WI0400130_GEO THERMAL_20120518

Beverly Eaves Perdue
Governor
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 18, 2012
NC Department of Cultural Resources
1610 Fort Fisher Boulevard South
Kure Beach, NC 28449
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0400130
To Whom it May Concern:
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 ://portal.ncdenr.or g/web/wq/ap s.
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.O.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity\ Affirmative Action Employer
.One · .. North Carolina
;Natural/11
Permit Number WI0400130
Program Category
Ground Water
Permit Type _
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilltv
Facility Name
Kimball Hall Building -Charlotte Hawkins Brown
Museum -
Location Address
6136 Burlington Rd
·Gibsonville
Owner
Owner Name
NC 27249
N C Department of Cultural Resources
Dates/Events
Orig Issue
05/13/10
App Received Draft Initiated
04/05/10
Scheduled
Issuance
Central Files: APS_-_ SWP_
05/24/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Janice Scott
8275 Tournament Dr
Memphis TN
Major/Minor
Minor
Region
Winston-Salem
County,
Guilford
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Mark Cooney ·
4605 Mail Service Ctr
Raleigh NC
Public Notice Issue
05/13/10
Effective
05/13/10
381250851
276994604
Expiration
04/30/15
_R_e ___ g_t.i_la_te_d_A_c_ti_v_it_ie_s _______________ .::...:R=e-=g-=u=es=t=e=d::....::/R-=e=c=-=e=iv.::...:e=d=---=E~ve=n=t=s'------------
Heat Pump Injection Additional information requested
Outfall NULL
Waterbody Name
RO staff report requested
RO staff report received
Additional information received
Stream Index Number Current Class
04/15/10
04/16/10
05/04/10
05/06/10
Subbasin
Permit Number WI0400130
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michaei, ropers
Coastal SW Rule
Permitted Flow
Facillty Name
Kimball Hall Building - Charlotte Hawkins Brown
Museum
Location Address
6136 Burlington Rd
Gibsonville NC 27249
Central File& APS 5WP
05/06/10
Permit Tracking Slip
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Janice Scott
8275 Tournament Dr
Memphis TN 381250851
Major/Minor Region
Minor Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Name Owner Type
N C Department of Cultural Resources Government - State
Owner Affiliation
Mark Cooney
4605 Mail Service Ctr
Raleigh NC 276994604
Scheduled
Arig Issue App Received Draft Initiated Issuance
Public Notice issue Effective
E! "
04/05/10
-A I tl 10
_��� )!5
Reoulated Activities
dues e 1 ecefv!Rd Eyepjs
Heat Pump Injection
Additional information requested
04/15/10
RO staff report requested
04/16/10
RO staff report recelved
05/04/10
Additional information received
05/06/10
❑utfall NULL
Waterbody Name Stream Index Number Current Class Subbasin

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
May 13, 2010
Mark Cooney, Capital Projects Director
North Carolina Department of Cultural Resources
4605 Mail Service Center
·Raleigh,-NC 27699-4605
Subject: Issuance of Injection Well Permit
Permit No. W10400130
Dear Mr. Cooney:
. Issued .to· North Carolina Dept. of
-Cultural Resources -Charlotte
Hawkins Brown Museum
Guilford County
Dee Freeman
Secretary
In accordance with your application received April 5-~ 2010, I am forwarding Permit No. WI0400130 for
the construction and operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well
.system to be located at the Kimball Hall Building at.the Charlotte Hawkins Brown Museum, 6136
Burlington Road, Gibsonville, NC 2 7249, permit shall be effective from· the date of issuance until April
30, 2015-, and shall be subject to the conditions and limitations stated therein.
Please pay special attention to Part VII.2 of the pennit and submit copies of the Well Construction
Completion form (GW-1) after construction. Please submit all data within 30 calendar days of ·
completion· of installation ·of geothermal well(s) to the following address:
Aquifer Protection Section (APS)
Underground Injection Control.(UIC) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
Additionally, your UIC systeni is subject to inspection by the APS. Per special condition Part Il.3, in the
event that there will be multiple wells · with separate clusters, one well identification tag-per 'cluster'· of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location accordn:ig to 2C .02l3(g).
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 nottransferable 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 me at (919).715-6166.
cc: Sherri Knight-Winston-Salem Regional Office
Central Office File -WI0400130
Appalachian District Health Dept.
Sincerely,
~~~
Michael Rogers, ~.G.-{Nc & FL)
Environmental Specialist
Janice Scott -Midsouth Geothermal, LLC (faxed to 901-748-9097')
Attachment( s)
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
M��s;�4�����+�Il��� �'��ti7:�►M��11�1C�7
North Carolina Dept. of Cultural Resources —
Charlotte Hawkins Brown Museum.
FOR THE CONSTRUCTION AND OPERATION OF 9 TYPE 5QM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code ?C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at the Kimball Hall Building of the Charlotte
Hawkins Brown Museum, 6136 Burlington Rd., Qibsonvilie, Guilford County, NC 27249, and will be
constructed and operated in accordance with the application received April 5, 2010, 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 of an injection well and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked. from the date of its issuance until April 30, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through Ili hereof.
Permit issued this the 130' day of May 2010.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission,
Permit W10400130 UIC/5QM Page 1 of 5
ver. 03/2010

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 (l 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 afforded reasonable protection against damage during construction and use.
PART II-WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Pennittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number (919) · 715-6166, and the Winston-Salem Regional Office Aquifer Protection Section Staff,
telephone number [phone].
2. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site ( e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
3. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III-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.
Permit WI0400130 UIC/SQM
ver. 03/2010
Page 2 of 5
PART IV-PERFORMANCE STANDARDS
• :J
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 arid 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 Pennittee of the· responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive · prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not-specifically authorized by
the permit.
3. At least. forty-eight (48) hours prior to the initiation of .the <;>peration -of the facility for injection, the
Perinittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number (91.9) 715-6166. ·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. ·
PARTVI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quali~y may, upon
presentation of credentials, enter and inspe~t 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
sampl~s of groundwater, surface water, or injection fluids.
2. Division 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.
Permit WI0400130 UIC/SQM
ver. 03/2010
Page 3 ·ot 5
PART VII-MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Winston-Salem Regional Office
585 \Vaughtown Street
Winston-Salem, NC 27 :l 07
[phone]
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Winston-Salem Regional Office within 30 days of
completion of well construction. Copies of the GW-1 fonn(s) shall also be given to the Permittee and
retained on site to be made available for inspection.
3. A copy of the site map updated with manifold locations required in Part II.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Winston-Salem Regional Office within
30 days of completion of well construction.
4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground '\1/ater protection will be established and an
acceptable sampling reporting schedule shall be followed.
5. The Pennittee 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.
6. 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.
