WI0400086_GEO THERMAL_20120523

,rrrr.�.�rsa
Affl. G a
North Carolina Department of-Erwir-onment and:Natural- Resources-.
Division -of -Water_ Quality_
Beverly Eaves- Perdue_ Charles Wakild,.P. E.
Governor Director
May 23, 2012
Kathryn Combs
299 Brandy Road
Stoneville, NC 27048
Subject: Notification of Rule Revisions Affecting
Closed -Loop Geothermal Injection Well Permit Holders
Permit Number: WI0400086
Dear Ms. Combs:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed -loop geothermal injection well
system. This letter. is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards — Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed -loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http://Liortal.ncdenr.org/web/wq/aps.
If you have any- questions regarding, your current permit or the rule revisions; please -feel free to -
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636 One
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604 Nd thCarolll1a
Phone: [phone] FAX: [phone]
Internet: www.ncwateroualitv.org Naturally
An Equal Opportunity': Affirmative Action Employer i!

Permit Number W10400086
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael,rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Kathryn Combs SFR
Location Address
299 Brandy Rd
Stoneville NG 27048
Owner
Owner Name
L Kathry Combs
n
di
f
Central Files: APS SWP
11/10111
Permit Tracking Slip
Status
Project Type
In review
Renewal
Version
Permit Classification
Individual
Permit Contact Affiliation
L Kathryn Combs
299 Brandy Rd
Stoneville
NC 27048
MajorlMinor Region
Minor Winston-Salem
County
Rockingham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
L Kathryn Combs
299 Brandy Rd
Dates/Events Stoneville NC 27048
Scheduled
Brig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Ex,pirati n
04/19107 11110111 Ill ��!{ to Of to
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name Stream Index Number Current Class Subbasln

NLQENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Lois Kathryn Combs
299 Brandy Road
Stoneville, NC 27048
Division of Water Quality
Coleen H. Sullins
Director
November 29, 2011
Ref: Issuance of Injection Well Permit W10400086
Dear Ms. Combs:
Dee Freeman
Secretary
In accordance with the application received on November 10, 2011, I am forwarding permit number W10400086
for the continued operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system. This
permit shall be effective from the date of issuance until October 31, 2016, and shall be subject to the conditions and
limitations stated therein.
Please pay special attention to Part V.2. The Permittee shall retain all records of repairs, pressure tests,
maintenance, and other activities needed to maintain normal operating conditions.
In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an
application to renew the permit 120 days prior to its expiration date. This permit is not transferable to any person
without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or michael.roVersw nedenn,gov if you have any questions about your permit.
Best Regards,
''Michael Rogers, P.G. (NC cot FL)
CC' Sherri Knight, Winston-Salem Regional Office
WI0400086 Permit File
Rockingham County Environmental Health Dept.
q{} ;:E'F^an07FC710NSECTION
'sE3fi Mail xrrui:x''erster. fi;9lklq},. Maru� �:�lpiin� 27@�5 ���8
LOCADM 2� 8 CODA14I BOVIceWm, nAlaip. None Gatvim WKV
Pharr� tF .'1:saipBfS:� a1u.y15_11d14BVC•uxtarnerSump' ::,',74.:
An EgwM Gpponumsy , nffsrnfow AGiinq Enpfoyw
NoolitbCarolina
aturallb

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMSSION
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 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Lois Kathryn Combs
FOR THE CONTINUED OPERATION OF TYPE 5QM INJECTION WELL(S), defined in Title ISA North
Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed -loop
geothermal -mixed -fluid heat pump system. This system is located at 299-Brandy Road, Stoneville,
Rockingham County, and will be operated in accordance with the application received November 10, 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 of an injection well and 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 October 31, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through VII hereof
Permit issued this the 29th day of November 2011.
oleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit # W10400086 LJTC15QM Renewal Page 1 of 4
Version 1/2010

PART I — OPERATION AND USE GENERAL CONDITIONS
1 _ This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
PART II — PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
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 III — 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.
Permit # W10400086 UICI50M Renewal Page ' of 4
Version 1/2010

PART IV- 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 V — MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall retain all records of repairs, pressure tests, maintenance, and other activities needed to
maintain normal operating conditions.
3. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Winston-Salem Regional Office, telephone number 336-771-5000, 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;
4. 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.
5. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall tape such
immediate action as may be required by the Director.
PART VI — PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
Permit # WI0400086 LTIC/SQM Renewal Page 3 of 4
Vmlon 1/2010

7t �� i �� : ►`►del ai�� �li.I � �! 1I��_]rli��1��
1, The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(1), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing? operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel -packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(1) within 30 days of completion of abandonment.
3. The written documentation required in Part V11(1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh; NC 27699-1636
Permit # W.10400086 UICI5QM Renewal Page 4 of 4
Version 112010

Rogers, Michael
From:
Mitchell, Patrick
Sent:
Friday, November 18, 2011 2:39 PM
To:
Rogers, Michael
Subject:
FW: WI 0400086 Combs 5QM renewal
Attachments:
Combs App.pdf
Michael,
will not have time to conduct a pre -permitting inspection, Go ahead with the permit renewal.
Patrick L. Mitchell, LSS
NC DENR - DWQ
Aquifer Protection Section
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Knight, Sherri
Sent: Tuesday, November 15, 2011 10:29 AM
To: Mitchell, Patrick
Subject: FW: W10400086 Combs 5QM renewal
Existing permit
Sherri knight, PE
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Rogers, Michael
Sent: Monday, November 14, 2011 5:11 PM
To: Knight, Sherri
Subject: W10400086 Combs SQM renewal
Sherri -
Attached is a 5QM renewal application. Please let me know If you wish to conduct a pre -permitting inspection or not.

Thanks
Michael Rogers, P.G. (NC & FL)
Envlronmerdal Specialist
NC Div of Water Quality- Aquifer
1636 Mall Service Center
Raleigh. NC 276W1636
Direct Line [phone]; Fax
Protection Section WS)
715-W48 (put to my attn an cover letter)
http:llportaLncdonr.ortllwgPL_ �/apslgwpro/permit applicabonsi�geotheanApps
&mO carm spandence to and from this mkkass may be a dwa to the North Carolina Publ+c Records Law and may be dlsdosad to third parties

HCDEN
Nogh Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Govemor
Kathryn Combs
299 Brandy Rd,
Stoneville, NC 2.7048
Dear Ms. Combs:
Division of Water Quality
Coleen H, Sullins
Director
November 10, 2011
Dee Freeman
Secretary.
Sub j ect: Acknowledgement of
Application No. WI0400086
Kathryn Combs SFR
Injection Mixed Fluid GSBP
Well System (5QM)
Rockingham County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on 11/10/2011. Your application package has been assigned the number listed
above, and the primary reviewer is Michael Rogers.
Central and Winston-Salem 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 Aquifer Protection Section 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 Michael Rogers at 919-
715-6166 or michael.rogers@ncdenr,gov,
incerely,
.far Deta�k�
atts
+Greater Protection Unit Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Permit File W10400086
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Camlina 27699-1635
Lauton: 2728 Capital Boulevard, Ra6eigh, North Camlins 27604
Rhone: 919-733-3221 I FAX 1: 919-715-0588: FAX 2: 919-715-6048I Customer Service: '1-877-623-6746
Internet, wwnw.ncwaterau0v.om
An Equal Opportunity 1 AMsnalive Action Employer
One
ort Nh Carolin a
,, jqUA'Z' 71 l(

