WI0500011_GEO THERMAL_20120518

Beverly Eaves Perdue
Governor
AVA
; NCDENR
North Carolina Department of Environment and Natural Resources
i Division of Water Quality
Charles Wakild, P. E.
Director
May 18, 2012
James Newport Family Trust
114 Riverbluff Road
Littleton, NC 27850
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0500011
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 ISA 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.org/web/wq/aps.
If you have any questions regarding your current permit or the rule revisions, please feel free to contact our underground injection control staff at [phone].
Sincerely,
/j LA_.~/ ?v<-(J /YU/<A-
Eric G. Smith, P.G.
Hydro geologist
cc.: UIC Pennit Fi1e
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 \ Affirmali11e Act[on Employer
NiTui Carolina
/vaturnll!f
Permit Number WI0500011
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Coa$tal SW Rule
Permitted Flow
Facilit
Facility Name
James Newport Family Trust SFR
Location Address
114 Riverbluff Rd
Littleton
Owner
Owner Name
NC
James Newport Family Trust
Dates/Events
27850
Orig Issue
02/14/90
App Received Draft Initiated
05/16/11
Scheduled
Issuance
Central Files: APS_ SWP_
06/08/11
Permit Tracking Slip
Status
Active
Project Type
Renewal
Version
3.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Warren
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Barbara Newport
114 River Bluff Rd
Littleton NC 27850
Public Notice Issue
06/08/11
Effective
06/08/11
Expiration
05/31/16
_R_e ...... ~_u_la--t_e_d_A_c __ t_iv_it_ie.;;_s;;___ ______________ Re ouested/Received Events
Heat Pump Injection RO staff report requested
RO staff report received
Outfall NULL
Waterbody Name Stream Index Number Current Class
05/26/11
05/31/11
Subbasin
Permit Number WI0500011
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Fac"li t
Facility Name
James Newport Family Trust SFR
Location Address
114 Riverbluff Rd
Littleton
wn er
Owner Name
NC
James Newport Family Trust
Dates/Ey ents
27850
Scheduled
Orig Issue
02/14/90
App Received Draft Initiated Issuance
05/16/11
Re a ulated Activities
Heat Pump Injection
Outfall NULL
Central Files : APS_ SWP_
06/01/11
Permit Tracking Slip
Status
In review
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Warren
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Barbara Newport
114 River Bluff Rd
Littleton NC
Public Notice Issue Effective
Req uested /R eceived Ev e n t s
RO staff report requested
RO staff report received
27850
Expiration
05/26/11
05/31/11
Waterbody Name Stream Index Number Current Class Subbasin
A.VA
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Ms. Barbara Newport, Trustee
James Newport Family Trust
114 RiverbluffRd.
Littleton, NC 27850
Division of Water Quality
Coleen H. Sullins
Director
June 8, 2011
Ref: Issuance of Injection Well Permit WI0500011
Issued to James Newport Family Trust
Littleton, Warren County, North Carolina
Dear Ms. Newport:
Dee Freeman
Secretary
In accordance with the application received on May 16, 2011, I am forwarding permit number WI0500011 for the
continued operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system located at the
above referenced address. This permit shall be effective from the date of issuance until May 31, 2016, and shall be
subject to the conditions and limitations stated therein.
Additionally, your UIC system is subject to inspection by the APS and at the time of the inspection must display a
permanently affixed identification plate identifying the presence of closed-loop geothermal wells. This is in
.accordance with requirements of 15A NCAC 2C .0213(g) and Part 1.4 of your permit issued June 8, 2011. In the
event there are multiple wells with separate clusters, one well identification tag per 'cluster' of wells should be
permanently affixed to the heating and cooling unit or other nearby permanently fixed location in a clearly visible
location.
Also, please pay special attention to Part V.2. The Permittee shall retain all records of repairs, pressure
tests, maintenance, and other activities needed to maintain normal operating conditions.
In order to contin'1e uninterrupted legal use of the injection facility for the stated purpos·e, you must submit an
application to renew the permit 120 days prior to its expiration date. This permit is not transferable to any person
without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or [e-mail] if you have any questions about your perm.it.
cc: Jay Zimmerman, Raleigh Regional Office
WIOSOOO 11 Permit File
Warren County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, ~aleigh, North Carolina 27699-163fi
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
Internet: www.ncwateraualitv .ora
An Equal Opportuniiy I Affim1ative Actio'.1 Employer
Best Regards,
-~7 rs --
Michael Rogers, P.G. (NC & FL)
None .. C 1. _ . ort11 aro 1na
)vtlturall!f
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
James Newport Family Trust
FOR THE CONTINUED OPERATION OF 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 114 Riverbluff Road, Littleton, Warren
County, NC 27850, and will be constructed and operated in accordance with the application received May 10,
2011, and in conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit_
This permit is for operation of an injection well and shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until May 31, 2016, and shall be
subject to the specified conditions and limitations set forth In Parts I through VII hereof.
Permit issued this the 0' day of June 2011.
r
Cole en H. Sullins, Director
� i'Sion of Water Quality
By Authority of the Environmental Management Commission.
W105000 UICI5QM-M.F. Renewal Page 1 of 4
Version IM10

PART I-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. In the event that there are 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 according to 2C .0213(g).
PART II-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART III-OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
W I0500 0 1 1 UIC/5QM-M.F. Renewal
Version 1/2010
Page 2 of 4
PART IV -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART V-:-MONITORING AND REPORTING REQUIREMENTS
1. Any monitori_ng (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall retain all records of repairs, pressure tests, maintenance, and other activities
needed to maintain normal operating conditions.
3. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Raleigh 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;
4. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
S. 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 VI-PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
WI050001 UIC/SQM-M.F. Renewal. Page 3 of4
Version 1/2010
PART VII -CHANGE OF WELL STATUS
I. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 1 SA NCAC 2C .0213(h)(l ), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in l 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
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part VII (1) and (2) (G) shall be submitted to :
WI C50(l01 }
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/SQM-M.F. Renewal
Version 1/2010
Page 4 of 4
Ro gers, Michael
From: Zimmerman, Jay
Sent:
To:
Tuesday, May 31, 2011 8:14 PM
Rogers , Michael
Subject: RE: WI 0500011 James Newport Family Trust
go ahead and issue.
From: Rogers, Michael
Sent: Tuesday, May 31, 2011 5:58 PM
To: Zimmerman, Jay
Subject: RE: WI 0500011 James Newport Family Trust
This is a renewal.
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)
http://portal.ncdenr.org/web/wq/aps/qwpro/permit-applications#geothermApps
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: Zimmerman, Jay
Sent: Friday, May 27, 2011 9:33 AM
To: Rogers, Michael
Subject: RE: WI 0500011 James Newport Family Trust
ls this a renewal or pe1mit for new inj well? applicant references that the wells "are used ... " only for A/C
From: Rogers, Michael
Sent: Thursday, May 26, 2011 5: 12 PM
To: Zimmerman, Jay
Subject: WI 0500011 James Newport Family Trust
Jay-
Please find attached a SQM renewal application. Please let me know if you wish to conduct a pre-permitting inspection or
not.
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)
http://portal.ncdenr.org/web/wq/aps/qwpro/permit-applications#geothermApps
. 1
E-mail co,respondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
2
UoMAPS - Warren County NC Public Access
Page I of I
y� Warren County _ GIS/Mapping System
i w Click Here To Start Over
Tilenfity I_ay'e:r; r tlse Map Tq�s
PARCELS (Map Tips Available)
RM'rINW,
r !J i Feaiure Found
Y/1
Zoom To Seale: �'O
f�uirk Searrh: 3020-123780 1 GO
M,.)t] Layers I Fnials j t' OV
Addr° SSINdIFIP, PdIVO1 Sed.rch l Results
1. ar aro qrr,-.iporH
+ ri4rash Map R rl:
Aer .3I
r' Ae-i•als 2OC15
r Aerials 200?
- y �!� Aerials 7l71�7
rldanes
t 38 iq ►8L! ding;FoAp ili
►Eri irosimei itai
n ►l cv its cif It terr-st
Zoom In Buffer Tax Card PIN NAME 1 ADRS CIn' STATE ZIPC MAPN DESC
Zoom In Buffer Tax Card' 3028-12-3780 NEWPORT DAMES L 114 RIUERBLUFF ROAD LnTLETON NC 27850 LLB 88 LT 9R/HSE/SUMMEV
4
httn•Ilwww-warrPnrs»�rit�mrn;e .,.-..1.............. � --- r*

GoMAPS - Warren County NC Public Access
a' .n' r� .�-•r a¢e tsV
U 1 D rbo
PR 1
D 3" 3
3D_ A
4 8D '-
D
4 t' L31) B D �D
PIll VATH ;,n
7 'C
7D D r
4'- °
8�t OD85
BD 57C
._�.'H
2 ,.
g. B 1 2
&
n d 3E
L 4
1 15.E r o i5 �3 02
7 u v 3 101
.36r8 ■ B 5 a
- 47
8
3l L3D84 ti .
L3 D 3
LID 57A ,
LEGEND
ADDRESS_ POINTS
BUILDING -FOOTPRINTS
INTERSTATE 85
NC_HWY_43
NC HWY_58
,fry,
NC-HWY_903
US_158,_BYR
U 9158 E
US_HWY_1
US-HWY-401-_S
l7 F%A RN

Thursda Mav 26 2011
N
A

Warren ·county, NC Property Record Card Page 1 of 1
+OWNERSHIP 10052009 28833 301 !PROPERTY DESCRIPTION ITAX SUBDIVISIONS IMAP NUMBER CARD NO + ______________ ------------
NEWPORT JAMES L & BARBARA J LT 9R/HSE/SUMMEWD SEC I RIVER TOWNSHIP L3B 88 1
RECORD NUMBER:. 15304
ROUTE
368 LF WF
114 RIVERBLUFF RD
LITTLETON NC 27850
DEED: 431 256 06161986 80000-22 114 RIVERBLUFF RD
LITTLETON FIRE
LISTER:SC071907
REVIEW:SW030909
+----------------,--------,------,--------,,------------------* I TOPO I STREET I UTILITY I ZONING
+
+
+
+
+
+
+
+
+
+
,:,
c-
ATGARAGE.
• ■ ■■ ■■• ■ I
*
* .B ... *: .. ,
. D .*
*
. . * ....
5 5
: ... 26 ... :
A-
!ROLLING !PAVED IWELL I
'1 INOOUTLETISEPTIC j I ELECTRIC
NOTES:PLAT 20/27
NBHD
0600
l#ILAND CLASS I SIZE IBASERATE*FRNT*DPTH*ADJ=ADJRATE*UNITS=LND-VALUE
ll4JWATERFRTI 2.LTI 3000001-----13000001--21 600000
LAND VALUE: 600000
l#IOTHER FEAT SIZE IBASERATE*COND =ADJRATE*UNITS=OFB-VALUE
SNG FAML. 1 65BBOAT.HSE 40* 45.00 1080
. 2 66CBOATLIFT 1* 3325.00 2
.. * 3 67CDOCK 240*
4 39CBULKHEAD 200*
*. DECK *
E-5
* 5 12CBT PAV 4000*
5
27 ~ 0.90
2 3500.00 0.95
1 10.00 0.90
1 63.88 0.90
1 2.00 0.90
9.00 240
57.49 200
1.80 4000
48600
6650
2160
11498
7200
* * .. *.. 7
*
. * ..
OTHER VALUE:
IFNDATIONIXTRFNISHIROOFTYPEIROOFMTRLISIZE/QTYI DPRT:2-RES GOOD
I STN I CED/REDW I GABLE I ASPHSHNG I I
I I I I 11.00STHTI
IWALLFNSHIFLOORS IHEAT&AIRIHEATFUELI I
IDRY WALLIH/W PARQIHTG & ACIELECTRICI 3 BDRMI
I I
CARPET I I I 7 ROOMI VINYL I 1.00LFUF
76108
+ _______________ _
·DWELLING CONVTNAL A+20 B1990 GOOD CONDITION + ___________________________________________ _
DIMENSIONS:A-CXUllR4XXR3DlXXU3RlXXR19D6XD5R26U5XU6Rl9XXR8D25XXD9L27XD5XD5Ll3XXL13U5XU5XL18U6XXU10R4XXL13U5X
B-CXL19U7XXUllR4XXR19D7XXDllL4X C-R7Ul0CXL35U9XXU23R8XXR35D9XXD23L8X D-CXL4Dl0XXD5Rl3XXR4Ul0XXU5Ll
3X E-L4Dl0CXL4DllXXD17R48XXR13U5XU7XL13DSXXU5Ll3XU5XUllL31XH + ___________________________________________ _
#ISTRUCTUREISKTCH-SF*STHT=
+A lASNG FAMLI 2004 1.00
+
3.00 BATHSI
1 FIREPLACE
1 CHIMNEYS
40%UNF-BSMT
60%FIN-BSMT
B 86 UTil.:ROOM
C 77 ATGARAG E
D 80 PORCH
E 88 DECK
E 79 PATIO
237 1.00
877 1.00
150 1.00
594 1.00
594 1.00
3206HSF,
AREA
2004
802
1202
237
877
150
594
594
RATE*GRDF+HEAT+EXWL*WLHT=ADJRAT*
90.20 1.20 2.50 1.00 --1111.74
4800.00 I o.oo
19.84 1.20
49.61 1.20
51. 77 1. 20
51. 86 1.20
43.75 1.20
28. 36 1.20
6.60 1.20
1. 38
4720.00
23.81
60.91
62.12
62.23
52.50
34.03
7.92
6460TSF RPCN-136.45/HSF
AREA=
2004
802
1202
237
877
150
594
594
RPCN*
223927
14400
0
4720
19096
73214
14722
54576
7875
20214
4704
DEPF*CNDF=STR-VALUE
0.87 --
0.87
0.87
0.87
0.87
0.87
0.87
0.87
0.87
0.87
0.87
194816
12528
0
4106
16614
63696
12808
47481
6851
17586
4092
437448 VALU-118.71/HSF 380578
·STRUCTURE VALUE: 380578 + ___________________________________________ _
VALUATION! VALUEIPREV-VAL.IP-N%1 SALEIS-N%1 TOTAL VALUE 1056686
+---------,---------,-------,---------LAND I 600000 I 210000 I 2 8 5% I I
OTHERFEAT 761081 49844,152%,061619861 I STRUCTURE! 323491 314571 102% 431-256
TOTAL I 9995991 5744151174%1 800001249%1
329TV/HSF
24SP/HSF
+--------------------------------------------GEOGRAPHIC-ADJUSTMENT-NBHD: 600 CAVB: 380578 * 0.85= 323491 TOTAL APPRAISED-VALUE: 999599 +_· ___________________________________________ _
1
Show with Larger Font
http://www.warrencountyncgis.org/PRC/CreatePRC_2.pl?ShowLink=No&recNum=l5304 5/26/2011
1,
A7'A
HCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
May 24, 2011
Barbara Newport, Trustee
James Newport Family Trust
114 River Bluff Road
Littleton. NC 27850
Subject: Acknowledgement of Application No. WI0500011
James Newport SFR
Injection Mixed Fluid GSHP Well System (SQM)
Warren
Dear Ms. Newport:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on May 16, 2011. 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.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON TIDS PROJECT.
Sincerely,
·Q~A-~
for Debra J. Watts
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Permit Application File WI0500011
AQUIFER PROTECTION SECTION
1636 lVlail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Bouievard , Raleigh. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www .ncwaterauali tv .o rq
An Equal Opportun iiy \ Affi rmative Action Emp loyer
None .. C 1. ortn aro..ma
/vaturaltu
A
NORTH CAROLINA DEPARTMENT OF ENVIRON MN'T AND NATURAL, RESOLrRCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP MIXED -FLUID GEOTHERMAL V ECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system
(check one) New Application Renewal* Modification
• For renewals complete farts A-C and the signature page.
t or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
rin
DATE: S 1 i V L
PERMIT NO. a2 ❑ �o pp /I (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence BusineWOrganization
Government: State Municipal County Federal
B. PERMIT APPLICANT - For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
Mailing Address: il-4 ter b
City: LiL4-r, s State: tt Zip Code: .1795 0 County: LED aAyar-An
Day Tele No.: A �K G -- ? Cell No.: .'75.2 S-3a ,A
EMAIL Address: )D t aA--� gmm,�Q" m alL Fax No.:
dtrr's
C. LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 3D -!2 0 -y 1 2za7:q Glr) County: &ZA- zR .tJ
(2) Physical Address (if different than mailing address): W .LL\% A-k E- j2u Sth"I S lclA.
e-
City: I.,1, _jj-�V ►.a State: NC Zip Code: X i 2 5 r7 -
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
GPU U1C 5QM Pemut Application (Revised 1/24/2011) Page 1

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: Depth of each boring (feet):
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Chemical additives to be used: R-22 Propylene glycol - Ethanol
Other (other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc):
(4) Well casing. If the well(s) will use casing then provide the tie (steel, PVC, plastic, etc.), diameter, depth,
and extent of casing appearing above ground:
(5) Groat (material surrounding well casing and/or piping): ,
(a) Grout type: Cement Bentonite** Other (specify).
** 9y selecting hentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(1 )(A7, which requii es a cement type grout.
(b) Grout depth of tubing (reference to land stirface): frohl tQ (feet)
If well has casing, indicate grout depth. from to s (feet)
G. WELL LOCATIONS —Maps must be scaled or otheywix accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s)'. Label all features clearly and include a north arrow.
(1) Attach a site -specific map showing the locations of the following:
• P. * Proposed injection wells" * Buildings * Property boundaries
SiRaee kater bodies * Water supply weIIs
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
Existing or potential so-urces of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can he
obtained and downloadedfrom the applicable county GIS website. Typically, the property can be searched by
owner name or address The location of the wells In relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand Also, a `laver' can he selected showing topographic contours or
elevation data.
GPUfUIC 5QM Permit Application (Revised 1/24/2011 ) Page 2

R CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1, for a corporation: by a responsible corporate officer,
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the _propert :- deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty- of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those indA iduals
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."
Signature of Property Owner/Applicant
Cq&Xrs C) Jaj {.s_,,a,�
Print or Type Full Nance
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if an),
Print or Type Fuld Name
Submit two copies of the completed application package to:
DW¢ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QM Permit Application (Revised U241201 1) Page 3

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: %V
PermitteeName: '. rn r-N t-,k r. c- r?oAT
VA Address: t 1_ ��_�_�c-_n-� _ ,mot L.■" "ta`�oi.t 7 1`lr ?79 :5C
Please check the selection which most closely describes the current status of your injection welt system:
1) K Well(s) still used for injection activities, or may be in the future.
2) ❑ Well(s) not used for injection but is/are used for water supply or other purposes.
3) ❑ injection discontinued and: a) ❑ Well(s) temporarily abandoned
b) ❑ Wells) permanently abandoned
c) r l' Well(s) not abandoned
4) ❑ Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description ofhaw the well
was sealed and the type of material used to fill the well if permanentl)+ abandoned):
Permit Rescissii m;
If you checked (2),(3), or (4) and will not use a well for injection on this site in the future, you should request rescission ofthe
permit. Do you wish to rescind the permit?
❑ Yes ❑ No
Certification:
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
_1 lie
Si nature—,�, n `� Date �T
Revised 5/05 GWIIlIC-58

A~A B.,1~ .. ~ __ .1. __
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
James Newport
114 Rivberbluff Road
Littleton, NC 27850
Coleen H. Sullins
Director
May 2, 2011
Subject: Notice of Expiration (NOE)
SQM Geothermal Injection Well
Permit No. WI0500011
Warren County
Dear Mr. Newport:
Dee Freeman
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Quality (DWQ) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above-referenced operating permit for
the underground injection well system, which was issued to you on September 13, 2006, and
expires on September 30, 2011, is soon due for renewal. If you wish to keep this permit and
operate the injection well system, the permit must be renewed and issued in your name.
If Your Injection Well is Currently Inactive:
If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed under NCAC Title 15A, Subchapter
2C, Section .0214. When each well is plugged and abandoned, the well abandonment record
(Form GW-30) must be submitted to our office to certify that the abandonment was properly
conducted.
If there has been a change of ownership of the property, an Injection Well Penn.it
Name/Ownership. Change Form must also be submitted. The GW-30 and Name/Ownership
Change forms can be found at http ://portal.ncdenr .onz./web/wo/ aps/ {!Wnro/reporting-forms.
If Your Injection Well is Currently Active:
If the injection well system is still active and you wish to renew your permit, the renewal
application must ·be submitted within 120 calendar days of the expiration of your permit.
According to our records, you must submit your permit renewal by June 2. 2011.
AQUIFER PROTECTION SECTION
1636 Mail Service Center1 Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-71:i-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportuni~ \ Affirmative Action Employer
One North Carolina
vVaturall!I
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit one of the following
enclosed forms:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for Injection with
Geothermal Heat Pump System for Type SQM Well(s) if the injection well system on
your property is still active.
-OR-
B. Status of Injection Well System if the injection well system is inactive or has been
temporarily or permanently abandoned.
Please submit the appropriate forms to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
http ://h2o.enr.state.nc.us/ap s/gp u/forms.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please contact me by phone at [phone] or by email at eric.u.smith@.ncdenr.gov.
Sincerely, . _.......!4'.L--__ _
~ ell fau li,1-i
Eric G. Smith, P.G.
Hydro geologist
Enclosures
cc: Raleigh Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI050001 l w/o enclosures
2
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RA.LEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF FOUR WELLS FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Mr. James Newport
FOR THE OPERATION OF FOUR (4) TYPE 5QM INJECTION WELLS, 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 114 Riverbluff
Road, Littleton, in Warren County, North Carolina, and will be operated in accordance with the
application submitted on August 7, 2006, and in conformity with the specifications and
supporting data submitted, all of which are filed with the Department of Environment and
Natural Resources and are considered a part of this permit.
This permit is for the operation only, and does not waive any provisions of the Water Use Act or
any other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be
in compliance with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and any
other Laws, Rules, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until September 30,
2011, and shall be subject to the specified conditions and limitations set forth in Parts I through
VIII hereof.
Permit issued this the day of , 2006.
ItAlan W. Klimek, Pirector
Division of Water :Quality
By Authority of the Environmental Management Commission.
Permit No. W10500011 PAGE 1 OF 6
GWILJIC-5QM ver, 7/04

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 fujection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that
are generally subject to flooding include those with concave slope, alluvial or colluvial
soils, gullies, depressions, and drainage ways.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each injection well shall have permanently affixed an identification plate.
PART II -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). fu the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances which may be
imposed by other local, state, and federal agencies which have jurisdiction. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
PART III -PERFORMANCE STANDARDS
PennitNo. WI0500011
GW/UIC-5QM ver. 7/04
PAGE 2 OF 6
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Pennittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modificatiqn, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions-of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Pertnittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility. ·
PART IV -OPERATION AND MAINTENANCE REQUIRE~NTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Pennittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
PART V -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary
Permit No. WIOS000l 1_
GW/UIC-SQM ver. 7/04
PAGE3 OF6
by the Division of Water Quality to insure surface and ground water protection, will be
established and an acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report .by telephone, within .48 hours of the occurrence or first
knowledge of the occurrence, to the Raleigh Regional Office, telephone number (919)
791-4200, any of the following:
(A) Any occurrence at the injection facility which results in any unusual
operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report to
the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
PART VII-PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an
extension.
PART VIII -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) 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.
Permit No. WI0500011
GW/UIC-5QM ver. 7/04
PAGE40F6
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
( C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
·at intervals not exceeding 10 feet, and grout injected through the
perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion of
abandonment.
3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
Permit No. WI0500011_
GW/UIC-SQM
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
ver. 7/04
PAGESOF6
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 08/23/2006 Coanty: Warren
To: Aquifer Protection Section Central Office Permittee: James Newport
Central Office Reviewer: On Oi Project Name: UIC 50M
Regional Login No: 05 Application No.: WQ0500011
I. GENERAL INFORMATION
1. This application is (cu-* au th-t aPpty): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rare infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation ® Other Injection
Was a site visit conducted in order to prepare this report?. es or
a. Date of site visit: 08/23/2006 by phone.
❑ 503 regulated ❑ 503 exempt
Is (including in situ remediation)
No.S2--� -
b. Person contacted and contact information: James Newport Ph. # 252 586 2897
c, Site visit conducted by: JGreer
d. Inspection Report Attached: 0 Yes or ❑ No.
2. Is the following information entered into the BIMS record for this application correct?
N Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location.:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
e. Regulated Activities / Type of Wastes (e.g,, subdivision, food processing, municipal wastewater):
For Dispo ai and 1n'tction Sites:
(If multiple sites either indicate which sites the information avvIies to. coov and paste a new section into th
document for each site. or attach additional pages for each site)
a Locations): 114 Riverblufi Road, Littleton NC 27850
b. Driving Directions: 401Nto 156N to 4 N to FIgwmung Dairy Rd R to end Lon SummeFwoods Dr.
Riverbluff Rd H on R
c. USGS Quadrangle Map name and number: B27NW Littleton
d. Latitude: 36.30.00 Longitude: 77.54.25
II. NEWAND MAJOR MODIFICATTIONAPPLICATIONSLthis section not needed }or renewals or minor
modit'ecations, skip to next section) - - -
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: LIC 5QM Heat Exchange, Four_Welts

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
0 Yes O No O NIA. Ifno, please explain: __
3. Are the new site conditions ( soils, topography, depth to water table, etc) consistent with what was reported
the soil scientist and/or Professional Engineer? D Yes D No D NI A. If no, please explain: _
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? I
Yes D No D NIA. Ifno, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. OYesONol
NIA. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No O NIA. Ifno, please explain: __
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No D NI A. If yes, please attach a map showing areas of 100-year floodplain and please expl~
and recommend any mitigative measures/special conditions in Part IV: __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, pl~
attach a map showing conflict areas or attach any new maps you have received from the applicant to
incoiporated into the permit: __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitorir
monitoring parameters, etc.) adequate? D Yes D No D NIA. Attach map of existing monitoring w
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend a
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes O No O NIA If yes, attach list of si1
with restrictions (Certification B?)
Ill RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or maior modificatio
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#: __
2. Is the design, maintenance and operation ( e.g. adequate aeration, sludge wasting, sludge storage, effiuc
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D 1'
If no, please explain: __
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequate
assimilating the waste? D Yes or D No. Ifno, please explain: __
4. Has the site changed in any way that may affect permit (drainage added, new wells inside the complian
boundary, new development, etc.)? lfyes, please explain: __
5. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
0 Yes or D No. Ifno, please explain: __
6. Are the existing application rates (hydraulic or nutrient) still acceptable? D Yes or O No. If no, pleti
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitori
parameters, etc.) adequate? D Yes O No D N/A. Attach map of existing monitoring well network
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to t
groundwater monitoring program: __
8. Will seasonal or other restrictions be required for added sites? D Yes O No O N/ A If yes, attach list of si1
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, please attacl
map showing conflict areas or attach any new maps you have received from the applicant to be incotp0rat
into the permit: __
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing pennit correct? [
Yes or D No. Ifno, please explain: ___ _
11. Were monitoring wells properly constructed and located? D Yes or D No D N/ A. If no, please explw
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? 0 Yes
D No D N/ A. Please summarize any findings resulting from this review: __ _
13. Check all that apply: D No compliance issues; D Notice(s) of violation within the last permit cycle; [
Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently und
moratorium. If any items checked, please explain and attach any documents that may help clari
answer/comments (such as NOV, NOD etc): ___ _
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? 0 Y
D No D Not Determined D N/ A.. If no, please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this pennit? [
Yes or D No ON/A. Ifyes, please explain: __
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPL/CA TIO NS (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 (5A 7)
~ Closed-loop heat pump system (SQM/SQW)
□ In situ remediation (Sn
D Closed-loop groundwater remediation effluent injection (5Lf'Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? 0 Yes D No
3. Are there any potential pollution sources that may affect injection? D Yes D No
Wliat is/are the pollution source(s)? . What is the distance of the iniection well(s) from the pollution
source{s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? ---=ft=.
5. Quality of drainage at site: 0 Good O Adequate O Poor
6. Flooding potential of site: D 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 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)? 0 Yes or O No. l
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollutioi
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 watei
failure to assimilate injected fluid, poor heating/cooling)?
0 Yes ~ No. If yes. explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since pennit issuance
or last inspection? D Yes IZ! No. If yes, e;,mlain:
3. For renewal or modification of groundwater remediation pennits (of any type). will
continued/additional/modified injections have an adverse impact on migration of the plume or management oj
the contamination incident? D Yes ~ No. If yes, explain:
4. Drilling contractor: Name: __
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address:
Certification number: __
5. Complete and attach Well Construction Data Sheet.
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V EVALUATIQNA;NV RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with 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:
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:
Reason - -
6. List specific special conditions or compliance schedules that you recommend to be included in the permit whe
issued. Make sure that you provide a reason for each special condition.
7. Recommendation: ❑ Hold, pending receipt and re%view of additional information by regional office- ❑ Hol
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 Wer[s}. �J
Signature of APS regional supervisor:
Date: ��IF
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
Svstern is operating. no changes

AQUIFER PROTECTION SECTION l i s
APPLICATION REVIEW REQUEST FORM
Date: August_ 16, 2006
To: ❑ Landon Davidson, ARO-APS ❑ David May, WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Charlie Stehman, WiRO-APS
❑ Andrew Pitner, MRO-APS ❑ Sherri Knight, WSRO-APS
® Jay Zimmerman, RRO-APS
From: Qu Qi, Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
i4 Mail: [e-mail]
A. Permit Number: W10500011 '� �o7We-4o4 t3of7 N c-47
B. Owner: James Newport
C. Facility/Operation: Newport Residence
❑ Proposed ® Existing ❑ Facility ❑ Operation
D. AvOleation:
I. Permit Type: ❑ Animal ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ IIE Lagoon ❑ GW Remediation (ND)
® LIC - (5QM) closed loop mixed fluid geothermal
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2 Project Type: ❑ New ❑ Major Mod. ❑ Minor Mod. ® Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
® Return a Completed Form APSSRR.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO*.
* Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS represeutatives in order to prepare a complete Attachment B Por
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:
FORM: APSARR 02/06 Page l of 1
Date: A?

Compliance Inspection Report
Permit: WI0500011
SOC:
Effective: 11/28/01 Expiration: 11/30/06 Owner: James L Newport
Effective: Expiration: Facility: James Newport SFR
County: Warren
Region: Raleigh
Contact Person: James L Newport
Directions to Facility:
Summerwood Subdivision -Lot 9R
Primary ORC:
Secondary ORC(s):
On-Site Reprasentative(s):
Related Permits:
Inspection Date: 08/23/2006
Primary Inspector: Jimmie W Greer
Secondary lnspector(s):
Reason for Inspection: Routine
Entry nme: 09:0o AM
114 Riverbluff Rd
Littleton NC 27850
Phone: [phone]
Certification: Phone:
Exit Time: 09:10 AM
Phone: [phone]
Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Mixed Fluid GSHP Well System (SQM)
Facility Status: ■ Compliant O Not Compliant
Question Areas:
■Other
(See attachment summary)
Page: 1
Permit: WI0500011
lnapection Date: 08'2312006
Inspection Summary:
owner -Facility: James L Newport
Inspection Type: Compliance Evaluation Reason for Visit: Routine
08/23/2006 JGreer called Mr. James Newport and no changes has been made on the system,system is running ok,
Other
Comment:
Yes No NA NE
Page:2
Central Files: APS SWP
08ID7/ps
e�rfnit fvumner W10500011
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
In review Renewal
Permit Typa
Jersr-n Permit Classificatlorn
Injection Mixed Fluid GSHP Well System (50M)
individual
Primary Reviewer
Permit Contact Affiliation
qu.gi
James Newport
Permitted Flow
114 Riverbluff Rd
Littleton NC 27850
Facility Name Major/Minor Region
James Newport SFR Minor Raleigh
Location Address County
114 Riverbluff Rd Warren
Littleton NC 27a5Q Facility Contact Affiliation
Owner Name Owner Type
Individual
James L Newport Owner Affiliation
James Newport
114 Riverhluff Rd
Littleton NC 27850
i',
Scheduled
Orig Issue App Reeeived Draft Initiated Issuance Public Notice ISsva Effective Expiration
02/14/90 08107/06
Requiatecl Activities
Unknown 00
=,uII.II, I , I
Waterbody Name Stream Index Number Current Class Subbasin

Application Reviewer: ~~ .... ~ (' ( \tl <; · (I, f""
Pre-Review: Conducted? ffi" Yes D No
O.K. to Process? D Yes D No
If No, What Action Is Needed? D Pre-Review Return
D Hold, Pending Receipt of Addinfo.: _____________ _
Name/Affiliation of Person Contacted: --------------------------
Date ( s) of Contact: ____________ D By Phone D By E-Mail D By Letter
Owner: ~ Existing : D Unknown Owner Type [B-Non-Gov't (0 Ind. or D o"rg) D Gov.-Municipal
D Gov.-County D Gov.-State D Gov.-Federal
Facility/Operation: 0 Proposed !kr"Existing D Facility D Operation
Regulated Activities: --------------------------------
Application/Permit:
Fee Category:
Permit Type:
l;t I L
,ype. sfttl'\
Project Type:
D ND Major (New $1090, Major Mod $325) D ND Minor (New $675, Major Mod $205)
D Sewer Ext. ($400) D SFR (New $50, Major Mod $15) D Recycle ($300) 0 Other
D Sewer Ext. D Collection System (O&M) D Pump & Haul
0 Surface Irrigation D Surface Irrigation -SFR D Reuse
0 High-Rate Infil. D Recycle O Infil./Evap. Lagoon O GW Remediation (ND)
For Residuals: D Land App. D D&M D · ·surface Disposal D Animal
D 503 D 503 Exempt
D New O Major Mod. D Minor Mod. ~Renewal D Renewal· w/ Mod.
Notes:--------------------------------------
i::n D M'. R TM~ ru /(l') /1 Q
m
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RENEWAL APPLICATION FOR PERMIT To USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM
Type 5A7 and 5QM Wells
In accordance with the provisions ofNCAC Title 15A: 02C.0200
complete application and mail to address on the back page.
RECEW I DENR I DVVQ
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY AC"'PROTECTlON SECTION
DATE: 11K _ M , 20 1411�4P AUG 0 7 20ffi
A. PERMIT APPLICANT
Permit Number: HI 1PX" d4067 (W10#40-0, listed at the bottom of each page of your permit)
Name: �r J r
Address:
City e . State: i G°. Zip code:.Z
County: ILL'.'v I' Ile Telephone:ir_=:-572.i ,r8'G .; 7 _
B PROPERTY OWNER (if different fxom applicant)
Name. -
Address:
City: State: Zip code;
County: _ Telephone:
C. STATUS OF APPLICANT
Private: Federal: Commercial: State: Public:
Native American Lands:
D. FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Public or Commercial).
Name of Business or Facility:
Address:
City: State: Zip code:
County: Telephone:
Contact Person:
Standard Industrial Code(s) which descnbe commercial facility:
Revised 7/06
GWUC-57 HPR
Page 1 of 3