7. In the event that the permitted facility fails. to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit WI0400130 UIC/SQM
ver. 03/2010
Page 4 of 5
PART IX-CHANGE OF WELL STATUS
1. The Pennittee shall provide written notification within 15 days· of any change of status of an injection
well. · Such a ~hange would include the discontinued use of a well for injection. _-If a well is taken
completely out of service temporarily, the-Pennittee must install a sanitary seal. If a well is not to be used
for any purpose, then that well must be permanently abandoned according to ISA NCAC 2C .0213(h)(l).
Notification shall be submitted to the.addresses given in Part VII.I of this permit.
2. When ·operations have ceased at the facility and a well will no longer be used for any purpose, the
·pennittee shall abandon that injection well in accordance with the procedures specified in ISA 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 4o so could lead to the contamination of an undergroll:lld source of drinking water.
(D) Each well shall be ·completely filled with cement grout, which shall be introduced_ into the well
through· a pipe that extends to the bottom of the well and is raised as the well is filled.
, (E) In the case_of gravel-packed.wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet,. and grout
injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into. or
between underground sources of drinking water and in· accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in ISA NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit WI0400130 UIC/SQM
ver. 03/2010
Page 5 of 5
AQUIFER PROTECTION REGIONAL STAFF REPORT
1 I
Date: 04/27/10 County: Guilford
To: Aquifer Protection Central Office Permittee: NC Dept. Cultural Resources
Central Office Reviewer: Rogers Project Name: Charlotte Hawkins Brown Museum
Regional Login No:__ Application No.: Wl0400130
L GENERAL INFORMATION
1. This application is (check all that apply): ~ New D Renewal
RECEIVED/ DENR / DWQ
Aquifer Protection Section
D Minor Modification D Major Modification MAY O 4 2010
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
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation IZ! Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? cgj Yes or D No.
a. Date of site visit: April 26, 2010
b. Person contacted and contact information: J. Wayne Poole, General Contractor [phone];
!!Culler(i ',hvac-cas.com. Ken -Mid-South Geothermal but contact Janice Scott
j [e-mail]
c. Site visit conducted by: Sherri Knight
d. Inspection Report Attached: D Yes or~ No.
2. Is the following'information entered into the BIMS record for this application correct?
IZ! Yes or D No. If no~ please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
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): None
For Disposal and Iniection Sites:
{If multiple sites either indicate which sites the information applies to, copy and paste a new section into the
document for each site, or attach additional pages for each site)
a. Location(s): 6136 Burlington Road, Gibsonville·, NC
b. Driving Directions: From Winston-Salem take I-40 to exit #132 Mt Hope Church Road. Turn right on
Knox Road (.2 mile) and go approximately 2.2 miles to Burlington Road (Hwy 70) and turn right. The
facility is located on the right.
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
FORM: staff report -NC Cultural Resources uic.doc 1
AQUIFER PROTECTION REGIONAL STAFF REPORT
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section)
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No IZ! N/f\.. Ifno, please explain: __
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? D Yes D No IZ! N/ A. If no, please explain: __ Does the
application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? IZ! Yes D No
D N/ A. If no, please explain: __ Is the proposed residuals management plan adequate and/or acceptable to
the Division. D Yes D No IZ! N/ A. If no, please explain: __
4. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No IZ! N/ A. If no, please explain: __
5. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No IZ! NIA. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
6. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or IZ! 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: __
7. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No IZ! NIA. Attach map of 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. For residuals, will seasonal or other restrictions be required? D Yes D No IZ! NIA If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or maior modification
systems)
Description Of Waste(S) And Facilities
1. Are there appropriately certified ORCs for the facilities? D Yes or D No.
Operator in Charge: __ Certificate #: __
Backup-Operator in Charge: __ Certificate #: __
FORM: staff report -NC Cultural Resources uic.doc2
AQUIFER PROTECTION REGIONAL STAFF REPORT
t I
2. Is· the design, maintenance and operation (e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D No.
If no, please explain: __
3. Are the site conditions ( soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? D Yes or D No. If no, please explain: __
4. Has the site changed in any way that may affect permit (drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain: __
5. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
D Yes or D No. If no, please explain: __
6. Are the e,cisting _ application rates (hydraulic or nutrient) still acceptable? D ·Yes or D No. If no, please
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes D No ~ N/A. Attach map of 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 sites? D Yes D No~ N/A If yes, attach list of sites
with restrictions (Certification B ?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D 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: ___ _
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? D
Yes or D No. Ifno, please explain: ____ _
11. Were monitoring wells properly constructed and located? D Yes or D No ~ N/A. If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? D Yes or
D No D N/ A. Please summarize any findings resulting from this review: __ _
13. Check all that apply: ~ No compliance issues; D Notfoe(s) of violation within the last permit cycle; D
Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently under
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? D Yes
D No D Not Determined ~ NI A.. If no, please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit?
D Yes or~ No D N/A. If yes, please explain: __
FORM: staff report -NC Cultural Resources uic.doc3
AQUIFER PROTECTION REGIONAL STAFF REPORT
IV. 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:
D Heating/cooling water return flow (5A7)
[8J Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
D Other (Specify: __________________ _
2. Does system use same well for water source and injection? D Yes IZ! No
3. Are there any potential pollution sources that may affect injection? D Yes IZ! No
What is/are the pollution source(s)? None known. What is the distance of the injection well{s) from the
pollution source(s)?
4. What is the minimum distance of proposed injection wells from the property boundary?_> 100 ft.
5. Quality of drainage at site: IZ!Good D Adequate D Poor
6. Flooding potential of site: [8J Low D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes or D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program:
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? [:8J Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Iniection Well Permit Renewal And Modification Only:
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)?
D Yes D No. If yes. explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes, explain:
3. For renewal or modification of groundwater remediation permits (of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes D No. If yes, explain:
FORM: staff report -NC Cultural Resources uic.doc4
AQUIFER PROTECTION ~GlpNAL STAFF REPORT
4. Drilling contractor: Name: MidSouth Geothermal
Address: 8275 Tournament Drive . Suite 185
Memphis . TN 28125
Certification number:
5. Complete and attach Well Construction Data Sheet.
FORM: staff report -NC Cultural Resources uic.doc5
AQUIFER PROTECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application. 9 wells proposed. Water will be
supplied by the City of Greensboro. Sewer system will pump back up to the street to the City of Greensboro.
2. Attach Well Construction Data Sheet -if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? D Yes [8] No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information;
8. [8] Issue; D Deny. If deny, please state reasons:
9 . Signature of report preparer(s): ________________________ _
Signature of APS regional supervisor: _____________________ _
Date: _______ _
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: staff report -NC Cultural Resources uic.doc6
Rogers, Michael
From:
Sent:
To:
Subject:
Attachments:
Staff report attached
Sherri Knight, PE
Knight, Sherri
Tuesday, May 04, 201 O 12:17 PM
Rogers, Michael
wi0400130
staff report -NC Cultural Resources uic.doc
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: {336) 771-4632
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.
