WI0700195_Staff Report_20210211 (2)

DocuSign Envelope ID: C4C36592-59BE-4CFD-BF67-3DB349936163
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: 1/4/16 Permittee(s): Thomas & Melinda Kay Amsler
Permit No.: WI0700195
To: APS Central Office County: Craven
Central Office Reviewer: Shristi Shrestha Project Name: Ini. Heating/Cooling Return Well
Regional Login No:
I. GENERAL INFORMATION
1. This application is (check all that apply): ❑ SFR Waste Irrigation System ® UIC Well(s)
❑ New ® Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
n Land Application of Residuals ❑ Attachment B included El 503 regulated El 503 exempt
n Distribution of Residuals ❑ Surface Disposal
❑ 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. Date of site visit: 2/8/21
b. Person contacted and contact information: Melinda Kay Amsler
c. Site visit conducted by: R. Sipe
d. Inspection Report Attached: ® Yes or ❑ No.
2. Is the following information entered into the BIMS record for this application correct?
® Yes or n No. If no, please complete the following or indicate that it is correct on the current application.
For SFR Treatment Facilities:
a. Location: NA
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude: Method Used (GPS, GoogleTM, etc.);
e. Regulated Activities / Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For UIC 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): no change since permit was issued.
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude: Method Used (GPS, GoogleTM, etc.);
APS-GPU Regional Staff Report (Sept 09) Page 1 of 4 Pages

DocuSign Envelope ID: C4C36592-59BE-4CFD-BF67-3DB349936163
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
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.
2.
3.
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:
Does system use same well for water source and injection? ❑ Yes ® No
Are there any potential pollution sources that may affect injection? ❑ Yes ® No
What is/are the pollution source(s)?
source(s)? ft.
. What is the distance of the injection well(s) from the pollution
4. What is the minimum distance of proposed injection wells from the property boundary? N/A_
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: NA
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? ® Yes or n 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. See attached map
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 n No. If yes, explain: At the time of the inspection water was coming out of the pressure relief
valve on the wellhead of the injection well; however, the well appeared to be otherwise structurally sound. The
permittee was notified and stated she would contact her contractor about performing maintenance on the well.
2. For closed -loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? n Yes n No. If yes, explain: NA
APS-GPU Regional Staff Report (Sept 09) Page 2 of 4 Pages

DocuSign Envelope ID: C4C36592-59BE-4CFD-BF67-3DB349936163
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
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? ❑ Yes ❑ No. If yes, explain: NA
4. Drilling Contractor: Name: Jamie Canter w/ Applied Resource Management, P.C.
Address: 257 Transfer Station Rd.
Hampstead, NC 28443
NC Certification number: 3253-A
5. Complete and attach NEW Injection Facility Inspection Report, if applicable
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the Application: At the time of the inspection water
was coming out of the pressure relief valve on the wellhead of the injection well; however, the well appeared to
be otherwise structurally sound. The permittee was notified and stated she would contact her contractor about
performing maintenance on the well. No issues were noted that would preclude renewal of the permit.
2. Attach new Injection Facility Inspection Form, if applicable
3. Do you foresee any problems with issuance/renewal of this permit? n 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:
APS-GPU Regional Staff Report (Sept 09)
Page 3 of 4 Pages

DocuSign Envelope ID: C4C36592-59BE-4CFD-BF67-3DB349936163
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Condition
Reason
7. Recommendation: n Hold, pending receipt and review of additional information by regional office; n Hold,
pending review of draft permit by regional office; n Issue upon receipt of needed additional information;
Issue; n Deny. If deny, please state reasons:
8. Signature of report Preparer(s):4
544.
Signature of APS regional supervisor: u''Z Te. i'
2/9/2021
Date:
VI. ADDITIONAL INFORMATION AND SITE MAP (Sketch of site showing house and waste irrigation
system, spray or drip field, location of well(s), and/or other relevant information- SHOW NORTH ARROW)
See attached map
WI07001 95
Ct
s
ti�4
Google Earth
02021 Google
Supply Weil
100 ft
A
N
APS-GPU Regional Staff Report (Sept 09)
Page 4 of 4 Pages