E.
F .
G.
H.
I.
J.
K.
L.
INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
l ~e_
WELL USE Is(are) the injection well(s) also used as the supply well'<'for either of the following?
(1) The injection operation? YES_ NO
(2) Your personal consumption? YES_ NO.)(_
CONSTRUCTION DATA
(1)
(2)
Specify at:iY and all modifications to the well casing, grout or screens since the issuance of the previous
injectio~ermit.
v<P /J
NC. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes. A faucet on both influent (groundwater entering heat pump) and
effluent (water being injected into th~ well) lines is required. Is there a faucet on:
(a) the influent line? YES V"" . NO __
(b) on the effluent line? YES~ NO __
CURRENT OPERATING DATA i
(1) Injection rate: Average (daily) { gallons per minute (gpm)
(2) Injection volume: Average (daily) ~ gallons per day (gpd)
(3) Injection pressure: Average (daily) ? pounds per square inch (psi)
(4) Injection temperature: Annual Average 7 degrees Fahrenheit (°F)
INJECTION-RELATED EQUIPMENT
Attach a diagram showing any modifications to injection equipment since the issuance of the previous injection
permit including the engineering layout of the (1) injection equipment, and (2) exterior piping/tubing associated
with the injection operation. The manufacturer's brochure; ifdetai1ed,.should satisfy (i).
LOCATION OF WELL(S) Attach a map . z::;j ,9r,1f. r""'ilt f yi/'l,,..,.;t;..,"' th JJ!/CI -
Include a site map (can be drawn) showing: the orientation of and distances between the injection well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
ground-source heat pump well system; include buildings, property lines, surface water boaies, any other potential
sources of groundwater contamination. Label all features clearly and include a north arrow to indicate
orientation.
PERMIT LIST: Attach a list of all permits or construction approvals, received or applied for by the applicant
that are related to the site. Examples include:
( 1) Hazardous Waste Management program permits under RCRA r / f9.'...q___-
(2) NC Division of Water Quality Non-Discharge permits 1 [ n :.,.:.----
(3) Sewage Treatment and Disposal Permits tl4 A. e.. -
---OTHER MODIFICATIONS: Indicate any other modifications to the injection well system (equipment, fluid,
operation, etc.) that have occurred since the issuance of the previous injection permit and have not been noted
elsewhere on this application.
//{?A e
Revised 7 /06 GW /UIC-57 HPR Page 2 of3
M. CERTIFICATION
"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 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."
/gignature of Well Owner err Authorized Agent)
ff authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
N CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property rights in the
well(&). A well is real property and its construction on land rests ownership in the land owner in the absence of
contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the
applicant to operate an injection well(s) as outlined in this application and that it shall be the responsibility of the
applicant to ensure that the injection well(s) conform to the Well Construction Standards (Title 15A NCAC
Subchapter 2C .42ii0)
(Stgnattue of Property O'wnet if Different From Applicant)
Please return the completed Application package to;
UYC Program
Aquifer Protection Section
North Carolina DENR DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Revised 7106 GW"C-57 HPR Page 3 of 3

James & Barbara Newport
114 Rlverblu#f Rd
iUMeton, NC 27850
EA
�
�+r�+�l+�i�+�i+i�++e+ltrrirrrl'r'l�111}I+iF�leirl+iliiioil��r+

Mlchaei F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Ornek, P.E. director
Division of Water Quality
August 8, 2006
James Newport
114 Riverbluff Road
Littleton, NC 27850
Subject: Acknowledgement of Application No. W1050001 I
James Newport SFR
Injection Mixed Fluid GSHP Well System (5QM)
Warren
Dear Mr. Newport:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on August 7, 2006. This application package has been assigned the number
listed above and will be reviewed by Qu Qi,
The reviewer will perform a detailed review and contact you: with a request for additional iri ormation 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 Qu Qi at 919-715-6935, 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 hM):Hh2o.enr,state.n_e.us/documents/dwci orgchan.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUHUES ON THIS
PROJECT.
Sincerely,.
for Debra J. Watts
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Permit Application File WT0500011
Aquifer Protection Section 1636 Mail Service Center
Internet: www_ncwat r u i .o Location: 2728 Capital Boulevard
An Equal OpportunitylAflirmalive Action Employer— 50% Recycledfl0% Post Consumer Paper
Npc i thCarolina
Naturally
Raleigh, NC 27699-1636 Telephone; [phone]
Raleigh, NC 27604 Fax 1 : (919) 715•0588
Fax 2: [phone]
Customer Service: [phone]

r^Q
I; ! r■
i, r
August 2, 2006
James & Barbara Newport
114 Riverbluff Road
Littleton, NC 27850
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7002 2410 0003 0274 1735
Michael F. Easley, Governor
William G. Ross Jr., Secretary
,gorth Carolina Department ofi nvironrnent and Natural Resources
Subject: Notice of Expiration
Injection Mixed Fluid GSHP Well System (5QM)
UIC Permit No. WI0500011
Jaynes Newport SFR
Warren County
Dear Mr. & Mrs. Newport:
Alan W. Klimek, P.E. Director
Division of Waler Quality
The Underground Injection Control (UIC) Program of the Division of Water Quality is
responsible for the regulation of injection well construction and operation activities within the
state of North Carolina. Our records -show that the operating permit referenced above for the
geothermal heat pump injection well at 114 Riverbluff Road in Littleton, North Carolina
will expire on November 30, 2006. In addition, our records do not indicate that the well has
been abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must take one of the following
actions:
A. Submit the form RENEWAL APPLIu voN FoR PEPMT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUAfP SYSTEM (form GWIUIC-57 HPR) if the injection well on your property is still
active;
B. Submit the form STATUS OF INJECTION WELL SYSTEM (form GWIUIC-68) if the injection
well is inactive or has been temporarily or permanently abandoned.
If the injection well is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.0214. Jf the injection well is to be permanently abandoned, a well abandonment record must be
submitted to our office to certify that the abandonment was properly conducted. If the injection
Aquifer Protection Section 1636 Mail Service Center
Internet! ww4 ncwateruualiiy&m Location; 2728 Capital Boulevard
An Equal OpportunllylAPfirmat}ve Action Employer-50% Recycled110% Post Consumer Paper
Isla hcaroltna
'Naturally
Raleigh, NC 27699-1636 Talephone. [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2- [phone]
Customer 5erviwi [phone]

James & Barbara Newport
August 2, 2006
Page 2 of2
well is still active, a renewal application is to be submitted at least 3 months prior to the
expiration of this permit.
Please submit the appropriate form(s) within 30 calendar days of the receipt of this letter. If you
have any questions regarding the pennit and injection well rules, or if you would like assistance
completing these forms please call Qu Qi at [phone], or email him at [e-mail].
Sincerely,
~L,,J ,.___.----
Jesse Wiseman
Aquifer Protection Section
Enclosures
1. GW/UIC-57 HPR
2. GW /UIC-68
cc: Raleigh Regional Office -APS w/o enclosures
APS Central Files -Permit No. W10500011 w/o enclosures
T :irren County -Search
Property Details for NEWPORT JAMES L & BARBARA J
Account Number: 28833 301
Record Number: 15304
Property Location: 114 RIVERBLUFF RD
Billing Addre.ss 1:
114 RIVERBLUFF RD
LITTLETON NC
27850
Township: RIVER TOWNSHIP
Neighborhood: 0628
DeedBook/Page: 431 -256
Actual Year Built: 1990
Heated Area: 3206
Base Rate:
Legal Description: LT 9R/HSE/SUMMEWD SEC I 368 LF
WF
Land Class: -40WATERFRT
Structure Class: DWELLING
http://www.ustaxdata.com/nc/warren/warrendetails.cfm ?record.ID= 16950
Page 1 of 1
8/2/2006
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
August 2, 2006
MEMORANDUM
To:
From:
Re:
Jay Zimmerman
Raleigh Regional Office
Jesse Wiseman J W·
Central Office Aquifer Protection Section
Notice of Expiration
Injection Mixed Fluid GSHP Well System (SQM)
UIC Permit No. WI0S000 11
J runes Newport SFR
Warren County
UIC Permit No. WI0S000l 1 (Injection Mixed Fluid GSHP Well System (SQM)) issued to James
Newport is due to expire on November 30, 2006. A Notice of Expiration regarding thi~ permit
was sent by this office to James & Barbara Newport on August 2, 2006. This letter is attached
for your records. No regional action is necessary at this time.
Attachment
cc: AP S Central Files -Permit No. WI0500011
MEMORANDUM
DMSION OF WATER QUALITY
GROUNDWATER SECTION
November 27, 2001
To: Jay Zimmerman, L.G., Regional Groundwater Supervisor
Groundwater Section
Raleigh Regional Office
From: Mark Pritzl M-f>. [e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section
Raleigh Central Office
Re: Issuance of a Closed-Loop .Geothermal-Mixed-Fluid Injection Well System
(Type SQM.):
Permit Number WI0500011 to operate 4 wells for the injection of a ~losed-loop
ground-source heat pump system has been issued to James Newport, _in Littleton, North Carolina.
This is a renewal permit and the Underground Iniection Control Group appreciates Jim
Greer's assistance with the inspection and review tasks. Please retain the application and
paper work for the RRO-UIC files. If you have any questions regarding this permit or the UIC
program, please contact me at [phone] or Evan Kane at [phone].
cc: CO-UIC Files
Enclosures
Michael F. Easley, Governor
Wiliam G. Ross Jr„ Secretary
North Carolina Department of Environment and Natural Resources
November 27, 2001
Mr. James Newport
9 Ri verblu ff Road
Littleton, NC 27850
Dear Mr. Newport:
Gregory J. Thorpe, Ph. D.
Acting Director
Division of Water Quality
In accordance with your application submitted on October 18, 2001, we are forwarding
Permit No. WI0500011 for the operation of a vertical closed -loop geothermal mixed -fluid
heat pump injection well system at 9 Riverbluff Road, Littleton, North Carolina, in Warren,
County.
This permit shall be effective from the date of issuance until November 30, 2006, and shall be
subject to the conditions and limitations stated therein. 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.
If you have any questions regarding your permit please feel free to contact me at (919) 715-
6165 or Mark Pritzl at (9 1 9) 715-6166.
Sincerely,
LJ
Evan O. Kane
Hydrogeologist
Underground Injection Control Program
cc: COARC Files
RRO-EPIC Files
Enclosures
-4 A
Tb MR -
Customer Service Division of Water Quality I Groundwater Section
1 800 623-7748 1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet. http://gw.ehnr.state.nc.us

Name Da te Initials T ype of PermiUComments
Cva,1 t<~U"C u/i~/o\ tjf-0¥'.--
M ark Pri tzl ,,1-,.,~1~ IA f ◄ ~at PumJJ !.i'"Q,')1 Rem ed ia tion Other -. .
Melilth:J E'.ac1 1eL
Debra Watts
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In .accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
James Newport
FOR THE OPERATION OF A 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 9 RiverbluffRoad,
·Littleton, North Carolina, in Warren County, and will be operated in accordance with the
application dated October 18, 2001, and in conformity with the specifications and supporting
data submitted, all of which are filed with the Department of Environment and Natural Resources
and are considered a part of this permit.
This permit is for Operation only, and does not waive any provisions of the Water Use Act or any
other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be in
compliance with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and any
other Laws, Rules, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its.issuance until November 30,
2006, and shall be subject to the specified conditions and limitations set forth in Parts I through
IX hereof. ...\v-·~ .
Permit issued this the i'6 day of ~( , 2001.
lr ~j-~
Ted L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0500011
ver.3/01 GW/UIC-5
PAGE 1 OF6
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must coniply-with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation· of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of.this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface
cannot migrate into the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each injection ~ell shall have permanently affixed an identification plate.
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection-
well, to the Division of Water Quality (Division), within 30 days of completion of well
construction.
PART II -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.
Permit No. WI050001 l
ver.3/01 GW/UIC-5
PAGE 2 OF 6
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
· complying with any and all statutes, rules, regulations, or ordinances which may be
imposed by other local, state, and federal agencies which have jurisdiction. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
PART ill -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater which will render it unsatisfactory for nonnal 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
~ennittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair~ modification, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation .of this facility.
PART IV -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.
PART V -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
Permit No. WIOS000l l
ver.3/01 GW/UIC-5
PAGE3 OF6
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including _groundwater, surface water, or soil sampling) deemed necessary
by the Division of Water Quality to insure surface and ground water protection, will be
established and an acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Raleigh Regional Office, telephone number (919) 571 "'.,
4700, any of the following:
(A) Any occurrence at the injection facility which results in any unusual
operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or. in any report to
the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
PART VII -PERMIT RENEWAL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
PART VIII -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued us·e of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal.· If a well is not to be used for any purpose that well must be
permanently abandoned according to ISA NCAC 2c ·.0213(h)(l), Well Construction
Standards.
Permit No. WI050001 l
ver.3/01 GW/UIC-5
PAGE4 OF6
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
{A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Drilled wells shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have
not been removed, neat-cement shall be injected into the well completely
filling it from the bottom of the casing to the top.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
Permit No. WI0500011
ver.3/01
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion of
abandonment.
•
PAGE 5 OF 6
GW/UIC-5
3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
Groundwater Section-VIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART IX .. OPERATION AND USE SPECIAL CONDITIONS
None
Permit No. WIOS000 11
ver.3/01 GW/UIC-5
PAGE 6 OF 6
North Carolina Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM S
INJECTION WELL PERMIT NO.. WI osbcW DATE da 0
NAME OF OWNER
LOCATION OF INJECTION WELL (and source well(s), if applicable) 4
/ C' r-11JW-e- LPG Af-
(Street) road or lot and subdivision, county, town, ifdierent than owner's address, plus description of location on site)
Potential pollution source Z/2,J� Distance from well U 3
Potential pollution source zA-1 n .6I Distance from well » /I :# Z
�/ 1I i/ /",[ n At /f i,, �i I/ I � # 73.
Potential pollution source o d e, Distance from well a/ e
Minimum distance of well from property boundary /;25-1 /
Quality of drainage at site
ao dequate,poor)
Flooding potential of site
(high,moderat ow
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, ant
girth arrow.)
rel
�rn
vr3
--i_�► . x
sn x
w p
f
DESCRIBE INJECTION SYSTEM (vertical closed Iaap, encased borehole or cased water well, • separate source well and
injection well; combination source and injection well, or other description as applicable)
AL
�.r l �' � �1 e.f '-aL ' AI j �• �v - �t��r� � — �1 Tr� t� -!C� ,�-�_.?.-r-..L �L%�

INJECTION FACILI - Y INSPECTION REPG-_T -FORM B (CONTINUED
' WELL CONSTRUCTION
Date constructed � �
& ! s� / jsp
Drilling contractor; Named
Address
"04 v —3. � s"!5—,0,l
Registration
number
a i± ,' —�
J
/O, ?�~� ate
��6
Total depth of well
Total depth of source well Z D o
(iapplicable)
Inspection point
Measurement Meets minimum standards Comments
Casing
I . "7- Yes Na
� ' �
Depth
Diameter
/0 17z
/y
72-
fr l %
(- f�I'l�-
Height (A.L.S.)
I'Iz /yy
Grout
'
✓,I✓
Depth
7,4;- zo ZV
z o
Screens
Depth(s)
/
�ZA
Length(s)
f •� �
� '' ✓
I.D. Plate
•
✓
Static water level
�y
3 1,
Well yield
Enclosure
A'r
�p !t � �p
�n G! � rrx.��d
a9-jWe--,J &94W� G2A�
Enclosure floor
C>u e-r "�P � c--
(concrete)
Sampling port
(Iabeled)
ley��
Zoo
-77
Water tight pipe entry
------
Well enclosure entry
Vent
Functioning of heat pump system Determine
from the owner ifheatpump functions properly.)
INSPECT4� �_
r--
f .� l _
_ Officezrr�
WITNESS
Address
WITNESS Address March 1998

Lai P�- " %G2:
3`A � � r-c CuJ• P�2!
� uL�
UJr4"T ,Cfz- LkA7- L-L

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
October 29, 2001
MEMORANDUM
To:
From:
Jay Zimmerman, L.G., Groundwater Supervisor
Groundwater Section
Raleigh Regional Office
Mark Pritzl f\e [e-mail]
Hydrogeological Technician II
UIC Group
Central Office
Re: Request for review of a closed-loop geothermal-mixed-fluid injection well, type SQM,
system permit renewal application and a routine inspection of James Newport's
geothermal injection wells in Littleton, NC, Warren County.
1. Please review the application and submit any comments to CO-UIC. Retain the
application for your UIC file.
2. Please inspect the proposed injection facility to verify the location and construction
plans specified in the application and to also verify compliance with NCAC
T15A:02C.0200 standards, using the enclosed Injection Facility Inspection Report (form
B) as a guide.
3. Return any application review comments and the completed Injection Facility
Inspection Report (form B) by November 30, 2001. If the inspection cannot be
accomplished by this date, please inform RCO-UIC promptly. The UIC group greatly
appreciates your assistance with the completion ofUIC program activities.
After the permit has been issued and operation is about to commence, the RCO-UIC may request
the RRO to inspect the facility in operation
Michael F_ Easley, Governor
William G. Ross Jr., Secretary
North Carolina 0epartrnent of Environment and Natural Resources
�� j
October 29, 2001
James Newport
9 Riverbluff Road
Littleton, NC 27850
Dear Mr. Newport,
Gregory 3. Thorpe, Ph.D.
Acting Director
Division of Water Quality
Your renewal application for a permit to use wells for a "Closed -Loop Geothermal -
Mixed -Fluid -Injection Well System" has been received and is under review. A member of the
Groundwater Section's Raleigh Regional Office staff will be contacting you to arrange an
inspection of the geothermal injection systern as part of the review.
If you have any questions regarding the permit or injection well rules please contact me
at [phone] or Evan Kane at [phone].
cc
�wA
Customer Service
1 800 623-7748
LIC Files
RRO Files
Sincerely,
944
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone, [phone] Fax: (919) 715-t1588 Internet: http:11gw.ehnr.state.nc.us

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT. HEALTH, AND NATURAL RESOURCES
APPLICATION FOR PERMIT RENEWAL To USE A WELL(S) FOR INJECTION WITH
A HEAT PUMP SYSTEM
Type SA7 and 5QM Wells ra
v
In accordance with the provisions of NCAC Title 15A: 02C.0200 [a's
oM
complete application and mail to address on the back page. �
eo
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY =m
DATE: eV _ & , 20_g4
A. SYSTEM CLASSIFICATION: Does the system re -circulate only potable water without any additives
such as
corrosion inhibitors or antifreezes in continuous piping which isolates the fluid from the environment?
YES If yes, do not complete this form. A form GW-57 CL, (Notification Of Intent 'Ta Construct A
Closed -Loop Geothermal -Water -Only Injection Well System), should be completed.
NO X If no, then continue completing this form.
B, PERMIT APPLICANT
Name:
w
Address: a" ;5 / &! - - —
City: f ; J. bra State: Zip code: 07
County:�r�er. _ Telephone: f,'L 1 ......,_
C. PROPERTY OWNER (if different from applicant)
Name:
Address:
City: State: Zip code:
County: Telephone:
D. STATUS OF APPLICANT
Private: Federal: Commercial: State: Public:
Native American Lands:
E. FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Public or Commercial).
Name of Business or Facility:
Address:
City: State: Zip code:
County: Telephone: Contact Person:
Standard Industrial Code(s) which describe commercial facility:
ver.3101 GWI[]IC-57 HPR rage 1 of 3

