WI0500042_GEO THERMAL_20180214

Permit Number WI0500042
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Fl~w
Facility
Faclllty Name
Jonathan B. & Tara B. Cage
Location Address
1230 Mordecai Dr
Raleigh NC
Owner
Owner Name
Jonathan B
Dates/Events
Orig Issue
6/27/2002
App Received
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27604
Cage
Draft Initiated
Scheduled
Issuance Publlc Notice
Central Files: APS __ · SWP
2/14/2018
Permit Tracking Slip
Status
Active
Project Type
Renewal
Version
4.00
Permit Classiflcatiori
Individual
Permit Contact Afflliation
Major/Minor
Minor
Faclllty Contact Afflliatlon
Owner Type
Individual
Owner Affiliation
Jonathan B Cage
1230 Mordecai Dr
Raleigh
Region
Raleigh
County
Wake
NC
Issue
2/12/2018
Effective
2/12/2018
27604
Expiration
1/31/2023
Requested /Received Events
Administrative amendment request received
RO staff report requested
RO staff report received
Streamlndex Number Current Class
10/4/17
10/9/17
217/18
Subbasin
Permit Number WI0500042
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Faclllty_ Name
Jonathan B. & Tara 8. Cage
Location Address
1230 Mordecai Dr
Raleigh NC
Owner
Owner Name
Jonathan 8
Dates/Events
Orig Issue
6/27/2002
App Received
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27604
Cage
Draft Initiated
Scheduled
Issuance
Central Files: APS SWP
2n/2018
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affillatlon ·
Major/Minor
Minor
Faclllty Contact Affillatlon
Owner Type
Individual
Owner Affiliation
Jonathan 8 Cage
1230 Mordecai Dr
Raleigh
Region
·Raleigh·
C~unty
Wake
NC 27604
Public Notice Issue Effective Expiration
Requested /Received Events
Administrative amendment request received
RO staff report requested
RO staff report received
Stream~ndex Number Current Class
10/4/17
10/9/17
2n/18
Subbasln
Water Resources
Environmental Quality
February 12, 2018
Jonathan B. & Tara B. Cage
1230 Mordecai Drive
Raleigh, NC 27604
Re: Issuance of Injection Well Permit
Permit No. WI0500042
Geothermal Heating/Cooling Water Return Well
Wake County
Dear Mr. and Mrs. Cage:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Interim director
In accordance with your permit renewal application and change of ownership request received October
4, 2017, I am forwarding Permit No. WI0500042 for the continued operation of geothermal
heatinglcooling water return well(s) located at the above referenced address. Please note that this
renewed permit shall become effective on February 12, 2018. This permit shall be effective from date
of issuance, until January 31, 2023, and shall be subject to the conditions and limitations stated therein.
Please Note:
• Samples from the influent and effluent sampling ports of your geothermal well system
were collected on November 17, 2017. Laboratory analytical result show that Total
Coliform bacteria was detected in both influent and effluent samples. Hence, we
recommend having a licensed well contractor to inspect the well casing for any cracks.
Please find the attached laboratory report.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Resources. If you have any questions regarding your permit or the Underground
Injection Control Program please call me at [phone].
Best Regards,
' Ncothirlq compare,_
Stare of North Carolina I Environmental Quality a Division of Water Resources
Water Quality Regional Operations Section
1636 Mail Service Center 1 Raleigh, North Carolina 27699-1636
919-707-9129

Shristi Shrestha
Underground Injection Control (UIC)-Hydrogeologist
Division of Water Resources, NCDEQ
Water Quality Regional Operations Section
cc: Rick Bolich -Laura Robertson, Raleigh Regional Office
Central Office File, WI0500042
Wake County Environmental Health Department
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Jonathan B. & Tara B. Cage
FOR THE CONTINUED OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defined in Title 15A North Carolina Administrative Code 02C .0224(a), which will be used
for the injection of heat pump effluent. The injection well(s) located at 1230 Mordecai Drive, Raleigh, NC 27604,
Wake County, NC will be operated in accordance with the application submitted October 4, 2017, and in
conformity with the specifications and supporting data, all of which are filed with the Department of
Environmental Quality and are considered a part of this permit.
This permit is for continued operation of an injection well shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until January 31, 2023, and shall be
subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 12th day of February.
For Linda Culpepper, Interim Director
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Permit #WI0500042
UIC15A7
ver. 11/15/2015
Page 1 of 5

PART I -PERMIT GENERAL CONDITIONS
1. The Permittee shall comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Noncompliance with
conditions of this pe~it constitutes a violation of the North Carolina Well Construction Act and is grounds
for enforcement action as provided for in N.C.G.S. 87-94
2. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data [15A NCAC 02C .021 l(a)].
3. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data [15A NCAC 02C .0211(1)].
4. This permit is not transferable without prior notice and approval. In the event there is a desire for the facility
to change ownership, or there is a name change of the Permittee, a formal permit amendment request must
be submitted, including any supporting materials as may be appropriate, at least 30 days prior to the date of
the change [15A NCAC 02C .021 l(q)].
5. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met [15A NCAC 02C .0203].
PART II -WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed in accordance
with the requirements of rule 15ANCAC 02C .0107 except as required in Item #2 below.
2. Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC 02C .0107
except that the entire length of the casing shall be grouted in such a way that there is no interconnection of
aquifers or zones having differences in water quality that would result in degradation of any aquifer or zone.
For screened wells, grout shall be emplaced from the top of the gravel pack to the land surface. For open-
end wells, the casing shall be grouted from the bottom of the casing to the land surface [15A NCAC 02C
.0224( d)(2),(3)].
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing conditions.
[15A NCAC .0225(g)(8)].
4. The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [15A NCAC 02C .0224(d)(4)].
5. Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal as defined in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .0107(j)(2)].
Permit#WI0500042 UIC/5A7
ver. 11/15/2015
Page 2 of 5
7. A completed Well Construction Record (Form ow~t) shall be submitted as· described in Part V.5 of this
permit. ·
PART III -OPERATION AND USE CONDITIONS
1. The Permittee shall comply with the conditions of this permit and properly operate · and maintain the
injection facility in compliance with the conditions of this permit and the rules of I SA NCAC 02C .0200,
eyen if-compliance requires a reduction or elimination of the permitted activity [ISA NCAC 02C .021 l(j)].
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface water
or groundwater resulting from the operation of this facility. In the event that the facility fails to perform
satisfactorily, including the creation ~f nuisance conditions or failure· of ~he injection zone to adequately
assimilate the injected fluid, the Permittee shall· titlce immediate. corrective actions that may be required,
such as the repair, modification, or abandonment of the injection facility [ISA NCAC 02C .0206].
PART IV -INSPECTIONS [ISA NCAC 02C .021 l(k)]
l. Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation of credentials, enter and inspect any property, premises, or place on or related to the
injection facility at any reason~ble time for the purpose of determining compliance with this permit, may
inspect or copy arty records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwater, surface water, or injection fluids. ·
2. DWR representatives shall have reasonable access for purposes of inspection, observation, and sampling
associated with injection and any related facilities as provided for in N.C.G.S. 87-90. -
3. Provisions shall be made for collecting any necessary samples of the injection facility's activities.
PART V -MONITORING AND REPORTING REQUIREMENTS
1. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on-site and available for inspection [ISA NCAC
02C .0224(t)(2), ( 4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State and
_compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
.0224(f)(l )] .
3. The Permittee shall report any monitoring or other information that indicates noncompliance with a specific
permit condition, that a contaminant may cause a violation of applicable groundwater quality standards, or
that a malfunction of the injection system may cause the injected fluids to migrate outside· the approved
injection zone or area. As specified in rule 15ANCAC 02C .021 l(r), noncompliance notification shall be
as follows:
(A) Oral notification shall · be given within 24 hours of the occurrence, or first knowledge of the
occurrence, to the Raleigh Regional Office, telephone number 919-791-4200.
(B) Written notification shall be made within five days of the occurrence and submitted to the addresses
in Item #5 below.
Permit#WI0500042 UIC/5A7
ver. 11/15/2015
Page 3 of 5
(C) The written notification shall contain a description of the noncompliance and its cause; the period of
noncompliance, including dates and times; if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and any steps taken or planned to reduce, eliminate, and
prevent reoccurrence of the noncompliance.
4. The Pennittee shall record the number and location of the wells with the register of deeds in the county in
which the facility is located. [15A NCAC 02C .0224(f)(3)].
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
UIC Program Staff
Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Water Quality Regional Operations Section
DWR Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
PART VI-PERMIT RENEWAL [15ANCAC 02C .0224(c)]
As required by rule an application for permit renewal shall be made at least 120 days prior to the expiration
date of the permit. This permit condition does not apply if the Permittee chooses to discontinue operation
of the well for injection of effluent from the geothermal heating and cooling system associated with this
permit.
PART VII-CHANGE OF WELL STATUS [15A NCAC 02C .0240]
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complying with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to rule
15A NCAC 02C .0113(b) in order to prevent the well from deteriorating and acting as a source or conduit
of contamination, which is prohibited by General Statute 87-88(c).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well
seal that cannot be removed without the use of hand or power tools.
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall permanently abandon that injection well in accordance with the procedures specified in 15A
NCAC 02C .0113(b), which include, but are not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
such removal will not be responsible for, or contribute to, the contamination of an
underground source of ddnking water. ·
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected prior to sealing in accordance with rule 15A
NCAC 02C .011 l(b)(l)(A),(B), and (C).
Permit#WI0500042 UIC/5A7
ver. 11/15/2015
Page 4 of 5
(D) Each well shall be .completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In those cases when a subsurface cavity has been created as a -result of the injection
operations, each well shall be abandoned in such a manner that will prevent the movement
of fluids into · or between underground sources of drinking water.
(F) The Permittee shall submit a Well Abandonment Record (Forni GW-30) as specified in
1.5A NCAC 2C .0224(±)(4) within 30 days of completion of abandonment.
5. The written documentation required in Part VII ( 4)(F) shall be submitted to the addresses specified in Part
V.5 above:,.
Penn.it#WI0500042 UIC/5A7
ver.· 11/15/2015
Page S of S
WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
Date: 02/02/2017
To: Shristi Shrestba
Central Office Reviewer
Permit No. WI0500042
County: Wake
Permittee/Applicant: Jonathan & Tara Cage
Facility Name: Cage Geothermal Well
I, GENERAL INFORMATION
1. This application is (check aft that apply): ❑ New ® Renewal
0 Minor Modification D Major Modification
a. Date of inspection: 11 /17/2017
b. Person contacted and contact information: Tara Gage. tn� g, orn-9 L -271]7
c. Site visit conducted by: Laura Robertson Elliott & Zachary Thom€
d. Inspection Report Printed from B1MS attached: 0 Yes ® No
e. Physical Address of Site including zip code: 1230 Mordecai Drive. Raleigh. NC 27604
f. Driving Directions if rural site and/or no physical address:
g. Latitude: 35.746196 Longitude: -78.631002
Source of Lat/Long & accuracy (i.e., Ooogle Earth, GPS, etc.): Gooele Earth
1.of
IL DESCRIPTIONOFI INJECTION WELL(S) AND FACILITY �q � �
® Geothermal Heating/Cooling Water Return8
��
❑ In situ Grotmdwater Remediation 2Qa♦$
ElNon-DischargeGroundwater Remediation �afonaW0"9'
❑ otations ' Other (Specify: __,_
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system:
Were samples collected from Influent/Effluent sampling ports? ® Yes ❑ No.
Provide well construction information from well tag: No Well TagVjjb1e.
b. Does existing or proposed system use same well for water source and injection? ❑ Yes ® No
1f NQ, please provide source/supply well construction info (i.e., depth, date drilled, well contractor,
etc.) and attached map and sketch location of supply well in relation to injection well and any other
features in Section IV of this Staff Report.
3. Are there any potential pollution sources that may affect injection? ❑ Yes ® No
What is/are the pollution source(s)?
What is the distance of the injection well(s) from the pollution source(s)?
4. What is the minimum distance of proposed injection wells from the property boundary?
S. Quality of drainage at site: ® Good
6. Flooding potential of site: ® Low
❑ Adequate ❑ Poor
❑ Moderate ❑ High
Rev. 6, l-20I5 Page i

WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
7. For Groundwater Remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. If No,
attach map of existing monitoring well network if applicable and recommend any changes to the groundwater -
monitoring program.
8. Does the map included in the Application reasonably represent the actual site (property lines, wells, surface
drainage)? ❑ Yes ❑ No. If No, or no map, please attach a sketch of the site. Show property boundaries,
buildings, wells, potential pollution sources, roads, approximate scale, and north arrow.
9. For Non -Discharge groundwater remediation systems only:
a. Are the treatment facilities adequate for the type of waste and disposal system? ❑ Yes ❑ No ❑ NSA.
If no, please explain:
b. Are the site conditions (soils, topography, depth to water table, etc.) consistent with what was reported by
the soil scientist and/or Professional Engineer? ❑ Yes ❑ No ❑ N/A. If no, please explain: _
III. EVALUATIONAND RECOMMENDATIONS
I. Do you foresee any problems with issuance/renewal of this permit? 0 Yes ® No. If yes, explain.
2. List any items that you would like WQROS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
r- Item 1 Reason
l-- ]
3. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition
4. Recommendation
0 Deny. If Deny, please state reasons:
❑ Hold pending receipt and review of additional information by regional office
❑ Issue upon receipt of needed additional information
® Issue
-
Reason
5. Signature of report preparers):
Signature of WQROS Regional Supervisor:
Date:
Rev. 6. 12015 Page 2

WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
IV. ADDITIONAL REGIONAL STAFF REVIEW COMMENTS/ATTACHMENTS (If Needed)
- The well is protected by a large well cover. The pad is not in the greatest condition, which calls the casing
integrity into question. See photos.
- The homeowners' water supply is from City of Raleigh; they do not drink from this MC well.
- The red valve used to collect the effluent sample had previously been broken, but completely snapped off
when trying to turn the broken piece at this inspection. The plastic valve needs replacing whenever the next
maintenance is conducted on the well.
- Total colifarm bacteria was detected in both the influent and effluent samples on 11/17/2017. The RRO
recommends having a licensed well contractor inspect the casing for any cracks or areas in need of repair, then
having the well disinfected and sampled again after disinfection for total coliform bacteria.
Rev. 6 1 2015 Page 3

4
el .L11gj1
toc. Oasts': 1•:3Q MORDECAI ORi1E•INFLUENT
%crrrrt1 1f'ie4 . CalieCt.r L RCA RTSCN c'+'+:1.io
Prian PRO Hcpc:rs -in RRO Locarrcn ID SP992WpQS05042
r rr.t e35+r+ µEli$'€ Co!4ect Date 1111712011 Prmr V COMPL1ANCF,
C17;eroenc, 0.4:1IEt1 Tisre 04:2,5 S b1 a 7.131:,7 GROUNDWATER
Ce:w: res r1;1 5em;.le iZesll 1 Le: Type Wator 5t0W Fy
Final Report
North Carolina 1)ivi5ion of V ucr R04)1.11'10, Water SctciicOs Section Laboratory I{r:stills
:amp#IID ACa4a51
PO •lured►„ra
Damrote.e.c: 11,2rr2a7
Teen, RaSe.vtd
Wneforlcs lcgre10 MSWiFT
Dettory:Ached Harrdi7elivefeiJ
FtraI Rapers Date 1f22118
Peper1 Pt.nl L) k aI12272010
It this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
CAS Anafy,e Namq Pre.
Sample tempetatu+e al receipt by tab
Result/
LAB
8.3
Units
.c
IUlethod Analys.
Peferenco Date
rt.r7 F3AL!Trt1EP
M1C
Co1Iform, MF Fecal in liquid 1 1 B2 tuF p1-5-,.q-1 sm s.2.'..' 0.101: 11s17r17 ESrAPPOnu r
Coilioun, MF Taal in liquid 1 9 CFy+ts307;11 SNI i'f22: 6-19s7 : E,l%;17 E9TAFFORi)1
NUT
NO2•NO3 as N In liquid C032 2.3 as r: 5PA7353, PE1r 2 11?2.14=17
WET
Bromide 0.4 0.4 i! EPA' tide, re:21 11 1 71 CGP.£EN
C711b iree
?.1 25
n1Fj L
EPA1000 rau:.1 11117,1'
t�GFc��7
Fluoride
U -r,t.l EPA 300 i re+11
1f•:,1- CGREEN
SUIlate
2,0 26
ETA 300 0 ser2 1 1(!-7 ?
Taial Dissolved Soi;ds in itquid 12 200 na 1 spa 3», C"Ian€ 1,r; :GREcr1
MET
7425-9Lt5 Al by ICP 50 50 U
1i:PA2C0.7-P.ev4,1 .11`2707 ESTAFFCP.b:
744."7C•2 Ca by ICP 0.10 31 ngjr P .200.7 17.41 it 11 ze 1T E574FFORO's
T.140 '•g ✓w=d by ICPMS
0 50 0.50 U ug'l :CC d Pev5 4 l i 22 1i EEr*FFr1.-Dt
7447-•47.3 Cr by ICPMS 5,0 5.0 U eig . tE-PA R.;v13 4 71 28 17 ESTAFF•a?b:
744''50,3 Cu by ICPMS
2.0 100
u¢;l
gPA.CGQ a aty5: I1;2? 1i ESTAr`FORDI
is .3-ss4 Fe by 'ICP 50
50 U ugE
EPA:[1O 7 ae'r'a 4 t 1:2717 ES;riFFO:r?DI
7140-05.7 K by ICP
0 10 3.3
regt
EFh209: Fev4-t 11.2e417 E57f.FFCROs
.439.a5.J Mg by 1CP
0.10 9.8
01VL
EPA :E307 I?avrz a 112a 17 ESTA;,FCI '
74313•9G•S Mr, by ICP
10 10U
011_ EPA:00; F:syss - 112: 17 EStAFFO?:t01
7440.23•5 Na by ICP 0.10 14 6?L EPA 2007 Re01 s 11 :3r17 ES-AFFOrRDi
7440-G2 0 N•i by ICPMS
21 uq'l CF„2_00as1ci5,4 11,2377 ESTAFFFOr"k,01
7?.39-92.1
Pb tsy ICPMS
,0 2.0 U
ua'L
EP 2006Re•.54 112> li EStAFF0R01
7441- f-:
Zn by ICPMS
1a 17 ¢71L EPA2r:t] 8 R.r5.; 112s i7 ESTAFFOR,.01
iNSS Chernlglry Latlnralcry' 16_2.1 Mail 3erv1cc Cotner, Ratelair. fit 27629. r623 1919) 733.3109
"Nei Oe•ecli rr -tl dots notify! cafe U a I,srrt;M? r 1 aesyt'fee but tr1Dl +hC . na1}1a Inn! crctcCtt•t7 at ❑r a31t,t1 Sit PQL
Paget or

41:1.18s�
North I al-j11111_l I)15 isi in 11 al L'i 4 Ienc s ithitr ti ry i{t uJj.
C.ae0rfer tNOMtPNiJECAI',Ze;lvt.eFFLIJ-Jrt
Caur*/ & n Cliac":- L P69ER t^,}li UPI •
Re; -p RAG Fesc . to PRO :.1r. it • SPfrg:Y4ID n0r}.14
R rm. ps►n 1NE1.15E c^InC:lr Ilttrr7ry'r :0., r comALIANCE
merg y r,.r.4 r Time 99.4Q .. ..11y,,r :r GPOUNDVJAtect
rJ'. Yet. ti S:1rn[ve Cars W11.4 4uplJ
Final Report
3rrprelU AC44852
Po IJ4rr.ypi p
z sre P4ce tics 1trly12011
.tb
ul...=n • L J,n11i MSW FT
i1?Irverr Nahlalf.Nanrl anitrrnrvd
.1440enpartOak, IO2Z14
Megan Fp,nl :lair 12t%7,i)701
ftthls iepart is ►nbrlrtlpretrminiry',part, the t' uttS haye .i¢t boeJti v.sltrblvet. i3++ lint else (or Pegulaterypurposes.
CA$ I. At' IY1. 'ialn
,-,
Feson
Et, Uu cLlia
LAE
Sample temf ratule ai 14rs +pi ty 12b 5.3
Units
Metrrad i+n3t't5i3
F7eteren,:e Date in=d IB tr
•i. l.lr .uT1IE-
Ml IC
Cc:l form. MF Feczl ,n liquid 1 t ei2
Copt form h1F Twat rn liquid 1 21 = 't .1 t ' in7; 7
NUT
NO2 • NOS 3s N m l,gwrd 0 012 2. T tea' P.
WEF
Bromide 0 4 _ 0_4 LI loo.0 - s7
OnioTeJe 10 25 1,117i17
F1uaritle fj .i 0.4 U F•'L .0 real
Salfaie 2 0 26 rev2.S
.Taal D:sso[aed Sam in flit.rn
207
r129-n
Ai by ICP
5Cr
MET
50 U
tig:L
Co7t ty /CF 0 1D
30 R'= -
- .:1.11.5 fd lay ICPMS 0 90 0.S0 Ll nit
74'041.1 Cr by ICPMS 5.0 5.0 U t'9'i. EPA - -"t. s 1:,
:44D•5r-L4 CU by ICPMS 2 0 200 u - 20 <'<5.,. 11Jzeri-
7.473•4?•B Gn Dy IC50 50 U .4.= 1F
;�39.95 t FJig by ICP
0 10 9.7
1-=39.95•6 Mn by ICP
At
STAFFGR
1.0 1.. c r3= Ji'' Fs::,s 11.,2 117 '
7+46•2;-5 Na by ICD
Q.1[ 35
744C-82 n Ni by 1CFNMS
2'
1439.92.0 pb by IC1'FM!S ...
Zn by ICPMS
CI
4 %1f28it7 :: r c rr._'r-
Id •v5.
3u5.4 J •
�7u: r1.'initlr{ LaDcoxIPri>-• It.71 l.lsri error: r, to orrrer. H3+.6:„ r.++: 77e-r1 15e j1V1 711 14r:

WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW· REQUEST FORM
Date: October 9, 2017
To: Rick Bolich -Laura Robertson
From: Shristi Shrestha, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0500042
A.
B.
C.
A pp licant: Jonathan B & Tara B. Cage
Facillty Name:
A pp lication:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
_I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 30 calendar days,_please return a com pleted W OROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: _________________ Date: ____ _
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 092614 Page 1 of 1
pzz
Water Resources
Environmental Quality
October 9, 2017
Jonathan B. & Tara B. Cage
1230 Mordecai Drive
Raleigh, NC 27604
RE: Acknowledgement of Application No. WI0500042
Geothermal Heating/Cooling Water Return Well
Wake County
Dear Mr. and Mrs. Cage:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
S. JAY ZLMMERMAN
Director
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and change of ownership application received October 4, 2017. Your
application package has been assigned the number listed above, and the primary reviewer is Shristi
Shrestha
Central and Raleigh Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Water Quality Regional Operations Section
(WQROS) requests your assistance in providing a timely and complete response to any additional
information requests.
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. If you have any questions, please contact Shristi
Shrestha at 919-807-6406 or email at Shristi.shrestha[rncdenr.gov.
Sincerely,
Ofiweake
For Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch Division of Water
Resources
cc: Raleigh Regional Office, WQROS
Permit File WI0500042
; ! I Co/ [r1/4.
State of North Carolina i Environmental Quality R Division of Water ResoUuees
Water Quality Regional operations Section
1636 Mail Service Center 1 Raleigh, North Carolina 27699-1636
919-707-9129

RECEIVED/NCDEQIOWR
N th C I. n rt t r E · t I Q 1·ty n· · · · r w t R OCT ~ ·4, 2017 or aro ma . epa men . o nVU'onmen a ua 1 -1vis1on o • a er · esou-rces
e r ua ity
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION~~ratio s Section
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN ·WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application /Renewal*_. __ Modification __ Permit Rescission Request*
*For Permit Renewals or Rescission.Request, complete Sections A thru E, and M (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: ~l,,_ /5 ,20 tf-PERMITNO. i.l.Jl.050QQ:J:;!... (leaveblankifNewApplication)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New WelVPerinit Application)
1. Current Use of Well
a. I wish to continue to use the well as lk(Geothermal Well D Drinking Water Supply Well
D Other Water Supply Use-Indicate use (i.e., irrigation, etc.) ________ _
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy ofthe Well Abandonment
Record (GW-30).
D Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ~S D NO
If yes, indicate New Owner's contact information:
Name(s) J. o n ~a"' 6 C"'Je a-rvf, fa,,,-":-B. (_hj e..-
Mailing Address: / 2:30 M»rd.Rco. .. J () r \,UL,
City: R..al ~jb,, State: NC. Zip Code: .J.r}o Of County: W 4.-k.tz._,
DayTeleNo.: '1l'1,-~?-1-/C/Cj f: EmailAddress.: +a~a.Ca jJ2._fZ J l7l.al.R, Conv
B. STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence ✓ Business/Organization __
Government: State Municipal__ County__ Federal
C. WELL OWNER(S)/PERMIT APPLICANT -For single family residences, list all persons listed on the
property deed. For all others, list name of business/agency and name of person and title with delegated authority
to sign: .. ~ o .--. o....:h:--"""' 6 . C' ~ i T 0,;v-t:1.. B . Ca_1"----
Mailing Address: \ 2 ~0 Uo~ctU J)r \l,;Q.,
City: R ,J~ I,,,., State: lJJ;,zip Code: ,;),J1&b,f County: l..LJ nJ<:e ,.
Day Tele No.: q \4 -~1:1 'I q Cf -l: Cell No.: qi 9 ... B 51-~ 3 / B q
EMAIT.,Address: ±lLY&\.C...O..._B~~ 8VVllua .. Cvr:hfaxNo.:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 1
D. WELL OPERA TOR (if different from well owner) -For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
to sign: ____________________________ _
Mailing Address: ______________________________ _
City: ____________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: ______________ _____;E=m=a1=·1--=;._A=d=dr=e=s=s.'-'--: ___________ _
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: I Jo~ CJ 4 3:1 lo\ County: {J) iv\< <2,_,
(2) Physical Address (if different than mailing address): _______________ _
City: ____________ County _________ Zip Code: ____ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
R~c.e,\ V ,2.d. / DEN R..../ [) WQ_ Y: / 1-,/ u,' 2,
Aq w[~ fnb,~ ~
CompanyName: ('s -~yi OY\ c.U C!f>¢1 e-~)
Contact Person"--: _______________ EMAIL Address: __________ _
Address: _________________________________ _
City: _________ Zip Code: ____ State: __ County: ________ _
Office Tele No.: Cell No.: Fax No.: ________ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: ___________________________ _
NC HVAC Contractor License No.: ________________________ _
Company Name: _______________________________ _
Contact Person: EMAIL Address: --------------------------
Address: ----------------------------------
City: _________ Zip Code: ____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ----------------
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES __ _ NO __ _
YES __ _ NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS -As specified in 15A NCAC 02C .0224 (d):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page2
(a) For screen and ·gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface; ·
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
____ *EXISTING WELLS ____ PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
( e) Grout material( s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107({)(8)
(t) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATINGDATA
(1) Injection Rate: Average ( daily) gallons per minute (gpm).
(2) Injection Volume: Average ( daily) gallons per day (gpd).
(3) Injection Pressure: Average ( daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP-As specified in 15A NCAC 02C .0224(b)(4), attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area loca~ed within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15ANCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which.the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 3
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand Also, a layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that persons authorized agent)
15A NCAC 02C .0211(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2, for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the person(s) listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, 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."
n Fi
Print or Type Full Name and Title
;12lr
Signature of Property Owner/Applicant
Print or Type Full Name and TitPe
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev, 4-15-2016 Page 4

GEOTHERMAL HEATING/COOLING WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxes. Fill in depths below land surface (BLS) and
details of well construction on the blank tines provided. Use additional sheets as needed.
Open -Hole Well Design
Proposed ❑ Existing
❑ Injection; ❑ Supply;
❑ Dual Purpose
I1and Surface
Record Depths Below
Lind Surface (BLS)
on Lines Prodded
i
Bottom of casing
(Ft. BLS)
}
(Ft.)
Screened Well Design
E Proposed ❑ Existing
❑ Injection; ❑ Supply;
❑ Dual Purpose
Return or Supply Line
Casing
Total Depth
(Ft. BLS)
Grout
WELL DETAILS
Casing Material:
Casing Diameter (in.):
Grout Type:
Grout Depth (BLS):
Top of Bentonite Seal (if present):
Bottom of Bentonite Seal
Screen Material:
Screen Slot Size (in.):
Sand/Gravel Pack
Material Type:
Bedrock
Open Hole
Bentonite Seal
(if present)
Sand/Gravel Pack
Screen
(Ft.)
Record Depths Below
Land Surface (BLS) on
Lines Provided
1
(FL BLS)
(FL BLS)
Bottom of casing
(Ft. BLS)
(Total Depth
Ft. BLS)
NC Certified Well Driller Name: Certification No.:

North Carolina Department of Environmental Quality
Division of Water Res_ources
PERMIT NAME/OWNERSHIP CHANGE APPLICATION FORM
I. INSTRUCTIONS
1. Complete this form in its entirety as follo~s:
( a) Change of Ownership -Provide the information in Parts II and III and submit legal documentation of the
transfer of ownership such as a contract, deed, _article of incorporation, etc~ The certifications in part IV
must be signed by both the current permit holder, if available, and the new applicant(s). ·
(b) Name Change Only-Provide the information in Parts II and III. Sign the certification for the new
· applicant in part IV ;2. ·
2. Submit the properly completed form to the address on bottom of Page 2.
II. CURRENT PERMIT INFORMATION
1. Permit Number: /JJJ0500Q t../:2
2. Permittee riame(s): MI' ~s · C'.-t,vv! ~V\V\ f 5. tiJ· 1 ) ,·s Sr ·
3. For Business/Governmental Agency-Permit signing official's name and title: ________ _
(Person legally responsible for permit)
4. Mailing Address: \ 2 ~ 0 Mo r k ~ ..Dv-t\.A....J
a~ R ~~~~ s~: Ne ~= ~t 0o q
telephone number: (9 \ 4 ) J.. 11 --19 Of 3: Fax number: ~ ____ _
EMAILAddress: ±a.v-(A.~ _e <c)M OJ'.{,. en~
S. Physical Address ofWell(s) (if different than mailing address)
City: ____________ County: ________ Zip: _____ _
ID. NEW OWNER/ NAME INFORMATION
1. This request . for a permit change is a result of:
~ Change in ownership of property/company
_b. Name change only
_ c. Other (please explain):
Permit/Name Change of Ownership Form Rev. 3-1-2016 Page 1
2. New Owner's name(s) as listed on the property deed (Please Print/or Type):
❑ Y1 C.�IGt • tr C��Q..
e
0.4.101
3. If Business or Governmental Agency- Permit signing official's name and title:
(Person legally responsible for permit)
4. Mailing Address: 1 2.`a o +vl0rcl4Cc:J i"+r'u_' _.
City: f kd i. r State: rJ <L Zip: 1 0 1
DaylCell Phone No. (`I i 9 ) 7 i IT / } Fax number: ( )
EMAIL Address: ÷ 0.1-GtrC-a e 4yUI CI_ .1c • Cam• __
IV. CERTIFICATION
I. Current Permittee's Certification (Please print or type):
I, 1'A i v -- T&.v vi s Fattest that this application for name/ownership change has been reviewed
and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information and attachments are not included,
this application package will be returned as incomplete. I understand I will continue to be responsible for
compliance with the current permit until a new permit is issued.
2. New Applicant(s)'s Certification (Please print or type):
I/We, 1.4 vt .) c c� [ c�4- , attest that this application for
name/ownership change has been reviewed and is accurate and complete to the best of my knowledge. I
understand that if all required parts of this application are not completed and that if all required supporting
information and attachments are not included, this applica ' n package will be returned as incomplete. I further
certify that I will operate and maiilain the permitted fay in accordance with the permit and related regulatory
requirements.
Signature: _
Signature: - ,!2 t
de 6 __ ,
Date: / // .7/ L
Date:
/ 5/ / 7-
SUBMIT THE COMPLETE APPLICATION PACKAGE VIA ONE OF THE FOLLOWING METHODS:
U.S. Postal Service:
Water Quality Regional Operations Section
NC Division Of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
Courier / Special Delivery / In Person:
Water Quality Regional Operations Section
NC Division Of Water Resources
512 North Salisbury Street
Raleigh, NC 27604
TELEPHONE NUMBER: [phone]
Permit/Name Change of Ownership Form Rev. 3-1-2016
Page 2

rt
m
ru
ET"
rL
ET'
0
C7
n
Total Post(
U.S. Postal Servicer,.r
CERTIFIED MAIL, RECEIPT
(Domestic Mal Only; No Insurance Coverage Provided)
For del ery Information visit our website at www.usps.comi?.
ru
Q
Postage
Certified Fee
Return Reoelpt Fee
(Endorsement Required)
Restricted Delivery Fee
(Endorsement Required)
sentrn Jonathan B & Tara B Cage
-BfAr,_?,1234 Mordecai Dr.
orPosoxNRaleigh, NC 27604-1343
C State, 2
Postmark
Here
ER: COMPLETE THIS SECTION
;ompiete items 1, 2, and 3. Also complete
.tem 4 if Restricted Delivery Is desired.
Print your na_ to and t'I.ddress on the reverse
so that we can return the card to you.
• Attach thls card to the back of the maiipiece,
or on the front if space permits,
1. Article Addressed to:
Jonathan B & Tara B Cage
1230 Mordecai Dr.
Raleigh, NC 27604-1343
COMPLETE THIS SECTION ON DELIVERY
A. Slgnatu
0 Agent
VJ0 Addressee
e
D. is delivery address ...erent from Item 1? • Yes
If YES, enter delivery address below: 0 No
3. Service Type
❑ Certified Mail
❑ Registered
0 Insured Mail
❑ Express Mail
❑ Return Receipt for Merchandise
0 C.Q.D.
4. Restricted Delivery? (Extra Fee)
0 Yes
2. Ardcie Number
(Transfer from service label
7012 1640 0000 9792 3186
PS Form 3811, February 2004
Domestic Return Receipt
t 02595-o2-M-1540

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
Water Resources S. JAY ZIMMERMAN
Environmental Quality Director
September 1, 2017
CERTIFIED MAIL # 7012 1640 0000 9792 3186
RETURN RECEIPT REQUESTED
Jonathan B & Tara B Cage
1230 Mordecai Dr.
Raleigh NC 27604-1343
Subject: Notice of Expiration (NOE)
Geothermal Water ReturnlOpen-Loop.Injection Well
Permit No. WI05000442
Wake County
Dear Mr.& Mrs. Cage.,
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) 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
geothermal injection well system located on your property at the above referenced address was
issued on May 11, 2012, and expired on April 30, 2017. Per permit conditions and requirements
per 1 5A NCAC 2C .0224(c), the renewal application must be submitted at Ieast 120 calendar days
prior to expiration of the permit if you wish to continue operating the injection well on your
property.
If Your Geothermal Water Return Well is Still Currently Being Used for Injection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells - Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
bttp://portal.ncdenr.org/web/wglaps/gwpro/permit-applications.
'Nnr h11 . Corr pa
State of North Carolina J Environmental Quality 'Division of Water Resources
Water Quality Regional Operztianm. Section
1636 Mail Service Center I Raleigh, North Carolina 27699-1636
919-747.9129

If Your Geothermal Water Return Well is NO LONGER Beim Used for Infection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply welt, irrigation well, inactive, plugged and
abandoned, etc.). If it 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
.0240. When the well is plugged and abandoned, a 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:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. 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 shristi.shrestha(lncdenr.gov.
Regards,
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Raleigh- Regional Office — WQROS w/o enclosures
Central Files - Permit No. WI0500042 w/o enclosures

m
ru
m
1640 0000 9792
ru
r-R
U.S. Postal Servicerr,
V_RIJFIED MAIL-;.t RECEIPT
( omest Mail Only: No Insurance Coverage Provided)
For delivery information visit our website at www.usps.com,
J S E
Postage
Corned Fee
Return Receipt Fee
(Endorsement Required)
Restricted Delivery Foe
(Endorsement Required)
Total Postage
sow To Mims & Tannis Hillis
31;v;,10.;- 1230 Mordecai Dr.
wPDa"0. Raleigh, NC 27604-1343
City, SUN, Z/P4
Poelmedi
Here
PS Form 3SOO August 2QV __ See Reverse for Instructions

ROY COOPER
{
Governor
Environmental
Quality
January 17, 2017
CERTIFIED MAIL # 7012 1640 0000 9792 3032
RETURN RECEIPT REQUESTED
Mims & Tannis Hillis
1230 Mordecai Dr.
Raleigh, NC 27604-1343
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0500042
Wake County
Dear Mr. & Mrs. Hillis:
WILLIAM G. ROSS, JR.
Acting Secrelary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) 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 gate. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on May 11, 2012, and expires on April 30, 2017. Per permit conditions and requirements
per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120 calendar days
prior to expiration of the permit if you wish to continue operating the injection well on your
property.
If Your Geothermal Water Return Well is Still Currently Being Used for Infection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Perrnit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http:llportal.ncdenr.orglweblwglapslgwprolpermit-applications.
If Your Geothermal Water Return Well is NO LONGER Being Used for Infection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.).
'"`Not fit. Compare
State of North Carolina I Environmental Qujity I Division of Water Resources
Water Quality Regional Operation' Section
i 636 Mail Service Center I Raleigh, North Carolina 27699-1636
919-707-9129

If it is no longer being used for any purpose, it must be permanently abandoned according to the
regulatory requirements listed under NCAC Title 1 5A, Subchapter 2C, Section .0240. When the
well is plugged and abandoned, a 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:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. 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 shristi.shrestha(iv,nedenrgov.
Regards,
WWAyegyfa
Shristi Shrestha
FHydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Raleigh- Regional Office — WQROS w/o enclosures
Central Files - Permit No. WI0500042 w/o enclosures

6Al -AVA
MCDEMR
North Carolina Department of Environment and Natural Resources
lk L'rl ~ I::\\ L""' Perdue
( 11 'llt I
MEMORANDUM
Division of Water Quality
Charles W akild, P. E
Director
August 24, 2012
Dee Freeman
Secretary
To: Michael Rogers, The Central Office, APS
Through: Jay Zimmerman 5~
From: Lin McCartney
Subject: Analytical Result Report-WI0500042, Mims Hillis,
Geothermal Heating/Cooling Water Well
Wake County
,1 ,1 ·, Protection Section
I \ l.11 '-.~ • , ~ c 11L 1. Raleigh, North Carolina 27699-1628
l..ccat.ion: 3800 Barrett Dr., Raleigh. North Carolina 27609
, I 1 2 II • 1 • I 1 I
lmcrnci: www.ncwaten ualit '.Orb!
11 I 1'1, Opportunity\ Affirmative Action Employer
RECEIVEDIDENRIDWQ
AUG 2 8 2012
Aquifer Protection Section
One .
North Carolina /yaturallu
A7A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P. E Dee Freeman
Governor Director Secretary
August 24, 2012
Mims and Tannis Hillis
1230 Mordecai Drive
Raleigh, NC 27604
Subject: Permit No. WI 0500042
Geothermal Heating/Cooling Water
Well
Wake County
Dear Mr. Hillis,
Enclosed please find the analytical results of the subject well water which was sampled on March 25,
2012. The feeding (groundwater entering heat pump) and the returning (water being injected into the
well) of the geothermal well system were sampled.
All the parameters, which were analyzed, were in compliance with the 2L Groundwater Quality
Standards except iron. The iron concentrations were 2300 micro grams per liter (ugll) for feeding and
1600 ugll for returning. These results indicate that the iron concentration was elevated above to the 2L
Groundwater Quality Standards of 0.3 ppm (300 ug/1). Elevated levels of iron in water can impart a
rusty color, produce sediment, impart a metallic taste and cause reddish or orange staining of plumbing
fixtures and laundered items. Although aluminum concentrations were high also (1300 ugll for feeding,
950 ug/1 for returning), aluminum is not regulated under 2L Groundwater Quality Standards.
If you have any questions, please contact me at [phone].
Sincerely,
b1 (ark h Qy
Lin McCartney
Environmental Senior Tech
Cc: RRO-APS Files
A.{uitc:: { roueliun Section
1628 Mall Service Center. Raleigh, North Carolina 27699-162E
Lozatina: 3800 Berrett Dr., Raleigh. Ncnh Caroline 27609
Phnrte 919.791-420O 1 FAX. 419-. 71-47i R
Internet: vveywjtrry}lalitk,Qry,
an Equal Opportuntry 1 Aftirmsuve Acion T mbf .yef
None
rthCarolina
jVaturallg

D`f't'O Laboratory Section Results
County WAKE
River Basin
Report To RROSP
Collector' L MCCARTNEY
Region: RRO
Sample Matrix: GROUNDWATER
Loc. Type WATER SUPPLY
Emergency Yes/No
COC Yes/No
iY+6ArA-
Q++- .Pam�.
,_Q.
a _-+
Q ", 'V
VisitlD
Loc. Descr.: MIMS HILLIS
Sample ID: AB82917
PO Number # 12G0319
Date Received: 0412512012
Time Received: 13:35
Labworks LoginID DLEAVETr
Report Generated: 5/29/12
Date Reported: 08/16/2012
Location ID: 5P092W10500042_FEED
Collect Date: 04/25/2012
Collect Time: 12:30
Sample Depth
CAS #
LAB
Analyte Name
Sample temperature at receipt by lab
POL
Result/
Qualifier
1.6 "C
Units
Method Analysis Validated by
Reference Date
4/25/12 DLEAVITT
M!C
Coliform, MF Fecal in liquid
1 1 B2
CFt11100m1 APE-1A9222D-20th 4/25/12 ESTAFFORD1
Coliform, MF Total in liquid
1 1B2
CFU/140ml APHA9222B-20th 4/25/12 ESTAFFORD1
WET
Ion Chromatography
TITLE mg/L EPA 300.0 5/3/12 CGREEN
Chloride
1.0 25 mg/L EPA 300,0 5/3/12 CGREEN
Fluoride 0.4 0.4 U mg/L EPA 300.0 5/3/12 CGREEN
Sulfate
2.0 24 mg/L EPA 300.0 5/3/12 CGREEN
Total Dissolved Solids in liquid 12 206 rng1L APHA2540C-18TH 5/1/12 CGREEN
NUT
NO2+NO3 as N in liquid
0.02 2.8
mg/L as N Lac10-107-04-1-c 4/25/12 CGREEN
MET
7429-90-5 AI by ICP 50 1300 ug/L
EPA 200.7 5/15/12 ESTAFFORDI
7440-70-2 Ca by ICP
0.10 35 mg/L EPA 200.7 5/15/12 ESTAFFORD1
7440-47-3 Cr by ICPMS
10 10 U ug/L EPA 200.8 513/12 ESTAFFORD1
7440-50-8 Cu by ICPMS 2.0 550 ug/L EPA200.8 5/3/12 ESTAFFORD1
7439-89-6 Fe by ICP
50 2300 ug/L EPA200.7 5/15/12 ESTAFFORD1
Hardness by Calculation
1.0 130 mg/L SM234OBEPA 200.7 5/15/12 ESTAFFORDI
7440-09-7 1C by ICP 0,10 4,3 mg/L EPA200.7 5/15/12 ESTAFFORD1
7439-95-4 Mg by ICP
0.10 11 rng/L EPA 200.7 5/15/12 ESTAFFORDI
7439-96-5 Mn by ICP 10 63 ug/L EPA 200.7 5/15/12 ESTAFFORD1
7440-23-5 Na by ICP
0.10 15 mg/L EPA 200.7 5/15/12 ESTAFFORDI
7440-02-0 Ni by ICPMS
2.0 49 ug/L EPA 200.8 5/3/12 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0
2,5 ug/L EPA200.8 5/3/12 ESTAFFORD1
7440-66-6 Zn by 1CPMS 10 47 ug/L EPA200.8 5/3/12 ESTAFFORDI
Laboratory Section» 1623 Mall Service Center, Raleigh, NC 27699.1623 [phone]
For a detailed description of the qualifier COdeS refer to i.ittp'+1i.nrca ncOnr,nrg J .:,I;rya =Code}enttEdpnrol.nrlanr.erg4wa6�11ablaf nfairerhaq',
Page 1 of 1

