WI0300103_Regional Office Historical File Pre 2018

N1C' R
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Joan Summerhays
16822 Lake Shore Dr.
Cornelius, NC 28031
Dear Ms. Summerhays:
Division of Water Quality
Coleen H. Sullins
Director
September 1, 2010
IE W HE
SEP — 7 2010 LUJ
NC DEN h MR.O
DWG) -Aquifer Protection
Subject: Issuance of Injection Well Permit
Permit No. WI0300103
Issued to Joan Summerhays
Mecklenburg County
In accordance with your application received June 24, 2010, I am forwarding Permit No. WI0300103 for
the continued operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system
located at 16822 Lake Shore Drive, Cornelius, Mecklenburg County, NC 28031. This permit shall be
effective from the date of issuance until August 31, 2015, and shall be subject to the conditions and
limitations stated therein.
Please pay special attention to Parts IV.1 and VII.2.A of the permit in which the Permittee is required
to notify the Regional office in any event that the system performs unusually or unsatisfactorily,
including any repair to the system.
Additionally, your UIC system is subject to inspection by the APS and at the time of the inspection must
display a permanently affixed identification plate in accordance with requirements of 2C .0213(g). Please
insure this is completed in accordance with permit condition Part 1.6 of this permit issued September 1,
2010.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit three months prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Quality. If you have any questions regarding your permit or the Underground Injection
Control Program please call me at [phone].
Sincerely,
John McCray,
Environmental Specialist
cc:
e A_ Pitner © Mc .oresvi1le Regional Office -
Central Office File — WI0300103
Mecklenburg County Environmental Health Dept.
Freeman
Secretary
Enc: Permit WI0300103

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
Joan Summerhays
FOR THE CONTINUED OPERATION OF 10 TYPE 5QM INJECTION WELLS, defined in Title 15A North
Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed -loop
geothermal -mixed -fluid heat pump system. This system is located at 16822 Lakeshore Dr, Cornelius,
Mecklenburg County, NC 28031, and will be constructed and operated in accordance with the application
received June 24, 2010, and in conformity with the specifications and supporting data submitted, all of which
are filed with the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation only, and does not waive am/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 August 31, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the \ day of (2010.
t.,„\ Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.

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 not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
6. Each geothermal injection well system shall have permanently affixed an identification plate on a nearby
building or other permanently fixed structure indicating the location and presence of underground UIC
wells according to 2C .0213(g).
7. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section — UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section — Mooresville Regional Office
610 East Center Avenue, Suite 301
Mooresville, NC 28115
[phone]
GW-ls must be submitted within 30 days of completion of well construction. Copies of the GW-1
form(s) shall be retained on -site and available for inspection.
8. Well construction records must also be submitted for the existing water supply wells on -site as well as a
site map showing any water supply wells on adjacent properties as specified in NCAC .0211(d)(1)(D).
PART II — WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone] and the Mooresville Regional Office Aquifer Protection Section Staff, telephone
number [phone].
WI0300103 2

• 2. Boreholes shall not connect separate aquifers which have differences in water quality (e.g., shallow
surficial aquifers, saprolite, fractured bedrock, etc.) as specified in 15A NCAC 2C .0213(d)(8)(C) and
shall be filled with bentonite grout from the lowermost water bearing zone to land surface as specified in
the permit application.
PART III — OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire. for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
PART IV — PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the 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 — OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number [phone]. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it isin compliance with permit
conditions.
WI0300103 3

PART VI - INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must 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
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 Mooresville Regional Office, telephone number [phone], any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
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 e Permittee shall take such
immediate action as may be required by the Director.
PART VIII — PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
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)(1), Well
Construction Standards.
WI0300103 4

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 accordancewith 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.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(1) within 30 days of completion of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
WI0300103

D
ENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Joan C. Summerhays
16822 Lakeshore Drive
Cornelius, NC 28031
Division of Water Quality
Coleen H. Sullins
Director
May 24, 2010
Subject: Notice of Expiration (NOE)
5QM Geothermal Injection Well
Permit No. WI0300103
Mecklenburg County
Dear Ms. Summerhays: .
Dee Freeman
Secretary
MAY 25 ge
NC DENR MRO
DWQ -Aquifer Protection
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Quality (DWQ) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for
the underground injection well system, which was issued on February 15, 2005, and expired on
February 15, 2010, has not been renewed. If you wish to keep this permit and operate the
injection well system, the permit must be renewed and issued in your name. Our records do not
indicate that the well system has been plugged and abandoned.
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
forms:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for Injection with
Geothermal Heat Pump System for Type 5QM Well(s) if the injection well system on your
property is still active.
-OR-
B. Status of Injection Well System if the injection well system is inactive or has been temporarily or
permanently abandoned.
If there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form must also be submitted.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard. Raleigh. North Carolina 27604
Phone: [phone] FAX 1: 919-715-0588; FAX 2: 919-715-60481 Customer Service: 1-877-623-6748
Internet: www.ncwateroualitv.orq
An Equal Opportunity \ Affirmative Action Employer
NorthCarolina
, atura l