F. INTECTION PROCEDURE (specify any modifications to the imection procedure since the issuance of the
previous injection permit)
G. WELL USE Is(are) the injection well(s) also used as the supply well(s) for either of the following?
(1) The injection operation? YES NO__ ­�K
(2) Your personal consumption? YES NO X
H. CONSTRUCTION DATA
(1) Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection permit.
if
14 >Ofj G
(2) NC. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes. A faucet on Moth influent (groundwater entering heat pump) and
effluent (water being injected into the well) lines is required. Is there a faucet on:
(a) the influent line? ves____no
(b) on the effluent line? yes_ no
I. CURRENT OPERATING DATA
(1)
Injection rate: Average (daily)
gallons per minute (gpm)
(2)
Injection volume: Average (daily)
gallons per day (gpd)
(3)
Injection pressure: Average (daily)
pounds per square inch (psi)
(4)
Injection temperature: Annual Average
degrees Fahrenheit (' F)
INJECTION -RELATED EQUIPMENT
Attach a diagram showing any modifications to injection equipment since the issuance of the previous injection
permit including the engineering layout of the (1) injection equipment, and (2) exterior piping/tubing associated
with the injection operation. The manufacturer's brochure, if detailed, should satisfy (1).
K. LOCATION OF WELL(S) Attach a map
Include a site map (can be drawn) showing: the orientation of and distances between the injection well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
ground -source heat pump well system, include buildings, property lines, surface water bodies, any other potential
sources of groundwater contamination. Label all features clearly and include a north arrow to indicate
orientation.
L. PERMIT LIST: Attach a list of all permits or construction approvals, received or applied for by the applicant
that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
ver,3/01 GWIUIC-57 Hl?R Page 2 of 3

M. OTHER MODIFICATIONS: Indicate any other modifications to the injection well system
(equipment, fluid, operation, etc.) that have occurred since the issuance of the
previous ire' ction permit and have not been noted elsewhere on this application.
N. CERTIFICATION
"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 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."
(Sign re of Well Owner or Aut rued Agent)
If authorized agent is acting on beha f of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
O. CONSENT OF PROPERTY OWTIER (Owner means any person who holds the fee or other property rights in the
well(s). A well is real property and its construction on land rests ownership in the land owner in the absence of
contrary agreement in writing,)
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the
applicant to operate an injection well(s) as outlined in this application and that it shall be the responsibility of the
applicant to ensure that the injection well(s) conform to the Wen Construction Standards (Title 15A NCAC
Subchapter 2C .0200)
(Signature of Property Owner if Different From Applicant)
Please return the completed Application package to;
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
(Telephone: [phone])
ver.3101 GWIUTC-57 HPR Page 3 of 3

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER DUALITY, GROUNDWATER SECTION
STATUS OF INJECTION WELL. SYSTEM
Date: Off -20Gr Permit Number: WIC' _S- 600/1
Name: �.�r!• t 1 T �r�,r _�_, �V
Address:,k
Please check the selection which most closely describes the current status of your injection well.
In addition, please provide the requested information.
1) /< Well is still used for injection activities.
2) Well is used for water supply.
3) T Injection discontinued;
a) Well temporarily abandoned b) _ Well permanently abandoned
Describe the method used to properly abandon the injection well. (include a description of how the well
was sealed and the type of material used to fill the well if permanently abandoned): If you checked two
(2), report the pumping rate and what the water is used for.
Certification: (For well abandonment)
"I hereby certify, under penalty of law, that I am personally responsible for the proper abandonment
of any injection well as required in Title 15A NCAC 2C .0214 Criteria and Standards Applicable to Injection
Wells."
(Signature)
Certification: (For information verification)
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
information submitted in this document, and that to the best of my knowledge the information is true,
accurate, and complete."
(Signature)
i
ver.3101 G W /U IC -fib

F 1NA7F MIcnael F. Easley, Governor
roo R�G William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
co) Gregory J. Thorpe, Ph,D,
y Acting Director
Division of Water Quality
October 12, 2001
Tames Newport
9 Riverbluff Road
Littleton, NC 27850
Dear Mr. Newport:
Our records show that the operating permit for the injection well on your property did expire on
November 30, 1999, In addition, our records do not indicate that the well has been abandoned.
In order to comply with the regulatory requirements for permitted injection facilities (15A NCAC
2C .0211), you must submit either, the enclosed Application for Permit Renewal to Use a Wells)
for Injection with a Heat Primp System (form GW-57 HPR) if you are still using your injection well
or submit the enclosed Status oflnlection Well System (form GW-68) that certifies that the injection
well is no longer in use. If the well is no longer to be used for any purpose, it must be permanently
abandoned according to the regulatory requirements (15A NCAC 2C .0213), and you must submit
the enclosed Well Abandonment Record (form GW-30). The appropriate form(s) should be
forwarded to us by October 31, 2001; to allow adequate time for well water sampling and analysis.
If you have any questions regarding the permit and injection well rules or would like assistance
completing these forms please contact me [phone].
cc: UIC Files
Enclosures
APA
f4L�JE —NR
Customer Service
1 800 623-7748
Sincerely,
M 4 ',
Mark Pritzl
Hydrogeological Technician It
Underground Injection Control
Division of Water Quality 1 Groundwater Section
1636 Mail Service Center Raleigh, NC 27699.1636
Phone: [phone] Fax: [phone] Internet: http:llgw.ehnr.state. nc.us

R042814A.STS
Newpmrt
1W L,,At
PFSTAT Ver 3.3
Copyright (c) Trimble Navigation, Ltd, 1991, 1994. All rights reserved
R042814A.COR Statistics Version 3.3
Recs Mean Std Dev Minimum Maximum
Latitude 180 36o30'00.89382"N 5.91.154 36o30100.58206"N 36o30'01.22063"N
Longitude 180 77o54'24.53454"W 3.82385 77o54'24.88584"W 77o54'24.22503"W
Altitude 180 37.76078 7.93079 24.93710 56.20789
No velocity records in file.
No DOP records in file.
Start GPS Week #798 ❑n 04/28/95 at 14:29:43
End GPS Week #798 on 04/28/95 at 14:36:53
Datum : WGS-84
Coordinate System : Latitude/Longitude
Altitude Made : Height Above.Ellipsoid
Altitude/Distance Units : Meters
Velocity Units : Meters/Second
Page 1

R0428148.STS
PFSTAT Ver 3.3
Copyright (c) Trimble Navigation, Ltd:, 1991, 1994. All rights reserved
R0426148,COR Statistics Version 3.3
Recs Mean Std Dev Minimum Maximum
Latitude 185 36a30'01.00799"N 2.21762 36o30100.8267611N 36m30101.09480"N
Longitude 185 77o54'24.5676871W 1.87795 77o54'24.67823"W 77o54124.37806"W
Altitude 185 38.64894 3.60795 16.16133 42.01704
No velocity records in file.
No DGP records in file.
Start GPS Week #798 on 04/28/95 at 14:37:20
End GPS Week #798 on 04/28/95 at 14;41:51
Oatum ; WGS--84
Coordinate System ; Latitude/Longitude
Altitude Mode : Height Above Ellipsoid
Altitude/Distance Units : Meters
Velocity Units : Meters/Second
Page 1

R042814C.STS
PFSTAT Ver 3.3
Copyright (c) Tr~mble Navigation, Ltd, 1991, 1994. All rights reserved
Statistics Version 3.3
Recs Mean Std Dev Minimum Maximum
Latitude
Longitude
189 36030 '01.00391"N
189 77054'24.63842"W
5.56223 36030 1 00.42922 11 N 36030 1 01.48475 11 N
3.92342 77054'25.07513"W 77054'23.99033"W
Altitude 189 44.34449 6.87539 27.70937 102.87190
No velocity records in file.
No DOP records in file.
Start GPS Week #798 on 04/28/95 at 14:42:10
End GPS Week #798 on 04/28/95 at 14:47:10
Datum
Coordinate system
Altitude Mode
Altitude/Distance Units
Velocity Units
WGS-84
Latitude/Longitude
Height Above Ellipsoid
Meters
Meters/Second
Page 1
~
IW~I
R042814D.STS
PFSTAT Ver 3.3
Copyright (c) Trimble Navigation, Ltd, 1991, 1994. All rights reserved
4 2 814D .COR Statistics Version 3.3
Recs Mean Std Dev Minimum Maximum
Latitude
Longitude
185 36C2'30'00.9 5 584"N
185 77C2'54'24.7 91 09 "W
3.00048 36C2'30'00.58449"N 36C2'30'01.26623"N
2.40961 77C2'54'25.10297"W 77C2'54'24.07912"W
Altitude 185 42.68939 5.50045 24.28708 70.32335
No velocity records in file.
No DOP records in file.
Start GPS Week #798 on 04/28/95 at 14:48:07
End GPS Week #798 on 04/28/95 at 14:55:13
Datum
Coordinate System
Altitude Mode
Altitude/Distance Units
Velocity Units
WGS-84
Latitude/Longitude
Height Above Ellipsoid
Meters
Meters/Second
Page 1
I RR.O
I Warrefl Co.
'1ime~ ~ewp(J('Y
9 'R\vQJ'{ot(,(_.Pf Road
lJ-/He-ftm , NC J.t-f So
@1q) 5gl,-289 =J-
(q r q) 5 g & -(p '1"' Ul I
f 1atflt~ £~r1,
.
~~: (!)Odlrv--'1b3 Al ~ 4 -/;-,_,~ Lf1 v;..,
~dY\..., , IV,e_ • ~ / 11z ,,,.:J__._ @~ ./\A.fl" ( trtt.i:o
,, ')
SR. ;Jt,s / SR-1.is'-f) ~ ~ NtvE. r 3~.
(u-_J-~ (f 19---.;,J ..:klu. ~ ~s Cr. fo J ~ ; f ~
~ ~ ~~ .fo .J;tu A-u-~
w~ )~ ~ ~ ~ s~~
SM-~ ~ ~ 1-o ~ tJYJi, Uwf S'~-
~ ~, ~~~ A/41-': OYJv ~i?W'~. (~q).
~ <.IU-OA~ :__ ..-<A-,-~~ • ~ .:::l:ki, f. .. :~
(FY\ ~ ./!A.,.t---'. ~ ~ L~ ·~ tLu k-,-.-JG-/
(.,A/11.d.JJ>_ ~ j'LCLM--<-'' ChJ... ~ ~ -" UL ~ ~
/}?JJ\_~ ~ 1~ JNvJ· 1-~ ~ ~~ ~,
4e r
I
4
•.
A.• 71 r �41 r Tr. - r "t I�//n ff 'M '. Kf^'J 1A
�;, �— —t ��a<•, fir.+ �2
- j4Z_ L a' r(ji1 i
04.
ROANOKE-
57
237 z38 55' 239
SCALE 1:24 WO
O
1000 2000 3000 4000 5" 6000 7000 FEET
5 0 1 KILOMETER
CONTOUR INTERVAL 10 FEET
DATUM IS MEAN SEA LEVEL
' COMPLIES WITH NATIONAL MAP ACCURACY STANDARDS
BY U. S. GEOLOGICAL SURVEY, WASH INGTON 25. D. C.
ING TOPOGRAPHIC MAPS AND SYMBOLS IS AVAILABLE ON REQUEST
1 MILE
1046
0
.All
1010000
(N.C-)
ra
030,
Z40rnr—oevwarvA� suwv [r. wnsnrnaron. v. -.—gas+ n �
�r rn_ 241w0mE. 2 330 000 FEET (N.C.) 77
ROAD CLASSIFICATION
Medium -duty._.._._. Light -duty . ... .... ..... ...... _
Unimproved dirt= -=__
0 State Route
VIRGINIA
QUADRANGLE LOCATION
3677�322
GASBURG, VA. —N. G.
SW/4 WHITE PLAINS IT QUADRANGLE
N3630—W7752.5/7.5
1963
AMS 5457 IU SW--SERfES V834

NATURAL AND ECONOMIC RESOUR(2 ES sc' a �s r 1AUN r H UAHuL,INA y"wv
_EI0H, NORTH' CAROLINA r..+ w ,Fier,rat ia+ �i h�m quad. 7.5 MINUTE SERIES (TOPOGRAPHIC) L,A
MAS6U�G) 238 55' 239 240 741 233a FEET 77'52'30"
'36 W W F
ifc •�`.rt '1��}} 'ys - C] ��( r �` �i [age 4041
• y',}/ 7�t _..w - --- •f }f f, � ~- �f 1��11 ' � 7 16"' r � �. — - � ) _ ✓• "� �
.0 � 7 ! r ' i [��`'Iy7� _ ,�J'i _ ' •r %%%j}Sf�oa � �-'lh'�I I
dpI
1AEVA WN••gym '~ tip 1 oaU Uao
n•' tv�,•�a. `� � .. ,`. { � 4�1�°.•wY'�,, ,�� - - �' - f� f �� �_.--�. {� i '��¢ ''�-'''� � ,� 1 r,ri FEET
�j [ ar lr■l � IAh ! A'� . I v� [(II •'ti. � ,/ . 11 I �%{ r .3 �� .1}Tr �. 1 l[ , rl
4� �� 1 F•I'! ��'.��:� 1 � � �5� 0. � I l� QIQ '"' 'rl !'+i i � � S�� '�, "7�
4pp•�, tt air ` { �A + G, tar r I , {I,. i; '�F ti s� i
1.-- � } �/_ a ��_ � r ,•,� � � � 1 ! %% ate. if
-�r - -�. Gt ].r r ]• � .. y )v ILi�1�kn,�1C..
+�, N�nA __ � ��3v �' �.�xa 1 { f ,5 1 �t 1 � •I• l� -', `y �l 1 - Fr
A!A
rl l ; r f �e� r� ° $� ` _�u �' t� 4 ]t�_�d r - �r ( {� re "Cruesroad Y r
1 �c ri' :t
( _- ^�j p ;_ -=- r1 y EI r ( 1, r 1 ��
}.� l s,r�r'' r� �� fl� ��1 I I / 1 L 1 !Vfc� 1. f7 �-r,��t�l�i�. _?� C- :t -ilk .�
) 1 I"! .k'Urf'_ 'J1 '�, �•f;`i 1.6 `�Sa�� 'r• r � �l I F ,� y ��I`'`__-- - �-1,-_{--�, 'i� 1 � ( r
If
r
�f� -- }� L����_I���r- � .l __FFff�:_.;. w`- _�-'-(. .` •�_�` S 1[ �1� [[[ � S 2q7 '�@a�r��•:� `�
117
01
f 1 '`.2 �f• �1 '� 1 I l��i C) 1 L P r
4940
13-1
/49
] 1 / �• _r^ ' cam- 1�.�}` L�{ �1 .I�, J� I �r• _._
r;
-.rr, �1 _' �__._�.�ll, .•,� s�:r rr��;�tCCr. ?� t�:.,�.��.0 k

