WI0300380_GEO THERMAL_20180726

ROY COOPER
GMfflOr
MICHAELS. REGAN
~
UNDA CULPEPPER
ltilntn Olr«IOI'
Gary G. & Susan D. Clark
8426 Catawba Cove Dr.
Belmont NC 28012
Re: Issuance of Injection Well Permit
Permit No. WI0300380
NORT~ CAROUNA
~IQuclllly
July 26, 2018
Geothermal Heating/Cooling Water Return Well
Gaston County
Dear Mr. and Mrs. Clark:
In accordance with your permit application received June 4, 2018, I am forwarding Permit No.
WI0300380 for the construction/operation of geothermal heating/cooling water return well(s) located
at the above referenced address. This permit shall be effective from date of issuance, until June 30,
2023, and shall be subject to the conditions and limitations stated therein.
Please Note:
• Within 30 days of injection well completion/operation, the Permittee shall contact the
Mooresville Regional Office Staff in order to have samples collected at the source well and
injection well. [15A NCAC 02C .021 l{k)]
• Records of well construction, repair, or abandonment shall be submitted within 30 days of
completion of such activities. Copies of such records shall be retained on-site and available for
inspection [15A NCAC 02C .0224(f)(2), (4)].
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to· its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Resources. If you have any questions regarding your permit or the Underground
Injection Control Program please call me at [phone].
~
North carolina Department of Environmental Quality I Division of Water Resources I AFOGW Section
512 North Salisbury Street I 1636 Mail Service Center I Raleigh, North carolina 27699-1636
919. 707 .9129
Best Regards,
Shristi Shrestha
Underground Injection Control {UIC)-Hydrogeologist
Division of Water Resources, NCDEQ
Water Quality Regional Operations Section
cc: Cory Basinger-Edward Watson, Mooresville Regional Office
Central Office File, WI0300380
Gaston County Environmental Health Department
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
. PERMIT FOR THE USE OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Gary G. & Susan D. Clark
FOR THE CONSTRUCTION/ OPERATION OF 1 GEOTHERMAL HEATING/COOLING WATER RETURN
WELL(S), defined in Title 15A North Carolina Administrative Code 02C .0224(a), which will be used for the
injection of heat pump effluent. The injection well(s) located at 8426 Catawba Cover Dr., Belmont, Gaston
County, NC 28012 will be constructed/operated in accordance with the application submitted June 4, 2018, and
conformity with the specifications and supporting data, all of which are filed with the Department of
Environmental Quality and are considered a part of this permit.
This permit is for construction/ operation of an injection well shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until June 30, 2023, and shall be
subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 26th day of July 2018.
For Linda Culpepper, Interim Director
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Pennit#WI0300380 UIC/5A7
ver. 11/15/2015
Page 1 of5
PART I-PERMIT GENERAL CONDITIONS
1. The Permittee shall comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is grounds
for enforcement action as provided for in N.C.G.S. 87-94
2. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data [15A NCAC 02C .021 l(a)].
3. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data [15A NCAC 02C .0211(1)].
4. This permit is not transferable without prior notice and approval. In the event there is a desire for the facility
to change ownership, or there is a name change of the Permittee, a formal permit amendment request must
be submitted, including any supporting materials as may be appropriate, at least 30 days prior to the date of
the change [15A NCAC 02C .021 l(q)].
5. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met [15A NCAC 02C .0203].
PART If-WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed in accordance
with the requirements of rule 15A NCAC 02C .0107 except as required in Item #2 below.
2. If a separate injection well is used then it shall also be constructed in accordance with the requirements of
rule 15A NCAC 02C .0107 except that the entire length of the casing shall be grouted in such a way that
there is no interconnection of aquifers or zones having differences in water quality that would result in
degradation of any aquifer or zone. For screened wells, grout shall be emplaced from the top of the gravel
pack to the land surface. For open-end wells, the casing shall be grouted from the bottom of the casing to
the land surface [15A NCAC 02C .0224(d)(2), (3)].
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing conditions.
[15A NCAC .0225(g)(8)].
4. The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [15A NCAC 02C .0224(d)(4)].
5. Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal as defined in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .0107(j)(2)].
Permit#WI0300380 UIC/5A7
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Page 2 of 5
7. A ~ompleted Well Construction Record (Form GW-1) shall be submitted as described in Part VI.5 of this
permit.
