by ICP 10 63 ug/L ESTAFFORD
Ca by ICP 0.10 22 mg/L EST AFFORD
Cd by ICPMS 2.0 ·2.0 u ug/L ESTAFFORD
Cr by ICPMS 25 25 u ug/L ~STAFFORD
Cu by ICPMS 2.0 11 ug/L EST AFFORD
Fe by ICP 50 50 • U ug/L EST AFFORD
K by ICP 0.10 2:2 mg/L ESTAFFORD
Mg by ICP 0.10 4.8 mg/L EST AFFORD
Mn by ICPMS 10 ~o u ug/L EST AFFORD
Na bylCP 0.10 9.6 mg/L EST AFFORD
NI bylCPMS 10 10 u ug/L ESTAFFORD
Pb bylCPMS 10 10 u ug/L ESTAFFORD
SebylCPMS 5.0 5.0 u Ug/L EST AFFORD
Zn by ICP 10 10 u ug/L EST AFFORD
NUT
Nitrate as N in llquld 0.01 0 :31 mg/Las N CGREEN
Nitrite as N In liquid 0.01 0.01 u mg/Las N CGREEN
NO2+NO3 as N in liquid 0.02 0.31 mg/Las N CGREEN
WET
Total Dissolved Solids in liquid 10 127 mg/L MOVERMAN
Laboratory Section» 1623 Mall Service ed. , Raleigh, NC 27699-1623, (919) '733-3908
Page 1 of 1
COUN-rf : !REDELL
QUAD NO:
DIVISION OF VV ATER QUALITY
C'l,emlstty Laboratory R,eport / Grv■-d Water Qulity
SAMPLE PRJOIUTY
(!]ROUTINE □EMERGENCY
REPOllTTO _W...;A_T'--_______ Regional Office □ CHAIN OF CUSTODY
~ SAMPLE TYPE
I I
M'W5,6,7,8 COLLECTOR(S) :_T_S_W_SS_E_R ____ _
DA TE: 4118/2006
TIME: 11 :36
PURPOSE:
LABORATORY ANALYSIS
800 3 10 moll
COO High 3-40 m•Jl
C00Low335 mall.
Colifonn; MF Fecal 3 1616 /IOOml
Colifunn: MF Tow 31504 1100ml
TOC mivl
Turbidirv NTU
Rcsiduc... Susnended 530 " m2'l
Total Summded solids. mo/l.
pH units
Allca!initv lo oH 4.5 mg/I..
All<alinity to pH 83 moll
Catbonale mvll
Bicarbonate mo/l
Carl>on dioxide me.It.
Chloride mo/l
Chromium: Hex 1032 ug/1..
Color. True 80 c.u.
Cyanide 720 rngll.
COMMENTS :
Owner.
Location or Site:
RONALD HOLDEN
I I
Description of sampling point ___________________ _
SampfmgMelhod:
Rcmarlcs:
X Dis$. Solids 70300 127 mo/l. )C A2-Silva 46566
Fluoride 95 I mo/l )t Al-Aluminum 46S51
Hardncs$: total 900 '7/, mRIL )C A.5-Anmic 465S1
Hardness: (n~) 902 mRIL )C Ba-Barium 46558
Phenols 32730 uo/l )C Ca-<:alciwn 46552 ·
Spcci6c Cond. 95 umhos/cm2 )C Cd-OM!miwn-46559 -
Sulfate mg/I.. )C Q,.Chmmium 46560
Sul6dc 74 5 mg/I.. j( c,;. c-,,,. ! 042 ---
MBAS mo/l )C Fe-Iron 1045
Oil and Grease mg/L Hg-Men:,uy 71900
Silica mo/l. )( K-Porassium 46555
Boron )( Mg-Magncsiwn 927
Formalddwdc m2'l. )C Mn-Manl!llllese 1055
NH3asN610 m,,/[ )( Na-Sodium 929
TIOl as N625 m2/l.. ,: NI-Nickel
X NO2 +NO3 as n 630 0.31 mJl/1. )C Pl>-Lc:ad46564
P: Total as P 665 mo/l )C Se-Selenium
P04 mg/I.. }C Zn-Zinc 46567
Nitrate (NO3 as N) 620 0.31 mgll.
Nitrite (NO1 as N) 615 0.0tU mgll.
LabNumber : AB03130
OaLc: ~ : 411-'/2006
Tune Ra:cived : 9:35 AM
cc:/iv O Co
011etq>Orted : S/16/2006 1
5.0U ugll. Omxnn,hlorine Pesticides
sou ug/1.. Ommoohosohorus Pesticides
5.0U owl. Nitroer,, Pesticides
63 uo/l
22 mo/[ Acid Herticidcs
2.'oti'ui]L -.
-_ 2!\ll" ufft. -·Scinivo1aiilcs
-·,1.-ugiL TPH-Oiesei Ran2e
50U ug/L
uv/1. VolllJlc Onzanic:s (VOA boule)
22 m•ll
4 .8 mg/L TPH-Oasoline Range
t0U ullil, TPH·BTEX. Gasoline Rani,;e
9.6 ml!IL
,ou ug/1..
10U ug/1..
5.0U ug/1..
10U ug/1..
"8031~
GROUNDWATER FIELD/LAB FORM
LOCATION CODE ___ WI0300051
COUNTY : !REDELL
QUAD NO: Serial No.
SAMPLE TYPE
IK]water
SAMPLE PRIORITY
IK)Routtlne
North caronna
Department of Envtronment and Natural Resources
DMSION OF WATER QUALITY -GROUNDWATER SECTION
Lab NumberU O I}~~
Lat. Long.
□Son Oemergency
00tt1er (ROCKS and Ceramic TileS)
0 Chain of Custody
MW-
5,6,7,8
Data RecelvedO 6,(.) if/ o/.Time: 0 1 5 3/
Rec'd By: HIJ1W From: Bus, ~and Del.,
Other:. ________________ _
REPORT TO
SHIPPED BY:
RALEIGH CENTRAL OFFICE
COURIER
Data Entry By:, ____ Ck:, _______ _
Data
Reported: ____________ _
COLLECTOR(S)
FIELD ANALYSES
THOMAS SLUSSER DATE: ◄/18/06 Purpose: Baseline, Com.;.;.r;.;pla.ccin:.;..;t.::.• .....;Cc.:o:.:.;m""pc.:clia;;;;;n.:..:cec.;c,..., .;;;;LU_;;;_S_;;;_T-'-'''-'-Pes=tid-"'._;;;_dec....;:;.Stu=dy,_,._Oth::..c:.c.;;;.erc....-___________________ _
TIME:_11 :30 AM_ OWner. RONALD HOLDEN
pH<IOO 6.45 Spec. Cond.~157.7 __ at2f Location or Site:
Temp. 19.8 Odor · none Description of sampfmg point WEU HEAD ( INJECTION WELL EFFLUENTI
Appearance '-"C=L=EAR----'-'-----------Fleld Analysis By: _KEVl __ N_B_U_BAK ________ _
LABO RA TORY ANALYSIS
Sampling Method:
Remarks:
well pump Sample Interval: -------,F'llq-..,., .. ...,. ... -........ -, --"-----,-u"'"1c---G""E""o""TH=ERMAL PERMIT
<"'"'-r.,.._ ,-;,T..,,__ olc.l
B0D3 10 mglL X Diss. Solids 70300 mo/L X 1Ait--s1lwt 46566 uiilL Olpnochk,rine Peoticid<s
.COO H,ll,h J40 mo/[ Flumide9SI rm,/1 X Af.:~Af!557 : uv/1_ -Pesticides
CODLowlJS ·--.mo/I. Hardness: !clal 900 rMJL_ X >..Anenili45~5i -u.n.. N.-Pesticides
Colifunn: MF Fecal 31616 ./IOQml Hanlness: (~J 902 m<dl. X Ba-&n-um 46ssl: . -ue/L
Coliform: MFTolal 31504 1100ml Pbeools 12730 ua/1. X Ca-Oiiciiaii 46552-mall Acid Herbicides
roe cn&'I So,dJ;cComl.95 umhos/cm2 X Cd-<:adium ~59 ue/1..
Turbility NnJ Sullille mglL X Cr-Oii-omium 46560 ug/L Semlvolatilcs
Reudue.. $um,ndod 530 mg/L Sulfido7~S mall. X Cu-c.,,...,., t 04-2 uan: lPH-Dicx}it.n,,,,
moll. X .Fe-Iron 1045 UJ!/L
Oiland(ln:ase ,naJ( Ju-Morcu,y 71900 uo/1 Volatile Organics (VOA botllc)
DH units X J::.Powsium 46SSS mw'L
Alblmity 10 off 4, S nuz/L SILICA m.it X Mg-Munesium 927 mg/1. TPH-Gasoline R.ans•
AJknlinih, to pH 8.3 moll. X Mn--lOSS u.n.. TPH-BTEX Oasoline Range
Clli>on,im moll. ' NR3aN6l0 me/L X Na-Sodium 929 RllllL
Bicatbooato mg/L I'~, TKNasN62S me/L X Ni-N'ickel uoJI
Carbon dioxide m.n. :!~ X N02 +N03 u n 630 moil.
Chloride mri/1., P: Totahs P 66S mglL
Chromium: He,: I 032 no/I. ~ i'v Al.)J b."/Flr'~:;,=l)lf.::r,
Color: TIUC 80 c.u.
Cyanido720 mglL
X J'l>.Lcad 465M w,/1..
X Se-Seleai1lm u•II
X Zn Z.0046567 uaA.