If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed under NCAC Title 15A, Subchapter
2C, Section .0214. When each well is plugged and abandoned, the well abandonment record
(Form GW-30) must be submitted to our office to certify that the abandonment was properly
conducted. If the injection well system is still active and you wish to renew your permit, the
renewal ;application must be submitted within 30 calendar days of the receipt of this letter to:
I.
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
http://h2o. enr.state.nc.us/aps/gpu/fonns.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call me at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
Attachments
cc: Mooresville Reg onalDffice APS-w/o enclosures
APS Central Files - Permit No. WI0300103 w/o enclosures

Date: February 15, 2005
To: Andrew Pitner
MRO-APS
Copies Sent: 1 Vuifer
From: Evan Kane Protection Section
Telephone: [phone]
E-Mail: [e-mail]
Subject: Permit Number WI0300103
AQUIFER PROTECTION PERMITTING INFORMATION TRANSI igAbLAMENT
AND NATURAL RE oURCES
RECEIVED
FEB 1 7 2005
MOORESVILLE REGIONAL OFFICE
DWQ-GROUNDWATER SECTION
Fax: [phone]
The attached documents for the subject permit application are being transmitted to you for:
For RO:
X Additional information for your files — no review is necessary
n Additional information for your review — please update Form NDSRR and return.
❑ Additional information for your review — please complete Form NDSRR.
❑ Additional information for your review — attach Attachment B for Certification.
n Documents misdirected - for you to take action as appropriate.
For co -reviewers:
n Additional information for your files — no review is necessary
n Additional information for your review — please update the appropriate review form.
n Additional information for your review — please return the appropriate review form.
Thanks to you and Kevin Bubak for your assistance with this permit.
FORM: APPITM 040928 Page 1 of 1

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
February 15, 2005
Ms. Joan C. Summerhays
16822 Lakeshore Drive
Cornelius, NC 28031
Dear Ms. Summerhays:
In accordance with your application submitted on January 24, 2005, we are forwarding Permit Number
WI0300103 for the operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well
system at 16822 Lakeshore Drive in Cornelius, North Carolina.
This permit shall be effective from the date of issuance until February 15, 2010, 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 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. -
Please read the permit carefully to be sure you understand all its conditions before constructing and
operating the injection well system. If you have any questions regarding your permit, please call me at
[phone].
Sincerely,
Evan O. Kane, P.G.
Underground Injection Control Program Manager
cc: file
ooresville Regional Office
Akers Custom Comfort
No Carolina
aatura!!y
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636
Internet: http://h2o.enr.state.nc.us 2728 Capital Boulevard Raleigh, NC 27604
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper
Phone [phone] Customer Service
Fax [phone]
Fax [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
Joan C. Summerhays
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5QM INJECTION WELL,
defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of
operating a vertical closed -loop geothennal-mixed-fluid heat pump system. This system is
located at 16822 Lakeshore Drive, in Cornelius, Mecklenburg County, North Carolina, and will
be constructed and operated in accordance with the application submitted January 24, 2005, 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 February 15,
2010, and shall be subject to the specified conditions and limitations set forth in Parts I through
IX hereof.
Permit issued this the day of Fjrj-CvtGly, 2005.
J.�
IATed L. Bush, Jr., Chief
Aquifer Protection Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0300103 PAGE 1 OF,6'l
5QM-DX ver. 2/05

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 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, 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 - WELL CONSTRUCTION SPECIAL CONDITIONS
1. Prior to constructing the injection well system, the permittee or his agent shall test the pH of
the soil at a depth of three feet at the planned well location. If the resulting soil pH is less
than 6 standard units or greater than 11 standard units, the well system shall be equipped with
a compatible cathodic protection system.
2. At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall
notify the Aquifer Protection Section -Underground Injection Control (UIC), Central Office
staff, telephone number [phone] and the Mooresville Regional Office Aquifer
Protection Section Staff, telephone number [phone].
3. All underground tubing shall be refrigeration grade copper tubing.
Permit No. WI0300103 PAGE 2 OF 7
5QM-DX ver. 2/05