PART III-WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing each injection well, the Permittee shall notify the
Underground Injection Control (UIC) Central Office staff, telephone number 919-707-3662 and the
Mooresville Regional Office Staff, telephone number 704-663-1699. [15A NCAC 02C .021 l{k)].
2. Within 30 days of injection well completion/operation, the Pennittee shall contact the Mooresville Regional
Office Staff in order to have samples collected at the source well and injection well. [15A NCAC 02C
.021 l{k)]
PART IV -OPERATION AND USE CONDITIONS
1. The Pennittee shall comply •with the conditions of this permit and properly operate and maintain the
injection facility in compliance with the conditions of this permit and the rules of 15A NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C .021 lG)].
2. The issuance of this permit shall not relieve the Pennittee of the responsibility for damages to surface water
or groundwater resulting from the operation of this facility. In the event that the facility fails to perform
satisfactorily, including the creation of nuisance conditions or failure of the injection zone to adequately
assimilate the injected fluid, the Permittee shall talce immediate corrective actions that may be required,
such as the repair, modification, or abandonment of the injection facility [15A NCAC 02C .0206].
PART V -INSPECTIONS [15A NCAC 02C .021 l(k)]
1. Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation of credentials, enter and inspect any property, premises, or place on or related to the
injection facility at any reasonable time for ~he purpose ofd~teritiining compliance with this permit, may
inspect or copy any records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwater, surface water, or injection fluids.
2. DWR representatives shall have reasonable access for purposes of inspection, observation, and sampling
associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary samples of the injection facility's activities.
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on-site and available for inspection [ 15A NCAC
02C .0224(f)(2), (4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State and
compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
. 0224( f)( 1)].
Pennit#WI0300380 UIC/5A7
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Page 3 of 5
3. The Permittee shall report any monitoring or other information that indicates noncompliance with a specific
permit condition, that a contaminant may cause a violation of applicable groundwater quality standards, or
that a malfunction of the injection system may cause the injected fluids to migrate outside the approved
injection zone or area. As specified in rule 15A NCAC 02C .021 l(r), noncompliance notification shall be
as follows:
(A) Oral notification shall be given within 24 hours of the occurrence, or first knowledge of the
occurrence, to the Mooresville Regional Office, telephone number 704-663-1699.
(B) Written notification shall be made within five days of the occurrence and submitted to the addresses
in Item #5 below.
(C) The written notification shall contain a description of the noncompliance and its cause; the period of
noncompliance, including dates and times; if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and any steps taken or planned to reduce, eliminate, and
prevent reoccurrence of the noncompliance.
4. The Permittee shall record the number and location of the wells with the register of deeds in the county in
which the facility is located. [15A NCAC 02C .0224(f)(3)].
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
UIC Program Staff
Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Water Quality Regional Operations Section
DWR Mooresville Regional Office
610 East Center Ave.
Mooresville, NC 28115
PART VII-PERMIT RENEWAL [15A NCAC 02C .0224(c)]
As required by rule an application for permit renewal shall be made at least 120 days prior to the expiration
date of the permit. This permit condition does not apply if the Permittee chooses to discontinue operation
of the well for injection of effluent from the geothermal heating and cooling system associated with this
permit.
PART VIII-CHANGE OF WELL STATUS [15A NCAC 02C .0240]
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complying with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to rule
15A NCAC 02C .0l 13(b) in order to prevent the well from deteriorating and acting as a source or conduit
of contamination, which is prohibited by General Statute 87-88( c ).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well
seal that cannot be removed without the use of hand or power tools.
Pennit#WI0300380 UIC/5A7
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Page 4 of 5
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall permanently abandon that injection well in accordance with the procedures specified in 15A
NCAC 02C .0113(b), which include, but are not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected prior to sealing in ·accordance with rule 15A
NCAC 02C .0l l l(b)(l){A),(B), and (C).
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In those cases when a subsurface cavity has been created as a result of the injection
operations, each well shall be abandoned in such a manner that will prevent the movement
of fluids into or between underground sources of drinking water.
(F) The Pennittee shall submit a Well Abandonment Record (Forni GW-30) as specified in
15A NCAC 2C .0224(f)(4) within 30 days of completion of abandonment.
5. The written documentation required in Part VIII (4)(F) shall be submitted to the addresses specified in
Part VI.5 above.