G '
l
i

Action code: Apply00004
APPLICANT Name: Newport, Mr. James
State and Zip: NC 27850
FACILITY Name:
State and Zip:
Facility ID Number:-NCS000000107
Address: 9 Riverbluff Road City: Littleton
County: Warren Telephone#: [phone] Fax#:
Address: City:
County: Telephone#: Fax#:
Permit Number: WI0500011 Application (new or renew): renew Permit Type (conop}: hpconop
Renew Not. Sent: 8/15/94
Appl. Rec-Incomplete:
2nd Renew Not. Sent: 10/24/94 Appl. Rec.-Complete: 10/26/94
Appl. Return: Analytical Report Recd:
Appl. Acknowledge: 10/26/94
RO REQUESTED TO: Review Appl: 10/26/94 Inspect: 10/26/94 Sample (renewal}:
RO Sends Appl. Review to CO: RO Inspects: 11/16/94 RO Samples: Lab Report:
PERMIT: to Manager: 11/01/94 to Supervisor: 11/07/94
to Permit tee: 11/2.9/94 Copy Filed: 11/29/94
to ACGW: 11/28/94 Approved: 11/29/94
Copy to RO: 11/29/94 Entered Uicfile: 11/29/9~
Permittee Informs, Ready to Operate: RO Requested to Inspect: RO Inspects:
Analytical Report (New Source}: GW-1 Received:
Permit Process Completed: 11/29/94
State of North Ca .ina
Department of Environment,
Health and Naturol Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
MEMORANDUM
To:
From:
Jim Greer
GROUNDWATER SECTION
November 29, 1994
Groundwater Section
Raleigh Regional Office
Karen Harmon
UIC Group
Groundwater Section
Raleigh Central Office
Re: Issuance of injection well permit.
.AWA
DEHNR
Permit No. WI0S000ll to use a well for injection has been
issued to Mr. James Newport; a copy of the permit is enclosed for
your files.
cc: UIC Files
RRO Files
Enclosures
P.O. Box 29536, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ l 0% post-consumer paper
State of North Cc;;-lina .
Department of Environment,
Health and Natural Resources
Division of Environmental Management
I
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
.A. Preston Howard, Jr., P.E., Director
Mr. James Newport
9 Riverbluff Road
Littleton, NC 27850
Dear Mr. Newport,
GROUNDWATER SECTION
November 29, 19.94 ·
AVA
DEHNR
In accordance with your application dated Octob~r 26, 19~4, we
are forwarding a permit for the Operation and Use of four wells,
for the purpose ·-of injecting heat pump effluent, in Warren County.
This permit is a renewal of Permit _No. 92 -0052· -WO -0001,
which was issued on February 14, 1990·, and shall be effective from
the date of issuance until November 30, 1999, and shall be subject
to the conditions and limitations as specified herein. This
permit, Permit No.-WI0500011, replaces and shall also supersede
Permit No. 92 -0052 -WO -· OOOL Please note that the permit
numbering system has been revised so that your permit has a new
number.
In order to continue uninterrupted· legal use of the wells for
the stated purpose, you should submit an application to renew the
permit six months prior to its expiration date.
If you have any questions regarding your permit please feel
free to contact me at (919) 733 -3221, ext. 407.
cc: UIC Files
RRO Files
Enclosures
a~e2½~i1'
A. Elizabeth Morey ~
Manager (/
Underground Injection Control Program
P.O. Box 29536, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post-consumer paper
NORTH CAROLINA
~NVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF FOUR WELLS FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87;
Article 21, Chapter 143, and other applicable Laws, Rules arid
Regulations
PERMISSION IS HEREBY GRANTED TO
Mr. James Newport
FOR THE OPERATION OF FOUR INJECTION WELLS for the purpose of
injecting heat pump effluent. These wells are located · at 9
Riverbluff Road,. Littleton, North Carolina, in Warren ·County, and ~
will be operated in accordance with the application dated October
26, 1994, and. in conformity wit_h the specifications and supporting
data submitted, all of . which are filed with · the Department of
Environment, Health, and Natural Resources and are considered a
part of this permit. ·
-This permit is for Operation only, and does not waive any
provi_sions of the Water Use Act or a~y other· applicable Laws, Rules
or Regulations. Operation and use of the inj~ction wells shall be
in compliance with Title 15 North Carolina Administrative Code 2C,
. 0100· and . 0200 and any other . Laws, Rules, and Regulations
pertaining to well construction and use.
This permit is a renewal of Permit No. 92 -0052 -WO -0001
which was is·sued on February 14, 1990, and shall be effective,
unless revoked, from the date of its issuance until November 30,
1999, and shall be subject to the conditions and limitations
specified in Parts I through VIII herein. This permit replaces and
shall also supersede Permit No. 92 -0052 -WO -0001.
Permit issued this the cR q#-1 day of Novemb.er, 1994. --=====~------1£2: h ~ A~~?
Groundwater Section
Division of Environmental Management
By Authority of the Environmental Management Commission.
PERMIT NO. WI0500011
PART i -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 (15 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:-91.
2. This permit is effective only with respect to the nature,
volume of materials and rate of injection, as described in
the application and other supporting data.
3. This permit is not transferable without prior notice to, and
approval by, the Director of the Division of Environmental
Management (Directcir). 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.
4. 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 haye ,
jurisdiction. Furthermore, the issuance of this permit does
not imply that all regulatory requirements have been met.
PART II -PERFORMANCE STANDARDS
1. The injection facility shall -be effectively maintained and
operated at all times so that there is no contamination of
groundwaters which will render them unsatisfactory for normal
use. In the event that the ~acility 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 Environmental Management {Division) such as the
repair, modification, or abandonment of the injection
facility.
2. The Permittee shall be required to comply with the terms and
conditions of this permit even if compliance requires a
reduction or elimination of the permitted activity.
PAGE 2 OF 6
3. The issuance of this permit shall not relieve the Permittee
of the responsibility for damages to surface or groundwaters
resulting from the operation of this facility.
PART III -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.
PART IV -INSPECTIONS
1. Any duly authorized officer, employee, or representative of
the Division ·of Environmental Management may, upon
presentation of credentials, enter and inspect any property,
premises, or place on or related to the injection facility at
any reasonable time for the purpose of determining compliance
with this permit, may inspect or copy any records that must
be maintained under the terms and conditions of this permit,
and may obtain samples of groundwater, surface water, or
injection fluids.
2. Department representatives shall have reasonable access for
purposes of inspection, observation, and·sampling associated
with injection and any related facilities as provided for in
N.C.G.S.· 87-90.
3. Provisions shall be made for collecting any necessary and
appropriate samples associated with the injection facility
activities (see attached diagram).
PART V -MONITORING AND REPORTING REQUIREMENTS -
1. Any monitoring (including groundwater, surface water, or soil
sampling) deemed necessary by the Division of Environmental
Management to insure surface and ground water protection,
will be establish:ed and an acceptable sampling reporting
schedule shall be followed.
2. The Permittee shall report by telephone, .within 48 hours of
the occurrence or first knowledge of the occurrence to ~he
Groundwater Section Staff, Raleigh Regional Office, telephone
PAGE 3 OF 6
number [phone], of any of the following:
(A) Any occurrence at the injection facility which
results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons, that
renders the facility incapable of proper
injection operations, such as mechanical or
electrical failures.
3. Where the Permittee becomes aware of an omission of any
relevant facts in a permit application, or of any incorrect
information submitted in said application or in any report to
the Director, the relevant and correct facts or information
shall be promptly submitted to the Direct"or by the Permittee.
4. In the event.that the permitted facility fails to perform
satisfactorily, the Permittee shall take such immediate
action as may be required by the Director.
PART VI -PERMIT RENEWAL
The Permittee shall, at least six (6) months prior to the
expiration of this Permit, request an extension.
PART VII -CHANGE OF WELL STATUS
1. The Permittee· shall provide written notification within 15
days of any 6hange of status of an injection well. Such a
change would include the discontinued use 6f a well for
injection. If a well is taken completely out of service
temporarily, the Permittee must install a sanitary seal. If
a well is not to be used for any purpose that well must be
permanently abandoned according to 15 NCAC 2C .0113, Well
Construction .Standards.
2. When operations have ceased at the facility and a well will
no longer be used for any purpose, the Permittee shall
abandon that injection well in accordance with the procedures
spe.cified in 15 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.
PAGE 4 OF 6
(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 dould lead to the contamination
of an. underground source of drinking water.
(D) Each well shall be completely filled with cement
grout, which shall be introduced into the well
through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case-of gravel-packed wells in which the
casing and screens have not been removed,. the
casing shall be perf6rated opposite the gra~el
pack, at intervals not exceeding 10 feet, and
grout injected through the perforations.
(F) In those cases when, as a result of the·injection
operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that
will prevent the movement of fluids into or
between underground sources of drinking water and
in accordance with the terms and conditions of the
permit.
(G) The Permittee shall submit a Well Abandonment
Record (Form GW-30) as specified in 15A NCAC 2C
.0213(h) (1) within 30 days of completion of
abandonment.
3. The written documentation required in Part VII (1) and (2)
(G) shall be submitted to:
Groundwater Section -UIC Staff
DEHNR -Division of Environmental Management
P. o·. Box 29535
Raleigh, N.C. 27626 -0535
PART VIII -SPECIAL CONDITIONS
The fluid used in the closed-loop heat pump system shall be
comprised·of clean water or a mixture of clean water and
propylene glycol. THE USE OF ETHYLENE GLYCOL, ALCOHOLS OR OTHER
CHEMICALS NOT SPECIFICALLY APPROVED BY THE DIRECTOR, DIVISION OF
ENVIRONMENTAL MANAGEMENT, ARE EXPRESSLY PROHIBITED.
PERMIT NO. WI0100006
PAGE 5 OF 6
ATY+ACIMM" 9
PERMIT NO. W10500011
Min. 5 teat of Pit Casing
(must extend at least 12 incheg
H'E•AT
abase sand surface)PUMP
w•
V.1, r•� ir1+' i T G' '' , •� .'., iii•
•%�.; 1, {. Y.,,j: i:� .,a., �11 :1' •;. •�G %'f-�1.1.. it rR
•}'. •,
• �; i'r'
'�• s•
p! •;o "r. �:s�S _ s •� sue• . C +rX i 5�1}�S!C (�{ljr : �r�i �r •�3 cri'I .r '1' 1 .{ �C.: u+ ^„ {
�• .:} { • .1 . tii. + yl����`1 .ij• "y� . �. �.�.1 tt ■ :s: 4'1.r1,11 :�F �,::': i�I• •RH i*Ir; -:�..
•,• '-�!'.r•� �' 4
if; i�. ice•: ,;}l.... .�.,�;:7 y.v"
ry:a: •}:7. �1 :}' a
-- rf �1. ."�i
•e'
�• 1
+.
•.t^fr •jT�l. .ri': 1.r/ ! il•7� ..��: .l•y. .1.. rr** .,+7., .!1 -. c:r, �. ��_
A'r :vf`+. •.�' r r -�. S f��•-. .!�•`r• :i� 'r,��"••+L•'
• •.`,•�.�{r,��'Tii`• a• .r '� +�l•=f.:;;' �r{L._. �g.ie• } '+4`.. 's: .r• •::�'+:'a'.. •�
1•'
..
't
;�• '.: .ir" 'tir .=.. r: �i ry`��� 'i: .1 :.�:;1_ta
•+•
•. •,
'i'
��\•+.
-'a••
:ti •' it '1. -• '.•":.
VERTICAL CLOSED LOOP
'
°�=•lol.INJECTION
WELL, USING
UNCASED BOREHOLE
M
The injection facility design, incorporates four wells, each one a
closed loop within a sand -filled borehole, grouted from 0-20 feet
and cased from 1 1/2 feet above ground level to solid rock (66-72
feet). The injection wells are connected to each other and to
the heat pump via a common influent line and a common effluent
line.

State of North Carolina
Department of Environment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
MEMORANDUM
To:
From:
Jim Greer
GROUNDWATER SECTION
October 28, 1994
Groundwater Section
Raleigh Regional Office
Karen Harmon
UIC Group
Groundwater Section
Raleigh Central Office
AVA
D EHNR
Re: Request for review of application for perm±t renewal and for
routine inspection of facility with Injection well Permit No.
WI0S000ll (92-0052-WO-0001), issued February.14, 1990, to Mr.
James Newport.
1. Please review the application and submit any comments to
RCO-UIC by November 11, 1994 (within 2 weeks). Retain the
application for your UIC files.
2. Please inspect the injection well facility to visually
determine the integrity of wellhead construction and other
requirements for compliance with the NCAC T15A:02C.0200
standards, using the enclosed Injection Facility Inspection
Report (form B) as a guide.
Please inspect the injection well facility by November 18,
1994 (within 3 weeks). (If inspection cannot be accomplished by
this date, please inform RCO-UIC promptly.) Send a copy of the
completed Injection Facility Inspection Report (form B) to RCO-
UIC.
cc: UIC Files
RRO Files
Enclosures
P.O. Box 29536, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post-consumer paper
. I State of North Ca1 vlina
Department of Environment,
Health and Natural Resources
Division ·of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
Mr. James Newport
9 Riverbluff Road
Littleton, NC 27850
Dear Mr. Newport,
GROUNDWATER SECTION
·october 28, 1994
AVA
DEHNR
Your application for the renewal of a permit to use a well
for injection has been received and is under review. Your
injection well facility will be inspected as part of the review.
Final action on the permit will be taken by the expiration date
of the current permit, February 1, 1995.
If you have any questions regarding the permit please feel
free to contact me at (919) 733 -3221, ext. 431.
cc: UIC Files
Sincerely,
'/(_a,J..tA,__Q.~~
Karen A. Harmon
Hydrogeological Technician II
Underground Injection Control Program
P.O. Box 29536, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post-consumer paper
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
APPLICATION FOR PER1VIIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A HEAT PUMP SYSTEM
Class 5 Wells
TO: DIRECTOR, NORTH CAROLWA DIVISION OF ENVIRONMENTAL MANAGEMF',Nr
DATE: .j�, ecT -- 19Y
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and regulations pursuant
thereto, APPLICATION is hereby made for a PERMIT to construct and/or use a well or well system as described
below and in any accompanying data submitted as part of this APPLICATION.
Please type or print clearly.
A. PERMIT APPLICANT
Name:
Address: _
City:
County:
Telephone:
B. STATUS OF APPLICANT
Federal
Public
Native American Lands
f
code: ;Z:z = "❑
State Private X
Commercial Other
C. PROPERTY OWNER (if different from applicant)
Name: �->-- &-
Address:
City: Zip code:
County:
Telephone:
D. FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Public or Commercial)
Name of Business or Facility.
Address:
City:
County:
Telephone:
Contact Person:
E. HEATING CONTRACTOR DATA
Name: S
Address:
City: —
County:
Telephone:
Contact Person:
F.
code:
G. WELL USE Will the injection well(s) also 5e used as the supply well(s) for either of the following:
(a) The injection operation?
(b) Your personal consumption?
YES NOOK —
YES NO
GW-57 HP (October 1994) Page 1 of 4

H. CONSTRUCTION DATA (check one)
EXISTING WELL being pwposed fo uAs an injection well. Provide the data
in (1) through (7) below to the best of your knowledge. Attach a copy of
Form G W-1 (Well Construction Record) if available.
PROPOSED WELL. k be constructed for use as an injection well Provide the
data in (1) through (7) below as PROPOSED construction specifications. Submit
Form GW-1 after construction.
(1) Wall Drilling Contractor's Name: ��� f w,lI'os
NC Driller Registration number: .0 -2
r
(2) Dated constructed: I �ZQ Approximate depth. ;Z40 i
r
(3) Well casing:
(a) Type: Galvanized steel Slack steel Plastic'Other(specify)
(b) Inside diameter, G inches; Wall thickness inches or schedule # -:yd� 7
(c) Casing depth: From -/'z ,ft. (reference to land surface)
lo
Casing extends above ground — ' _ ! Inches (must be at least 12 inches)
(4) Cement grout
(a) Around inner or "primary" casing: From 4 jc-2'0 ft.
(b) Around outer (pit) casing, if present: From Ys, , to ft.
(5) Screens (if applicable): Q
(a) Type: • Inner diameter_ inches
(b) Depth: From to feet below land surface
(6) Gravel (if applicable): Erg to feet below land surface
(7) N.C. State Regulations (�tle ISA NCAC 2C Section .0200) require the permittee to make•.
provisions for monitoring well head processes. A faucet on both influent (groundwater entering heat
pump) and effluent (water being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? yes no (b) the effluent line? yes no
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EhaSTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAELABLE BY OTHER MEANS.
PROPOSED OPERATING DATA
(a) Injection rate: Average (daily)_ __gallons per minute (gpm)
(b) injection volume: Average (daily) gallons per day (gpd)
(c) Injection pressure: Average (daily)—pounds/square inch (psi)
(d) Injection temperature: Annual Average degrees F
INJECTION FLUID DATA
(W Fluid source. If underground, from what depth, formation and type of rock/sediment unit will the
fluid be drawn (e.g., granite, limestone, sand, etc.).
Depth: Formation: Rock/sediment unit:
(a) SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well).
Attach a copy of Form G W-1 (Well Construction Record), If Form GW-1 is not available,
provide the data in pan H (1) through (7) of this application form to the best of your
knowledge.
(2) Chemical Analysis of Source Water. The following chemical characteristics MUST accompany this
application: I"C-� P• �'pj -.,c ulr l-k- .
pH ; Total hardness ppm (parts per million or mg/1); Iron ppm;
Chloride ppm; Nitrate ppm; Coliform bacteria countsllGOml,
NOTE: Assistance in determining these values may be obtained by contacting (a) your local or county
health offical, (b) a commercial water -testing laboratory, (c) your well drilling contractor, or
(d) the regional Hydrogeologist, North Carolina Dept. of Environment, Health, and Natural
Resourcm
GW-57 HP (October 1994) Page 2 of 4

K. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the (1) injection equipment, and
(2) exterior piping/tubing associated with the injection operation. The manufacturer's brochure, if
detailed, should satisfy (1) above
L. TOPOGRAPIUC MAP
Attach a scaled topographic map which extends one mile beyond the property boundaries of the
facility and indicates the location of the facility.
M. LOCATION OF WELL(S)
Attach a detailed, scaled map of the site of the facility, showing the location of and distances
between the proposed wells(s) (source wells and injection wells) and any waste (including hazardous
waste) treatment, storage or disposal facilities; buildings; property boundaries; surface water bodies;
and any other potential source of groundwater contamination. Additionally, indicate on the map the
direction and distance to existing wells (injection wells, water supply wells, dry wells, abandoned
wells) located within 1,500 feet of the proposed injection weil(s). include with the reap a description
of each existing well, incorporating type, construction i:nfortnation, date drilled, and depth. Indicate
on the map at least two nearby reference points such as roads, road intersections, steams, etc., and
identify them by US, NC or SR (county secondaryroads) numbers or name. Label all features
clearly. Include a north arrow on the map to indicate orientation.
N. CERTIFICATION
"l 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 she information
is true, accurate and complete. I arcs aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the injection well and all related appurtenances in accordance with the
approved specifications and conditions of the Permit"
(Signature of Owner or ,Authorized Agent)
Prease supply a letter signed by the owner
authorizing the above agent, if authorized agent is signer.
O. CONSENT OF PROPERTY OWNER (Owner merits any person who holds the fee or other property rights
in the well being constructed. A well is real property and its construction on land rests ownership in the
land owner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as oulined in this application and that it shall be
the responsibility of the applicant to ensure that each injection well conforms to the Well
Construction Standards (Title 15A NCAC 2C .0200)
Name of Property Owner (Print):
Mailing Address:
(Signature of Property Owner if Different
From Applicant)
GW-57 HP (October 1994) Page 3 of 4