1
,Rogers, Michael
From:
Sent:
Janice Scott ·[e-mail]]
Thursday, May 06, 2010 2:53 PM
To: Rogers, Michael
Cc: Janice Scott
Subject: RE: North Carolina department ofcultural affairs WI 0400130 5/6
Mr. Rogers,
At the time, I did not know who we were planned on using. Now we plan to
use: Benford Graham NCWC 2373-A Graham & Currie Well Drilling.
Unfortunately, if we have to do these ahead, I may not know. Sorry for the inconvenience.
Thank you,
Janice E. Scott
Office Manager
MidSouth Geothermal, LLC
8275 Tournament Dr. Ste. 185
Memphis, TN 38125-0851
Office [phone]
Fax [phone]
[e-mail]
www.midsouthgeothermal.com
-----Original ·Message-----
From: Rogers, Michael [mailto:[e-mail]]
Sent: Thursday, May 06, 2010 1:01 PM
To: Janice Scott
S_ubject: FW: No.rth Carolina department of cultural affairs WI 0400130
Who is.the North Carolina c~rtiffed driller for this project? There was no
driller listed on the application.
Michael Rogers, P.G. (NC & FL)
Environme~tal Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct ·Line [phone]; Fax [phone] (put to my attn on cover ·1etter)
E-mail correspondence to and from this address may be subject .to the North
tarolina Public Records Law and may be disclosed to third parties
-----Original Message-----
From: Rogers, Michael
Sent: Thursday, May 06, 2010 10:32 AM
To: 'Janice Scott'
Subject: North Carolina department of cultural affairs WI 0400130
1
I Received the staff report Tuesday. I will be working on this today or
tomorrow and the permit will probably go out next week.
Michael Rogers, P.G. {NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section {APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line {919) 715-6166; Fax [phone] (put to my attn on cover letter)
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
-----Original Message-----
From: Janice Scott [mailto:[e-mail]]
Sent: Monday, April 26, 2010 1:10 PM
To: Rogers, Michael
Cc: Janice Scott
Subject: re: new 5QW application 4/26-Davidson Co. Comm. College
Mr. Rodgers,
Attached is a new 5QW application. Please process and let me know if you
need anything else.
Thank you,
Janice E. Scott
Office Manager
MidSouth Geothermal, LLC
8275 Tournament Dr. Ste. 185
Memphis, TN 38125-0851
Office {901)748-9095
Fax {901)748-9097
j scott@midsouth geothermal.com
www.midsouth geothermal.com
2
Rogers, Michael
From:
Sent:
To:
DCR -AH -Charlotte Hawkins Brown
Thursday, May 06, 2010 12:58 PM
Rogers, Michael
Subject: RE: physical address
Physical Address is 6136 Burlington Hoad, Gibsonville, NC 2724,9.
Our website has the location using Google Maps. :It shows the correct street view of the Visitor Center.
Charlotte Hawkins Brown Museum
T-336.449.4:846
F-336.449.0176
Visit our wehs:ite, WWW .ll(~hi ~torici,\itec·. org/ chb .
Please note that this e-mail address has changed to [e-mail].
Find the Charlotte Hawkins B1~ow11 Museum ou Facehook!
E-mail correspondence to and from this address may he subject to the North Carolina Public Records Law "NCGS.Ch.132" and
may he disclosed to third parties by an authorized state official. The Charlotte Hawkius Brown Museum is owned and operated
by the State of North Carolina as an agency of the Division of State Historic Sites and Properties, North Carolina Departmeut of
Cultural Resources.
From: Rogers, Michael
Sent: Thursday, May 06, 2010 12:47 PM
To: DCR -AH -Charlotte Hawkins Brown
Subject: physical address
Would you please confirm your correct physical address and zip code.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div· of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn o'n cover letter)
E-mail con-espondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
l
· Godwin, Ton ya
From:
Sent:
To:
Cc:
Subject:
[e-mail]
Wednesday, April 14, 2010 12:07 PM
[e-mail]
Godwin, TolJ_ya
NEW ETU Ticket: need city added
--------------ETU TICKET--------------
New Ticket #: 20247'
RequestType: SOFTWARE
Probl'emType: BIMS
Detail: Refer to Permit# WI0400130. Request to have the city of Gibsonville added to
the drop down box in the Facility Details address location for 6136 Burlington Rd. Please
contact me-for further information needed. Thanks, Tonya Support Desk:
htt p ://h2o.enr.state~nc.us /etu /su pp ort /
1
Godwin, Ton ya
From: Godwin, Tonya
Sent:
To:
Tuesday, April 13, 2010 12:40 PM
'Janice Scott'
Cc:
Subject:
Roger~10=1
RE: W~47-NC Dept of Cultural Resources-correct address 4/12
Janice, I need you to confirm the city for the facility address that has been given. When we
enter the address into our system, it pulls up in the City of Sedalia. Is it Sedalia or
Gibsonville?
Thank you,
Tonya Godwin
Aquifer Protection· Section
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-5348
919-715-0588 (Fax)
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.
-----Original Me s's age-----
From: Janice Scott [mailto:[e-mail]]
Sent: Tuesday, April 13, 2010 12:17 PM
To: Rogers, Michael ·
Cc: Janice Scott; Godwin, Tonya
Subject: re: WI0500247~NC Dept of Cultural Resources--correct address 4/12
Tonya,
Attached is the address from the architect. I'm not sure where Lin came up with 11 1636" but
everything I have has 6136.
Please let me know if there is anything else you need me to do.
Thanks,
Janice E. Scott
Office Manager
MidSouth Geothermal, LLC
8275 Tournament Dr. Ste. 185
Memphis, TN 38125-0851
Office (901)7'48#.::9·095
Fax [phone]
j scott@midsouth geothermal.com
www.midsouth geothermal.com
-----Original Message---~-
1
Janice-
There is a discrepancy between the address of the facility on the form you sent and the
address provided to Lin McCartney with the regional office.
The address on the application is 6136 Burlington Rd., Gibsonville NC 27342.
The address provided to Lin is 1636 Burlington Rd, which is in Sedalia ·NC.
The addresses and zip codes and counties are not jiving.
Please provide the correct street address, zip code, and County in which the facility is
located to Tonya in order to put into our database and provide a permit
number/Acknowledgement letter.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
2
Godwin, Ton ya
From: Godwin, Tonya
Sent:
To:
Tuesday, April 13, 2010 3:36 PM
'Janice Scott'
Cc: Rogers, Michael
Subject:
Attachments:
FW: WI0500247-NC Dept of Cultural Resources--correct address 4/12
Document(22).pdf
Janice, thank you for calling me. I am going to see about getting Gibsonville added into our
system since all of your paperwork reflects that. We want to try & have the records on our
and your end as accurate as possible. In the meantime, I will move forward with processing
the appli~ation. The county for this application pack~ge is Guilford and a copy of the
package will go to the Winston-Salem Regional Office. Thank you for your assistance with the
paperwork and have a nice evening. Please call or email me if you need further assistance
with this package.