Permit #WI0300380 UIC/5A7
ver. 11/15/2015
Page 5 of 5
Permit Number
Program Category
Ground Water
Permit Type
WI0300380
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Gary & Susan Clark SFR
Location Address
8426 Catawba Cove .Dr
Belmont
Owner
Owner Name
Gary
Dates/Events
NC
Orig Issue
7/26/2018
App Received
6/4/2018
Re g ulated Activities
Heat Pump Injection
Outfall
Waterbody Name
28012
Clark
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
7/27/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affillatlon
Major/Minor
Minor
Facility Contact Affillatlon
Owner Type
Individual
Owner Afflliatlon
Gary Clark
8426 Catawba Cove Dr
Belmont
Region
Mooresville
County
Gaston
NC
Issue
7/26/2018
Effective
7/26/2018
28012
Expiration
6/30/2023
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
6/6/18
7/23/18
Subbasln
Permit Number WI0300380
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facillty Name
Clark SFR
Location Address
8426 Catawba Cove Dr
Belmont
Owner
Owner Name
Gary
Dates/Events
NC
Orig Issue App Received
6/4/2018
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
28012
Clark
Draft Initiated
Scheduled
Issuance
Central Files: APS SWP
7/25/2018
Permit Tracking Slip
Status
In review
Version
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Gary Clark ·
8426 Catawba Cove Dr
Belmont
Region ·
Mooresville
County
Gaston
NC 28012
Public Notice Issue Effective Expiration
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
6/6/18
7/23/18
Subbasin
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 ? SA NCAt< �ZG .o " 4
GEOTHERMAL HEATING/COALING WATER RETURN WELLAS)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
X New Application Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages I and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page, Illegible Applications Will Be Returned As Incomplete.
DATE: May 30 .20_18_ PERMIT NO. €^!-103 G Q 6$ cleave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New WeIllPermit Application)
1. Current Use of Well
a. I wish to continue to use the well as ❑ Geothermal Well ❑ Drinking Water Supply Well
❑ Other Water Supply Use- Indicate use (i.e., irrigation, etc.)
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the We]I Abandonment
Record (GW-30).
❑ Yes, I wish to rescind the permit Fy��,�
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES ❑ NO.
If yes, indicate New Owner's contact information: F^atl^rr. .
Name(s)--
Mailing Address:
City: _Stater —Zip Code: County:
Day Teie No.: _ _Email Address.:
H. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence _X Business/Organization
Government: State Municipal County Federal
C. WELL OWNER(S)IPERMIT APPLICANT — For single family residences, list all persons listed on the
property deed. For all others, list name of businesslagency and name of person and title with delegated
authority to sign: Gary G. Clark and Susan. D Clark
Mailing Address: 8426 Catawba Cove Dr
City: Belmont State: NC Zip Code:28012 County: Gaston
Day Tele No.: 248-765-4007 Cell No.: 248-765-4007
EMAIL Address: 2eeclark59?d=ail.eom Fax No.:

D. WELL OPERA TOR (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=ail="=-=A-=.::d=dre=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): ______________ _
Same as mailing address
City: ___________ County ________ Zip Code: ___ _
F WELL DRil.,LER INFORMATION
Well Drilling Contractor's Name: __ Jam ______ es--=--A ..... D ___ ar ___ b__.y ___ J ____ r ______________ _
NC Well Drilling Contractor Certification No.: ___ 2""""'6'""""0-=6A'-=--______________ _
Company Name:James Darby Well Drilling
Contact Person: James A Darby Jr EMAIL Address: [e-mail]
Address: 2512 ZinkerRd. _______________________ _
City: Rock Hill Zip Code: 29732 State: SC County: _Y-=-=or==k'------
Office Tele No.: _803-329-2424 __ Cell No.: _803-415-1853 __ Fax No.:803-329-4935
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HV AC Contractor's Name: __ H~e..,....ym~an=-T=--=-C-=oxt~on=----------------
NC HVAC Contractor License No.: __ 3-=244 ............. 8 __________________ _
Company Name:CR Heating and Cooling
Contact Person: Heyman T Coxton {Trevor) EMAIL Address:[e-mail]
Address: 4241 Bookout Rd
City: Rock Hill Zip Code: 29730 State: ~County: ___ Y ___ or==k'-------
Office Tele No.: _803-984-4173_ Cell No.:_ 803-367-7760 ___ Fax No.:-=n/:=..;:a::...__ __ _
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES X NO ___ _
(2) Personal consumption? YES X NO ___ _
L WELL CONSTRUCTION REQUIREMENTS-As specified in 15A NCAC 02C .0224 (d ):
(1)
(2)
The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107 .