4. Prior to installation, all tubing to be placed in boreholes ("loops") shall be checked for leaks
by pressurizing the loop to a gage pressure of at least 350 pounds per square inch (psig),
immersing the loop in water and examining it for leaks. Loops with leaks shall not be
installed. A copy of the leak test record (quality control tag) shall be submitted to the Aquifer
Protection Section within 30 days of completion of well construction.
5. Prior to installation, each loop shall be visually inspected for damage such as kinks, dents,
and scrapes. Each loop shall be checked to verify that the nitrogen charge applied to the loop
by the manufacturer before shipping is still present at a pressure of at least 300 psig. The
loop manufacturer shall be notified in the event of damage or pressure loss, and the
manufacturer's instructions shall then be followed. The nitrogen charge may be released only
when the loop is installed and ready to be connected to the manifold.
6. Boreholes shall be of sufficient size to allow for insertion of the loop as well as a tremie pipe
for grouting.
7. After insertion of the tubing into the boreholes, an approved grout (as defined in Title 15A
North Carolina Administrative Code 2C .0100) shall be pumped via tremie pipe into the
annular space of each borehole so as to completely fill it from bottom to top.
8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material
shall have a galvanic potential as close as practicable to that of the tubing material.
9. Dry nitrogen shall be circulated through the tubing during brazing to prevent oxidation of the
tubing.
10. After installation and prior to operation of the system, a mechanical integrity test shall be
conducted by pressurizing the injection well system to 400 psig with dry nitrogen and
monitoring for leaks using an ultrasonic or other leak detector of equal sensitivity and
monitoring pressure in the system for at least 2 hours. Any pressure fluctuation other than
that due to thermal expansion and contraction of the testing medium shall be considered a
failed mechanical integrity test. Any leaks shall be located and repaired prior to charging the
system with refrigerant.
11. The location of each of the system manifolds shall be recorded by triangulation from two
permanent features on the site (e.g., building foundation corners). The permittee shall retain a
copy of the triangulation records. The permittee shall also submit a copy of the triangulation
records to the Aquifer Protection Section within 30 days of completion of well construction.
12. The written documentation required in Part II, paragraphs (4) and (11) shall be submitted to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Permit No. WI0300103 PAGE 3 OF 7
5QM-DX ver. 2/05

PART III - OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances which may be
imposed by other local, state, and federal agencies which have jurisdiction. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
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
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 V - OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section -
Underground Injection Control (UIC), Central Office staff, telephone number (919) 715-
6182. Notification is required so that Division staff can inspect or otherwise review the
Permit No. WI0300103 PAGE 4 OF 7
5 QM -DX ver. 2/05

injection facility and determine if it is in compliance with permit conditions.
PART VI - INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must 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 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 Mooresville Regional Office, telephone number
[phone], 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;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
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.
Permit No. WI0300103 PAGE 5 OF 7
5QM-DX ver. 2/05

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 120 days prior to the expiration of this permit, request an
extension.
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)(1), 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
Permit No. WI0300103 PAGE 6 OF 7
5QM-DX ver. 2/05

sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(1) within 30 days of completion of
abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Permit No. WI0300103 PAGE 7 OF 7
5QM-DX ver. 2/05

MOORESVILLE REGIONAL OFFICE
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
February 9, 2005
MEMORANDUM
To: Evan Kane Central office
From: Kevin Bubak Hydro Tech 1
Enclosed: Aquifer Protection Staff Report Site review for Proposed UIC closed
loop system for Jody Summerhays

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: January 24, 2005
To: n Landon Davidson, ARO-APS
n Art Barnhardt, FRO-APS
E Andrew Pitner, MVIRO-APS
Jay Zimmerman, RRO-APS
From: Evan Kane , Groundwater Protection Unit
Telephone: [phone]
E-Mail: [e-mail]
❑ David May, WaRO-APS
n Charlie Stehman, WiRO-APS
❑ Sherri Knight, WSRO-APS
Fax: [phone]
A. Permit Number:
B. Owner: Jody Summerhays
C. Facility/Operation:
® Proposed n Existing ❑ Facility ❑ Operation
D. Application:
1. Permit Type: ❑ Animal ❑ Surface Irrigation n Reuse ❑ H-R Infiltration
❑ Recycle ❑ FE Lagoon ❑ GW Remediation (ND)
® UIC - (5QM) closed loop mixed fluid geothermal "Direct Expansion" heat
pump system
For Residuals:
❑ Land App.
❑ 503
❑ D&M
❑ 503 Exempt
❑ Surface Disposal
❑ Animal
2. Project Type: ® New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: n I would like to accompany you on a site visit.
System circulates R-22 (Freon) in copper tubing. We have permitted two other systems of this type in the
Winston-Salem Region. I have attached a copy of one of these permits so you can see the type of special.
conditions we have required in the past.
DEPT.NCUPJ RALN ESOURCES
Attached, you will find all information submitted in support of the aboQt1-re't"eg�tcation for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
® Retum a Completed Form APSSRR.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU. MOORESVILLE REGIONAL OFFICE
❑ Issue an Attachment B Certification from the RO*. DWQGROUNDWATER SECTION
* Remember that you will be responsible for coordinating site visits, 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:
FORA 1:APSARR 09/04 Page 1 of 1
JAN 2 6 2005

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: _1
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? . ft.
5. Quality of drainage at site: Good ❑ Adequate ❑ Poor
6. Flooding potential of site: Yj 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)? 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.
►_3
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 ves, 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 yes. 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? n Yes ❑ No. If ves, explain:
4. Drilling contractor: Name:
FORM: APRSR040929-1-staff report template.doc 4

