WI0300051_Regional Office Historical File Pre 2018

Water Resources
ENVIRONMENTAL QUALITY
June 2, 2016
Anne Holden
124 Tall Oak Drive
Mooresville, NC 28117
Subject: Permit Rescission
UIC Permit No. WI0300051
Geothermal Heating/Cooling Water Return Well
Iredell County
Dear Ms. Holden:
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Director
Reference is made to your request for rescission of the subject Geothermal Heating/Cooling Water Return
Well Permit located at the above referenced address. Staff from the Mooresville Regional Office has
agreed that a permit is no longer required. Therefore, in accordance with your request, Underground
Injection Control (UIC) Permit WI0300051 is rescinded, effective immediately.
Since the geothermal injection is inactive and you do not plan on using the well for any other
purposes, the well should be temporarily or permanently abandoned by a NC certified well driller
according to 15A NCAC .0100 and/or .0200. Please coordinate with Ed Watson with the
Mooresville Regional Office (704-663-1699) to abandon the well.
if in the future, you wish to operate a Geothermal Heating/Cooling Water Return Well injection system,
you must first apply for and receive a new permit. Operating a geothermal heat pump injection system
without a valid permit may result in the assessment of civil penalties and/or the use of other enforcement
mechanisms available to the state.
[f it would be helpful to discuss this matter further, please do not hesitate to call Michael Rogers
at [phone].
Sincerely.
�6 r " Jay Zimmerman, P.G., Director
Division of Water Resources
Attachment(s)
cc: Mooresville Regional Office - WQROS
Central Files - Permit No. W10300051
Iredell County Environmental Health Dept.
State of North Carolina ; Environmental Quality . Water Resources
1 ,i 1 Mail set -me Center Raleigh, North Carolina'-7(99-'1611
919 707 9000

J011 1V Vl lY •JJ
/sr coo/
NORTH: CAROL1NA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PEST TO CONSTRUCT AND/OR EM 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: DIRECTOR, NORTH CAROLINA. DIVISION OF WATER QUALITY
DATE:. IA Al. I! , 20
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1) Type 5A7 wells inject water used to provide heating or cooling for structures.
(2) ,� Type 5QM wells contain a subsurface �syates a fluid other iliof continuous a ► ppotab water.
g, that is
isolated from the environment an
This includes systems that circulate additives such as antifreezes and/or corrosion
inhibitors.
(3) Type SQW 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. thencompete fo GW 5 CL Notification Of Intent To
Construct A Closed -Loop Geothermal -Water Only Infection Well System.
R. PERMIT APPLICANT
Name: • : R
vL • IiU" DOA?
Address: I G2 774 Ak- :Da 1 ✓L
at Zip Code:-7 i17_ County: �°i�—"-
City: �7Jan --5 coo cc c State: p
Telephone: 70 - 6 4 2 - _3 S Jr.;
C. PROPERTY OWNER (if different from applicant)
Name:: s.4.77C
Address:
City:Sate: Zip Code: County:
Telephone:
D. STATUS OF APPLICANT
Private:
Federal: Commercial:
State: Municipal: Native American Lands:
Page 1 of 4
GW 57 HP (Jan: 2000)
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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:
pL• m p 1.v : � rr c � v rCn l 7.....:*-1... ,
F. HEAT PUMP CONTRACTOR DATA )%`''
Name: l- Ii /`fir
Address:
73 3 2 04T 57 ,ir-eiY;«' R,r.
City:
01M-A h v iTZ Zip Code: ' County: �L''‘. "' .
Telephone: 7Q jr 5 / . Contact Person:
G. INJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.)
F'Rui,1 R 5-ry4-,, �� Frrr 17 4.,6•c1-c- /5
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fat:L� %J A1R J- P mPP. !146c..m' - C 7,' /
Alt-"3 %�.�? rte.. S r+R � .s � ja rR=Si %=2ee.-+ �A�e S:D.
+ Z!"_a - /VCY ti f u:.u7 f.t' =Z iL�:r3) A -PP m. /
jc� j3C jc7vY�.�a.7 lb �5a1?PLC Li
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
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.
PROPOSED WELL to be constructed for use as an injection well. Provide the
data in (1) through (7) below as PROPOSED construction specifications. Submit
Form GW- 1 after construction.
(1) Well Drilling Contractor's Name: 1 K
NC Contractor Certification number: / Al 57
(2) Date to be constructed:' Fen a Number of borings: 1
Approximate depth of each boring (feet): 1 L`xs J /90
(3) wen 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 0 to ye' ft. (reference to land surface)
Casing extends above ground / 6 inches
(b) NO
Page 2 of 4
GW- 57 HP (Jan, 2040)

Jan 1U 'Ul 15:UU v. U4/U5
(4) Grout .(material surrounding well casing and/or piping):
(a)
(b)
Grout type: Cement Bentonite Other (specify)
Grouted surface and grout depth (reference to land surface):
around closed loop piping; from _ to (feet).
around well casing; from to _ (feet).
(5) Screens (for Type 5A7 wells)
(a) Depth: From to feet below ground surface.
(6) N.C. State Regulations (Title ° 15A NCAC 2C .0200) require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent (fluid being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? yes ✓ no (b) the effluent line? yes ✓ no
(7) SOURCE WELL CONSTRUCTION INFORMATION (if different from Injection well).
Attach a copy of Form GW-1 (Well Construction Record). If Foam GW-1 is not available.
provide the data in part K (1) of this application form to the best of your knowledge.
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
PROPOSED OPERATING DATA (for Type 5A7 wells)
(1) Injection rate: Average (daily) gallons per minute (gpm). "D% 'r
4
o z — "4;1
,�
(2) Injection Volume: Average (daily) gallons Pr
, per day y�..#v ; o c� - � m.�v��
(3) Injection Pressure: Average (daily) pounds/square inch (psi). d c �� r -df
(4) Injection Temperature: Average (January) 44,9 ° F. Average (July) 6 3 ° F. 1.39 ; o 'V o
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: J j © Formation: CL - G ock/sedimeut unit: & 2 tre
(2) Chemical Analysis of Source Fluid (for Type 5QM wells)
Provide a complete listing of all chemicals added to the circulating heat transfer fluid:
L. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
GW- 57 HP (Jan, 2000) Page 3 of 4

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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 dearly 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 trap nacre.
N. PERMIT LIST: Attach a list of all pennits 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
0. CERTIFICATION
"I hereby certify, under penalty of law, that 1 have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the information
is true; accurate and complete. I am aware that there are significant penalties, including the possibility
of fines and imprisonment. for submitting false information. 1 agree to construct, operate, maintain,
repair. and if applicable, abandon the injection well and all related appurtenances in accordance with
- the approved -specifications and conditions of the Permit."
(Signature of Well Owner or Authorized Agent)
1fauthorized agent is acting on behalfofthe 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.. 20.00) Page 4 of 4

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JUL-31-2000 09:46 AM B&K WELLDRILLING_IMC T04 r3iz area
002,1 (o, v _ 4 aL (-
North Carotins • Department of Environment and Natural Resources • Division of Water Duality - Groundwater Section
1638 Mail Service Center • Raleigh, N.C. 2761)9.1638-Frhone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: K W EI Dt
WELL CONTRACTOR CERTIFICATION 0: J Jr
STATE WELL CONSTRUCTION PER MITI*:
-
1. WELL USE (check AppIIcobr. Boc): Residentla►g, Municipal El Industrial ❑ Agricultural LJ Monitoring ❑
Recovery 0 Heat Pump water Injection ❑ Other El 1f Other. List Use:
2. WELL LOCATION: (Show sketch of use location below) ,..�� /
Nearest Town: t�Ynk-a , r'l c County. - riff / /
16n
(Road Name sap Numbers, Community or Su Msion and LO
of No.) DRILLING G DEPTH
3. OWNER `trj, •CrttdSs'D�'t. /cB/.f From To Formation Description
'treat or I�aule NO. ��jj.•�/
d�./(o 5'
Addiess
City or own State Zfp Code
4. DATE DRILLED /Al /9 9
5. TOTAL DEPTH /96
6. CUTTINGS COLLECTED YES Q NOE
7. DOES WEAL REPLACE EXISTING WELL? YES E NO(Z
®. STATIC WATER LEVEL Below Top of Casing: c) FT_
(useit Above Top of Casing)
9. TOP OF CASING IS {4FT. Above Land Surface'
'Top of casing taretlnated et/or below lone surface requlree ■ Mitlnce In aCeor-
canc. with ISA NCAC 2CAOLIS
10. YIELD (gprn): yic 3 METHOD OF TEST. )f/ 1 MO
l t . WATER ZONES (depth).
12. CHLORINATION: Type Kitnr t
13. CASING:
Amount Jff-ir
If addivonat space Is needed use back of form
Wait Thickness LQCATION SKETCH
Depth r Diameter or Weight/Fr. tr _Matcher
i (Show direction and distance from at least two State
From a. To �o Ft __J �',r r Y
Roads, or other map reference points)
hrorn To— FI.
Frorn To Ft. -
14. GROUT:
Depth A ` Malarial •Method t '`-` ) j -'f

INSPECTION C
IREDELL COUNTY DEPARTMENT OF PLANNIN
PHONE: [phone] & 704-878-5437 DAY 0 NIGHT
PERMIT #: 73/ 7 OWNER:
ADDRESS:
IMPORTANT: This permit placard must be displayed on the premises in a co
this placard will result in refusal to make inspections.
GENERAL CONST.
Iredeil
Date
qlr
Iredell•Co'
4 Si • ,
Date
By
Slab
of`
Framing
Wall Insulation
Final
Oils
ELECTRICAL
Saw Service
c.5witrylrOktiorii
•
Date
% A .1 a' •
ay-
Slab
Rough
Iredell •Cou
_^.-• . • -
Service Change
flnal
It is wiiawfu:; to eccuov or to permit the occupancy of any but,
tifizazi; of oc—.7cancv : 1.een It is the contractors responsibi
Department :tserv-...s the rig:rt :o reje..:t eznv work c)ncealed pror tr-
PLUMBIN
Sink
leaden Co
Date
BY.
.•.
Rough
By
Slab
Rough
Gas Pipe
Vent
Fire Place
ana I
ons
ons
ense) nianY