WT''D%I% la6oraton1Sectfon .Results
County WAKE
River Basin
Report To RROSP
Collector: L MCCARTNEY
Region: RRO
Sample Matrix: GROUNDWATER
Loc. Type: WATER SUPPLY
Emergency Yes/No
COC Yes/No
Sample ID: AB82918
q'C �' R rE9 PO Number # 12G0320
Date Received: 04/25/2012
-.4 DWC1"5,-.
j i Time Received: 13:35
C N Labworks LaginlD DLEAVITT
Report Generated: 5129112
Date Reported: 08/15/2D12
VisitID
Loc. Descr.: MIMS HILLS
Location ID: 5P092WI0500042_666111- ekL L'oilect Date: 04/25/2012
Collect Time: 13:00
Sample Depth
CAS # Analyte Name
LAB
Sample temperature at receipt by lab
PQL
Result/
Qualifier
1.6
oC
Units
Reference Date
Method Analysis Validated by
4/25/12 ❑LEAViTT
M I C
Coliform, MF Fecal in liquid
1 1 62
CFU1100ml APHA9222D-20th 4/25/12 ESTAFFORD1
Coliform, MF Total in liquid
1 1 62
CFU1100m1 APHA9222B-20th 4125/12 ESTAFFORD1
WET
Ion Chromatography
TITLE mg/L EPA 300.0 5/3/12 CGREEN
Chloride
1.0 24 mg/L EPA 300.0 5/3/12 CGREEN
Fluoride 0.4 0.4 U mg/L EPA 300.0 5/3/12 CGREEN
Sulfate
2,0 24 mg/L EPA 300.0 5/3/12 CGREEN
Total Dissolved Solids in liquid 12 202 mg/L APHA2540C-18TH 511/12 CGREEN
NUT
NO2+NO3 as N in liquid
0.02 2.9
mg/L as N Lac10-107-04-1-c 4/25/12 CGREEN
MET
7429-90-5 Al by ICP 50 950 ug/L EPA 200.7 5/15/12 ESTAFFORDI
7440-70-2 ca by ICP
0.10 34 mg/L EPA 200.7 5/15/12 ESTAFFORDI
7440-47-3 Cr by ICPMS 10 10 U ug/L EPA 200.8 5/3/12 ESTAFFORD1
7440-50-8 Cu by ICPMS
2.0 520 ug/L EPA200.8 5/3/12 ESTAFFORD1
7439-89-6 Fe by ICP
50 1600 ug/L EPA 200.7 5/15/12 ESTAFFORD1
Hardness by Calculation
1,0 130 mg/L SM2340BEPA200.7 5/15/12 ESTAFFORD1
7440-09.7 K by 1CP
0.10 4.0 mg/L EPA 200.7 5/15/12 ESTAFFORDI
7439-95-4 Mg by !CP
0.10 10 mg/L EPA 200.7 5/15/12 ESTAFFORDI
7439-96-5 Mn by ICP
10 51 ug/L EPA 200.7 5/15/12 ESTAFFORDI
7440-23-5 Na by ICP
0.10 15 mg/L EPA 200.7 5/15/12 ESTAFFORD1
7440-02-0 Ni by ICPMS
2_0 49 ug/L EPA200.8 5/3/12 ESTAFFORDI
7439-92-1 Pb by ICPMS
2.0 2.2 ug/L EPA 200.8 5/3/12 ESTAFFORD1
7440-66-6 Zn by ICPMS
10 41 ugrL EPA200.8 5/3/12 ESTAFFORD1
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 2769941623 [phone]
Far a detailed descnption of the quaLif er COtles refer to hry�Ihe.,nr1,ncdnnr.nrg,l.•:_•::.;:..• • .r°s tncnnn;grNpara rau,tif..r arlwr eht1011Lmnal.nafAnr.9MrV+AI wglltihMaftir4/tnehasslnt:,
Page 1 of 1

Permit Number WI0500042
Program Category
Ground Water
Permit Type
Injection Heating/CooHng Water Return Well (5A7)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Mims & Tannis Hillis, Jr. SFR
Location Address
1230 Mordecai Dr
Raleigh
Owner
Owner Name
Mims
Dates/Events
NC 276041343
Hillis
Scheduled
Orig Issue
06/27/02
App Received Draft Initiated Issuance
04/02/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
05/17/12
Permit Tracking Slip
Status
Active
Project Type
Renewal
Version
3.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mims Hillis Jr.
1230 Mordecai Dr
Raleigh NC
Public Notice Issue
05/11/12
Effective
05/11/12
Re g uested/Received Events
RO staff report requested
RO staff report received
276041343
Expiration
04/30/17
04/11/12
05/03/12
Waterbody Name Stream Index Number Current Class Subbasin
Permit Number WI0500042
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Mims &·Tannis Hillis, Jr. SFR
Location Address
1230 Mordecai Dr
Raleigh
Owner
Owner Name
Mims
Dates/Events
NC 276041343
Hillis
Scheduled
Orig Issue
06/27/02
App Received Draft Initiated Issuance
04/02/12
Regulated Activities
Heat Pump Injection
Outfall MULL
Central Files: APS_ SWP_
05/07/12
Permit Tracking Slip
Status
In review
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mims Hillis Jr.
1230 Mordecai Dr
Raleigh NC
Public Notice Issue Effective
Re guested/Received Events
RO staff report requested
RO staff report received
276041343
. Expiration
04/11/12
05/03/12
Waterbody Name Stream Index Number Current Class Subbasin
ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
-~ __ Beverly Eaves Perdue Charles Wakild,-~E. ___ -___ ]~e freeman ____ _
----~ ----Governor
Mims and Tannis Hillis, Jr.
1230 Mordecai Dr.
Raleigh, NC 27604
Re: Issuance of Injection Well Permit
Permit No. WI0500042-
Issued .to Mims and Tannis Hillis, Jr.
Wake County
Dear Mr. and Mrs. Hillis:
Director -~ ---Secretary
May 11, 2012
In accordance with your application received April 2, 2012, I am forwarding Pennit No. WI0500042 for the operation of a
SA 7 geothermal underground injection control (UIC) well heat pump system located at the above referenced address.
This permit shall be effective from the date of issuance until April 30, 2017, and shall be subject to the conditions and
limitations stated therein.
The Raleigh Regional Office collected groundwater samples from your geothermal system on April 25, 2012. After the
laboratory analytical results are received, the results will be forwarded to you by.the regional office.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application to renew
the permit 120 days prior to its expiration date. As indicated in the permit,.this permit is not transferable to any person
without prior notice to, and approval by, the Director of the Division of Water Quality. If you have any questions
regarding your permit or the Underground Injection Control Program please call me at [phone].
Best Regards,
~ !G-;----
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
cc: Jay Zimmerman, Raleigh Regional Office
Central Office File, WI0500042
Wake County Environmental Health Dept.
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.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
Nirth Carolina
/Vaturall!f
_ =NORTH CAROLINA
ENVIRONMENTAL. MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH� NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Mims and Tannis Hillis, Jr.
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 1230 Mordecai Dr., Raleigh, Wake County, NC 27604, and will be constructed and
operated in accordance with the application received April 2, 2012, and in conformity with the specifications
and supporting data, 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 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 April 30, 2017, and shall be
subject to the specified conditions and limitations set forth in Parts 1 through VIII hereof.
Perit issued this the It)
n day of V' "'7r , 2012.
harles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #W10500042
UIC/5A7
var. 03/2010
Page 1 of 5

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (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 sealed with a water-tight cap or well sealed, as defined in G.S. 87-85(16).
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
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). Inthe 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. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
PART III -PERFORMANCE ST AND ARDS
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
Permit #WI0500042 UIC/SA7
ver. 03/2010
Page 2 of 5
..
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Pennittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The 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 -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shail be properly maintained fl!ld 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.
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 m.1rilber 919-791-4200, 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;
Permit #WI0500042 UIC/SA7
ver. 03/2010
Page 3 of-5
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 tha.Cthe-·petmittea-facility--fails to perform satisfactorily, the Permittee shall take such
immediate action aflnaybe required by the · Director.
PART VII -PERMIT RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
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.
(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..
Permit #WI0500042 UIC/SA7
ver. 03/2010
Page 4 of 5
(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 #WI0S00042
Aquifer Protection Section-VIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/SA7
ver. 03/2010
Page 5 of 5
#A
HCDEHR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
MEMORANDUM
Division of Water Quality
Charles W akild, P. E
Director
May 1, 2012
Dee Freeman
Secretary ·
To:
Through:
Michael Rogers, The Central Office, APS
Jay Zimmerman~--
From: Lin McCartney c/ fV\ .
Subject: Staff Report-WI0500042, Mims Hillis, 5A7 Geothermal
Well Renewal Application
Wake County
Aquifer Protection Section
1628 Mail Service Center, Raleigh, North Carolina27699-1628
Location: 3800 Barrett Dr., Raleigh, North Carolina 27609
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterg ualhv.org
An Equal Opportunity \ Affinnative Action Employer
RECEIVED/DENR/OWQ
MAY O 3 2G\Z
Aquifer Protection Section
Nirthcarolina Natura/lg
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: Mayl, 2012
To: Aquifer Protection Central Office
Central Office Reviewer: Michael Rogers
Regional Login No: __ _
L GENERAL INFORMATION
1. This application is (check a11 that apply): D New ~ Renewal
County: Wake
Permittee: Mims Hillis
Project Name: Injection 5A 7 Well
Application No.: WI0S0.0042
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D. Evaporation/Infiltration Lagoon
□ Land Application of Residuals
D Distribution of Residuals
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation ~ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ~-Yes or D No.
a. Date of site visit: 04-25-2012
b. Person contacted and contact information: Mims Hillis, 919-833-0328, 919-810-1440
c. Site visit conducted by: Lin McCartney
d. Inspection Report Attached:~ Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
~ Yes or D No. ff 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: __
RECEIVED/DENR/DWQ
MAY O 3 2012
Aquifer Protection Section
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Disposal and Injection Sites:
(If multiple sites either indicate which sites the information applies to, copy and paste a new section into the
document for each site, or attach additional pages for each site)
~-Location(s): 1230 Mordecai Dr .. Raleigh. NC 27604
b. Driving Directions: Capital Blvd., take Atlantic Ave exit, turn left onto Wake Forest Rd, turn right onto
Chestnut St, turn left onto Mordecai.
c. Latitude: 35-47-39 Longitude: 78-37-57
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications. skip to next section)
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
2. Are the new treatment facilities adequate for the type of waste and disposal system?
FORM: Staff.Report-Hillis 1
AQUIFER PROTECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities ..... New, Renewal, And Modification
1. Type of injection system:
IZJ Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation ( 51)
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes
3. Are there any potential pollution sources that may affect injection? 1zi Yes
IZJNo
□No
What is/are the pollution source(s)? The sewer line. The sewer line is approximately 141 feet distance from the
well.
4. What is the minimum distance of proposed injection wells from the property boundary? 13Jl
5. Quality of drainage at site: lzi Good D Adequate D Poor
6. Flooding potential of site: 1zi 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: NI A
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? lzi Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes lzi No. If yes, explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes, explain:
3. For renewal or modification of groundwater remediation permits (of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes D No. If yes, explain:
FORM: Staff.Report-Hillis 4
AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Drilling contractor: Name: Bing's Well Drilling
Address: 6032 US 1 By-Pass South
Kittrell, NC 27549
Certification number: 2062
5. Complete and attach Well Construction Data Sheet.
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet -if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? D Yes ~ No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
FORM: Staff.Report-Hillis 5
AQUIFER PROTECTION REGIONAL STAFF REPORT
7, Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
8. Signature of report preparer(s): I V•
Signature ofAPS regional supervisor:
Date: 0 77-J/ 7,—
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
Well construction inspection and well water sampling were conducted on April 25, 2012,
The following comments are highlighted as a result of the inspection.
A review of the construction data indicates that the subject geothermal injection well has been constructed
in accordance with N.C. State Regulations (Title I5A NCAC 2C), Well Construction Standards.
The following items were checked:
1. Well Casing
• Casing diameter: 6.25 inches
• Casing depth: from ground to 42 feet. Casing extends above ground 12 inches.
• Type: Galvanized Steel.
Grout
• Grout type: Cement
• Grout depth: from 0 to 20 feet
3 Identification plate
• The information on the well tag is as following: Constructed Date: 7-29-2002; Depth of
the pump: 80 feet; Depth of the well: 545 feet; Yield: 20gpm
4 The location of the well
• The sewer line (potential pollution source) is approximately 141 feet distance from the
well.
• The minimum distance of the well from the property boundary is about 13 feet.
• The minimum distance of the well from the building is 53 feet.
Over all, this geothermal injection well is in compliance with well construction standards.
However, we are awaiting the lab results of the well water to complete this application process.
FORM: Staff.Report-Hillis 6

Permit: WI0500042
SOC:
County: Wake
Region: Raleigh
Compliance Inspection Report
Effective: 06/14/07 Expiration: 07/31/12 Owner: Mims Hillis
Effective: Expiration: Facility: Mims & Tannis Hillis SFR
1230 Mordecai Dr
Contact Person: Mims Hillis Title:
Raleigh NC 276041343
Phone: [phone]
Directions to Facility:
From downtown Raleigh at Capital go east on Peace St appx .5 mile and turn L on Person St./Wake Forest Rd. Go east on Wake
Forest Ro.ad 5 .bJocl<,s. Turn L on Chestnut St. then R on Mordecai Drive. Property on L corner.
System c1asslf1cat1ons:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 04/25/2012
Primary Inspector: Lin McCartney
Secondary lnspector(s):
Entry Time: 12:00 PM
Certification: Phone:
Exit Time: 01 :30 PM
Phone: [phone]
. Ext.4243
Reason for Inspection: Routine Inspection Type: Compliance Sampling
Permit Inspection Type: Injection Heating/Cooling Water Return Well (5A7)
Facility Status: ■ Compliant O Not Compliant
Question Areas:
■Wells ■ System Operations
(See attachment summary)
Page: 1
Permit: WI0500042
Inspection Date: 04/25/2012
Owner -Facility: Mims Hillis
Inspection Type: Compliance Sampling Reason for Visit: Routine
Inspection Summary:
Well construction inspection and well water sampling were conducted on April 25, 2012.
The following comments are highlighted as a . result of the inspection.
A review of the construction data indicates that the subject geothermal injection well has been constructed in accordance
with N.C. State Regulations:
The following items were checked:
1. Well Casing
* Casing Diameter:6.25 inches
* Casing depth: from ground to 42 feet.
* Type: Galvanized Steel
2. Grout
* Grout type: Cement
* Grout depth: from Oto 20 feet
3. Identification Plate
* The information on the well tag is as followings: Constructed Date: 7-29-2002; Depth of the pump: 80 feet; Depth on the
well 545 feet; Yield: 20 gpm
4. The location of the well
* The sewer line (potential pollution source) is approximately 141 feet distance from the well.
* The minimum distance of the well from the property boundary is about 13 feet.
* The minimum distance of the well from the building is about 53 feet.
System Operation
Is same well used as source well and injection well?
Is injection well capable of assimilating injected fluid?
Injection flow rate at time of inspection (gpm)
Has system owner/operator noticed any abnormalities (turbidity, air in system, poor heating/cooling, etc) in
system operation?
Comment on system operation
Is system operation and construction consistent with that described in application?
Describe inconsistencies between application and observed operation/construction
Comment:
Yes No NA NE
■DOD
•□□□
10
□□•□
■DOD
■DOD
Page: 2
AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: Ap ril 11, 2012
To: 0 Landon Davidson, ARO-APS
□ Art Barnhardt, FRO-APS
□ Andrew Pitner, MRO-APS
~ Jay Zimmerman, RRO-APS
□ David May, WaRO-APS
0 Morella Sanchez King, WiRO-APS
0 Sherri Knight, W-SRO-APS
From: Michael Ro gers Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E-Mail: Michael.Ro gers @ncdenr.gov
A. Permit Number: WI 0500042
B. Owner: Hillis
e:.. ·tri~UitytOperation: _
D Proposed ~ Existing D Facility D Operation
D. Application:
1. f~r.mit,Type.: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D 1/E Lagoon D GW Remediation (ND)
~ UIC -SA70pen'L.oop Geothermal Well
For Residuals: □ Land App. □ D&M
D 503 D 503 Exempt
D Surface Disposal
D Animal
2. PtQJeciType: □ New □ Major Mod. □ Minor Mod. ~ Renewal □ Renewal w/ Mod.
E. Comments/Other Information: lxJ
NOTE: Please return a completed APSARR after completing the site inspection and collecting water s_amples. At a
later date, after the laboratory results are received by your office, send us a copy of the cover letter & laboratory
analytical results, which you send to the Permittee. Please record all information on the well tag, if present, and put
on staff report. Thanks.
~ Return a completed APSARR after the site inspection. At a later date, after the lab results are
received, please send a copy of the cover letter & laboratory analytical results, which you send to
the Permittee.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: -------------------Date: _____ _
F:ORM: APSARR 07 /06 Page 1 of 1
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Charles Wakild, P.E. Dee Freeman
Secretary
Mims Hillis, Jr
Tannis Hillis
1230 Mordecai Drive
Raleigh, NC 27604
Dear Mr. and Mrs. Hillis:
Director .
April 10, 2012
Subject: Acknowledgement of
Application No. WI0500042
Mims & Tannis Hillis SFR
Injection Heating/Cooling
Water Return Well (5A7)
System
Wake County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on April 2, 2012. Your application package has been assigned the number listed
above, and the primary reviewer is Michael Rogers.
Central and Raleigh Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection· Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
Sincerely,
O~A.-~
for Debra J. Watts
cc: Raleigh Regional Office, Aquifer Protection Section
Permit File WI0500042
AQUIFER PROTECTION SECTION
1636 Mai~Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwatergualify.org
An Equal Opportunity \ Affirmative Action Employer
Groundwater Protection Unit Supervisor
NirthCarolina
/Vatura/ly
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
OPEN -LOOP GEOTHERMAL INJECTION WELLS
These wells discharge groundwater directly into the subsurface as part ofa geothermal beating and cooling system
(check one) New Application ✓ Renewal* Modification
For renewals complete Parts A-C and the signature page.
Pr'nt or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 3 /21 . 20
PERMIT NO. bit! 05 000 '2 (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence Business/Organization
Government:
State Municipal
County Federal
B. PERMIT APPLICANT — For individual residences, list each owner an property deed. For all others,
state name of entity fand name of person delegated authority to sign on behalf of the business or agency:
AT,tx%, 8e.11/e7 /4./4 r.
n m .'S _ Weer e F
Mailing Address: / 2 3 0 /470'I e e d: Pe.
City: _ R 4 / e i', At State: 4 Zip Code: 2.6 Q 4' County: 14.-#4 k e
Day TeleNo.: 9f9 -h'33 -03.E S Ce11No.: VV!'Y - SIa —'P#a
EMAIL Address: /474 4 sfilor //r 5 er., q : / • c ea.+.1Fax No.:
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(I) Parcel Identification Number (PIN) of well site: / 70 griq gt 3 f 1 County: W+* k e.
(2) Physical Address (if different than mailing address):
City: State: NC Zip Code:
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.: Ce11 No.: Fax No.:
REQEIVEDIDENRIDWQ
APR 0 2 2012
Aquifer Protection Section
GPUfIIIC 5A7 Permit Application (Revised 3f18f2011) Page 1