LABUSEONLY n ,Q
TEMPERA TIJJIB ON AlUllV Al/-. I / -
LAB COMMENTS:
GW-54 REV. 12187 FOR DISSOLVED ANALYSIS -SUBMIT FTLTERED SAMl'LEAND WRITE "DIS" fN BLOCK
RONALD HOUJIEH U 8 SHEET
-
-
NC Division of Water Quality Laboratory Section Results
Loe. Descr.: RONALD HOLDEN
Location ID: WI0300051
County: IREDELL
River Basin
Report To RROAP
Region:· RRO
Collector: TSLUSSER
Sample Matrix: GROUNDWATER
Loe. Type: MONITORING WELL
Sample Depth
Collect Date: 04/18/2006
Collect Time:: 10:15
na yte Name
LAB
Sample temperature at receipt by lab
MET
AgbylCPMS
Al by ICP
As by ICl='MS
Ba by ICP
Ca by ICP
Cd by ICPMS
Crby ICPMS
Cu by ICPMS
Feb~ ICP
Kby ICP
Mg bylCP ,
Mn bylCPMS
Na by ICP
NI by ICPMS
PbbylCPMS
Se by ICPMS
Zn by ICP
NUT
Nitrate as N In llquld
Nitrite as N In liquid
N02+N03 as N In liquid
WET
Total Dissolved Solids In llqu]d
PCL Result
5.0
50
5.0
10
0.10
2.0
25
2.0
50
0.10
0.10
10
0.10
10
10
5.0
10
0.01
0.01
0.02
10
0.9
5.0
50
5.0
64
23
2.0
25
11
50
2.2
4.8
10
9.9
10
10
5.0
10
0.31
0.01
0.31
118
Sample ID: AB03129
PO Number# 6G0701
VisitlO
Date Received: 04/19/2006
Tlme· Recelved: 09:-35
Labwork~ LoglnlD MMA
Date Reported: 05/23/2006
Quallfler
u
u
u
u
u
u
u
u
u
u
u
u
Units Approved By
•c JGOODWIN
ug/L ESTAFFORD
ug/L EST AFFORD
ug/L EST AFFORD
ug/L EST AFFORD
mg/L EST AFFORD
ug/L EST AFFORD
ug/L ESTAFFORD
ug/L EST AFFORD
ug/L EST AFFORD
mg/L EST AFFORD
mg/L ESTAFFORD
ug/L EST AFFORD
mg/L EST AFFORD
ug/L EST AFFORD
ug/L EST AFFORD
ug/L EST AFFORD
ug/L ESTAFFORD
mg/Las N CGREEN
mg/Las N CGREEN
mg/Las N CGREEN
mg/L MOVERMAN
RECENED / OENR / DWQ
AQUIFER PROTEC TIO f SECTION
JUN I 5 2006
Laboratory Section» 1623 Mall Service Ci , Raleigh, NC 27699-1823 (919) ·733-3908
Page 1 of 1
7c__
5~~/o<c
COUNTY : !REDELL
QUADNO;
DIVJSroN OF WATER QUALITY
Olommry Laboratory Repo.rt / Gro .. d Watu Q••lilY
SAMPLE PRIORilY
[g]R01.l1lNE □EMERGENCY
REPORT'IO _W--'A-"-T _______ Rcgional Olli~ D CHAIN OF CUSTODY
@ SAMPLE TYPE
I I ~ COLLECTOR(S) :...;T...;S ... L __ u __ ss __ ER ______ _
DATE:
TIME:
4/11112\ff 10
MW-1,2,3,4
I I
PURPOSE: Owner: RONALD HOLDEN
Localioo or S ~ .. ,
Dtscriplioo of sampling point ___________________ _
Sampling MC!hocl:
RCITUUics:
LABO RA TORY ANALYSIS
900310 moll X Diss. Solids 70300 118 m!!IL. X Ag-Silva 46S66 5.0U ug/L
COOHi2h340 m[!/L Fluoridc9SI mg/\. X Al-Aluminum 46557 SOU ue/L
CODLow33S mg,'L Hardness: total 900 ·-z-i moll X Mo-Arsenic 4655 I 5.0U ugll.
Colifonn: MF Fecal 31616 1100ml Hardness: (non-<:arb) 902 m2'1. X Ba-Barium 46S58 64 og/L
Coliform: MFTotal 31504 /IOOrnl Pheools32730 ug/1, X Ca-Calcium 465S2 23 m,/1._
roe mllll Soecific Cond. 95 umhos/cm2 X Cd-Cadmium 46559 2.0\J ugii.-
Turbidity NTU Sulfalc mgll. X Cr-Oiromiwu 46560 ·-:---tsliiig.i(. -
Residoc ., Susj,codcd S30 mg/L Sutfidc74S m2'L X Cu-Com>cr 1042
.. Tt 'µgil:.--
1'otal Susocndcd solids mg,'L MBAS ml!A X Fe-Iron I 045 50\J uo/1
OilondGrease m"/1 H2-Mercury 7 I 900 ul!/L
lr>H units Silica mRIL X K-P-ium 4655S 2.2 au,/L
Alkalinity lo pH 4.S mg/L Boron X Mil· M•onesium 927 4.8 m"11
Alkalinity 10 oH 83 mg/L Fonnaldellyde moll X Mn-MA•"""""' 1055 10U uo/1
Carbonare mg/L NH313N6I0 llll!/[ X Na-Sodium 929 9.9 mo/L
Bicarborwe mRIL TKNasN62S m2'L )( Ni-Nickel 10\J ug/L
Carbon dioxide mpjl,. X N02 +N03 as n 630 0.31 mgll. X Pb-Lead 46564 10U uoll
Chloride mJ!/L P: Total as P 665 m2'L X Se-Selenium 5.0U ug/l,
Chromium: Hex 1032 u!!IL. P04 mg/I. X Zn-Zinc 4656 7 10U ug/L
Color: True SO c.u. Niuatc (NO, 13 N) 620 0.31 mg,'L
Cyanidc720 mg/L Nitritc(N<>, as N) 615 0.01U mg/I.
COMMENTS,
Lab Number : AB03J29
Date Received : 4119f.l006
Tune Received : 9:3S AM
Received By : HMW
'7C.., 2 {:J.:i I O Cc,
Date rq,orud : 5/1612006
Ornnochlorine Ptsticich:s
Pesticida
NitroRCll Ptsticidcs
Acid Habicidcs .
Scmivolatilcs
TPH•Dicsd Range
Vola1ilc Orgoni,;s (VOA honk)
TPH-0,,solinc Range
TPH-Bll:X Gasoline R.an2c
AII03129
GROUNDWATER FIELD/LAB FORM
SAMPLE TYPE SAMP LE PRIORITY
LOCATION CODE WI0300051 [[]water [[] Routtlne
COUNTY : IREDEU
QUAD NO: Serial No. O so11 □Emergency
Lat. Long .
O 0ther {ROCKS and Ceramic TIies)
REPORT TO RALEIGH CENTRAL OFACE
SHIPPED BY: COURIER 0 Chain of Custody
MW-
North Caronna
Department of Environment and Natural Resources
DMSION OF WATER QUALITY • GROUNDWATER SECTION
Lab Number,
Date R
Rec'd By:
1,2,3,4 Other:
Data Entry By: Cit:
Data
Report&d:
C0LLECTOR(S) : THOMAS SLUSSER DATE: 4/18/06 Purpose: Base6ne, Complaint, Compliance, WST. Pesticide Study, Other
FIE LD ANALYSES TIM E:_10:15 AM __ Owner: RONALD HOLDEN
Spec. Cond.94_ 132.9 __ at 25'· Location or Site:
Temp. __,,._1.,...,3,...,_3=-------_Od~or~-~"one=------
6.1
Oesaiption of sampling point WEU HEAD ( PUMPING WELL INFLUENT) Appearance ~C=LEAR ____________ _
Field Analysis By: _KEV_I_N_B_U_BAK _________ _
Sampling Method:
Rem arks:
well pump Sample Interval: --------=-"'". ___ ..... c1--'-----u ,..,,c,....G-=-E=o-=-nt-ERIIAL PERMIT
LABORATORY ANALYSIS
80D310 moA, X Dua. Solid& 70300 mo/I_ -X A~ifw<-46566 -ao/1 -Pesticides coo Hi2h.340-..... _ • . . • •. moll. Fluoride 95 I ma.1. X Al:-~~-,46~57 _ ua/L P,;stitj,S..
.COD uiw.331. .. ---mg/L Hardness: IOlal 900. m,r/L . X At,Aisome,46SSJ. .. uo/L Ni ...
ColifomL MF Focal 31616 : /U)0ml Hm-Jneu: (.-t>) 902 moll X S.8"'i1DD-465-S8 ·,. .. _ no/L
Colifann: MF Total 31 S04 /IOOml Phenols J2no uoA, X Ca-Calcium ~52_ _ ma/L Acidlf..t,ioidos
TOC -11 Sooeific Cand. 9S umho&ICIIIZ X Cd-Cadium ~59 ua/L
Tu,t,itity NIU Sulfate moil X Q--Ouomiwn 46S60 no/I Scmi\oolabi..
Residue.. S03!lendcd 530 m,r/L Sulfide 745 m,r/L X Cu-C..0-I 04_2 u o/L TPH-Diescl -
m,r/L X Po-Iron 1045 uo/L
Oilando,_,, mg/L HR-Ma-cu,y 719QO w,/1_ VoLttile o...nioa /VOA bottle)
nR IDUls X K-Poias.ium 46SSS n,glL
All<alinitv 1o pH 4.S m!t/1. SllJCJ\ mg/L X M 927 malt ll'H-Oaoolinc llm,..,
Allr.alinitv 1o pH 8.3 mg/L
CaJbonale -" ' NBlas N 610 """'
X Mn 1055 ug/L
X Na-Sodium 929 moil.
TPH--BT£X Gasoline ho~•
Bicarbonate moll. 1KNuN62S rru,/1 X N'1--Nicul uo/L
Carbondio,udc m,r/L ' X N02 +N03 u o 630 m,r/L
Otloride fflDII. .J P: Total a P 665 m •lL
Chtomimn: Heir 1032 wdL ~ Ill~) (!Ill /IRE. '>~IZ\r; h
I( Pl>-Lcad 46564 uglL
X Se-Seleniom w,/L
X Zn Zinc 46567 ua/L
Color. True 80 O.IL
,,
""""w72o mg/L
LABUSE ONLY ,J) Cf
1EMP£RAIURE ON ARRJV I
t.AB COMMENTS:
3W-54 REV. 12187 FOR DISSOLVED ANALYSIS • SUBMTI' F1L'1'EJIED SAMPLE AND Wll1TE "DIS" IN BUX:K
RON,oU> "OUIEN N I SICEFI
-
MOORESVILLE REGIONAL OFFICE
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SE(:TION
April 18, 2006
MEMORANDUM
To: Thomas Slusser
DWQ Raleigh Central Office Parker Lincoln Building
From: Kevin Bubak Hydro Tech 1
Attached: APSSRR Form for Ronald Holden Permit # WI 0300051
N ..
To:
AOUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
D Landon Davidson, ARO-APS
□ Art Barnhardt, FRO-APS
[g) 'n_.ln·,, Pit111. .• \ffl(). \pc;;
0 Jay Zimmerman, RRO-APS
0 David May, WaRO-APS
□ Charlie Stehman, WiRO-APS
□ Sherri Knight, WSRO-APS
From: Thomas Slusser , Groundwater Protection Unit
Telephone: [phone] -..£: Fax: [phone]
E-Mail: thomas.s1usser a ncmail.net
A. Permit Number: '.~:_ur , ~
B. Owner: RONALD & ANNE HOLDEN
MAR 22 3X>G
C. Facilit\'/Operation: RONALD HOLDEN -SFR NCOENRMRO
-. ·u fe· Protection
0 Proposed ~ Existing D Facility anon
D. Application:
1. Permit Type: 0 Animal D Surface Irrigation D Reuse D H-R Infiltration
□
[g)
Recycle D IIE Lagoon D GW Remeruation (ND)
UIC -(5A7) open loop geothermal __
For Residuals: 0 Land App. □ D&M
D 503 D 503 Exempt
D Surface Disposal
D Animal
2. Project Type: 0 New D Major Mod. D Minor Mod. cg] Renewal D Renewal w / Mod.
E. Comments/Other Information: D I would like to accompany you on a site visit.
Attached, you will find all information submitted in suppo1t of the above-referenced application for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
[g) Return a Completed Form APSSRR.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Cettification from the RO*.
* Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete AttachmenfB for
certification. Refer to the RPP SOP for additional detail.
