WI0400099_GEO THERMAL_20090320

,, HCD ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Mark and Cynthia Riggins
2430 Wayne White Road
Pleasant Garden, NC 2731 3
Coleen H. Sullins
Director
March 20, 2009
Subject: 5A7 Geothermal Injection Well Permit Application
Dear Mr. & Mrs. Riggins:
Dee Freeman
Secretary
We requested a more detailed site map in a letter sent to you on January 6, 2009 (copy attached). To date, the Division of
Water Quality has not received the map and, therefore, the application is deemed incomplete and is being returned.
In order to obtain a permit, you will need to re-submit an application prior to operating your geothermal system.
Operating a geothermal system without a perm.it is a violation of North Carolina Administrative Code Title 15A,
Subchapter 2C, Section .021 l(a).
If you have any questions please call me at [phone].
Sincerely,
~~~~
Attachment
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. Wl0400099
Randolph County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh , North Carolina 27604
Environmental Specialist
GPU-Aquifer Protection Section
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Seivice : 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
N~ithcarolina
Jvatura:ll!f
Michael F. Easley, Governnr
William G. Ross Jr., Secretary
Forth Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
January 6, 2009
Mark and Cynthia Riggins
2430 Wayne White Road
Pleasant Garden, NC 27313
Subject: Permit No. WI0400099
5A7 Geothermal Injection Well
Randolph County
Dear Mr. and Mrs. Riggins:
We received your application package for the renewal of the above referenced permit to operate a 5A7
Geothermal Injection well on October 17, 2008. However, the site reap that was attached was not sufficient. A
more detailed site map showing elevation contours and layout of the house. utility building(s), existing and
proposed well locations, septic tank, and property boundaries is needed.
Therefore, please submit the detailed site map within 10 days of receipt of this letter. Please find attached
an aerial photo (AP) of your property and a topographic map of the area. Draw on the maps the needed items
previously mentioned. A self-addressed envelope is included for your convenience. Please send the original maps
to my attention at the address below and a copy to:
Stephen Berry
NCDENR-DWQ
585 Waughton Street
Winston-Salem. NC 27107
Include the permit number (W10400099) on the correspondence. If you need additional information
concerning this matter, please contact Stephen Berry at 336-771-5000 or me at [phone]. Thank you for
your cooperation.
Sincerely,
Michael Rogers
Environmental Specialist
GPU-UIC
Attachment(s)
cc: Winston-Salem Regional Office — Stephen Berry wlattachments
APS Central Files
Aquifer Protection Section
Internet http://h2o.enr.state.nc.us
.�� Carolina
iNaheralli
636 Mai{ Service Center Raleigh, NC 27699.1636 Phone [phone] Customer Service
2728 Capital Boulevard Raleigh, NC 27604 Fax [phone]
Fax [phone]
An Equal Opportunity/Affirmative Action Employer — 50°1° Recycted1l0%a Post Consumer Paper

Randolph Ccunty, NC - Printable Parcel Map
Page 1 of 2
Randolph County, NC - Printable Parcel Map
The data collection used to produce this media was last updated on 12/31/2008
©9:13:36AMEST.
Parcel ID Nbr
7788219025
Owner Name
RIGGINS MARK & CYNTHIA
Owner Address
2430 WAYN E WHITE RD
Owner City/St/Zip
PLEASANT GARDEN, NC 27313
Property Description
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North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
March 20. 2009
Mark and Cynthia Riggins
2430 Wayne White Road
Pleasant Garden, NC 27313
Subject 5A7 Geothermal Injection Well Permit Application
Dear Mr. & Mrs. Riggins:
We requested a more detailed site map in a letter sent to you on January 6, 2009 (copy attached). To date, the Division of
Water Quality has not received the rnap and, therefore, the application is deemed incomplete and is being returned.
In order to obtain a permit, you will need to re -submit an application prior to operating your geothermal system.
Operating a geothermal system without a permit is a violation of North Carolina Administrative Code Title 15A,
Subchapter 2C, Section .0211(a).
If you have any questions please call me at [phone].
Sincerely,
Att1/4.-dea_—e
Michael Rogers
Environmental Specialist
GPU-Aquifer Protection Section
Attachment
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No. W10400099
Randolph County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center. Raleigh, North Carolina 27699.1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] FAX 1: 919.715-058B; FAX 2: 919-715£6481 Customer Service. 1-877.623-6748
Internet www.ncwatemualitv.ortl
An Equal Upporrunity? Alrnaliva Action Employer
Coe-4- tznk.11 l oai 'o 0003 00,40 4 w I u
North Carolina
Naturally

Michael F. Easley, Governor
1�y a a�tQ� William G. Ross Jr.. Secretary
r North Carolina Department of Environment and Natural Resources
- - Coleen H. Sullins, Director
Division of Water Quality
January 6, 2009
Mark and Cynthia Riggins
2430 Wayne White Road
Pleasant Garden, NC 27313
Subject: Permit No. WI0400099
5A7 Geothermal Injection Well
Randolph County
Dear Mr. and Mrs. Riggins:
We received your application package for the renewal of the above referenced permit to operate a 5A7
Geothermal Injection well on October 17, 2008. However, the site map that was attached was not sufficient. A
more detailed site map showing elevation contours and layout of the house, utility building(s), existing and
proposed well locations, septic tank, and property boundaries is needed.
Therefore, please submit the detailed site map within 10 days of receipt of this letter. Please find attached
an aerial photo (AP) of your property and a topographic map of the area. Draw on the maps the needed items
previously mentioned. A self-addressed envelope is included for your convenience. Please send the original maps
to my attention at the address below and a copy to:
Stephen Berry
NCDENR-DWQ
585 Waughton Street
Winston-Salem. NC 27107
Include the permit number (WI0400099) on the correspondence. If you need additional information
concerning this matter, please contact Stephen Berry at 336-771-5000 or me at [phone], Thank you for
your cooperation.