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: _______________________________ _
Contact Person.-'-: ______________ ______cE=MA'-=-=I=L'--"A--=-d=-d=r--=-e=ss=: ___________ _
Address:-----------------------------------
City: _________ Zip Code: ____ State: __ County:
Office Tele No.: Cell No.: Fax No.: -----------=--=-=-~'--'----------
F. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
G. WELL CONSTRUCTION DATA
(1)
____ PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(6) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
____ EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (6)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
GW-1) if available.
Well Construction Date: _______ Number of borings: ___ _
Depth of each boring (feet): _______ _
(2) Well casing type: Galvanized steel __ Black steel __ Plastic_._ Other (specify) _____ _
Casing thickness (in.): __ Diameter (in.):~--
Well depth: from: ___ to: ___ feet below land surface
Casing extends above ground ____ inches
(3) · Grout material surrounding well casing:
(a) Grout type: Cement__ Bentonite* Other (specify) ______ _
*By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from ___ to ___ feet
(4) Well Screen or Open Borehole depth (relative to land surface): from ____ to ____ feet
(5) N.C. State Regulations (Title ISA NCAC 2C .0200) require the Permittee to make prov1s1ons for
monitoring wellhead processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Is there a faucet on:
(a) Influent line? Yes No (b) Effluent line? Yes No
(6) Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Form G W-1 ). If Form G W-1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment units will the groundwater be withdrawn? ( e.g.
granite, limestone, sand, etc.)
Depth: _______ Formation: ______ Rock/sediment unit: _______ _
NOTE: THE WELLDRILLINGORHEATPUMP CONTRACTOR CAN HELP SUPPLYTHEDATAIFTHIS
INFORMATION IS OTHERWISE UNAVAILABLE.
GPU/UIC 5A 7 Permit Application (Revised 3/18/2011) Page 2
H. 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/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
I. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site-spec_ific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(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 be
obtained and downloaded from the applicable county GJS 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, 0th.er
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
·elevation data.
GPU/illC SA 7 Permit Application (Revised 3/18/2011) Page 3
3. 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 thepropertx 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.
"1 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. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Signature of Property Owner/Applicant
/11: wi s 8t, r/ev A 1, f Tr
Print or Type Full Name
Signat xre o i Property O nei9Applicant
(Cvini.5 vk[o ire v., f4, is
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVEDJDENRIDWQ
APR 022012
Aquifer Protection Section
GPUIUIC 5A7 Permit Application (Revised 3/1812Q11) Page 4

A'e,'fA
~•;,I.~ -.. , ___ _
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Charles Wakild, P. E. Dee Freeman.
Mims & Tannis Hillis
1230 Mordecai Drive
Raleigh, NC 27604 .
. Director
March 1, 2012
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WI0500042
Wake County
Dear Mr. & Ms. Hillis:
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 constniction and operation
activities within the state. Our records indicate that the above-referenced operating permit. for
the ·underground· injection well system located on your property ·at 1230 Mordec·ai Drive in
Raleigh, NC, which ·was issued to you on .June 14, 2007, and expires ori July 31, 2012, is soon
due for renewal. If you wish to keep this permit and operate the injection well systeni, 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 tha~ the abandonment was properly
conducted.
If there . has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form must also be submitted. The GW-30 and Name/Ownership
Change forms can be found at http://portal.ncdenr.orn/web/wq/aps/gv\i])ro/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 April 2~ 2012.
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.ncwaterguality .org
An Equal Opportunity\ Affirmative Action Employer
NOnchC ·1• ort . aro 1na
/valttrnll!f
Secretary
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 Wells) for Injection with
Geothermal Heat Pump System for Type 5A7 Wells) 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
h ttp :I/porta l.nc den r. o rJweb/wq/apsl gwp ro/pe rm i t-app l i ca ti ons# i eothermA pp s
Thank you in advance for your cooperation and timely response. If you have any questions,
please contact me by phone at [phone] or by email at eric.g.smith aancdenr.gov.
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Raleigh Regional Office - APS w/o enclosures
APS Central Files - Permit No. WI0500042 w/o enclosures

Permit Number WI0500042
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael.rogers
Permitted Flow
Facilit
Facility Name
Mjms & Tannis Hillis SFR
Location Address
1230 Mordecai Dr
Raleigh
Owner
Owner Name
Mims
Dates/Events
Orig Issue
06/27/02
NC
App Received
06/14/07
276041343
Hillis
Draft Initiated
Scheduled
Issuance
Central Files: APS_ SWP_
08/08/07
Permit Tracking Slip
Status
In review
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County_
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mims Hillis, Jr
1230 Mordecai Dr
Raleigh
Public Notice
NC 276041343
0~ I,~ I oEr lve ~liU(,<J) 1-2,
_R_e __ g_u_la_te_d_A_c_ti_v _it_ie_s _______________ ~R=e_.q=u~es-·t-e-d-/R=e~c~e=iv~e~d~E~v ~en~t~s __________ _
Heat Pump Injection
Outfall NULL
Waterbody Name
RO staff report requested
RO staff report received
Stream Index Number Current Class
06/20/07
07/18/07
Subbasin
u o :£ tl~ £ l srw LO
1-71
f
Mlrcreer r. basiey, Liov&nor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Colee n li Sullins, Director
Division of Water Quality
August 7, 2007
Mims and Tannis Hillis
1230 Mordecai Drive
Raleigh, NC 27604
Re: Issuance of Injection Well Permit
Permit No. WI0500042
Issued to Mims and Tannis Hillis
Dear Mr. and Mrs. Hillis:
In accordance with your signed application received June 14, 2007, I am forwarding Permit No.
WI0500042 for the operation of a 5A7 geothermal underground injection well (UIC) heat pump
system located at 1230 Mordecai Drive, Raleigh, Wake County, North Carolina. This permit
shall be effective from the date of issuance until July 31, 2012, 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 four (4) months prior to its expiration date. As indicated in.
the permit, this permit is not transferable to any person without prior notice to, and approval by,
the Director of the Division of Water Quality.
Also attached is a summary of the laboratory sampling results from water samples collected from
your geotherizi.al well on July 10, 2007.
If you have any questions regarding your permit or the Underground Injection Control (UIC)
Program please call Mr. Qu Qi at [phone] or me at (919) 715 -6166.
Best Regards,
Michael Rogers
Senior Environmental Specialist
GPU — UIC Control Program
cc: Jay Zimmerman — Raleigh Regional Office
Central Office File
Attachment(s)
Aquifer Protection Section 1636 Mail Service Center
Internet: lrttp://www.ncvvateraualitv.ora 2728 Capital Boulevard Raleigh, NC 27604
An Equal opportunttylAffirmativa Action Employer- 50°% Recyciedli0'% Post Consumer Paper
Raleigh, NC 27699.1636
N�One tCarolina
Naturally
Telephone: [phone]
Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other
applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
MIMS AND T ANNIS HILLIS
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North
Carolina Administrative Code 2C .0209( e )(3)(A), which will be used for the injection of heat
pump effluent. This injection well is located at 1230 Mordecai Drive, Raleigh, North Carolina,
and will be operated in accordance with the application received June 14, 2007, and in
conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for 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 July 31, 2012,
and shall be subject to the specified conditions and limitations set forth in Parts I through VIII
hereof.
Permit issued this the [relay of ~ , 2007 .
. [)Jlm-J w~
~oleen H. Sullins, Director
\" vivision of Water Quality
By Authority of the Environmental Management Commission.
WI0500042 Page2
PART I-WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (ISA NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not 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 well shall have-permanently affixed an identification plate.
8. ~ completed Well Constn:iction Rec~rd (Form GW-1) must be submitted for each injection-
well to, DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1636
Mail Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well
construction.
PART II -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.
WI0500042 Page3
PART III -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 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 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.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
WI0500042 Page4
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 prqtection,
will be established and an acceptable sampling reporting schedule shall be followed.
2. ThePermittee 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 followi~g:
(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 sµbmitted 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 Perm.ittee 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 discontinuation of 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 butnot 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.
WIOS00042 Page S
(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:
WI0500042
Aquifer Protection Section-DIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Page 6
LABORATORY ANALYTICAL RESULTS
' .
5A7 GEOTHERMAL UNDERGROUND INJECTION CONTROL (UIC) WELL
PERMIT NO.: WI 050042
PERMITTEE: Mims and Tannis Hillis
SAMPLE COLLECTED DATE: 7/10/2007
Coliform, total Coliform, fecal pH Total Dissolved Solids Chloride, Cl
1 CFU/100ml 1 CFU/100ml units mg/L ·mg/L
MCL=1 MCL=1 MCL = 6.5-8.5 MCL = 500 MCL=250
Influent 1 1 6 188 19
Effluent 1 1 6 182 20*
NO2-+ NO3-as N Phosphorus Nitrate Nitrite Silver, Ag
mg/L -mg/L m g/L mg/L uQ/L
MCL= 10 MCL=nss MCL=10 MCL=1 MCL=17.5
Influent 4 0.04 4 <.01 <5
Effluenl 3.9 0.04 .3.9 -:::.01 <5
Calcium, Ca Cadmium,Cd Chromium, Cr Copper, Cu Iron, Fe
mg/L ua/L µg/L ~g/L ua/L
MCL=nss MCL=1.75 MCL=50 MCL = 1000 MCL=300
Influent 26 <1 <10 420 <50
Effluent 27 <1 <10 520 <50
Manganese, Mn Sodium, Na Nickel, Ni Lead, Pb Selenium, Se
µg/L mg/L ug/L IJQ/L µg/L
MCL=50 MCL= nss MCL= 100 MCL=15 MCL=50
Influent 12 13 57 <10 <5
Effluent .14 13 75 <10 <5
MCL = Maximum Contamination Level per NCAC 2L .0200 (GA Standards)
nss = no state standard
na = not analyzed
*The laboratory sample matrix interfered with the ability to to make any accurate determination; Estimated
Sulfate
mg/L
MCL=250
22
22
Aluminum, Al
ua/L
MCL= nss
<50
<50
Mercury, Hg
µg/L
MCL= 1.05
na
na
Zinc,Zn
pg/L
MCL=1030
32
47
Ammonia, NH3 TKN
mg/L mg/L
MCL=nss MCL=nss
<.02 <.2
<.02 <.2
Arsenic,As Barium, Ba
µg/L ua/L
MCL=50 MCL=2000
<5 na
<5 na
Potassium, K Magnesium, Mg
mg/L mg/L
MCL= nss MCL=nss
na 8.5
na 8.7
DWQ Laboratory ,5 ection (Results
LOC. Visor.:
Location Ifl:
County.
River Basin
Report To
Region:
Collector
Sample Matrix:
Loc. Type:
Sample Depth
MIMS HILLIS
RROAPNLC
WAKE
RROAP
RRO
E OWEN
GROUNDWATER
WATER SUPPLY
°F \IVA7-E-,
G
Sample ID '
PO Number#
V.sitID
Collect Date:
Collect Time::
Date Received:
Time Received-
1abworks LoginI❑
Date Reported:
Emergency Yes/No
COC Yes/No
AB19051
760530
0711012007
10-30
07f10/2007
11:15
MMA
07/31/2007
Sample Qualifiers and Comments
Routine Qualifiers
Far a more detailed description of these qualifier codes refer to www.dwglab.org under Staff Access
A -Value reported i5 the average of two or more determinations
B1-Countable membranes with s20 colonies; Estimated
B2- Counts from all filters were zero.
83- Countable membranes with more than 60 or 80 colonies; Estimated
54-Fitters have counts of both >60 or 80 and < 20; Estimated
85-Too many colonies were present; too numerous to count (TNTC(
.12• Reported value failed to meet QC criteria for either precision or accuracy; Estimated
.13-The sample matrix interfered with the ability to make any accurate determination; Estimated
J6-The lab analysis was from an unpreserved or improperly chemically preserved sample; Estimated
Ni-Tile component has been tentatively identified based on mass spectral library search and has an estimated value
N3-Estimated concentration is < POL and MDL
NE -No established POL
P-Elevated PQL due to matrix interference and/or sample dilution
Q1-Holding time exceeded prior t0 receipt at lab.
02- Holding time exceeded following receipt by lab
POL- Practical Quantitaiion Limit -subject to change due to instrument sensitivity
U- Samples analyzed for this compound but not detected
X1- Sample not analyzed for this compound
LAB
Laboratory Section 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
Page 1 of 3

:N"C <DWQ La6oratory Section ()Jssults Sample ID AB19051
Location•ID: RROAPNLC Collect Date: 07/10/2007
Loe. Descr.: :_:MIMS HILLIS Coiled Time:: 10:30
Visit ID
CAS# Analyte Name PQL Result Qualifier Units Analyst/Date Approved By /Date
Sample temperature at receipt by lab 10.9 ·c DSAUNDERS MMATHIS
Method Reference 7/10/07 7/13/07
MIC
Collfonn, MF Fecal In liquid 1 B2 CFU/100ml BSWANSON MOVERMAN
Method Reference APHA9222D-20th 7/10/07 7/16/07
Collfonn, MF Total In liquid 1 82 CFU/100ml BSWANSON MOVERMAN
Method Reference APHA9222B-20th 7/10/07 7/16/07
Alkalinity to pH 4.5 of llquld _TITLE_ niglL as CaC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7/19/07
Alkallnlty4.5. 66 mglL as CaC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7/19/07
Alkallnlty8.3 1 u mgll as CaC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7/19/07
Bicarbonate 66 mgll as CaC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7/19/07
Carbonate 1 u mg/Las CaC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7/19/07
pH....Alkallnlty 6.2 mg/Las CaC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7/19/07
WET
Total Dls&olved Solids In liquid 12 182 mglL AWILUAMS MOVERMAN
Method Reference APHA2540C-18TH 7/11/07 7/19/07
Chlortde 1.0 20 J3 mglL MIBRAHIM MOVERMAN
Method Reference EPA300.0 7/16/07 7f1.0/07
Fluoride 0.4 0.4 u mglL MIBRAHIM MOVERMAN
Method Reference EPA300.0 7/16/07 7'1.0/07
Ion Chromatography _TITLE_ mgll.. MIBRAHIM MOVERMAN
Method Reference EPA300.0 7/16/07 7f1.0/07
Sulfate 2.0 22 mgll.. MIBRAHIM MOVERMAN
Method Reference EPA300.0 7/16/07 7'1.0/07
NUT
NH3 as N In liquid 0.02 0.02 u mgllasN MAJAYI CGREEN
Method Reference Lacl0-107-06-1.J 7/10/07 7/13/07
Total Kjeldahl N as N In liquid 0.2 0.20 u mgllasN MOVERMAN CGREEN
Method Reference Lachat107-06-2-H 7/13/07 7/16/07
N02+N03 as N In liquid 0.02 3.9 mgllasN MAJAYI CGREEN
Method Reference Lac10-107-04-1-c 7/10/07 7/19/07
Laboratory Section>> 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page 2of3
¾C <DWQ La6oratory Section ~sults Sample ID AB19051
-'
Location, ID: RROAPNLC Collect Date: 07/10/2007
Loe. Descr.: :_:MIMS HILLIS Collect Time:: 10:30
Visit ID
CAS# Analyte Name PQL Result Qualifier Units Analyst/Date Approved By /Date
Phosphorus_total as P In llquld 0.02 0.04 mg/LasP GBELK CGREEN
Method Reference Lac10-115-01-1EF 7/11/07 7/17/07
Nitrate as N In liquid 0.02 3.9 mg/LasN MAJAYI CGREEN
Method Reference Lachat107-04-1-c 7/17/07 7/19/07
Nlbtte as N In llquld 0.01 0.01 u mg/LasN GBELK CGREEN
Method Reference Lachat107-04-1-c 7/12107 7/19/07
MET
7440-22-4 AgbylCPMS 5.0 5.0 u LVL DSTANLEY EST AFFORD
Method Reference EPA200.8 7/13/07 7/30/07
7429-90-5 AJbylCP 50 50 u LVL PGAUTHIER ESTAFFORD
Method Reference EPA,200.7 7/23/07 7fJ0/07
7440-38-2 AsbylCPMS 5.0 5.0 u LVL DSTANLEY EST AFFORD
Method Reference EPA200.8 7/13/07 7/30/07
7440-70-2 CabylCP 0.10 27 mg/L PGAUTHIER ESTAFFORD
Method Reference EPA200.7 712.3/07 7/30/0.7
7440-43-9 CdbylCPMS 1.0 1.0 u ug/L DSTANLEY ESTAFFORD
Method Reference EPA200.8 7/13/07 7/30/07
7440-47-3 Q'bylCPMS 10 10 u ugll DSTANLEY EST AFFORD
Method Reference EPA200.8 7/13/07 7/30/07
7440-50-8 CubylCPMS 2.0 520 ugll DSTANLEY ESTAFFORO
Method Reference EPA200.8 7/13/07 7/30/07
7440-48-4 FebylCP 50 50 u uglL PGAUTHIER ESTAFFORD
Method Reference EPA200.7 7/23/07 7/30/07
7439-95-4 MgbylCP 0.10 8.7 mglL PGAUTHIER ESTAFFORD
Method Reference EPA200.7 7123/07 7/30/07
7439-96-5 MnbylCPMS 10 14 uglL PGAUTHIER EST AFFORD
Method Reference EPA200.8 712.3/07 7/30/07
7440-23-4 NabylCP 0.10 13 mglL PGAUTHIER ESTAFFORD
Method Reference EPA200.7 7/23/07 7/30/07
7440-02-0 NlbylCPMS 10 75 uglL DSTANLEY EST AFFORD
Method Reference EPA200.8 7/13/07 7/30/07
7439-92-1 PbbylCPMS 10 10 u uglL DSTANLEY ESTAFFORD
Method Reference EPA200.8 7113/07 7/30/07
7782-49-2 SebylCPMS 5.0 5.0 u uglL DSTANLEY EST AFFORD
Method Reference EPA200.8 7/13/07 7/30/07
7440-66-6 ZnbylCP 10 47 uglL PGAUTHIER ESTAFFORD
Method Reference EPA200.7 712.3/07 7/30/07
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page 3of3
GROUNDWATER FIELD/LAB FORM
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
County Lk) f \. t
Quad No Serial No
Lat. _ Long
Report To: ARO, FRO, MRO " RO aRO, WiRO,
WSRO, Kinston FO, Fed. Trus entre' Off., Other:
Shipped by: Bus, CCourier
Collector(s): T �#' ❑`w1 f,
FIELD ANALYSES
pH is , (] Spec. Cond. Z /b ' 7 at 25° C
Temp.10 3 , c} °C Odor rZ.�n r'
Appearance LAP 4 le -
Field Analysis By: LA7 c' A
LABORATORY _ANALYaES
SAMPLE TYPE SAMPLE PRIORITY
® Routine
❑ Emergency
Water
Soil
❑ Other
❑ Chain of Custody
I.,�er 6�11
Date 7 —1C — 07 Time ) E'• 5D IAPh
Owner
Location or site [ v m C f
fie
Purpose:
Baseline, Complaint
Description of sampling point
Sampling Method
Remarks
Lab Number �1UL
Date Receivedd '20 WO Time
Rec'd by:From: Bus, Courier
Other
Data Entry By: Ck•
Date Reported:
0537
mpliance'6yS7, Pesticide Study, Federal Trus
/1 5
utc � ILA
(4 [ )s R{T2 A eItb N� 7[. oy
(Punaaaag t r‘,.1
Sample Interval
11 P4 4�7- 123�
BOO, 310
mgll
L(
Diss. Solids 703o0
m/1
Ag - Silver 46566
ug/1
COD High 340
mgll
Flouride 951
mgll
Ar-Al
- Aluminum 46557
ug/i
COD Low 335
m9/I
A(
Hardness: Total 900
mall
As - Arsenic 46551
ug/1
L[
Coliform: MF Fecal 31516
1100m1
XL
Hardness {non-carb] 902
mall
Ba - Barium 46558
ug/1
)(
Conform: MF Total 31504 -
/100m!
Phenols 32730
uall
X
Ca - Calcium 46s'7
rngA
TOC 680
mg/
Specific Cond. 95
uMhoslcm2
ak
Cd - Cadmium 46559
ug/I
Turbidity 76
NTU
X
Sulfate 945
moil
..
Cr - Chromium 46560
ug/1
Residue., Suspended 530
P
m 9/1
Sulfide 745
mgll
4
Cu - Copper 46562
uaA
}C
Fe - Iron 46563
ug/1
011 and Grease
mgl±
H9 - Mercury 71900
ug/I
pH 403
units
K - Potassium 46555
mg/I
k
Alkalinity to pH 4.5 410
mg/1
\
Mg - Magnesium 46554
mgll
7(
Alkalinity to pH 8.3 415
mg/I
Mn - Manganese 46565
ug/1
x
Carbonate 445
mgll
NI-i as N 610
mq/
Na - Sodium 46556
mgfl
K
Bicarbonate 440
mg/1
TKN as N 625
m !
Ni - Nickel
uyl
Carbon dioxide 405
nigh
}4
NDe. + NO, as N 630
mull
Pb - Lead 46564
uq/1
do
Chloride 940
mg/I
X
P: Total as P 665
mull
5e - Selenium
ug/I
Chromium: Hex 1032
ug/1
Y
NO \_Ampfgq
Zn - Zinc 46567
ug/1
Color: True 80
CU
2.
Cyanide 720
mg/1
Lab Comments: (^[1< < 0 M y.rii . �� LA L k l MILS pre S • isll 0 AL 1b SOy fik )•Cr
in e is pfls. w� S f„L -1- tJo J P �{ 2 D.
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCB's
Semivolatile Organics
TPII - Diesel Range
Volatile Organics (VOA bottle)
TPH - Gasoline Range
TPH - BTEX Gasoline Range
/of r
GW-54 REV.1219
For Dissolved Analysis - submit filtered sample and write "l)15" In bl*