When you receive this request fom1, please write your name and dates in the spaces below, make a .j;Qpy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
1
/. , () I/ /, j_
RO-APSReviewer: ~--~~~~ ______ Date: _!j_J/8(D/p
FORM: APSARR 02/06 Page l of l
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 4/18/06
To: Aquifer Protection Central Office
Central Office Reviewer: Thomas Slusser
Regional Login No: __ _
1. GENERAL INFORMATION
County: Iredell
Permittee: Ronald Holden
Project Name: __
Application No.: WI0300051
1, This application is (check all thst apply): D New 181 Renewal
0 Minor Modification O Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
D Attachment B included
D Surface Disposal
0 503 regulated D 503 exe111pt
D Ciosed-loop Groundwater Remediation 181 Other Iajection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IZ! Yes or D No.
a. Date of $ite vis it: 4/18/06
b. Person contacted and contact information: Ronald Holden 704/662-3530
c. Site visit conducted by: Kevin Bubak
d. Inspection Report Attached: D Yes or IZ! No.
W. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
181 Heating/cooling water return flow (SA 7)
D Closed-loop beat pump system (SQM/SQW)
0 In situ remediation (SI)
0 Closed-loop groundwater remediation effluent injection {SL/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? ~ Yes O No
3 . Are there any potential pollution sources that may affect injection? D Yes 181 No
What is/are the pollution source(s)? __ .,_. _,Wh..:.=a=t--"'is:c..cth=e -=d=istan==ce;:;..:.of=--th=e =in~jec=ti=o=n---'-w=--=e=ll=( s,,__.)-"fr=o=m::...::th=e~p=o=ll=uti=' o=n
source(s )? ft.
4. What is the min imum distance of proposed injection wells from the property boundary? 56 ft.
5. Quality of drainage at site : IZ! Good D Adequate D Poor
6. Flooding potential of site: ~ Low D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? 0 Yes D No. Attach
map of existing monitoring well network if applicable . If No, explain and recommend any changes to the
groundwater monitoring program: __
FORM: ronald Holden aps report form
AQUIFER PROTECTION REGIONAL STAFF REPORT
8. Does the map presented rep.resent the actual site {property lines, wells, surface drainage)? 181 Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Iniectioo Well Permit Renewal And Modification Only:
1. For heat pump systems, are 1here any abnormalities in heat pwnp or injection well operation ( e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes ~ No. If yes, explain :
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes , explain:
3. For renewal or modification of g roundwater remediation permits (of any type ). will
continued/additional/modified injections have an adverse im pact on mi gration of the plume or management of
the contamination incident? D Yes D No. If yes. explain:
4. Drilling contractor: Name: __
Address:
Certification number: __
5. Complete and attach Well Construction Data Sheet.
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.: According to what MRO have on
tile there bas been no modification of the system.
2. Attach Well Construction Data Sheet-if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? D Yes 181 No. If yes, please explain
briefly. __
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
FORM: ronald Holden aps report fonn 2
AQUIFER PROTECTION REGIONAL STAFF REPORT
Condition Reuon
6 . List specific special conditions or compliance schedules that you recommend to be inc luded in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7. Recommendation: 0 Hold, pending receipt and review of additional infonnation by regional office; D Hold,
pending review of draft permit by regional office; 0 Issue upon receipt of needed additional information;
8. ~ Iss ue; D Deny. If deny, please state reasons: __ l~-M~ 9 . Signature of report preparer(s): -----~~---..,,..-_.,,, _________ _
Signature of APS regional supervisor: ~ ;
Date: 4/18/06
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
I s poke to Mr. Holden about the injection well not having a working effluent s pigot and advised him to get one
installed for easier sampling. I also discussed with him about trying injection into his French drain he has for
his gutters to avoid having to deal with pennitting.process from the state. Over all the system seems to be in
good working order heat exchange difference was around five to seven degrees Celsius from pumping well to
injection well. Sample were taken for metals, total dissolved solids and nitrate/nitrite.
FORM: ronald Holden aps report form 3
Michael fl. Easley, Governor
William G. Ross Jr .. Secrcto,ry
North Carolin.a Department of Environment and Natural Resources
Alan W. Klimek, P.6. Director
Division of Water Quality
March 21, 2006
Anne and Ronald Holden
124 Tall Oak Drive
Mooresville, NC 28 1 17
Ref: Receipt of Permit Renewal Application
Injection Permit# WI0300051
Dear Mr. and Mrs. Holden:
Your renewal application for a permit to use a well for the injection of geqthennal heat pump
effluent has been received and is under review. A member of the Aquifer Protection Section's
Mooresville Regional Office staff will be contacting you to arrange an inspection of the injection
well and collect water samples as part of the review.
Please contact me at (9 19) 715-6166 or Evan Kane at [phone] if you have any questions.
cc: Andrew Pitner, Mooresville Regional Office
CO-UICFile
Aquifer Protection Section 1636 Mai l Service Center
Internet: hlrp://www.ncwn1erquali1 1:,org 2728 Capital Boulevard
Best Regards,
Thomas Slusser
Hydrogeological Technician II
Underground Injection Control Program
Ra leigh, NC 27699-1636
Raleigh, NC 27604
Telephone;
Fnx I :
Fax 2:
~{th Carolina
1\/llfllrnllu
(9 I 9) 733-3221
(919)7 15-0588
[phone]
An Equal Opportunity/Affirmative Action Employer-SO% Recycied/10% Post Consumer Paper Customer Service: [phone]
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEAL TH, AND NATURAL RESOURCES
RENEW AL APPLICATION FOR PERMIT TO USE WELL{S) FOR INJECTION WITH A
HEAT PUMP SYSTEM
TO:
A.
Type'5A7 and SQM Wells
In accordance with the provisions ofNCAC Title 15A: 02C.0200
complete application and mail to address on the back page.
DIRECTOR, NORTH CARO LINA DIVISION OF WATER QUALITY
DATE:/YJ IVZ c d 6 , 2o~a<-.;:;;.6=:;....· __
PERMIT APPLICANT w;z:,o:;~~ .
Permit Number: ~ C, • 0-7-F/-ffV'no ~, listed at the bottom of each page of your permit)
Name: R ow..._~ I.. /-Jo LD£U
Address: /,l, Y 7AL I.. , ?A-1< -:-Z,,~, .,,,.,
City: m""" FS a , I ~ J4,: State: tJ C, Zip code: .2 1 14 7
County: LJ./1 , & LL Telephone: ----''----.:....:;~~-------"'----"-=---
B . PROPERTY OWNER (if different from. applicant)
Name: f',Jn-,~
Address:------------------------------
City; _______________ State: __ _ Zip code: ______ _
County: ___________ Telephone:---------------·
C. STATUS OF APPLICANT
Private: ___ Federal: __ Commercial: ____ State: ___ Public: __ _
Native American Lands: __ _
D. FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Public or Commercial).
Name of Business or Facility: ______________________ _
Address: ____________________________ _
City: _______________ State: __ _ Zip code: ______ _
County: ___________ Telephone: ______________ _
Contact Person: __________________________ _
Standard Industrial Code{s) which describe commercial facility: ____________ _
Revised 5/05 GW/UIC-57 HPR Page 1 of3
E. INJECTION PROCEDURE (specify any modifications to the mjection procedure since the issuance of the
previous injection permit)
S/4-~E
F. WELL USE Is(are) the injection well(s) also used as the supply well(s) for either of the following?
(l) Toe injection operation? YES_ NO __
(2) Your personal consumption? YESJL NO __
G. CONSTRUCTION DATA
H .
( 1) Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection perm.i t.
(2) NC. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes. A faucet on both influent (groundwater entering heat pump) and
effluent (water being injected into the well) lines is !;quired. ls there a faucet on:
(a) the influent line? YES_ NO_tr_
(b) on the effluent line? YES_ NO __
CURRENT OPERA TING DATA
(1) Injection rate: Average (daily) 7 gallons per minute (gpm) ,.. '
(2) Injection volume: Average (daily) ('.!,., L
t C gallons per day (gpd) w141:JJ "J?. u · .-, w I A.I'
(3) Injection pressure: Average (daily) +'r pounds per square inch (psi)
(4) Injection temperature: Annual Average tJ.ol° degrees Fahrenheit (°F)
I. INJECTION-RELATED EQUIPMENT
Attach a diagram showing any modifications to injection equipment since the issuance of the previous injection
permit including the engineering layout of the (1) injection equipment, and (2) exterior piping/tubing associated
with the injection operation. The manufacturer's brochure, if detailed, should satisfy (1).
J . LOCATION OF WELL(S) Attach a map
Include a site map ( can be drawn) showing: the orientation of and distances between the injection well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
ground-source heat pump well system; include buildings, property lines, surface water bodies, any other potential
sources of groundwater contamination. Label all features clearly and include a north arrow to indicate
orientation.
K. PERMIT LIST: Attach a list of all permits or construction approvals, received or applied for by the applicant
that are related to the site. Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
L . OTHER MODIFICATIONS: Indicate any other modifications to the injection well system (equipment, fluid,
operation, etc.) that have occuned since the issuance of the previous injection pennit and have not been noted
elsewhere on this application.
Revised 5/05 GW/UIC-57 HPR Page 2 of3
M . CERTIFICATION
"I hereby certify, under penalty of law, that I hav.e personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment, for
submitting false information. I agree to 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."
V (Signature of Well Owner or Authorized Agent)
If authorized agent is acting on behalf of the well ow11er,
please supply a letter signed by the owner
authorizing the above agent.
N . CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property rights in the
well(s). A well is real property and its construction on land rests ownership in the land owner in the absence of
contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the
applicant to operate an injection well( s) as outlined in this application and that it shall be the responsibility of the
applicant to ensure that th.e injection well(s) conform to the Well Construction Standards (Title 15A NCAC
Subchapter 2C .0200)
Revised 5/05
(Signature of Property Owner if Different From Applicant)
Please return the completed Application package to:
UICProgram
Aquifer Protection Sectio.n
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
GW/UIC-S7 HPR Page3 of3
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL KESOURCES
DI VI SION OF WATER QUALITY, AQUIFER PROTECTION SECTION
STATUS OF INJECTION W ELL SYSTEM
' • ~ J -r ,.;:;:t"\ Pe rmit N u mber:~ wjUzt,. .::-£17;1-~J½-.,,t ....t-'-""3~}c..__..:, ~
Perm ittee Name: ~ 11Jl4< P . . -lo L..l)/1" N
Address: .~¢ T111u.. ~J.11<. ,It/
Please check the selection which most closely describes the current status of your injection well.
In addition, please provide the requested information.
1) JL_ Well is still used for injection activities. t,pJ/ ~ f-,-~ ~
k, c~ 4. ~ A.AJ ~ -<u, '.'t1 .. ~
2) Well is not used for injection b ut is u sed forwatei"s upply or other purposes.
3)
4)
Injection discontinued a nd : a ) __ Well temporarily abandoned
b ) __ Well permanently abandoned
c)~ Well not abandoned
Injection well never constructed
If you checked (2), describe the well use (potable water supply, irrigation, etc), including pumping rate and other
relevant information.
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description of
how the well was sealed and the type of material used to fill the well if permanently abandoned):
Certification: (For well abandonment)
"I hereby certify, under penalty of law, that I am personally responsible for the proper abandonment of any
injection well a s required in Title 1 SA NCAC 2C .0214 Criteria and Standards Applicable to Injection Wells."
Signature Date
Certification: (For information verification) .../'
"I hereby certify, under penalty of law, that I hav e personally examined and am familiar with the information
submitted in this document, and that to the best of my knowledge the information is true, accurate, and complete."