Sincerely,
ri
Michael Rogers
Environmental Specialist
GPU-UIC
Attachment(s)
cc: Winston-Salem Regional Office — Stephen Berry w/attachments
APS Central Files
Ni"` Caraiina
atk ailij
Aquifer Protection Section 1636 Mail Service Center Raleigh. NC 27699-1636 Phone [phone] Customer Service
Internet: http,lm2o.enr.state.nc.us 2728 Capital Boulevard Raleigh, NC 27604 Fax (9I9) 715-0588 1-877-623-6748
Fax [phone]
An Equal Opportunity/Affirmative Aulion Employer - 50% Recycled/10% Post Consumer Paper

Randolph County, NC - Printable Parcel Map
Page 1 of 2
Randolph County, NC - Printable Parcel Map
The data collection used to produce this media was last updated on 12/31/2008
@ 9:13:36 AM EST.
Parcel ID Nbr
7788219025
Owner Name
RIGGINS MARK & CYNTHIA
Owner Address
_
2430 WAYN E WHITE RD
Owner City/StIZip
PLEASANT GARDEN, NC 27313
[Property Description
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Subdivisions
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(Outlined)
Tax Parcels
Coverage
2O07 Aerial
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RECEIVED / DENR / OWQ
AQUtFFR'PRnTFr.TtnN S~CTION
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR9CT 1 7 2008
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 5-A 7 'WELL(S)
--1-New Permit Application OR ____ Renewal (check one)
DATE: /o -1S--68 '20 o~~..j
t -~
PERMIT NJ> .. W.£ 0 "{. (7cJC •:tCf (leave blank ifNEW permit application)
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): JJ'f a, r k Dr°' {?fl r I<. Ua ( '?\ l
C p±lu-A. f:tucb Rc5j ;:,...""'
(1) Mailing Address: ?. 4 3 0 lJg Y,11 e {;J /2 ife {<cf!
City: ff ea. .s ~ 6 tt r& ~State: /!!.L. Zip Code: ~ 7 3 ( 3 County: f< 4Y1t de.-, f p ~
I
Home/Office Tele No.: 33G -bg5 -9 '2 0 '5' Cell No.: 336-3 I L -] I ZS
EMAIL Address: ,m a,-k. c '.j ~j , "'l .s @ j 111 o. ; ( , co ?l1
(2) Physical Address of Site (if different than above): ______________ _
City: ________ State: __ Zip Code: _____ County: ____ _
Home/Office Tele No.: ___________ C-=-e=l .... l N'"""'o:a-:..:,___ ________ _
EMAIL Address: ______________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: __________________________ _
Contact Person~: ________________ E __ MA-=-==IL;..;A;;..:;.d=d=-re=s=s: _________ _
Address: ____________________________ _
City: ________ State: _Zip Code: _____ County: ______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: _____________ _
GPUl{)lC SA 7 Well -Pennit Application (Revised 9/2007) Page 1
tttUtivto L) W Lou
laaulFrP'PPnTFt'TI{lN cFCTION
OCT 17 zon:
C. WELL DRILLER INFORMATION
Company Name: Ce4t r0 Co-4''U (L a l /'t t fFtci
Well Drilling Contractor's Name: 0?7y ry ,C[d
NC Contractor Certification No.:
Contact Person: T Lfh y , ci-e ire F �' c� EMAIL Address:
Address: q CC -NC 116.y -4/
City: -Bela C reek Zip Code: 2 7 2.07 County: C et In
Office Tele No.: q -5-qZ "gal Cell No.: Ci ' -7 oq- { �8
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Se I-'
Contact Person: EMAIL Address:
Address:
City: Zip Code: County:
Office Tele No.: Cell No.:
E. STATUS OF APPLICANT
Private: k Federal:
State: Municipal:
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
L14 k 4 f-r .t �vcA' cat c, -11 t k c. !?' f 7'p e 5d“ C
' !L-/
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(l) The injection operation?
(2) Personal consumption?
YES h< NO
YES ' NO
H. WELL CONSTRUCTION DATA (Skip to Section I if this is a Permit RENEWAL)
PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1)
through (7) below as PROPOSED construction specifications. Submit Form GW-1 after
construction.
EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through
(7) below to the best of your knowledge. Attach a copy of Form GW-1 (Well Construction
Record) if available,
(1) Date to be constructed: /I-) - Z cV 5? Number of borings: / -f p j
Approximate depth of each boring (feet): �]
(2) Well casing. Is the well(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES
If yes, then provide the casing information below,
Type; Galvanized steel Black steel Plastic X' Other (specify)
Casing thickness: _ _31 diameter (inches): depth: from 3.0 to 60 ft. (reference to land surface)
Casing extends above ground 13 + inches \ / f�
GPlJIl11C 5A7 Well Permit Application (Revised 9/2007) Page 2

I.
(3)
(4)
(5)
(6)
(b) NO
RECEIVED / DENR / DWQ
AQUIFl=R·PRnTFr.T!ON SF:CTION
OCT 17 2008
Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement .X Bentonite __ Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
__ Around closed-loop piping; from ___ to __ (feet).
~ Around well casing; from O to ¥ (feet).
Well(s) Screen Information
Depth of Screen: From · to ___ feet below land surface
N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead water quality and processes. A faucet on both Influent (groundwater entering heat
pump) and Effluent (water being injected back into the well) lines is required. Will there be a faucet on:
(a) Influent line? Yes+ No__ (b) Effluent line? Yes-X.-No __
Source Well Construction Information (if the water source well is a different well than the injection well)
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available, provide the
following data: -
Groundwater Source. From what depth, formation, and type. of rock/sediment units will the groundwater
be withdrawn? (e.g. granite, limestone, sand, etc.) '::
Depth: :Z. 7£'-: Formation: 1rt1M1~ Rock/sedimentunit: ______ _
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITIIER EXISTING OR PROPOSED WELLS IF . .
THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
OPERATING DATA
(1) Injection rate: Average (daily) L gallons per minute (gpm).
(2) Injection Volume: Average ( daily) ~gallons per day (gpd). / l.f 4 0
(3) Injection Pressure: Average ( daily) ~ pounds/square inch (psi).
( 4) Injection Temperature: Average (January) .£f;J_° F, Average (July) ]Q° F.
J. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
K. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
( 1) Include a site map ( can be drawn) showing: buildings, property lines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and . any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
·geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property ·boundaries and
indicate the facility's location and the map name.
GPU/UIC 5A7 Well Permit Application (Revised 9/2007) Page3
L. CERTIFICATION
RECEIVED I DENR I DM
AQUIFFR'ARITFi'.TInN SECTION
O C T 17 2008
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and 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.
l am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. 1 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."
1r' //24-
SitG of Property Owner/AtSplicant
/t{ r k (. IZ't Cyr 2
Print or Type Full Name tJ
Si ai •'ure of Property Owner/Appli
Print'or Type Full Name
131 `1 S
Signature of Authorized Agent, if any
Print or Type Full Name
Please return two copies of the completed Application package to
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
5
(IPU/UIC SA7 Well Permit Application (Revised 9t2007) Ptige 4

Randolph County, NC - Geographic Inquiry System
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RANDOLFM COUNTY.IEBAI,Th DEPARTMENT • •
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. •
Whito copy: Haalth Deportment Pink copy:.Prolparty Owner Yellow cop: Ccrarector

Michael F. Easley, Governor
William G. Ross Jr., Secrete!),
North Carolina Department of Environment and Natural Resources
Coker! H. Su11ins, Director
Division of Water Quality
January 6, 2009
Mark and Cynthia Riggins
2430 Wayne White Road
Pleasant Garden, NC 27313
Subject Permit No. WI0400099
5A7 Geothermal Injection Well
Randolph County
Dear Mr. and Mrs, Riggins:
We received your application package for the renewal of the above referenced permit to operate a 5A7
Geothermal Injection well on October 17, 2008. However, the site map that was attached was not sufficient. A
more detailed site map showing elevation contours and layout of the house, utility buildings), existing and
proposed well locations, septic tank, and property boundaries is needed.
Therefore, please submit the detailed site map within 10 days of receipt of this letter. Please find attached
an aerial photo (AP) of your property and a topographic map of the area. Draw on the maps the needed items
previously mentioned. A self-addressed envelope is included for your convenience. Please send the original neaps
to my attention at the address below and a copy to:
Stephen Berry
NCDENR-DWQ
585 Waughton Street
Winston-Salem, NC 27107
Include the permit number (W10400099) on the correspondence. If you need additional information
concerning this matter, please contact Stephen Berry at 336-771.-5000 or me at [phone]. Thank you for
your cooperation_
Sincerely,
Michael Rogers
Environmental Specialist
GPU-UIC
Attachment(s)
cc: Winston-Salem Regional Office — Stephen Berry w/attachments
APS Central Files
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636
Internet: http://h2o.enr.state.nc.us
2728 Capital Boulevard Raleigh, NC 27604
Phone [phone]!
Fax [phone]
Fax [phone]
N�� a
Caro ins
,Natarall!
Customer Service
1-877-623-6748
An Equal OpporiunitylAffirrnative Action Employer - 50% Recycled/10% Post Consumer Paper

Randolph County, NC - Printable Parcel Map
Page 1 of 2
Randolph County, NC - Printable Parcel Map
he data collection used to produce this media was last updated on 12/31/2008
@ 9:13:36 AM EST.
Parcel ID Nbr
7788219025
Owner Name
R1GGINS MARK & CYNTHIA
Owner Address
2430 WAYNE WHITE RD
Owner City/St/Zip
PLEASANT GARDEN, NC 27313
Property Description
WEATHERLY FARMS;L4
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Michael F. Easley, Governor
William G. Ross Jr,. Seereutry
North Carolina Department of Environment and Natural Resources
Cohen H. Sullins, i]irectot
Division of Water Quality
January 6, 2009
Mark and Cynthia Riggins
2430 Wayne White Road
Pleasant Garden, NC 27313
Subject Permit No. WI0400099
5A7 Geothermal Injection Well
Randolph County
Dear Mr. and Mrs. Riggins:
We received your application package for the renewal of the above referenced permit to operate a 5A7
Geothermal Injection well on October 17, 2008. However, the site map that was attached was not sufficient. A
more detailed site map showing elevation contours and layout of the house, utility building(s), existing and
proposed well locations, septic tank, and property boundaries is needed,
Therefore. please submit the detailed site map within 10 days of receipt of this letter. Please find attached
an aerial photo (AP) of your property and a topographic map of the area. Draw on the maps the needed items
previously mentioned. A self-addressed envelope is included for your convenience. Please send the original maps
to my attention at the address below and a copy to:
Stephen Berry
NCDENR-DWQ
585 Waughton Street
Winston-Salem, NC 27107
Include the permit number (WI0400099) on the correspondence. If you need additional information
concerning this matter, please contact Stephen Berry at 336-771-5000 or me at [phone]. Thank you for
your cooperation.
Sincerely,
fi
Michael Rogers
Environmental Specialist
GPLI-UIC
Attachment(s)
cc: Winston-Salem Regional Office — Stephen Berry wlattachments
APS Central Files
9sr NCaro -nt
1atura4'
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Phone [phone] Customer Service
interne: hatp:llh2a.enr.state.nc.us 2728 Capital Boulevard Raleigh, NC 27604 Fax [phone]
Fax [phone]
An Equal Opportunity/Affirmative Action Employer - 50°% Recydedr10% Post Consumer Paper

Randolph County, NC - Printable Parcel Map
Page 1 of 2
Randolph County, NC - Printable Parcel Map
The data collection used to produce this media was last updated on 12/31/2008
© 9:13:36 AM EST.
Parcel ID Nbr
7788219025
Owner Name
RIGGINS MARK & CYNTHIA
Owner Address
2430 WAYNE WHITE RD _
Owner City/St/Zip
PLEASANT GARDEN, NC 27313
Property Description
WEATHERLY FARMS;L4
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2007 Aerial
Photos
http://www.co.randolph.nc.us/scripts/esrimap. d11?name=Randolph&Cmd=CreatePrintWind... 1/6/2009

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RECEIVED / DENR / DWQ
AQU\FFR·PRnTFr.TtnN SF-CT10N
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR9CT 1 7 2008
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 5-A7 WELL(S) L New Permit Application OR ____ Renewal (check one)
DATE: lo -, s-_ -68 . . 20 o-~ ~,~
1--~
PERMIT NO. · l-Jf CJ c)() 0 9C( (leave blank if NEW permit application)
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on-property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): JYla r k Dr O.. ff! r R Lia I '71. '>
C y:n ±du 0-t1 cb RctJ Z-vt ,;.