Please return the completed Application package to:
GW-57 HP (October 1994)
UIC Program
Groundwater Section
North Carolina DEHNR-DEM
P.O. Box 29535
Raleigh, NC 27626-0535
(telephone: [phone])
Page 4 of 4
_,i..:,.t,,.11.t, .l"I\Jl'\.ll.l :,..,rl.l'\.\Jt.....l.l"lrl ~n~.....-, ... ~~ ,o• ,.i..l l'f.111,U.lJ..:i QJ..:,~11.:iU \.l\JC-\J .... .l'\.rt..0111'-'J
5457 Ill SW '30"
(GASBURGJ 238 233000 0 FEET 77 "52
Lo, Ut--r ::: .. ~
Fo(G·, N E)J .. J f c)fG'T
( 4 1~ I<: F,° I i 2,>'C fl fl NC:;' v JS t. '--::_
(9-tD' ~pA<'H·-'~)
vJ0-1'~
I--~ z_t;tJ( ___ .-----:?°er 1)/~L '-
'·
\
~~Wff1' ~d'L WGLL
\
LO(
\
·---------•\., _____ ·-·•···-----
DIAGRAM OF PROPOSED
CONSTRUCTION SPECIFICATIONS
Straight -Screened
or _
Gravel -Packed Well
(Constructed in unconsolidated formations)
surface
Oven --End Well
(Constructed in consolid--
�LL-A L ated forma'
A) Casing: C&REN T io{
1) Inner: typeSDR-17 I. D. 601bs./ft.
l4
+ Z ft. (depth)- 40 ft. (into rock)
2) Outer: type I. D. lbs.'ft.
f(depth) ust TI*P4ITE
t. ( F ) TZI,LL=D T[7 scRi� E
l9
V SDR -I-7 Tc`
$} Cement: 10ELow ROCK
1) Inner Casing: D ft. to ft.
2) Outer Casing: ft. to .71 )ft
Rock
liaCk
C) Screen(s): type I. D.
SCA NG
ao V..
ft. to ft.
WA, MeZ
ft. to ft.
pp
D) Gravel: t`1 t^I 't. to ft. in.
(size)
-�
(Fill in each blank that applies and use appropriate diagram
to show proposed construction including, but not limited to,
casing (outer and inner), sealing material (cement, clay,
etc.), packers, screens, gravel, chemical feed lines, etc.)
Location Diagram: (Previously prepared maps may be submitted provided they con-
tain information required in item (g) of the application). )
r' T!•ILQIYAL ► F—LDP0
POL.LY BVTyt.E"+C P'P'24
c Laseo P2oPNrz LVA TSR
Q?r Vo��[YE
C4 w %ML�
�
C� zoo o eprw . �ea�, we�.�.s TO
f4MAT W.sec►fA V,LQC .
Coau4*+ r
era wF�

1Vfa�
� nct
U
Hd i4,
1
r !iI
r 40
Q
� 4
1
r�
�,-
r
I�
f

�N a
L
n�
14
41

J 1 I~
. i i ~-~ ~ ~~ 1
.j 82
~~N51~ -e~ ~ ~ 1 ~ ~ ~j
J ;:-~ i . ~~
.r i!· 1~-1 , -~ i J ..
• -~ ' r ; '-~ j/ j 1
"--' "')
State of North Ce Mina
Department of Environment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B, Howes, Secretary
A. Preston Howard, Jr., P.E., Director
GROUNDWATER SECTION
October 28, 1994
MEMORANDUM
�r
D E H NIF4,;0
y C
— en
To- Jim Greer
Groundwater Section
Raleigh Regional Office
From: 'Karen Harmon -,
UIC Group
Groundwater Section [��HNR RALEIGH REGIONAL. OFFICE I
Groundwater
Raleigh Central Office
Re: Request for review of application for permit renewal and for
routine inspection of facility with Injection well Permit No.
W10500011 (92-0052-WO-0001), issued February 14, 1990, to Mr.
James Newport.
1. Please review the application and submit any comments to
RCO-UIC by November 11, 1994 (within 2 weeks). Retain the
application for your UIC files.
2. Please inspect the injection well facility to visually
determine the integrity of wellhead construction and other
requirements for compliance with the NCAC T15A:02C.0200
standards, using the enclosed Injection Facility Inspection
Report (form B) as a guide.
Please inspect the injection well facility by November 18,
1994 (within 3 weeks). (If inspection cannot be accomplished by
this date, please inform RCO-UIC promptly.) Send a copy of the
completed Injection Facility Inspection Report (form B) to RCO-
UIC.
CC: UIC Files
RRO Files
Enclosures
P.O. Box 29536, Raleigh, North Coroilno 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10%post-consumer paper

INJECTION FACILITY INSPECTION REPORT -FORM B (CONTINUED)
WELL CONSTRUCTION
Date constructed
Drilling contractor: Name 4- `�-'
Address C
4S
Registration n er !_
Total depth of well J / Total depth of source well
0 6? , 7 1'P (ff app)fca6Te)
Inspection point
Casing
Depth
Diameter
Height (A.L.S.)
Grout
Depth
Screens
Depth(s)
Length(s)
I.D. Plate
Static water level
Well yield
Enclosure
Enclosure floor
(concreted)
Sampling port
(labelled)
Water tight pipe entry
Well enclosure entry
Vent
ionina of
INSPECTOR
WITNESS
WITNESS
Measurement Meets_minimum standards Comments
Yes No
v
L7
LZ
M
t pump system (Determine frc the owner ff beat wu+i7v
4. 1 L.! � �M
Office /�
Address
Address
DULY. 19 9 4
pmPer' ZY• )
1

North Carolina Department of Environment, Health, and Natural Resources
Division o.' nvironmental Nanagement - Grou ater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WI r3J A d r DATE
NAME OF OWNER �'L-i r� r=o qyy e 5
ADDRESS OF OWNER
{Street) road or Tot and suddivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable)
road or lot and suddivision , county, town, if different than owner's address, plus description of location on site)
Potential pollution source
Potential pollution source
Potential pollution source
Distance from well
- --49 Distance from well
-—— Distance from well
Minimum distance of well from property boundary
Quality of drainage at site -_ 0 11 Flooding potential of site
(good, adequate, poor)
L�
(high,moderate, low)
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources, roads, approximate
scale, and north arrvw.)
DESCRIBE INJECTION SYSTEM (vertical closed loop, encased borehole or cased water we I l; separate source we l l and
injection well; combination source and injection well; or other description as applicable)

r, n ri f y, r l •.. f
fr1 nAnnll�tA rrr►u1rl�rtr r,r IUtvn�t i,iLolAiol�ti ski 1'ioi,InAflliii 6 v�1 wli
tail tyrt"Wit bi&Y a -•.-.
�,,,nr'•►ti►, rw to it Al- SW1A(*Lq*t - &kkiok4+iAtM Ocitdit }��,� +iti. 1AIiI�t }1f►. .
r.n. t+nx *tNt-r1wl►nrlltc 1ti*f�.Fllbil� NiN iN-Itsi� �itit• tBHd. ''' '�t:4•
` �+1tnu1 �NTd •,+
WELL c ot'is muc-tioH hp-com) HA,tn btid+� _
kn1. I,Ylfl�nt.�.
MOSELEY; & 'Nib H �i!1T INC. r
P. 0: Svxif in CID14 1 AC I On t ems'
ao I r M�ltt homotn stquctt❑N
an ► t=rr h�❑ls1n�Tlt]N f�UA,4g�n _
rI t. t.ocAttot I. Ist►ow IlkIttub of Ilik toe i11bn balowj
Ipme0g1 tnww We'7L� 4
If„n,I, f:r.rnrn„rrlry, nr S,rhrlIvImInl, and Lot NoJ
Al' y4
�f� 1� r
-tSlrnnT of f j
[:11Y nr r4wr1 $lulu Z41 codd
,A 11 1+1111,1 rlt A�P_ -90 ..... Mr, or *PtL �� .
fltAi Itrt•111 �J,�• _ [.t1I1111tiS cnLLr cII] LjYfr3 L
,r •f •: writ Per r•1 A Cr r Kilt III tr: INC. 11, 7 C-1 Yee 1-4"F!o
.1 rn Ito I. VIA It III I VI!I r 1. V jbvvn fah or E:A51110,
Urpolow
1f,1 tyr t:A�111r; 1R __ j _ r t, ArinvF LAWSurrrAr:E•
,�1, r+ 1onr��; _ �•-_-_..- l.lrrll[1r] yr 1ESt
A I I 2fit ir r Irirlot,I
All 11111f 1A t I01I
f'Ar:Ir11t
wall 11 1 �s k1"
ltnt,}Ir T11an1plet ar Wnp►I1, �Id1ell;tl
rI
rlrrn
r:ruult
Rl11611nl M 0'i3d
aCU_ t1Ale ag�CednaltJ
,if III rrt
t.►I'T�rH
t rnrn.-. ln...
f:IIAVI j r•Ar•1:
nr'rriu,
Utnmill�► i51ol b46 i+1ril tiri4
t f In. In. _
sr: i MA 61161
t,'otfrtl¢: 4 V Y
bi0iynILLINO LOG
hom to p1r alien bakerlotion
_e__.la
-- - -
r,• �T tI,I,1111ohAl Aodc6 #s handed u:A �icf< ni Ir,rm�-_
imc A11K��
M6* &H—Ildh Arid JISIAnci Irom 41 t6A111 1*0 Vale hn.11
61 biblof libili 4100d boln11;i
�I.�f�1 rnrn►-- . _... —_ 1n. .. --- t 1 -• _
(rnrn
III LIA111(S 0, ;4n•��}
M-7
t t�{, ltrrlrE,Y CE1ttlrr mAt miT ttj WA bvll�5lhilc E�h�AIJF+ Wttt4 NcAc 9c, WELL trills ltictim
UAWAfllrS. AIR] tIIAt A cony bl ilis hitiMa MAI; ��A1��t�tS�L! 0 fit W bw�h.
1r51AIilht bk b VORAbi "bh Abbli 6A1�
•' S,rlrn+l} ifil{jin i IrF hF„livA r1A.tenll01%m6nf and CCfiY In w611 aµnrf

rvnrrl aurnlxiG bMrA14r4�ihlr nF�i�A�►Al1#� a�t4&>�Nirffi 6��l81�F
r.e. inx 11+64r l+�!lld�tlC ltil I. �#104 HIN sN-a Id
WELL CONST"UCT101`4 hEt_O_l11) �Ailri bbdl
ma�yy• tt $ �'
P. 0, - IJ,414 6 V: . I i• e
711-1-lr+o
t}Itt WILL boWhUcttoN
'm l_rn nv_fjwnl noi4 NuFAl31=11
wrt1. locA1ToIJ; (Show +hatch of 114 toe6jt6n Wow)
Iler*rrz+l tnwn-
PinnrI ir.wrtnu+rrlly, or SSuhdlvletnnA'And Lol Nn.1
n
j n! Or T1vl1 e40. p
Clly or 1 r+wn Sletn ,Zfl? t:ode
►A Ir 0111(_trl) AIL. U5F W wtLL
Ir,+Al IIPITl_;_,-p�� cut twos coUtcftb tjyb4�
t--
r(+► �. Wrl I III`r 1. ACF 1 XM 7111Ct WCt1l tj yoo lid ko
rt rn11r- wArrn l l vrl � kt, t] I]boya foh W 4:404d,
bvlr+w
t l+r' ()r c AS11113 l5 _} z- y. A vF LA
!!U Wl1F A+:;t.
Nil 1 r1 Idrrn'1 .... -_� . — — 1AE TII`]El ct itst a.,PrC --
Y: A 1 r II 7otm. s (r1rnllrJ .� / i
t8rit f!i rmdllon blikerlpllon
Id
:-_.-
,,Ill rN1111A1101t Ivor; ickmo& Amount r•
r:Artrlr: 11 il.i•Illlghbl 1porl It h6oded V0 W4 bl
I.fanN, b(Arnetnr or We p +11 A11 N s!�t 5-q
l rn+++ 11It _ to �%Q �I ZID9-`2) p�G -..f� J§k6ip { 11p %ti And 01ilrinai Itelm of 16#11 I*ti tlsll¢ 1ln,lr
r rprn _- — t o _ .. 1, - 61 611,14 Wall tileAnal holn10
bnh11}
I�I�11lilnl
II,�� :'':
Irn+n
To_
!;r• fir FM
br+�1Fr
I]Irn,�l8i tic[ $ItA
Jr11@ IA —
�J� 1 form _
, t n..
f. 1n,
In.
s rnrn __. —�,
I
+ r:r1A VI`1 r Ac:l,,,
l]npR+
tit
MA 061
j [f
1 T1! I,IA►11L� ��
_._
:sr:iw+�=+wxA4+Ewrri���
100 11F►IEPy cMItY flfAI t111s WIFLI WAb WAthl %#Ag
�'�� III►lill It �1cA� ��, wt1J! �ot�SfrT tla+
S111T1[)Anos, Alit) IIIAI A copy & tlis h*Codtu NO. bt t�3 t WRIL b it-ft
I31014Aitht t* .b thAbibh bN At* -lit "bAft
lk'Amll 10dNXI44 Rv4 1bli1r*1:I1 lJdmoarmbni and to to w6f a-Anhl

• i
--------------
, ., .• •·. •• .I • ',,,.
..:. : L : is , ,,'y•.
71
F 1
mom t,1 Oxtjo►,a OVIAlliTi Wil t * Wt OtkL Wok" ANb {>'oi/tMr►'t *A#9.
mWON rw pr►vs+a►�AL WAACtiW h - OkOk i iAHA #kt 0*
r.a. ta,ax ltNr - wutt�pntkC. !►/1i,iibl� M fa ill--ibf�3
..�'. .._ ...., rtm bF
duht N!. tIIAHlI Ne..
Min* Mort
WELL CONSt"UCtION •M(;0111) NiOn btidb _
5ELEV, 8r"I ASi -
aLLMo CONTRACTOR � �+��
infum nms-mAmN NUMOVI 1 p Mlutlt NUM �q:
1WE,t L LOCATION: (Show Ilk etch of #f,A 10tsOAr, Woo
flpnFo li Town
rnnnrl. Cot*m+u+THy, or Subd;vltlan and Lai No.) 1
d d 4
ji
5 rani er o to N01
-City or T wn �51efd - -�r� Codb
oA it hnittrD 917 Ust Or WELL
MIAs ttrrm—..�RL6_— C01194(75 .CDIIECt�LtbdY�!
ri(irWFU ttt;t•{.ACE EX1stima WELL'S U ,r
Yeb �a
nt„Tin WArrn I r.vr-.0 rf, [��.86 Ow
i0l, (it t:A§IIJtT,
t(,r or CAS1140 is �. _ I:1, AvdvE LAND guiltAut.
�ii t h farm► __�.� #IE mom ❑k itsf ;r
r
wntt:n zOrfES tdrt,tl+}: __,.��CZ�C�S� -
b bully: t l i a ►� +� 2 1
behllti DhILLINa Lao
ti ti U P ►m811011 bAAed0lon
^� M
E (Pa a t✓
71 if Orilf 1A I lot) type Amotinl
I Wall pp
1)nrtt. f)iamOjAf or Weighl/I , mmildl
norm 10 ,72
I ("pout: ,
bevilr I:ielGtltii WIIi$d
rrorn } _ fa- l4- a � A6;, wl
from Tq•_ f=4. _,.�
��Ii_#t�l;fi#Ibhlf !v>+Jt:! 4� hftAded u3! bs;cA _ryf ri.tm
.L.bCAtI N-sK#=TC1�
`.. WW 460016N And dlslAne4 I►ahi A# Wil I*ty stn#A hom
HF Briltal:l H#:f#f f448tltit:l acln#s?
,.fir,•• �:': ,' •
t7rnti, blgtriildtloiItB l,Ir#1�i1#il w; ;; ; , n
L `
f
t , Jm 1 n f•f, #n. Ift. ....-,,... •. � .
rror•+_ Td l•l. lki. �, _ ya'•, ...
F�. 1,ItAvEL r►[rk: ,: ..y:.
f)enit+ slt'1 IIAS 6►i8� i' r �•' `'��'::.�
] r f orT, -To-
r rom_ 1p
14 t1( kgAt1KS
I Do ItFrtESY CtrftltY OlAt tills VOLL IkAb w4glMW
. eegj
91ANUAnus. ANa IflAt A OcOl bl: tl" hto6hlb NAB, gol#i0-_01
,Z
►�5
1 /,7"
l NHr ft ReAa fe, WW
A A600 6Ali
}it•IfdfiffiOM l Min6aAm6n# find Eovy io well bank

State of North c~~~una
Department of E. ironment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
AVA
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
DEHNR
GROUNDWATER SECTION
October 28, 1994
MEMORANDUM
To:
From:
Jim Greer ' :0n rn rt lli 301994W rn w-Groundwa ter Section , '~" l
Raleigh Regional OffiLJ~_-$1 INiy
Karen Harmon : U I IN
UIC Group ---------l
Groundwa ter Sect ion OHfNR RALEIGH REGIONAL OFFICE
Raleigh Central Office.
Re: Request for review of application for permit renewal and for
routine inspection of facility with Injection well Permit No.
Wio"S000ll (92-0052-WO-0001), issued February 14, 19·90, to Mr.
James Newport.
1. Please review the application and submit any comments to
RCO-UIC by November 11, 1994 (within 2 weeks). Retain the
application for your UIC files.
2. Please inspect the injection well facility to visually
determine the integrity of wellhead construction and other
requirements for compliance with the NCAC T15A:02C.0200
standards, using the enclosed Injection Facility Inspection
Report (form B) as a guide .
. Please inspect the injection well facility by November 18,
1994 (within 3·weeks). (If inspection cannot be accomplished by
this date, ·please inform RCO-UIC promptly.) Efe.nd a copy of the
completed Injection Facility Inspection Report (form B) to RCO -
UIC.
cc: Uic ·Files
RRO Files
Enclosures
P.O. Box 29536, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post-consumer paper
\
Lo Pc -AN-
0 vCs—
c!I , Qr �L µa ►�'s C � � �
-Ra '-
ih c
•r
H 0
r ,
�q KE . (�S /-) Sit

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
GROUNDWATER SECTION
Date:--- &[ 4.-7
STATUS OF INJECTION WELL SYSTEM
Permit Number: WI
Name:
Address. f, '� r T� � 'r •f • ,�c�n �'`' �+J�
r �
Please check the selection which most closely describes the current status
of your injection well. In addition, please provide the requested
information.
1) if Well is still used for injection activities.
2) Injection discontinued;
a) Well temporarily abandoned b)_ well permanently abandoned
Describe the method used to properly abandon the injection well. Include a
description of how the well was sealed and the type of material used to
fill the well if permanently abandoned:
Certification: (Far well abandonment)
"I hereby certify, under penalty of law, that I am personally
responsible for the proper abandonment of any injection well as required in
Title 15A NCAC 2C .4214 Criteria and Standards Applicable to Injection
wells.°
(Signature)
Certification:(For information verification)
°I hereby certify, under penalty of law, that I have personally
examined and am familiar with the information submitted in this document,
and that to the best of my knowledge the information is true, accurate, and
complete."
i
(Signature
GW - 68