Pr
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP MMED-FLUID GEOTHERMAL INJECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system
(check one) New Application Renewal* Modification
* For renewals complete Parts A-C and the signature page.
int or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incompl
DATE: 0 1--!
20 R
PERMIT NO. (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence Business/Organization
Government: State Municipal County Federal
9.
B. PERMIT APPLICANT — For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
Z,n i f , I Y I e rw 6 s
Mailing Address:` 4 '"X,_J
City: °" "'` l 1 ` State: IV' Zip Code: � -7 County;
Day Tele No.: _7) r` 6`Z3_1 ,t -,4r3 Cell No.:
EMAIL Address: Fax No.:
A
LOCATION OF WELL SITE — Where the injection wells are physically located-
(1) Parcel Identification Number (PIN) of well site:
(2) Physical Address (if different than mailing address):
City:
i 'J t tllij11MA1� 114)ZZI0E 0(1)0
State: NC Zip Code:
County.
Well Drilling Contractor's Name: _
NC Well Drilling Contractor Certification No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
GPUIWC 5Q3M Permit Application (Revised 1/24/2011) Page 1

E. BEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
Zip Code:
F. WELL CONSTRUCTION DATA
Cell No.:
State: County:
Fax No.:
(1) Number of borings to be constructed*: Depth of each boring (feet):
* If existing water suppit, wells will be used then provide the information in ite►zz (4) below.
(2) Chemical additives to be used: R-22
Other
Propylene glycol
Ethanol
(other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc):
(4) Well casing. If the well(s) will use casing then provide the tie (steel, PVC, plastic, etc.), diameter, depth.
and extent of casing appearing above ground-
(5) Grout (material surrounding well easing and/or piping):
(a) Grout type: Cement Bentonite** Other (specify)
** By selecting bentonite grout, a variame is hereby requested to 15A NCAC 2C .0213(d)(1)(A), which requires a cement type grout
(b) Grout depth of tubing (reference to land surface): from to (feet)
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow,
(1)
(2)
Attach a site^specific map showing the locations of the following:
* Proposed injection wells # Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: Inmost cases, an aerial photograph of the property parcel showing property lines and 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 boundaries, houses, septic taroks, other
wells, etc. can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data
GPUIUIC 5QM Permit Application (Revised 1124/2011) Page 2

13. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C A211(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 official;
4. for all others: by the well owner (which means all persons 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 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, l believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit.,"
Signature of Property Owner/Applicant
41s9-77tryn� enfu 4✓3
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type full Name
Submit two copies of the completed application pack -age to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QM Permit Apphcadon (Revised 1/24/2011) Page 3

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: V A' v -- e)qQ GOO (P KMW Combs
I—S 299 Brandy Road,
Permittee Name: [ /�' Stonevft. NC 27M
Address: �/t--•' "� R• �- �k7� !v �i 2-,70 V 27
Please check the selection which most closely describes the current status of your injection well system:
1) vwell(s) still used for injection activities, or may be in the future.
2) ❑ Weil(s) not used for injection but is/are used for water supply or other purposes.
3) ❑ Injection discontinued and: a) ❑ Well(s) temporarily abandoned
b) ❑ 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, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used toabandon the injection well, (Include a description of haw the well
was sealed and the type of material used to, fill the well if permanently abandoned)
Permit Rescission:
If you checked (2), (3), or (4) and will not use a well for injection on this site in the future, you should request rescission of the
permit. Do you wish to rescind the permit?
❑ Yes ❑ No
Certification:
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
ignature Date
Revised 5105 GMIG-68 ►; r c : c _� D� ,r?

ALIT.RWA
HCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quallty
Beverly Eaves Perdue Coleen H. Sullins
Govemoi Director
October 20, 2011
CERTIFIED MAIL # 7006 2150 0003 5467 0998
RETURN RECEIPT REQUESTED
Locust Point, lnc
299 Brandy Road
Stoneville, NC 27048
Subject: Change of Ownership
Permit No. WI0400086
5QM Geothermal Injection Well
Rocldngham County
Dear Locust Point, Inc.:
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 construction and operation
activities within the state. Our records indicate that the above -referenced permit was issued to
Kathryn Combs on April 197 2007, and expires on March 31, 2012.
This permit was issued for the operation of a 5QM (Closed -Loop Mixed -Fluid) Geothermal
Injection Well on your property located at 299 Brandy Road, in Stoneville, North Carolina. As
the new property owner, you are responsible for maintaining this permit. Therefore, it is
important that you submit a Chancre of Ownership form within thirty. (30) bays of receipt of this
letter.
Since the permit is set to expire shortly and in order to comply with the regulatory requirements
listed under North Carolina Administrative Code (NCAC) Title 15A, Subchapter 2C, Section
.0211, you must also submit one of the following farms:
ACtE11FER PROTECTION SECUfoN
1636 Mail Service Center, Ralegh, North Carolina 2.75994636
Loudon: 2726 Capital Boulevard, Ralel h, North Carolina 27604
Pnone: 919.733-3221 I FAX 1: 915-715-0588 FAX 2: 519.715.60481 Customer Servir ai 1.877-623-6748
Intemet: www.newaterouallbr.ara
An Equal Opportunity I Affirmative Atioo Employer
One
NorkhCarolina.
,X ural tj

A. Application for Permit (Renewa1) to Construct andlor Use a WeI1(s) for Injection
with Geothermal Heat Pump System for 7�pe 5QM 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 has been
temporarily or permanently abandoned.
Please submit the 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 Change of
Ownership form, a renewal application, and a U1C Well System Status form are attached along
with a self-addressed envelope. The above referenced forms are also available on-line at the
DWQ website at http://Rortal.ncdenr_ore/web/wg/Ms/--woro/permit-applications#p-eotherr ADD .
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. g.smith4'v1icdenr.aov.
Sincerely,
.I
Z�4 Z, �
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Winston-Salem Regional Office - Aquifer Protection Section w/o enclosures
APS Central Files — Permit W 0400086 w/o enclosures

ACR CA per'�}}
RCVGNR
North Carolina Department of Envirgnment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H, Sullins
Governor Director
October 20, 2011
CERTIFIED MAIL # 7006 2150 0003 5467 0998
RETURN RECEIPT REQUESTED
Locust Point, Inc
299 Brandy Road
Stoneville, NC 27048
Subject: Change of Ownership
Permit No. WI0400086
5QM Geothermal injection Well
Rockingham. County
Dear Locust Point, Inc.:
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 construction and operation
activitics within the state. Our records indicate that the above -referenced permit was issued to
Kathryn Combs on April 19, 2007, and expires on March 31, 2012.
This permit was issued for the operation of a 5QM (Closed -Loop Mixed -Fluid) Geothermal
Injection Well on your property located. at 299 Brandy Road, in Stoneville, North Carolina. As
the new property owner, you are responsible for maintaining this permit. Therefore, it is
important that you submit a Change of Ownershir+ form within thirty (30) days of receipt of this
letter,
Since the permit is set to expire shortly and in order to comply with the regulatory requirements
listed under North Carolina Administrative Code (NCAC) Title ISA, Subchapter 2C, Section
.0211, you must also submit one of the following forms;
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Ralegh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, Norlh Carolina 276N
Phone: [phone] FAX 1: 9%-715d0588; FAX 2: 919.71MD481 Customer Service,1.877.62M74$
Intemet Wwn(W5M0al[tYgQ
An Equal Opponunity 1 Afrmalive Action Emp4Dyer
Naturallzl
NorthCar ohna