Sincerely,
Tonya Godwin
Aquif~r Protection Section
1636 --Mail· Service Center
Raleigh, NC 27699-1636
919-715-5348
919-715-0588 (Fax)
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.
-----Original Message-----
From: Janice Scott [mailto:[e-mail]]
Sent: Tuesday, April 13, 2010 12:17 PM
To: Rogers, Michael
Cc: Janice Scott; Godwin, Tonya
Subject: re: WI0500247-NC Dept of Cultural Resources--correct address 4/12
Tonya,
Attached is the address from the architect. I'm .not sure where Lin came up with "1636" but
everything I have has 6136.
Please let me know if there is anyt~ing else you need me to do.
Thanks,
Janice E. Scott
Office Manager
MidSouth Geothermal, LLC
B275 Tournament Dr. Ste. 185
Memphis, TN 38125-0851
Office [phone]
Fax [phone]
j scott@midsouth geothermal.com
www.midsouth geothermal.com
1
-----Original Message-----
Janice-
There is a discrepancy between the address of the facility on the form you sent and the
address provided to Lin McCartney with the regional office.
The address on the application is 6136 Burlington Rd., Gibsonville NC 27342.
The address provided to Lin is 1636 Burlington Rd, which is in Sedalia NC.
The addresses and zip codes and counties are not jiving.
Please provide the correct street address, zip code, and County in which the facility is
located to Tonya in order to put into our database and provide a permit
number/Acknowledgement letter.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
2
Godwin, Tonya
From:
Sent:
Janice· Scott [e-mail]]
Tuesday, April 13, 2010 12:17 PM
To: Rogers, Michael
Cc: Janice Scott ; Godwin, Tonya
Subject:
Attachments:
re: WI0500247-NC Dept of Cultural Resources--correct address 4/12
Document(22).pdf
Tonya,
Attached is the address from the architect. I'm not sure where Lin came up with "1636" but
everything I have has 6136.
Please let me know if there is anything else you need me to do.
Thanks,
Janice E. Scott
Office Manager
MidSouth Geothermal, LLC
8275 Tournament Dr. Ste. 185
Memphis, TN 38125-0851
Office [phone]
Fax [phone]
j scott@midsouth geothermal.com
www.midsouth geothermal.com
-----Original Message-----
Janice-
There is a discrepancy between the address of the facility on the form you
sent and the address provided to Lin McCartney with the regional office.
The address on the application is 6136 Burlington Rd., Gibsonville NC 27342.
The address provided to Lin is 1636 Burlington Rd, which is in Sedalia NC.
The addresses and zip codes and counties are not jiving.
Please provide the correct street address, zip code, and County in which the
facility is located to Tonya in order to put into our database and provide a
permit number/Acknowledgement letter.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section {APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line {919) 715-6166; Fax [phone] (put to my attn on cover letter)
1
Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Tuesday, April 13, 2010 11 :23 AM
'Janice Scott'
Cc: Godwin, Tonya
Subject: RE: 5QM-NC Dept of Cultural -Resources proj--jobsite correction 4/5
Janice-
There is a discrepancy between the address of the facility on the form you sent and the
address provided to Lin McCartney with the regional office. The address on the application
is 6i36 Burlington Rd., Gibsonville NC 27342. The address provided to Lin is 1636 Burlington
Rd, which is in Sedalia NC. The addresses and zip codes and counties are not jiving.
Please provide the correct street address, zip code, and County in which the facility is
located to Tonya in order to put into our database and provide ·a permit
number/Acknowledgement letter.
Thanks
Michael Rogers, P.G. (NC & FL}
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS}
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line (919} 715-6166; Fax [phone] (put to my attn on cover letter)
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
-----Original Message-----
From: Janice Scott [mailto:[e-mail]]
Sent: Monday, April 05, 2010 4:59 PM
To: Rogers, Michael
Cc: Janice Scott
Subject: re: SQM-NC Dept of Cultural Resources proj--jobsite correction 4/5
Michael,
Attached is the corrected first page of the SQM referenced above. The project does not have
a permit# as yet. I have spoke w/Ms Lin MccArtney.
The project is still in her Raleigh District, so everything is good on that part for the pre-
inspection. I just wanted to make sure that your records would be correct. The owners rep.
listed the wrong address.
Let me know if you need anything else.
Thank you,
Janice E. Scott
Office Manager
MidSouth Geothermal, LLC
8275 Tournament Dr. Ste. 185
1
G()dwin, Ton ya
From: [e-mail]
Sent:
To:
Tuesday, April 13, 2010 10:48 AM
Godwin, Tonya
Subject: Delete Permit# in BIMS
Ticket: 20237
Status: CLOSED
Username: tonya_godwin
RequestType: SOFTWARE
ProblemType: BIMS
Detail: Please delete Permit# WI0500247 in BIMS.
Incorrect information created on permit. Will
be creating new permit#. Thanks, Tonya
Resolution: This ticket has been re s olved. The application
has been deleted as requested. Should you need
further assistance, please conta ct ETU . Thank
you for using ETU Support .•. Tom
HandledBy: tom_moore
1
Godwin, Ton ya
From:
Sent:
To:
Cc:
Subject:
[e-mail]
Tuesday, April 13, 2010 10:32 AM
[e-mail]
Godwin, Tonya
NEW ETU Ticket: Delete Permit# in BIMS
--------------ETU TICKET--------------
New Ticket#: 20237
RequestType: SOFTWARE
ProblemType: BIMS
Detail: Please delete Permit# WI0500247 in BIMS. Incorrect information cre~ted on
permit. Will be creating new permit#. Thanks, Tonya Support Desk:
htt p ://h2o.enr.state.nc.us /etu /su pp ort /
1
Rogers, Michael
From:
Sent:
To:
Cc:
Subject:
Hi Michael,
Mccartney, Lin
Tuesday, April 06, 2010 11 :35 AM
Rogers, Michael
Watts, Debra
Injection Well W 1050024 7 for NC Dept. of Cultural Resources
As I was setting up an inspection to follow up on the injection well application for NC Department of Cultural Resources
{WI0500247), I discovered an error on the physical address of the job site. The correct address for the injection well
installation site is 1636 Burlington Rd., Sedalia, NC 27342. I have googled the site and verified this address with the
driller. Based on this address, it is within Guilford County, Winston-Salem Region.
Thanks,
Lin McCartney
APS, Raleigh Regional Office
919-791-4243
E-mai!'co'fre·sp·ondence to and from this address may be subject to the North Carolina Public Records Law and: m"a"/6e
disclosed to third parties.