Report tq: _RR0 _____ _
Lab Number: AB19051
:ition Location: 11230 MORDCAI
DR RALEIGH
NC 27604
Sample Type: WATER
Date collected: 7/10/07 ----------
NC DENR/DWQ Laboratory
Sample Anomaly Report (SAR)
Sample ID: EFF 1
County: WAKE
Priority: ROUTINE
Date received: 7/10/07 -------
Region:
Collector:
Date analyzed:
RRO
ED OWEN
7/16/07
Affected Parameter(s): __;_C_H--'L--'O=-RID __ E ______________________________ _
Analytical Area (check one):
[81WCH
□NUT
□METALS
□MICRO
□VOA
□PEST
0SVOA
The following anomalies occurred (check all that apply):
□Samples OQuality Control
□Improper container used
0VOA vials with headspace
□Sulfide samples with headspace
□Samples not received, but listed on fieldsheet
□Samples received, but not listed on fieldsheet
□Mislabeled as to tests, preservatives, etc.
□Holding time expired ·
□Prior to receipt in lab
□After receipt in lab
□Insufficient quantity for analysis
□Sample exhibits gross non-homogeneity
□Sample not chemically preserved properly
OpH out of range (record pH):
□Improper chemical
□Residual chlorine present in sample
□Color interference
□Heavy emulsion formed during extraction
□Sample bottle broken in lab -no reportable results
~Other (specify):Sample matrix interfered with the spike recovery.
□Instrument failure -no reportable results
□Analyst error -no reportable results
□Surrogates · □None added
□Recovery outside acceptance limits
□Spike recovery
0Noneadded
□Recovery outside acceptance limits
□Failed to meet criteria for precision
□Internal standards
□Blank contamination
OQC data reported outside of controls (e.g., QCS, LCS)
□Incorrect procedure used
0SOP intentionally modified with QA and Branch Head
approval
□Invalid instrument calibration
□Elevated detection limits due to:
□Insufficient sample volume
Comments: Spike recovery MS( Matrix spike) & MSD( Matrix spike duplicate) were out of range 85.41 % and 89.05 %, , acceptance
limits is 90-1 I 0% .
Corrective Action: Doubled the spike strength and reanalyzed, MS and MSD recovery were 81.91 % and 83.89%.
OSample.s were rejected by DWQ Lab. Authorized by: Date:
□Accepted and analyzed after notifying the collector or contact person and determining that another sample could not be secured.
Osample(s) on hold until:
~Sample reported with qualification. Data qualification code used:J~
O0ther (explain):
Notification Required? D Yes ~ No
Person Contacted: Date: --
Form completed by: __._M~ag,._d_i _Ib_r_ah_in_~..__ _____ IY'-__ LJ ____ _
Lead Chemist Review (initial):
IJ9BI0CHEM~ □PEST __
□METALS__ □VOA __
C .. ·· · Branch Head Review (initi~ :.J. () -O ! l
_)A/QCReview (initi~ 7/a..'YO/
QA \Fonns\Laboratory\SAR
Date: 7/19/2007
OSV0A _. __
Logged into database by (initial): ___ _
I 0/23/0 I dbs
WC (D WQ Laboratory .Section ,Results
i,si 05'00041
Loc. Oescr.:
Location ID:
County-
River Basin
Report 7o
Region:
Collector.
Sample Matrix-
Lac. Type:
Sample Depth
MIMS HILLIS
RROAPNLC
WAKE
RROAP
RRO
E OWEN
GROUNDWATER
WATER SUPPLY
a�wAr&-,
14�
of,
"7\\`')\
Sample ID: •
Pa Number#
VisitlD
Collect Date:
Collect Time:.
Date Received:
Time Received:
Labworlts LoginlO
Date Reported.
Emergency Yes/No
COC Yeslbfo
A819050
760529
07/10/2007
10:30
07110/2007
11:15
MMA
07/31/2007
Sample Qualifiers and Comments
RECEIVED 1 DEAR ► MO
AothFrp apn-rctstnN QrtrTnoy.
AUG O 6 20Di
Routine Qualifiers
For a more detailed description of these qualifier codes refer to www.dwglab.org under Staff Access
A -Value reported is the average of two or more determinations
BI-Countable membranes with <20 colonies; Estimated
B2- Counts from all fillers -were zero-
B3- Countable membranes with more than 60 or 80 colonies; Estimated
BA -Filters have counts of Math >60 or 80 and < 20; Estimated
B5-Too many colonies were present: too numerous to count (TNTC)
J2- Reported value !ailed to meet QC criteria for either precision or accuracy; Estimated
J3-The sample matrix interfered with the ability to make any accurate determination; Estimated
J6-The lab analysis was from an unpreserved or improperly chemically preserved sample, Estimated
N1-The component has been tentatively identified based on mass spectral library search and has an estimated value
N3-Estimated concentration i5 < PQL and >MDL
NE -No established PQL
P-Elevated PQL due 10 matrix interference and/or sample dilution
01-Holding bme exceeded prior to receipt al lab.
02- Holding time exceeded following receipt by Jab
POL- Practical Quantilation Limit -subject to change due to instrument sensitivity
U- Samples analyzed for this compound but not detected
X1- Sample not analyzed for this compound
LAB
Laboratory Section?> 1623 Mail Service Center, Raleigh, NC 27699.1823 1919) 7333968
Page 1of3

NC (JYWQ La6oratory Section ~sults Sample ID AB19050
location ID: ...RROAPNLC Collect Date: 07/1012007
C
Loe. Oescr.: ;::--MIMS HILLIS Collect Time:: 10:30
Visit ID
CAS# Analyte Name PQL Result Qualifier Units Analyst/Date Approved By /Date
Sample temperatu,a at recel~ by lab 9.3 ·c DSAUNDERS MMATHIS
Method Reference 7/10/07 7/13/07
MIC
Collfonn, MF Fecal In llqwl B2 CFU/100rnl BSWANSON MOVERMAN
Method Reference APHA9222D-20th 7/10/07 7/16/07
Collfonn, MF Total In llquld 1 CFU/100ml BSWANSON MOVERMAN
Method Reference APHA9222B-20th 7/10/07 7/16/07
AlkaDnlty to pH 4.5 of llquld _TITLE_ mg/Las CsC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7119/07
Alkallnlty4.5 63 mglLasCsC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7/19/07
Alkallnlty8.3 1 u mg/Las CsC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7/19/07
Bicarbonate 63 mglL as CsC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7119/0t
Carbonate 1 u mglL as CsC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7/19/07
pH....Alkallnlty 6.2 mglL as CsC03 ADESAI MOVERMAN
Method Reference APHA2320B-20th 7/13/07 7/19/07
WET
Total Dissolved Sollds In liquid 12 188 mglL AWILUAMS MOVERMAN
Method Reference APHA2540C-18TH 7/11/07 7/19/07
Chlortde 1.0 19 mglL MIBRAHIM MOVERMAN
Method Reference EPA300.0 7/16/07 7/20/07
Fluortde 0.4 0.4 u mglL MIBRAHIM MOVERMAN
Method Reference EPA300.0 7/16/07 7/20/07
Ion Chromatography _TITLE_ mglL MIBRAHIM MOVERMAN
Method Reference EPA300.0 7/16/07 7/20/07
Sulfate 2.0 22 mg/I.. MIBRAHIM MOVERMAN
Method Reference EPA300.0 7/16/07 712.0/07
NUT
NH3 as N In Dquld 0.02 0.02 u mg/LasN MAJAYI CGREEN
Method Reference Lacl0-107-06-1-J 7/10/07 7/13/07
Total Kjeldahl N as N In liquid 0.2 0.20 u "'9'Las N MOVERMAN CGREEN
Method Reference Lachat107-06-2-H 7/13/07 7/16/07
NO2+NO3 as N In liquid 0.02 4 .0 mgllasN MAJAYI CGREEN
Method Reference l.ac10-107-04-1-c 7/10/07 7/19/07
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page2of3
!NC <D'WQ La6oratory Section 1?ssufts Sample ID AB19050
Location ID: RROAPNLC Collect Date: 07/10/200?
Loe. bescr.: -MIMS HILLIS .Collect Time:: 10:30
Visit ID
CAS# Analyte Name PQL Result Qualifier Units Analyst/Date Approved By /Date
Phosphorus_total as P In liquid 0.02 0.04 mg/Las P GBELK CGREEN
Method Reference Lac10-115-01-1EF 7111/07 7/17I07
Nitrate as N In liquid 0.02 4.0 mgllasN MAJAYI CGREEN
Method Reference Lachat107-04-1-c 7/17/07 7/19107
NHrtte as N In llquld 0.01 0.01 u mglLas N GBELK CGREEN
Method Reference Lachat107-04-1-c 7112107 7/19/07
MET
.7440-22-4 AgbylCPMS 5.0 5.0 u ug/L DSTANLEY ESTAFFORD
Method Reference EPA200.8 7113/07 7/30/07
7429-90-5 AlbylCP 50 50 u ug.lL PGAUTHIER ESTAFFORD
Method Reference EPA200.7 7123/07 7/30/07
7440-36-2 AsbylCPMS 5.0 5.0 u ug/L DSTANLEY EST AFFORD
Method Reference EPA200.8 7/13/07 7/30/07
7440-70-2 CabylCP 0.10 26 mglL PGAUTHIER ESTAFFORD
Method Reference EPA200.7 7123/07 7/30/07
7440-43-9 CdbylCPMS 1.0 1.0 u ug/L DSTANLEY ESTAFFORD
Method Reference EPA200.8 7113/07 7/30/07
7440-47-3 CrbylCPMS 10 10 u ug/L DSTANLEY EST AFFORD
Method Reference EPA200.8 7/13/07 7/30/07
7440-50-8 CUbylCPMS 2.0 420 ug/L DSTANLEY ESTAFFORD
Method Reference EPA200.8 7/13/07 1/30/01
7440-46-4 FebylCP 50 50 u ug/L PGAUTHIER EST AFFORD
Method Reference EPA200.7 7123/07 7/30/07
7439-95-4 MgbylCP 0.10 8.5 mgll PGAUTHIER ESTAFFORD
Method Reference EPA200.7 7123/07 7/30/07
7439-96-5 MnbylCPMS 10 12 ug/L PGAUTHIER ESTAFFORD
Method Reference EPA200.8 7123/07 7/30/07
7440-23-4 NabylCP 0.10 13 mg/L PGAUTHIER ESTAFFORD
Method Reference EPA200.7 7123/07 7/30/07
7440-02-0 NlbylCPMS 10 57 Ug/L DSTANLEY EST AFFORD
Method Reference EPA200.8 7113/07 7/30/07
7439-92-1 PbbylCPMS 10 10 u uglL DSTANLEY EST AFFORD
Method Reference EPA200.8 7/13/07 7/30/07
7782-49-2 SebylCPMS 5.0 5.0 u ug/L DSTANLEY ESTAFFORD
Method Reference EPA200.8 7/13/07 7/30/07
7440-66-6 ZnbylCP 10 32 ug/L PGAUTHIER ESTAFFORD
Method Reference EPA200.7 7/23/07 7/30/07
Laboratory Section» 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone] Page 3of3
- GROUNDWATER FIELD/LAB FORM
County
Quad No Serial No
Lat Long
Report To: ARO, FRO, MRO ARO, WaRO, WiRO,
WSRO, Kinston FO, Fed. Trus antral Off., Other
Shipped by: Bus, iCourie Hand Del. 1�er YAV
Collector(s)- E c.l ZLJ Pt Date —10- D
FIELD ANALYSES?
pH4° s_ ' 0 Spec. Cond.94 Z l • at 25° C
Temp.° 1 °C Odor Al ,11i F
Appearance
Field Analysis By: 01Pn
LABORATORY ANALYSES
SAMPLE TYPE SAMPLE PRIORITY
Water Routine
Soli D Emergency
❑ Other
❑ Chain of Custody
Purpose:
Time ) O Baseline, Complaint,
Owner
Location or site J
Description of sampling paint
Sampling Method
Remarks
fz_1)
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
Lab Number
Date Receive
Rec'd by'
Other
Data Entry By. Cie
Date Reported:
fiance LUST, Pesticide Study, Federal Trust
— el,"41
1 i e C Gar, f 7 [17L �T? �, oy
(A,)
urnp
Sample Interval
/S
1-, 4`18N 4f4-1 1j - i77-03.8
BOO, 310
mg/1
,C
Diss. Solids 70300
mall
Aq- Sliver 46566
ugll
Organochionne Pesticides
COD High 340
mgll
Fl❑uride 951
mill
r
A
Al - Aluminum 46557
ug/1
0rganophosphorus Peslicides
COD Low 335
mgll
1(
1 rdness: Total 900
mg/1
As - Arsenic 46551
_ u.
Nitrogen Pesticides
X
Coliform: MF Fecal 31616
110OmI
j(
Hardness (non-.arb) 902
mq/1
Ba - Barium 46558
ug
_
Acid Herbicides
A.
Coliform: MF Total 31504
1100rn1
Phenols 32730
ug/1
X
Ca - Calcium 46552
mall
PCB's
TOC 680
mall
Specific Cond. 95
uMhos/cm'
X(
Cd - Cadmium 46559
u• I
r
Turbidity 76
NTI!
,X
Sulfate 945
rnq/l
X
Cr - Chromium 46560
ugl}
Residue., Suspended 530
man
Sulfide 745
mq/1
X
Cu - Copper 46562
u911
Fe - Iron 46563
ugfl
Semivolatile Organics
011 and Grease
mill l
Hg - Mercury 71900
ug/1
F
TPH - Diesel Range
pH 403
units
1( - Potassium 46555
mgll
)S
Alkalinity to pH 4.5 410
mg/1
/(
Mg - Magnesium 46554
rngll
X
Alkalinity to pH 8.3 415
mg/t
1
4
/[
Mn - Manganese 46565
ugll
A
Carbonate 445
mgll
X
NH. as N 610
mg/1
Na - Sodium 46556
mg/I
Volatile Organics (VOA bottle)
Bicarbonate 440
milli
TKN an N 625
mg/1
Ni -Nickel
u411
TPH - Gasoline Range
Carbon dioxide 405
mgf
}(
NO,, + NO._as N 630
mall
Pb - Lead 46564
ug/1
TPH - BTEX Gasollra Range
4
Chloride 940
mg11
'
P: Total as P 665
mg/1
Se - Selenium
ugll
Chromium: Hex 1032
ug!
'(
N 0 , k x Epi't
X
Zn - Zinc 46567
ugll
--
Color. True 80
CU
9f
Cyanide 720
mg/1
cc��
Lab Comments: 9.IFS f Ail +r+AVE - N 1 T. p 1,4 2II, L ti 2 30 y - -4_
mec 11,K)0 e ,).b
GW-54 REV. 12/9
For Dissolved Analysts - submit fillered sample and write "DIS" in b1'

AQUIFER· PROTECTION SECTION REGIONAL STAFF REPORT
Date: 07/10/2007
To: Aquifer Protection Section Central Office
Central Office Reviewer: Michael Rogers
Regional Login No: 05
County: Wake
Permittee: Mims and Tannis Hillis
Project Name: UIC-(SA 7) Open Loop
Application No.: WI0500042
L .GENERAL INFORMATION
1. This application is (check all that apply): D New ~ Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation ~ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ~ Yes or D No.
a. Date of site visit: 07/10/2007
b. Person contacted and contact information: Mims Hillis, Phone# [phone]
c. Site visit conducted by: Ed Owen
d. Inspection Report Attached:~ Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
RECEIVED / DENR / DWQ
AQUIFERWlnTFr.TION SF:CTION
JUL 18 .200Zl
~ Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
l;>. Driving Directions: __
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Disposal and Injection Sites:
(If multiple sites either indicate which sites the information applies to, copy and paste a new section into the
document for each site, or attach additional pages for each site)
a. Location(s): 1230 Mordecai Drive, Raleigh, NC 27604
b. Driving Directions: From Raleigh, Person St. go Eon Wake Forest Rd., 5 blocks Turn Lon Chestnut St. &
Mordecai Dr. on L comer.
c. USGS Quadrangle Map name and number: Raleigh West-D24SW
d. Latitude: 35.47.39 Longitude: 78.37.57
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications. skip to next section)
Description Of Waste{S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
FORM: Hillis staff report.doc 1
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No D N/A. Ifno, please explain: __
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No D N/ A. If no, please explain: __
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes D No D N/ A. If no, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division.
NI A. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
0Yes D No D N/A. Ifno, please explain: __
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
0Yes0No0
D Yes D No D N/ A. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit: __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEW AL AND MODIFICATION APPLICATIONS (use previous section for new or maior modification
systems)
Description Of Waste(S) And Facilities
1. Are there appropriately certified ORCs for the facilities? D Yes or D No.
Operator in Charge: __ Certificate #: __
Backup-Operator in Charge: _. _ Certificate #: __
2. Is the design, maintenance and operation ( e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D No.
If no, please explain: __
3. Are the site conditions (soils, topography, depth to water table, etc) maintained app_ropriately and adequately
assimilating the waste? D Yes or D No. If no, please explain: __
FORM: Hillis staff report.doc 2
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
4. Has the site changed in any way that may affect permit ( drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain: __
5. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
D Yes or D No. Ifno, please explain: __
6. Are the existing application rates (hydraulic or nutrient) still acceptable? D Yes or D No. If no, please
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Will seasonal or other restrictions be required for added sites? D Yes D No D N/ A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, please attach a
map showing conflict areas or attach any new maps you have received from the applicant to be incorporated
into the permit: __
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? D
Yes or D No. Ifno, please explain: ____ _
11. Were monitoring wells properly constructed and located? D Yes or D No D N/ A. If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? 0 Yes or
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; D
Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc): ____ _
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? D Yes
D No D Not Determined D N/ A.. If no, please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? D
Yes or D No D N/A. Ifyes, please explain: __
FORM: Hillis staff report.doc 3
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.).
Description Of Well(S) And Facilities -New. Renewal, And Modification
1. Type of injection system:
[8] Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation ( 51)
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? [8] Yes D No
3. Are there any potential pollution sources that may affect injection? D Yes [8] No
What is/are the pollution source(s)? . What is the distance of the injection well(s) from the pollution
source{s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 25 ft.
5. Quality of drainage at site: [8] Good D Adequate D Poor
6. Flooding potential of site: ~ 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: N/ A
8. Does the map presented represent the actual site (property lines, wells, surface drainage)?~ Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation ( e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes [8] No. If yes, explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes [8] No. If yes, explain:
3. For renewal or modification of groundwater remediation permits {of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes D No. If yes, explain: NIA
4. Drilling contractor: Name: Bing's Well Drilling
FORM: Hillis staff report.doc 4
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address: 6032 US 1 By -Pass South
Kittrell , NC 27549
Certification number: 2062
5. Complete and attach Well Construction Data Sheet.
FORM: Hillis staff report.doc 5
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVAL UA TION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, please explain
briefly.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item
Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition
Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition
Reason
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
8. Signature of report preparers): cll
Signature of APS regional supervisor:
Date: 711 JJ! U .2
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
System is running good, no problems
7- (O _ 0 1
FORM: Hillis staff report.doc 6

\
.
"
Compliance Inspection Report
Permit: WI0500042
SOC:
Effective: 06/27/02 Expiration: 07/31/07 Owner: Mims Hillis
Effective: Expiration: Facility: Mims & Tannis Hillis SFR
County: Wake
Region: Raleigh
Contact Person: Mims Hillis
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 07/10/2007
Primary Inspector: Ed Owen
Secondary lnspector(s):
Jimmie W Greer
Reason for Inspection: Routine
Title:
Entry Time: 10:00 AM
Certification:
1230 Mordecai Dr
Raleigh NC 276041343
Phone: [phone]
Phone:
Exit Time: 11 :30 AM
Phone:
Phone:
Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well (5A7)
Facility Status: ■ Compliant D Not Compliant
Question Areas:
■Welis
(See attachment summary)
Page: 1
Permit: WI0500042
Inspection Date: 07/10/2007
Inspection Summary:
Owner -Facility: Mims Hillis
Inspection Type: Compliance Evaluation Reason for Visit: Routine
WI0500042 Heat Exchange System working good, No problems. Effluent temperature was 38.9 degrees C and Influent
temperature was 31.3 degrees C.
Influent & Effluent Water Samples taken on 7-10-07
Lab Codes:
lnfl=7G0529
Effl=7G0530
Page: 2
North Ca itna Department of Environment an4 natural Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WI U r rya , e;�. DATE V 7 o it
NAME OF OWNER `7 ,,,)
ADDRESS OF OWNER IYJ:s ram. f / v�
(Street/ road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable) ► p- _
v r' de. ca. a_i 1b;Z t ve_ 'd1- f\ �-�t•� v S - , .� 0,U Cc L f`z2
/ 2)J i C'-JACK' / JG / 5,r^r'r_ d+ } / %�Z�r) ct r,ALl '
(Street! road or lot and subdivision , county, town, if different than owner's address, plus description of location on site)
Potential pollution source ue Distance from well
Potential pollution source fl2V .I Distance from well
Potential pollution source Distance from well
Minimum distance of well from property boundary •
Quality o ainage at site Flooding potential of site
equate poor) (high,moderat=ice
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, otentt'a! pollution sources, roads, approximate scale, and
north arrow.) /
L
DESCRIBE NJECTION SYSTEM (vertical closed loop, uncased borehole or 'cased water well; separate source well and
injection well; combination source and injection well; or other description as applicable)
�r A C �� — V Aet
4717? 9
��7

INJECTION FACILIT INSPECTION REPOT - -FORM B (CONTINUED,
WELL CONSTRUCTION
)
Date constructed �• 15 ���`� y �' - � )
Drilling contractor: Name))l 1 iec G ,LE.4 �..
Address 0 3 ` r ) ice• -- f'i s S t)Lf-• 4
lG , -t er_ // ) Al L j
Registration number
f _/A,,de L'-2 .
Total depth of well S345 Total depth of source well 6 , -
(f applicable)
Inspection point Measurement Meets minimum standards Comments
Yes No
Casing
Depth q-3 ' •�
Diameter '44 "
Height (A.L.S.) / `
Grout
Depth a — -to '
Screens
Depth(s) A /1.4
Length(s)
I.D. Plate
Static water level
Well yield
Enclosure
Enclosure floor
(concrete)
Sampling port
(labeled.)
Water tight pipe entry
Well enclosure entry
Vent
Ha
Functioning of heat pump system (Determine from the owner if heat pump functions properly)
,+F714%.I S 7171r't- le- t' r ) J rl 1 17 L - -' l I
INSPECT e-----: c-.1.•--1- Office -R+'p•S
Address
WITNESS Address riarchrt99&
WITNESS _ _.