A, Application for Permit (Renewal) to Construct andlor Use a Wells) for Injection
with Geothermal Heat Pump System for Type SQM Well(s) if the injection well
system on your property is still active.
-UR-
B. Status of Injection Well System if the injection well system is inactive or has been
temporarily or permanently abandoned.
Please submit the 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 Change of
Ownership form, a renewal application, and a UIC Well System Status form are attached along
with a self-addressed envelope. The above referenced forms are also available on-line at the
DWQ website at htW:llporW-ncdenr.ore/web/wglaps/-ynro/permit-applications#p-eothermAuus.
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.g.smith(n?ncdenr.sov.
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc; Winston-Salem Regional Office - Aquifer Protection Section w/o enclosures
APS Central Files — Permit W10400086 w/o enclosures

(Dornestic Mail Only; No Insurance Coverage Frvvidec
For delivery information visit our website at www.usps.comv
Postage
tin
0artiffed Fee
m
C3
Saturn Receipt Fee
- - ._F93te�t5ra
F gr
O
(EndorsarnartRequired)
d
Rastftw Oalivery Fee
r3
(Endorsement Required)
N
rl
ru
-row Poste
Locust point, Inc.
.n
299 Brandy Rd.
s=
Stoneville, NC 27048
iri-
-' Po lion N
,
u
■ Complete items 1, 2, and 3. Also complete
ftern 4 if Restricted Deilvery 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 mailplece,
or on the front if spate permits.
1. Article Addressed to:
Locust point, Inc.
299 Brandy Rd.
Stoneville, NC 27048
A. Signature
X Agent
(�IR Ndr:�ee
B. Received by ( Printed Name) C. Date of Delivery
fit) -; II
D. Is delivery address different from item 1? 0 Yes
If YES, enter delivery address below. i3 No
3. Service Type
13 Celmed Mais 13 Express Mai
❑ Registered © Return Recelpt for MerCtxMise
13 Insured Mall D C.O.O.
4. Restricted Delivery? (&ft Fee) 13 Yes
2. Article Number 7006 2150 0003 5467 0998
(f�ansfer tram ser4ce rebel)
PS Form 3811, February 2004 Domestlr: Return Recelpt 102595-02-Wl540

Rocldngharn County NC - Pamei No: 168588
DASI 6/10/11
ROCKINGHAM COMM
PAGE I
TIMH I:G2i29
PROPERTY CARD
PROD# AS2006
USSR Rc=X
FOR YEAR 2011
LACOBT POINT INC PARCEL ID.. 168589
PIN... 7969 01 29 "IS 00
LOCATION... BRANDY RD
STOIStTIi.J
DEW YEAR/BOOFPAGR., 2004 ADM COMB
299 BRANDY RD
PLAT HOOK/PAGB.. E4 37
Omn ID., 119380E
LBGAL DESC.2.63 AC BRANDY RD
DISTRICT., 117 SHILOH FD
TONBSHIP... 2 ZZ.&K VILLE
STONWILL8
NC 27048-7730
NBRROOD... R103 MAYODAN
DESCRIPTION
SINGLE FAMILY RES
ER CLASB..
DESCRIPTION
LAND USE AMUCOLTURE RMIDEN'IAL P 5 A2 COUNIT
MAMAnw..
7/09/2007 BY MMCCLi 7Kx VALUKD. , 1/19/2011 BY 1tMCCLnnw
VISITED.....
BY MM PREV PARCEL, 165293E1
RAt7TINfi#
PARCEL STATUS... ACTIVE
BALER BISTURY
----------
DEED BK/FAGS SALE DATE a M- In' TAIDCENT DISQUALMED SALE AMOUNT
ADM COM 1/01/2004 MIT FAST TRAC$ SPLI
-----------------`- LARD SEGMENTS ----------
LND S17AT LAND
M SOPS CODE TYPE/CODE LAND QTY LAND RATS 13M SSPt
1 RA 100 AC RA 2.630 41500.OD .O0 .00
LUV., LU A3 1.630 590.00
2 RA 100 AC RA I.D00 41500.00 .0O ,00
3 RA 10D UB RH 2.000 1D,000.00 .00 .00
TOTAL ACRES.. 2.S3G
TOTAL I9 LU.. 1.630
-^--•••------••-•_-•- IMPROVEMERT 5 1 X&JOR TWR-M
MAIN SIR AR814,, 1,186.00 ACT/EFF YR/A3E,, 1940 1960 51
$TART....,..... 1GO DESCRIPT.... SINGER FAMILY DNELLIN6
MAIN GROUND SF.... 1.186.000
BUILT USE...... 01 SINGLE FAMILY DIIZLL33G
LOCATION tl.,,.. 301 HRAWRY RD
COMPONENT TYPR/CODS/1089C PCT UNITS RATS STR# STRIt
-------------------`------------------------------------------------
AC OPR OPEN PORCH RAISED 100 190.00 12.00
AC ORR OPER PORCH RAISED 100 200.00 12.00
AC ST STOOP 1GO 29.00 6.00
MA ROS SFR MAIN AREA FRAME 100 1186.00 60,00 1.00
EM 04 VINYL SXUn i 100 176.00 .9O
AR 004 FOPMD ROT ArX & CEN100 1186.00 4,so
PD EL03 AVERAGE XLXt '*TC Igo 1.00 ,00
- PD Exo4 VIM s1DIm6 zoo 1.00 .00
- PD FLOI W/H CARFET 50 1.00 .00
- PD FLO2 SOFT PINE 40 1-00 .00
- VD FL03 JOHINT VILPYL 10 1.00 .00
- PD FN34 CONTINUUM WALL HRIC100 I.QO .00
Pagel of 3
CATEGORY.. REAL, & PBRSM=
------------------------------------------
STAMP AMOUNT USED WAKE
LOCUST POINT INC
------------------------------------------
TOT
CURRENT
LOCI szat OTgt T'OP% ADa
VIM
.00 210.00 90.00 100.00 189,00
13,863
LO ADS & VALUE.. 100
961
.00 220.00 90.00 100.00 189.00
a,506
.00 .00 .00 .00 .00
10,000
TOTAL LAND FMV„
32,369
TOTAL LAND LUV..
19,466
------------`--------------`---------`-----------
VIBITED., HY
MAMAINED.. 2/31/2008 BY STRDRNTOi
CURAHffT USE.,.. CR CURRENT USB RSSMHNTX L
But NGT4 Plitt CD91k
---------- ------------
111.00
*CMSFL
1,440
2,400
150
78,997
0
5.337
0
0
0
0
0
0
http:llard=2.wehgis.ne AinkedfUes/nwRockingham/cards/16/168588.ht3n 10/19/2011

Rockingham County NC - Parcel No: 168588
Page 2 of 3
DATE eqo/ll
R0�"KxUMM emwv
PAM z
TM 1.02:25
PROpmy CARA
PROGO AS2006
IMER RD1 IE
FM YEAR 2011
LOCI] r POM INC PAIM ID.. 1985SO
ag 9415
OD
Y14PRUMWT M 1 MAUQR IMPR-M
-----------------
- -----------------------
-------`
i. NWORKNT TYM/CQPE/MMC PCT
tA41TS RATE sTR1t BTRk
ST9fk
% MIr WSir
COOT "PL
- P11 IR01 1$T FYPY�R SRY9iALL 194
1.00 .00
0
- P17 PL03 PLi1 ene AVRR.WK 100
1. Dc .04
D
- PD RP01 GA" ROOF 100
I.Do -DO
0
- Pa S%01 RF MATERLRL ASPULT 100
1,Du 40
0
- PL D03 4 VXXTRtE SRTH 100•
1.D0- 3200.84
3,200
.,,
PCT COWL=
100
x
91'Si4
RCR...
COQwrr sm hw
100.00
7C
91,514
QUAL,. QG
a CQUSTRUCPIOM GRADE A
100.90
x
91,514
IMEM DA
51 YEW
..DO
- 0
A=:.
V53 XCAL VOR
30.00
- ,'t7,454
FOLIC. -
5.00
- 3 , ZD9
30,651 T
--TMV--.
60.e57
http://kuims2.webgis.net/linko es/ncVRock;�am/cards/Idf1d8588.htm 10/19/2011