(1) Mailing Address: 7.. 4 3 0 LJ~ r.?1 <e LJ /2 ;-l-e . R. cJ!.
City: f(ea .s ~ 6 (l r-& ~State: /!!.L. Zip Code: ~ 7 3 I 3 County: K e.ai de, f p 7
J
Home/OfficeTeleNo.: 336-{&>5-Gl cDS' CellNo.: 3.36-31 Z-]/25
' • /4) ·, EMAIL Address: (11'.) a r-1< °' r 'j.j, ::!>-$ 0 J 1n a 1 , C 01>1
(2) Physical Address of Site (if different than above): _______________ _
City: ________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: ___________ C~e=ll~N....aoa.a.,.: _________ _
EMAIL Address: ______________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: ___________________________ _
Contact Person-: --------------'E=MA...........,=IL=--A ....... d __ d"""'re:=.s==s: _________ _
Address: _____________________________ _
City: ________ State: __ · Zip Code: _____ County: ______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: _____________ _
GPU/IBC 5A7 Well Permit Application (Revised 9/2007) Page 1
1itt;ClVtU i Utiuh UVVL!
AQU FFR'PPnTPCTInM SECTtON
OCT 17 zoos,
C. WELL DRILLER INFORMATION
Company Name: C E.:41 �r .i C ro ( . a ` ..
Wet] Drilling Contractor's Name: l r'' 71r� S� /I c� J
NC Contractor Certification No.: ._; -7 `, S)
Contact Person: ! c' �! ll.rte v-e c /� EMAIL Address:
c55 NC IL( "Li ` I
City: - (-cz reek Zip Code: Z j 2.0 7 County: jl r1 L- ►1 LG irF
Address:
Office Tele No.: 0( r{ -5-4{Z-S01- f Cell No.: Cl lc(' 7O'1— g(-73
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: 5 I-P
Contact Person: EMAIL Address:
Address:
City: Zip Code: County:
Office Tele No.: Cell No.:
E. STATUS OF APPLICANT
Private: )t Federal:
State: Municipal:
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection wells) will be used)
(die t'r ttni G„To k, re e :)t :
ter' � �t1� E L t iPJC�I e-; :..k C- 7 i �. f j CY fil t {'� G rll “ C
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES .
YES 7=
NO
NO
H. WELL CONSTRUCTION DATA (Skin to Section I if this is a Permit RENEWAL)
PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (l)
through (7) below as PROPOSED construction specifications. Submit Form GW-1 after
construction.
EXISTING Weil(s) being proposed for use as an injection well. Provide the data in (1) through
(7) below to the best of your knowledge. Attach a copy of Form GW-1 (Well Construction
Record) if available.
(1) Date to be constructed: /j-) - Z(o) Number of borings: / 3
Approximate depth of each baring (feet): : 11 S
(2) Well casing. is the well(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES X If yes, then provide the Lasing information below.
Type: Galvanized steel Black steel Plastic K Other (specify)
Casing thickness: 31_ diameter (inches): * depth: from 30 to 60 ft. (reference to land surface)
Casing extends above ground 13 t inches `6 sue.
GP31MC 5A7 Well Perini[ Application (Revised 9/2007) Page 2

I.
(3)
(4)
(5)
(6)
(b) NO
RECEIVED/ DENR / DWQ
AQUll=l=R·PRnTFr.TION SF.CTION
OCT 17 2008
Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement .X Bentonite __ Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
__ Around closed-loop piping; from ___ to __ (feet).
~ Around well casing; from D to 25:' (feet).
Well(s) Screen Information
Depth of Screen: From ____ to ___ feet below land surface
N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead water . quality and processes. A faucet on both Influent (gro~dwater entering heat
pump) and Effluent (water being injected back into the well) lines is required. Will there be a faucet on:
(a) Influent line? Yes-4--No___ (b) Effluent line? YesJi.._ No __
Source Well Construction Information (if the water source well is a different well than the injection well)
Attach ·a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available, provide the
following data: --
Groundwater· Source. From what depth, formation, and type of rock/sediment units will the groundwater
be withdrawn? (e.g. granite, limestone, sand, etc .. ) ... 1.
· Depth: :-Z 7 ~ Formation: J rtlA111-'?..., Rock/sediment unit: ______ _
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR PROPOSED WELLS IF
THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
OPERATING DATA
(1) Injection rate: Average (daily) L gallons per minute (gpm).
(2) Injection Volume: Average (daily) ~gallons per day (gpd). /~ 4 0
(3) Injection Pressure: Average (daily)~ pounds/square inch (psi).
(4) Injection Temperature: Average (January) -51)__° F, Average (July) J.Q.° F.
J. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
K. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a site map (can be drawn) showing: ·buildings, property lines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between ·the proposed well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
GPU/UIC 5A7 Well Permit Application (Revised 9/2007) Page 3
L CERTIFICATION
RECEIVED 1 DENR 1 DWQ
ACKHFPP DPCITFCTION SFCTION
OCT 17 2008
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and 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."
T
%l 'rear
Signature of Property Owner/A plicant
ti L Par)e r
Print or Type Full Name
Signature of Property OwnedApplio5
PrinVor Type Full Name J
Signature of Authorized Agent, if any
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPL1/[_IIC 5A7 Well Permit Application (Revised 9120071 Page 4

Randolph County, NC - Geographic Inquiry System
http:llwww.co.randolph.nc.us/scriptslesrimap. dll?name=Randolph&Gerd=MapFro.. _
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DAIS

AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 12/19/2009
To: Aquifer Protection Central Office
Central Office Reviewer: Michael Rogers
Region~ Login No: n/a
L GENERAL INFORMATION
1. This application is (check all that apply): ~ New D Renewal
Conaty: Randolph
Permittee: Mark Riggins
Project Name: Riggins
Application No.: WI0400099
· D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application.of Residuals
D Distribution of Residuals
0 Attachment B included
0 Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation ~ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ~ Yes or D No.
a. Date of site visit: 11/05/2008
b. Person contacted and contact information: Mark Riggins (see application)
c. Site visit conducted by: Stephen Berry
d. Inspection Report Attached: D Yes or tZf No.