State of North cc lino
Department of Environment,
Health and Natural Resources
Division of Environmental Management.
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
GROUNDWATER SECTION
October 24, 1994
Mr. James Newport
9 Riverbluff Road
Littleton, NC 27850
Dear Mr. Newport,
.AVA
DEHNR
Our records show that the operating permit for the heat pump
injection well on your property will expire on February 1, 1995,
1994. In addition, our records do not indicate that the well has
been abandoned. In order to comply with the regulatory
requirements for permitted injection facilities (15 NCAC 2C
.0211), it is imperative that you either submit the enclosed
Application for Permit to Construct and/or Use a Well for
Injection (form GW-57HP) or submit the enc,losed Status of
Injection Well System (form GW-68) that certifies that the
injection facility is no longer in use. If the well is no longer
to be used for any purpose, it must be permanently abandoned
according to the regulatory requirements (15A NCAC 02C .0113),
and· you must submit the enclosed Well Abandonment ·Itecord (form
GW-30). The appropriate form(s) should be forwarded to us by
November 4, 1994. A copy of the previous application is also
enclosed for your reference. Y
If you have any questions regarding your Permit please feel
free to contact me at (919} 733 -3221, ext. 431.
Sincerely, x~a.-~
Karen A. Harmon
Hydrogeological Technician II
Underground Injection Control Program
P.O. Box 29536, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post-consumer paper
State of North Cat na
Department of Environment.
Health and Natural Resources �� ■
Division of Environmental Management ;
James B. Hunt. Jr., Governor
Jonathan B. Hawes.,Secretary
A. Preston Howard, Jr., P.E., Dlrector
GROUNDWATER SECTION
August 15, 1994
Mr. James Newport
5025 Fleming Street.
Annandale, VA 22003
Hear Mr. Newport,
Our records show that the operating permit for the heat pump
injection well. on your property will expire on February 1, 1995,
1994. In addition, our records do not indicate that the well has
been abandoned. In order to comply with the regulatory
requirements for permitted injection facilities (15 NCAC 2C
.0211), it is imperative that you either submit the enclosed
Application for Permit to Construct and/or Use a well for
Injection (form GW-57HP)�or submit the. enclosed Status of
.injection Well System (form GW-58) that certifies that the
injection facility is no longer in use. If the well is no longer
to be used for any purpose, it must be permanently abandoned
according to the regulatory requirements (15A NCAC 02C .0113),
and you must submit the enclosed Well Abandonment Record (form
GW--30). The appropriate form(s) should be forwarded to us by
October 14, 1994. A copy of the previous application is also
enclosed for your reference.
If you have any questions regarding your Permit please feel
free to contact me at 019) 733 - 3221, ext. 431,
Sincerely,
�� a - 4"V�
Karen A. Harmon
Hydrogeological Technician II
Underground Injection Control Program
Groundwater Section
cc: UIC Files
RRO Files
Enclosures
P.O. Box 29535, Raleigh, North Carolina 27624-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post -consumer paper

State of North Carolina
Department of Enrrironment, Health, and Natural Resources
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor
Wiliam W. Cobey, Jr., Secretary February 14, 1990
Mr. James Newport 5025 Fleming Street lv�
rE C�1�
Annandale, VA 22003 J.Ot4Nlj R C
Dear Mr. Newport: qoo L�►��yl��
In accordance with your application dated February 5, 1989
we are forwarding herewith Permit No. 92- or/52-Wo-0001 for the
Operation and Use of a well, for the purpose of injecting heat
pump effluent, in Warren County.
This Permit shall be effective from the date of
issuance until February 1, 1995 and shall be subject to the
conditions and limitations stated therein.
In order to continue uninterrupted legal use of this
well for the stated purpose, you should make application for
permit renewal at least 30 days prior to its expiration
date.
Sincerely,
rthux Mouberry
Raleigh Regional Supervisor
BC/ja
Attachment.
cc: UIC Files
L Files
Mr. Ronald C. Walter
Halycon Homes, Inc.
PoQudon Pre►endon Pays
P.O. Box 27687, Raleigh. North Carolina 276U-7687 Telephone [phone]
An EquaJ Opportunity A9Jrma&e Action Employer