1
Rogers, Michael
From:
Sent:
Janice Scott . [e-mail]]
Monday, April 05, 2010 4:59 PM
To: Rogers, Michael
Cc: Janice Scott
Subject:
Attachments:
re: SQM-NC Dept of Cultural Resources proj--jobsite correction 4/5
Document(32).pdf
Michael,
Attached is the corrected first page of the SQM referenced above. The project does not have
a permit# as yet. I have spoke w/Ms Lin MccArtney.
The project is still in her Raleigh District, so everything is good on that part for the pre -
inspection. I just wanted to make sure that your records would be correct. The owners rep.
listed the wrong address.
Let me know if you need anything else.
Thank you,
Janice E. Scott
Office Manager
MidSouth Geothermal, LLC
8275 Tournament Dr. Ste. 185
Memphis, TN 38125-0851
Office {901)748-9095
Fax {901)748-9097
j scott@midsouth geothermal.com
www.midsouth geothermal.com
1
From: David Black [mailto:[e-mail]]
Sent: Monday, April 05, 2010 2:32 PM
To: Jerry Poole; Romaine, T-ony
Cc: Gary Culler
Subject: RE: Kimball Hall
6136 Burlington Road
GibsonviHe 1 .NC_ 47.f.4~ CaQ ~ ~ ~ LL-f) , .
David R~ Black Al~ l froj~e~t
HagerSinith DESIGN PA
300 South Dawson St. I PO Box 1308
Raleigh, NC 27601
'----P: {919) 821•5547
C: (9is) 302 -3176
D: [phone]
F: [phone]
www .ha g e r smith.com
30 Years. Innovation. Service. Vision
.. -.. --·-·----·---------~-------
'''"."-:-·-..--...... -·
--.. ···--··-·-·-·-··
Rogers, Michael
From: Zimmerman, Jay
Sent: Thursday April 01, 2010 2:58 PM
To: Rogers, Michael
Subject: RE: WI 05D0247 North Carolina Dept. of cultural resources
r
Will do next week �,-•-�F •.
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: Wednesday, March 31, 2010 2:45 PM
To: Zimmerman, Jay
Subject: FW: WI 0500247 North Carolina Dept. of cultural resources
Please find attached 5QM app. Since this is a goy job, we will need a formal staff report. FYI- We have had problems
with MldSouth Geothermal before.
thanks
Michael Rogers, P.C. (NC & FL)
Environmental Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspon do o ce to and from this address rimy be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Rogers, Michael
Sent: Wednesday, March 31, 2010 2:43 PM
To: Zimmerman, Jay
Subject: WI 0500247 North Carolina Dept. of cultural resources
Michael Rogers, P.G. (NC & FL)
Environmentaf Specialist
NC Div of Water Quality- Aquifer Protection Section (A PS)
1636 Mail Service Center
Ra€eigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-m all correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties

Rogers, Michael
From: Rogers, Michael .
Sent:
To:
Wednesday, March 31, 2010 2:45 PM
Zimmerman,.Jay
Subject:
Attachments:
FW: WI 0500247 North Carolina Dept. of cultural resources
NC Dept of cultural resources.pdf
Please find attached SQM ap·p. Since this is a gov job, we will need a formal staff report. FYI-We have had problems
with MidSouth Geothermal before.
thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
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: Wednesday, March 31, 2010 2:43 PM
To: Zimmerman, Jay
Subject: WI 0500247 North Carolina Dept. of cultural resources
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
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
1
Beverly Eaves Perdue
Governor
"'~A a.;;~~
NCDENR
North CaiOlina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
April 14 , 2010
Mark Cooney -Capital Projects Director
N.C. Department of Cultural Resources
4605 Mail Service Center
Raleigh, NC 27699-4605
Subject: Acknowledgement of Application No. WI040013 0
Burlington Road
Injection Mixed Fluid GSHP Well System (SQM)
Guilford
Dear Mr. Cooney:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on April 5, 2010 : This application package has been assigned the number listeti 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 [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 htu ://h2o.enr.state.nc.us/documents/dw q omchart.p df.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUffiIES ON THIS PROJECT.
:;J'~
for Debra ~tts
Supervisor
cc: Winston-Salem Regiona] Office, Aquifer Protection Section
Janice Scott (Midsouth Geothermal, LLC., 8275 Tournament Dr., Ste. 185, Memphis, TN 38125)
Permit Application File WW400130
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 27~8 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone]~ \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer ~ervice : ·J-877-623--6748
Internet: www.ncwaterguality.org
An Equal Opportunity Afiirrnaiive Action Employer
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PAGE 03104
PAGE B8
NC Codetar CzirdffCalinn No.: 2 t '
t'"Im Pcrsc�tn R7 — 4 f i
Address:�ls
City: *Le-- is zip Oodo-m—Alk cmtr: -�La * -
Ofl3aeTekNo.:
L MDAT RUMS CONTRAC1`CIR'[S�i'ORMATION (ffdl$eNnt diem driller)
Comps q
Address: $a'lST�iLY+C►1v}Q.�'�C' . ske- - J "
CIT. Zip Ccda•'3, Coam4Y. %►O - lj
QF6ce Tclt Nat l-+1� �!'J��_ WNc.: LIQtj l;coq�7
T. INJECTION MOCEDUM (briefly ftmbe how tht injection well(s) will be used)
ltsea UA
G. WELL CONURUCrION DATA n R 1 g PCEWR
t l) Proposed date to be conmmUed: : b Number of bodw--
AppmArane depth ofeauh baring (fe*):• —S Q
(2) Ch micel addltivas to be vaed is akwd-loop systert (oY those chemiesis ind m=d have bean 2Wroved).
R 22 _Y,_. p,,pyl=r gl. col etk�anv! other (athor adder will
need prior approval by NCDM before use)
(3) Type of tubing to be used (copper, PVC, eta): _E!) P9 ID IQS� �'c,D r (0, .
(4) Well casi* is the wa(s) easad7 (check either (a.) YES gS (h.) NO below)
(a) M if yes, than provide casing inf'ormatlon Fuch u t= (steel, rVC, plastic, etc.), Q40
oft, and e= of easing appearing above ground-
(b) rry v y strr �G3�� as r c e Be, re lmdve O
(5) Grwt [material sumwtdl�,vett erring sad�or piping]:
(a) Grout type: Cemaut Hentonita Outer (GPcxlfj)
(b) Grasu depth of tubing ( agnnce to land surtb -' f M d to 1ETC- (&.a)
Ifwell has eaaing, lndlcate grunt depth: ftm � to (feet)
R. LNSWnoN.RELATED EQtVbMNT
Attach a diaLpm showing tho eagiata tlg layout cr proposed modification of time iWeellan equipment and emlor
pipingltub$tg essooiatt:d with the injection operntion. The atanufaem ar's brochure sway provide supplatowtWy
lafvrmcdon.
r3Ptmc -Qbi Weft ftlWf Appltastiva Mx+W 7r.408) Pena x

PAS ©4104
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CAS SYSTEP-
nzf)-wuTt Ott l HERMAL,
AMC)] M copies of maps showing llse Ulft-ing idunUation:
PAGE N
(1) Include Q she mnp (= be drawn) shoving: buildings, praperty lines, surface wafter badies, potentiat.aau ms
af' - vundwata; conwmina.tlon and the gtienlation of and distances betwestt Elie proposed t ll(3} and any
existing well(s) or wn-,ae diapoW .facilhies suoh na septic tatter or droly fields located within 10011 feetoft�c
geolliumal Feat pump wall sxs' m. Label all features 6early and includip n ngrdLarTg
Include ratopoampllia map of IN axon extending ant tnib: fmmthe propeny boundaries and
indicate th>: ReilityIs tOcWivn and the map name.