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
January 18, 2001
MEMORANDUM
To: Matt Heller, L.G.; Groundwater Supervisor
Groundwater Section
Mooresville Regional Office
From:
Mark Pritzl . [e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section, Central Office
Dry. or'
CQNVIRONMENT, SHCEAt.,T
0 NATUIi;Lai. R1 . ouRCE.ti
JAN 22 2OO1
gi.48100 OF ITILITERIAR 011P116E1FUT
ME1 EM Q f NI OF 1r5K
Re: Request review of a new injection well permit application for the operation of an open loop
geothermal heat pump system.
The CO-UIC has received an application by Mr. Ronald L. Holden for a new permit for the
construction and operation of an injection well located at 124 Tall Oak Drive, Mooresville, NC.
The proposed injection well will be part of an open loop geothermal heat pump system, therefore
a type 5A7 well.
1. Please review the application and submit any comments to CO-UIC. Retain the
application for your UIC file.
2. Please' inspect the proposed injection well site to verify that the location and construction
plans submitted in the application are accurate and that the NCAC Title 15A 2C.0200
standards are being complied with, using the enclosed Preconstruction Injection Facility
Inspection Report -Form (A) as appropriate.
Please return any comments immediately upon application review. You are requested to return the
completed Preconstruction Injection Facility Inspection Report -Form (A) to the CO-UIC by
February 15, 2001. If the inspection can not be accomplished by this date, please inform the CO-
UIC. The UIC Group appreciates your assistance in the review and evaluation of this permit
application. Please contact me if you have any questions or comments at [phone] or
Meliktu Fanuel at [phone].
cc: UIC Files
Enclosures

WAIF
q�G Michael F. Easley `O
Governor
CO r- Sherri Evans -Stanton, Acting Secretary
Department of Environment and Natural Resources
Y Kerr T. Stevens
Division of Water Quality
January 18, 2001
Mr. Ronald L. Holden
124 Tall Oak Drive
Mooresville, NC 28117
Dear Mr. Holden:
Your application for a permit to use a well for the injection of geothermal heat pump
effluent has been received and is under review. A member of the Groundwater Section's
Mooresville Regional Office staff will be contacting you to arrange an inspection of the injection
well and collect water samples as part of the review.
If you have any questions regarding the permit or injection well rules please contact me
at [phone] or Meliktu Fanuel at [phone].
cc: CO-UIC Files
MRO-UIC Files
A VA
NCO ENR
Customer Service
1 800 623-7748
Sincerely,
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: http://www.gw.ehnr.state.nc.us

tJ b'(
North Carolina
Department of Environment, Health, and Natural Resources
Division of Environmental Management
Groundwater Section
WELL AND PUMP INSPECTION REPORT
Well Location: J--ttzi6Y.I_ 20. -
(Town, Community, Subdivision and Lot No.)
Owner f c5 L t er
Address: l a LI akl CcJ . L/e
NOOV`P-Su((IL)L
l'7
Date -6/ - O r
WELL PTY E r atd so u.lc_
County
Road/Street 12-4, Cq
Quad No. Al(e,1 a -C
Serial No.
Lat. 'S5� 54 f ®� Long. '7o U-55
..t/
Well Construction
Drilling Contractor LAJ
Name
Permit Required ? (re
Location - Distance From:
Water Tight Sewage/waste collection
Waste disposal (septic tank drain field)
Other Poll: Source (
Other Poll. Source (
Casing
Type
Depth
Weight/thickness
Height (A.L.S.)
Other ( ) ..
prillino Fluids/Additives
Type
Grout
Type
Thickness
Depth
Other ( ) .
Screens
Screened interval
Other (
Development
Total. Suspended solids
Turbidity
Settleable Solids
J.D. Plate
Well Contractor
Abandonment
Temporary
Permanent
Check Items
Measured
Address
Meets Min. Standards
Yes I No
Rea. #
Remarks
tt) eQ4 fZt w
(Permit No. Jiu c/ / 20 r• )
Q a�
l•'
(Circle one)
sU Carbon Galy. Stain. St. Other
is
,/ ?Lay?
D rt_u3n4.10
L/
%gL�l l,✓/� f�Ej1 G2' 7�
gfr
;yD
G'W-iA Rav 1 nig?
Applies to wells constructed after December 1, 1992

Check Items
Measured
Meets Min. Standards
Yes No
Remarks
Well Test
Duration
Frequency/Accuracyof measurements
Other (
Disinfection
Chlorination
Other (
Cuttings
Reports
Construction (GW-1)
Abandonment (GW-30)
Well Head Completion
Access port
Hose bib
Pitless Adaptor
Pitless Adaptor Unit
Suction line
Tee (jet)
Valved flow
Vent
Water tight pipe entry
Well entry
Applies to wells constructed after December 1, 1992
Date Well Constructed I zg qq , ,
Pumo Installation
Pump Installation Contractor /" fi / r%/ ���� Ve
Name Address
PUMP CQNTRACTQR I.D. PLATE PRESENT ? (Y/N)
Rea.
Date Pump Installed - -�
Violations noted attributable to the pump installation contractor are as follows: G /DD
(1)
(2)
(
(3)
INSPECTOR
Name Office
Wi`nes(es) `Mt /4-)1.6 •19
(If Available)
Name
Address Type
Name
Address Type

Water Resources
ENVIRONMENTAL OUALITY
May 16, 2016
Mrs. Anne Holden
124.Tall .Oak Drive
Mooresville, NC 28115
SPAT MCCRORY
Governor
ONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Director
RE: Underground Injection Control (UIC) Sampling
Results
WI0300051 Holden 5A7 Geothermal UIC
Mooresville; Iredell County
Permit Rescission Request
Dear Ms. Holden:
On April.21, 2016, staff from the Mooresville Regional Office (MRO) of the Division of Water
Resources sampled the water supply well at your residence for the purpose of water quality. During our
visit, we discovered your geothermal well had been bypassed and was no longer in service. As a result, a
permit. rescission of the.geothermal underground injection well heat pump has been initiated.
The samples were analyzed by the Division of Water Quality (DWQ) lab for metals, nitrates and other
inorganic constituents. The results indicate, at the time of sampling:
1) The water supply well tested negative for Total and Fecal Coliform Bacteria.
2) Total Nitrates were measured to be within groundwater standards.
3) No exceedances of metals were detected.
4) Total Dissolved Solids are within groundwater standards.
If you have not already done so, please submit the permit rescission form to Mr. Michael Rodger at our
central office in Raleigh. A complete copy of the DWQ lab results is enclosed for your review. The MRO.
will forward the lab results to the central office in Raleigh as part of the permit rescission process.
Should you have any questions, please feel free to contact me at [phone] ext. 2198 or by email at
[e-mail].
Edward Watson
Hydrogeologist
Water Quality Regional Operations. Section . .
Division of Water Resources
Enclosures: 05-21-16 sample results, definitions of laboratory symbols,
Cc: Michael Rogers, UIC, Raleigh (email)
State of North Carolina 1 Environmental Quality I Water Resources I Water Quality Regional Operations
Mooresville Regional Office 1610 East Center Avenue, Suite 301 I Mooresville, North Carolina 28115
704 663 1699

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Antimony (Sb) pg/L
Vanadium (V) µg/L
CaCO3, to 4 5/8 3
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Alkalinity, as pH
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mg/L
Residue. Total (Total Solids) mg/L
Residue Volatile/Fixed, Total mg/L
X
X
Arsenic (As) µg/L
,Barium (Ba) µg/L
X
Zinc (Zn) µg/L
BOD• Biochemical Oxygen Demand, 5-day
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Residue. Suspended (Suspended Solids) mg/L
Beryllium (Be) pg/L
Boron (B), Total µg/L
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Revision: 2/06,

WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM RECEIVED/NCDENR/DWR
Date: April 19, 2016 APR 21 2016
To: Corey Basinger - Andrew_ Pitner �'
WQROS
MOORESVILLE REGIONAL OFFICE
From: Shristi Shrestha, WQROS — Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax [phone] E-Mail: [e-mail]
Permit Number: WI0300051
A. Applicant: Anne Holden
B. Facility Name:
C. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a completed WOROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: Date:
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 092614 Page 1 of 1

Water Resources
ENVIRONMENTAL QUALITY
April 19, 2016
Anne Holden
124 Tall Oak Dr.
Mooresville, NC 28117
RE: Acknowledgement of Application No. WI0300051
Geothermal Heating/Cooling Water Return Well
Iredell County
Dear Ms. Holden:
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
RECEIVEDINCDEN i5VcR
APR 21 2016
WQROS
MOORESVILLE REGIONAL OFFICE
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on April 13, 2016. Your application
package has been assigned the number listed above, and the primary reviewer is Shristi Shrestha
Central and Mooresville 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 peiniit applications, the Water Quality Regional Operations
Section (WQROS) requests your assistance in providing a timely and complete response to any
additional information requests.
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. If you have any questions, please contact Shristi
Shrestha at 919-807-6406 or email at [e-mail].
Sincerely,
Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
cc: Mooresville Regional Office, WQROS
Permit File WI0300051
State of North Carolina Environmental Quality Water Resources
1611 Mail service Center I Raleigh, North Carolina 27699-1611
919 707 9000