AQUIFER PROTECTION REGIONAL STAFF REPORT
Address:
Certification number:
5. Complete and attach Well Construction Data Sheet.
FORM: APRSR040929-1-staff report template.doc 5

AQUIFER PROTECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
I . 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 F 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 preparer(s):-
Signature of APS regional supervisor:
Date: cl (:)S
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: APRSR040929-1-staff report template.doc 6

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 WeI1(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? ft.
5. Quality of drainage at site: IN Good ❑ Adequate ❑ Poor
6. Flooding potential of site: gi 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)? RI 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 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? ❑ Yes ❑ No. If yes, explain:
4. Drilling contractor: Name:
FORM: APRSR040929-1-staff report template.doc 4

AQUIFER PROTECTION REGIONAL STAFF REPORT
Address:
Certification number:
5. Complete and attach Well Construction Data Sheet.
FORM: APRSR040929-1-staff report template.doc 5

AQUIFER PROTECTION REGIONAL STAFF REPORT
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
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; X
Issue; ❑ Deny. If deny, please state reasons:
8. Signature of report preparer(s):
Signature of APS egional supervisor:
Date:
-/__ \ R bs'
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: APRSR040929-1-staff report template.doc 6

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/A

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: January 24, 2005
To: ❑ Landon Davidson, ARO-APS
❑ Art Barnhardt, FRO-APS
® Andrew Pitner, MRO-APS
❑ Jay Zimmerman, RRO-APS
From: Evan Kane , Groundwater Protection Unit
Telephone: [phone]
E-Mail: [e-mail]
❑ David May, WaRO-APS
❑ Charlie Stehman, WiRO-APS
❑ Sherri Knight, WSRO-APS
Fax: [phone]
A. Permit Number:
B. Owner: Jody Summerhays
C. Facility/Operation:
Proposed ❑ Existing
D. Application:
1. Permit Type: ❑ Animal
❑ Recycle
pump system
❑ Facility n Operation
❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ I/E Lagoon ❑ GW Remediation (ND)
• UIC - (5QM) closed loop mixed fluid geothermal "Direct Expansion" heat
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt n Animal
2. Project Type: New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
System circulates R-22 (Freon) in copper tubing. We have permitted two other systems of this type in the
Winston-Salem Region. I have attached a copy of one of these permits so you can see the type of special
conditions we have required in the past.
eN
AND N ATUDEPT.URALFN ESOUVIoNRCES
Attached, you will find all information submitted in support of the abo e-re e;t,m ot+mlication for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
Return a Completed Form APSSRR.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU. MOORESVILLE REGIONAL OFFICE
❑ Issue an Attachment B Certification from the RO*. DWQGROUNDWATER SECTION
* Remember that you will be responsible for coordinating site visits, 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.
JAN 2 6 2005
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 09/04 Page 1 of 1

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
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: DIRECTO,N1pTH CAROLINA DIVISION OF WATER QUALITY
DATE: ! -, 20
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1)
(2)
(3)
Type 5A7 wells inject water used to provide heating or cooling for structures.
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: -0/125 cS 'DL( IJJ,7✓YJE�,f4,$ (aka, a- JoanCam, Suini-i7ti-.
8�
Address: /6 ? 5A426 2'& City: rjeijS,J�S State: rIC Zip Code2 c3i County: Er—HZ-16&G
Telephone: '2e -/&S5 --oe,gq
C. PROPERTY OWNER (if different from applicant)
Name:
Address:
City: Sate: Zip Code: County:
Telephone:
D. STATUS OF PLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
GW-57 HP (Jan, 2000)
Page 1 of 4

E. FACILITY (SITE) DATA
(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:
F. HEAT PY1(Li$PCCONTRACTOR DAT Name: Cu5-7441 /nktr
Address: ) Z 7S 69632,1 '► i �!
City: Sro L6 Zip Code: / I C County: Oc
Telephone: 326- tj 91- .,3 4Contact Person: ,71 //!L14 S
G. INJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.)
607N /4i/ Ptior
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO pc„,
CONSTRUCTION DATA (check one)
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.
Y. 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 constru n.
(1) Well Drilling Contractor's Name: I Ot j ( 6( 7 i01
NC Contractor Certification number: A/53
(2) Date to be constructed: " 30- 05 Number of borings: / 0
Approximate depth of each boring (feet): 50
(3) Well casing: Is the well(s) cased?
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel Black steel Plastic Other (specify)
Casing depth: From to ft. (reference to land surface)
Casing extends above ground inches
(b) NO
GW-57 HP @an, 2000) Page 2 of 4