I. POTABLE WATER 'MI L{S)
Ana Urcrr any pow-bie w.a u Wellti) on the subjut ptojwtty or adjaoerr properties? YES -,lqo
If Yes., than indicate lacaf n On anached Map(s).
IC CER`C'MCATMN
Note. This permit AI1.jiltcntion must, 1]c sipad by aaeh parson appearing. an the recorded I .nl property deed.
"I herdy aertfy, ►Ender penalty of jaw, clrttt 1 haw pumnully examined and ain famlllar with she infottaatim)
submitted in thin docurnent and all aaachmorm themem and than, Eased on my inquiry of those individuNE
immediately responsible for obtnivin said infonnatioq. I ba11vve that the inrotnmtion is true., accu nic and complete.
I ace aware Eliot There air sigaifrcant penalties, incivding the pesslEility of ulnas and imprisonment, for submitting
Use hsformation. l agree to construct, app-r�atte, alaintaip, repair, and if appticeule. sbandon the ilyert;.vo well and
ell misted appurmnaa�ces to .accordwGe w R1) Elie s'1ppLo=d s pecificattorS and wad Mom of tilt: Femt.'
!/4
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Print or Type Full Name
i DGNR [ DVVQ Sigttatlste tsfF'rapdrty c]%meYAplalienai
y,.jAq 25 Z0 is Fries or TYpe: Full Name
Signature of Autharizcd Agwt, if any
Print at TL P% PQ Name
Plewt. t tam two copal r4 the. con-platod Appiicntlnn pat kne tw
North Carolina DENA-DW Q
Aqui£ev Pr❑tectinrt Seeliata
1636 MAD Sftrvied C'eofer
Mulelgit, NC. 27699-1636
Talcpbanc (919) M-3221
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27249 - Google Maps Page 1 of 1
C;O i)gie maps Address Gibsonvi Ile, NC Get Google Maps on YPhone
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NC Historic Sites -Charlotte Hawkins Brown Musellll).
Select a Site: Ahout NCHS Oul' Offit,\S Coutact lfo Home
Charlotte Hawkins
Brown Museum
African American Education
F ounded in 1902 by Dr.
Charlotte Hawkins
Brown, Palmer
Memorial Institute
transformed the lives of
more than .2,000 African
American students. Today,
the campus provides the
setting where visitors can
explore this unique
environment where boys
and girls lived and learned
during the greater part of
the 20th century. The
museum links Dr. Brown
and Palmer Memorial
Institute to the larger
themes of African American
history, women's history,
social history, and
education, emphasizing the
contributions African
Americans made in North
Carolina.
Dr.Brown
A Student Remembers
Early Life
The Site Today
Overview
A Brief History
More About the
Museum
Existing -Structures
Canary Cottage, Dr.
Brown's home
Teacher l\tlaterials (PDF)
A ~ibliography
Other
Information
Honors for the Charlotte
Hawkins Brown Website
http://www.nchistoricsites.org/ chb/ chb.htm
Page 1 of2
Visit C.H.Brown Museum
C
Map & Directions
Local ·weather
Facilities
Special Events
Contact Us
Charlotte Hawkins Brown
Museum
P.O. Box-B --------
-edalia, NC 27342
Phone: (336) 4 9-4·8~
Fax: [phone]
Email: [e-mail]
Hours of
Operation
Monday-Saturday, 9 a.ni. -5
p.m.
Closed Sundays and most
major state holidays.
5/6/2010
NC Historic Sites -Charlotte Hawkins Brown Museum
Brown and the
Palmer Memorial
Institute
Rules for ~~-~-•-v~
A National Figure
Civic Life
Social GracesH
Education
Line of
Achievement
The School
The Birth and Grcnvth of
Palmer :Memorial
Institute
Campus Views
Student Life
Sports at PMI
Former Campus
Structure
Return to top of page
North Carolina t listoric Sites is a division of the
North Carolina Department of Cultural Resources
Office of Archives~-History
http://www.nchistoricsites.org/chb/chb.htm
Page 2 of2
Last Updated 03/12/2010 13:23:43
5/6/2010
LISPS - ZIP Code Lookup - Find a ZIP + 4 Code By Address Results
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6136 BURLINGTON RQ
GIBSONVILLE NC 27249 -
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Central Files' AP5 SWR
03/30/10
Permit Number W10500247
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
In review New Project
Permit Type
Version Permit Classification
Injection Mixed Fluid GSHP Well System (50M)
Individual/
Primary Reviewer
Permit Contact Affiliation
michael.rogem
ti
Janice Scott
Coastal SW Rule
8275 Tournament Dr
Memphis TN 381250851
Permitted Flow
3cilit.
Facility Name
East Jones Street
Location Address
109 E Jones St
Raleigh
NC 27601 —,
Owner
Owner Name
North Carolina Department of Cultural Resources
Ma,ior/Minor Region
minor Raleigh
County
Wake p-ae
Facility Contact Affili-5Y:on1
Owner Type
Government - State
Owner Affiliation
Mark Cooney
4605 Mail Service Ctr
Raleigh
Scheduled
Crig Issue App Received raft Initiated Issuance Public Notice Issue
03/25/10
Re -.elated Activities
Outfail I
Waterbody Ne Stream Index Number Current Class
NC 27699
Effective Expiration

8310912011) 12:03 3363666860
-,. & V Sul I #d�PUy J
A WELL DRILLER Ii+MTORMA.TION
I«
P.
CAS SYSTEMS
MID SOUTH 0eDTW-h%AL
Ctxmpatly Name: I � 4 �'
Well Uri 4 Cact utor'a Name: _
NC Coautor CartWmdon Na:
coutacr
Addra=
Gib. ztp Cadva-a -- Cauaty.