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 WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: ,20
PERMIT NO. WI O 3 00661 (leave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave Blank if New Application)
1. Current Use of Well
a. Continue to use as Geothermal Well Drinking Water Supply Other Water
Supply
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
❑ Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued?
If yes, indicate new owner's contact information:
RECEIVEDNCDEQ/DWR
APR 13 2016
❑ YES n N/Yater Quality
j ional Operations Section
Name(s)
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence Business/Organization
Government: State Municipal County Federal
C. WELL OWNER(S)/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:
Mailing Address: Aril I ( H d i d e 1't
City: f10U Y05 V State:1\% C Zip Code: 2 1/ ! County: Q dell
Day Tele No.: 70— 6 6 , -.3 5-3 ()
EMAIL Address: Fax No.:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 1

D. 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.: Email Address.:
E. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: County:
(2) Physical Address (if different than mailing address):
City: State: NC Zip Code:
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Ce11 No.: Fax No.:
G. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name:
NC HVAC Contractor License No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.:
Cell No.: Fax No.:
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO
I. WELL CONSTRUCTION REQUIREMENTS — As specified in 15A NCAC 02C .0224(d):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 2

(3)
(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.
A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTING WELLS PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
(c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water -bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(1)(8)
(f)
(g)
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
K. OPERATING DATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) ° F.
L. SITE MAP — As specified in 15A NCAC 02C .0224(b)(4), attach a site -specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 3

NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a `layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that 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 all the person(s) listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
Signature of Property Owner/Applicant
Print or Type Full Name
r it & o l d e7)
Signature of Property Owner/Applicant
Print or Type Full Name
Aoki 11 e-- 0/C
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 4

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application Renewal* Modification _X_Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete. Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: April 21
Application)
, 2016 PERMIT NO. WI0300051 (leave blank if New
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as ❑ Geothermal Well ❑ Drinking Water Supply Well
❑ Other Water Supply Use- Indicate use (i.e., irrigation, etc.)
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES ® NO
If yes, indicate New Owner's contact information:
Name(s) Anne Holden
Mailing Address: 124 Tall Oak Drive
City: Mooresville State: NC Zip Code:28117 County:
Iredell
Day Tele No.: [phone] Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence X Business/Organization
Government: State Municipal County Federal
Geothermal Water Return Well Permit Application Rev. 3-1-2016 _ Page 1

C. WELL OWNER(S)/PERMIT APPLICANT — For single family residences, list all persons listed on the
property deed. For all others, list name of business/agency and name of person and title with delegated authority
to sign: •
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Ce11 No.:
EMAIL Address: Fax No.:
D. WELL OPERATOR (if different from well owner) — For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
to sign:
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: County:
(2) Physical Address (if different than mailing address):
City: County Zip Code:
WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
-. Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.:
Ce11 No.: Fax No.: .
G. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name:
NC HVAC Contractor License No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.:
Ce11 No.: Fax No.:
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 2

R
(1) The injection operation? YES NO
(2) Personal consumption? YES NO
I. WELL CONSTRUCTION REQUIREMENTS —As specified in 15A NCAC 02C .0224(d):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
(a) For screen and gravel -packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTING WELLS PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
(c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e)
(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(0(81
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
K. OPERATING DATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily), gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) ° F.
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 3

1
L. SITE MAP — As specified in 15A NCAC 02C .0224(b)(4), attach a site -specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a `layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that 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 all the person(s) listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
Signature of Property Owner/Applicant
Print or Type Full Name and Title
Signature of Property Owner/Applicant
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 4

t
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 5

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

NCDENR
A TA
0
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director, Division of Water Quality Secretary
May 27, 2011
Anne Holden
124 Tall Oak Drive
Mooresville, NC 28115
RE: Underground Injection Control (UIC) Sampling Results
WI0300051 Holden 5A7 Geothermal UIC
Mooresville, Iredell County
Dear Ms. Holden:
On May 4, 2011, staff from the Mooresville Regional Office (MRO) of the Aquifer Protection Section (APS)
sampled the influent and effluent lines of your geothermal underground injection well heat pump system. The
samples were analyzed by the Division of Water Quality (DWQ) lab for metals, nitrates and other inorganic
constituents. The results indicate, at the time of sampling:
1) The water supply well tested positive for Total Coliform Bacteria. The MRO recommends well
chlorination, replacement of the broken vent pipe (if you have not already done so) and follow-up
sampling with your Iredell County Environmental Health Department. Their Mooresville office number
is: [phone].
2) The sample collected from the system "Out" Line showed Copper and Zinc at levels greater than your
water supply well but still below the NC groundwater standards. It is possible this is a result of an
insufficient purge time. Please contact me when your system contractor is scheduled for routine
maintenance. The MRO would like to follow-up while the contractor is on -site.
A complete copy of the DWQ lab results is enclosed for your review. I am also including a copy of the "How to
Disinfect Your Well" brochure, for your information. Your certified well contractor may also be of assistance
should you have any concerns with well chlorination. The MRO will forward the lab results to the central office in
Raleigh. Should you have any questions, please feel free to contact me at [phone] ext. 2184 or by email
at Maria.Schuttecncdenr.gov.
Sincerely, \
Maria Schutte
APS Environmental Senior Technician
Enclosures: 05-20-11 sample results, definitions of laboratory symbols, "How to Disinfect Your Well" Brochure
Cc: John McCray, APS-GPU-UIC, Raleigh (email)
Judy Melville, Iredell County Environmental Health, Mooresville (email)
Division of Water Quality / Aquifer Protection Section / Mooresville Regional Office
610 East Center Avenue, Suite 301, Mooresville, North Carolina 28115
Phone: [phone] FAX: [phone] \ Customer Service 1-877-623-6748 \ Internet: www.ncwaterouality.orq
One
NorthCarolina
Naturally
An Enna) Oonorfinity 1 Affirmative Action Emnlover — 50% Recycled i 10% Post Consumer Paner

NC DIVISION OF WATER QUALITY
LABORATORY ANALYTICAL RESULTS
5A7 GEOTHERMAL UNDERGROUND INJECTION CONTROL (UIC) WELL
PERMIT NO.: WI0300051
PERMITTEE(S): Anne Holden
SAMPLE COLLECTION DATE: 05/04/2011
Parameter
Fecal Coliform
Total Coliform
Total Dissolved Solids'
Chloride, CI
Fluoride, FL
Sulfate, SO4
units
CFU/100m1
CFU/100m1
mg/L
mg/L
mg/L
mg/L
NC MCL and/or EPA Standard
NC MCL = < 1
NC MCL = 1
NC MCL = 500
NC MCL = 250
NC MCL = 2
NC MCL = 250
EPA SDWS = 500
EPA SDWS = 250
EPA PDWS = 4.0
EPA SDWS = 250
Influent Sample Results (Water Supply Well)
< 1
3
96
1.7
< 0.4
7.6
Effluent Sample Results (HVAC "In" Line)
< 1
< 1
96
1.7
< 0.4
7.7
Effluent Sample Results (HVAC Out Line)
< 1
< 1
122
1.7
< 0.4
7.9
Parameter
Nitrate
Nitrite
Nitrate + Nitrite
Hardness as CaCO3 (by
Calculation)
Aluminum, Al
Arsenic, As
units
mg/L as N
mg/L as N
mg/L as N
mg/L as CaCO3
pg/L
pg/L
NC MCL and/or EPA Standard
NC MCL = 10
NC MCL = 1
NC MCL = 11
NS
NS
NC MCL = 10
EPA PDWS =10
EPA PDWS =1
EPA PDWS =11
EPA SDWS = 50 to 200
EPA PDWS =10
Influent Sample Results (Water Supply Well)
0.54
< 0.01
0.54
63 *
< 50
< 2.0
Effluent Sample Results (HVAC "In" Line)
0.54
< 0.01
0.54
66 *
< 50
< 2.0
Effluent Sample Results (HVAC "Out" Line)
Not Analyzed
Not Analyzed
0.53
66 *
< 50
< 2.0
Parameter
Barium, Ba
Calcium, Ca
Cadmium, Cd
Chromium, Cr
Copper, Cu
Iron, Fe
units
pg1L
mg/L
pg/L
pg/L
pg1L
pg/L
NC MCL and/or EPA Standard
NC MCL = 700
NS
NC MCL = 2
NC MCL = 10
NC MCL = 1000
NC MCL = 300
EPA PDWS = 2000
EPA PDWS = 5
EPA PDWS = 100
EPA SDWS = 1000; PDWS = 1300
EPA SDWS = 300
Influent Sample Results (Water Supply Well)
72
18
< 1.0
< 10 •
22
< 50
Effluent Sample Results (HVAC "In" Line)
75
19
< 1.0
< 10
10
< 50
Effluent Sample Results (HVAC "Out" Line)
95
19
< 1.0
< 10
440
< 50
Parameter
Potassium, K
Magnesium, Mg
Manganese, Mn
Sodium, Na
Nickel, Ni
Lead, Pb
units
mg/L
mg/L
pg/L
mg/L
pg/L
pg/L
NC MCL and/or EPA Standard
NS
NS
NC MCL = 50
NS
NC MCL = 100
NC MCL = 15
EPA SDWS = 50
EPA PDWS = 15
Influent Sample Results (Water Supply Well)
2.1
4.4
< 10
9.4
< 2.0
< 2.0
Effluent Sample Results (HVAC "In" Line)
2.2
4.4
< 10
9.6
< 2.0
< 2.0
Effluent Sample Results (HVAC "Out" Line)
2.1
4.4
< 10
9.4
12
< 2.0
Parameter
Selenium, Se
Zinc, Zn
pH (field)
units
pg/L
pg/L
units
NC MCL and/or EPA Standard
NC MCL = 20
NC MCL = 1000
NC MCL = 6.5-8.5
EPA PDWS = 50
EPA SDWS = 5000
EPA SDWS = 6.5 to 8.5
Influent Sample Results (Water Supply Well)
< 5.0
15
6.26 @ 13.8C
Effluent Sample Results (HVAC "In" Line)
< 5.0
< 10
6.45 @ 17.5C
Effluent Sample Results (HVAC "Out" Line)
< 5.0
71
6.54 © 21.8C
NC MCL = North Carolina Maximum Contamination Limits per 15A NCAC 2L .0200
EPA PDWS = Environmental Protection Agency Primary Drinking Water Standards
EPA SDWS = Environmental Protection Agency Secondary Drinking Water Standards
NS = No Standard
` Calculation performed by MRO

cepy
MOORESVILLE REGIONAL OFFICE
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
April'18, 2006
MEMORANDUM
To: Thomas Slusser
DWQ Raleigh Central Office Parker Lincoln Building.
From: Kevin Bubak Hydro Tech 1
Attached: APSSRR Form for Ronald Holden Permit # WI 0300051