2. Is the:following information entered into the BIMS record for this application correct?
~ Y ~s or O No. If no, please complete the following or indicate that it is correct on the current application.
For Disposal and Iniection Sites:
(If multiple sites either indicate which sites the infomiation applies to, copy and paste a new section into the
document for each site, or attach additional pages for each site)
a. ~ation(s ): 2430 Wayne White Road, Pleasant Garden,
b. Driving Directions: From WSRO, 40W to 220.S; Left on NC-62 (Climax}, --Smiles: right on Racine road,
~lmile; Left on Wayne White Road, first house on the right
c. USGS Quadrangle Map name and number: Unknown
d. Latitude: 35°53'39.821"N Longitude: 79°43'58.212W
W. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed--loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well{S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
~ Heating/cooling wat~ retmn flow (SA 7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
0 Closed-loop groundwater remediation effluent injection (5Lf'Non-Discharge")
D Other (Specify: · )
i. Does system use same well for water sow-ce and injection? 0 Yes
REC_EIVED I DENR / DWQ 181 N0 Aqu1fer Protection Section
DEC 3 0 2008
AQUIFER PROTECTION REGIONAL STAFF REPORT
3. Are there any potential pollution sources that may affect injection? D Yes ~ No
What is/are the pollution source(s)? NIA.
What is the minimum distance of proposed injection wells from the property boundary? >50 ft. {well was to be
constructed at time of site visit.
4. Quality of drainage at site: 0 Good
5. Flooding potential. of site: D Low
6. NIA
IZI Adequate O Poor
~ Moderate D High
7. Qoes the map presented represent the actual site (property lines, wells, swface drainage)? 0 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.
I have requested this information from the well owner, and to date, no information has been received.
lniection :Well Permit Renewal And Modification Only:·
1. For heat pump systems, are there any abnormalities in heat pump or iujection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes D No. If yes, explain: System was not in operation at time of site visit; I have requested
to be present when system in charged.
2. NIA
3. NIA
4. Drilling contractor: Name: Tony "Steve" Sullivan
Address: 9565 NC HWY 42
Bear Creek, NC 27207
Certification number: 3238
5. Complete and attach Well Construction Data Sheet.
See aJtached
AQUIFER PROTECTION REGIONAL STAFF REPORT
V .. EVALUATION AND RECOMIOENDATIONS
1. Provide any additional narrative regarding your review of the application.: A down hole camera proved the
well is properly constructed. Static water level was lowered to insure casing was properly seated into bedrock.
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, please explain
briefly.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item
Reason
Detailed Site map (contour lines, all onsite
buildings, setbacks from septic, etc.
Application requirements
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
None
N/A
6. List specific special conditions or compliance schedules that ytfu recommend to be included in the permit when
issued.. Make sure that you provide a reason for each special condition:
Condition
Reason
Onsite inspection when system goes online
Owner has acquires used heat pumps; may be
potential source of contamination
Sample effluent at time of site visit
Used heat pumps may be potential source of
contamination
Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ® Issue upon receipt of needed additional. information; ❑
Issue; ❑ Deny. If deny, please state reasons:
8. Signature of report preparer(s):
Signature of APS regional supervisor:
Date: 11 il4 Zoo

AQUIFER PROTECTION REGIONAL STAFF REPORT
Figure 1. Existing well with no ID plates Fig.2 Existing well location (background)
Fig. 3a. Onsite burn refuse Fig. 3b. Onsite bum refuse (cont.)
Attached: Water sample analysis (R&A Alb and DWQ lab results)
GW-36Form
TTC (DWO Laboratory Section, (_Lesufts
County:
River Basin
Report To WSROAP
RA N DOLPH
Coltector. S BERRY
Region: WSRO
Sample matrix ?ROLINDWATER
Loc. Type: . ;ATER SUPPLY
Emergency YesIMo
COC Yes/No
l.iso':D
Loc. Zescr._ MARK AND CYN: till. rR.'GCiWS
Location ID: 41 76WlO400 99
ICollect Date: 1110512u38
j:,cllec`•. Time . :10
Sample Quaiifers ar i Comments
Sampl4 lD:
PO Number
''ate Received:
Time iRece iad:
L2bwori(s r ngi;ilD
Gate Repo:: iss.
Report Ganera:ed:
Sample Dept:1
8G 1487
11/06/2008
48:30
1i2S RKER
1212/0.;
12/02/2006
Rct tine Ciy2F le-s
F-c.- --. more detailP'fi description of mess geaIff;er ::Cdes
A -Value reported is the average of two or ;nova de;enr.:nattcrps
Bl-Cour.tabte membranes with <20 ,lcnies; Estimated
32- Counts t-om alt fitters were zero.