U1Oce Tate No.: `1��8 —Sees— Gw.: of � 8 Cat
SltAT )PtW COi►1'J RACPOK mCRMATIm (If dUrcrent than drlllcr)
Camgtwy
COD%d.P
city. zip Co&:33 � — Casty. G-VV-ug-11 -
Office Tole No : CtAmDVS- 9L7 - Na.: q OO A •Dq�7 _
MOCiLDURS (briefly dery -be how the Lojeailou vall(s) wliL be used)
G. WELL CONSTRUMON DATA WdDJ2 Man it Itg&JLR- gendt l ffi�iB"4NAx l
t_i) Pmposad data to be constmetcd: _ d Its- iD _ Number of bodop;
AWW-Amm depth of ewch baFiag (feet) �5 ( _
PACE 03/04
PAGE 0.4
(2) C.hmmied additivca to be used is closed -loop symm (arty those chemicals Wicwzd have bm zppmwd).
R.23 -[—rrow,mr g1,YwI efiutnal nrher (other addkives wW
need prior approval by NCDENR before use)
(3) Tyke of tubing to be used (copper, PVC. eoc): jP9 Q 1!j C, - U-0ce
(4) Wcit casing. U The woll(s) eand? (check either (a.) YES s (b) NO below)
(a) i' if yes, then provide rasing inibrmation Fuck a = (ateai. l?VC., piaatic, ete.), motet,
k , and 2M of rasing appearing above Smund:
(b) NO t ._, _gyp a2� y s u � � ass r ►.,+fie ge. YE, M dVe.
(S) GmW (malaria] mmc mdigg well Ming anftr 004):
(a) Groin type: Cemom Bemonirn �4 Odecr (apeciW
(b) Groat depth of tubing (relbrerrce to lead surQ=): $'am y5 - W L S'(IVL)
if wall ha caning, indkmc grout depth: fem � to (fut)
R. LN-TEMON-RELATED XQUIPMENT
Attach, a dittgsatn obawing the eugirlefg layout or proposed modifimift of the irs cdca equipitiebtt aad m mufor
glphtgrbbfmg associated with dia injection operation. Thd manuTlrrA is brochm may provlde mpplamutuy
ka mcdon.
(1P TAAC W Wd1 t ouir AWkicadaa (RMaat WN08) ?W 1

PAGE 04104
031es1290 12:83 33636E5060
L WCATION O MUS)
GASSYSTEM
MID-W( H SEU1MMMAL
Attasl) Wo copies of maps sshint Abe following lnforwstialy
PAGE 04
(1) Tnelade a site asap ,can be dmvm) showing: btrildings, properiy linea, svizewater budicq, potebtl! atlelmcs
of Z ndw=r contamination and ilia orientation of and. &tsnuz between t#ta proposed wells) attd. atty
e isti> wt 11{e) or wttxtq di�Tst�til s�aAlflcs sttoh as segue tttnk9 yr dralu fields pallid wfthltt 1400 feet rat tha
geothermal heat l F wall systm. T:stsel ail 3rattucs elsari�v utd: c da WXVLprMyt.
N'i'] include a toposmp+lt<ie Map of the turn extralding arts miles from1he.pr4perly boundaries and
itldtCate tlw *611ty's tortttion emd the Ynap nunla.
T. P.QTAaE WAT11:R WZLL{S)
Ara the:rc :thy patrWle water wcll(5) vn the subjeetproperty or adjacent propxrtlns7 —i'zS Y No
If Yew, than indicate location on attaeiied nlap(s).
IC. CJRP- WICAT30N
Wotc:'Rrt�;permit &pplication touo be s1ped by La& person uppearing on thq reeer•d4d legnt property tiSed.
*1 hereby eeCdTj; under penalty of law, that I haves pmondkly cuminad and am i'aslailiar "ith the information
submirted in this document and ell attachmz:ras tltcrew and that, based on my loquhy of those utdividuWri
#tsutseditst* m9powthlc far obtaivjng said inforrnetlrrtt, 11Nslicva that the 'in1b oration is true, Rmime and complete.
T am aware Ow There are sipifarartt penalties, imludiug file pu�ally of fsmd p5 TuDem, far slmitfs,m�
False iafcmmion..1 agree to oogstruct, operate, ttmalti>aiv, repatr, and if app11cablc..atP-n6oa the ii3jeraiolt well anti
all muted spptatanance$ in. accaiYl race w} h the *proved spccifimdo;v end =ditlons otthePetniii"
*7sx!alur�a�rop�,W=IXPP.41
4
i RK• W*1JJ9,4
Print or TYPO Full Name
95CIW! IDENR I Dif 4 19 Sigatout of property ow erlAgpliaatlt
hpovfm Pfniet lim getllD'It
MAR 25 2010, Print or -rye Full Pcow
Sisaeuxre of Authorized Agezu, if any
[runt or TYPGF-W l
Please rarkUM t%vo copses of Tbe. co VIEIed Application pat:l;agt: to:
North CNrolba» DNNft-bWQ
Aquifer PrateMrnt Section
TAC Prpgrsma
163.6 Mail service Cexktcr
Rideloki, NC 27699-1636
Tdcpbtone (91.9) 733-322]1,
GPWLIC SQA1 WellPGmh AWAtc-,604 {tt:vxe 7*00Ry "F3

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CHARLGT1E HAW
swo IEIECPoAL
STATE HISiUIGC 97E
KUPIL HALL REMATICH
HCRTH CAR"k
DEPARTIM
OF CIXTW RESMM

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W" CAROLM
DEPARTMENT
OF OLTCRAL RESOURCES
DSO j0~r06617-02
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NCE)
North Carolina Department of Environment and Natural Resources
Division of Water Duality
Beverly Eaves Perdue cofeen H. Sullins
Governor Director
March 30, 2010
Mark Cooney - Capital Projects Director -
NC Department of Cultural Resouces
4605 Mail Service Center
Raleigh, NC 27699
Subject: Acknowledgement of Application No. W10500247
East Jones Street
Injection Mixed Fluid GSHP Well System (5QM)
Wake
Dear Mr. Cooney:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on March 25, 2010. 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 [e-mail]. If the
reviewer is unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorgaruzed. To
review our new organizational chart, go to htti,://h2o.enr.smte.ne.us/documents/dwcLorgchart.p
PLEASE REFER TO THE AROVL, APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT
Sincerely,
fior Debra J. Watts
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Janice Scott (Midsouth Geothermal LLC) 8275 Tournament. Dr Ste 185, Memphis, TN 38125
Permit 'Application File W10500247
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raleigh, North Carolina 27699.1636
Location 2728 Capital Boulevard, Raieigh. North Garolina 27604 Doe
Phone: [phone] I FAX 1: 919.715-0588: FAX 2: 919-71M0481 Customer Service 1-877-623.674$ North �`arolina
Intemee wuw.ncwaternualltv,oro
An Equal Oppanunq I Albrmalive Action Employer r ' ahma " y

AV'A
NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
~arch 30, 2010
Mark Cooney -Capital Projects Director
NC Department of Cultural Resouces
4605 'Mail Service Center.
