WI0400308_APPLICATION FOR PERMIT_20130903

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 .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELLS
These wells inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
(check one) X New Application Renewal* Modification
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: Au2ust 26
, 20 13
PERMIT NO. (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence _X Business/Organization
Government: State Municipal County
RECEIVEDIDENRIDWQ
SEP 0 3 2013
Aquifer Protection Section
Federal
B. WELL OWNER/PERMIT APPLICANT — For individual residences, list owner(s) on property deed. For all
others, list name of entity and name of person delegated authority to sign on behalf of the business or agency: _
Ron Henries
Wanda Henries
Mailing Address: 360 Spencer Miller Road
City: Deep Gap
Day Tele No.: 828-264-6956
EMAIL Address:
State: NC_ Zip Code:28607 County: Watauga
Cell No.: 828-773-8059
Fax No.:
C. WELL OPERATOR (if different from well owner) — For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the
business or agency:
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Cell No.: _
EMAIL Address: Fax No.:
D. LOCATION OF WELL SITE — Where the injectionwells are ph sically located:
rakMel v!«�•S_as
k (1) Parcel Identification Number (PIN) of well site: County: Wataui J a
(2) Physical Address (if different than mailing address):
City: State: NC Zip Code:
GPU/UIC 5A7 Permit Application (Revised 8/8/2013) Page 1

E. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Albert Slate
NC Well Drilling Contractor Certification No.: 2791
Company Name: Dewey Wright Well & Pump �j
Contact Person: Dewey Wright Jr. EMAIL Address: tie *2-
Address: Hwy 105-421 By Pass hae.5341%."
City: Boone Zip Code: 28607 State: NC County: Watauga
Office Tele No.: 828-264-2651 Cell No.: Fax No. 828-264-6125
F. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: Winston Petrey
NC HVAC Contractor License No.: 11342
Company Name:
Contact Person:
Mountaineer Heating. and Cooling
Winston Petrey EMAIL Address:
[e-mail]
Address: PO Box 1905
City: Boone
Zip Code: 28607 State: NC County: Watauga
Office Tele No.: 828-264-6625 Cell No.:
Fax No.: 828-264-1421
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation?
(2) Personal consumption?
YES X
YES X
NO
NO
H. 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:
(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.
GPU/UIC 5A7 Permit Application (Revised 8/8/2013) Page 2

I. WELL CONSTRUCTION SPECIFICATIONS
(1)
Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTING WELLS 1 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)
(f)
(g)
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(1)(8)
Length of well screen or open borehole and depth below land surface
Length of sand or gravel packing around well screen and depth below land surface
J. OPERATING DATA
(1) Injection Rate: Average (daily) 4 gallons per minute (gpm).
(2) Injection Volume: Average (daily)-5 -11gallons per day (gpd).
* depends on thermostat set point and heat pump run time
(3) Injection Pressure: Average (daily) ()-- / pounds/square inch (psi).
* Not applicable (lye- 4 y )
(4) Injection Temperature: Average (January) ° F, Average (July) ° F.
* +- 8 to 10 degrees of the well water temp
K. SITE MAP — As specified in 15A NCAC 02C .0224(b1(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 located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(4(21 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)
0. 1,") ,s kir 1°1/4103
GPU/UIC 5A7 Permit Application (Revised 8/8/2013) Page 3
7

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.
GPU/UIC 5A7 Permit Application (Revised 8/8/2013) Page 4

L. CERTIFICATION (to be signed as required below or by that person's 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 the well owner (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."
Signat�t a of Property OV,,
der/Applicant
R • "1-Vah t't eri r1` e-S
Print or Type Full Name
k
ir. iyx1EA-10
SignatureAof,�P,roperty Owner/Appl4cant
"ko fI&7he$
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:
DWR - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5A7 Permit Application (Revised 8/8/2013) Page 5