133- Countable membranes with more than 6C JJ c6onies: Estimated
-B4-Filters have counts >60 or 5O and c 2^; Estimated
85-Too .many colonies were p:-eseri::an n•irr_eroLs court (-CNTC)
J2- reported value. `a.fed to ;neet QC coterie for eater precision or accuracy: Estimated
13--The sample matrx intone ed with the ability to :"rake any cccurate deer ninat;cn, Estimated
J6-The lab analysis was from an unpreserved or improperly chemically preserVec sample; Est rnate.i
Ni-The component has been tentatively identified based on mass spectral 'bray search and `las an est
refer t ur'ri.er Stu Access
N"..":.-Est:mared conce ra:ior .s < PC:._ and 7M>rL
NE -No establisher' PQL
P-Elevated POL due to interfe;once a,.dlcr samr_le dilution
Qt.-Holding time e-x edrad prior to receipt at lab-
Q2- ilo,3ing time exceeded `cllowing receipt by lab
?C'_- Practicet Quantitatian Limit-subje.ipt to change d. a to inst-urnont sensitivity
tJ- Samples analyzed for this compound but not detected
Xi- Sample not analyzed for this cornpcl.+nd
mated -
I AR
:sa'a.:., >> :322. 27aPr-. -

Sample ID A237377
4PC761/00.4.:.3099
Jescr.: MARK AND CYNTHIA RIGGINS
sit ID
a6orctcrj Suction c.�os fts
LAB
CAS # Analyze !dame
Coi:ect Cate: 11/05/2008
Collect Time:: 1110
. e3 tit
Analyst, Date Approved By /Date
Sample temperature at rece p: by Lab 2.6 °C DSALINDERS HPARKER
Method Reference
WET
toil Ghroma:og:-aphy
Method Reference EPA 300.0
1 � / /fe 1116108
T1TI E_ :r:g/L AWILL1AI. S CGREEN
1 i/:3/08 - De
Total Dissolved 5oiids in liquid
Method Reference APNP2540 -18TH
2 156
:.h1or'de 1.0
Method Reference E?A
F1uaride
Mvhod Ref renca EPA 3Ck. s
Sulfate
Method Reference E?A 300.0
NUT
mriL
E'EN
11/6/08 11113/On
$.1 rng/L AWILL!A' S CGREEN
11 /13i J8 11/19/08
AWILLIAMS CGREEN
1 3/C8 .•78
2.3 2.3 .J A1nr1L Lt MS CGREEN
11/13/08 D8
NO2-NO3 as N in liquid 0.02
Method Refetence Lae 0-107-04-1-c
3.5 reg/L ss N MOVERMAN CGREEN
1117108 11/19/08
itrata as N 1, iiy-uid 0.02
Method Reference LecherD7-04-1-c
Nitrite as N in liquid 0.0 i
Me.'hod Reference Lac` et107-04-`-C
MET
3S rng1L as MOVERMAN CGREEN
11/10/08 11/13/0B
C.01 • _ as X MAJAYI CGREEN
1116/08 111/'0108
7440-22-4 Ag oy ICPMS 5.0 5.0 U ug/L J.:URGEVICH ESTAFFORD
Method Reference EPA 200.8
11/12/U 12/2108
7429-90-5 AI by ICP 50 50 U ug/L BSKNNER ESTAFFORD
Method Reference EPA 200.7
11/7/08 1212/08
7440-38-2 As by ICPMS 5.0 5.0 U ug/L JJURGEVICH ESTAFFOFID
Method Reference EPA 200_8
11/ 2148 1212/08
7440-38-3 Ba by ICP 10 U ug/L DSTAP LEY ESTAFFORD
Method Reference EPA 200.7
11/7108 12/1103
7440-70-2 Ca by ICP 0.10 35 ing/L DSTANL.EY ESTAFFORD
Method Reference EPA200.7
11/7/08 12/2/08
7440-43-9 Cd by 1C2MS 1.3
Method Reference 2PA 200.E
1.0 U ug/L JJ'JRGEVIC'.-t ESTAFFORD
11/12/08 12/2/08
7440.47-3 Cr by 1CPMS
Mettioc{ Reference EPA 20C.8
3 U ug/L J JURGEVICH ESTAFFCRD
11/12/08 12/2108
ab�f=tcri Se;:Mor» 1623 Ser4.:^B :"a: •.;-, - :n Y 27 S8S-1 E23 . TF3-?£;z8 Page 2 3

Sample ID
b33?377
4P0761I00400099
Jescr.:
.sit ID
MARK AND CVNT!?IA RICr:NS
WC ®WQ La6ora oaj Se•.' ti`m n Resi.dis
Coliect Date:
Collect Time:
•
A,aiyte
7440-5C-8 Cu by ICPMS
Method Reference EPA 200.8
7440-48-4 Fe ay ICP
Method Reference EPA 2G0.;
2.0
/05/2008
11:10
Resut: Cualit:P: Units
2.0 U
7439-97-6 Hg 245.1
Method Reference EPA 245.1
C.2
7440-09-7 K by ICP
Method Reference EPA 200.7
0.10
50 t#
0.20 :1
1.2
Analyst/Date
ug/L
- Jeri By /Dale
JJURGEViCH
11/12/08 •
DSTANLEY
11(1P 8
7439-95-4 Mn by tCP
Method Reference EPA 200_7
7439-96-5 Mn by 1CP
Method Refc:anw
EPA 2Cv_7
7440-23-4 3 by:CI'
rv1ethec Reference EPA 2C0.7
10
7.1
ug/L
m iL
r.1g1L
ESKINNER
711201=8
ESTAFFORD
12l2108
ESTAFFORD
12J2108
ESTAFFORD
12i2l08
DSTANLEY
1117108
ESTAFFORD
1212108
DSTANLEY
11(7/08
ESTAFFORD
12121u8
10
7.7
7440-02-0 Ni by ;CPMS
Method Reference EPA 700.8
10
:439-92-1 Pb by ICPMS
Met -rod Reference EPA 200.8
7 782-4S-2 Se by ICPMS
Method Reference EPA 200.8
7+ '0-8s-5 Z::y ICPMS
nreIE4:=i Reference EPA2GC.8
5.0
10 U
ug/L
DS"AN ..EY
11R108
DSTANLEY
11/7108
JJURGEVICH
i 1/13108
ug1L
ESTAFFORD
12/2/08
ESTAFF.DRD
12./2P8
ESTAFFORD
1212J08
JJURGEVIC-I
11112J08
ESTAFFORD
12J2J08
5.0
ti
WA-Telt (4fitaDO ss = It* nil_ of CZ CO5
ECaCo31 * z.5ECa'J + ` l GM,xl1
a 2.5 (3S) .c'1.1 (;.t)
I1l0-4I V1 IL.
JJURGEVtCH ESTAFFORD
11/12/os 12/2108
JJi.iRGE11IC!-! ESTAFFORD
11/12/08 12J2I08
(coMiao,4 C WA01.1 i Alp)
Lab —.-Iry:-be s

GROUNDWATER E F;EL D/LAB 702.114
COUNTY •
QUAD NO:
Let.