Signature Date
Revised 5/05 GW/UIC-68
Michael F. Easley, Governor
William 0. Ross Jr., Scoretary
North Carolina Department of Environment and Natural Resources
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7002 2410 0003 0274 8963
Ronald Holden
124 Tall Oak Drive
Mooresville, NC 28117
Ref: Notification of Expiration
December 5, 2005
North Carolina Well Construction Standards
Applicable to Injection Wells -Subchapter 2C
UIC Permit No. WI0300051 Issued to Ronald L. Holden
Dear Mr. Holden:
Alan W. Klimek, P.E. Director
Division of Water Quality
The Underground Injection Control (UIC) Program of the Division of Water Quality is responsible for
the regulation of injection well construction and operation activities within the state of North Carolina.
Our records show that the operating permit referenced above for the injection well on your property will
expire on February 28, 2006. In addition, our records do not indicate that the well has been abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative Code
(NCAC) Title 15A, Subchapter 2C, Section .0211, you must take one of the following actions:
A. Submit the form RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITif A
HEAT PUMP SYSTEM (form GW/UIC-57 HPR) if the injection well on your property is still
active;
B. Submit the form STATUS OF INJECTION WELL SYSTEM (form GW/UIC-68) if the injection well is
inactive or has been temporarily or permanently abandoned.
If the well is no longer being used for any purpose, it must be permanently abandoned according to the
regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section .0214. I f the injection
well is to be permanently abandoned, a well abandonment record must be submitted to our office to
certify that the abandonment was properly conducted.
Aquifer Protection Section
Internet: http://h2o,enr.state.nc.us
l 636 Mall Service Center
2728 Capital Boulevard
Raleigh, NC 27699-1636
Raleigh, NC 27604
An Equal Opportunity/Affirmative Action Employer-50% Recycled/1 0% Post Consumer Paper
~Carolina
;vafllrallu
Phone [phone] Customer Service
Fax [phone]
Fax [phone]
ltu11a id Hu Iden
December 5, 2005
Page 2 of2
Please submit the appropriate form(s) within 30 days of the receipt of this letter. If you have any
questions regarding the permit and injection well rules, or if you would like assistance compl eting these
forms please contact Thomas Slusser at (919) 71 5-6 166 or Evan Kane at [phone].
cc: DWQ -Mooresville Regional Office w/o enclosures
CO-U IC Fil es w/o enclo sures
Enclosures
Sincerely,
Jesse Wiseman
Processing Assistant
UIC Program
CERTIFIEDMAIL
RETURN RECEIPT ~QUESTED
7002 2410 0003 0274 9847
Ronald Holden
124 Tall Oak Drive
Mooresville, NC 28117
January 17, 2006
Ref: Notice of Regulatory Requirement
North Carolina Well Construction Standards
Applicable to Injection Wells -Subchapter 2C
Michael F. Ensley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resou_rces
Alan W. Klimek, P.p. Director
Division of Water Quality
UIC Permit No. WI0300051 Issued to Ronald L. Holden
Dear Mr. Holden:
The Underground fujection 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. The purpose of this letter is to inform you , as the current pro perty
owner, ·of your res ponsibilities pertaining to in jection well rules.
The permit referenceq .above w~ issued for the construction and operation of an injection well at
12_4 Tall Oak Drive in Mooresville, North Carolina. This permit will expire on February 28,
2006. _This office attempted to bring your injection well into compliance by sending you a
notificatio.n of expiration, a blank application for permit renewal, and an injection weU status
form in D ecember 5 , 2005. To date the UIC Program has not received either the renewal
application or the status form. Please note that, as stated in PART vnr of your permit, a renewal -
applications should have been submitted at least 3 months prior to the expiration of this permit..
-In order to comply with the regulatory requirements listed under North Carolina A~strative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211 , you must take one of the following
actions:·
A. Submit the· form RENEW AL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION
WITH A HEAT PUMP SYSTEM (form GW/UIC-57 HPR) if the injection w~ll on your
property is still active;
B. Submit the form STATUS OF INJECTION WELL S YSTEM (form GW/UIC-68) if the injection
well is inactive or has been temporarily or permanently abandoned.
Aquifer Protection Section I 636 Mail Service Center
Internet: http://h2o.enr.state.nc.us 2728 Capital Boulevard
Raleigh, NC 27699-1636
Raleigh, NC 27604
An Equal Opportunity/Affirmative Action Employer-SO% R~ycled/10% Posl Consumer ?aper ·.
'(elephone:
Fax I:
Fax2:
Customer Service:
N~Caro!i,na
/Vllllutlll{I
(91 9) 733-3221
(91 9) 715-0588
[phone]
[phone]
Ronald Holden
January 17, 2006
Page 2 of2
If the well is no longer being used for any purpose, it must be permanently abandoned according
to the regulatory requirements listed under NCAC Title :t5A, Subchapter 2C, Section .02 14. If
the injection well is to be permanently abandoned, a well.abandonment record must be submitted
to our office to certify that the abandonment was properly conducted.
Again, we have provided you with the _appropriate materials to update your UIC permit. You
must respond within 15 days of the receipt of this letter, or a Notice of Violation will be issued to
you, which carries the possibility for an assessment of fines or cessation of operation of the -
inj ection well system. Please contact Thomas S lusser at [phone] or myself at (919) 715-
6182 if you have any questions about this correspondence, the utc Program, or the enclosed
forms.
Enclosures
cc: DWQ -Mooresville Regional Office w/o enclosures
CO-UIC Fifes w/o enclosures
Sincerely,
~o.f_-
Evan 0. Kane, L.G.
UIC Program Manager
■ Complete Items 1, ~-• 1d 3. Also complete
Item 4 H Restricted Delivery Is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mallpiece,
or on the front if space permits.
1. Artlcle Addressed to:
R onald Holden
124 T all Oak.Drive
Mooresville, NC 28 1 17
D. Is delJvery address different from Hem 1?
If YES, enter dellvery addrees below: □ No
3. Selvlce'fype
Ill certified Man □ Express Mall
□ Registered □ Retum Receipt for Merchandise
□ ·Insured Mall □ C.O.D.
4. Aestrtcted Delivery? {Extnt FH) □ Yes
7 002 2 4 1 □ □ 0 □3 □274 9847
PS Form 3811, August 2001 Domestic Return Receipt 2ACPRl-03-Z.o985
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natu1111 Resources
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7002 2410 0003 0274 8963
Ronald Holden
124 Tall Oak Drive
Mooresville, NC 28117
Ref: Notification of Expiration
December 5, 2005
North Carolina Wen Construction Standards
Applicable to Injection Wells -Subcbapter 2C
UIC Permit No. WI0300051 Issued to Ronald L. Bolden
Dear Mr. Holden:
Alan W. Klimek, P.E. Director
Division of Water Quality
The Underground Injection Control (UIC) Program of the Division of Water Quality is responsible for
the regulation of injection well construction and operation activities within the state of North Carolina.
Our records show that the operating permit referenced above for the injection well on your property will
expire on February 28, 2006. In addition, our records do not indicate that the well has been abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative Code
(NCAC) Title 15A, Subchapter 2C, Section .02 11, you must take one ·of the following actions:
A. Submit the fonn RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM (form ·GW/UIC -57 HPR) if the injection well on your property is still
active;
B. Submit the form STATUS OF INJECTION WELL SYSTEM (form GW/UIC-68) if the injection well is
inactive or has been temporarily or permanently abandoned.
If the well is no longer being used for any purpose, it must be permanently abandoned according to the
regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section .0214. If the injection
well is to be permanently abandoned, a well abandonment record must be submitted to our office to
certify that the abandonment was properly conducted.
Aquifer Protection Section
Internet: http://h2o.cnr.state.nc,us
1636 Mail Service Center
2728 Capital Boulevard
Raleigh, NC 27699-1636
Raleigh, NC 27604
An Equal Opportunity/Affirmative Action Employer -50% Recycled/10% Post Consumer Paper
N.?,{thCarowia
/Vllfrlfllil(f
Phone [phone] Customer Service
Fax [phone]
Fax (919) 715·6048
Ro na ld HulJ~n
December 5, 2005
Page 2 of2
Please submit the appropriate form(s) within 30. days of the receipt of this letter. If you have any
questions regarding the permit and injection well rules, or if you would like assistance completing these
forms please contact Thomas Slusser at [phone] or Evan Kane at (919) 7 15 -6182.
Sincerely,
~0 ~
cc: DWQ -Mooresville Regional Office w/o enclosures
CO-ulC Files w/o enclosures
Enclosw-es
Jesse Wiseman
Processing Assistant
UICProgram
■ Complete Items 1, ... _.Id 3.Also complete
Item 4 H Restricted Dellvery ls desired.
■ Print your name and address on the reverse
so that we can retum the card to you.
■ Attach this card to the back of the mallplece,
or on the front If space permits.
1. Article Addressed to:
Roger Holden
124 Tall oat Drive
Mooresville, NC 28117
0. Is dsllvery addl8SS dffel8!lt from Item 1? □ Yes
lfVES, enter dellveryaddress below: □ No
~-SerYlce'fype
· I( Certified Mall □ Express Mall
□ Registered □ Return Receipt for Merchandise
□ Insured Mall □ C.0.0 .
4. Restricted Delivery? (Extra Fee) □ Yes
7 □□2 241 □ □□03 0274 8963
PS Form 3811, August2001 Domestic Return Receipt 2ACPRl-03-Z-0986
MEMO
To V a&!_c )~J
& W -U I e_ ULCU,i.M
DATE: 9µ I lo I 7
SUBJECT: we.. 4-lldyi/j
~
j)~ ~Ctttn ~-
'
~(J.,u_~~~J;~n,~
tf 11 IL,~ ~~ Ju-,-,, 6 Ja,i.d ~ ~ (,fl!.-~f.Uld;}~ an ~,At,l~QI,
From : 9f(u.£l.l da<du!-t_LJ
.. ~..,, m /UJ • 4 aJ .
t· ~~~·~ North Carolina Department of Environment
~-.. ':;;;;'!;,•'!f!l tit ,altB. and Natural Resources ~ ' 'CJ9 Printed on Recycled Paper
COUNTY: !REDELL
QUAD NO:
REPORTTO
COLLECTOR(S) :
_~_IR_O-'--_________ R,gion•l Offia,
CALDWELL
DATE:
T IME:
PURPOSE :
LABORATORY ANALYSIS
8OD310
COD Ii iith 340
C0OLow335
X Coliform: MF Fecal 31616
X Coliform: MF Tol>I 31504
TOC
Turbititv
Residue .• Susprndcd 530
Total Sweended solid.<
X pH
Alklllinit,• to pH 45
Alkalinily lo pl I ~.3
Carbonale
Bicaroonale
Carbon dio,ide
X Chloride
Cluomium: Hex 1032
Color: True 80
Cvanide 720
COMMENTS:
,..,,.,i ~
I B;!,Q
I 82.Q\ .