GEOTHERMAL HEATING/COOLING WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxes. Fill in depths and details of well construction on
the blank lines provided. Use additional sheets as needed.
O en -Hole Well Desi n
Proposed Existing
❑:Injection; ❑ Supply;
113 Dual Purpose
Land Surface
Record Depths Below
Land Surface on Lines
Provided
92
(Ft.)
1 (Ft.)
Screened Well Design
❑ Proposed ❑ Existing
❑ Injection; ❑ Supply;
❑ Dual Purpose
Return or Supply Line
Casing
400
Grout
WELL DETAILS
Casing Material: PVC
Casing Diameter (in.): 6 1/8
Casing Thickness (in.): .350
Grout Type: bentonite
(cement, bentonite, or mix)
Screen Material:
Screen Slot Size (in.):
Sand/Gravel Pack
Material.
Bedrock
Open Hole
Bentonite Seal
(if present)
Sand/Gravel Pack
Screen
}
(Ft.)
Record Depths Below
Land Surface on Lines
Provided
(Ft.)
(Ft.)
(Ft.)
(Ft.)
NC Certified Well Driller Name Albert Slate Certification # 2791

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NSITE'WASTEWATER PERMIT # NTI \- 14
ma

%reevt gold .ler--deco
Permit Number WI0400308
Central Files: APS SWP
10/31/13
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Primary Reviewer Permit Contact Affiliation
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Ron & Wanda Henries SFR
Location Address
360 Spencer Miller Rd
Boone NC 28607
Owner
Major/Minor Region
Minor Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Name Owner Type
Individual
Ron Henries Owner Affiliation
Dates/Events
Ron Henries
Owner
360 Spencer Miller Rd
Boone
NC 28607
Orig Issue App Received Draft Initiated
10/31/13 09/03/13
Scheduled
Issuance
Public Notice Issue
10/31/13
Effective Expiration d
10/31/13 09/30/18
Regulated Activities Re• uested/Received Events
Heat Pump Injection RO staff report requested
RO staff report received
Additional information requested
Additional information received
Outfall NULL
09/10/13
10/21/13
10/24/13
10/28/13
Waterbody Name
Stream Index Number
Current Class Subbasin

Permit Number W10400308
Central Files: APS SWP
10/28/13
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Ron & Wanda Henries SFR
Location Address
360 Spencer Miller Rd
Boone NC 28607
Owner
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Ron Henries
Owner
360 Spencer Miller Rd
Boone NC 28607
Major/Minor
Minor
Region
Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Name
Ron
Dates/Events
Henries
Owner Type
Individual
Owner Affiliation
Ron Henries
Owner
360 Spencer Miller Rd
Boone NC 28607
Orig Issue
App Received Draft Initiated
09/03/13
Regulated Activities
Scheduled
Issuance
Public Notice Issue Effective Expiration
1 3IJJg io13i/1 3 t`2r'/•76I g
Requested/Received Events
Heat Pump Injection
Outfall NULL
Additional information received
RO staff report requested
RO staff report received
Additional information requested
09/10/13
10/21/13
10/24/13
Waterbody Name Stream Index Number Current Class Subbasin

Rogers, Michael
From: Rogers, Michael
Sent: Thursday, October 24, 2013 3:28 PM
To:'[e-mail]'
Subject: Ron and Wanda Henries Geothermal Well Permit WI0400308/
Can you give me the final as -built well construction information (GW-1 form) including average
daily injection rate, volume, and pressure. You can scan the GW-1 and return as a reply to this
email. Thanks.
Michael Rogers, P.G. (NC & FL)
Hydrogeologist
NCDENR - DWR
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records. Law and may be disclosed to third parties.
1

ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Water Quality Programs
Pat McCrory Thomas A. Reeder John E. Skvarla, III
Governor Director Secretary
September 9, 2013
Ron Henries — Owner
Wanda Henries
360 Spencer Miller Rd.
Boone, NC 28607
Dear Mr. and Mrs. Henries:
Subject: Acknowledgement of
Application No. WI0400308
Ron & Wanda Henries SFR
Injection Heating/Cooling
Water Return Well System
Watauga County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on 09/03/2013. Your application package has been assigned the number listed
above, and the primary reviewer is Michael Rogers.
Central and Winston-Salem Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
icerely,
for Debra J. atts
Groundwater Protection Unit Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Albert Slate — Dewey Wright Well & Pump, Hwy 105-421 ByPass, Boone, NC 28607
Winston Petrey — Mountaineer Heating and Cooling, P.O. Box 1905, Boone, NC 28607
I!ennit Fife WI0400308 _
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: httn://portal.ncdenr.orq/web/wq/aps
An Equal Opportunity l Affirmative Action Employer

AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 10/17/13 County: Watauga
To: Aquifer Protection Central Office Permittee: Ron & Wanda Henries
Central Office Reviewer: Michael Rogers Project Name: Ron & Wanda Henries SFR
Regional Login No: Application No.: WI0400308
L GENERAL INFORMATION
1. This application is (check all that apply): ® New ❑ Renewal
❑ Minor Modification ❑ Major Modification
n Surface Irrigation ❑ Reuse n Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals
❑ Distribution of Residuals
❑ Attachment B included
❑ 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 n No.
a. Date of site visit: 10/02/13 & 10/14/13
b. Person contacted and contact information: Ron & Wanda Henries 828-Z73-8059 (cell)
c. Site visit conducted by: Derek Denard and Patrick Mitchell
d. Inspection Report Attached: ® Yes or ❑ No.
2. Is the following information entered into the BIMS record for this application correct?
® Yes or r] No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
e. Regulated Activities / Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For Disposal and Injection Sites:
(If 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): RECENEDIDENRIDWQ
b. Driving Directions: QCT 2,1 Z013
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
AgciferProte l°118
II. 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: APS permit staff report.docx 1

AQUIFER PROTECTION REGIONAL STAFF REPORT
❑ Yes ❑ No ❑ N/A. If no, 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? ❑ Yes ❑ No ❑ N/A. If no, please explain:
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? ❑
Yes ❑ No ❑ N/A. If no, please explain:
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. ❑ Yes ❑ No ❑
N/A. If no, please explain:
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
❑ Yes ❑ No ❑ N/A. If no, please explain:
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
❑ Yes ❑ No ❑ 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)? ❑ Yes or ❑ No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit:
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? ❑ Yes ❑ No ❑ N/A. Attach map of existing monitoring well
network if applicable. Indicate the 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? ❑ Yes ❑ No n N/A If yes, attach list of sites
with restrictions (Certification B?)
III. RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or major modification
systems)
Description Of WasteSS) And Facilities
1. Are there appropriately certified ORCs for the facilities? ❑ Yes or ❑ 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? IT Yes or ❑ No.
If no, please explain:
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? ❑ Yes or ❑ No. If no, please explain:
FORM: APS permit staff report.docx 2

AQUIFER PROTECTION 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?
❑ Yes or ❑ No. If no, please explain:
6. Are the existing application rates (hydraulic or nutrient) still acceptable? ❑ Yes or ❑ No. If no, please
explain:
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? n Yes n No ❑ N/A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program:
8. Will seasonal or other restrictions be required for added sites? ❑ Yes ❑ No ❑ N/A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? ❑ Yes or [j 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? ❑
Yes or ❑ No. If no, please explain: _
11. Were monitoring wells properly constructed and located? n Yes or ❑ No N/A. If no, please explain:
12. Has a review of all self -monitoring data been conducted (GW, NDMR, and NDAR as applicable)? ❑ Yes or
❑ No ❑ N/A. Please summarize any findings resulting from this review:
13. Check all that apply: ❑ No compliance issues; ❑ Notice(s) of violation within the last permit cycle; ❑
Current enforcement action(s) ❑ Currently under SOC; ❑ Currently under JOC; ❑ 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? ❑ Yes
❑ No ❑ Not Determined ❑ N/A.. If no, please explain:
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? ❑
Yes or ❑ No ❑ N/A. If yes, please explain:
FORM: APS permit staff report.docx 3