03/09/2005 14:46 919-715-95ee
NCDESNR/WATER L IJAL
PAGE B1
Duration
Frequency/Accuracy of measurements
Other ( )
Pis Infed► ........,
Ch lorinatlon �.
Other.
Cuttinni
Construction (GW-1)
Abandonment (0W-30)
Wol1tsad Care et
Access port
Hose bib
Pitiess Adaptor
Pitlssa Adaptor Unit
Suction kne
Teo (jet)
Valved flow .. .
Vent _...,.
Water tight pipe entry
Well entry........•
Click Items
Measured
Meets twit,.
Yes
5landar is
i N9
•- ap.vcs
f0 nr. '. 3 S 5. �,� ► rt.oe' i
,</
L-
g ; ft%Jar °ate Sr _
_
rat d lh^P
Cam__
r
_
1 "s�`�b o►FArcii' -
c-
'-J
PCreai C-IPA 4 #-pr
16
L
Applies to wells constructed after December 1,1992
pgte Well Constructs 5 "e J S-AZ
• Perms installation
Pump Installat ontraetcr
Name Addrats
PUMP CONTRACTQFI IJQ. PL1IFRESENT ? (YIN)
Rep. l
Q1r..Pur p Instated .44 ?
Violations noted attributable to the pump installation contractor are as follows.
(1)
(2)
(3)
INSPECTOII
2
Nance Ciicr
Witn ess's)
(II Available) Name Address Type
Name
Address Tvaa
1

03/09/2006 14:19 919-715-05BB
NCDE8NP / WA TER QUAL
North Carolina
r •artment or Environment and Natural Res, -cgs
Division of Water duality
Groundwater Section
. WELL AND PUMP INSPECTION. FIEFKMT -7
Well Location:
(TovoCornrnunay. Subdivlsion and WWI
Owner i'77, •J-1 WI
Address. / 7— 4e:, 12./ts-d,
C heuck 51.3i.s:
ell ContractW ri, •
1743.12
Contractor ce on 0
Permit e
Location- Distance from:
Water Tight Sewage/waste collection
Waste disposal (septic tank drain field)
Other Poll. Source
Other Poll. Source (
Caslag
Type
Depth .
Weight/thickness ,
Height (A.,1__S.)
Other (
FluidsfAdditives
Type.
Grout
Type
ThIckrt ass
Depth ... „
Other ( ) -
$c_reen%
Screened interval
Other (
bevelonment,
Total Suspended solids
Turbidity
Settleable Solids
t.D. Plate
Well Contractor
Abandonment ...—
Temporary
.Permanent .
GW-35 Rev. 1/2000
PAGE 12
Date eS —
WELL TYPE „/ ).1e.ci—q4d;
Cc unty
Road/Street Pt
Quad No
Serial No
Lat. Long.
Well Construction U &At5‘.
)•4
Moro= C
Check hero
MgAsured
Meets Win.
Yea
Standards
No
im..aics
t.---1
(Permit No. )
. .
(aide efle)
Plastic Garber:TAM tsin. St Other
471S
..., /
Lis 2.
E4 me ck• bLervtf:
Applies to wells constructed alter December 1, 1992
(C;nrIt nn RrlivrIrAo:0

A3/09/2ee6 14:19 919-715-9588
NODE&hR/WATER QLIAL PAGE 19
gnu$ 54.

03/09/2006 14:19 919-715-0588
NCDEPARLWATER GILIAE=
a
1
is
ti
T
9 �
fr
T T
►•A• • • • fir••
( I
k f '
1! •'
e
I ' r
11►
Ii'
.._.sm.
s
Tr• neur •++.
pKotaINGER OF
!e
1234 tMORDECAI ORXVE
t7 • cAAT or 0 r+Rr& i Immo O
LOT�^'KOCK SECTION re
UMW $ROO weanirp n+ wEiK� C�JIYY �IEQl 11
mete =D Mr SOON OF MI?1 L. PAGE, ...•
CMOS s a - PAGE r•-; 7 - ,.j"r
.00
..mtvic.storio
Jpins
almeg ▪ ▪ E1•NUr.
PREP EF
■it1is$
Spas .
3604/20
slo ea!
DAVIOPi.MOLT
.ITj
KEI H J. rHAATmamm
rrteEt G0
y.�
GLENN D. WARP & ASSOCIATeS
GPM CFPGINSER a SuAVEYol5
RAiAZON, N.C.
ss• .. S 71 e
�• ...r-

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: June 20. 2007
To: D Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS
0 Andrew Pitner, MRO-APS
~ Jay Zimmerman, RRO-APS
From: Michael Rogers , Groundwater Protection Unit
Telephone: [phone]
E-Mail: [e-mail]
A. Permit Number: WI 0500042
B. Owner: Mims and Tannis Hillis
C. Facility/Operation: __
0 Proposed
D. Application:
~ Existing
0 David May, WaRO-APS
□ Charlie Stehman, WiRO-APS
□ Sherri Knight, WSRO-APS
Fax: [phone]
D Facility D Operation
1. Permit Type: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D I/E Lagoon D GW Remediation (ND)
~ UIC -(5A7) open loop geothermal __
For Residuals: □ Land App. 0 D&M
D 503 D 503 Exempt
D Surface Disposal
D Animal
2. Project Type: D New D Major Mod. D Minor Mod. ~ Renewal D Renewal w/ Mod.
E. Comments/Other Information: D I would like to accompany you on a site visit.
Note: The requested days for the submittal of the staff report (SR) has changed. Per the request of Debra
Watts. the requested dates for the submittal of the SR have been changed to 2 weeks for a UIC report. and
4 weeks for a SFR report.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 14 calendar days, please take the following actions:
~ Return a Completed APSARR Form.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certific'ation from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: ------------------Date: _____ _
FORM: APSARR 07 /06 Page 1 of 1
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins Director
Division of Water Quality
June 15, 2007
MIMS HILLIS
1230 MORDECAI DR
RALEIGH NC 27604-1343
Subject: Acknowledgement of Application No. WI0500042
Mims & Tannis Hillis SFR
Injection Heating/Cooling Water Return Well (5A7)
Wake County
Dear Mr. Hillis:
The Aquifer Protection Section of the Division of Water Quality (the Division) acknowledges receipt of
your permit application and supporting materials on June 14, 2007, This application package has been
assigned the number listed above and will be reviewed by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if
necessary. To ensure the maximum efficiency in processing permit applications, the Division requests
your assistance in providing a timely and complete response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior
to final action by the Division. Please also note at this time, processing permit applications can take as
long as 60 - 90 days after receipt of a complete application.
If you have any questions. please contact Michael Rogers by phone at [phone] or by email at
[e-mail]. If the reviewer is unavailable, you may leave a message, and they will
respond promptly. Also note that the Division has reorganized. To review our new organizational chart,
go to http:llh2o.enr.state.nc.usldocumentsldwq_ori_=chart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES
ON THIS PROJECT.
S incerel
For Debra J. Watts
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Permit Application File W10500042
Aquifer Protection Section 1636 Mail Service Center
Internet: www.nawaterouaiitv.nra Location: 2728 Capital Boulevard
An Equal Opportunity/Affirmative Action Employer- 50% Recycledll0% Post Consumer Paper
,pith Carolina
;IVaturtzlf j/
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax I: [phone]
Fax 2: [phone]
Customer Service: [phone]

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 of NCAC Title 15A: 02C.0200
complete application and mail to address on the back page.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: O , 20 a ?
A. PERMIT APPLICANT
Permit Number: het' 0 $ OOD #' Z (WION#14#/#, listed at the bottom of each page of your permit)
Name: .."47.1•N s t 4 /f s
Address: / a 8 .1 w P ore
City: ePsrl C 7 4
County: Wit ITC e
State: Fr G Zip code: 2 7 4 d 41
Telephone: T f 4 — ,/ .r— 6'3.z d
B, PROPERTY OWNER (if different from applicant)
Name:
Address:
City: State: Zip code:
County: Telephone:
C. STATUS OF APPLICANT
Private: lr- 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 describe commercial facility:
Revised 7/06
GW/UIC-57 HPR Page 1 of 3

E. INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
n • ~ • ,,/,' F, 'c ., t , 'e> .. s
F. 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 __
(2) Your personal consumption? YES__ NO~
G. CONSTRUCTION DATA
H.
(1)
(2)
Specify any and all modifications to the well . casing, grout or screens since the issuance of the previous
injection permit.
ho ,,,.,,,,.of,'/;'c4, ~~ .. ,
NC. State Regulations (15A NGAC, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes. A fatldet on botii influent (groundwater entering heat pump) and
effluent (water being injected into the well) lines is required. Is there a faucef on:
(a) the influent line? YES ~ NO__ .
(b} on the-effluent line? YES~ NO __
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)
I. 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).
J. 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.
K. 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
L. 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.
#'I -,.,._17 ~/ I~/ e 4 h ~,,,, 5
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."
(Signature of Well Owner or Authorized Agent)
If authorized agent is acting on behalf o, f 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(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 Well 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
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Revised 7/06
GWIUIC-57 HPR Page 3 of 3

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: WZ O 5 000 to
Permittee Name: r'1►`r6, 5 f r 1/i 5
Address: /.Z /0-?.#dec4,. 431. I t/e/y !,reC SZ 7649
Please check the selection which most closely describes the current status of your injection well system:
1) ells} 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) ( Well(s) permanently abandoned
c) ( Well(s) not abandoned
4) ( Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description ofhow the well
was sealed and the type of material used to fill the well if pernianenily abandoned)
Permit Rescission:
If you Checked (2), (3), or (4) and will not use a well for injection on this site in the future, you should request rescission of the
permit. Do you wish to rescind the per it?
( Yes
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."
` � •2 GA?
Signature Date
Revised 5/05 GWIUIC-68

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Namral Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
May 24, 2007
Mims & Tannis Hillis
1230 Mordecai Drive
Raleigh, NC 27604-1343
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7006 2150 0003 5466 2948
Subject: Notice of Regulatory Requirement
Injection Heating/Cooling Water Return Well (5A7)
UIC Permit No. W10500042
Mims & Tannis Hillis SFR
Wake County
Dear Mr. & Mrs. Hillis:
The Underground Injection Control (LTIC) 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. The purpose of this letter is to inform you. as the current property
owner. of your responsibilities pertaining to injection well rules.
The permit referenced above was issued for the construction and operation of a geothermal heat
pump injection well at 1230 Mordecai Drive in Raleigh, North Carolina. This permit will expire
on July 31, 2007. This office attempted to bring your injection well into compliance by sending
you a Notice of Expiration, a blank permit renewal application, and an injection well status form
in March 28, 2007. To date the i TIC Program has not received either the renewal application or
the status form. Please note that, as stated in PART VIII of your permit, a renewal application is
to be submitted at least 3 months prior to the expiration of this permit.
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 APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP 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 GW/UIC-68) if the injection
well is inactive or has been temporarily or permanently abandoned.
N% Carolina
)Vaturalli
Aquifer Protection Section 1636 Mail Service Center
Internet: www.nuwazerquaiitv.oro Location: 2728 Capital Boulevard
An Equal CppartunItylAfflrmative Action Employer— 50% Recycledf10°% Post Consumer Paper
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

Mims & Tannis Hillis
May 24, 2007
Page 2 of2
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. If the well is to be permanently abandoned, a well abandonment record must be
submitted to our office to certify that the abandonment was properly conducted.
Again, we have provided you with the appropriate materials to update your UIC permit. You
must respond within 30 calendar days of the receipt of this letter, or a Notice of Violation will be
issued to you, which carries the possibility for an assessment of fines or cessation of operation of
the injection well system. Please call me at [phone], or email me at [e-mail] if
you have any questions about this correspondence, the UIC Program, or the enclosed forms.
Sincerely,
~~
Qu Qi, P.G.
UIC Program Manager
Enclosures
1. GW /UIC-57 HPR
2. GW /UIC-68
cc: Raleigh Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0500042 w/o enclosures
Search Results
REID:
OWN5R1:
ADDR1:
ADDR2:
ADDR3:
DEED BOOK:
DEED PAGE:
DEED DATE:
DEED ACRES:
BLDG VAL:
LAND VAL:
BILLING CLASS:
DESCRIPTION:
MAP NAME:
PIN NUM:
PIN EXT:
CITY:
PLAN JURIS:
TOWNSHIP:
YEAR BUILT:
SALEPRICE:
SALEDATE:
TYPE USE:
DESIGN STYLE:
UNITS:
LAND CLASS:
OLD PARCEL NUMBER:
0059491
HILLIS , MIMS B JR &
TANNISW
1230 MORDECAI DR
RALEIGH NC 27604-1343
07930
0486
3/2/1998
0.21
142940
70000
INDIVIDUAL
LO17 & PT 18 MORDECAI
BM1920-110
170416
1704943961
000
RAL
RA
RALEIGH
1923
190000
3/2/1998
Single Family
Conventional·.
O·
RESIDENCE-< 10 ACRES-
HOME SITE
G043-G0220-001 O
RALEIGH SITE ADDRESSES 1
STREET NUM: 1230
STREET SUITE:
STREET DIR PRE:
SliREET NAME:
STREET TYPE:
STREET DIR SUF:
ADDRESS TYPE:
ADDRESS STATUS
CODE DESCR:
MORDECAI
DR
Parcel
ACTIVE
http://imaps.co.wake.nc.us/imaps/txt_CAMA.asp?pin=1704943961&pinext=OOO
Page 1 of 1
5/24/2007
North Carolina
r 'artment of Environment and Natural Res,- -ces
Division of Water Quality
Groundwater Section
1
Well Location: /PararaC.
[Tow4ommunity, Subdivision and Lot No.)
/72" rra sue. ,/•
1b 2.. r.
.,.4 /u( 744,41
Clftr 3,;, ate.
Well Contrac?/('.lt2 R'
Contractor Cert aion # Z.,
•
Permit Re uired )
Location - Distance From;
Water Tight Sewage/waste collection
Waste disposal (septic tank drain field)
Other Poll. Source ( }
Other Poll. Source ( }
Casing
Type
Depth
Weight/thickness
Height (A.L.S.)
Other ( j
Drilling Fluids!Atfditives
Type
Grou
Type
Thickness ...
Depth
Other ( j
Screens
Screened interval
Other ( 1
Development
Total Suspended solids
Turbidity
Settleable Solids
1.D. Plate
Well Contractor
Abandonment ...,
Temporary
Permanent
GW•36 Rev. 1/2000
Date —ate
WELL TYPE ! �•�� c {
County Lae."--).*
Road/Street_
Quad No
Serial No
Lat..�
Well Construction 6 t15.7-. G{6.) � Fi s
Address
Check Items
Measured
Meets Min.
Yes
Standards
No
Renarks
)
(Permit No.
t✓
(Circle one)
Other
Plastic Cartorc-Galy. Main. St.
ii S
:..,4x,�
v
Applies to wells constructed after December 1, 1992
(Cnnl nn Rnvarsn

Well Test
)
Check Items
Measured
Meets Min.
Yes
Standards
No
I�em_arks
Duration
Frequency/Accuracy of measurements
Other (
Disinfection
L.•-•-
Chlorination
Other (
]
Cuttings
Nrfl
,
Reports
`..---
Construction (GW-1) -
Abandonment (GW-30)
Well Head Completion
.....
c�
Pe a S ,t
=
+ -
Access part
Hose bib
Pitless Adaptor
Pitless Adaptor linit
Suction line _
Tee (jet)
Valved flow
Vent
Water tight pipe entry
Well entry
Applies to wells constructed after December 1, 1992
Date Well Constructed
Pump Installation
lee e) pi (CA0 4`iG-71vt e 4 a! / .r1
Pump Installatontractor C—]
Name Address
PUMP CONTRACTOR l.D. PLATE PRESENT ? (Y/N) Date Pump Installed Q {c.�C�
Violations noted attributable to the pump installation contractor are as follows:
(1)
(2)
(3)
Reg. #
INSPECTOR F�
Witness(es)
(If Available)
Name
Office
Name
Address Type
Name
Address Type

0FWA7-9
0 i
Michael F. Easley, Governor
William G. Ross Jr„ Secretary
North Carolina Department of Environment and Natural Resources
Man W. Klimek, P.E. Director
Division of Water Quality
March 28, 2007
Mims Hillis, Jr.
1230 Mordecai Drive
Raleigh, NC 27604
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7006 2150 0003 5465 0631
Subject: Notice of Expiration
Injection Heating/Cooling Water Return Well (5A7) Permit
UIC Permit No. WI0500042
Hillis, Jr., Mims - SFR
Wake County
Dear Mr. Hillis:
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 system on your property at 1230 Mordecai Drive in
Raleigh, North Carolina will expire on July 31, 2007. In addition, our records do not indicate
that the injection well system has been abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title I SA, Subchapter 2C. Section _02 11, you must take one of the following
actions:
A. Submit the form RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITHA
HEAT PUMP SYSTEM (form GW/UIC-57 HPR) if the injection well system on your
property is still active;
B. Submit the form S7.4TUSOFINJECTION WELL SYSTEM (form GW/UIC-68) if the injection
well system is inactive or has been temporarily or permanently abandoned.
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. If the injection well system is to be permanently abandoned, the well
abandonment record(s) must be submitted to our office to certify that the abandonment was
Aquifer Protection Section 1636 Mail Service Center
lttternet: www.ncwatereruaiitv.ora Location: 2728 Capital Boulevard
An Equal Opportunity/Affirmative Action Employer-5D% RecyCledllO% Post Consumer Paper
1 o hCarolina
,Naturally
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax [phone]
Fax 2: (9i9)71 a-6048
Customer Service: [phone]

Mons Hillis
March 28, 2007
Page 2 of 2
properly conducted. If the injection well system 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 permit or injection well rules, or if you would like assistance
completing these forms please call Qu Qi at [phone], or email him at tiu.uir ncmail.net.
Sincerely,
Jesse Wiseman
Aquifer Protection Section
Enclosures
] . GWI[JIC•57 HPR
2. GWIUIC-68
cc: Raleigh Regional Office - APS w/o enclosures
APS Central Files - Permit No. WI0500042 w/o enclosures

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
May 9, 2006
Mims Hillis
1230 Mordecai Drive
Raleigh, NC 27604
Ref: Injection Well Sample Results
SFR Irrigation Pem3it # WI0500042
Type 5A7 Injection Well
Dear Mr. Hillis:
On March 20, 2006 Mr. Jim Greer of the Aquifer Protection Section's Raleigh Regional Office
conducted an inspection of your injection well associated with your geothermal heating/cooling
system. As a part of this inspection Mr. Greer collected samples of the well water entering your
heat pump system (influent) and of the water exiting the system (effluent). Laboratory test
results indicate there are no water quality problems, and a copy of the test results is included for
your reference.
Our records indicate that your permit is due to expire on July 31, 2007. As stated in Part VIII of
your permit you are reminded to request renewal of your permit at least three months prior to the
expiration date. For your convenience a permit renewal application is enclosed for future use.
This form is also available on our website at httlt://h2o.enr.state.nc.us/aps/sinnl/docl.lments/GW-
57HP.pdf.
Please contact me at 919-715-6166 or Thonias.Slusserrrr ncrnail.net if you have any questions or
need assistance.
Best regards,
)4,141-LQ
Thomas Slusser
Hydrogeological Technician II
Underground Injection Control Program
enclosure
:c.! W10500042 permit file
NnthCaralina
Naturally
Aquifer Protection Section 1636 Mail Service Center
Internet: ham://www.novaterylt�litv.orr 2728 Capital Boulevard
Raleigh, NC 27699-1 636
Raleigh, NC 27604
An Equal Opportunity/Affirmative Action Employer- 50% Recycledfl0%Past Consumer Paper
Telephone: [phone]
Fax 1: [phone]
Fax 2: [phone]
Customer Service: (877) 6623-6748