7.BQ
-·3Q
mgi l
m1tl l
mr. L
1100ml
1100ml
mRI I
NTU .
m1t/L
m~1L
unil.5
mit/L
mg.I.
m11:L
mg/L
m~/L
mit/L
UJt/L
c.u .
mg /L
Owner:
Location or Sitt:
O"-'cription of sampling point
S.1mpling Method:
Remarks:
X Diss. Solids 70300
Fluoride 9S1
X Hardncs.~: toL\I 900
Hardnw: (non-cam) 902
Phenols 32730
Specific Cond. 9S
Sulfa te
Sulfide 74S
MDAS
Oil and G rea""
Silica
Doron
Fonnaldoh,·de
NHJ as N 610
TKN :UN 62S
X N02 +NOJ as n 630
P: Total as P 665
POI
DIVISION Or-WATER QUALITI'
Ch,mi>try L•boutory Rcpor1 / Ground W~tcr Qu,lily
S.AMe.l.E 1'.RIORIT_Y
E)ROl.rrlNE
□ CHAIN OF CUSTODY
~ SAMPLE TYPE
180 mg!L
m~/1.
80 mg/L
mg/L
ugl l
umhos /cm2
mg/L
m,t/1.
mg/L
mg/L
nigll
ll'g L
mRI L
mg/L
0 .24 mgl L
mR/L
mJI/L
□EMERGENC Y
□.
Ag-Silver 46566
X Al-Aluminum 46557
A,-A rscnic 4655 I
D•-Barium 46558
X Ca-Calcium 46S52
Cd-C•dium 46S59
X Cr-Chromium 46560
X Cu-Copper 1042
X l'c-Iron 10-15
112-Mercury 71900
X K-Pot,,ssium 46555
X M2-Ma11.nc,ium 92 7
X Mn-ManJ!'lne,c 1055
X Na-Sodi um 929
X Ni-Nici.cl
X Pb-Lc•d 46564
Sc-5c:lenium
X Zn..Zlnc 46567
ug, L Or1t11nochlorinc Pmicides
160 U~l l Organoohosohon» r .. t1 cidcs
ug/L Nitro~en r ... Licidcs
ug/L
36 mg/L Acid H<rbid des
uit l
25U u~il. Scmi\'Olalil.,,
8 .3 u~i L Tl'H-Die.sd RAni,;e
sou ui:·t.
ug/L Vol.ltile Organics (VOA bottle)
3 .0 mw l
4 .5 m~.'L TPI I-Gasoline Rantc
11 ·~ I. 1 PJl .nl r:x \IMOHnc l{;ans:c
9 .B m2;L
IOU ug,"L
!OU ug/L
ug/L
37 ua/L
1009116.>I•
COUNrY : IRF.OE_l._t _______ _
QUAONO:
REPORTTO
COLLECTOR(S) :
-'-~-'-m.;..oc;_ _________ Rcglonal Office
CALDWELL
DATE: §.llillOJll
TIME:
PURPOSE:
LABORATORY ANALYSIS
BOO310
COOHiahl◄O
CODLow33S
X Colifonn: MF Fecal 31616
X Coliform: MF Tolal 31504
TOC
Turbitil\'
Residue., Suspen ded 530
T olal Suspended rolid,
X IPH
Alkalinity to DH 4.5
Al).alinity lo pl l 8.3
C...bonatc
Bicarbonalc
Carbon dioxide
X thloride
Chromium: Hex 1032
Color. True RO
Cvanidc 720
COMMENT S:
1$.~:::
m11t L
nlli/L
mR/L
I 82.0 1 100ml
IQ 1100ml
mJ!/1
NTU
m2/L
mJl/L
7.4Q units
matt
ml!.'L
ma/L
mg/L
m2/L
SQ mg/L
UJl/L
c.u.
mJ!/L
tcl
OwnC1:
Location or Site:
Dcscriplion or .<;\lnpling point
Sampling Method:
lu:marks:
X rn ... Solids 70300
Fluoride 951
X 1-lardnw:-lotal 900
Hardnc5s: (non-carb) 902
Phenols 32 7 30
Specific Cond. 95
Suff::ue
Sulfide 745
t.llJAS
Oil and Grca>c
Silica
Boron
Formatdchvdc
NHJ as N 610
TKNas N625
X NO2 +NOJ as n 630
r: Total as P 665
POI
Dl\'JSION OF WATER QUAI,IT\'
Chcmi~lry Lahor:,tory Hcriorl / Groun d \Vat,,. Qu,,tily
SAMPLE PRJQ!illl
□ROUTINE
D CHAIN OF CUSTODY
6Y:) SAMPLE TYl'E
120 mi:,L
m2/L
52 ma l l
m2/L
ui:I L
umhos/cm2
ma;1.
ma.'L
OIJlJ I.
mJ!/L
mgtL
m2,L
ma/L
012/L
0 .41 ma/L
mg/L
ma/L
□EMERGENCY
□
Ag-5ih·rr ~6566
X A~Aluminum 465S7
As-Arsenic 4655 l
Ba-Barium 46558
X Ca -Calcium 46552
Cd•C.1dium 46559
X Cr.Chromium 46S60
X Cu-Conn,r 1042
X f,.1ron IOl5
Ha· M<rcury 71900
X K-Potassium 46555
X MJ?· Mal!ncsium 927
X Mn-Mang.1ncsc 1055
X Na. Sodium 929
X Ni-Nick<!
X Pl>-Lead 465~
Sc.Selenium
X Zn...Zinc 46567
ua'I. O12,1nochlorinc l'cslicidcs
160 UJ?IL O12anoohosphorvs Pesticides
ua/L Nitro11cn Pesticides
usi/L
19 mg/L Acid Herbicides
usi/L
25U U!1 L Semivol;,tilcs
6.3 ua.'L TP!l.Dits<I RanJlC
sou ug/1.
ugtL Vol.!tilc Or~nics (VOA boUlc)
2.6 mitL
4.0 mg.'L TPH-Gl\501inc RanJ?•
IOU U!\ "I_ Tl'll-llTEX Ga.,olinc RanJlc
9.8 mJ1/L
IO U og/L
IOU UR/L
ug/L
53 ugil
IG098Sx1,
June 29, 2001
Growidwater Section -UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh. NC 27699 -1636
Reference No. WIO300051 issued to Ronald L. Holden
Enclosed are the Well Construction Record and a plumbing diagram for the final
approach to resolving problems of water capacity for my water to air, geothermal heat
pump.
A test was conducted to see if there was adequate volume of water in the original well to
allow the discharge from the heat pump to be injected directly into this well It was close
to being adequate, but not on the coldest days of winter. The well started to cool down
after a run of one hour and the unit tripped off on its freeze protection circuit.
The addition of a second well, located twelve feet apart has solved the thermal problem at
least on the cooling mode. It is assumed that the heating mode will work with the same
success.
Care was taken to avo id any contamination to water lines or crossing of any lines. Slicing
of lines occurred only at a well container box to avoid any possible leak that could
possibly draw any contaminated ground water into the system plumbing circuit.
Susie Caldwell of the Mooresville Ground Water Dept. has taken several samples for
testing for contaminates.
I hope that this report is adequate for conforming to the permit granted to me for the
addition of an injection well.
The driller diagram of the lot layout is not quite accurate as shown on my sketch
enclosed.
Sincerely,
~::L 7fJI,...
Ronald L. Holden
0
'-r::: r
I
N ...,,
:J:
c..:,
N
'11 '
JUN -26-2001 04:01 PM B&K WELLDRILLING _IHC 70 ◄ 8~2 4705 P .01
rionh Caro/In•· Oepanrntnt ol !tw1ronrr,•"• •Mt N•tur•J RHOLJICH. Dlvi&ion or w1111 Cullity • GruuncJwa111 , Si1c1ion
1~6 Mall S1rvlc1 C•n111r, R1l1lgh, N.C, 2761KM6!1&-Pno"-111,0) 733-3221
WELL CONSTRUCTION RECORD WEl,,L CONTRACTOR:
WILi. CONTRACTOR CERTIFICATION #: --:~.U.~~---~
STATI! WILL CONS'fAUCTION PERMIT#:,
WELL US! (en~ck Appllnlll• Ila•): f\esldentlal ~ .-111.1nlcipal □ Industrial □
Reeova,y □ Heat Pump Waler Injection~ Otner O If Otl'\er, LISI Uao:
Agricultural 0 Monllorlng C
:? . WELL LOCATIO ' (Show ak•_teh of lhll locution below) ' Ye dill
· -Co11nty: ---'-'-'::;:..,=-'-"-="'------
DRILLING l.OG OEPTH
3.
4 . 0AT~1~~;~i:;O (,! ,01 orra•
S. TOTAi. OEPTH ~t .... i:-.5 __ _
6 , CUTTINGS·dOu.ECTED YES O NOIY'
7. DOES WELL Al!PLACE EXISTING WELL? YESi NO~
8. STATIC \i,'ATER LEVe:L Below Top of 0Hlng; _ . FT,
12 ' (Ult ••• I Above Top C.aing)
9 , TOP OF CASING IS __,~CJ,..___ FT. Abov~ Land Surface•
•Top ol ·••IIIQ .. lffllNl•d allot MIOW '·"d .u,,.ff te11111l1H I Yll'tll\O• In 1aeor•
11enoe wilt• 11A f'CAC IC ,p ~
Fram l'o
------·---
,o. YlcLD (gpm): -L. MET~f~F TEST Open'oJM
11 . WAT!:R ZONES (depth):, ___ 5 __________________ _
12. CHLOFUNAllON: Typl;) (1 la•t-r-,
13 . CASING:
Amount /¥1
WIJA TIIICkMS.
() Oepm u I 9"f}''Y OtwV,.t, ~~J'i&'
FtOffl ---To_::IJ._Ft.U!/,JI,....... ~
From To-Ft .. ---
FtQm---To---Fl,,---
l4. GROUT:
Cep~ M ,terlel
From .D_ To ~F1.,"2otia'f«A-I
From ___ Tc ___ Ft. __________ _
15. SCREeN:
k.Peplh".) ¥ Diameter Slot Size
From Jf,JC._ To~ Fl -In. -'"·----
~•terial
II addllional 1pacs is needlld IAII Dacllol lonn -------------------··
LOCATION §t<ETQ1
(Show dirRtlon Ind dletano, ltOffl ., IHll lwo s,.,.
Roads, or 01h11, map relartru:tt pol111f I
6 wl ,, ,,
t ~l::/,7? t"ftnUJ
From _To_ Fl.-In. -In.----1 1),-,'t:_
From-TO-Fl.-In ,-'"·----r
Hi . SANOJGRAVEL PACK: /4
Depth 5'1.e Material ~ h
;;:: _-__ ~~::::;!:::::: ~
,1. REMARKS: __________________ _.;.. ____ L~--------
I DO HEAEBY CEATtFV THAT THIS WELL W/Ji CON9TFIUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION 5TAN0AROS, ANO THAT A r>Y F THIS RE OAD HAS B N PAOVIOEO TO TW! WELL. OWN!A.
FOR OFFICE use ONL y , .. )G-o/
S10NATUAE OF ftEFISON CTING THE WEU
Submit orlgll'lll lo Dlvlllon of Wate, QliIU1y, Oll>vnclw11er !leclk>11 within 30 d.iya
Serial No, OW·I Alilf, 1:2119
L. __ r!
t-:#{i;t,, . ·-
1.~~-J .. (N_.'!~(II)
(
h-~,>S(:: __ .,,~ '-~-
·1
'.,.