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: March 20, 2006
To: ❑ Landon Davidson, ARO-APS
n Art Barnhardt, FRO-APS
® Andrew Pitner, MRO-APS
Jay Zimmerman, RRO-APS
From: Thomas Slusser , Groundwater Protection Unit
Telephone: [phone]
E-Mail: thomas.slusser(incmail.net
❑ David May, WaRO-APS
n Charlie Stehman, WiRO-APS
n Sherri Knight, WSRO-APS
Fax: [phone]
A. Permit Number: WI0300051
B. Owner: RONALD & ANNE HOLDEN
C. Facility/Operation: RONALD HOLDEN - SFR
Proposed ® Existing
D. Application:
MECEOWE
1.111 MAR 2 2 2006
NC DENR MRO
DWQ - Aquifer Protection
Facility "---177eration
1. Permit Type: ❑ Animal I Surface Irrigation ❑ Reuse
❑ Recycle I I I/E Lagoon
UIC - (5A7) open loop geothermal
Land App. D&M
503 I 1503 Exempt
For Residuals:
2. Project Type: I I New
H-R Infiltration
n GW Remediation (ND)
II
Surface Disposal
Animal
Major Mod. I I Minor Mod. ® Renewal n Renewal w/ Mod.
E. Comments/Other Information: I I I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
® Return a Completed Form APSSRR.
Attach Well Construction Data Sheet.
Attach Attachment B for Certification by the LAPCU.
7 Issue an Attachment B Certification from the RO*.
* Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS 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: /IVO ife
FORM: APSARR 02/06
Page 1 of 1

AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 4/18/06
To: Aquifer Protection Central Office
Central Office Reviewer: Thomas Slusser
Regional Login No:
County: Iredell
Permittee: Ronald Holden
Project Name:
Application No.: WI0300051
L GENERAL INFORMATION
1. This application is (check all that apply): ❑ New ►1 Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse n Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 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: 4/18/06
b. Person contacted and contact information: Ronald Holden 704/662-3530
c. Site visit conducted by: Kevin Bubak
d. Inspection Report Attached: ❑ Yes or No.
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? /1 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? 56 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:
FORM: ronald Holden aps report form 1

AQUIFER PROTECTION REGIONAL STAFF REPORT
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.
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? n Yes ❑ No. If yes, explain:
4. Drilling contractor: Name:
Address:
Certification number:
5. Complete and attach Well Construction Data Sheet.
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.: According to what MRO have on
file there has been no modification of the system.
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? n Yes /1 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:
FORM: ronald Holden aps report form 2

AQUIFER PROTECTION REGIONAL STAFF REPORT
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: n 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;
8. Issue; ❑ Deny. If deny, please state reasons:
9. Signature of report preparer(s):
Signature of APS regional supervisor:
Date: 4/18/06
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
I spoke to Mr. Holden about the injection well not having a working effluent spigot and advised him to get one
installed for easier sampling. I also discussed with him about trying injection into his French drain he has for
his gutters to avoid having to deal with permitting_process from the state. Over all the system seems to be in
good working order heat exchange difference was around five to seven degrees Celsius from pumping well to
injection well. Sample were taken for metals, total dissolved solids and nitrate /nitrite.
FORM: ronald Holden aps report form 3

GROUNDWATER FIELD/LAB FORM
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
LOCATION CODE
COUNTY :
WI0300051
IREDELL
QUAD NO:
Lat.
Serial No.
Long.
REPORT TO : RALEIGH CENTRAL OFFICE
SHIPPED BY : COURIER
COLLECTOR(S) :
FIELD ANALYSES
pH 400 6.1
THOMAS SLUSSER DATE: 4/18/06
TIME:_10:15 AM_
Spec. Cond.94 _132.9 at 25
Temp. 13.3
Appearance CLEAR
Odor none
SAMPLE TYPE
X❑ Water
❑Soil
SAMPLE PRIORITY
X❑ Routtine
❑ Emergency
❑Other (ROCKS and Ceramic Tiles)
❑ Chain of Custody
Lab Number
Date Received Time:
Rec'd By:
Other:
Data Entry By: Ck:
Data
Reported:
Purpose: Baseline, Complaint, Compliance,
Owner:
Location or Site:
LUST Pesticide Study, Other
RONALD HOLDEN
From: Bus, Courier, Hand Del.,
Description of sampling point
Sampling Method:
Field Analysis By: KEVIN BUBAK Remarks:
LABORATORY ANALYSIS
BOD 310
mg/L
COD High 340
mg/L
COD Low 335
mg/L
Coliform: MF Fecal 31616
/100m1
Coliform: MF Total 31504
/100m1
TOC
mg/1
Turbitity
NTU
Residue., Suspended 530
mg/L
pH
units
Alkalinity to pH 4.5
mg/L
Alkalinity to pH 8.3
mg/L
Carbonate
mg/L
Bicarbonate
mg/L
Carbon dioxide
mg/L
Chloride
mg/L
Chromium: Hex 1032
ug/L
Color: True 80
c.u.
Cyanide 720
mg/L
LAB COMMENTS :
WELL HEAD ( PUMPING WELL INFLUENT)
well pump
(Pump, bailer, etc)
Sample Interval:
UIC GEOTHERMAL PERMIT
X
Diss. Solids 70300
mg/L
Fluoride 951
mg/L
Hardness: total 900
mg/L
Hardness: (non-carb) 902
mg/L
Phenols 32730
ug/L
Specific Cond. 95
umhos/cm2
Sulfate
mg/L
Sulfide 745
mg/L
mg/L
Oil and Grease
mg/L.
SILICA
mg/L
NH3 asN610
mg/L
TKN as N 625
mg/L
X
NO2 +NO3 as n 630
mg/L
P: Total as P 665
mg/L
(Pumping Time, Air Temp., etc.)
X
Ag-Silver 46566
ug/L
X
Al -Aluminum 46557
ug/L
X
As -Arsenic 46551
ug/L
X
Ba-Barium 46558
ug/L
X
Ca -Calcium 46552
mg/L
X
Cd-Cadium 46559
ug/L
X
Cr-Chromium 46560
ug/L
X
Cu- Copper 1042
ug/L
X
Fe- Iron 1045
ug/L
Hg- Mercury 71900
ug/L
X
K-Potassium 46555
mg/L
X
Mg- Magnesium 927
mg/L
X
Mn-Manganese 1055
ug/L
X
Na- Sodium 929
mg/L
X
Ni-Nickel
ug/L
X
Pb-Lead 46564
ug/L
X
Se -Selenium
ug/L
X
Zn_Zinc 46567
ug/L
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
Semivolatiles
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
LAB USE ONLY
TEMPERATURE ON ARRIVAL:
GW-54 REV. 12/87
FOR DISSOLVED ANALYSIS - SUBMIT FILTERED SAMPLE AND WRITE "DIS" IN BLOCK
RONALD HOLDEN INFLUENT LAB SHEET

GROUNDWATER FIELD/LAB FORM
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
LOCATION CODE
COUNTY :
WI0300051
IREDELL
QUAD NO: Serial No.
Lat. Long.
REPORT TO : RALEIGH CENTRAL OFFICE
SHIPPED BY : COURIER
SAMPLE TYPE SAMPLE PRIORITY
X❑Water X❑Routtine
❑Soil ❑Emergency
❑Other (ROCKS and Ceramic Tiles)
❑ Chain of Custody
COLLECTOR(S) : THOMAS SLUSSER DATE: 4/18/06 Purpose: Baseline, Complaint, Compliance, LUST Pesticide Study, Other
FIELD ANALYSES
pH 400 6.45 Spec. Cond.94 _157.7 at 2f Location or Site:
Lab Number
Date Received Time:
Rec'd By: From: Bus, Courier, Hand Del.,
Other:
Data Entry By: Ck:
Data
Reported:
TIME:_11:30 AM_ Owner: RONALD HOLDEN
Temp. 19.8 Odor none Description of sampling point
Appearance CLEAR Sampling Method:
Field Analysis By: KEVIN BUBAK Remarks:
LABORATORY ANALYSIS
BOD 310
mg/L
COD High 340
mg/L
COD Low 335
mg/L
Coliform: MF Fecal 31616
/100ml
Coliform: MF Total 31504
/100m1
TOC
mg/1
Turbitity
NTU
Residue., Suspended 530
mg/L
pH
units
Alkalinity to pH 4.5
mg/L
Alkalinity to pH 8.3
mg/L
Carbonate
mg/L
Bicarbonate
mg/L
Carbon dioxide
mg/L
Chloride
mg/L
Chromium: Hex 1032
ug/L
Color: True 80
_ c.u.
Cyanide 720
mg/L
LAB COMMENTS :
well pump
(Pump, bailer, etc)
X
Diss. Solids 70300
mg/L
Fluoride 951
mg/L
Hardness: total 900
mg/L
Hardness: (non-carb) 902
mg/L
Phenols 32730
ug/L
Specific Cond. 95
umhos/cm2
Sulfate
mg/L
Sulfide 745
mg/L
mg/L
Oil and Grease
mg/L
SILICA
mg/L
NH3 as N 610
mg/L
TKN as N 625
mg/L
X
NO2 +NO3 as n 630
mg/L
P: Total as P 665
mg/L
WELL HEAD ( INJECTION WELL EFFLUENT)
Sample Interval:
UIC GEOTHERMAL PERMIT
(Pumping Time. Air Temp., etc.)
X
Ag-Silver 46566
ug/L
X
Al -Aluminum 46557
ug/L
X
As -Arsenic 46551
ug/L
X
Ba-Barium 46558
ug/L
X
Ca -Calcium 46552
mg/L
X
Cd-Cadium 46559
ug/L
X
Cr-Chromium 46560
ug/L
X
Cu- Copper 1042
ug/L
X
Fe- Iron 1045
ug/L
Hg- Mercury 71900
ug/L
X
K-Potassium 46555
mg/L
X
Mg- Magnesium 927
mg/L
X
Mn-Manganese 1055
ug/L
X
Na- Sodium 929
mg/L
X
Ni-Nickel
ug/L
X
Pb-Lead 46564
ug/L
X
Se -Selenium
ug/L
X
Zn_Zinc 46567
ug/L,
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
Semivolatiles
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
LAB USE ONLY
TEMPERATURE ON ARRIVAL:
GW-54 REV. 12/87 FOR DISSOLVED ANALYSIS - SUBMIT FILTERED SAMPLE AND WRITE "DIS"IN BLOCK
RONALD HOLDEN EFFLUENT LAB SHEET
•