(4) Grout (material surrounding well casing and/or piping): -
(a) Grout type: Cement Bentonite Other (specify) 6 ) P1 -G6-767
(b) Grouted surface and grout depth (reference to land surface):
around closed loop piping; from S to 50 (feet).
around well casing; from to (feet).
(5) Screens (for Type 5A7 wells)
(a) Depth: From `e 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 K no (b) the effluent line? yes 9( no
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 IFTHIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
(7)
J. PROPOSED OPERATING DATA (for Type 5A7 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 5QM wells)
Pro% de a complet listing of all chemicals added to the circulating heat transfer fluid:
ie-ri:Gt`?a!
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 (Jan, 2000) 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 well(s) 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."
ignature of Well Owner or Authorized Age
If 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
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW-57 HP (Jan, 2000) Page 4 of 4

SURVEYING - PLANNING - MAPPING
P.O. iox 27a7 [phone]
HUHTERSVILLE. NC 28070 FAX [phone]
BASE FLOOD ELEV. = 761.0'
FIRST FLOOR ELV. = 764.0'
LOWEST ADJ. ELV. = 763.9'
2ND FLOOR ELV. = 772.5'
HIGHEST ADJ ELV. = 770.9'
GARAGE ELV. = 771.0'
A/C ELEVATION = 769.1'
s-14ti
ol
Lot 6
Now or Formerly
Elizabeth W. Thornton
DB 2726 PG 459
vt
ti
10
4a0'a„ Shed
0
z Story sack
d6ro�• w/eo.•m.nt
N
3SlPtb
NPS
NPS
Flout
0
Gaxebor
Chain Link Fence
s By�b.s~
N 7205'00. W
80.00
NPS
LOT 7 ee
Port of Lot 81 0
27,149 SQ.FT.
0.6233 ACRES 110
Underground
Utilities
Deck 18.5'
31.7' 'I
23.8
30.83 47.1' n
Si
m 2
5.0
imp'
1
S 71.3755' E
11555
PRIVATE STREET
LAKE SHORE DRIVE
Except as .p.ciflcally .tat.d or .hown on thin plat. thle
. ur,.y does not r.fl.ct any of the following easements,
e ncumbrances, restrictive covenants, .ubdhl.lon ro.t:lotions.
Toning or other land u.. regulation®. and any otter facts
that o complete title examination may dodoes.
I certify that this .urvey was prform.d by
me (Klou. E Krueger), under my .up.r.t.lon.
Thl. survey 1. of on .xl.ting parcel o1 land.
Tho Row Error of pours was bettor than 1:10,000.
ThI. property is locatod In Zone AE — (Base
Flood Areas dotcrmined)
as .horn on FlRN mop Panel 370488 0005 A
dated January 10. 2000. .
DATE of:
Survey 04/12/01
Drawing 04/12/01
Job Ho: 2311
File: 16822LAKE
Drown by. KEK
Map Recorded In Map Book 10 Page 77 Deed Recorded In Deed Book
Lot 7 & Part 8 Block -D., Lake Norman Island Tax Parcel # 001-032-07
Currently Owned by. Vernon Curtiss Smith & Jane Reed Smith To be Conveyed to
LAKE NORMAN
Get*
vac• ,s
b���.d �s �� rt
eti
ti
SIP
0.17'
IaAUS E KRUEGER PLS L-3808
EIP
e rtc
Lot 9 & Part of 8
Now or Formerly
Lawrence C. Moore
& wt Marjorie D.
DB 2950 PG 447
EIP
v o
NPS Edge of P
AE — Iron betw.an
Lot, g&10
N 70i1 20' W
115.4r
own•nt
O
tI
N
EIP
0 30 e0 120
1 inch = 60 ft.
For Buyer:
BRIAN. P. & KATHLEEN LINDE
Physical Survey of
16822 LAKE SHORE DRIVE
CORNELIUS, NORTH CAROLINA 28031
LEMLEY TOWNSHIP, MECKLENBURG COUNTY
Exit 25
SITE
VICINITY MAP — Not to Scale
LEGEND
SET.Aaf
EASELFNT _ , —. + — •
. —
PROPERTY LINE
UNES NOT sJR.EYED — — — — —
FEATURE
RIGHT OF WAY
SEI RCN PIN O SP
DISfNO IRON PIN 0 OP
co104E1E uONUUFNT Dow
NO FIN SET 0 NPs
WATER DETER
Z 1
PORFA LE PO'O..
carol BASIN
SEWat YAHNOIE ()
LAM POST
it
UTa1TY sox *
0SLTR1c sox
0
8048 Page 260
Brian P. Linde & Kathleen Linde

Print Map
rage i or i
Location of 16822 Lake Shore Dr 28031
Lake Norman South
7.5-minute Quadrangle
NC SPCS E: 436618.7, N:189778.5 meters (NAD83)
Long: -80.9056470 W, Lat: 35.4458224 N (NAD83)
http://gis.enr.state.nc.us/topoviewer/gisprintjsp
1/10/2005