If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107 , except that:
(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:
____ *EXISTING WELLS 1 PROPOSED WELLS
*For existing wells. please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
( e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited/or sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107{0(8 )
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERA TING DATA -NOTE: This is a standing column well -all water pulled for geothermal use is returned
(1) Injection Rate: Average (daily) _2.S_gallons per minute (gpm). Estimate
(2) Injection Volume: Average (daily) _3600_ gallons per day (gpd). Estimate
(3) Injection Pressure: Average (daily) _O_ pounds/square inch (psi). (Open discharge)
(4) Injection Temperature: Average (January) _50_° F, Average (July) _72 ° F. Estimate
L. SITE MAP-As specified in 15A NCAC 02C .0224(b )( 4 ). attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in ISA NCAC 02C .0107 a 2 located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
NOTE. Inmost cases an aerial photograph of the property parcel showing property lutes and structures can be
obtained and downloaded from the applicable county GIS websire. 4pically, the property can be searched by
owner name or address. The location of the wells in relation io property boundaries, houses, septic tanks, other
wells, ere- can then be drawn in by hanrL Also, a `layer' can be selected showing topographic contours or
elevation data
AL CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A (' � ' U2 .0211(v + 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 propegy deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Sig ure f Property Owner/Applicant
Gary Clark - Owner
Print or Type Full Name and Title
_./I'.. -
Signature of Property Owner/Applicant
Susan ❑ Clark - Owner
Print or Type Full Name and Title
Signature of Authorized Agent, if any
NIA _
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]

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GASTON C U TY DEPARTMENT OF NTH & HUMAN SERVICES
ENViRONNU&NTAL HEALTH DIVISION
991 W. H[IDSON BLVD., GASTOM[A, N-C— 280S2 L '7 D
70"53-5200
rmit Void Alter 60 Months WELL INSTALLATION OR REPAIR PERMIT
PERMIT # 1 Z696
wrier/Applicant; Dal( - . _ sa-lr�4 - Date: J- :;k, - 116 _
�zliintg Addrm: Phone:(H) (W)7[AS 400-7
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Water T10t Sorrel° Line...._ 50,
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saws" Syate>en ............. 108,
Building Foundatloaa....... — 25'
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Raton County and/or North—
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VATER SUPPLY 11MR—xATI0x: �T
• Well loprtmn, instalUtio>9 and protection mast meet state I regalatloaa, and must a Ina eeted and approved by a representative of
the Gaston County H*Ah Department before any portion of the to put into «. . '
■ The eiltng of the well by the Health Department staff is to provide protecilGn'from KNU paRsil�te soarces of coniamination. No quantity
and/or quality oP water is gnaranteed at any site by the Health Department. 1
■ Alter the well it in service, contact the Gaston County ke ' Lental Healtb Sectio •SS3•dlW for hRctedological and Inargauk water
Samples. }
]ATE ISSUED 12, EBB - `
)ATE wr LL EMA SPEMON COMPLETE s
rE$ PAID $ LLD❑ — DATE — Ii> CEI PT #—
)ATE SAMPLES COLLECTED DATE ACFERiOLOGIGAL RESULTS RESULTS
...1__...i.r... v...r►a n.......,d... v ukt UMWAIR Dent, Yd6ow: A.pulirant Copy

Permit No. WI0300380
Date: 06/15/2018
To: Mike Rogers
Central Office Reviewer Michael Rogers
Permittee/ Applicant: (Gary G. and Susan D. Clark)
Facility Name: Clark SFR
I. GENERAL INFORMATION
1. This application is (check all that apply): ~ New D Renewal
County: Gaston
D Minor Modification D Major Modification
a. Date of Inspection: 06/13/2018
b. Person contacted and contact information: Gary Clark [e-mail] / [phone]
c. Site visit conducted by: Edward Watson, Hydrogeologist
d. Inspection Report Printed from BIMS attached: ~ Yes D No.
e. Physical Address of Site including zip code: 8426 Catawba Cove Drive, Belmont, NC 28012
f. Driving Directions if rural site and/or no physical address: Travel on 1-77 South to 1-485 outer to exit lOB
to enter 1-85 West toward Belmont, NC. Travel~ 33 mile on 1-85 exiting on exit 27 Belmont/Mt. Holly.