,..fa e o L'L/:!tf"l.~-I)~(' r
I I I I ......, -. .
-I -· ~ ,_I
I.. I
' I I .l . ::-
;·, A"·-
M;l0--....--' -;_ ~~
;Dq/t'J,.IISlf __.
' •-· ,..·,..,.,,.-• ••·• \, •••.• ,' •· •I, •• __ .,.,_ .. :._
fl&.~R ; . .
',.,_ -. ·--····-.. -~-...... ' ........ : ._ .. , :~ ......
-----
0 1~r~T10M
wtl-L
._p '" '"'?
North Caroll. _ Department of Environment and N-_ -'ral Resources
Division of Water Quality -Groundwater Section
INJECTION FACILITY INSPEC TION REPORT -FORM B
INJECTION WELL PE RMIT NO. WI OS O O O 51
NAME OF OWNER 72,," v,.a,\,.d /.., Ho L l e.n
.
ADDRESS OF OWNER I ~ 4 1 0,L l Q;1.k , ~r I ve.., , M1t>o v-e..s v', tl e u C
(Street/ road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable) !oMktf ,;, mzi<ar
~ ' '"1= 1 :f ~Ult , , ~
(Street/ road or lot and subdiv ision, county, town, if different tha n owners address, plus description of location on site)
Potential pollut ion source J!r.J.~ <-,_,_rJ~-m l ,:x Distance from well-~~ ~"
Potent ial pollution sourc e • :, Distance from w ell --------------
Pote ntial polluti on source D istance from well ---------------
Minimum di stance of well from p ro perty boW1dary R,:-,;.J,,,
Quality of drainage at site ~ Flooding potential of site 1-<r>,J
. (good,adequate,poorJ 11 , 1 (high,moderate,low)
kA-i---1~ l o 5 Q -:, 't D'-1 L ol")C)l'"t11-cdG ! Bt) Q 5 s ' IS''
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential p ollution sources, roads, approximate scale, and
north arrow.) ~t:, 1 -~~ /
c:J ' -I
J>rl ~ ---
ffj{
~ I M ~./-. ,-..,,.I e,u,-1,...
DE SCRIBE INJECTION SYSTEM '(vertical c fo st loop, uncased borehole or cased water well; separate source well and
injectio , well; ~mbination source and injection well; or other description as a.pplicable;
.b, ..:J.t 1.-. )Ji , -uJ ' .. ~#Md WS /4 ' I :
INJECTION FACILr·-y INSPECTION REPO1 'f -FORM B (CONTINUED)
WELL CONSTRUCTION
Date constructed It:, -dlo • ~oo /
Drilling contractor: Name t,l, 1'...,_ JI r,;i -6 cl /( W«.,t,J 1>~1,:'6. :Z,i.,C.,
Address / ~ x" m+-. />< v rr1 e 1-cc r 1',lt,0 r-e.s "u f 1?-tJ c t?< i' I 17
Certification number ____ ..;;.,..· -'2"'--""-t/'--q _____ _
Total depth of well / ~ Total depth of source well ______ _
(if applicable)
Inspection point
Casing
Grout
Depth
Diameter
Height (A.L.S.)
Depth
Screens
Depth(s)
Length(s)
I.D. Plate
Static water level
Well yield
Enclosure
Enclosure floor
(concrete)
Sampling port
(labeled)
Measurement Meets minimum standards Comments
Yes No
7 0 ii
b ,, ~
/II '' ~
V
/II}
✓
'H)
V
V
.
Water tight pipe entry
Well enclosure entry
Vent I.A I i if I n s :h,. ti
Functioning of heat pump system (Detenninefrom the owner if heat pump functions properly.)
./ t
INSPECTOR ,JJ A;, &. ld},.A'd,Ji
WITNESS j}\A . J:b.-¼n .
Office m-1Lo
Address /~ t/,~ (2,.4 ~
WITNESS Address --------------------------March 1998
Name Date Initials Typ e of Permit/Comments
-
Mark Pritz! 1..2-r-Jat µp,,... Heat Pump_/ Remediation Othe r -Meliktu Fanuel 1,l?. rni bm )t;1,.,
Debra Watts '2--,J / dl 0ovJ
DMSION OF WATER QUAL_ITY
GROUNDWATER SECTION
February 12, 2001
MEMORANDUM
To: Matt Heller, L.G., Goundwater Supervisor
Groundwater Section
Mooresville Regional Office
From: Mark Pritzl f1{J.. [e-mail]
Hydrogeologica) Technician II
UICGroup
Groundwater Section
Raleigh ·central Office
Re: Issuance of a Open-Loop G~othermal Injection Well System (Type SA 7):
Permit Number WI03000Sl to operate a well for the injection of a open-loop
ground-source heat pump syste m has been issued to Ronald L. Holden , in Mooresville, North
Carolina.
1. Please inspect the injection well site to verify that the location and construction plans
submitted in the application are accurate and the NCAC Title 15A 2C .0200 standards are
being complied with, using the enclosed lhjection Facility Inspection Report (form B) as
appropriate.
2. Collect samples from the influent and effluent sampling ports and submit the results to
the CO-UIC.
You are requested to return the completed Injection Facility lnspectfon: Report (fonn B) to
the CO-UIC by March 31, 2001 . If the inspection can not be accomplished by this date,
please inform the CO-UIC. The UIC group greatl y appreciates Susie Caldwell's assistance
with this review . If you have any questions regarding this review or the UIC program, please
contact me at [phone] or MeliktuFanuel at (9 19 ) 715-6165.
cc: CO-U IC F iles
Enc losure s
Ronald L. Holden
124 Tall Oak Drive
Mooresville, NC 28117
Dear Mr. Holden:
Michael F. Easley
Governor
William G. Ross Jr., Secretary
Department of Environment and Natural Resources
February 9; 2001
Kerr T. Stevens
Div.lslon of Water Quality
In accordance with your application dated January 11, 2001, we are forwarding Permit No.
WI030005 l for the construction and operation of a geothermal beat pump injection system at
124 Tall Oak Drive, Mooresville, North Carolina, in I redell County. Water samples will be
taken at the influent and effluent sampling ports of this geothermal heat pump system after
construction is complete. Please note, if these sample results exceed groundwater quality
standards, it is the well owner's responsibility to take corrective action as stated in Title ISA
Subcbapter 2C, Section .0206.
This permit shall be effective from the date of issuance until February 28, 2006, and shall be subject
to the conditions and limitations stated there in. In accordance with NCAC Title 15A, Subchapter
2C, Section .0213(h), the well owner is responsible for submitting a record of well construction
within 30 days of completion. The well construction data for every well constructed for this project
should be submitted on the GW-1 form and this form is enclosed for your convenience.
If you have any questions regarding your permit please feel free to contact me at (919) 7 15-6166
or Meliktu F anuel at [phone].
cc: CO-UIC Files
MRO-UIC Files
Enclosures
Customer Service
1 eoo e23-n4e
Sincerely,
ft~~
Mark Pritzl
Hydrogeological Technician 11
Underground Injection Control Program
Division of Water Quality / Groundwater Sedion
1636 Mall Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: http://www.gw.ehnr.state.nc.us
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
Ronald L . Holden
FOR THE CONSTRUCTION AND OPERATION OF A TYPE SA 7 INJECTION WELL,
defined in Title ISA North Carolina Administrative Code 2C .0209(e)(3)(A), which will be used
for the injection of heat pump effluent. This system is located at 124 Tall Oak Drive,
Mooresville, North Carolina, in Iredell County, and will be constructed and operated in
accordance with the application dated January 11, 2001, and in conformity with the
specifications and supporting data submitted, all of which are filed with the Department of
Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation 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 pennit shall be effective, unless revoked, from the date of its issuance until February 28,
2006, and shall be subject to the specified conditions and limitations set forth in Parts I through
X hereof.
~ Permit issued this the \ C day of ~t.VJ'(U..C-la , 2001.
Ted L. Bush, Jr., Assistant Chi ef
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. Wl030005 L PAGE 1 OF 6
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Pennittee must comply with all conditions of this pennit 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 pennit 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 s urface
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 reas onable protection against damage during
construction and use.
7 . Each injection well shall have permanently affixed an identification plate.
8 . A completed Well Construction Record (Form GW-1) must be submitted for each
injection well, to the Division of Water Quality (Division), within 30 days of completion
of well construction.
PART Il -WELL CONSTRUCTION SPECIAL CONDITIONS
,<.J
At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall
notify the Groundwater Section-Underground Injection Control (UIC), Central Office
staff, telephone number'[phone].
PART m-OPERATION AND USE GENERAL CONDmONS
1. This permit is effect ive only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
Perm it No. WI03000 51 PAGE 2 OF 6
2. This pennit is not tran s ferable 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 t here is a name change of the Pennittee, a formal pennit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Pennittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances which may be
imposed by other local, state, and federal agencies which have jurisdiction. Furthermore,
the issuance of this pennit does not imply that all regulatory requirements have been met.
PARTIV-PERFOR1'1.ANCESTANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater which will render it unsatisfactory for normal use. In
the event that the facility fails to perfonn satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Pennittee 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 Pennittee shall be required to comply with the tenns and conditions of this pennit
ev.en if compliance requires a reduction or elimination of the pennitted activity.
3. The issuance of this permit shall not relieve the Pennittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
•J
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or
activity not specifically authorized by the permit.
3. At least forty-eight ( 48) hours prior to the initiation of the operation of the facility for
injection, .the Permittee must notify by telephone the Groundwater Section-Underground
Injection Control (UIC), Central Office staff, telephone nwnber [phone].
Notification is required so that Division staff can inspect or otherwise review the injection
facility and determine if it is in compliance with pennit conditions.
Pennit No. WI030005 l PAGE3 OF 6
PART VI -INSPECTIONS
I. 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 detennining
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 groundwater1
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 VIl -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 shaU be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Mooresville Regional Office, telephone number (704)
663-1699, any of the following :
(A) Any occurrence at the injection facility which results in any unusual
operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the faci lity
incapable of proper injection operations. such as mechanica l or electrical
• y failures.
3. Where the Pennittee becomes aware of an omission of any relevant facts in a pennit
application, or of any incorrect infonnation 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 Perrnittee shall
take such immediate action as may be required by the Director.
Permit No. W1030005 l PAGE40F6
PART VIII -PERMIT RENEW AL
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 Pennittee sha1l 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 Pennittee must
instaH a sanitary seal. If a well is not to be used for any purpose that well must be
pennan~ntly abandoned according to 15A NCAC 2C .0213(h)(l ), 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)
(B)
(C)
(D)
(E)
(F)
Permit No. Wl030005 l
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.
The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
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.
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. A)
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.
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,
PAGE 5 OF 6
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion
of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Groundwater Section-VIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X -OPERATION AND USE SPECIAL CONDITIONS
Water samples will be taken at the influent and effluent sampling ports from the
geothermal heat pump system after construction is complete. If the sample results reveal
violatio-n(s) of groundwater standards, it is the well owner's responsibility to take
corrective action as stated in Title lSA North Carolina Administrative Code 2C .0206. In
addition, the well owner shall take imme.diate actions including those actions that may be
required by the Division of Water Quality such as repair, modification, or abandonment of
the injection facility.