JR
*511144C"‘"
Akers Custom Comfort, Inc.
128 Gordon Dr. Stokesdale, NC 27357
Office [336] 427-7882 Fax [336] 427-6750
North Carolina Division of Water Resources
Ground Water Section
Attn. Mr. Evan Kane
1636 Mail Service Center
Raleigh, NC 27699-1636
January 19, 2005
Re: Application for Permit; DX Geothermal Heat Pump Loop [Vertical] installation
Mr. Kane,
C)
0)
Enclosed is an application to permit and install two DX Geothermal Heat Pumps at the residence of Mrs. Joan "Jody" Summerhays at
16822 Lake Shore Dr. in Cornelius, NC. The first application was sent December 23, 2004. I received the damaged documents back
today and I am resubmitting the application.
This is an existing home and is a retrofit application. The installation will follow the guidelines as previously established in the other
DX installations [pressure/tank testing and grouting procedures]. Enclosed are two copies of the application, site survey map, topo-
graphic map and installation specifications. Soil tests reveal a pH of 6.0. The home is on public water as are all homes in the area. The
septic field is in the rear of the home and exceeds the minimum fifty -foot distance requirements. The proposed loop field is in the front
of the home at the left front corner. Underground Locators have been contacted to locate the utilities and ensure safe minimum
distances to the loop field. The loop field will be marked on the lawn for the local inspector to observe during his site visit once UL
has completed their work.
If you have any questions, please contact me at 336-681-8496. I look forward to talking with you soon.
Sincerely,
Dwayne Akers
Akers Custom Comfort
1
NC DEPT. OF ENVIRONMENT
AND NATRU� L VED RESOURCES
JAN 2 i 2005
MOORESVILLE REGIONAL OFFICE
DWO-GROUNDWATER SECTION

r

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
January 24, 2005
Ms. Joan C. Summerhays
16822 Lakeshore Drive
Cornelius, NC 28031
Dear Ms. Summerhays:
Your application for a permit to construct and use vertical direct expansion heat pump system has been received
and is under review. A member of the Aquifer Protection Section's Mooresville Regional Office staff will be
contacting you to arrange an inspection of the injection well site as part of the review.
If you have any questions regarding your application, please call me at [phone].
cc: file
ooresville Regional Office
Akers Custom Comfort
Sincerely,
Evan O. Kane, P.G.
Underground Injection Control Program Manager
AND NATURAL RESOURCES
RECEIVED
JAN 2 7 2005
MOORESVILLE REGIONAL OFFICE
DWQ-GROUNDWATER SECTION
Aquifer Protection Section
Internet: http://h2o.enr.state.nc.us
NorthCarolina
Naturally
1636 Mail Service Center Raleigh, NC 27699-1636 Phone [phone] Customer Service
2728 Capital Boulevard Raleigh, NC 27604 Fax [phone]
Fax [phone]
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
April 14, 2004
MEMORANDUM
TO: Ted Bush
THROUGH: Debra Watts j' `i(i5D
FROM: Evan Kane
RE: Injection Well Permits for Direct Expansion Heat Pumps:
Collins, WI0400038, Davidson County
Mohorn, WI00400039, Guilford County
Charles C. Collins and Jason Mohorn have each applied for a permit to construct and operate
closed -loop, mixed -fluid geothermal injection well system as part of a vertical direct expansion
(DX) heat pump system at a residential site. I recommend that the requested permits be issued and
offer the following summary to assist you in evaluating this recommendation.
Direct Expansion Background
A vertical DX heat pump system entails burying copper refrigeration tubing in vertical boreholes
connecting the tubing to a heat pump and circulating Freon 22 (R-22) through the subsurface
portions of the system in order to exchange heat directly with the ground. According to the
manufacturers, direct expansion heat pump systems are much more efficient than traditional air-to--
air heat pump systems, which exchange heat by passing outdoor air over refrigeration coils, or
even water -source heat pump systems, which exchange heat by circulating water through a heat
exchanger. Under the injection well regulations in 15A NCAC 2C .0200, vertical DX systems meet
the definition of a "closed -loop geothermal -mixed -fluid heat pump injection well system" (15A
NCAC 2C .0209(E)) This type of injection well requires a construction and operation permit for
each site\at which it is to be used. Currently we have only permitted water -source heat pump
injection -'ells under this regulatory definition.
The proposed vertical DX systems are manufactured by ECR Technologies. In February 2001,
Mr. Harvey Sachs, a consultant to ECR, submitted information to the Groundwater Section
regarding vertical DX systems and requesting our feedback on the permitting requirements for
such systems. In a letter from Arthur Mouberry dated February 15, 2001, the Section responded to
Mr. Sachs that the system did not meet regulatory requirements for injection wells and would not
be permitted due to mechanical integrity issues related to potential corrosion of the copper piping,
potential leaking of the chlorinated hydrocarbon refrigerant in the system, and an organic
constituent in the grout proposed for use with the system.
In 2003, the Section agreed to re-examine whether vertical DX systems could be permitted in
1 of 4