NC Division of Water Tiaality Laboratory Section Resv'fs
Loc. Dasar,: MIMS HILLIS UIC EFFLUENT
Location ID; RROAPNLC
County: Wake
River Basin
Report To RROAP
Region: RRO
Collector: J GREER
Sample Matrix: GROUNDWATER
Loc. Type: WATER SUPPLY
Sample Depth
Collect Date: 03/20/2006
Collect Time:: 09:15
Sample ID: AB02213
PO Number # 6G0464
VlsitID
Date Received: 03/20/2006
rime Received: 10:30
Labworks LogIniD JWA
Date Reported: 04/26/2006
Analyte Name
PQL Result Qualifier Units Approved By
LAB
Sample temperature at receipt by lab
MET
At by ICP 50
Ca by ICP 0.10
Cr by ICPMS 25
Cu by ICPMS 2.0
Fe by ICP 50
K by ICP 6.10
Mn by ICPMS 10
Na by ICP 0.10
Ni by ICPMS 10
Pb by ICPMS 10
Zn by 1CP 10
MIC
5.2
50 U
25
25 U
190
50 U
2.9
10 U
13
19
10 U
51
"C
JGOODWIN
ugiL RBYRD
mg1L RBYRD
ug/L RBYRD
ug/L RBYRD
ug/L RBYRD
mg/L RBYRD
ug/L RBYRD
mglL RBYRD
uglL RBYRD
ug/L RBYRD
ug/L RBYRD
Caliform, MF Fecal in liquid 1 1 B2 CFUl100m1 CGREEN
Coliforrn, MF Total in liquid 1 1 B2 CFUl100m1 CGREEN
NUT
Nitrate as N in tiquld 0.01 3.3 mg/L as N CGREEN
Nitrite as N in liquid 0,01 0.01 U mgJL as N CGREEN
NO2+NO3 as N In tiquld 0.02 3.3 mglL as N CGREEN
WAR()
Alkalinity4,5 67 mg/t. as CaCO3 CGREEN
Alkalinity8,3 1 U mg/L as CaCO3 CGREEN
Bicarbonate 67 mg/L as CaCO3 CGREEN
Carbonate 1 U mg/L as CaCO3 CGREEN
pH 6.1 mg/L as CaCO3 CGREEN
WET
Chloride in liquid 5 18 mg/L CGREEN
Total Dissolved Solids in liquid 10 175 mg/L CGREEN
AQUIFER OT ECN/EW
SECTION
MAY 0 4 2006
Laboratory Sectlonan 1623 Mall Service Canter, Raleigh, NC 27699-1623 [phone]
Page 1 of 1

DIVISION OF WATER QUALITY
Chemistry Laboratory Report / Ground Water Quality
COUNTY: WAKE SAMPLE PRIORITY
QUADNO: (!]ROUTINE □EMERGENCY
REPORT TO _RR_O _________ Rcgional Office
COLLECTOR($) :_J_G_RE_E_R _____ _
DA TE: 3n0/2006
TIME: 9:15
□ CHAIN OF CUSTODY @ '.¥~/veJ-~ SAMPLE TYPE
PURPOSE: COMPLIANCE Owner: MIMS HILLIS
Location or Site: 1230 MORDECAI DRIVE RALEIGH NC 27604
Description of sampling point _____________________ _
Sampling Method:
Remarks: UIC EFFLUENT WI0500042
LABORATORY ANALYSIS
BOD3IO mg/L X Diss. Solids 70300 175 mg/L Ag-Silver 46566
CODHigh340 mg/L Fluoride951 mg/L X Al-Aluminum 46 557
CODLow335 mg/L Hardness: total 900 mg/L As-Arsenic 4655 I
X Coliform: MF Fecal 31616 1 B2 /lOOml Hardness: (non-carb) 902 me/L Ba-Barium 46558 -
X Coliform: MF Total 31504 1B2 /lO0ml Phenols 32730 ug/L-X Ca-Calcium 46552
TOC mgll Specific Cond. 95 umhos/cm2 Cd-Cadmium 46559
Turbidity N1U Sulfate mg/L X Cr-Chromium 46560
Residue., Suspended 530 mg/L Sulfide745 m2/L X Cu-Copper 1042
Total Suspended solids mg/L MBAS mg/L X Fe-Iron 1045 ·
Oil and Grease mg/L Hg-Mercury 71900
pH 6.1 units Silica m(¥L X K-Potassium 46555
X Alkalinity to pH 4.5 67 mg/L Boron Mg-Magnesium 927
Alkalinity to pH 83 1U mg/L Formaldehyde m2/L X Mn-Man~ese l 055
Carbonate 1U mg/L NH3 as N 6IO mg/L X Na-Sodium 929
Bicarbonate 67 mg/L TKNasN625 mg/L X Ni-Nickel
Carbon dioxide mg/L X NO2 +NO3 as n 630 3.3 mg/L X Pb-Lead 46564
~ -ride 18 mg/L P: Total as P 665 mg/L Se-Selenium
.. _ Jmium: Hex 1032 ug/L P04 mg/L X Zn-Zinc 46567
Color: True 80 c.u. Nitrate (NO3 as N) 620 3.3 mg/L
Cyanide720 m(¥L Nitrite (N~ as N) 615 0.01U m(¥L
COMMENTS:
ug/L
SOU ug/L
ug/L
ug/L
25 mg/L
u2/L
25U ug/L
190 ug/L
SOU ug/L
ug/L
2.9 mglL
mg/L
10U ug/L
13 mg/L
19 ug/L
10U ug/L
ug/L
51 ug/L
Lab Number : AB02213
Date Received : 3/20n006
Time Received : 10:30 AM C),~By4~·~/D ~
·~ leleased By : SMM
Date reported : 4(24/2006
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
Semivolatiles
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
AB02213
GROUNDWATER FIELD/LAB FORM
County
Quad No Serial No
Lat. Long. 'ice"
Report To: ARO, FRO, MRO RO)WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust ntral Off., Other:
Shipped by: Bus, Courier, Other-
Collector(s)-r-.?,-' Date ! `7/
=L� ANALYSES Owner .fr"72'
4AMPLE TYPE SAMPLE PRIORITY
121 Water [r Routine
❑ Soil ❑ Emergency
❑ Other
0 Chain of Custody
plies ,(• / Spec. Cond. 1 at 25° C
94
Temp.10 Lam:. °C Odor 4 i r'
Appearance (J --►.
Field Analysis By:t c. 1�-�-
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
p8b .73Lab Number /
Date Received Time / /'-7
Rec'd by• // nit/L./ From: Bus, Courier, an e .
Other:
Data Entry By.
Ck:
Date Reported:
Purpose:
Baseline, Com IaInt, oJjaLUSB , Pesticide Study, Federal Tr her: �2 u) =
Location or site 12 27 �.a
Description of sampling point
Sampling Method
Remarks
um• &wer, 8to
.��
-Sample-interval
LABORATORY ANALYSES 2. i3- ,.,i C-=---).:2 C )SJ2,->ir q
BODS 310 mgll
54
Diss. Solids 70300 mail
Ag - Silver 46566 ugll
Organochlorine Pesticides
COD High 340 _ mgll
r
Flouride 951 mg/l
>'
Al - Aluminum 46557 ugll
Organophosphorus Pesticides
COD Low 335 mg/I
X
Hardness: Total 9001'4') z mall
As - Arsenic 46551 uq/l
Nitrogen Pesticides
Coliform: MF Fecal 31616 1100m1
Hardness (non -cart) 902 mgii
Ba - Barium 46558 ugll
Acid Herbicides
Coliform: MF Total 31504 /100ml
Phenols 32730 ugll
?''
Ca - Calcium 46552 mall
PCB's
TOC 680 mgll
Specific Cond. 95 uMhoslcrnz
Cd - Cadmium 46559 uq/1
Turbidity 76 NTU
Sulfate 945 m lg^I
X
Cr - Chromium 46560 uq/1
Residue., Suspended 530 mg/1
Sulfide 745 mq/I
Cu - Copper 46562 ugll
>,--
Fe - Iron 46563 ugll
Semivolatile Organics
Oil and Grease mglt
Hg - Mercury 71900 ugll
TPH - Diesel Range
P" 4a3N dJ j- nct-units
}C
K -Potassium 46555 mgll
:>,
Alkalinity to pH 4.5 410 mall
Mg - Magnesium 46554 mg/l
Alkalinity to pH 8.3 415 mgll
_
).4
Mn - Manganese 46565 ugli
Carbonate 445 mg/1
NH, as N 610 mall
>
Na - Sodium 46556 mall
Volatile Organics (VOA bottle)
Bicarbonate 440 mq/I
TKNI as N 625 mall
)
Ni - Nickel ugll
TPH - Gasoline Range
Carbon dioxide 405 mgll
X(
NOe + NO, as N 630 mg/1
x
Pb - Lead 46564 ugll
TPH - BTEX Gasollre Range
Chloride 940 mgll
P: Total as P 665 mqil
Se - Selenium ugll
Chromium: Hex 1032 ugll
)(Zn
- Zinc 46557 uq/1
Color: True 80 CU
Cyanide 720 mall
Lay Comments: CTLa rmi 's [�'�' �. 243t L�r 1 1.-Y2C_:-J ,+'�,rr- -- r,,��1G �i r�%�) 4-14 �� 771, J1 . < - • zZ
i7 + M1I 0 -2, <i s" 4 r r-�.f x� L: .4 7� ce' '; z 2 p2 Cs
rrl .4 - h : ,I v- ✓t; 63 - 2 D
GW-54 REV. 121; For Dissolved Analysis - submit filtered sample and write "DIS" in be

NC Divi$ion of Water r ality Laboratory Section Resur ··
r
Loe. Descr.: MIMS HILLIS UIC INFLUENT
'Location ID: RROAPNLC
County: Wake
River Basin
ReportTo . RROAP
- \ 1\)~
Sample ID: AB02212
{ PO Number# 6G0463
¥· VisltlD
Region:· RRO Date Received: 03/20/2006
Collector: J GREER Time Received: 10:30
Sample Matrix: GROUNDWATER
Loe. Type: WATER SUPPLY
--~
Labworks LoginlD JWA
4 /:J.& /vro Sample Depth
Collect Date:· 03/20/2006
Collect Time:: 09:00
nalyte Name
LAB
Sample temperature at receipt by lab
MET
Al by ICP
Ca by ICP
Crby ICPMS
Cu by ICPMS
Fe by ICP
Kby ICP
Mn by ICPMS
Na by ICP
Ni by ICPMS
Pb by ICPMS
Zn by ICP
MIC
Coliform, MF Fecal in liquid
Coliform, MF Total in liquid
NUT
Nitrate as N in liquid
Nitrite as N in liquid
NO2+NO3 as N in liquid
WARO
Alkalinity4.5
Alkalinity8.3
Bicarbonate
Carbonate
pH
WET
Chloride in liquid
Total Dissolved Solids In liquid
PQL
50
0.10
25
2.0
50
0.10
10
0.10
10
10
10
0.01
0.01
0.02
5
10
Result
4.6
50
26
25
180
50
2.9
10
13
18
10
52
1
3.3
0.01
3.3
63
63
6.1
20
170
Date Reported:
Qualifier
u
u
u
u
u
82
82
u
u
u
Laboratory Section» 1623.Mail Service Center, Raleigh, NC 27699-1623 [phone]
PaQe 1 of 1
04/26/2006
Units Approved By
oc JGOODWIN
ug/L RBYRD
mg/L RBYRD
ug/L RBYRD
ug/L RBYRD
ug/L RBYRD
mg/L RBYRD
ug/L RBYRD
mg/L RBYRD
ug/L RBYRD
ug/L RBYRD
ug/L RBYRD
CFU/100ml CGREEN
CFU/100ml CGREEN
mg/Las N CGREEN
mg/Las N CGREEN
mg/Las N CGREEN
mg/L as CaCO3 CGREEN
mg/L as CaCO3 CGREEN
mg/L as CaCO3 CGREEN
mg/L as CaCO3 CGREEN
mg/L as CaCO3 CGREEN
mg/L CGREEN
mg/L CGREEN
RECEIVED/ DENR/ OWQ
AQUIFER PROTECTION SECTION
MAY O 4 2006
COUNTY : WAKE
QUASI NO:
DIVISION OF WATER QUALITY
Chemistry Laboratory Report / Gravid Wstcr Qudily
SAMPLE PJtl¢RD Y
QROUI1N1'EEMERGENCY
REPORT TO RRO Regional Office CHAIN OF CUSTODY
W❑ SAMPLE TYPE
MIMS HILLIS
COLLFCIiOR(S) J GREER
DATE: 3n6f2006
TIME: 3:00
PURPOSE: COMPLIANCE ()woer-
LABORATORY ANALYSIS
BOO 310
mg/l.
con High 340
mg/L
COD Low 335
mg/L
X
Caliform: MF Fecal 31616
1 B2
II00ml
3C
Coiiform: MFTotal 33504
1B2
Il00ml
Inc
mgll
Turbidity
NW
Residue., Suspended 530
mg,R.
Total Suspended solids
mglL
PH NS PER OS
6.1
units
X
Alkalinity to pH 4.5
53
mg/L
Alkalinity to pH 8.3
1 U
ing/L
Carbonate
1U
mgJL.
Bicarbonate
03
mg/L
_
Carbon dioxide
m 'L.
biocide
20
mg/L
hsomium: Hex 1032
ug/1.
[Color: True 80
cm.
yanide 720
mg/L
COMMENTS :
Location or Site:
Description of sampling point
Sampling Method:
Remarks:
1230 MORDECAI DR
RALEIGH NC 27601
IIIC INFLUENT
W30500042
X
Dias. Solids 70300
170
inglL
Fluoride 951
mg/L
Hardness: total 900
NS PER D5
mg/L
Hardness: (non-carb) 902
mg/L
Phenols 32730
ug/L
Specific Cod_ 95
umhuslc n2
Sulfate
mg/L
Sul fide 745
mg/L
MBAS
nig/E_
Oil and Grease
mg/L
Silica
mg/1.
Boron
Formaldehyde
ritg/L
Nli3 as N 610
mg(L
TKM as N 625
ing/1.
X
NO2 +NO3 as n 630
3.3
mg/L
P: Totn! as P 665
milt
PO4
mg/L
Nitrate (NO3 as N) 620
3.3
mg/L
Nitrite (NO1 as N) 615
0.010
mg/1.
Ag-SiIvcr 46566
rig&
X
AI -Aluminum 46557
50U ugli.
As -Arsenic 46551
_ - ug/L
Ba-Barium 46558
ug/1.
X
Ca -Calcium 46552
28 mg/L
Cd-Cadmium 46559
ug/L
X
Cr-Chromium 46560
25U ug/L
x
Cu- Capper 1042
180 ug/L
x
Fe -Iran 1045
50U ugJ1
11g- Mercury 7 3900
ng/L
1(
IC -Potassium 46555
2.9 mg/L
Mg- Magnesium 927
mg/L
X
Mai -Manganese 1055
10U ug/L
7C
Na- Sodium 929
13 mill.
X
Ni-Nickel
18 ug/L.
1[
Ph -Lead 46564
10U ug/I.
Se -Selenium
ug/L
X
7n-Zane 46567
52 ug/L
Lab Number : AS02212
Date Received : 3/2012006
Time Received - 30:30 AM
Received Fay : HMW
97,c.
Date reported : 4n4I20o6
Orgenochlarine Pesticides
Orgenophasphonis Pesticides
Nitto_gen Pesticides
Acid Herbicides
Sauivoladlits
1PH-Diesel Range
Volatile Organics (VOA home)
TPH-Gasoline Range
TPFi-BTEX Gasoline Range

GROUNDWATER FIELD/LAB FORM
County I c�
Quad No Serial No
Lat % 3 Long '7' ' �'
r t�RUF�PaLC1 = LoCctfzov Code
+Report To: ARO, FRO, MRO, AB IaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other
Shipped by: Sus, Couri
Collector(s):_. Date 3l� 0/-VZ.
1ELD ANALYSE / `
pH400 C . G Spec. Cond.94 g2r,. J at 25° C
Temp.10 1 '.' ' °C Odor /1o4-
Appearance Clan x
Field Analysis By:
SAMPLE TYPE
Igt Water
❑ Soli
❑ Other
SAMPLE PRIORITY
Routine
Emergency
❑ Chain of Custody
Other-_ -
Time
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
Purpose:
Baseline, Complai
Owner r.
Location or site ; 2—
Description of sampling point
Sampling Method
Pi 0 1 Lab Number
Date Received Time /0 3 7
Ftec'd by -
From: Bus, Courier, 6and D
Other
Data Entry By: Ck-
Date Reported:
om Iiaace L USr, Pesticide Study, Federal Tfulst- ❑there J
-- , --L h ) S Syrl�
Sample Interval
I/
[
Remarks PJnnP. naJ�, Brc.I
LABORATORY _ CIALYSES _ . _ .s. il--__. /.:"r?S iDnr2).,;
BODS 310 mgl!
Ai
Diss. Solids 70300 mo/1
Aq - Silver 46566 ugll
Organochlorine Pesticides
COD High 340 mglt
Fiouride 951 mg/1
)<
Al - Aluminum 46557 ug/1
Organophosphorus Pesticides
COD Low 335 mg/1
X
Hardness: Total 900 N 5 I 05 mg/I
As - Arsenic 46551 uq/I
Nitrogen Pesticides
Coliform: MF Fecal 31616 1100m1
Hardness (non-carb) 902 mg/I
Ba- Barium 46558 ugll
Acid Herbicides
PCB's
A
Coliform: MF Total 31504 11130m1
Phenols 32730 ug/I
Ca - Calcium 46552 mg/1
TOC 680 mgll
Soecific Cond. 95 uMhoslcm2
Cd - Cadmium 46559 ugll
Turbidity 76 NTU
Sulfate 945 mg/1
Cr - Chromium 46560 uq/I
Residue., Suspended 530 mg/1
Sulfide 745 mg/1
Cu - Copper 46562 u2l1
Fe - Iron 46563 ug/1
Semivoiatile Organics
Oil and Grease mgll
Hg - Mercury 71900 ug/1
TPH - Diesel Range
pH 403 5 jay,
. v 0
K - Potassium 46555 mg/1
j�
Alkalinity o pH 4.5 410 gli
Mg - Magnesium 46554 mgll
r
Alkalinity to pH 8.3 415 mglt
Mn - Manganese 46565 41
Carbonate 445 mg/1
NH, as N 610 moll
j4✓
Na - Sodium 46556 mgll
Volatile Organics (VOA bottle)
Bicarbonate 440 mg/1
TKN as N 625 moll
)4,
Ni - Nickel ug/I
TPH - Gasofine Range
TPH - BTEX Gasolire Range
Carbon dioxide 405 mg/1
)(
NO, + NO, as N 630 Ati.i ,,aig/!
)-.
Pb - Lead 46564 ugll
X.
Chloride 940 mg/1
P: Total as P 665 mq/1
Se - Selenium ugl!
Chromium: Hex 1032 ugll
•>;
c.c.—cf.-0_,i,r.,_ _-
Zn - Zinc 46567 ug/1
Color. True 80 CU
.k
Cyanide 720 mg/1
Lab Comments: Ly4tv1-,Trv, �' �'�r'vt ( f-` r7 / J C S 4 �7=-� -Pl °'.1.) r/3�
GW-54 REV. 12f,
For Dissolved Analysis - submit filtered sample and write "DI5" in b'

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 03/20/2006
To: Aquifer Protection Section Central Office
Central Office Reviewer:
Regional Login No: 05
/tisSeW/
County: Wake
Permittee: Mims Hillis
Project Name: UIC
Application No.: WI0500042
L GENERAL INFORMATION
1. This application is (check all that apply): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporationllnfiltration Lagoon
❑ Land Application of Residuals
❑ Distribution of Residuals
❑ Attachment B included
E Surface Disposal
❑ 503 regulated ❑ 503 exempt
n Closed -loop Groundwater Remediation ® Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
a.
b.
c.
d.
Date of site visit: 03/20/2006
Person contacted and contact information: Mires Hillis , 9198330328
Site visit conducted by: JGreer
Inspection Report Attached: ® Yes or ❑ No.
2. Is the following information entered into the RIMS record for this application correct?
® Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a.
b.
c.
d.
Location:
Driving Directions:
USGS Quadrangle Map name and number:
Latitude: Longitude:
e. Regulated Activities / Type of Wastes (e.g., subdivision, food processing, municipal wastewater): NIA
For Disposal and Injection Sites:
(If multiple sites either indicate which sites the information applies to, copy and paste a new section into the
document for each site, or attach additional pages for each site)
a. Location(s): 1230 Mordecai Drive. Raleigh NC 27604
b. Driving Directions: From Raleinh. Person St 20 E ont Wake Forest Rd_ 5 Mks Turn L on Chestnut St &
Mordecai Dr. on L cornor.
c. USGS Quadrangle Map narne and number: D24SW
d. Latitude: 35.47.39 Longitude: 78.37.57
If. NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals orrminor
modifications, skip to next section)
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification:
FORM: WI0500042.MH 1