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:
® Heating/cooling water return flow (5A7)
❑ Closed -loop heat pump system (5QM/5QW)
❑ In situ remediation (5I)
❑ Closed -loop groundwater remediation effluent injection (5L/"Non-Discharge")
❑ Other (Specify: )
2. Does system use same well for water source and injection? ® Yes ❑ No
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)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? <50 ft.
5. Quality of drainage at site: ® Good ❑ Adequate ❑ Poor
6. Flooding potential of site: ® Low ❑ Moderate ❑ High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program:
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? n Yes or ❑ No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
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)?
❑ 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? ❑ Yes ❑ No. If es. explain:
3. For renewal or modification of groundwater remediation permits (of anv type, will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? ❑ Yes ❑ No. If yes. explain:
FORM: APS permit staff report.docx 4

AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Drilling contractor: Name: Dewey Wright Well Drilling, Dewey Wright. Jr.
Address: Hwy 105-421 ByPass
Boone, NC 28607
Certification number: 2791
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? ❑ 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: APS permit staff report.docx 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):
Signature of APS regional supervisor:..,
Date: Qf /7/ 3
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
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FORM: APS permit staff report.docx 6

North Cal.,ana Department of Environment and lratural Resources
Division of Water Quality — Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI OL( 00 3C, $
DATE OF INSPECTION: l J/ Z `2 / �/ !y/li
INSPECTOR: � e rP /c via Vet
NAME OF PERNIITTEE(S) 00 14./ 114q e h Yr c f
MAILING ADDRESS OF PERMI'1'1'EE '3 % 0 5ie e kic e v A; lie), ,E l{
PHYSICAL ADDRESS OF SITE (if different than above)
PERSON MET WITH ON -SITE /Q o Ne tierTELE NO.
WELL(S) STATUS:
Existing and operating Class V Well
do oiie /4/C 2? '?
Existing well proposed to be converted to Class V well
Proposed/not constructed
LAT/LONG OF WELL(S) N 3 62 . &2 l / G✓ g1 e 70 & Z 6 /
Appx. distance of well to property boundaries:
828 — 7 7.3 - YDs ,
ec1/
Appx. distance of well from foundation of house/structure: " 2)ycL( / I d /titi /J/
t
Appx. distance of well from septic tank/field (if present): ' `' C-S—
Appx. distance of well to other well(s) (if present): /11/f4 Jr,. le
Appx. distance to other sources of pollution: 1//4moo "/,p
Flooding Potential of Site: high moderate `/c"*`,r 4
el
(-01 r ao y q,4(( PI-
A IZ'tu t, 2f1U
Comments:
Injection Facility Insp. Report (Rev. Sept 2009) Page 1 of 3 Pages

Well Construction Information
Date Constructed:
Well Contracting Company: be we Wi-f j14 f i'✓e (( £ril
Well Driller Name: bew et, kr,
NC Well Cert. No.: 2. "?' I
Address: 4-wi.i 1 o - i ) O i2uii 6 o 0,, e Arc 25 b v-?
Telephone No.: Qz$ 4 Z L - 21 r ; Cell No.:
Email Address:
Proposed Depth of Well(s): `1 0 D
Total Depth: (jo g
Casing:
Depth: '? ; Diameter:
Grout:
Total Depth of Source Well, if present:
sue_.
; Type (gay. steely , etc.): PVC -
Depth: 1'2 ; Type (cement,
Well ID Plate Present (Y or N): I/
y H 140 �/ I
Influent spigot (Y or N): 1
V
f_
Well Sampled? (Y or N): _
Static Water Level: 13 0
, etc.): L4'4 frn%; Placement
; Stick Up: / —Z ft
/ u ��
ress. etc.). ) 9 0
; Heat Pump ID plate present (Y or N): 0-7 cr_fe%J C -
7 51?
E P g ( or N):
u ntsri o CY
; If Yes, Lab Sample ID numbers:
Injection Information (if applicable):
Injection Rate: GPM
Injection Pressure: PSI
Injection Volume: GPD
Temperature- Summer: _ F°
Temperature- Winter: F°
Comments/Notes l vft Ilce4 4
r /
IN i' e -" I /tip FJar '�. e-al i- Si /l/ ei7G e ,
c
01(60 .4c'iI6[
N_
u fry e v P, /4, I 4e t/
of c,(lec/.
1 r� Ji�% 5 �
Injection Facility Insp. Report (Rev. Sept 2009) Page 3 of 3 Pages