\
\
I
\
I
\
\
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL, HEALTH, & NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL MANAGEMENT
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION/USE OF A WELL OR WELL SYSTEM FOR
INJECTION
In accordance with the provisions of Article 7, Chapter
87; Article 21, Chapter 143, and other applicable Laws,
Rules and Regulations
PERMISSION IS HEREBY GRANTED TO
Mr. James Newport
FOR THE OPERATION AND USE OF AN INJECTION WELL/WELL SYSTEM
located at Lot #92, Summerwood Sub-division at Littleton,
North Carolina in Warren County, in · accordance with the
application dated September 18, 1988 and in conformity with
the specifications and supporting data submitted, all of
which are filed with the Department of Environmental,
Health, & Natural Resources and are considered a part of
this Permit.
This Permit is for Operation and Use only, and does not
waive any provisions or requirements of the Water Use Act or
any other applicable Laws, Rules or Regulations. Operation
and.use of a well or well system shall be in compliance with
Title 15 North Carolina Administrative Code 2C, and any
other Laws, Rules and Regulations pertaining to well
construction and use.
"' This Permit shall be effective, unless revoked, from
the date of its issuance until February 1,1995 and shall be
subject to the specified conditions and limitations set
forth in Parts I and II hereof.
Permit issued this the 14th day of February, 1990
~~~7 ~ur Mouberry
Regional Supervisor
By Authority of the Environmental Management
Commission.
PERMIT NO. 92-0O,Z-WO-0001
PART I PERMIT NO. 92-CO>L~wo-0001
A. GENERAL CONDITIONS
1. The Permittee must comply with all conditions of
this Permit and with the standards and criteria
specified in 15 NCAC 2C .0200. Any Permit
noncomp~~ance constitutes a violation of the
appropriate Act and is grounds for . enforcement
action; for Permit termination, revocation and
reissuance or . modification; or for denial-·of a
Permit renewal application.
2. I~ shall not be a defense for a Permittee in an
enforcement action that it would have been
necessary to halt . or reduce the permitted
activity in order to maintain compliance with the
conditions of this Permit.
3. The Permittee shall take all reasonable steps to
minimize or correct any adverse impact on the
environment resulting from noncompliance with
this Permit.
4. The Permittee shall give advance notice to the
Director of any planned changes in the permitted
facility or activity which may result in
noncompliance with the Permit.
5. The Permittee shall report· all in~tances of
noncompliance, not reported under condition 1. of
this Part, at the time monitoring reports are
submitted.
6. Where the Permittee becomes aware of a failure to
submit 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 antl correct facts or
information shall be promptly submitted by the
Permittee.
7. The Permi~t~~ shall give notice to the Director
as soon as possible of any planned physical
alterations or additions to the permitted
facility.
8. In the event that the permitted facilities fail
to perform satisfactorily, the Permittee shall
take such immediate action as may be required by
the Director.
...
PART I (Continued ) PERMIT NO. 92-005Z..wo-0001
9. The injection system shall be effectively
maintained and operated at all times so that
there is no contamination of groundwaters, or
other actions or occurrences which renders them
unsatisfactory for normal use. In the event the
facilities fail to perform satisfactorily,·
including the creation of nuisance conditions,
the Permittee shall take such immediate
corrective action as may be required by the·
Director.
10. De.partment representatives shall have reasonable
access for purposes of inspection, observation
and sampling associated with injection and
related facility.
11. This Permit is not transferable without prior
notice to, and approval by, the Director.
12. An application for modification, renewal or
transfer of this Permit shall be filed with the
Department at least 30 days prior to the
expiration date of this Permit.
13. Provisions shall be made for collecting samples
of facility effluent, both prior to its entrance
to treatment devices and subsequent to leaving
the treatment devices but before entering the
injection well.
PART II
A. SPECIF~C CONDITIONS
1. The Permittee shall install, in a readily
accessable location, a sampling tap or other
device suitable for collecting a sample of the
fluid in the injection system~
2. Within sixty (60) days of commencement of
injection activities, but no later than May 1,
1990, the Permitee shall submmmit a laboratory
analysis of the fluid used in the injection well
system described in the permit application.
3. THE FLUID USED IN THE CLOSED-LOOP HEAT PUMP
SYSTEM SHALL BE COMPRISED OF CLEAN WATER OR A
MIXTUE OF CLEAN WATER AND PROPHYLENE GLYCOL. THE
USE OF ETHYLENE GLYCOL, ALCOHOLS OR OTHER
CHEMICALS NOT SPECIFICALLY APPROVED BY THE
DIRECTOR, DIVISION OF ENVIRONMENTAL MANAGEMENT,
ARE EXPRESSLY PROHIBITED
/// NOTHING FOLLOWS///
DONALD G. WALTER
President
Licensed General Controctor "4wr
HALCYON HOMES, Inc.
CUSTOM BUILDERS
92 Summerwood Drive
Littleton, NC 27850 9191586-6761

NORTH CAROLINA
ENVIRONMENTAL MANA09NIENT COMMISSION
DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR
INJECTION
CLASS 5 WELLS
TO: DIRECTOR, NORTH CAROLINA DIVISION OF ENVRONMENTAL MANAGEMENT
DATE: 65 FL 5 , l9 q
1n accordance with the provisions of Article 7, Chapter, 87; Article 21, Chapter 143, and regulations
pursuant thereto, APPLICATION is hereby made for a PERMIT to construct and/or use a well or well system as
described below and in any accompanying data submitted as a part of this APPLICATION.
2esi�ce 5 l T C
A. OWNER DATA: Name: ZAMEZ NeWeC4kT
Address: 5 2S LEmt%-4& 5T it R SUMME Rt1,OOD 5U9`041f
City: ANqAmP4LE4 o Zipcode:LA MLCTar, t%at L ITSO
County: Telephone: ws�gmr.1--+ 0"+Ty
Ownership: Federal
Public
Other (Specify)
State Private �-
Commercial
B. FACILITY DATA (Fill out ONLY if the injection well(s) is (are) for the purpose of ser►ring a business or
industry):
Business/Corporate Name. _ r!%4
Address:
City: _ - -- Zipcode:
County: Telephone:
C. HEATING CONTRACTOR DATA (For heat pump systems only. Please give information for the contractor
that installed or will install your system):
Name:
Address:
City:
— — -- -C W r►1-�. .
Zipcode: Telephone:-
D. INJECTION PROCEDURE: Briefly describe how the injection well(s) will be used.
CLOMC'D %-COP >VkE.AZ PuAP sy lar%. Jp ftL.Ly 13uTyt.MNe <'rKa 1'1At-
W = D sa t 'T o S C t4"Ca LotTiM E W t T H 1014
G L`fCd L QY Vd t-One - N D L1 Q014 1 mPk ra-r% n0 f►L aM
E. WELL USE: Will the injection well(s) also be used as the supply well(s) for either of the following?. -
(a) The injection operation? YES NO
(b) Your personal consumption? YES NO 1,10�
F. CONSTRUCTION DATA: (check one)
N ' EXISTING WELL being proposed for use as an injection well. Attach a copy of Form GW-1 (Well
Construction Record) and furnish (7 & 8) below. If Form OW-1 is not available, furnish the data in (1)
through (8) below to the best of your knowledge.
GW57B May, 1989. Replaces GW-57A, and GW-57B {2A4)

0.11 PROPOSED WELL to be constructed for use as an injection well. Furnish the data in (1) through (8)
below as PROPOSED construction specifications,
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING
OR PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
(1) Well Drilling Contractor's Name: [-Y G 5 E L G: i' 'fit N Ar-s I-1
(2) Date (to be) Constructed v , r` e-& cl C ; Appmximate Depth Y.O C] ft.
(3) Well Casing:
CQVG)
(a) Type: Galvanized Steel Black Steel Plastic Other (Specify)
(b) Inside Diameter: Cn inches; Wall thickness (inches) or schedule # SID, R 1
(c) Casing Depth: From + Z to - 6 0 ft. (referenced to land surface) �' 4 epyy 5 v e lPac- tv
60' G tr4-0� � WZFAc-
(4) Cement Grout:
(a) Around inner or "primary" casing; From d to ft.
(b) Around outer (pit) casing, if present: From � to ft.
(5) Screen(s): (if applicable) NIIdr
(a) Type: _ Inner Diameter: inches
(b) Depth: From to feet below land surface
(6) Gravel: (if applicable) N//�m: to feet below land surface
(7) N.C. State Regulations (15, 2, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes. A faucet on both the influent (water from well) and effluent (water
NIA into well) lines is required, Is there a faucet on (a) the influent fine YES NO , or (b)
the effluent line YES NO ?
(8) Attach a diagram showing the details of construction of the existing and/or proposed well(s).
G. PROPOSED OPERATING DATA: (Me manufacturer's brochure should include this information.)
(a) Injection Rate:
N/A (b) Injection Volume:
�`1 (c) Injection Pressure:
(d) Injection Temperature:
H. INJECTED FLUID DATA:
Average (Daily)
Average (Daily)
Average (Daily)
Winter Average (Daily) _
Summer Average (Daily)
— gallons per minute (gpm)
_ gallons per day (gpd)
pounds/square inch (psi)
degrees F
degrees F
Fluid Source (From what depth and what type of rock/sediment unit does the fluid to be injected
derive, i.e. granite, limestone, sand, etc.)
Depth: RoeWsediment unit:
(2) Chemical Analysis of Source Water: The following chemical characteristics MUST accompany
this application;
tql)4 pH ; Total Hardness_
Chloride ppm; Nitrate
GW-57B May, 1989, Replaces GW-57A, and GW-5713 C2I84}
ppm (parts per million or mgA); Iron ppm;
ppm; Coliform bacteria counts/100 ml
ra

c r
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
APPLICATION FOR PERMIT TO CONSTRUCT A WELL
To: NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION CS Em e , 19,90
Gentlemen:
In accordance with the provisions of Article 7, Chapter 87, General Statutes of
North Carolina, and regulations pursuant thereto, application is hereby made by
3'A,r1S5 n1 M'W pc4kZ_ for a permit to construct
(name of well owner) -'
a well as described below and in the accompanying data submitted as a part of this
application.
(a) Name of Property owner 3'AC'1S5 CV E W joa[2Z
(b) Location of Property LdT CIR SQ9. Lj-rTLCTC)#Q WC WAZeC'M
(Road, Community, Subdivision Lot N6 Town County
C k.OSMO Lace 1.k =AT P U rn p. rY 6 r V k fl
(c) Purpose of well GgodwAO. 'SeAo_Fp 5y5'teM _LAJl_ PfCoT 01xC-HA%j= G+w►t� _ —
(d) Will proposed well replace an existing well
(e) Total capacity of existing system: gallons per day
Well No. Yield
(f) Proposed well:
Well No.
Yield
Construction type
OfMh4 t:'r D
(open end, screened, gravelpacked,
etc.)
Estimated depth
'2. d> C�
Estimated Yield n►//
n
Estimated date of
construction:
Begin 16 FT-9- q o Complete
15' FC_6& 90
(g) Drilling Contractor: M d,3Cr-Ley -_ *-4 A511 _ [ $ 04 3Ca - .557 11
(h) Location of Well: Provide a detailed map showing the location of the proposed well
and any wells in the existing system to at least two (2) nearby reference points such
as roads, intersections, and streams. Identify roads with State Highway road
identification numbers. Show all existing water supply wells within a radius of
1,000 feet of the proposed well.
(i) Well Construction Diagram: Provide a diagram showing pr-dlsos^-' - :,P, .:txuction
specification. (See Form GW-22A) 56-L-5 5T.
the ApptZeant h.eAeby agnee a t%e pu poe ed A t.s Ftr.s A A Lc , VA 2 Z a o 3
wet uzW be conafticted in accordance with
¢ppuved aped 'ccr ti. and condaionQ o�
the a Permit.
Axef I�rZL 5
Signature of Well Owner or Agent
14 A L.c YG N H...r0M��� 1 z►1t
► -C. 6lQtNCE-0/L CTR. VCd Z,47&1
Title
GW-22 Revised 1011/80
(tiling Address of Well Owner (Required)
L.�ZT�.� TDn+� l•�c. �78"5p Ca7G 1_
Mailing -Address of Agent
PERMIT NO. issued 19

DIAGRAM OF PROPOSED
CONSTRUCTION SPECIFICATIONS
Straight -Screened
" or -
Open-End"Well
Gravel -Packed Well
Constructed in consolid-
(0nstracted in unconsolidated
formations)
aced format "a s)A.
�' A _�
land surface
N
A)
Casing:
CEReN
1] Inner:
typeSM I l I. D.
(n r lbs./ft.
+ 'Z
ft. (depth)- &O
ft. (into rock)
00
2) Outer:
type I. D.
lbs./ft.
U
ft. (depth)
BEFT`LCD TD ?`RF
a''
N SOR -I I? TG
B)
Cement:
161 $ eLow 904K
1) Inner Casing:
D ft. to
- Z Q ft.
2) Outer Easing:
ft. to
-ft.
Rock
i
Rock
C)
Screen(s): ��type
I. D.
So-o
u6
ft. to
ft.
W+g
mr2
ft. to
ft.
D) Gravel: lit :t. to ft. in. 1
(size) "
fl
(Fill in each blank that applies and use appropriate diagram
to show proposed construction including, but not limited to,
casing (outer and inner), sealing material (cement, clay,
etc.), packers, screens, gravel., chemical feed lines, etc.}
Location Diagram: (Previously prepared maps may be submitted provided they con-
tain information required in item (g) of the application).
i" T14EeAAL WELFeD
P'OL.t.Y 9uTYtgr4c PIPG,
c c.ageo u�P W LVArert
� lo%
ItO_ t Z G4ye&L.
Qy upr.,.,tsE-
4 W }wS
r ZQQt � rcPPi4 �2.ETue..eac�.+T
4.
au4*r'r
r d weu.S

NOTE: Assistance in obtaining these values may be facilitated by contacting (a) yom local or county health
official, (b) a commercial water-testing laboratory, (c) your well drilling contractor, or (d) the Regional
Hydrogeologist, North Carolina Dept. ofNatural Resources & Community Development
NOTE: H injection system is not for a heat pump, then a detailed analysis of both the somce water and the
injection fluid may be required.
I. INJECTION-RELATED EQUIPMENT:
Attach a diagram showing the engineering layout of the (1) injection equipment, and (2) exterior
piping/tubing associated with the injection operation.
NOTE: The manufacturer's brochure, if detailed, should satisfy (1) above if the system is a heat pump.
J. LOCATIQNOFWELL(S):
Attach a detailed map showing the orientation of and distances between the proposed well(s), any existing
well(s)·that will in any way be involved in the injection opera-tion, and at least two (2) nearbyreference
points such as roads, toad intersections, streams, etc. The roads should be identified by U.S., N.C. or SR
(county secondary road) numbers, and streams should be named. In addition, the diagram should show the
direction and approximate distance to any existing water-supply .and/or injection wells within 1,000 feet of
the proposed injection well.
K. CERTIFICATION:
"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 infonnation, I believe that the information is true,
accurate and complete. I ·am aware that there are significant penalties, including the possibility of fines and
imprisonment, for submitting false information. I agree _to operate and use the injection well d all related
appurtenances in accordance with the approved specificationf'f d con.,,,n f the P nni '
~( /?Ill;$
(Signature of Owner or Authorized Agent)
1-J AL..C)"ON ..., e,rr~s. i Ii" C •
N.~. &e:NCSRA\.. CONTe?AClotZ.. c..tC.• rJ 2.47~
FOR OFFICE USE ONLY:
1. Initial Application: Complete__ Incomplete __
If INCOMPLETE, Date of Notification _____ and Resubmittal ____ _
2. Standard Industrial Code(s) which best reflect the principal products or services provided by this
facility -if applicable.
(a) ___ {b) ___ (c} ___ (d) __ _
3. APPLICATION NO. ______ _
GW-57B May, 1989, Replaces GW-S7A, and GW-S7B (2/84)
.Ors 1/rerv�iY�� tp sc4l�
r '
A � _ C�
!O !Qlzw
f
i
cr r r ve�l ! g

Aar
t
ev, 7 I
��� �r�l r�l�lil� Ire 7��J r.�rQwl�q f7o vG
�.7 jws Ifc�°�r7 c�•pcXr� ��'" f��lrS 17f/ -
'�Q

\ \
\ \
' \
LOI UN~ ~ ~ a,rtc. h_ Lo(' ._,...,.e
\ f:le~fl -. '-~ ¼N/C \ \~•~,
~, ------\
GAS'TOl'r
+ M1M rlr Ar rA1FT,Mli T M' HATUnAI Fw4il moo &Omill1>' 4u
r+rrl►►r+rr rx Ptr+Irr"awgITAI. IMiZA LOW - 1111o(bbwAtln Mc ibll
lil sr,x ill-1ultill"t1l 11114- hil WO M-160
twit Nb. 00161 Imb. _
M1nr4 IIlai1r1 r * ! c
WELL COMt UCTION hECO"D 1 All rr044 _
i16Ad#1 �nl, t�wa 1 ♦kn},
_ M05ELEY~&rHASH 9NT. ' NI C. --
P . D : Box _ ,, : • s r. � _:
t11 1 I? In Coll InACion _��,,, �-.. 5r._ $tAtt WtLL (cONstwCtlQfd
ill I Fri MMIS T 1tA T ION NUMHEM mum"""!
r:rl1. 1-f]CATloll phew ill knlch of R11A tociJlen bglow)
Ilrn,r,wt tr+w„• _.,..�!..f � l�,t� County- IIJ4 ri YrP �l _
jIl f nrnnryeer#ly, im S,r11r11vIrinrr and tot lan.l
tl,l+lIT r;r.b I.lff'�
d1 oul j
rrr777f;11y VC1%vol''llSioln z1v CodaII 111111 1 tiT � �(�_'__• 11SF or WFLI 02l,,,,�^
Irlr•nl orrtTT r,tiTtlTrr,S rnlLt.E ill UYA! OfJv
• r wr i 1 nr INAr:r r ,rt : l It it.t wr:1.1. 7 C-! ylls 1_+3-f7n
I r• 111- VIA 11 n 1 1 Vr•I r 1. Utoll t]r (:A5111C1,
- -- 114'1,e1nw
Ir+r T,r r,ASitu. It; l;C r�. rt, Allovr LAl10 S_UI rAi.1,
- -i�J r 11 I I+ 1Qr+T+I 3_.-. __..- 77lrItrr 111[11] Qr IE S1
WA rr 11 antic., lrir•!111,1 _-••I�3.1_r��
-t11 WMIATI011 Tyhln .C1OIQ-_C_T Amount -
A nip it'.
Well this l t11
flnr-lr+ ITl1rrnr+IRr or WillpT+t►r1. lyleipr1,11
1 rnrn ��Z -- to --&J2— r1 .fA SD -
+rnrn ___.-•_•-_.1n r1—._
I rnrn _ - .. _-_ 1 n _ . —.—r 1 _,
I;I]r+111
hnr111, Al41011n1 M it ad
Trn1n _ tn. vU C- T1 �t
I rr,f„ _ - — In ----- r f
111MISOr
binnlAler
8101 Silk r1r11prinf
y
rnrn . _ ---
l n - --
l 1 In,
In.
r 1, n . - - - ---
rtrre yr I 1'A I'Fe
111nnlr+ 51tr AAA Al
bApl11 bn'LLINa too
rem to O allon b!?Agrlplldn
JUT dej
11 rI+I,I1llollAl kpAc±r 1s nude use bkk of lr.rm.
A11 13 pq
tSho* direr-qen And d1011 Irani at 16AM two Slab hil
til b1t11•T ill 416ioll ball
C '
ft - W-- -1
I t,r1 llrfit Tly 17311liry 71IAI 11115 WM WAS G0118-111V O IN AttObbA14gA *1111 15 flcllc 2c. WELL c& LICTIC11
ItfA SIAriS. At47 toIAI A coPy or 1IAS hEcant) FIft bttk �bfttf1 I oit W bw1vt
5 r—v4A-11ntE b* CbldriiActbh b1i Molt DA1E
• Sollrn111 rrfti lnl If,- Mill!-Inh 61 Fn,lroltifnrnlal lfrTnnpnrnnn} and it Io K@ll nwnrr

rrl nu►r,t rrR er'rAR''b..►r t,w I�AiUr1Al lu+d 6oiiAAlr+t t>Ir1r��li Fl y.' .' to" orr" T OHIY
eryy«r+ c+r rr�,�.nc,►i,wrttA! Iuwuar!i�.s�r - �+ol►f�lAllw i�c ball r ��'.
*.v. Rnrt �> Mt - k�iR►rllLFl� #I#I I,H16A Is f66-MM Wit 14. U111111e. ,
WELL U01491PUCTION hEC_OM) bed#liskjAk
-
- — ` S E EY & NASH ENT. INC. ' P. Ur N �k+Yb§''
1Tl I i1iA CD}1TrIACt Oh B-45 'u.,�,. -
Wt1=1NtLL buMMbctlo4
Tn I -gin nms t"Ar1UN pthMit NNMOtn:
wr 1 t t CC A Itot 1; (Show 0 nleh of 114 laalljl'on b11vwf
llpKpp+l Thwn•
C1lnnrf. Co mmanrlly, or Sipbirlvisinn fllnd Lai No.)
[si•#�1 or
illy nr Tnwn S1nIn Zha codd
T►A fr nr11i.l.rr1 r � -- tisr- or wat moo
lr>lAt Tlrrill __.. J. CUT111AC;S OOLUCf! b UJY!* woo
r+►•I wil 1. fir r3.n(:F It xf, TOO wl:I.1_1 d Y`q Mt"wa
I n r1r- wAttn T T Vt., l . 23 t 1, U Rbvvn iOh Ot vAslon,
bel
I r+t• r)r CASIt113 IS —j t r. A vE LnwAIJU fsuTlr At;t ,
if 1 11 ropf"'I — _ fq myti ❑r tl:sf r --
V: A I r 11 7C1tIF S lrlrnll,1• -- )6 6�2,6 I
111 ►11111IA 11011 T ynn A►np!!hf f
l'F�111it
Well Ti IGk
hInmelpf s
ar WD�g1+Of Md1w11
rrmn
T 1 rrn —_ _- r I. --
;7n►1f1T•
bnnll,
l�tnl�rlel
4hat}
rrnm
tPip ire
�,-t1r rrr
I?nhll+
blam�fAl blot 6106
jnleord
I"..
tf. In.
In,
In,
rn
t 1. In.
1r1.
r;l1AVII r�ic�r,
r]rpu+
SIle
111i Arlclt
JV I1p1r,_ —
--rR- -
rI —
A fir MAIMS
bbilnitr:
b#blil b"UINO LOG
hbro U f r on billeflpllon
Q _l d
I
cl
if rl+I.11ll4n#1 i}psei lsY ntaded U'6 baek of tr.+n,. --
1
(Shdlk dlih,'IIwi Arlo JlslnheA tram at 1!l1e1 irks SId16 hmil
v bilj�l llt:lli filbtlnel bal"191
3
�y �
I Or) wriE. Ely cEtitit y TIIAt tilts WkU WAs P.,OR ICI O Ill bbbbbAkk Wltl# It HeAc #C, wttt bvltsr trot►
91AIR1'AMS. Alxo iIIAt A c&y ch 11Its i�Gohb 011; O1 "W"410 id tut Md OWNEft
MONATUnt t* btht"Aifb" bh Altllt ZVAA _
.' Submit 111101rrdl 16 blylOnh 61 kh%llbh1`M"l01 W"d17AMOnt and tOny la W911 4N'MPF

�w�.r�jil�+rotilliwr<:+ti� � . • ' 1. +!
t:i,,;j•••y ,i t :I� ! ���
tp
. r. ��i!llRttS'' i � • w• f{! � - ll 111 �t r . 1 •• :: . � 1 -
►K,r+rlr- a�n•w rul tbpr►,rit�•w}rr rh tuAttAhht Ao�4ia�af? ►ulti bbi+1�4A�fi b�•+l1.�� .. ..'.. fOf! b{t1C! ilA� f�Hl.t� �----.' .
bh,"c.m t+• nrritwo ti mith 0Aj4AoH*M - bka1J61bWAfM i&tNW
r.o. sox!It44I-IFFAt11tO Me- ifG11,Ni40Idj"+1"&j twit Ns, twit 148.�_
WELL Co14StnUCt10N filkWhO
W ELEY � NAM FT- m-- lreedel �n{- tlWai ant. _- -
P. 4. Box
rnl.lma camnAGTvn E1boTiy-- - §fAtt ft t bbNgthi ttION
wrtl- LOCAItolP tSho* Ilh9OF 61 {l,e IDclyfam WIv* j
fl*41 0 In"".
trsr,nd, [ prnn+ul+lly, tit SubdWitle- And LO NO
ILI-
' J .9G D! 110616 O p
CTIy b! 1 wn S111IA x111 l5de
I,r Ir wul (Irli s 7_ Ust or W11 cc
T rt r Al 11PI•II1 _..r��� ..__ cul f fmc1s CbLttc tkb
r,r,r z writ Ilrt-1 Aut txlc;TlW) W>tl_L7 U Y4* U-iGa
rTn110, WAIF11 tl VFI � �� fit. .} 6avd iCO br t:l§1I ti,
Ir.,t' Ur CAC1t1l) I$ --#%- t f. A9bvE LAlJti Whtkt.
1
VIT III lenr"l---.1---- mt lk)u Ot tt5i r:--
� 1n,rlt iU11L5 1drrll,j w—
boil, bhlLLINU Wd
ham tB br lloh bIII&I lleli
�,
';1N►1TlItIATIi]It type[-JDf�� J�}�,oHnl �.�-, �� "" � '"
c A rill III -.•.....II IIr1:11I1tl1►�I �{T1i;1 Ill hll�dltid ��� �� i51 It.}in.
1)nt,ll, h�ar*►Q{eI n�IWe�n�i+Fi3 #Jd111131�
..__, ��� � � Lt�CAtiIpN slt�tr� _
t lnrn 1n �_ t l b .,;`j.. Met d11911181{ slid 011IAfits Math aI lb!#f I*fj time fln.Tl
rrar+� _.__�� to __. Fl. _ ,..-•,,�' [yi l3{1lF{ HI:I{i IAI6}ari�8 $hl�,lly
I r;nom
bnntl, I�I�fetlnl fJ�tll,ad -
frnrn
r; f fit C 0
t3Rnllr
b1Arn�181 !3Io1 �If�r d�lelldl �.
from
10
t 1, trl, k
3 t,rlA
Vf L PACIC-
- '
AA
tier,:l,
§Ifs mi 41141
r r rrl
rl0rot
10
tl �nu5e
I t10 IIr-FIEVY
CEnittY
f1fAt Wls MLL wAb O 11� xIN ta R�it Wlff� I� hbAt m. WR1 b #Sthtl�tlpli
51AIA1AfttiS,
Ali) tIIAt A Gohr b1' 1F15 f GbhU F411 1 N 1 lip w�u CfWNEIt
z2A
tiafUf!"t bk t004t"AI✓ btu bN AM -lit bAtt ,
•'
W)"111 101d6Al 18 1blvltIbb 61 bopy+ 14 o,-611 6,4nA!

Hoff III e1,71t7LPM% bim-Anti WT tW NAnOtAl Mt *OA60 Alft 60A&Nrty 6r►�if
err+r+c>•+ dr V?reVK*** AL WAAollILOli - YWl►lbWA*M 111'+Ctk*
9164? - "Fu+a lkc. l t 11 i, f11C111 1!!ib f li��[f id}
- .•. .'.. fOI: pFFll� UI>� bNLY �'-•---
t�l�.
Lit Le+W ;fie
Mlr &
WELL coNstnucrION hF-COfID 014In 0046
*` i i�k5 N -INC.
—r 146ad4r Ent, 0*41 tnl—
MOSELEY:&' T. `
p . C. Box Y " of y 3c
Ir11LLINa CONMACTDIi �2' V9.- - =�- Otktt MaLt IbO40huC#ION
rntt_ to nE O1s MAI ION HUM E" � � POW "Umalab:
WCI.I. LOCATION: (Show sketch of 114 IoC010n 6410*1
110nreel lawn.
in'+++d. Commuedly. of SuIldlvlslon end Lot Me.)
O w"r n i Z, /1.j.p ._._a r O V 4
1 tr! or n7w7to Nei.)
C. 7
rZ
CIIY pr 1 wn Slate n CodA
t1A it nnil-tr1) USE or WrI,L �.,
InfAl I}FrIIi ct.1TIWas CoUtc1E0 �Y*3 !wd
Ii(+r-^. ►nrFl-! 11Fr1-ACE Exlsl0a WELL7 tl YAs tLwv
SIAIV- WA1fn I W7L- __Z_3 rt. C] above tan of cASINIn.
I[)r or GAstli0 IS —� ?— fi. AgOvF LAMU sutirk.t.
if l " Idnr:+). �� ME T I IOU OF it 91
r r
VVAIFI1 ZONES Idrnll,)7
^,1tI.[]f►rf1nTI1]11 IVVO �� Amount CA WA.
7 I:F SIr1f;
Doirlr, blar„eler or weighlirrri 1�alEtlal
r rem 10 —lam l�, d!__(__#' S� .
room TO—
toom
t c�nour;
t7antl� Iulalgrlal �Irrlhbd
Tonrn _�_ Tot
from Tv_, �I
7 Sr' for F N;
0)--Arrom
I o.3m
from
13, 13rtA►+FL 1'ACH
Vnru, blain04r
_ To to.
To FI,
_ T n 1• t.
Stof tits %44iloil61
In. In,
1n, In.
In. In,
bibih bMILLtNa Loa
tidal tD� kormallon b witollen
—Q
II tI.I:1III6t,Al tpiea It hooded ase bock of tr-fm.
�pCAtfO1u Stc�1Ck _____
Mhb* 61,01611 And dlslomcA Irom of 111101 I*o Slnl(1 hn.tt
bp GIHFf I+I:tlt 41611t,c1 boinlsl
VI:
I]en+h SI:� IAA 8r1e1
P/p rt0rn �.. toI't
r ram" To k I hers+
14 111. A A nl(5 :...�.-• xb.,�, •.:. .
I bo tIEritoy ctnllrY MAI 1141S WILL W0 t:6M§1hUdtb IN Alb `PIUANCt WItN It, NCAC fC, WALL Ct7NS7ft CTlarr
FTAHI)AnnS• AND 114AT Acopy or i"s I t:cohr; HAI. WN �FI+'3 b �0 tilt 4VM OWNER
' /7-Z
staaAll I� tONtI1Ab1bq on AIutItt 6ATC
S4rnit hilainil ll; blyltlbh 61 khi .hphinenlal Mjjn6vArn6nl and cony to well o%nr,
'/1

r -Mo.
TM QRIrnAAj
1 y
2- 7r
DATE:
SUBJECT:
� ,�..� � c.7`, u,1. Gam•-.�--�� ...t.-:..c-, _
out YY► wl+% Na� �0 2 �ft 141.
d�- TGr � s � Jae � r•H � 7`s J � U �e. c.�.�o►-c `i. � c� ,� �i on.� S'c.►'r1�'� °`'`'
I a.� aL�cJrC.� �.f �►-r-� Q r2I�� �-r� �dn��
I� G n ��l ► S J
I
a a�Ow
��J ,''�,,►,.Q..� S S f �1rs� / �C � � rI v tJi
f r� I S S C.vr, �.►Q`st
anno- d-.,% -e�J "P.� 0/ /OE
J 77"" fk c&rz. sryh. • � 2 . eJ
{� 5 0. Cu�U► '"
f.a. jo z A- rK
North Carolina Department of Natural
Resources &Community Development
.v0 7'c 5e ^► JO CC: aF st9A..Cd le l7ea T.,• AAR. Do�+aI WAIT.f-.) H Alyco,a Nor-t%� iz suw+ N+t �".*� � p
ro.r> r•1G 27