Rockingham CountyNC - Parcel No: 168588
Page 3 of 3
MTS a/10/11
Aoaxnfasm COUNTY
PAGE 3
TIME Is M 29
PROPBBTY CARD
PRO" AS2006
USER ROME
7M YZAA 2011
LOCORT POWT two
PARC11Yr M.- 169589
PIN ... 796E OS 2,99615
00
------------------------------ IIRPRDyz4wT 0 1 Wh=R IRPR-M
-----'--.'-�.------.-._-._-....
----------- •------
+---20 --- +
D 1
i 2
a a
�
1
A
35S
+--+-2H-+--+---10--+C5
8 1
1 A
-------------
AC ORR OPEU PORCH RAISED ---------
TRAV RRE ------------------------------
-------------
Ac OM OPsa PORCH 7t1ZM---------
TRAVSRSm ------------------------------
-------------
AC ST STOUP ---------
%7AVSRBZ ------------------------------
-------------
MA 101 SFR MAIN AREA FRAME PLODR: 1.00---------
TRAVBRSE ------------------------------
-=--------------------^-...-..-----
IKPROVSbU= R 2 MISC IKPR-Y
----------'--------------------------------------
NAM Fm AREA..
ACT/EFP WALRl.. 1850 1950 161
VISITED.. 10/02/2000
BY RT
BMT..........
100 USSCCAlPT.... CDOZODWE
MKWTAMMD.. 1/3112008 BY X=RNTM
BUILT USE......
19 A.SS SLDO
CURMW ME.... CA CURRENT USE #4RICt rrURAL
LOCATION 0.....
BRANDY RD
Oompom8NT TYPE/com/DESC PCT UNITS RATS STU STRt SI3i EaT% PERt CDSV
COST tCMPL
II8 la NA
1,00 1.00
QuAL . Qa GDo 000
IMOD x
a
PM.- DA Jae ?RUM
..00 - 0
D T
PCT COMPLM
lea
--rxv...
300
TOTAL. PARCEL VA MS.--- LAM / OVR IMPROVBNBNIS / mm
TOTAL LAMg%PROVS
2010 VALUE
PMVr'.... 32,368 51,157
93,525
79,529
APV...... 19,366 61,157
BD,623
70,223
DSFBRHSD. 12,902 0
12,902
$1206
http:/lardms2.webgis,netllinkedfiles/ncaocldngham/cmWi 6/16858S.htm 10/19/2011

State of North Carolina
Department of Environment and Natural Resources
Division of Water (duality
PERMIT NAME/OWNERSMP CHANGE
Any changes made to this form will result in the application being returned.
(TB7S FORM MAYBE PHOTOCOPIED FOR USE AS AN ORIGINAL)
1. REDUiRED ITEMS
1. Submit one original of the completed and appropriately executed Permit Name/Ownership Change Form.
For a change of ownership, the certification must be signed by both the current permit holder and the new
applicant. For a name change only, the certification trust be signed by the applicant.
2. Provide legal documentation of the transfer of ownership (such as a contract, deed, article of incorporation,
etc.) for ownership changes.
3. Change of Ownership Applications for Homeowners Associations (HOAs) shall include the HOAs Bylaws,
covenants, etc. [I5A 02T .0115(c)l
4. Submit a properly executed Operation and Maintenance Agreement for all Single Family residence Surface
Irrigation permits requesting a change of ownership.
11. CURRENT PERMIT ]INFORMATION
1. Permit number: Iq
2. Permit holder's name.'`"-rS
3. Permit's sighing official's name and title:
4. Mailing address: �
City. 1-, L Jt� Vie.
Telephone number:��
(Person iegally responsible for permit)
(title)
C_
Zip: ;i'y 0 <4.
Facsimile number; L__)
M. NEW OWNERINAME INFORMATION
IV6 NHS` r,j aw,
1. This request for a permit change is a result of:
a. Change in ownership of property/company
Name change only
~ `.c. Other (please explain):
Aquifer Protection Section ., f
FORM: PNOC 12/30/2009 Page 1 of 2 7
4/0-(,/Y-3 �-

2, New owner's name (name to be used in permit):
3. New owner's or signing official's name and title:
4. Mailing address:
City:
Telephone number: (_)
W. CERTIFICATION
(Person legally responsible for permit)
(title)
State: Zip:
Facsimile number:
1. Current Permittee's Certification:
I, , attest that this application for namelownership change has been
reviewed and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting information and attachments are not
included, this application package will be returned as incomplete. I understand I will continue to be
responsible for compliance with the current permit until a new permit is issued.
Signature:
2, Applicant's Certification:
I, , attest that this application for name/ownership change has been
reviewed and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting information and attachments are not
included, this application package will be returned as incomplete.. I further certify that the applicant or any
affiliate has not been convicted of an environmental crime, has not abandoned a wastewater facility without
proper closure, does not have an outstanding civil penalty where all appeals have been exhausted or
abandoned, are compliant with any active compliance schedule; and do not have any overdue annual fees
under Rule 2T .0105.
Signature: Date:
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING INFORMATION AND
MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DMSTON OF WATRA QUALM
AQUIFER PROTECTION SECTION
Via U.S. Postal Service
1636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
Via Courier / Special Deliverv:
2729 CAPITAL BOULEVARD
RALEIGH, NORTH CAROLINA 27604
TELEPHONE N[iMMR: [phone]
FORM: PNOC 12/30/2009 Page 2 of

Permit !dumber W10400085
Program Category
Ground Water
Permit Type
injection Mixed Fluid GSHP Well System (50M)
Primary Reviewer
michael.rogers
Permitted Flow
Facility Name
Kathryn Combs SFR
Location Address
299 Brandy Rd
Stoneville
011
Central Files: APS SWP
04/11/07
Permit Tracking Slip
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
L Combs
299 Brandy Rd
Stoneville NC 27048
Major/Minor Region
Minor Winston-Salem
County
Rockingham
NC 27048 Facility Contact Affiliation
Owner Name Owner Type
Individual
L Kathry Combs Owner Affiliation
n L Combs
299 Brandy Rd
Stoneville NC 2704E
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
02107/07 D gRflo 7 03/jj
Regulated Activities Reauested/Reeeiyed Events
Heat Pump Injection RO staff report received
RO staff report requested 02113/07
Outfall NULL
Waterbody Name Stream Index Number Current Class 5ubbasin