Permit No. WI030005 l PAGE60F6
MEMORANDUM
TO:
FROM:
SUBJECT:
DMSIQN OF WATER QUALITY
GROUNDWATER SECTION
February 2 , 2001
MarkPritzl
UIC Section
Groundwater, Parker Lincoln
Susie Caldwell r
Ronald Holden
UIC Permit Application
C>
"Tl ,.,.,
0::,
• C/1
Attached is Preconstruction Injection Facility Inspection Report -Form A for the Ronald
Holden residence, 124 Tall Oajc Drive, Mooresville, NC.
Please call if any questions.
Page 1 of 2
North Carolina Department of Environment and Natura) Resources
Division of Water Quality
Groundwater Section
PRECONSTRUCTION INJECTION FACILIT Y INSPECTION
REPORT-FORM A
INJECTION WELL PERMIT NO. WI ------DATE t -o l-o I
NAME OF OWNER f?o n ald Hr le f ~
ADDRESS OF OWNER I ~ ·/ l 0., tf Q=ttc. :Dr• 1,-e...
Maore".Vt 11 € /JC
(Street/ road or lot and Stuidivision, county, town)
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable) ____ _
1 ~~ 1 Mi c ~'"~ ~01..Lk Dc. ~~ u ·1 -°" : ,~'-' .J.,. ,., .c., > ~ ~ J 0 -
' > ., /, .. J.. _-. ~ -.. ,., • V .J
...;;-~ r, ~ <a ,-'.o;,... r.J j...L '-" &" ru~ ~I. "'?'?z ·J./1.,: r,,.♦Y -
7
(Street! road or lot and suddivision , county, to'H'.71, if differen t than owner's address, plus description of location on site)
Potential pollution source _-i------''l.'"--4.,-----'h'----r1"-'------Distance from well _5:_,f'---_
Potential pollution source Distance from well ___ _
Potential pollution source _________ Distance from well ___ _
' ,.
Minimum distance of proposed well from property bo~dary ~ -~ ~ ~~ _
Quality of drainage at site t'J,r-nL Flooding potential of site J 4 -w ~ · ~ ~ ~
(goo.;-1,adequate,poor) (high,moderate,low) ~ • '1\-a.u,i ~ -
·~~w<-1.1-
DRA W SKETCH OF SITE
(Show property boundaries, buildings, wells, potential pollution s ources, roads. approximate s cale. and north arrow.)
----------
Cl
March 9 8
Page2 of 2
PREC ONSTRUCTION INJECTION FACILIT Y
INSPEC TION REPORT -FORM A (cont.)
COMMENTS
U)u.L F ~ 1 I~ ,, , • -,:,,_,µ u•/ v" • 1--I Vl..(. "1 tlL ~ , )., tP -d
0
INSPECTOR -~ c!u.~
Office /.)? }Lo
WITNESS l-;J1A,. J{t') I -kl, "'}
Address .
I A t./ dal( {)aK ~ ~ Ne, x /II ?
WITNESS -------------Address
March98
MEMORANDUM
DMSION OF WATER QUALITY
GROUNDWATER SECTION
January 18, 2001
To: Matt Heller, L.G.; Groundwater Supervisor
Groundwater Section
Mooresville Regional Office
From: Mark Pritz} fl.f. [e-mail]
Hydrogeologica1 Technician II
UIC Group
Groundwater Section, Central Office
Re: Request review of a new injection well permit application for the operation of an open loop
geothermal heat pump system.
The CO-UIC has received an application by Mr. Ronald L . Hol den for a new permit for the
construction and operation of an injection well located at 124 Tall Oak Drive, Mooresville, NC.
The proposed injection well will be part of an open loop geothermal heat pump system, therefore
a type SA 7 well
1. Please. review the application and submit any comments to CO-UIC. Retain the
application for your UIC file.
z. P lease inspect t he proposed injection well site to verify that the location and construction
plans submitted in the application are accurate and that the NCAC Title ISA 2C.0200
standards are being complied with, using the enclosed Preconstruction Injection Faciliry
Inspection Report-Form (A) as appropriate.
Please return any comments immediately upon application review. You are requested to return the
completed Preconstruction Injection Facility Inspection Report-Fonn (A) to the CO-DIC by
February 15, 2001. If the inspection can not be accomplished by this date, please inform the CO-
UIC. The UIC Group appreciates your assistance in the review and evaluation of this permit
application. Please contact me if you have any questions or comments at (919) 715 -6166 or
Meliktu Fanuel at (9 19) 715-6165.
cc: UIC Files
Enclosures
WAJ".
i ? > ---I o\':;:::;:::::~"('
Mr. Ronald L. Holden
124 Tall Oak Drive
Moor:esville, NC 28117
Dear Mr. Holden:
Michael F. Easley
Governor
Sherri Evans-Stanton, Acting Secretary
Department of Environment and Natural Resources
January 18, 2001
Kerr T. Stevens
Division of Water Quality
Your application for a permit to use a well for the injection of geothermal beat pump
effluent has been received and is under review. A member of the Groundwater Section's
Mooresville Regional Office staff will be contacting you to arrange an inspection of the injection
well and collect water samples as part of the review.
If you have any questions regarding the permit or injection well rules please contact me
at [phone] or Meliktu Fanuel at [phone].
cc: CO-UIC Files
MRO-UIC Files
Awo,A ~-NCDENR
Customer Service
1 800 623-7748
Sincerely,
Mark Pritzl
Hydrogeological Technician Il
Underground Injection Control Program
Division of Water Quality / Groundwater Section
1S36 Mall Service Center Raleigh, NC 27699-1636
Phone; [phone] Fax: [phone] Internet: http://www.gw,ehnr.state.nc.us
I
I
Jan 10 ·01 14:59 P.02/05
., . N9R~~~Llr,Q .
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR ·USE A
WE~L(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type 5A7 and SQM Welb
In Accordance with the provt&tons of NCAC Title 15A: 02C.0200
Complete applkat{onand mall to adchD on the ~ack page.
TO: DIRECTOR. NORffl CAROLINA DMSION OF WATER QUALITY
DATE:. ':J"AJ\I , II , 20~
A. SYSTEM .CLAS$IFICATJON Please--check column which matches proposed system.
B.
(l) V Type 5A7 wellUnJect water med to provide heafinB or coolba8 for structwes. 1 ' ' •
(2) Type SQM wells contain a subsurface system of continuous piping, that k
tsolaled from the environment end circulates a fluid other than potable water.
This fncludes systems that drculate additives such as antlfreezes and/or conosion ~
inbJbltors. c_ ••
x-z
(3) Type SQW wells con• a subsorfaoe $)'SI.em of amdnuous .piptng, that Is -
isolated from the envJtonJPent and only cin:ulates potable water. If you seletted m
t1111 well type, then mng,1,~ fqnp GW-57 CL NOIJ/leatloa Ol lnttmt To -o
Comtruct A ClomJ.Loop GeolhenuJ. w.-,. Only /qj«:tloa Well SJSNm. ~
PERMIT APPLICANT
Name: . R o III A.&..D \.. • J4 o ._ r> ftAJ
Addre~:· / :i. ':I niu.a.. 011.I:: 7>~, VE
City: IJj.:>c,,~ cS v 11.,e.-State:~ Zip Code:.2S' 117 County: J:,a,.a_,__t-
Td~Jione: 7DY-t ,~-Js,o
C. ·PROPERTY OWNER (if different from applicant)
Name:; ___ S_A.... __ E _______________ _
Addm.1: _________________ _
City: _: ______ Sate:_ Zip Code: __ Coun1y: ___ _
Teleplione: ______ _
D. STAT:US OF APPLICANT
Prtvat!!: L Federal: _ Commercbl: _
State'::_:_ Munldpal:_ Nallw American Lands:_
CW• 5_7 HP (Ju; !,000) Page 1 of 4
Jan 10 '01 15 :00 P.03105
E. FACll.iTY (SITE) DATA
(Fill out ONLY if the Status of Owner ts Federal, State, Mwddpal or CommerdaJ).
Name of Businen or Facility: _______________ _
Address: _____________________ _
City: ---,-------ZJp Code: ___ County: _____ _
Telephone:· ________ Contact Person: _______ _
P. HEAT PUMP CONTRACTOR DATA ,Jl,g,.r 'Pll,,,.,,.P ✓'II/ ~/!W:.VI c.r 0 ~ J 'r' ..... •
Name : . t-11".r q ~1A/L 11 A/4
G.
H.
L
Address; '7.J 3 2 C)J.'D ~7~r,t:sV/{.u! Al\.
City: CJJ~1.g rrE Zip Code: • County: _Jfl,_ec._R_, ___ _
Telephone:,~ 7M;-5',S'-6 if~ I Contact Person : _______ _
INJECTI~ PROCEDl,/RE {Briefly descdbe how the mjtttJon well(s) will be used.)
WA n,? F-Ra,., A-S'1)hv o J1tC o wa'-1s v s.;-o ,.., "~ ~ 0, .... ~ T1< 1J, ri"'O
A-,Jo e.-7.,..,d4'-"Y E"~ ,4 &,J.<1"11:1('7» A-11~ ~ P .. -.P . Wts~ (7j>t.t"/-,-.e) '.
I.S TO D~ 1?~~-.o 7b "" .2~ NO~· '?u>"IP Wd-c..L, ~,~ ~>.-.c--. /~ -✓~M/6"1 ,r-,-. -l1t ;• $Jr>,
. SUt1'1.Y' t.v &'t.C. .
WELL ()SE WIU the lnjectfon well(s) also be used~ the supply well(s) for the folloWlng? ·
. / S"e-~ J#:S#AI..,.
(1) ~ Injection operation? YES __.v__ NO --.-
(2) Personal c:on5'1mpUon? YES ___ NO ~
CONST~\.!CTION DATA (check one)
EXISTING WELL being proposed for use as an injedion well. Provide tha data in
(1) through (7) below to the best of your knowledge. Attach a copy of Form GW•
I (Well Comtruction Record) If avaJJable.
PROPOSED WELL to be constructed for use as an iqjection well. Provfde the
data in (1) through (7) below as PROPOSED construction speciftcatlons. Submit
Form GW-1 after construction.
(1) Well DdllJng Contractor's Name: "S f K W i2 Lt... S~v , ~
NC Contractor CertlftcaUon number: ~(_¥_5'_.I.,__ _____ _
(2) Date to M! constructed: "-Fm J O O,' Nmnber or bodngs: _,._I __
Approximate depth of each bonog (feet}: < 1!'75 ]?4,-1J 1 90 I
(3) W~l casing: Is the well(s) cased?
(a) YES ./ ltyes, then provide the casing infonnatlon below .
Type: Galvanized steel __ . Black steel_·_ Plasd~ Other (specify) _____ _
Cawtig depth: From o ~ >/ () ' ft. (reference ro land surface)
Casirig it~tends aboveground , , Inches
(b) NO -.-
GW-57ltP Oao, 20IO) Pa,e2 of,
Jan 10 '01 15:00
(4) •C,out .(materiahumnmding well casing and/or piping):
(a) Grout type: Cemtnl__i. Bentonite _ Other (specify) ____ _
(b) Grouted surfatt and grout depth (fffemtce to land $urface):
_ around closed loop piping: liotn __ 10 __ (~t) .