4
North Carolina. Based on information provided by ECR Technologies and their distributor,
Gemma Tiller of AirBrokers HVAC, regarding the manufacture, quality control, installation, and
testing procedures for their systems, I believe it is reasonable to expect that these systems can meet
the mechanical integrity requirements of 15A NCAC 2C .0200 and thus are not likely to result in a
release of refrigerant to the subsurface. In particular, during our meeting with ECR, AirBrokers,
and Dwayne Akers on January 30, 2004 and in other correspondence from these parties, ECR and
AirBrokers indicated that:
1. they require installation of an active cathodic protection system to prevent corrosion of the
system at sites where soil pH is below 6 or above 11. ECR and AirBrokers indicate that
they will not sell a system to an installer without first obtaining soil pH test results for the
site;
2. they conduct multiple checks on the mechanical integrity of the loop tubing between
manufacture and installation, as well as a final mechanical integrity test after installation of
the loop;
3. they require new installers to complete a certification program to ensure that proper
procedures are used in the installation of these systems; and
4. they have no known subsurface failures of ECR's systems in roughly 20 years. I have
called environmental agencies in several states to determine if they have had any problems
with groundwater contamination resulting from vertical DX systems and found none were
aware of any problems, but also found that most states do not require individual permits for
these systems and therefore do not have any hard and fast data to track any failures.
Additionally, the organic component of the proposed grout is no longer an issue because ECR,
AirBrokers, and the permit applicants have indicated a different grout will be used than the one
proposed in 2001. The new grout, ThermalGrout Select, is a bentonite-sand mixture that contains
no organic constituents.
Though I have said that I believe that these systems are not likely to result in a release of
refrigerant to the subsurface, these systems are new to North Carolina, and little verifiable
information is available about their track record for subsurface releases (other than the longevity of
the company that makes them). For these reasons, I think it is very important that we make a
concerted effort to track each site with one of these systems once it is permitted. As described
below, the permits that I have drafted include special conditions regarding reporting of refrigerant
leaks and refrigerant recharging.
Site Background
Collins: The Collins site is an existing home served by a private well and on -site septic system.
According to the GW-1 submitted for the existing water supply well, the shallowest water -bearing
zone encountered in drilling lies at 150 feet below land surface (bls) and the well is cased to 60 feet
bls. Maps submitted with the application and the site inspection conducted by Chris Greene
indicate that the proposed injection well locations comply with the required minimum separation
distances from the septic system as well as the manufacturer's suggested minimum separation
distance from the water supply well.
Mohorn: The Mohorn site is a new home site served by county water and sewer. Separation
distances appear to be in compliance with required minimums.
2 of4

The applications submitted for each site indicate that the soil pH is within the acceptable range for
system installation without cathodic protection.
Site -Specific Aspects of the Proposed Injection Wells
At each site, ten injection wells will be drilled to approximately 100 feet each. Each borehole will
be grouted from 5 feet bls to 100 feet bls after insertion of the copper tubing loop.
Unique Permit Conditions for Vertical Direct Expansion Heat Pumps
I have incorporated several changes to the standard 5QM injection well permit conditions in the
attached permits. These changes are based on my own research and judgment as well as
suggestions provided by ECR via e-mail on April 9, 2004. I recommend that these special permit
conditions become standard for all DX systems regardless of manufacturer unless new information
leads us to change them.
The special conditions include:
1. Part II - Well Construction Special Conditions:
a. Soil pH testing must be performed prior to system installation and cathodic
protection must be installed if pH is less than 6 or greater than 11.
b. All underground tubing shall be constructed of refrigeration grade copper. This
ensures a minimum standard for the quality of the copper tubing used.
c. Tubing must be leak tested prior to installation (this is a factory test that ECR says
is standard procedure).
d. Tubing must be inspected before insertion into the borehole, including checking for
a factory -applied pressure charge.
e. Brazing material (solder) must be lead-free and must have a galvanic potential as
close <is practicable to that of the copper tubing. This is to prevent a galvanic
corrosion reaction between dissimilar metals at soldered joints.
f. Nitrogen must be circulated through the tubing during brazing (soldering) to
prevent oxidation corrosion of the tubing. This was a manufacturer
recommendation and appears to be a standard requirement in the refrigeration
industry.
g. The system must pass a mechanical integrity test prior to being charged with
rcfriycrant.
h. Mani fold (tubing header) locations must be recorded by triangulation. Records of
this i; 'ust be retained by the permittee and submitted to us for our records. This is to
a:d i ; : locating leaks or damaged portions of the system.
2. Part Vli - unitoring and Reporting Requirements: In addition to the standard
requirements that the pennittee report system malfunctions and system modifications to us,
I have added conditions that the permittee report to us any loss of refrigerant from the
system, re;_lualiess of the origin of the loss, as well as any recharging of the refrigerant
system. l l: 2 purpose of these reporting requirements is to ensure that if a leak occurs, we
are infornnc.: 1 dose the leak is "repaired" or diagnosed simply by repeatedly recharging the
refrigerant. 1 this way, any leaks that might impact groundwater will be limited in volume
(so long applicant complies with these permit conditions).
3 of 4