Michael F. Easley, Govemor
William G. Ross Jr., seerotary
North Carolina Deportment of Environment and Natural Resources
Alan W. KlimdS P.E. Aircam
Division of Water Quality
April 18, 2007
L. Kathryn Combs
299 Brandy Road
Stoneville, NC 27048
Re: Issuance of Injection Well Permit
Permit No. W10400096
Issued to L. Kathryn Combs
Dear Ms. Combs:
In accordance with your application received February 7, 2007, I am forwarding Permit No.
W10400086 for the operation of a "direct expansion" type vertical closed -loop geothermal heat
pump injection well system to be located at 299 Brandy Road, Stoneville, Roeldngh.am County,
North Carolina 27048. This permit shall be effective from the date of issuance until March 31,
2012, and shall be subject to the conditions and limitations stated therein.
Pay special attention to the well construction standards in Parts H and V of your permit.
You must notify this office (Raleigh Central Office) and the Winston-Salem Regional Office at
least forty-eight (48) hours prior to constructing the system, and forty-eight (48) hours prior to
initiation of the operation of the system.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit
an application to renew the permit three months prior to its expiration date. As indicated in the
permit, this permit is not transferable to any person without prior notice to, and approval by, the
Director of the Division of Water Quality. If you have any questions regarding your permit or
the Underground Injection Control Program please call Mr. Qu Qi at [phone] or me at
[phone].
Best R��Rogers
RegardsMichael
Environmental Specialist H
cc: Sherri Knight — Winston-Salem Regional Office
Central Office File — W10400086
Monte Jefferson— Home Energy, Inc.
Christopher Brantley— Appalachain. District Health Dept., Boone, NC
Attachment(s)
Aquifer Protection Section 1636 Mail service Center Raleigh, NC 27699-1636 Telephone: [phone]
Internet bgpJ/www.ncwatgMuality.org 2729 Capital Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal 0ppvWdty1A ve Won Employer— 50% Recyde l0% Post Consumer Paper Customer Service: [phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
i1 � : 01 ► r am r .I�a1 L ; •11 +, ; Il1t ; r Ji
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
L. Kathryn Combs
FOR THE CONSTRUCTION AND OPERATION OF 7 TYPE 5QM INJECTION WELLS,
defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of
operating a "direct expansion" type vertical closed -loop geothermal mixed -fluid heat pump
system. This system is located at 299 Brandy Road, Stoneville, Rockingham County, North
Carolina, and will be constructed and operated in accordance with the application received
February 7, 2007, 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 permit shall be effective, unless revoked, from the date of its issuance until March 31, 2012,
and shall be subject to the specified conditions and limitations set forth in Parts I through IX
hereof.
41% 1
Permit issued this the day of , 2007.
r
�1
Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. W10400086 Page 2

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (I SA NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that
are generally subject to flooding include those with concave slope, alluvial or colluvial
soils, gullies, depressions, and drainage ways.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use, Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each injection well shall have permanently affixed an identification plate.
S. A completed Well Construction Record (Form GW-1) must be submitted for each injection
well to: DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff 1636
Mail Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well
construction.
PART II - WELL CONSTRUCTION SPECIAL CONDITIONS
1. Prior to constructing the injection well system, the Permittee or his agent shall test the pH of
the soil at a depth of three feet at the planned well location. If the resulting soil pH is less
than 6 standard units or greater than 11 standard units, the well system shall be equipped with
a compatible cathodic protection system. All testing results shall be kept on site available for
inspection.
2. At least forty-eight (48) hours prior to constructing system, the I'mmittee shall notify the
Aquifer Protection Section's Underground Injection Control (UIC) Program Central Office
staff, telephone number [phone] and the Winston-Salem Regional Office Aquifer
Protection Section Staff, telephone number [phone].
3. All underground tubing shall be refrigeration grade copper tubing.
Parrmit No. W10400086 Page 3

4, Prior to installation, all tubing to be placed in boreboles C'loops") shall be checked for leaks
by pressurizing the loop to a gage pressure of at least 350 pounds per square inch (psig),
immersing the loop in water and examining it for leaks. Loops with leaks shall not be
installed.
5. Prior to installation, each loop shall be visually inspected for damage such as kinks, dents,
and scrapes. Each loop shall be checked to verify that the nitrogen charge applied to the loop
by the manufacturer before shipping is still present at a pressure of at least 300 psig. The
loop manufacturer shall be notified in the event of damage or pressure loss, and the
manufacturer's instructions shall then be followed. The nitrogen charge may be released
only when the loop is installed and ready to be connected to the manifold.
6. Boreholes shall be large enough to allow insertion of the loop plus a tremie pipe for grouting.
7. After insertion of the tubing into the boreholes, an approved grout (as defined in Title 15A
North Carolina Administrative Code 2C .0100) shall be pumped via tremie pipe into the
annular space of each borehole so as to completely fill it from bottom to top.
8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material
shall have a galvanic potential as close as practicable to that of the tubing material.
9. Dry nitrogen shall be circulated through the tubing during brazing to prevent oxidation.
10. After installation and prior to operation of the system, a mechanical integrity test shall be
conducted by pressurizing the injection well system to 400 psig with dry nitrogen and
monitoring for leaks using an ultrasonic or other leak detector of equal sensitivity and
monitoring pressure in the system for at least 2 hours. Alternatively, an equivalent vacuum
test is acceptable. Any pressure fluctuation other than that due to thermal expansion and
contraction of the testing medium shall be considered a failed mechanical integrity test. Any
leaks shall be located and repaired prior to charging the system with refrigerant. A copy of
the post -installation pressure or vacuum test record (initial pressure readingpressure
reading. and the duration of the test) shall be submitted to the Aquifer Protection Section.
The test records must be received by the Aquifer Protection Section at least twenty-four (24)
hours prior to the initiation of the operation of the facility for injection.
11. The location of each of the system manifolds shall be recorded by triangulation from two
permanent features on the site (e.g., building foundation corners). The Permittee shall retain a
copy of the triangulation records. The Permittee shall also submit a copy of the triangulation
records to the Aquifer Protection Section within 30 days of completion of well construction.
12. The written documentation required in Part 11. paragraphs 0 0) and { 11) shall be submitted to:
Aquifer Protection Section-U1C Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Permit No. WI0400086 Page 4

PART III - OPERATION AND USE GENERAL CONDITIONS
i. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, Miles, 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.
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 V - OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section's
Underground Injection Control (UIC) Program Central Office staff, telephone number
[phone], and the Winston-Salem Regional Office Aquifer Protection Section Staff,
Permit No. WI040DO86 Page 5

telephone number [phone]. Notification is required so that Division staff can
inspect or otherwise review the injection facility and determine if it is in compliance with
permit conditions.
PART VI - INSPECTIONS
1. Any duty 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 VII - MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed
necessary by the Division of Water Quality to insure surface and ground water protection,
will be established and an acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Winston-Salem Regional Office, telephone number
[phone], any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating
circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of
proper injection operations, such as mechanical or electrical failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
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.
Pernut No. W10400086 Page 6

4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as maybe required by the Director.
M7I:4>iIAUa9:0t1u198R1i►i- AM
The Permittee shall, at least 120 days prior to the expiration of this permit, request an
extension.
PART IX - CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. if a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(1), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 1 SA 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.
(H) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe, which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel -packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
(F) in those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
Permit No. WIG400086 Page 7

sources of drinldng water and in accordance with the terms and conditions
of the permit.
(0) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(1) within 30 days of completion
of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Program
DENR Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Permit No. W10400086 Page 9

WI 00400086
Subject: WI 00400086
From: Michael Rogers <[e-mail]}
Date: Wed, 11 Apr 200716:31:56 -0400
To: [e-mail]
Hello Chris -
Would you please enter the inspection info in BIMS for the above. I do not have the
information that needs to be entered.
7banks
1 of 1 V11/2007 5:19 PM

AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 4/10/07 County: RocldnQham
To: Aquifer Protection Central Office Permittee: Kathryn Combs
Central Office Reviewer: Michael Rogers Project Name: None (U'IC -- (5QM) closed loop
Regional Login No:. Application No.: WI 0400986
L GENERAL INFORMATION
1. This application is (check sit chat apply): X New ❑ Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation X Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? X Yes or ❑ No.
a. Date of site visit: 4/5/07
b. Person contacted and contact information: Monte Jefferson (Hoene Energy Inc.) 252-205-1251
c. Site visit conducted by: C. Greene
d. Inspection Report Attached: ❑ Yes or X No.
2. Is the following information entered into the BIMS record for this application correct?
❑ Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location;
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude; Longitude:
e. Regulated Activities / Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For Disposal and Injection Sites:
(If multinle sites either indicate which sites the information anvlies to. copv and paste a new section into the
document for each site. or attach additional panes for each site
a, Location(s): 299 Brandy Rd., Stoneville, NC 27048
b. Driving Directions: 158 E. to 220 N. to Mayodan-Eden exit (A. at light); Rt. 135 approx. 8 miles to Brandy
Rd. (rt.); veer right at Dave's Body Shop to end of road (0.4 miles) on gravel rd. to new gray house w/black
mailbox
c. USGS Quadrangle Map name and number: Southwest Eden
d. Latitude: 36028'3.30" Longitude: 79048'28.99" ("Earth Google" - source)
It. NEW AND MAJOR MODIFICATIONAPPLICATIONS (this section not needed for renewals or mirror
modifications, skip to next section? t
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification:
FORM: RegionalStaftReportCombs LTIC April 20071

AQUIFER PROTECTION REGIONAL STAFF REPOjRT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
❑ Yes ❑ No ❑ NIA. If no, please explain:
i
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? ❑ Yes ❑ No ❑ NIA. If noy0ease explain:
A. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? ❑
Yes ❑ No ❑ N/A. If no, please explain:
S. Is the proposed residuals management plan adequate and/or
N/A. If no, please explain:
6. Are the proposed application rates for new sites (hydraulic or
❑ Yes ❑ No ❑ N/A. If no, please explain:
7. Are the new treatment facilities or any new disposal s
❑ Yes ❑ No ❑ N/A. If yes, please attach a map
and recommend any mitigative measures/special
8. Are there any buffer conflicts (new treatment fac
to the Division
acceptable?
in a 100-year floodplain?
❑ Yes ❑No❑
areas of 100-year floodplain and please explain
in Part IV:
or new disposal sites)? ❑ Yes or ❑ No.. If yes, please
attach a map showing conflict areas or attach
any new maps you have received from the applicant to be
incorporated into the permit:
9. Is proposed and/or existing groundwater ,•monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? .'❑ Yes ❑ No ❑ N/A. Attach map of existing monitoring well
network if applicable. Indicate the r iew and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoiping program:
10. For residuals, will seasonal or
with restrictions (Certification fi?)
s stems
restrictions be required? ❑ Yes ❑ No ❑ N/A If yes, attach list of sites
Descrintion Of Waste[Sli And Facilities
1. Are there appropriately certified ORCs for the facilities? ❑ Yes or ❑ No.
Operator in Charge: Certificate #:
Backup- Oper for in Charge: Certificate #:
2. Is the design, maintenance and operation (e.g. adequate aeration, sludge wasting, sludge storage, effluent
etc) of the treatment facilities adequate for the type of waste and disposal system? ❑ Yes or ❑ No.
If no, please explain:
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? ❑ Yes or ❑ No. If no, please explain:
FORM: Regional5taffReportCombs UIC April 20072

AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Has the site changed in any way that may affect permit (drainage added, new wells inside compliance
boundary, new development, etc.)? If yes, please explain: f'
5. Is the residuals management plan for the facility adequate and/or acceptable to the Divisivsi7
❑ Yes or ❑ No. If no, please explain: f
r
6. Are the existing application rates (hydraulic or nutrient) still acceptable? ❑ WS or ❑ No. If no, please
explain:
7, is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? ❑ Yes ❑ No ❑ N/A. Attach map',O ' existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No,: explain and recommend any changes to the
groundwater monitoring program:
8. Will seasonal or other restrictions be required for added
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or
map showing conflict areas or attach any new map
into the permit:
Yes ❑ No ❑ NIA If yes, attach list of sites
sal sites)? ❑ Yes or ❑ No. If yes, please attach a
have received from the applicant to be incorporated
10. Is the description of the facilities, type and/or y6lume of waste(s) as written in the existing permit correct? ❑
Yes or ❑ No. If no, please explain:
11. Were monitoring wells properly constru d and located? ❑ Yes or ❑ No ❑ NIA.. If no, please explain:
12. Has a review of all self -monitoring data been conducted (GW, NDMR, and NDAR as applicable)? ❑ Yes or
❑ No ❑ N/A. Please summarise any findings resulting from this review: _
13. Check all that apply: ❑ 1,6 compliance issues; ❑ Notice(s) of violation within the last permit cycle; ❑
Current enforcement acti6n(s) ❑ Currently under SOC; ❑Currently under JOC; El Currently under
r
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc):
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? ❑ Yes
❑ No ❑ NovDetermined ❑ N/A.. If no, please explain:
15. Are there a issues related to compliance/enforcement that should be resolved before issuing this permit? ❑
Yes or o El N/A. If yes, please explain:
FORM: RegionalSWMeportCombs LJIC Apra 20073

AQUIFER PROTECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMITAPPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed -loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities —New, Renewal. And Modification
1. Type of injection system:
❑ Heating/cooling water return flow (5A7)
X Closed -loop heat pump system (5QM/5QW)
❑ In situ remediation (5I)
❑ Closed -loop groundwater remediation effluent injection (5LP'Non-Discharge")
❑ Other (Specify:
2. Does system use same well for water source and injection? ❑ Yes X No
3. Are there any potential pollution sources that may affect injection? ❑ Yes X No
What is/are the pollution source(s)? . What is the distance of the injection well(s) from the pollution
source(s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? Approx. 1320 f3.
5. Quality of drainage at site: X Good ❑ Adequate ❑ Poor
6. Flooding potential of site: X Low ❑ Moderate ❑ High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: N/A
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? X Yes or ❑ No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow. (Very crude drawing submitted, but qualitatively represents
features).
Iuiection Well Permit Renewal And Modification Un y:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
❑ Yes ❑ No. If ves. explain:
2. For closed -loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? ❑ Yes ❑ No. If yes, explain:
3. For renewal or modification of groundwater remediation permits (of any type), will
continued/additionailmodified injections have an adverse impact on migration of the plume or management of
the contamination incident? ❑ Yes ❑ No. If yes. explain:
FORM: RegionalSt dfReportCombs CTIC April 20074

AQUIFER PROTECTION REGIONAL STAFF REPORT
V. EVALUALION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuancetrenewwal of this permit? ❑ Yes X No. If yes, please explain
briefly.
4. List any items that you would like APS Central mice 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:
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. Recomyriendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information; X
Issue;[] Deny. If deny, please state reasons:
� ,f
S. Signature of report preparer(s): ,w J
Signature of APS regional supervisor;
Date; -41h I) a -7
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: Regioaal5taftReportCombs UIC April 20076