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
March 21, 2006
Anne and Ronald Holden
124 Tall Oak Drive
Mooresville, NC 28117
Ref: Receipt of Permit Renewal Application
Injection Permit # WI0300051
Dear Mr. and Mrs. Holden:
Your renewal application for a permit to use a well for the injection of geothermal heat pump
effluent has been received and is under review. A member of the Aquifer Protection Section's
Mooresville Regional Office staff will be contacting you to arrange an inspection of the injection
well and collect water samples as part of the review.
Please contact me at [phone] or Evan Kane at [phone] if you have any questions.
Best Regards,
SLeL)-01
Thomas Slusser
Hydrogeological Technician II
Underground Injection Control Program
cc: AFncirew Pttner¢' aie urlleRe omal=0
CO-UIC File
NorthCarolina
Naturally
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636
Internet: http://www.ncwatcrquality.ore 2728 Capital Boulevard Raleigh, NC 27604
An Equal Opportunity/Affirmative Action Employer-50% Recycled/10% Post Consumer Paper
Telephone: [phone]
Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM
Type 5A7 and 5QM Wells
In accordance with the provisions of NCAC Title 15A: 02C.0200
complete application and mail to address on the back page.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: C/ / 6 ,20 .6
I',L \ 2 2006
A. PERMIT APPLICANT
Gt/.3c-C;QS
Permit Number: C t,�r ' �—:xII0######, listed at the bottom of each page of your permit)
Name: ..� to 2> L J4-c L D 15.0
Address: /2 7 /�1. L (24 ,< --".1 ) IVQ
City: fY7,,,, r9 f.: S / State: A% ( Zip code: _ ? l l 7
County: 1 %�= ,L� � Telephone: - ;... 41 () () x 2 4` -?
B. PROPERTY OWNER (if different from applicant)
Name: entom
Address:
City: State: Zip code:
County: Telephone:
C. STATUS OF APPLICANT
Private: � Federal: Commercial: State: Public:
Native American Lands:
D. FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Public or Commercial).
Name of Business or Facility:
Address:
City: State: Zip code:
County: Telephone:
Contact Person:
Standard Industrial Code(s) which describe commercial facility:
Revised 5/05
GW/UIC-57 HPR Page 1 of 3

INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
S/4-M t�
F. WELL USE Is(are) the injection well(s) also used as the supply well(s) for either of the following?
(1) The injection operation? YES_ NO
(2) Your personal consumption? YES V NO
G. CONSTRUCTION DATA
(1)
Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection permit.
(2) NC. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes. A faucet on both influent (groundwater entering heat pump) and
effluent (water being injected into the well) lines is required. Is there a faucet on:
(a) the influent line? YES NO
(b) on the effluent line? YES NO
H. CURRENT OPERATING DATA
Injection rate: Average (daily)
Injection volume: Average (daily)
Injection pressure: Average (daily)
Injection temperature: Annual Average
7 gallons per minute (gpm)
Vs'
gallons per day (gpd) 6t/M N " r 6
pounds per square inch (psi)
40.'° degrees Fahrenheit (°F)
INJECTION -RELATED EQUIPMENT
Attach a diagram showing any modifications to injection equipment since the issuance of the previous injection
permit including the engineering layout of the (1) injection equipment, and (2) exterior piping/tubing associated
with the injection operation. The manufacturer's brochure, if detailed, should satisfy (1).
J. LOCATION OF WELL(S) Attach a map
Include a site map (can be drawn) showing: the orientation of and distances between the injection well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
ground -source heat pump well system; include buildings, property lines, surface water bodies, any other potential
sources of groundwater contamination. Label all features clearly and include a north arrow to indicate
orientation.
K. PERMIT LIST: Attach a list of all permits or construction approvals, received or applied for by the applicant
that are related to the site. Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
L. OTHER MODIFICATIONS: Indicate any other modifications to the injection well system (equipment, fluid,
operation, etc.) that have occurred since the issuance of the previous injection permit and have not been noted
elsewhere on this application.
Revised 5/05 GW/UIC-57 HPR Page 2 of 3

M. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment, for
submitting false information. I agree to operate, maintain, repair, and if applicable, abandon the injection well
and all related appurtenances in accordance with the approved specifications and conditions of the Permit."
(Signature of Well Owner or Authorized Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
N. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property rights in the
well(s). A well is real property and its construction on land rests ownership in the land owner in the absence of
contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the
applicant to operate an injection well(s) as outlined in this application and that it shall be the responsibility of the
applicant to ensure that the injection well(s) conform to the Well Construction Standards (Title 15A NCAC
Subchapter 2C .0200)
(Signature of Property Owner if Different From Applicant)
Please return the completed Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Revised 5/05 GW/UIC-57 HPR Page 3 of 3

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* 124 Tall Oak Dr Mooresville, NC 28117-6819
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DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
December 5, 2005
MEMORANDUM
To: Andrew Pitner
Mooresville Regional Office
From: Jesse Wiseman
Central Office UIC Program
Re: Notification of expiration of UIC Permit No. WI0300051
UIC Permit No. WI0300051 issued to Ronald L. Holden is due to expire on February 28, 2006.
Attached is the notification of expiration that was sent by this office to Ronald Holden on December
5, 2005. No regional action is necessary at this time.
Attachment

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
December 5, 2005
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7002 2410 0003 0274 8963
Ronald Holden
124 Tall Oak Drive
Mooresville, NC 28117
Ref: Notification of Expiration
North Carolina Well Construction Standards
Applicable to Injection Wells - Subchapter 2C
UIC Permit No. WI0300051 Issued to Ronald L. Holden
Dear Mr. Holden:
The Underground Injection Control (UIC) Program of the Division of Water Quality is responsible for
the regulation of injection well construction and operation activities within the state of North Carolina.
Our records show that the operating permit referenced above for the injection well on your property will
expire on February 28, 2006. In addition, our records do not indicate that the well has been abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative Code
(NCAC) Title 15A, Subchapter 2C, Section .0211, you must take one of the following actions:
A. Submit the form RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM (form GW/UIC-57 HPR) if the injection well on your property is still
active;
B. Submit the form STATUS OF INJECTION WELL SYSTEM (form GW/UIC-68) if the injection well is
inactive or has been temporarily or permanently abandoned.
If the well is no longer being used for any purpose, it must be permanently abandoned according to the
regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section .0214. If the injection
well is to be permanently abandoned, a well abandonment record must be submitted to our office to
certify that the abandonment was properly conducted.
NorthCarolina
Naturally
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]

>oak! I lulden
•ecember 5, 2005
?age 2 of 2
Please submit the appropriate form(s) within 30 days of the receipt of this letter. If you have any
questions regarding the permit and injection well rules, or if you would like assistance completing these
forms please contact Thomas Slusser at [phone] or Evan Kane at [phone].
Sincerely,
Jesse Wiseman
Processing Assistant
UIC Program
cc: ID .W.Qz-__MooresvilleRegional_Officew /o=enclosures;
CO-UIC Files w/o enclosures
Enclosures

JUN-26-2001 04:23 PM
8&K WELLDRILLING_INC 704 892 4705
P. 01
North Carolina • Dops'1ment of Environment and Natural RasoureAs . DivIsion of Wpler Quplity - Gmuri JwFltr.)r Section
106 Mail Service Canter - Raleigh, N.C. 27699-1e36.Phena (919) 73-3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ..K. ‘61.0Itill,
WEt.t. CONTRACTOR CERTIFICATION #: _f/(./
STATE WELL CONSTRUCTION PERMLT#:
1. WELL. USE (Check Applicable Roo Residential L ,unicipal ❑ Industrial ❑ Agricultural In
Recovery © Heat Pump Water Injection Other U If Other, List Use:
2, WELL LOCATIQ (show eltetch of the location below)
st Town:
/v1 m 1(PSU'I 1j Court), - 8A..
(HOad
:3 OWNER
Address
4. DATE DRILLEDte °
;a. TOTAL DEPTH
6. CUITINGS'CQLLECTED YES C NO
7, DOES WELL REPLACE EXISTING WELL? YES 2 NOZ
6. STATIC WATER LEVEL Below Top of Casing: (lelFT,
r ruse •7• if Abova Top 61 Lasing)
9. TOP OF CASING IS __la FT. Above Land Surface`
'Teo cr casing tarminsted at/or egiow land 81411410e requires a VArinnee In ACoor-
dunce with 15A WCAC 2C .
10. YIELD (gpm): 25 METtjp??F TENT tit
1 ; . WATER ZONES (depth):
12. CHLORINATION: Typo t Amount..,
13. CASING:
m i IItf, orSurdivi&Ori and Lot No.) DRILLING LOG
Ir r Pn- From To
•
•
Monitoring
DEPTH
rcrma;ion Description
If sdd;ttonal Space is needed use back of lvrm
LOCATE N S.KETQH
f depth J r�ayryot q.4�(plV VFt. M®:oriel (ahow directrort and dlatance from at least two State
Front V - • To Ft, _�JY"-. Roads, or other map reference points•)
From TnFt. _ ... - eP f a t) t / ��,
From - To.,.. --- - Ft. a p4,t�u rrl,Nr
14. GROUT: P!l
From 0 -.
From
15. SCREEN;
Depth
From To rt
From _.r-. To rt
From To Ft.
16. SAND/GRAVEL PACK:
Depth
From To
From To-
17. REMARKS:
Wall Th(cknaaa
Mani M terltal Me hod �,/
Tot � Ft,t' j7i't'.'r!/W/I/ %4d'Aff
70 ..�.. Ft.
Diameter Slot Size Material
In
In.
In
Size
Ft
Ft
In
In.
In
Material
I 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT PY F THIS RE ORD HAS 6 N PROVIDED TO THE WELL OWNER.
OR OFFICE USE -„)6-0/
FONLY
Quad No:
Seriat Nq
SIONATURP Ott PEFtSONCTtNO 7HE WELL DATE
Submit original to Rlvlolon 4i -Ater Ousilry, Oraurldwatar Soction Within 30 day3
GW I wv, 12/39

NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
P.O BOX 29578, RALEIGH, NC 27626-0578 - 2728 CAPITAL BLVD., RALEIGH, NC, 27604
PHONE [phone] FAX [phone]
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED/10% POST -CONSUMER PAPER

\v
MEMORANDUM
To:
From:
DIVISION OF WATER QU
GROUNDWATER SECTI
February 12, 2001
Matt Heller, L.G., Goundwater Supervisor
Groundwater Section
Mooresville Regional Office
Mark Pritzl /l l 2. Mark.Pritzl@r
Hydrogeological Technician II
UIC Group
Groundwater Section
Raleigh Central Office
Re: Issuance of a Open -Loop Geothermal Injection
Permit Number WI0300051 to operate a we
ground -source heat pump system has been issued to Ro
Carolina.
(z—
'frInko 41.6'4- —
UJ
1. Please inspect the injection well site to verify that they
submitted in the application are accurate and the NCAC Title 15A
eing complied with, using the enclosed Injection Facility Inspect]
appropriate.
2. Collect samples from the influent and effluent sampling ports
the CO-UIC.
o PP'fJ `/
3/ 23 — IJ�
You are reques . to retuthe completed Injection Facility Inspection Report (form B) to
the CO-UIC by Mar 3 , '; 014 If the inspection can not be accomplished by this date,
please inform the CO-UIC. The UIC group greatly appreciates Susie Caldwell's assistance
with this review. If ou have any questions regarding this review or the UIC program, please
contact me at (919) 7 5-6166 or Meliktu Fanuel at [phone].
At -sue n � - z — c r - AA
cc: CO-UIC Files
Enclosures

Michael F. Easley
Governor
William G. Ross Jr., Secretary
Department of Environment and Natural Resources
Kerr T. Stevens
Division of Water Quality
February 9, 2001
Ronald L. Holden
124 Tall Oak Drive
Mooresville, NC 28117
Dear Mr. Holden:
In accordance with your application dated January 11, 2001, we are forwarding Permit No.
WI0300051 for the construction and operation of a geothermal heat pump injection system at
124 Tall Oak Drive, Mooresville, North Carolina, in Iredell County. Water samples will be
taken at the influent and effluent sampling ports of this geothermal heat pump system after
construction is complete. Please note, if these sample results exceed groundwater quality
standards, it is the well owner's responsibility to take corrective action as stated in Title 15A
Subchapter 2C, Section .0206.
This permit shall be effective from the date of issuance until February 28, 2006, and shall be subject
to the conditions and limitations stated therein. In accordance with NCAC Title 15A, Subchapter
2C, Section .0213(h), the well owner is responsible for submitting a record of well construction
within 30 days of completion. The well construction data for every well constructed for this project
should be submitted on the GW-1 form and this form is enclosed for your convenience.
If you have any questions regarding your permit please feel free to contact me at [phone]
or Meliktu Fanuel at [phone].
cc: CO-UIC Files
MRO-UIC Files
Enclosures
Sincerely,
J
/14
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
NCD
Customer Service
1 800 623-7748
Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: http://www.gw.ehnr.state.nc.us

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Ronald L. Holden
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5A7 INJECTION WELL,
defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(A), which will be used
for the injection of heat pump effluent. This system is located at 124 Tall Oak Drive,
Mooresville, North Carolina, in Iredell County, and will be constructed and operated in
accordance with the application dated January 11, 2001, and in conformity with the
specifications and supporting data submitted, all of which are filed with the Department of
Environment and Natural Resources and are considered a part of this permit.
This permit is for 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 28,
2006, and shall be subject to the specified conditions and limitations set forth in Parts I through
X hereof.
Permit issued this the `b day of Feb 1y , 2001.
Ted L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. W10300051
PAGE 1 OF 6

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 the Division of Water Quality (Division), within 30 days of completion
of well construction.
PART II - WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall
notify the Groundwater Section -Underground Injection Control (UIC), Central Office
staff, telephone number [phone].
PART III - OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
Permit No. WI0300051 PAGE 2 OF 6

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 Penmittee 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 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 incompliance with permit conditions.
Permit No. WI0300051 PAGE 3 OF 6

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 (704)
663-1699, any of the following:
(A)
(B)
Any occurrence at the injection facility which results in any unusual
operating circumstances;
Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report
to the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
Permit No. WI0300051 PAGE 4 OF 6

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 Peiuiittee 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.
The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines thatfailure to do so could lead to the contamination of an
underground source of drinking water.
Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel -packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
Permit No. WI030005 1 PAGE 5 OF 6

(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
Water samples will be taken at the influent and effluent sampling ports from the
geothermal heat pump system after construction is complete. If the sample results reveal
violation(s) of groundwater standards, it is the well owner's responsibility to take
corrective action as stated in Title 15A North Carolina Administrative Code 2C .0206. In
addition, the well owner shall take immediate actions including those actions that may be
required by the Division of Water Quality such as repair, modification, or abandonment of
the injection facility.
Permit No. WI0300051 PAGE 6 OF 6

MEMORANDUM
TO:
FROM:
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
June 26, 2001
Mark Pritzl
UIC Program, Groundwater Section
Parker Lincoln Building, Raleigh
Susie Caldwell
GW, MRO Regional Office
SUBJECT: Ron Holden, UIC Permit
Form B
Mark, attached is the UIC Form B,Injection Facility Inspection, for compliance of the
UIC regulations for Mr. Ron Holden, Mooresville, Iredell County. Samples were taken today
(June 26, 2001) from both influent and effluent ports.
Please note that the permit for Mr. Holden, issued 2/12/2001, needs a different number
(...51 has been assigned to a NC DOT UIC permit).
Call if you have any questions, [phone], ext. 237.
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North Carolina Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WI 03 0 0051 DATE —dt — o /
NAME OF OWNER o ct;1, d L (cl. eh
ADDRESS OF OWNER i a
0-AF &rcc,.r ,e,) —
l czL( c .(c_Trt ve.
Moov'e5wile cc --
(Street/ road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable) ,16(jakij i,) /Tow-
(Street/ road or lot and subdivision , county, town, if different than owner's address, plus description of location on site)
Potential pollution source
Potential pollution source
Distance from well— b
Distance from well
Potential pollution source Distance from well
Minimum distance of well from property boundary
Quality of drainage at site-.-y-gc Flooding potential of site L -,.L)
(good,adequate,poor) v (high,moderate,low)
l.a. 4- : 35" `i a4" Lo�c); 4-uCie : at ° 5s' 15--
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and
north arrow.) e a A_ i,
Ifl
A\e'
DESCRIBE INJECTION SYSTEM (vertical closd loop, uncased borehole or cased water well; separate source well and
injectioi well; combination source and injection well; or other description as applicable)
w/ Chi ([Al5 W) a, -tut 7�:vi • tt (ea

INJECTION FACILITY INSPECTION REPORT —FORM B (CONTINUED)
WELL CONSTRUCTION
Date constructed - 00/
2 •
Drilling contractor: Name ,J, /3//,, 6 E/ /( W J
Address /_3,1 , i-, /YI o rn E /-.o Or AE.o <^6.S /ice , C
Certification number 419
Total depth of well / Total depth of source well
(f applicable)
Inspection point
Casing
Depth
Diameter
Height (A.L.S.)
Grout
Depth
Screens
Depth(s)
Length(s)
I.D. Plate
Static water level
Well yield
Enclosure
Enclosure floor
(concrete)
Sampling port
(labeled)
Water tight pipe entry
Well enclosure entry
Vent
Measurement
�D
Meets minimum standards Comments
Yes No
0 ell
o C) , —/'Z C. c1-10`,t;Z—t
-- "GL.ri-,./ -
eio L-e
i t l I ouc- .ter
IA); (( i n s-I-a i t
Functioning of heat pump system (Determine from the owner if heat pump functions properly.)
INSPECTOR S4lai.liL z, L J/ Office n 72 O
WITNESS j'\, _.
Address /a 4/Jai/ auk
WITNESS Address March 1998