. l ~ around well casJng; from_ to __ (feet).
(5) S~eeN·(fw Type $A7 wells)
(a) Depth : From_ lo _feet below ground surface.
(6) N~C. Slate luguladom (Tide 15A NCAC 2C .0200) require the pennittee to ~ke provisions
fot monitoring wellhead processes. A faucet on both lnftuent (fl~ mering heat ~p) and
effluent (fluid being. iqJected Into the well) lines is required. Will there be a faucet on:
(a) the influent Une? yes_L. no__ (b) the effluent line? yes__L no_
(7) SOURCE WEU.. CONSTRUCTION INFORMATION Of diffettnt-from tnjectJon well).
Atta.di a copy of Form CW-1 (Well Comarucdon Record). If Fonn GW-1 iS not avallab)e.-
provlde the data in part K (1) of this applicadon f onn to the best of your knowledge.
NOTE: THE WEU.l>RlWNG CON"iRAcTOR CAN sum.v THI! OATA fOR EITffSR EXISTING OR
PROPOSED WSW IF nus INFORMATION IS UNAV411.ABU!. BY OlHBR MEANS.
,. .
J. PROPOSED OPERATING J?ATA (for Type 5A7 weDs)
{I) Jajectlon rate: Average (daily) 7 gallons per minute (gpm). Iii} ~)l ~ ~
on -"""'"}g (2) Injection Volume: Average (daily) S:,t>.•u gaUom per day (gpd). 50?, :,., ...• S<':'1'-r
( v,.,v u, w 1!4~..:~ n_1. 0 · ) /IA ;:tt-tt -,,,,.., )11 3} lnjecttonPre~ure: .. 1 Average (daily) __ poundlilsquare in\;n (psi . acr ~A,loi/
(4) ~jecdon Temperaaure: Average (Janu.uy) "~ ° F. Average Ouly) 6 3 ° F: l,3'1/, P¥c> r/'f,
K. INJECTION FLUID DATA
(0 Fluid source (for Type SA7.wells) If underground. from whit depth, formation and type of
rock/sediment unlt will Ille fluid be drawn (e.g., grenile, limestone; sand. etc:.).
Depth: / :1'0 1 Formation:~ ~edimeot unit: G fZ.~ I~
(Z) Chemical Analysis of Source Pluid (for Type SQM wells)
_Provide a complete Usling of aU chemials added to «he ckculadng heat transfer fluid:
L INJECTION-RE.ATHD EQUIP~NT
'' Attach • diagram sboWing the engbieerlng Jayout of the bljeedon e:qutpment and exterior plWIW'tublng
usodatecl with the U\fection operalJon. The manufacturer's brochure may ptovtde supp_lem~
tnfotmation.
GW-57 JIP 0¥1\ 24>00) Pagt3 oft
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Jan 10 '01 15:01 P.C6/05
WCAlfION OP WEU(S) Adi.ch two maps,
(1) Include a site map (can be ~wn)' sbowJng: bulhtlno. property lines, surface water bodies,
po«endal sources of groundwater .conwnlna.tton and the orlentatJon of and distances ~n
the propost!d well(s) and uy existing well(s} or wai.te disposal fadlides such as septic tanks or
dtaln field., locat~ Withtn 1000 feet of. the geottLermal beat pump well system. Label all
features dearly and include a nc,rth arrow.
(2) Include a topogtapbic map of die area extending Ont! mile from the property boundaries and
tndkate lhe facility's locadon and the map name.
P.ERMff LIST: Attacb a list of all peimlts or comtruclion approvals that are related to the site.
Exampl~ include:
(l) .. Hmrdous Waste Maoagemerat program pe1'.IDils under RCRA
(i) ;NC DMslon of Watts Quality Non,Discharge permllu
(3) Sewage Treatment and Dtsposal Permits
CERTIFICATION
·1 .hereby ceitlfy, under penalty of law, that J have personally uamined and am familiar witb the
information submittfd in ~ document and aJJ attachmenfts thereto and that. based on my inquiry of
rhose Individuals immedlateJy responsible for obtaining said lnformation, l believe that the Information
Js ttUe~ accurate and mmpJe!_~. J am aware that there are sitJDlflcant penalties, tncludJng the po.,slblllty
of fines ,■nd imprisonment, Jor submlUlng false tnformatic1n. I agree to construct, operate, maintain,
repair; and if applicable. ,~don the tq)ectlou well and all related appurtenances lo accordance With
• the app~ed·specificatloM _and condjttom of the Permit,"
.z-yc,;~;;!.7.£~
(Signature of Well Owner or Authorized Age.nt)
If auth(Jfta!d ,gw,t IS aa/118 m WaJf of lbt w,/1 Olffltt,
pie~ supply a I~ ~r,,t!d by ,be Olf'Jff lUthorizJng the above agtftt.
F. CONS.ENT OF PROPERTY OWNER (Owner mean., any 1person who holds the fee or other · property
rights In the well being coMtructed. A well f s real prc,perty and lts construction cm 1-nd rests
ownership In the landowner in the absence of contrary agnmment in Writing.)
H lhe' property is owned by someone other than the applia111t. the property owner hettby CQnst.nts to
allow the applicant to con~ct each tnjecdon well is outl:lned in this application and that It shall be
the responsibility of the applicant to ensure that the lnjecdon well(s) conforms to tilt Well
Construction Standards (fi~e 15A NCAC 2C .0200)
" ,.
GW-57 HP Oa .. 2000)
(S1gnature Of Pro1perty Owner Jf Different From AppUcant)
Please return two copies of the completed ApJplicatlon package to:
UICProgram
Groundwater Section
North Carolina DENR• D,WQ
163& Mail Service Centler
Raleigh. NC 27699-1638
Telephone (919) 71S.6UiS
Page4 of4
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JUL-31-2808 09:46 AM B&K WELLDRJLLIHG-IHC 104 892 470:5
No"'1 Carolina• 0tpa11m11ntol !nvlronmtnl ar,:S Natur.il F\esourctt • OMsion ol Wa11r 01111i1Y • G101.1ndw1t1r 61e110 11
1630 Ma~ s,n11c1 c,m1, • R.t ltlgn, N.C, 21aea-,s39-F'hon1 (!HGJ 733.3221
P.01
WELL CONSTRUCTION RECORD WSll. CONTRACTOR; B ~ K w,p ·:3~;~ Tnc.•
Wl!&.LCONTRACTOft C!ATIFICATION #: __ {
STATI! Wl!LL CONSTRUCTION PERMIT#:
1. WELi. USE (Cheak Applli:abte 1110•1: Rt■lderitJaJS, Munlclp~I □ lndu11trl al □
Flecove'.X O Heal Pump Water lriJeclion O Ottitr O If Other, Lisi Use:
Agricullural □ Monitoring D
2 . WELL LOCATION: (Show sketch or the loeallon below) :c 1 //
Nwara,1 Town· dmrr.stJ , I ft co..,,ny: £r,:qtc _ ·
J,:li/ /411 /Jal Dr--µeJ,nc.c.l(:oi.v ("' __,;vc: OWAl4ffl--~ "'"' Jfo\..l>~
(Roa'2 Nam• ~ Numl>ef*, c_,-,1\Uy 11/ 6~bjld$ion and~ -DRILLING LOG OEPTH
3 . OWNEA .,V-,,ee,'· •1 «IV..J Fr0"1 To l'Offllalion l),uc/lpUOtl
Add(Vli$
Clly Of O'«ll SIAII ZID Coot
4. DATE OR11.lEO t/4,L, 9
5. TOTAL Dl!!PTH 194
6. CUTTINGS COI.LECTEO YES O NOIXJ
7. ooes WE:..L. AePLACE EXISTING WELL? YE-SO NOD.a
8 . STATIC WATE~ LF.VEl Beklw Top of Casi~: .!:f1L_ FT
/
/_ (Uae•••ll~vaTopolCaaing)
9 . TOP OF CASING JSfO I(\ FT. Abo110 I.and Surf~ce•
'TDp of u.s1151 \9r1911n■ted &I/or IJOlow Jeno a11r1ace ,.QllllrN ■ ~11111.nCe In a«.or-
o,nc• wllh 16A NC~C :ZCAOlll •1
10. YIELD (gprn); ~ McfHOD OF TEST {Jprn flbu)
11 . WATERZONES(dOl)lh): ____________ -~-------
12. CHLORINATION: Type ('/e,r-o.8
13, CASING:
Depth , l'.>1amettr
rflJrti-.... 0--To ~ Fl. _I, __
rrom To-FI .---
From ---To---Fl.---
14. G~OUT:
Deplh .....
Amount Jji/
Wail Thillflr1u•
or Wll_igh_1/Fl, Ct.rial ,,,,, ~
11 addnlonal 1paoe ls nettl.llld uae back ol tocrn
LOCATION St<ET,Ct:(
(sr,ow direction an(I dialance tror'tl .ii least two Stal~
Roads , or oll\er map rere,ence points}
,-t
INSPECTION CA
IREDELLCOUNTYDEPARTMENTOFPLANNIN
PHONE: [phone] & 704-878-5437 DAY O R NIGHT
PERMIT#: _....=-~--=--+--+-....,.... R: ..._~-=-----=---;.~--=
ADDRESS: _-1-.,#-','f-.r:r-rf---a-MC..... _,.~,--.-¼.--,-.,.lf-....._.,....~-.c..--..::.--"' __ _
IMPORTANT: This permit placard must be displayed on the premises in a co
this placard will result in refusal to make inspections.
GENERAL CONST.
i,edei nunliA'!~plCUOOI ;,_.:..-l=~'Ti-~-
·11t:::~·~~~:.---
P"--,1-~ -;.•· ' .:.;;,.,JI.~·~::-_!-;r--·t"'r.:~:-<·.· X;f~~ ... !
~iftif· -~ ~>~--. -; -
{
Framing
Wall Insulation
Final
ELECTRICAL
Slab
Underground
Rough ~~~;;~·,:;,,-.,~:,;,.: ~~1
.:-~·-:.·_,_;·-~ ··Br . . ._/ .,) ·• ,. . ·-, . . ·I ---··-··~ ~
Service Change
:11~~~:;~~~:-~1~~~·,>~·~
0. "I',
a,,...._' ~~~--:--"7" . --
Sewer/ Septic
1Ndlll
Dlle ---..:-~c.+-=-:,--
By _ _.:::s::,:e~--
Water Beater
Gas Pipe
Slab
Rough ;;;;~ ,."':.: ' .... ; . -~·
oa_·-i=,-~i--"it----
a,
Gas Pipe
Vent
Fire Place
------
: ,nal
t~·
< -
··-----, ...-------
~:_'j'c: It is u;.:.iwfu i ro eccl?$>~ 0r to pem1it the o.ccupancy -1f an) bt.:t -_ f ~ ·,pproved and a
:' ,.~fa:a;,~ of oc • .;_!>ancy h~: t-~en i~~:.:~,l It is the contractor'-rcsp on~ib il ' ': \l2·*~.;. lnspc-:tion
1JepartmeCit -:~-:erv -:,;ii the ng!1t :o rej t::~t .zny work_ c'.locealed pr·,,~ 1r ;ppr-.__ .; ,c ~~ense) o(~ny