Da SYSTEM..-
08 Ft
6ff'
4 Ft dine].�'�. .
OF MANIFOLD `�-
Fkl i
Q f � VIEW
FROM t
ABOVE 019 ft:
1
Q 60• 45• � 45'`' j
D3-024 Z4 F1
1� Loops) 45' 4 f 45 `
OF MANIFOLD t" `. .
`PIT ti.,•'
F D ,
..45, Y FROM 451..
Q
+5' 45• '
D3-030
(8 Loops)
d8 Ft 4040' � •
Q 2.S Ft
40•
• 4 •f t d�G�R.- ....
BASE OF MANIFfXD
p PIT Q
4p• 40,
VIEW
FROM{
Q ABOVED3-036 40' 0 a 40'
(9 Loops) i0
15U-EL Appendix 2/06
t ` 38.7• 32.7-
1.Y'. t. 'k ,Q
327• , .
1.73 Ft
0
4 Ot dan u
��
T
BASE OF K4NY LD =
7'
PIT
32.7
0
4
VIEV
FlMH
i
ABUVE -IF
''
D3-042 3S?.7... _ p
(11 Loops) 'q�3��.- --•

Building Sketch (Page - 1)
Borrow CN id Lois KathrynCombs
City R'pnCrt'� AddrEs�299 6r8nd� Road
Stoneville Camy RocMn ham Scale NC 4y (;odp 27040
LerKW BB & T Mortgage
22.4'
Deck 3a
s`
Covered Deok� �� 24.6'
61 12.a'
21.9' v r t6A' *+ G
Breakfast
,g; OAudraam '- , Bedroom
i- atfiL I C FamllyBath
5 N C a
q}ryi C ivtehen R44"' C I7
a§,1 Cov.Poreh
� I. 9 Foyer Living Bath m
-+ Dining
Roam Room r
C
4fl.2'
�i Covered Parch
9.3'
18-p'
Bedroom III
Beth Bedroom
C ] i C � �` _ N
S and Level- D.
Ofilce Sltting Area C la.n
11,4' a ifi.B'
a.m crronrr�
Commsnw
AREA CALCULATIONS SUMMARY
coda
Dom Aom
Ws"
Nat Total*
GLAA
F1ra6 Floor
2523,5
2523.5
GTIX2
Sacond Floor
1091.2
1091.2
PAP
Cawrad Porch
89.5
r.rad Porch
396.0
Covered Dock
336,4
Duck
138.9
960,7
Net LIVABLE Area (Rounded) I 3615
L{VtNG AREA BREAKDOWN
6makdawn Suhewala
Flra1: Floor
4.1 x
12,5
52.5
24.6 x
37,4
920.0
3,5 x
7.4
259
32.9 x
35.2
1L54:6
17.9 x
20.7
370.5
Saaood Floor
15,0 x
180
2700
16,3 x
23:0
374:9
5.2 it
13.0
67.6
1.0 x
4.9
4.9
11.9 x
16,0
179.5
11.0 x
11.7
12if,7
7.4 x
9.0
66.6
12 Rams
(Rounded)
3615
Forth SKT.91dSk1-'TOTAL for WlndoWs' appraisal software by a la mode, Inc. 1.800-ALAMODE

w

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQ11ST FORM
Date: February 13. 2007
❑ Landon Davidson, ARO-APS
❑ Art Barnhardt, FRCS-APS
Andrew Pitner, MR_D .APS
❑ Jay Zimmerman, RRO-APS
'L m: h#L , Crar ,sndwater Protection Unit
1'? Telephone: [phone] G6
E-Mail: Michael.Rogersfiirncmailmet
❑ David May, WaRO-APS
❑ Charlie Stehman, WiRO-APS
Z Sherri Knight, WSR{O-APS
Fax: (919J 715-0588
A. Permit Number: WI 0400086
B. Owner: Kathr-*-n Combs
C. Facilitk/Oyeration:
Z Proposed ❑ Existing ❑ Facility ❑ Operation
D. Ata )bcation:
1. Per•ntit Type: ❑ Animal ❑ SFR-Surface Irrigation[] Reuse ❑ H-R Infiltration
❑ Recycle ❑ IIE Lagoon ❑ GW Remediation (ND)
® UIC - (5QM) closed loop mixed fluid geothermal
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
503 El 503 Exempt ❑ Animal
2. Project Type: 0 New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod,
E. Comments/Other Information: ❑ I would like to accompany you can 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 21 calendar days, please take the following actions:
Return a Completed APSARR Farm.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
[� Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please vrite your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer:
k 1reer-e—
Date• '�_' 15 r o .-
FORM: APSARR 07/06 Page 1 of 1

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: February 13, 2007
To: ❑ Landon Davidson, ARO-APS ❑ David May, WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Charlie Stehman, WiRO-APS
❑ Andrew Pitner, MRO-APS ® Sherri Knight, W SRO-APS
❑ Jay Zimmerman, RRO-APS
From: Michael Rogers , Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E Mail: Michael.Romt mcmail.net
A. Permit Number: WI 0400086
B. Owner: Kathrvn Combs
C. FaeilihAoPeration:
® Proposed ❑ Existing ❑ Facility ❑ Operation
D. Application:
1. Permit Type: ❑ Animal ❑ SFR Surface Irrigation❑ Reuse ❑ H-R. Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Remediation (ND)
® UIC - (5QM) closed loop mixed fluid geothermal
For Residuals; ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type: ® New ❑ Major Mad. ❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 21 calendar days, please take the following actions:
® Return a Completed APSARR Form.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO, *
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer:
Date:
FORM: APSARR 07/06 Page 1 of 1

Q �,+�
Michael F. Easley, Governor
0
William G. Boss Jr., Secretary
�
North Carolina Department of Environment and Natural' Resources
}.
(�
Alan W. Klimek, P.E. Director
Division of Water Quality
February 9, 2007
Kathryn Combs
299 Brandy Road
Stoneville, NC 27048
Subject: Acknowledgement of Application No. W10400086
Kathryn Combs SFR
Injection Mixed Fluid GSHP Well System (5QM)
Rockingham
Dear Ms. Kathryn Combs.
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on February 7, 2007. This application package has been assigned the number
listed above and will be reviewed by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary.
To ensure the maximum efficiency in processing permit applications, the Division requests your assistance in
providing a timely and complete response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final
action by the Division. Please also note at this time.. processing permit applications can take as long as 60 - 90 days
after receipt of a complete application.
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at
michael.rogers .nemail.net. if the reviewer is unavailable, you may leave a message, and they will respond
promptly. Also note that the Division has reorganized. To review our new organizational chart, go to
http:llh2o.enr.state.nc.ustdocuments/dwQ. oruchart.rdf,
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUMMS ON THIS
PROJECT.
SincereI ,
I f 1N.
for De ra . arts
Superysor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Permit Application File WIG400086
N�oy` Carolina
)VQtuxl�lry
Aquifer Protection Section 1638 Mail Service Center Raleigh, NC 27699-1636 Telephone: [phone]
Internet www.ncwaterausit.org Location: 2728 Capital Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal QpportunitylAfflrmative Action Employer- 50% Recycledl10%Post Consumer Papar Customer Service: [phone]

` + 1
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type 5A7 and 5QM Wells
In Accordance with the provisions of NCAC Title 15A; 02C.0200
Complete application and mull to address an the back page,
TO; DIRECTOR NORTH CAROLINA DIVISION OF-WA7ER QUALITY
DATE; T 3 , 20 0-4-
A. SYSTEM CLASSIFICATION Please check column which matches proposed System,
(1) � Typo 5A7 walls inject water used to provide heating or cooling for structures,
(2) Type 5QM wells contain a. subsurface system of continuous piping, that is
isolated from the environment and circulates it fluid other than potabfe water,
This includes.systems that circulate additives such its antifreezes and/or wrr(.ion
inh ibitors.
Type SQW wells contain it subsurfiwe system of continuous piping, that is
isolated fi�om the environment and only circulates potable wafter, if you selected
this well type, then comDletc_I'orm [:W-57 Cjs, Norykation Of Intent To
Construct A Closen-Loop t evrhermakWaxe Only Injecdon WeH $vsrex.
13_ PERMIT APPLICANT
Name; �i- "r,rnfo_? r-) �•►rL.s
Address. 9 19 13 9-1+n» R d
City: stk-,- e.y 11 e.. Stine; JVG zip Goole;2_304g County:
Ielephone, &'N—`�rv—�3g-5saeZ
C. PROPERTY OWNER (irdillemnt ream applicant)
Name:
►Q
Address;
City;
Telephone:
STATUS OF APPLICANT
Private; Fcdcra.l;
State:
Sate: Zip Code;
Municipal;
County.
Commercial:
Native American Lands;
Ra:vi.wd 5105
CMUIC:-57 HP
Page I of