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COUNTY :
QUAD NO:
REPORT TO :
COLLECTOR(S) :
DATE:
TIME:
PURPOSE:
IREDELL
MRO
CALDWELL
6/26/2001
LABORATORY ANALYSIS
Regional Office
HOD 310
mg/L
COD High 340
mg/L
COD Low 335
mg/L
X
Coliform: MF Fecal 31616
1 B2,Q
/100m1
X
Coliform: MF Total 31504
1 B2.Q
/100m1
_
TOC
mg/1
Turbitity
NTU
Residue.. Suspended 530
mg/L
Total Suspended solids
mg/L
X
pH
7.8Q
units
Alkalinity to pH 4.5
mg/L
Alkalinity to p11 8.3
mg: L
Carbonate
mg/L
Bicarbonate
mg/L
Carbon dioxide
mg/L
X
Chloride
3 Q.
mg/L
Chromium: Hex 1032
ug/L
Color: True 80
c.u.
Cyanide 720
mg/L
COMMENTS:
Owner:
Location or Site:
Description of sampling point
Sampling Method:
Remarks:
DIVISION OF WATER QUALITY
Chemistry Laboratory Report / Ground Water Quality
SAMPLE PRIORITY
(ROUTINE
n CHAIN OF CUSTODY
n SAMPLE TYPE
RONALD HOLDEN
EMERGENCY
RECEIVE
SE
P 2 1 �001
WC DEPT. OF
Mom souAND Resou cEs
eciONAC OFFICE
X
Diss. Solids 70300
180
mg/L
Fluoride 951
mg/L
X
Hardness: total 900
80
mg/L
Hardness: (non-carb) 902
mg/L
Phenols 32730
ug/L
Specific Cond. 95
umhos/cm2
Sulfate
mg/L
Sulfide 745
mg/L
MBAS
mg/L
Oil and Grease
mg/L
Silica
mg/L
Boron
Formaldehyde
mg: L
NH3 as N 610
mg/L
TKN as N 625
mg/L
X
NO2 +NO3 as n 630
0.24
mg/L
P: Total as P 665
mg/L
PO4
mg/L
Ag-Silver 46566
ug/L
X
Al -Aluminum 46557
160
ug/L
As -Arsenic 46551
ug/L
Ba-Barium 46558
ug,/L
X
Ca -Calcium 46552
36
mg/L
Cd-Cadium 46559
ug/L
X
Cr-Chromium 46560
25U
ug/L
X
Cu- Copper 1042
8.3
ug/L
X
Fe- Iron 1045
50U
ug/ L
Hg- Mercury 71900
ug/L
X
K-Potassium 46555
3.0
mg/L
X
Mg- Magnesium 927
4.5
mg/L
N
Mn-Manganese 1055
11
ug:'L
X
Na- Sodium 929
9.8
mg/L
X
Ni-Nickel
10U
ug/L
X
Pb-Lead 46564
10U
ug/L
Se -Selenium
ug/L
X
Zn_Zinc46567
37
ug/L
Lab Number :
Date Received :
Time Received :
Received By •
1G0986
6/27/2001
9:00 AM
DS
Date reported 9/19/2001
Organochlorine Pesticides
Organopltosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
Semivolatiles
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TP1-I-BTEX Gasoline Range
1G0986.xls

GROUNDWATER FIELD/LAB FORM
Corinly-1 I
Quad NoN /a"La- C. Serial No
Lat. )) 6,141 011-" Long. P(1 551 is"
Report To: ARO, FRO,
SAMPLE TYPE
4Water
Soil
Other We ,y7
SAMPLE PFUIORITY
Routine
mrgency
RRO, WaRO, WiRO, Sfn of Custody
WSRO, Kinston FO, Fed. Trust, Central Off. lher: CPic P4/'mi —ei... e2.t 4i/e'6,
Shipped by: Bus, o rier Hand Del., Other• Cs; w - L° D'
Collector(s): 4 4L1 etie alleate b ^." ' O " Time
FIELD ANALYSES
pH400 9, 0 Spec. Cond.94 d7/. 4, al 25° C
Temp.10 1,/ rY °C Odor `1Z-072.0
Appearance Gym
Field Analysis By: 'c-L.r...L . aead_4A-Lei
LABORATORY ANALYSES
BOD., 310
COD High 340
COD Low 335
Coliform: MF Fecal 31616
rng/I
mg/1
mg/I
/100m1
Colilorm: MF Total 31504
TOC 680
Turbidity 76
Residue., Suspended 530
/100m1
mg/I
NTU
mg/1
pi 1403
Alkalinity to pl-I 4.5 410
Alkalinity to pH 8.3 415
Carbonate 445
Bicarbonale 440
Carbon dioxide 405
Chloride 940
units
mg/I
mg/I
mg/1
mq/I
mg/I
mg/I
Chromium: Hex i%32
Color: True 80
Cyanide 720
Lab Comments:
ug/I
CU
mg/1
Owner /0/7a C1 Gv-J/l/e-4-7
Location or site /a el 7-0. a Oak.
Description of samplinp point
Sampling Meithod `1,GL4
Remarks ,. 'LS,C ld /-14-1--,-. I�
A/ / /(r )"mpinglimo. ° uCr//1.�'%� ifkizd Eiaed ,rl/
�
Purpose:
9 /-5 /-- Baseline, Complaint,, or lime LUST, Pesticide Study, Federal Trust, Other
(circle ono)
North Carolina
Department of Environment, Health, and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
Lab Number
Date Received
Rec'd by:
Other
Data Entry By:
Date Reported:
Time
rom: Bus
r, Hand Del.,
Ck•
:Pr /cue. 40Ores //e ,t/ C F// 1
Hardness non-carb 902
Phenols 32730
Specific Cond. 95
Aq - Silver 46566
Al - Aluminum 46557
As - Arsenic 46551
Ba - Barium 46558
Cd - Cadmium 46559
Cr - Chromium 46560
uq/I
ug/I
uo/I
ug/I
mq/I
uq/I
ug/I
Cu - Copper 46562 ug/I
Fe - Iron 46563 ugll
I Ig - Mercury 71900 ug/I
I< - Potassium 46555 mg/1
MM - Magnesium 46554 mgJl
uq/I
mg/I
Tl� Ni - Nickel ug[L
Mn - Manganese 46565
Na - Sodium 46556
(Pump, bailor olc.)
Pb - Lead 46564
Se - Selenium
- Zinc 46567
J •�
uq/I
ug/I
uq/I
Sample Interval
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCB's
Semivolatile Organics
TPH - Diesel Range
Volatile Organics (VOA bottle)
TPH Gasoline Range
TPH - BTEX Gasoline Range
GW-54 REV. 7/96
For Dissolved Analysis - submit filtered sample and write "DIS" in bloc'

NC DENR/DWQ Chemistry Laboratory
Sample Condition Upon Receipt Anomaly Report (SCUR)
LabNumber:-
np1e;ID n Station. Location::
county: - izQ c�,Q,Q;Q. River Basin f rr
Collector 0 (Q /.. �r� / ( Time Begin: q.I J
Priority: 'Sample Type: .
Affected Parameters:
The condition of these samples were not acceptable because (check all that apply):
O Samples (affected samples are described below)
❑ Samples not received, but listed on fieldsheet
❑ Samples received, but not listed on fieldsheet
°C ❑ Samples not received, but listed on COC
❑ Samples received, but not listed on COC
❑ Mislabeled as to tests, preservatives, etc.
❑ Holding time expired
❑ Improper container used
❑ Insufficient quantity for analysis
❑ Coolers
❑ Samples were not received on wet ice
❑ No temperature blank submitted:
❑ Sample T° reading (IR gun):
❑ Cooler T° reading: °C
❑ Temperature >6°C. T° reading: °C
❑ Samples frozen
❑ Containers
❑ Leaking
❑ Broken
❑ Without labels
❑ VOA vials with headspace
❑ Sulfide samples with headspace
❑ Container Labels
❑ Not the same ID/info. as on COC
❑ Not the same ID/info. as on fieldsheet
❑ Incomplete. Missing the following:
❑ Station #/Sample ID
❑ Collection date
❑ Collector
❑ Analysis
❑ Preservative
❑ Other:
❑ Markings smeared or illegible
❑ Torn'
Chain of Custody
❑ No custody seals
❑ Custody seals not intact
❑ Not relinquished.
❑ No date/time relinquished
❑ No signature
❑ Incomplete information
❑ Documentation
❑ Fieldsheet wet/illegible
❑ Fieldsheet incomplete:
❑ Records not written in indelible ink
O Other (specify):
Comments: , COC 4C\\ N3 C b019 4Q9 ( C.tyt l d7pd at
Sus, Q Ca .uJQl .
Corrective Action:
❑ Samples were rejected by..DWQ Lab Authorizedby
1 Accepted and analyzed per collector's request after notifying the collector.
❑ Accepted and:analyzed after notifying the client and determining that another sample could not be secured.
❑ Sample(s) on hold until:
❑ Other (explain):
Person Contacted:
Unit Leader Review (initial):
NUT
WCH
Date: D (.0 / o� / D
Form completed by: Date: 0 lY
VOA
PEST
SVOA
MIC
MET
QA\Forms\Sample Receiving\SCUR
6/22/Oldbs