Summary
I believe that through a combination of quality control and installation standards required by ECR
and the testing, installation and reporting requirements of these permits, groundwater quality can
be protected from potential impacts of vertical DX systems. Therefore, I recommend issuance of
these permits.
Attachments — ohorn and Collins permits
4 of 4

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
Mr. Jason Mohorn
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5QM INJECTION WELL
SYSTEM, defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the
purpose of operating a vertical closed -loop direct expansion heat pump system. This system is
located at 3 Sail View Cove in Greensboro, Guilford County, North Carolina, and will be
constructed and operated in accordance with the application submitted March 19, 2004, 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 April 20, 2009,
and shall be subject to the specified conditions and limitations set forth in Parts I through X
hereof.
Permit issued this the / / day of , 2004.
Ted L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0400039
GW/UIC-5 ver. 3/01
PAGE 1 OF 7

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 borehole.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Within 30 days of completion of well construction, a completed Well Construction Record
(Form GW-1) must be submitted for each injection well to:
Groundwater Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART II - WELL CONSTRUCTION SPECIAL CONDITIONS
1. Prior to constructing the injection well system, the permittee or his agent shall test the pH
of the soil at a depth of three feet at the planned well location. If the resulting soil pH is
less than 6 standard units or greater than 11 standard units, the well system shall be
equipped with a compatible cathodic protection system.
2. 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] and the Winston-Salem Regional Office Groundwater
Section Staff, telephone number [phone].
Permit No. WI0400039 PAGE 2 OF 7
GW/UIC-5 ver. 3/01

3. All underground tubing shall be refrigeration grade copper tubing.
4. Prior to installation, all tubing to be placed in boreholes ("loops") shall be checked for
leaks by pressurizing the loop to a gage pressure of at least 350 pounds per square inch
(psig), immersing the loop in water and examining it for leaks. Loops with leaks shall not
be installed. A copy of the leak test record (quality control tag) shall be submitted to the
Groundwater Section within 30 days of completion of well construction.
5. Prior to installation, each loop shall be visually inspected for damage such as kinks, dents,
and scrapes. Each loop shall be checked to verify that the nitrogen charge applied to the
loop by the manufacturer before shipping is still present at a pressure of at least 300 psig.
The loop manufacturer shall be notified in the event of damage or pressure loss, and the
manufacturer's instructions shall then be followed. The nitrogen charge may be released
only when the loop is installed and ready to be connected to the manifold.
6. Boreholes shall be of sufficient size to allow for insertion of the loop as well as a tremie
pipe for grouting.
7. After insertion of the tubing into the boreholes, an approved grout (as defined in Title 15A
North Carolina Administrative Code 2C .0100) shall be pumped via tremie pipe into the
annular space of each borehole so as to completely fill it from bottom to top.
8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material
shall have a galvanic potential as close as practicable to that of the tubing material.
9. Dry nitrogen shall be circulated through the tubing during brazing to prevent oxidation of
the tubing.
10. After installation and prior to operation of the system, a mechanical integrity test shall be
conducted by pressurizing the injection well system to 400 psig with dry nitrogen and
monitoring for leaks using an ultrasonic or other leak detector of equal sensitivity and
monitoring pressure in the system for at least 2 hours. Any pressure fluctuation other than
that due to thermal expansion and contraction of the testing medium shall be considered a
failed mechanical integrity test. Any leaks shall be located and repaired prior to charging
the system with refrigerant.
11. The location of each of the system manifolds shall be recorded by triangulation from two
permanent features on the site (e.g., building foundation comers). The permittee shall retain
a copy of the triangulation records. The permittee shall also submit a copy of the
triangulation records to the Groundwater Section within 30 days of completion of well
constriction.
Permit No. WI0400039
GWTUIC-5 ver. 3/01
PAGE 3 OF 7

12. The written documentation required in Part II, paragraphs (4) and (11) shall be submitted
to:
Groundwater Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
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 pen -nit 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.
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
conditions, 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.
Permit No. WI0400039
GW/UIC-5 ver. 3/01
PAGE 4 OF 7

PART V - OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the 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
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 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 Winston-Salem Regional Office, telephone number
[phone], any of the following:
(A) Any occurrence at the injection facility which results in any unusual
PAGE 5 OF 7
Permit No. WI0400039
GW/UIC-5 ver. 3/01

operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
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.
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)(1), 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.
Permit No. WI0400039 PAGE 6 OF 7
GW/UIC-5 ver. 3/01

(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)(1) within 30 days of completion of
abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Groundwater Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X - OPERATION AND USE SPECIAL CONDITIONS
None
Permit No. WI0400039
GW/UIC-5 ver. 3/01
PAGE 7 OF 7