Randolph---
Seriai No.
Long.
REPORT TO S. Berry-WSR3
Sv�nDEO BY COURIER
COLLECTOR(S) Stephen Belly DATE:
F.ELD ANALYSES TIME: . %'
PH443 -j a Spec. Cond_gil•• at 25°C
Temp. t 5. L Odor NN
Appearance
Field Analysis By: Stephen
LABORATORY ANALYSIS
1:1OD 310 mglt !
[COD Hier 340 T mg/L
I COD Low 335
!Colifanm-MF Fes! 31616 . .
Conform: MY Total 3l5rr1 _ /100nl
�TOc mgli
3 rnfiidity
$Residua, Srtrxnded 530
'
1.n-a
mvji
.J.n, Co 16- Dr7 s-
4.5
IAlkalinity to pH 8.3
'Cu'..anete
units
nig/L
mgiL
I iBicarbanare mg/L J
L iCarbou dim6dc - m€R-
IX {Chloride
f!Chromium.: ilex I032
I kale'. "Otte SO C-4.
Cyanide 720
mot
LAB COMMENTS:
Noah Carolina
Sec: ~ant of Envi:on lent and .' atwrl Resources
DIVISION OF WAtER QUALITY - AQUIFER PROTECTION SECTION.
SAMPLE TYPE SAMPLE PRIORITY
L^_i W3tar Routine
nSoil Emergency
n Other
n Chain C:r Custody
Purpose: daseiihe
Owner:
Loca:3., or Site:
Description of sampling
Sampling Met,`lod:
Remancs:
IDiss. Solids 703E5
'Fluoride 951
!X 'Hardness: vocal990
[Hardness-- (noatrabj 902
:Phenols 32730
::ark & C;;nthia Biggins
Vtatar S1piry Head
Grab
Ls-T3i I--I2 Lab Number,c-;--
Date Received f I - ! n- C l] Time_
then Ey: r � From: R':s,ECou r-rl' '-Ia . ]El..
Data ;tom
Data
Reported:
-:',72376/ 4UE359
mg/L 66
tag/L 46557
mg/L _ _ .:.551
Orgennchlerine Pesticides
Orgaaopbas�tionss Pesticides
ug/L _-Nin-ogci Pesticides
met 1 - - -558 II&
arnnvscm2� -i559 ug L nail_ - 1E552 mrfi 1 Acid Herbicides
mg/L �, . _ 46560 ug/L
mgei. X iCu- Cop,cr 1042 6- it
r
mg/L X Ire- iron 1045 ug/L
mg/L ! Mg- Mercury 71900 ug/l-
X IiCJPomssiur446555
MeL X : -. r . 'Jai 927
! rX !Kn.-Manganese 1055
1Na- Sodium 929
INi-Ncckel
Pb-Lead46564
X ISe-Selenium
IX .ZrrZirw46567
SpeciEe Cond. 95
Sulfate
Sulfide 745
SILICA
41-13asN6:R
as N' 625 �1
NO2 +NO3asN630 ( ,ri.pl 1C#iJ"
n.To--X.esP665 `a
Nitrate (NO3 as N) 620
Nitrise (1N102 es 1v; 6l5
mgfL
mglL
opt
ug/L
iSemivoletiles
ITPH-D:eset Range
Volatile Organics (VOA bunk-)
mg/L l 1 IT'13 wne Range li
` ugR. iTrPH-1 i:X Gzwlire Range
I
l $
LAB USE_ -ii ,Y
TEMPERATURE ON ARRIVAL-
GW-54REV.71R3 FOR DJSSOLVEDANAL. .'SJS SiIBf.UTFILTERED SAMPLE AND F tTE"tiS" BLOCK

RE5EARCh & ANAIyTiCAL
LAbORATORiES, INC.
Analytical/Process Consultations
Novcn►ber 11, 2008
NCDWQ - Winston Salem Office
585 Waughtown Street
Winston Salem, NC 27107
Attn: Stephen Berry
Re: Bacteriological Testing
Sample Source- W0..I
Sample Date: 11/05/08
Sample Time: 1052
Sample Received: 11/05/08
Sample Analyzed: 11/05/08
Sample Number: 631416
Parameter Method Results
Total Coliform Colitag Absent
Fecal Coliform Colitag Absent
Analyst: S.J.
No Bacterial Contamination Found
No Fecal Contamination Found
P.D. Box 473 6106 Short Street • iternursviile, North Carolina 27284 • 338-P96-2841 • Fax 336-P96-0326
www,randalabs,com

Well Location:
Owner.
North Carolina
Department of Environment and Natural Resources
Division of Water Quality
Groundwater Section
WELL AND PUMP INSPECTION REPORT
P L.E 5_Ada r QAIzDEN Nay 4 -87• 3 "15423
(Town, Community. Subdivision and Lot No.)
M AQX 1)(2.PPEQ R16cr-iN S
Address: 2.410 WAYNe g WF1i IF Qc f
PLEASANT C J fNf 21-313
Date 12 I9 2 ooS WELL TYPE 'MR ik 1r ! S A7
County LAN DoLP#
Road/Street WOVE W ifTE &D•
Quad No. vsJlcNOWPl
Serial No. u JK,JOWJi!
Lat '5653'39konfLong.111.4e5S4_ W
Well Contractor
Well Construction
NIQJ
Name
Contractor Gertific ion #
Address
Check Items
Measured
Meets Min.
Yes
Standards
No
Remarks
Permit Required 7 (Y/N)
(Permit No. \L044 000 't )
l
.
Location - Distance From:
Water Tight Sewage/waste collection
Waste disposal (septic tank drain field)
Other Poll. Source { )
Other Poll. Source ( )..
-
Caine
Type
Depth
W elghlllhlckness
Height (A L S
0 th e r ( S(h1rb IA g> t W. ]
(Circle one)
Plastic Carbon Gaiv. Stain. St. Other
1
1
f-
V
II
Weil c1.46. i llw6-tr.4e1
Drilling FluidslAdditives
Type
Grout
Tyke , , , .