Turn left onto NC-273. After ~2 miles turn left onto S. Central Av. Take S. Central Av. for 4 miles,
then turn Right onto Lower Armstrong Rd/NC-273. Travel 2.36 miles and enter the roundabout and
take the 2nd exit onto S. New Hope Rd./NC-279 (Traveling briefly into S. Carolina). S. ~ew Hope Rd.
becomes Pole Branch Rd/SC/279. You are only on this road for -0.1 miles. Turn Right onto Catawba
Cove Dr. Travel for ~1.5 miles. The property is on the right.
g. Latitude: 35° 09' 32.51" Longitude: -81 ° 04' 02.85"
Source ofLat./Long & Accuracy (i.e., Google Earth, GPS, etc.): GCS WGS 1984 to nearest 1 second.
II. DESCRIPTION OF INJECTION WELL (S ) AND FACILITY
1. Type of injection system:
~ Geothermal Heating/Cooling Water Return
D In situ Groundwater Remediation
D Non-Discharge Groundwater Remediation
D Other (Specify:
2. For Geothermal Water Return Well(s) only
a. For existing ~eothermal system only:
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JUL Ja 2018
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Were samples collected from Influent/Effluent sampling ports? D Yes D No.
Provide well construction information from well tag: Well has not been constructed.
b. Does· existing or proposed system use same well for water source and injection? ~ Yes D No
If No, please provide source/supply well construction info (i.e., depth, date drilled, well contractor,
etc.) and attached map and sketch location of suppiy well in relation to injection well and any other
features in Section IV of this Staff Report.
3. The well has not been constructed. Samples will be collected after the system has been installed.
4. Quality of drainage at site: ® Good ❑ Adequate ❑ Poor
3. Flooding potential of site: ❑ Low ® Moderate ❑ High
b. Does the map included in the Application reasonably represent the actual site (property lines, wells, surface
drainage)? ® Yes ❑ No. if No, or no map, please attach a sketch of the site. Show property boundaries,
buildings, wells, potential pollution sources, roads, approximate scale, and north arrow.
III. EVUUATIONAND RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If Yes, explain.
2. Recommendation
❑ Deny. If Deny, please state reasons:
❑ Hold pending receipt and review of additional information by Regional Office
❑ Issue upon receipt of needed additional information
® Issue
3. Signature of Report Preparer(s): Edward Watson 06/15/2018
DocuS ig ned by -
Signature of WQROS Regional Supervisor:
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EA14CC681AF27425...

WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: June 6, 2018
To: Cory Basinger-Andrew Pitner
From: Shristi Shrestha, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0300380
A. Applicant: Gary & Susan Clark
B. Facility" Name:
C. App lication:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: New
E. Comments/Other Information:
_I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a com pleted WOROS Staff
Report.
When you receive this request form, please write· your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: __________________ Date: ____ _
COMMENTS:
NOTES: Please make sure to get a site map as stated in page 3 of the application
during site visit.
FORM: WQROS-ARR ver. 092614 Page 1 of 1
Kra -
Water Resources
Environmental Quality
Tune 6, 2018
Gary G. & Susan D. Clark
8426 Catawba Cove Dr.
Belmont NC 28012
RE: Acknowledgement of Application No. WI0300380
Geothermal Heating/Cooling Water Return Well
Gaston County
Dear Mr. & Mrs. Clark:
ROY COOPER
Gorcrnor-
MICHAEL S. REGAN
serrerar v
LINDA CULPEPPER
Inleriru Qir•erlor-
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on June 4, 2018. Your application
package has been assigned the number listed above, and the primary reviewer is Shristi Shrestha
Central and Washington Regional Office staff will perform a detailed review of the
provided application, and may contact you with a request for additional information. To ensure
maximum efficiency in processing permit applications, the Water Quality Regional Operations
Section (WQROS) requests your assistance in providing a timely and complete response to any
additional information requests.
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. If you have any questions, please contact Shristi
Shrestha at 919-807-6406 or email at [e-mail].
Sincerely,
For Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch Division of Water
Resources
cc: Mooresville Regional Office. WQROS
Permit File W10300380
' Not Iima Cot rrou►r►^
Sim orNorth Carolina j Environmental Quality j Division of Water Resource`+
Water Quality Reglanal ❑perarSons 5ecden
1636 Mail Service Center I Raleigh, North Cam]ina 27699.1636
919-707.9129