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No D N/A. Ifno, please explain: __
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No D N/A. Ifno, please explain: __
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes D No D N/ A. If no, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No0
NI A. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D N/A. 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 N/ A. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit: __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? ·D Yes D No D N/A. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: _. __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEW AL AND MODIFICATION APPLICATIONS (use previous section for new or maior modification
systems)
Description Of Waste (S) And Facilities
1. Are there appropriately certified ORCs for the facilities? D Yes or D No.
Operator in Charge: __ Certificate #: __
Backup-Operator in Charge: __ Certificate #: __
2. Is the design, maintenance and operation (e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D No.
If no, please explain:
FORM: WI0500042.MH 2
AQUIFER PROTEC.:TION SECTION REGIONAL STAFF REPORT
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
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 compliance
boundary, new development, etc.)? If yes, please explain: __
5. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
D Yes or D No. If no, please explain: __
6. Are the existing application rates (hydraulic or nutrient) still acceptable? D Yes or D No. If no, please
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program: __ __
8. Will seasonal or other restrictions be required for added sites? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, please attach a
map showing conflict areas or attach any new maps you have received from the applicant to be incorporated
into the permit: __
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? D
Yes or D No. Ifno, please explain: ____ _
11. Were monitoring wells properly constructed and located? D Yes or D No D N/A. If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? D Yes or
D No D N/ A. Please summarize any findings resulting from this review: __ _
13. Check all that apply: D No compliance issues; D Notice(s) of violation within the last permit cycle; D
Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc): ____ _
14. Have all compliance dates/conditions in th~ existing permit, (SOC, JOC, etc.) been complied with? D Yes
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 permit? D
Yes or D No D N/A. If yes, please explain: __
FORM: WI0500042.MH 3
AQUIFER PROTE(.;TION. SECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
~ Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation ( 51)
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? ~ Yes D No
3. Are there any potential pollution sources that may affect injection? D Yes IZ! No
What is/are the pollution source(s)? . What is the distance of the in'ection well s from the ollution
source(s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 25' ft.
5. Quality of drainage at site: ~ Good D Adequate D Poor
6. Flooding potential of site: IZ! 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: N/ A
8. Does the map presented represent the actual site (property lines, wells, surface drainage)?~ Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Iniection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation ( e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes ~ No. If yes, explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes IZ! No. If yes, explain:
3. For renewal or modification of groundwater remediation permits (of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes D No. If yes. explain: NIA
4. Drilling contractor: Name: Bing's Well DRLG
FORM: WI0500042.MH 4
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address: 6032 USl B/Pass
Kittrell NC 27549
Certification number: 2065
5. Complete and attach Well Construction Data Sheet.
FORM: WI0500042.MH 5
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVAL IJATION AND RECOMMENDATIONS
1, Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, please explain
briefly.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item
Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition
Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition
Reason
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information; EI
Issue; ❑ Deny. If deny, please state reasons:
8. Signature of report prep i er(s):
Signature of APS regional sup
Date: 7 z! oc'
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
System is runninc food. no Problems.
L--e-D4....1--ae
FORM: WI0500042.MH 6

Permit: W10500042
SOC:
County: Wake
Region: Raleigh
Compliance Inspection Report
Effective: 06/27/02 Expiration: 07/31/07 Owner: Mims Hillis
Effective: Expiration: Facility: Hillis, Jr., Mims- SFR
1230 Mordecai Dr
Raleigh NC 27604
Contact Person: Mims Hillis Phone: [phone]
Directions to Facility:
Primary ORC:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Certification: Phone:
Inspection Date: 03/20/2006 Entry Time: 09:00 AM Exit Time: 09:30 AM
Primary Inspector: Jimmie VV Greer phone: [phone]
Ext.246
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: injection Heating/Cooling Water Return Well (5A7)
Facility Status: ■ Compliant ❑ Not Compliant
Question Areas:
Other
(See attachment summary)
13-9P 6
Page: 1

Permit: WI0500042 Owner • Facility: Mims Hillis
Inspection Date: 03/20/2006
Inspection Type: Compliance evaluation Reason for Visit: Routine
Inspection Summary:
WI0500042 Heat Exchange System working good, No problems.
Otter
Comment:
s} NA NE
Page: 2

North Caroni... Department of Environment and Na.,.ral Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WI 05- pe ❑ 4 DATE zy4 01 z
NAME OF OWNER ill srrr 5 f II ,'S
ADDRESS OF OWNER i 3c1 7n rde. arordo
12.2- ec h c a�da
T, 9-33 c>33- S"
(Street/ road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable) i a-3a
to © d G e cs.. � 1 �� c� � � �` 1 �� , ?- J �. P LL f vnai`
� � f f'f"2 ,!>--? 0-4 e s 74i-i S I r'$"firFTIE)0.-1 C iw rJ e7r^
(Street/ road or lot and subdivision , county, town, if different than owner's address, plus description of location on site)
Potential pollution source 1.46e Distance from well
Potential pollution source ./ Distance from well
Potential pollution source
Distance from well
Minimum distance of well from property boundary S •
Quality * : ' age at site Flooding potential of site
dequate,poor) (high,moderat=r�►jr
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, otential pollution sources, roads, approximate scale, and
north arrow)
0
a
px
biz- 1
DESCRIBE NJECTION SYSTEM (vertical closed loop, uncased borehole ocased water well; separate source well and
injection well; combination source and )injection well; or other description as applicable)

INJECTION FACILI Y INSPECTION REPO' T -FORM B (CONTINUED)
WELL CONSTRUCTION
Date constructed 1` 15—) z7L17
Drilling contractor: Name -E::•i.44-'s !ate 1l
Address Os Z +r5
Registration number
)
41l
G5t
f) 4,3z)
= JL.
,Ls
G/.
Total depth of well 6—/5' Total depth of source well 5+4rrse
(if applicable)
Inspection point Measurement Meets minimum standards Comments
Yes No
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
(concrete) •
Sampling port
(labeled)
Water tight pipe entry
Well enclosure entry
Vent
(. 'ALA
I'
V-Zv'
/0
I24s4-► , £- y'. dw
.11 e_ n7ocrr.4sof d E19
Functioning of heat pump system (Determine from the owner f heat pump faenctions properly)
7;; e-k!/
INSPECT°
WITNESS 1
WITNESS
•
• Office
Address
Address
4440/ fat'
3/ / Ph'

TopoZone - The Web's Topographic Map, and more!
http:!/topozone.comlmao.asp?z= 17&n-3963719&e=713949&s=50&s...
- GET Data
MapIPhota Info
Topo Download t
Photo ❑ownioad
USGS Topo Maps
1:24K/25K Series
1:100K Series
1:250K Series
Map Size
Small
Medium
Large
View Scale
1. 50,000
Update Map I
Coordinate Format
❑IMIS
Coordinate Datum
WGS847NADe3
IDShow target
Email this map
Bookmark thls map
Print this map
gi 9i9loS ¢mP a 134T ..4*
Mr TaPOZoNr
Tradhaaa Take this map...
and customize it
Apol1T I15
35° 47' 39"N, 78° 37' 57"W (WGS84/NAD83)
USGS Raleigh West Quad
View TopoZone Pro aerial photos, shaded relief, street maps, interactive coordinate
a
0
0.7
1.9
2.1
2.9
0
0.4
0.0
1.2
1.6
TepoZone.cam ® 1999-2004 Maps a la carte, Inc. - All rights reserved.
Use of this site Is governed by our COndltIO1 5 and Terms of Use. We care about your privacy • please read our Privacy
Statement.
3.5
2 al
M=-a.06S
G=1.3B5
What's This?
1 of 1
3/10/2006 1:42 PM

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina ,.artment of Environment and Natural Resources
Alan W. Klimek, P,E. Director
Division of Water Quality
June 28, 2002
Mr. Mims Hillis
1230 Mordecai Drive
Raleigh, NC 27604
Dear Mr. Hillis:
In accordance with your application submitted on June 1 I, 2002, we are forwarding Permit No.
WI0500042 for the construction and operation of a geothermal heat pump injection system at
1230 Mordecai Drive, Raleigh, North Carolina, in Wake County. Water samples will be taken at
the influent and effluent sampling ports of your geothermal heat pump system after construction
is complete. Please note, if these sample results exceed groundwater quality standards, it is the
well owner's responsibility to take corrective action as stated in Title 1 5A Subchapter 2C,
Section .0206.
This permit shall be effective from the date of issuance until June 30, 2007, and shall be subject to
the conditions and limitations stated therein. In accordance with NCAC Title 15A, Subchapter 2C,
Section .0213(h), the well owner is responsible for submitting a record of well construction within
30 days of completion. The well construction data for every well constructed for this project should
be submitted on the GW-1 form and this forrn is enclosed for your convenience.
If you have any questions regarding your permit please feel free to contact Mark Pritzl at (919)
715-6166.
cc; CO-t]IC Files
RRO-UIC Files
Enclosures
ATA
Customer Service
1 800 623-7748
Sincerely,
J . U
Debra J. Watts
Permits & Compliance Supervisor
Division of Water Quality / Groundwater Section
1636 Mai! Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: http:llgw,ehnr.state.nc.us

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Mims Hillis Jr.
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5A7 INJECTION WELL,
defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(A), which will be used
for the injection of heat pump effluent. This system is located at 1230 Mordecai Lane, Raleigh,
in Wake County, North Carolina, and will be constructed and operated in accordance with the
application submitted on June 11, 2002, and in conformity with the specifications and supporting
data submitted, all of which are filed with the Department of Environment and Natural Resources
and are considered a part of this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the
Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an
injection well shall be in compliance with Title 15A North Carolina Administrative Code 2C
.0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well construction and
use.
This permit shall be effective, unless revoked, from the date of its issuance until July 31, 2007,
and shall be subject to the specified conditions and limitations set forth in Parts I through X
hereof.
Permit issued this the ,) \ _ day of , 2002.
Ted L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0500042 PAGE 1 OF 6
Ver.31O I GWIUIC-5

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (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 grave~ 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 well 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 -WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall
notify the Groundwater Section-Underground Injection Control (UIC), Central Office staff,
telephone number [phone].
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by~ the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
Permit No. WI0500042
Ver.3/01 GW/UIC-5
PAGE2 OF 6
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 ariy 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 IV -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 normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
c-onditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The 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.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Groundwater Section-Underground
Injection Control (UIC), Central"Office staff, telephone number [phone].
Notification is required so that Division staff can inspect or otherwise review the injection
facility and determine if it is in compliance with permit conditions.
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
Permit No. WI0500042
Ver.3/01 GW/UIC-5
PAGE3 OF 6
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples· of groundwater,
surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary
by the :Pi vision 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 VIII-PERMIT RENEWAL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
Permit No. WI0500042
Ver.3/01 GW/UIC-5
PAGE4 OF 6
PART IX -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(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.
(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. WI0500042
Ver.3/01
as specified in 1,5A 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 IX (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 X-OPERATION AND USE SPECIAL CONDITIONS
Water samples will be taken at the influent and effluent sampling ports from the
geothermal heat pump system after construction is complete. If the sample results reveal
violation(s) of groundwater standards, it is the well owner's responsibility to take
corrective action as stated in Title 15A North Carolina Administrative Code 2C .0206. In
addition, the well owner shall take immediate actions including those actions that may be
required by the Division of Water Quality such as repair, modification, or abandonment of
the injection facility.
Permit No. WI0500042
Ver.3/01 GW/UIC-5
PAGE60F 6
MEMORANDUM
DMSION OF WATER QUALITY
GROUNDWATER SECTION
June 28, 2002
To: Jay Zimmerman, L.G., Regional Groundwater Supervisor
Groundwater Section
Raleigh Regional Office
From: Mark Pritzl f'lf ~ [e-mail]
Hydrogeological Technician II
Underground Injection Control (UIC) Group
Central Office (CO)
Re: Request for inspection and sample collection of Mims Hillis geothermal injection well
system. This system is located at 1230 Mordecai Drive, in Raleigh, NC.
1. Please inspect the injection well site to verify that the location and construction plans
submitted in the application are accurate and the NCAC Title 15A 2C .0200 standards are
being complied with, using the enclosed Injection Facility Inspection Report (form B) as
appropriate.
2. Please -collect samples from the influent and effluent sampling ports and submit the
results to the CO-UIC Group.
You are requested to return the completed Injection Facility Inspection Report (form B) to
the CO-UIC by July 15, 2002. If the inspection can not be accomplished by this date,
please inform the CO-UIC group. The UIC group greatly appreciates Jim Greer's
assistance with this review. If you have any questions regarding this review or the UIC
program, please contact me at [phone] or Evan Kane [phone].
cc: UIC Files
Enclosure
•
Page 1 of 2
rr -it
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTION
REPORT -FORM A
INJECTION WELL PERMIT NO. WI DATE cc — D Z.
NAME OF OWNER S
ADDRESS OF OWNER
LI/
IZ���7fGJ�r cry. 1►��
A4C. .07Z f,a
(Street/road or lot and subdivision, county, town)
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable) ■�, — (V/� )
�7 "t r 'ter• SIC),- r�ir�-�� 1/ ��i► � . G�� 2 .
Fr,,,' ids 1 3a ' Fcv'- e, &I aj d- �� � �.� � �'Ac• ,01 e[-�
(Street/ road or lot and subdivision , county, town, if different than owner's address, plus description of location on site)
Potential pollution source U Distance from well
Potential pollution source Distance from well
Potential pollution source Distance from well
Minimum distance of proposed well from property boundary 'a
Quality of drainage at site Flooding potential of site
(_..r
adequate,poor) (high,moderate,CM.
DRAW SKETCH OF SITE
(Show property boundaries. buildings, wells, potential pollution sources, roads, approximate scale, and north arrow)
i
I :Z ad SZ Nfir Za
21%4°'
Ver.3/01
GW/UIC-1

Page 2 of 2
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cont.)
GPS Data:
Latitude: 5.d7 yi. Longitude: 7 fr7 ,
COMMENTS
t.1 4
1,fA1 c tttr�s
INSPECTOR {-L
Office 2--92..e / 4 S )
WITNESS
Address
WITNESS
Address
Ver3/01 GWfUIC-1

MEMORANDUM
DMSION OF WATER QUALITY
GROUNDWATER SECTION
June 13, 2002
To: Jay Zimmerman, L.G., Groundwater Supervisor
Groundwater Section
Raleigh Regional Office
From: Mark Pritzl /k~ [e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section·
Central Office
Re: Request for review of new injection well permit application (type 5A 7 open loop
geothermal.)
The CO-UIC has received a new application by Mims Hillis, for the construction and operation of
an injection well located at 1230 Mordecai Drive, Raleigh, NC. The proposed injection well will
be part of an open loop geothermal heat pump system, therefore a type 5A 7 well.
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 well site to verify that the location and construction
plans submitted in the application are accurate and that the NCAC Title 15A 2C.0200
standards are being complied with, using the enclosed Preconstruction Injection Facility
Inspection Report-Form (A) as appropriate.
Please return any comments immediately upon application review. You are requested to return the
completed Preconstruction Injection Facility Inspection Report-Form (A) to the CO-UIC by June
30, 2002. If the inspection can not be accomplished by this date, please inform the CO-UIC. The
UIC Group appreciates your assistance in the review and evaluation of this permit application.
Please contact me if you have any questions or comments at (91-9) 715-6166 or Evan Kane at(919)
715-6165.
cc: UIC Files
Enclosures
Michael F. Easley, Governor
Wiliam G. Ross Jr., Secretary
North Carolina L _,,artment of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
June 13, 2002
Mr. Mims Hillis Jr.
1230 Mordecai Drive
Raleigh, NC 27604
Dear Mr. Hillis:
Your application for a permit to use a well for the injection of geothermal heat pump
effluent 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 injection well and
collect water samples as part of the review.
If you have any questions regarding the permit or injection well rules please contact Mark
Pritzl at [phone].
cc: CO-UIC Files
RRO-UIC Files
ATA
NT"15L E NR
Customer Service
1 800 623-7748
Sincerely,
Evan G. Kane
Hydrogeologist
LTIC Program Manager
Division of Water Quality 1 Groundwater Section
1636 Mai! Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: http:llgw.ehnr.state.nc.us

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE4
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM(73
Type 5A7 and 5QM Wells
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: Maw 15 c a.
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1) Type 5A7 wells inject water used to provide heating or cooling for structures.
(2)
(3)
Type 5QM wells contain a subsurface system of continuous piping, that is
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes and/or corrosion
inhibitors.
Type 5QW wells contain a subsurface system of continuous piping, that is
isolated from the environment and only circulates potable water. If you selected
this well type, then complete form GW-57 CL, Notification Of Intent To
Construct A Closed -Loop Geothermal -Water Only Injection Well System.
B. PERMIT APPLICANT
Name: %^MS J1, /115 JR
Address: Q3 ❑ /iio,Pdeect r D,e,vr
City: f State: N.C. Zip Code: oj766y County: warn
Telephone: `7/ 7- I33 = 03 12
PROPERTY OWNER (if different from applicant)
Name:
Address:
City: Sate: Zip Code: County:
Telephone:
D. STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
GW-57 HP (May 1998) Page 1 of 4

E. FACILITY (SITE) DATA
F.
G.
H.
I.
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: ___________________ _
Address: __________________________ _
City: _________ Zip Code: ____ County: _______ _
Telephone: __________ Contact Person: _________ _
HEAT PUMP CONTRACTOR DATA
Name: 80L,Jm4;,/ l21ec£q/11C4 I ~v,cG'..S
Address: 1;; 19 Skrd, 'I/A-rTf-/)11, ·vb
City: ~lN;(.
Telephone: q/9-77;/A.-~7S9
Zip Code:» SI I County: _~_A_K◄_;e.. ___ _
Contact Person: S-1::.ve ~' 4),'1/A~
INJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.)
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES V
YES __ _
NO _C/_____,,,.-
NO ___ _
CONSTRUCTION DATA (check one)
(1)
(2)
(3)
EXISTING WELL being proposed for use as an injection well. Provide the data in
(1) through (7) below to the best of your knowledge. Attach a copy of Form GW-
1 (Well Construction Record) if available.
PROPOSED WELL to be constructed for use as an injection well. Provide the
data in (1) through (7) below as PROPOSED construction specifications. Submit
Form GW-1 after construction.
Well Drilling Contractor's Name: e,·n<;\ 's We.l\ D,--; ll,·~, 'INC. .
NC Driller Registration number: _cil._0_6_'l... _______ _
Date to be constructed: S-15-l>:Z... Number of borings: ___ _
Approximate depth of each boring (feet):_..5_/f._S _____ _
Well casing: Is the well(s) cased?
(a) YES ~ If yes, then provide the casing information below.
Type: Galvanized steel V Black steel __ Plastic __ Other (specify) ______ _
Casing depth: From + I to J./..2 ft. (reference to land surface)
Casing extends above ground I ~ inches
(b) NO
', --
GW-57 HP (May 1998) Page 2 of 4
• •
( 4) Grout (material surrounding well casing and/or piping):
(a)
(b)
Grout type: Cement V Bentonite Other (specify) ______ _
Grouted surface and grout depth (reference to land surface):
__ around closed loop piping; from ___ to ___ (feet).
~ound well casing; from~ to ~O (feet).
(5) Screens (for Type 5A7 wells)
(a) Depth: From __ to __ feet below ground surface.
(6) N.C. State Regulations (Title 15A NCAC 2C .0200) require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent (fluid being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? yes V no__ (b) the effluent line? yes ✓ no __
(7) SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well).
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available,
provide the data in part K (1) of this application form to the best of your knowledge.
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
J. PROPOSED OPERA TING DATA (for Type 5A 7 wells)
(1) Injection rate: Average (daily) · gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
K. INJECTION FLUID DATA
(1) Fluid source (for Type 5A7 wells) 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: _____ _
(2) Chemical Analysis of Source Fluid (for Type SQM wells)
Provide a complete listing of all chemicals added to the circulating heat transfer fluid:
L. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
GW-57 HP (May 1998) Page 3 of 4
M. LOCATION OF WELL(S) Attach two maps.
(1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing wells) or waste disposal facilities such as septic tanks or
drain fields located within 1000 feet of the geothermal heat pump well system. Label all
features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LIST: Attach a list of all permits or construction approvals 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
O. 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 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 Well Owner or Authorized Agent)
1f authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner authorizing the above agent.
P. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the injection well(s) conforms to the Well
Construction Standards (Title 15A NCAC 2C .0200)
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
P.O. Box 29578
Raleigh, NC 27626-0578
Telephone [phone]
GW-57 HP (May 1998) Page 4 of 4

1 0r4ecz
CA
Wake. Forte+- .

Sent Sy: Mobile, AL;
919 635 9397;
:a
{a,
►—
w
fp-
1t4:k
Jun-7•02 11:00AM;
13
a
1
Cs. lk
if7 c
PAR, OF (191
WIN
tit
9
..q
Yee MINT /Ott!
li 0
MOI
!I•r•sl` eis g•
1230 ►IIORDECAI DRIVE
0AA1 cr lA
LOT : SACK SECTION",
9.1111061111104_ 'tS.flnE"AI Pr ACE
rEC CEA IN 9COK OF YAP _1 Q-. PAGE 3 is ,IMIJ(t COUSTY REGISTRY
CSEOS 4 d3 PAGE 477 ,
In
REMAINCER OF
19
I
•
Iw R rrlM.rtlf-/r Ir
MU a MI' ■ •3 Mgr lib - tin. rob
__ - to
t . (71+iw SLAPumM
IN II.tYre
FR l/eRTY OF
PAI.EI61+
rrx[
]' r 2e
i0f t:no
▪ 00
►aI
1
MQSW I i laneibeo
DAVID R. I1OLT
and
KETTH J. HARTMANN
...--.-. "IICO+
GLENN O. WAHO & ASSOCIATES
GIVIL ENGINEER & SURVEYORS
RALEIGI.. N.C.
Page 416

Sent· ~y: Mobile, Alj 919 835 9397; Jun-7-02 11:08AM;
t'ost..ar t-ax Nole 7871