De p thr ............. ... ............... ...............
0iher ( )
�
VP
Screens
Screened interval
Other (
Development
Total Suspended solids
Turbidity
Settleable Solids
I.D. Plate
l
"
%
N/° Weil /puWtp 1•. f hies
Weil Contractor
Abandonment
!
Temporary
Permanent
GW-36 Rev. 1/2000
Applies to wells constructed after December 1, 1992
lilnnl n n RAvArsp1

Well Test
Duration
Frequency/Accuracy of measurements
Other (
Dist rirection
Chlorination
Other (
Cuttings.
Reports
Construction (GW-1)
Abandonment (GW-30)
Weil Head Como!etiort
Access port
Huse bib
Pitless Adaptor
Pitless Adaptor Unit
Suction line
Tee (jet)
Valved flow
Vent
Water tight pipe entry
Well entry
Date Well Constructed
Pump Installation Contractor
)
Check items
Measured
Meets Min. Standards
Yes No
Remarks
C liarr s+hkel pos4 Ga.Hre.►a. srarse i.
V Pir.24cmilki
Applies to wells constructed after December 1, 1992
PUMP Installation
Name Address Reg. #
PUMP QQN7RACTOR I.D. PLATE PRESENT ? (YIN) Date Pump Installed t1t.J+'CNovid
Violations noted attributable to the pump installation contractor are as follows:
(1)
(2)
(3)
INSPECTOR STTP4-et4 Beg.R`( W5RD-04PS
Name Office
Witness(es) -row( SUI.+-11i�41� Set. °� �Le-A on
(If Available) Name Address
CMr&iE❑ weu. b&Iu.0031,38
Type
Name
Address Type

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins Director
Division of Water Quality
October 20, 2008
Mark Draper Riggins
Cynthia Hucks Riggins
2430 Wayne White Road
Pleasant Garden, NC 27313
Subject: Acknowledgement of Application No. W10400099
Mark and Cynthia Riggins SFR
Injection Heating/Cooling Water Return Well (5A7)
Randolph
Dear Mr. & Mrs. Riggins:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on October 17, 2008. 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. Pleasealso note at this time, processing permit applications can take as long as 60 - 90 days
after receipt of a complete application.
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at
[e-mail]. If the reviewer is unavailable, you may leave a message, and they will respond
promptly. Also note that the Division has reorganized. To review our new organizational chart, go to
http://h2o.enr.state.nc.us/documents/d wa orkchart. pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS
PROJECT.
Sincerely,
aW4,.
6cou
for Debra 3.
Supervisor
cc: Winston-Salern Regional Office, Aquifer Protection Section
Permit Application File WI0400099
N rthCara inn
Naturally
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone: [phone]
Internet: www.ncwaterqualltv.orq Location: 2728 Capital Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2; [phone]
An Equal 0pportunityIAlffrrnative Action Employer 50% Recycledlla% Pot Consumer Paper Customer Service: [phone]

DATE,TIME
FAX NO./NAME
DURATION
PAGE(S)
RESULT
MODE
TRANSMISSION VERIFICATION REPORT
10/24 16:13
91336 7714630
00:02:19
08
OK
STANDARD
ECM
TIME 10/24/2008 16:15
NAME NCDE&NR/WATER QUAL
FAX [phone]
TEL [phone]
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
William G. Ross Jr., Secretary
Coleen H. Sullins, Director
Division of Water Quality
Aquifer Protection Section
Location: 2728 Capital Blvd.
Raleigh, NC 27604
Mailing Address: 1636 Mail Service Center
Raleigh, N.C. 27699-1636
FAX: [phone]
1919) 715-6048
Date: l oft-`�/4 e
FAX TO:
REF:
FAX NUMBER:
FROM: 1/4.4._
PHONE:
NO, OF PAGES INCLUDING THIS SHEET:

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: October 21, 2008
To: 0 Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS
0 Andrew Pitner, MRO-APS
D Jay Zimmerman, RRO-APS
0 David May, WaRO-APS
0 Charlie Stehman, WiRO-APS
[8] Sherri Knight, W-SRO-APS
From: Michael Rogers Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E-Mail: [e-mail]
A. Permit Number: WI 0400099
B. Owner: Mark and Cvnthia Riggins
C. Facility/Operation: __
~~ D Existing D Facility D Operation
D. Application:
1. Permit Type: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D 1/E Lagoon D GW Remediation (ND)
[8] UIC -(5A7) open loop geothermal __
For Residuals: D Land App. D D&M
D 503 D 503 Exempt
D Surface Disposal
□ Animal
2. Project Type: [8] ~--D Major Mod. D Minor Mod. D Renewal D Renewal w/ Mod.
E. Comments/Other Information: ~ ~ ~~l<i . l~ to accompany you on a site visit.
NOTE: If mv schedule will allow, I would like to go out in the field with your staff on this
inspection. Late in the morning or early afternoon works better for me {we can grab lunch on the
way).
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 14 davs of receiving laboratory analytical results, please take
the following actions:
~ Return a Completed APSARR Form and attach laboratory analytical results.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits 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: AP SARR 07 /06 Page 1 of 1
Permit Number W10400099
Central Files: APS SWP
10/20/08
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michaei.ragers
Permitted Flow
Facility
Facility Name
Mark and Cynthia Riggins SFR
Location Address
2430 Wayne White Rd
Pleasant Garden NC 27313
Owner
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Mark Riggins
2430 Wayne White Rd
Pleasant Garden
NC 27313
MajarlMlnor Region
Minor Winston-Salem
County
Randolph
Facility Contact Affiliation
Owner Name
Mark
Dates/Events
Orig Issue
Draper Riggins
App Received
10/17/08
Regulated Activities
Outfall NULL
Draft Initiated
Scheduled
Issuance
Waterbody Name
Owner Type
Individual
Owner Affiliation
Mark Riggins
2430 Wayne White Rd
Pleasant Garden
NC 27313
Public Notice issue Effective
Expiration
Stream Index Number Current Class Subbasln
1 aiceip AAP. "
,,4 (-0-az4