E.
F
G.
X.
a\P
FACILITY (SITE) DATA
(Fill out ONLY i{'the Status o['Owner is Federal, State, Municipal or Commercial),
Name of Business or Facility:
Address;
City;
Telephone:
Zip Code:
ITEAT PUMP CONTRACTOR DATA
Name{ [.1 ry\c- --a
Contact Person;
County:
Address:
City: Zip Code; County;
Tcicphonc.,N q� 316 - Mk l _ Contact Person: _ Vkovnk-e— .S "n
INJECTION PROCEDURE
1 as\ c.-e-ll
(Briefly describe how the injec.-tion wen(s) will be used.)
WELL USE Will the injection well(s) also be used nsthe supply wells) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO
CONSTRUCTION DATA (check one)
EXISTINC WELL being proposed f'or use as an injection well. Provide the data in
(1) through (7) below to the best of your knowledge. Attach a copy of Form OW-
1 (Well Construction Record) if'avatilahle.
PROPOSED WELL to be constructer! for Use as an injection well, Provide the
data in (1) through (7) below its PROPOSED construction specifications. Submit
Form GW-1 after construction. &A
(1) Well Drilling Contractor's Name: - .' a I bL
NC Contramor [: ertl f ic.ution number. "
(2) Date to be constructed: Number of borings: �
Approximate dcpth of'cach boring (feet): i `` C)IDt
(3) Well casing: Is the well(s) crised? �jq
(a) ES If,vrrp, then provide he wwwing informat' below.
Type: vanized steel Black steel Plastic Oath r (specify)
Caxin& de c: Ftrom to ft. refer+ence to land su • }
C s sing, extends ove ,ground inches
(b) NO
ltcviiud 5105
❑W/UIC,-57 HP
Page 2 of 4

(4) Grout (material surreaurid ing well casing and/or piping
'�+
(a) Grout type-, Cement I"3C71t[]nit�` Other (spec,i �)
(b) Gro surl'cwe and gout depth (reference to land surlhve);
at c►und closed loop piping; from -hie� to L-1 J��eet},
around well casing; from to (feet).
(5) Screens (for Type 5A7 wells)
(u) Depth: Fi-irn to feet below ground surlh e.
(6) 1V.C. StatC licguTa 'ores (Title i A NCAC 2C . 2QIJ} rCquit� permitt td InakC 3roViSipnB
for m nitoring w+el cs?ui pro= S, A litucct o both influcn (fluid crft 'ng ircat (+mA) anti
effluen 'fluid being; 'e uted into he well) lineas =luired. W I there be tt auuet on
(a) then lumit line`? -es n (b) the effluent ? yes no
(7) SOURCE WELLCONSTRUC:TION INFORMATION (ii'dl(lcrcnt (lroln injectio well),
Attach it copy of Form G W-1 (Well Construction Rcuord). If Form OW-1 is not available,
provide the data in part K (1) ol'this application [orm to the best of your knowledge.
NOTE; Tim WELL DRTLUNO CONTRACTOR CAN SUPPLY T1IL' i]ATA FOR 13IT MR EXISTING OR
PRUPUS1317 W13LLS IF TiIIS INFORMATION IS L NAVAILABLQ BY 07i1L'R MIIANS.
i PROPOSED OPERATING DATA (for Type 5A7 wells)
(1) 1 �ec:t+on rate: Average (daily lions per minute (&am).
(2) Inj tIo Volume: Average (daily) gallons prr tiuY (�*pd).
(3) lnjccti P1�cssurc: rage (daily) undslsquarc inch (psi).
(4) Injection e:mperature -, Averagr (Janus ' F, Avera�; ly) ' F.
K. INJECTION FLUID DATA
(1) Fluid source (for Type SA7 wells) II'underground, Iroin what depth, 11ormation and type of
rock/sediment unit will the fluid be drawn (e_g., granite, limestone, sand, etc-).
❑LpLh: Furrnati+rn: Rock/sediment unit:
(2) Chemical Analysis oI' Sourcc Fluid (for Type 5QM wells)
Provide a GDmplete listing WV1, chemicals added to the circulating heat trunsler fluid:
L. INJECTION -RELATED EQUIPMENT
Attach a diagnun showing the engineering luyottt ol'the injection equipment laid exterior piping/tubing
associated with the injection operation, The manufacturer's brochure may provide supplementary
in (brmation.
M LOCATION OF W ELL(S) Attach two maps.
Rcvi +cd 5/05 CIW/UIC`57 HP Page 3 of

(1) Include a site map (can be drawn) showing. buildings, property lines, suriitc:e water bodies,
potential sources of gmo.undwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal 11tuilities such as septic tanks or
drain fields locates! within 1000 feet of the geothermal heart pump well system. Label all
features clearly and include it north arrow.
include a topographic map. ofthe ama extending one mile from the property boundaries and
indicate the i1wility's location and the map name.
N, PERMIT LIST; Attaoll a list ot'ail permits or construction approvals that are t-elated to the site.
lixamples include;
(1) [Hazardous Waste Manay*ement prograsan perinits under RCRA
(2)_ NC ❑ivision oI' Waiter Quail ity Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
O. CERTIFICATION.
"I hereby ccrti l'y, undcr pcnttlty of law, that I have personally cxamined and ani familiar with the
ini'orarration submitted in this document and all attachments} thereto Lind that, based on my inquiry aI'
those individuals immediately responsible. for obtaining said information, I believe that the
information is true, accurate and complete. I aim aware that there are sign f icant penalties, including
the possibility of fines and imprisonment, for submitting false: informution. 1 agree to construct,
operate, maintain, repair, and il'applimble, abandon the injection well and all related appurtenances in
accordance with the approved specilic:ations and conditions oNhe Permit„
(Signature cV Wall Owncr or Authorised Agent)
Tf authoriser! agent b oaring un behay'af the well owner,
plaiwe supply a Ivitur sgnorl by ihre uwnter authorizing the above agent.
P. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rebus
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application autd that it shall be
the responsibility of the applicant to ensure than the injection well(s) conforms to the Well
Construction Standards Title I SA NCAC 2C .02O )
r2'3,a 7
(Signature OI' property owner i t' INf l'ere;nt From Appl icant)
Please return two copies (if the completed Apptication package to,
U i C Program
Atluiler Protection Section
North Carolina DENR-DWQ
1636 Mail Service Cenier
Raleigh, NC 27699-1636
'Telephone [phone]
Rcv1sed 5/09 ()W/L1ICr57 HA Pagc4 of

I
299 brandy rd sloneville, nc
4pd3w
4W
Nc-2250
2047 "i, o r
r rnage 4P 2007 TerfjMuitics
'Google
Painter 36'28'04,37' N 79*48'30.A9' W uloy yfiO3 11 _,Streaming 100---Ll Eju -ill �6!0 It

2