Raleigh, NC 27699 -
Subject: Acknowledgement of Application No. WI0500247
East Jones Street
Injection Mixed Fluid GSHP Well System (SQM)
Wake
Dear Mr. Cooney:
Dee Freeman
Secretary
The Aqu.ifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on March 25, 2010. This application package has been assigned the number listed above and will be reviewed by
Michael Rogers.
The reviewer will perfonn a detailed review and contact you with a request for additional information if necessary. To.ensure the
maximum efficiency in processing permit applications, th~ Division requests your assistance iii providing a timely and complete
response to any additional information requests. '
Please be aware that th~ 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 [e-mail]. If the
reviewer is unavailable, you may leave a message, and they will respond promptly. Al~o n0te that the Division has reorganized. To
review our new organizational ·chart, go to htrp://h2o.enr.state.nc.u.s/documents/dwg orn:chart.pdf.
PLEASE REFER TO THE.ABOVE APPLICATION NUMBER.WHEN MAKING INQUIRIES ON THIS PROJECT .
Sincerely,
for Debra J. Watts
Supervisor
cc: Raleigh Regionai Office, Aquifer Protection Section
Janice Scott (Midsouth Geothermal LLC) 8275 Tournament Dr Ste 185, Memphis, TN 38125
Permit Application File WI0500247
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raleigh, North Carolina 276~9-1636
Location : 2728 Capital Boulevard . Raleigh. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
lnterriet: www.ncwaterguality.org ·
An Equal Opportunity I Affirmative Action Employer
Nirth Carolina
/vaturall!f
Note:
This cop y reflects the correct department of
en v ironmental-health
pl\ -!'..£~ MC ...... EN ..... R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
May 13, 2010
Mark Cooney, Capital Projects Director
North Carolina Department of Cultural Resources
4605 Mail Service Center
Raleigh, NC 27699-4605
Subject: Issuance of Injection Well Permit
Permit No. WI0400130
Dear Mr. Cooney:
Issued to North Carolina Dept. of
Cultural Resources -Charlotte
Hawkins Brown Museum
Guilford County
Dee Freeman
Secretary
In accordance with your application received April 5, 2010, I am forwarding Pennit No. ·WI0400130 for
the construction and operation of a vertical closed-loop .geothermal mixed-fluid heat pump injection well
system to be located at the Kimball Hall.Building at the Charlotte Hawkins Brown Museum, 6136
Burlington Road, Gibsonville, NC 27249, perm.it shall be effective from the date of issuance until April
30~·2015, and shall be sub)ectto the conditions and limitations stated therein.
Please pay special attention to Part Vllw2 of the pennit and submit copies of the Well Construction
Completion fonn (GW-1) after construction. Please submit all data within 30 calendar days of
completion of installatfon of geothermal well(s) to the following address: ·
Aquifer Protection Section (APS)
Underground Injection Control (UIC) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
Additionally, your UIC system is subject to inspection by the APS. Per special condition Part 11.3, in the
event that there will be multiple wells with separate clusters, one well identification tag per 'cluster' of
wells shall be perman~ntly-affixed to the heating and cooling unit or other nearby permanently fixed
location iri. a clearly visible location according to 2C .0213(g).
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 me at [phone].
cc: Sherri Knight-Winston-Salem Regional Office
Central Office File -WI0400130
Guildford County Environmental Health Dept.
Sincerely,
~ ~ ~-e---
Michael Rogers, P.G. (N & FL)
Environmental Specialist
Janice Scott -Midsouth Geothermal, LLC (faxed to 901-748-9097)
Attachment( s)
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMNUSSION
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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
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North Carolina Dept. of Cultural Resources —
Charlotte Hawkins Brown Museum
FOR THE CONSTRUCTION AND OPERATION OF 9 TYPE 5QM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at the Kimball Hall Building of the Charlotte
Havdcins Brown Museum, 6136 Burlington Rd., Gibsonville, Guilford County. NC 1-71-49, and will be
constructed and operated in accordance with the application received April 5. 2010, 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 apart of this permit,
This permit is for Construction and Operation of an injection well and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until April 30, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 13'h day of May 2010.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit W10400130 UIC/5QM Page I of 5
ver. 03/2010

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. -The Pennittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Inj'ection Wells (ISA 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 };lydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways. ·
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II-WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least , forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone], and the Winston-Salem Regional Office Aquifer Protection . Section Staff,
telephone number [phone].
2. The location of each of the system manifolds shall be recorded by triangulation frol?-1 three permanent
features on the site (e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
3. One weU identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC2C .0213(g).
PART III-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.
Permit WI0400130 UIC/SQM
ver. 03/2010
Page 2 of S
PART IV -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and .operated at all · times so that there is no
contamination of groundwater that will render it unsatisfactory for normal ·use. In the event that the
facility fails to perform. satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Pennittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as ·the repair,
modification, or abandonment of the injection facility.
2. The Pennittee shall be required to comply with the 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
ground water resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and ·operated at all times.
2. The Permittee must notify the Division and receive . prior written approval from the Director of any
planned physical alterations or additions in the -permitted facility or activity not specifically-authorized by
the permit.
3. At least · forty-eight ( 48) hours prior to the· initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (Uiq
Program Central Office staff, telephone number [phone]. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions. ·
PART-VI -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 b~ maintained under the terms arid conditions of this permit, and .may obtain
samples of groundwater, surface water, or injection fluids.
2. Division 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. ·
Permit WI0400130 UIC/SQM
ver. 03/2010
Page 3 of S
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section -UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
W'inston-Salem Regional Office
585 W aughtown Street
Winston-Salem, NC 27107
[phone]
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Winston-Salem Regional Office within 30 days of
completion of well construction. Copies of the GW-1 form(s) shall also be given to the Permittee and
retained on site to be made available for inspection.
3. A copy of the site map updated with manifold locations required in Part II.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Winston-Salem Regional Office within
30 days of completion of well construction.
4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed.
5. 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 i~ any unusual operating circumstances;
(B) · Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or 9f 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.
7. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII-PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the pennit 120 days prior to its expiration date.
Permit WI0400130 UIC/SQM
ver. 03/2010
Page 4 of 5
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within · 1 s 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 Permitte~ must install a sanitary seal. If a weli -is not to be used
for any purpose, ·then that well must be pennanentlyabandoned according to ·1sA NCAC 2C .0213(h)(l).
Notification shall be submitted to the addresses given in Part VII.l of this permit.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 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.
(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 ~ater.
(D) Each well shall.be completely filled with cement grout, which shall be introduced into the well
through · a pipe that extends to the bottom of the well and is raised as the wen is filled.
, -CE) In the case of gravel-packed wells in which the casing _ and screens have not been removed, the
casing shall be perforated opposite the gravel pack; at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when~ as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such ·a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-3-0) as spe_cified
in lSA NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit WI0400130 UIC/SQM
ver. 03/2010
Page 5 of 5