Set affac4c4
//JO
DRAW SKETCH OF SITE ABOVE (Show property boundaries, buildings, other wells, septic
potential pollution sources, roads, approximate scale, and NORTH arrow)
1 ef 5 K-4 144 e..(
bC
l u V c Li Ai
Draw Schematic of well above showing TD, casing depth, grout, etc.
I\
Injection Facility Insp. Report (Rev. Sept 2009)
Page 2 of 3 Pages

Return line from
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Ron & Wanda Henries SFR W10400308

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Ron & Wanda Henries SFR WI0400308

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Dewey Wright Wen DZ1
Hwy. 421 ByPass P.O. Box 308, soon- :1119
PH# 328-264-2651 1 211607
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P. ATE COMPLETED: •
CASING DEPTH:._
SCREEN INTERVAL: TO
OW AL:
STATIC WATER LEVEL: at‘
YIELD
GPM OR SPECIFIC CAPACITY____—
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Ron & Wanda Henrics SFR W10100308

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
mate: September 10. 2013
c;ror,NJ'gr
O
❑ Landon Davidson, ARO-APS
❑ Art Barnhardt, FRO-APS
❑ Andrew Pitner, MRO-APS
❑ Rick Bolick, RRO-APS
in: Michael Rogers Groundwater Protection Unit
Telephone: [phone]
E-Mail: [e-mail]
Winston-Salem
Regional Office
0 David May, WaRO-APS
0 Morella Sanchez King, WiRO-APS
Sherri Knight, W-SRO-APS
Fax: [phone]
A. Permit Number: WI0400308
B. Owner: Henries
C. Facility/Operation:
RECEIVE NirD
wo
SEp1e
2013
Aiu arPro ,;°nSe
[E] Proposed 0 Existing ❑ Facility 0 Operation 0�
D. Application:
Z. Permit Type: ❑ Animal
❑ Recycle
❑ SFR-Surface Irrigation❑ Reuse ❑ H-R Infiltration
O FE Lagoon ® GW Remediation (ND)
® UIC —Geothermal Heatini/C.00lin2 Water Return Well
For Residuals: ❑ Land App. ❑ D&M 0 Surface Disposal
❑ 503 0 503 Exempt 0 Animal
2. Project Type: ® New 0 Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: M
NOTE: During the site inspection please record all well construction info from the well tag, if present. on the staff
report. Thanks. Check for potential flooding.
® Return a completed APSARR after the site inspection. At a later date, after sampling & the lab
results are received, please send us a copy of the letter you send to the Permittee containing
laboratory analytical results.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
li.stecl above. ( - �
R0-APS Reviewer: e 1 re, De V1�Date: 9 l/ z ) 3
FORM: APSARR 07/06 Page 1 of 1

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: September 10, 2013
To: ❑ Landon Davidson, ARO-APS
❑ Art Barnhardt, FRO-APS
❑ Andrew Pitner, MRO-APS
❑ Rick Bolich, RRO-APS
From: Michael Rogers Groundwater Protection Unit
Telephone: [phone]
E-Mail: [e-mail]
❑ David May, WaRO-APS
❑ Morella Sanchez King, WiRO-APS
® Sherri Knight, W-SRO-APS
Fax: [phone]
A. Permit Number: WI0400308
B. Owner: Henries
C. Facility/Operation:
® Proposed ❑ Existing
D. Application:
1. Permit Type: ❑ Animal
❑ Recycle
❑ Facility ❑ Operation
❑ SFR-Surface Irrigation❑ Reuse ❑ H-R Infiltration
❑ I/E Lagoon ® GW Remediation (ND)
UIC — Geothermal Heating:/Cooling Water Return Well
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type: ® New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information:
NOTE: During the site inspection please record all well construction info from the well tag. if presenton the staff
report. Thanks. Check for potential flooding.
® Return a completed APSARR after the site inspection. At a later date, after sampling & the lab
results are received, please send us a copy of the letter you send to the Permittee containing
laboratory analytical results.
❑ A• ttach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ I• ssue 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:
FORM: APSARR 07/06
Page 1 of 1
Date:

Rogers, Michael
From: Dewey Wright [[e-mail]]
Sent: Monday, October 28, 2013 8:26 AM
To: Rogers, Michael
Subject: Ronald Henries
Attachments: Henries.pdf
Attached you will find the well report requested for Ronald Henries.
Laura
1

1.WELL: CONTRACTOR:
ALBERT SLATE
Well Contractor (Individual Name)
DEV EY WRIGHT WELL & PUMP CO.. INC.
Well Contractor Company Name
STREET ADDRESS P. 0. BOX 3(i$
BOONS NC 286177
City or Town
1-2Ss1
Area code - Phone number
2.WELL INFORMATION:
SITE WELL ID #{if appficabie}
STATE WELL PERMIT WV applicable)
DWG or OTHER PERMIT #(ifapplicabt5-1325
WELL USE (ChecApplicable _ Box): Residential Water Sup*y
DATE DRILLED 12/24/2012
TIME COMPLETE W-00 — AM:❑ KM 0
3.WELL LOCATION:
cl p GAP 'i .ATAt7GxA
COUNTY
WILDCATRD. OW OLD BROWNFARMRD. OFF OL
(Street blame; Numbers, Community; Su division,. Lot No, Parcel. Zip Code)
TOPOGRAPHIC / LAND. SETTING:
O Slope 0 Valley 0 Flat 0 Ridge D Other
(check appropriate box)
LATITUDE 3 36412.622N May i9 ae ,
LONGITUDE' minutes, seconds or.
_ is a decimal format
Latitude/longitude sours ❑ GPS ❑ Topographic
map
(Iocatiop of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAiaQND IS
STREET ADDR —� ..... ,.
BOONE
- -- ••.,...LKUCTIOr'�"ECORD
North Caro; ,epatfinent of Enyironrnent and Natural Resources -. i7iv� i of yVaier Qualify
WELL CONTRACTOR CERTIFICATION # 2791
State Zip Code
City or Town State
Zip Code
i6'7?3-8054
Area code - Phone number
5.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 *10 CI
e. WATER LEVEL Below Top of Casing 30:
{Use "t" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land 1
' Top of casing terminated at/or below land surface may Surface*
a variancein accordance with 15A NCAC 2C .0118
e. YIELD (gpm):
METHOD OF T
120241
f. DISINFECTION: TyPeHTH Amount 55
g. WATER ZONES (depth):
From 233 20
From
From
6.CASING:.
From
From . 0
From
7-GROUT
From O To20
From To�
From
Depth
0 To 92
To 0 Ft
To Ft_
Depth Material MethodWiEN.
£ONIT Gravity. Flow
Ft.��
Diameter Slot Size Material
Ft. in. in.
Ft. in: in.
FL in. in.
Size.
Material
Formation Description
DIRTSAND
GRANITE
235 CREVICE
336 GRANGE
3Ei0 361 CREVICE
361 408 GRANITE
11. RE1ti S:
2 GPM 235 - 236:
To
8.SCREEN: Depth.
From To
From To
From To
9.SAND/GRAVEL PACK:
Depth
From To Ft.
From _To Ft:.
From _To Ft.
10. DRILLING LOG
From To
0..85
� 2
To
To
From 360 3 fJ
From To
From To
Thickness/
Diameter Weight Material
F¢"I/S .350 PVC
6GPl,d 360-361
0
0 CiPM_
I DO HEREBY CERI1FY THAT THIS. WELL: WAS CONSTRUCTED IN ACCORDANCE WITH
trig NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELLOWNER.
SIGNATURE OF CE . 1 WELL CONTRACTOR 2j
ALBERT SLATE DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.
1617 Mail. Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568
Form GW-la
Rev 7/05