COUNTY :
QUAD NO:
IREDELL
REPORT TO : MRO
COLLECTOR(S) : CALDWELL
DATE: 6/26/2001
TIME:
PURPOSE:
LABORATORY ANALYSIS
Regional Office
BOD 310
mg/L
COD High 340
mg/L
COD Low 335
mg/L
X
Coliform: MF Fecal 31616
1 B2,Q
/100m1
X
Coliform: MF Total 31504
1Q
/100m1
TOC
mg/1
Turbitity
NTU
Residue., Suspended 530
mg/L
Total Suspended solids
mg/L
X
pH
7.4Q
units
Alkalinity to pH 4.5
mg/L
Alkalinity to pH 8.3
mg/ L
Carbonate
mg/L
Bicarbonate
mg/L
Carbon dioxide
mg/L
X
Chloride
5 Q
mg/L
Chromium: Hex 1032
ug/L
Color: True 80
c.u.
Cyanide 720
mg/L
COMMENTS :
Owner:
Location or Site:
Description of sampling point
Sampling Method:
Remarks:
DIVISION OF WATER QUALITY
Chemistry Laboratory Report / Ground Water Quality
SAMPLE PRIORITY
n ROUTINE
n CHAIN OF CUSTODY
W❑ SAMPLE TYPE
RONALD HOLDEN
11 EMERGENCY
RECEI V
1
SEp 2 1 2001
NC DEPT.
MOOR NA �ResouRcEs
EN�
X
Diss. Solids 70300
120
mg/L
Fluoride 951
-
mg/L
X
Hardness: total 900
52
mg/L
Hardness: (non-carb) 902
mg/L
Phenols 32730
ug/L
Specific Cond. 95
umhos/cm2
Sulfate
mg/L
Sulfide 745
mg/L
MBAS
mgi L
Oil and Grease
mg/L
Silica
mg/L
Boron
Formaldehyde
mg/L
NH3 as N 610
mg/L
TKN as N 625
mg/L
X
NO2 +NO3 as n 630
0.41
mg/L
P: Total as P 665
mg/L
PO4
mg/L
Ag-Silver 46566
ug/L
X
Al -Aluminum 46557
160
ug/L
As -Arsenic 46551
ug/L
Ba-Barium 46558
ug/L
X
Ca -Calcium 46552
19
mg/L
Cd-Cadium 46559
ug/L
X
Cr-Chromium 46560
25U
ug/L
X
Cu- Copper 1042
6.3
ug/L
X
Fe- Iron 1045
50U
ug/L
Hg- Mercury 71900
ug/L
X
K-Potassium 46555
2.6, .
mg/L
X
Mg- Magnesium 927
4.0
mg/L
X
Mn-Manganese 1055
IOU
ugIL
X
Na- Sodium 929
9.8
mg/L
X
Ni-Nickel
10U
ug/L
X
Pb-Lead 46564
10U
ug/L
Se -Selenium
ug/L
X
Zn_Zinc46567
53
ug/L
Lab Number : 1G0985
Date Received : 6/27/2001
ime Received : 9:00 AM
Received By D
Released By .
�A G1 7
Date reported : 9/19/2001
Organocltlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
Semivolatiles
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
1G0985.xls

GROUNDWATER FIELD/LAB FORM
County -/- )2 L"D & .L
Quad Not 1 ct — 6 Serial No.
Lat. 356 34I 04-1-'1 Long. ,D° . S5' /5"
Report To: ARO, FRO, RRO, WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off.,
Shipped by: Bus, uried, Hand Del, Other
SAMPLE TYPE
KWater
Soil Other u/,
�e.,
SAMPLE PRIORITY
❑ Routine
to of Custody
Lt h - (, L() C',[?-
Collector(s): ,C 'J Date — -q /
FIELD ANALYSES
PH400 7Z' Spec. Cond.94 ' at 25° C
Temp.10 &3,, °C Odor ` z -z
ti
Appearance
Field Analysis By: , e- deL
LABORATORY ANALYSES
BODS 310 mq/I
COD High 340 mg/I
COD Low 335 mg/I
Coliform: MF Fecal 31616 /100m1
Coliform: MF Total 31504 /100m1
TOC 680
Turbidity 76
Residue., Suspended 530
mg/1
NTU
mg/1
pH 403 units
Alkalinity to pH 4.5 410 mg/I
Alkalinity to pH 8.3 415 mg/I
Carbonate 445 mg/1
Bicarbonate 440 mg/I
Carbon dioxide 405 mg/I
Chloride 940 mg/I
Chromium: Hex 1032 ug/I
Color: True 80 CU
Cyanide 720 mg/I
Lab Comments:
GW-54 REV. 7/96
North Carolina
Department of Environment, Health, and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
Purpose:
Time 9 /.3 A Baseline, Complaint,
Owner or) aLcl cis-,
Lab Number' - r "1
Date Received ' . 0 Time el : 07)
Rec'd by: i rom: Bus, ours , Hand Del.,
Other:
Data Entry By: Ck:
Date Reported:
(cUST, Pesticide Study, Federal Trust, Other
ircle ono)
Location or site /A % aE Oat ��2t ti�2, /,t-(,p,p�S v l i k i3 C. o ('// 7
Description of sampling point C Q 44-ea .ted(
Sampling Mhod� ,d C
Remarks Ae / Pump, bailor, olc.) Sample Interval
(pumping ti e, air letup. etc.)
t Fa �,� c Gi1 cre�� li No3 ' n �r b �iAit dz�e�
5Diss. Solids 70300 mq/I Aq - Silver 46566
uq%
Flouride 951 mq/1
Hardness: Total 900
mq/I
Hardness (non-carb) 902 mq/I
Phenols 32730 uq/I
Specific Cond. 95 uMhos/cm2
Sulfate 945
Sulfide 745
Oil and Grease
NH, asN 610
TKN as N 625
mq/I
mg/I
m q/I
• mq/I
mg/1
> NO, + NO, as N 630 mq/I
P: Total as P 665
mq/I
Al - Aluminum 46557 ug
As - Arsenic 46551
Ba - Barium 46558
Ca - Calcium 46552-
uq/I
ug/I
mq/I,
Cd - Cadmium 46559 uq/I
Cr - Chromium 46560 ug/I
Cu - Copper 46562 ug/I
Fe - Iron 46563 ug/I
Hg - Mercury 71900 ug/I
><. K - Potassium 46555 mg/I
Mg - Magnesium 46554 mg/I
Mn - Manganese 46565 ug/I
�Na - Sodium 46556 mq/I
. Ni - Nickel ug/I
>< Pb - Lead 46564 uq/I
Se - Selenium uq/I
For Dissolved Analysis - submit filtered sample and write "DIS" in block.
Zn - Zinc 46567 ug/I
.mod l/ S-oyz-
Organhchlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCB's
Semivolatile Organics
TPH - Diesel Range
Volatile Organics (VOA bottle)
TPH - Gasoline Range
TPH - BTEX Gasoline Range

Lab Number:
g-oq3
NC DENR/DWQ Chemistry Laboratory
Sample Condition Upon Receipt Anomaly Report (SCUR)
Doi g'
Station Location:
River Basin.
Date Begin. V.. / �� / Time Begin:: q, I S
Priority: Sample Type:
Affected Parameters:
sample ID:
.:ounty: Tacitti
Collector. 6 Ca.d.(ae,2 Q
oftaf2 0641,14‘_i
The condition of these samples were not acceptable because (check all that apply):
O Samples (affected samples are described below)
❑ Samples not received, but listed on fieldsheet
O Samples received, but not listed on fieldsheet
°C 0 Samples not received, but listed on COC
°C ❑ Samples received, but not listed on COC
°C 0 Mislabeled as to tests, preservatives, etc.
O Holding time expired
❑ Improper container used
❑ Insufficient quantity for analysis
❑ Coolers
O Samples were not received on wet ice
O No temperature blank submitted:
O Sample T° reading (IR gun):
O Cooler T° reading:
❑ Temperature >6°C. T° reading:
❑ Samples frozen
0 Containers
❑ Leaking
O Broken
❑ Without labels
❑ VOA vials with headspace
❑ Sulfide samples with headspace
0 Container Labels
O Not the same ID/info. as on COC
O Not the same ID/info. as on fieldsheet
O Incomplete. Missing the following:
o Station #/Sample ID
❑ Collection date
❑ Collector
❑ Analysis
❑ Preservative
O Other:
❑ Markings smeared or illegible
❑ Torn
Comments:
COC, -�o r 11C4- C b
f-12.c• Sus; Q Ca UQ t
Corrective Action:
Samples were rejected by DWQ Lab. Authorized,; by: ,
Accepted and analyzed per collector's request after notifying the collector.
❑ Accepted and analyzed after notifying the client and determining that another sample could not be secured.
❑ Sample(s) on hold until:
)tL Chain of Custody
O No custody seals
O Custody seals not intact
O Not relinquished.
O No date/time relinquished
O No signature
❑ Incomplete information
❑ Documentation
❑ Fieldsheet wet/illegible
❑ Fieldsheet incomplete:
O Records not written in indelible ink
❑ Other (specify):
I�cB C,ar recIlie Ct re pe COG
O Other (explain):
Person Contacted:
Unit Leader Review (initial):
NUT
WCH
QA\Forms\Sample Receiving \SCUR
Form completed by:
VOA
PEST
SVOA
MIC
Date: O O / / D I
Date: O (P / 9--/ / b 1
MET .
6/22/0Idbs

Report to: M0,0
GROUNDWATER SECTION
CHAIN OF CUSTODY (COC) RECORD
NC DENR/DWQ LABORATORY (check one): CENTRAL [ ] ARO [ ] WaRO
Page / of /
For Investigation of: LA C e. ] /) c c-- w� t 1 s Incident No.
Sample collector
and GW-54 forms
(print name)
completed by: 6A-L-5-�-z-- Cc+- �`-� t I Sample
collector's signature::
„-4LCt
(%: i `��..6-U
Field storage conditions and location (when applicable):
Lab Use Only
. LAB NO:
SAMPLE ID
QUAD. NO.
LOCATION
DATE
SAMPLED
TIME
SAMPLED
NUMBER
OF
CONTAINERS
0 491
0gF4
ato l a - b :?rmd(a=f
Id&,-) .; _O-4de-I/ i
/�6/01
Q. /51,'
% (,
S77
PQ 05 .
She,lca I_e� I S - Linc G:
'/L-6/l0 /
/3 -
:>2,'
Relin uished by (si ature):
\ j .r , • r (..:.ii,t: f52. t4/-8-1. i'
Date
6/2 6 / /
Time
l fi&p
Received by (signature):
Date
Time
Relinquished by (signature):
Date 1
Time/
Received by (signature):
Date
Time
Relinquished by (signature):
Date
Time
Received by (signature):
Date
Time
Method of Shipment (circle one):
-delivered Federal Express UPS
Other:
to Cou�er' Hand
Security Type and Conditions:
Sealed
dat.l,c..1-64/'
Broken by:
INTRALABORATORY CHAIN OF CUSTODY - Lab Use Only
LAB: NUMBERS:...
FROM. THROUGH
NUMBER.
-
`BO.TTLES
ANALYSES:: ;.;. .
•.REQUESTED
• RELINQUISHED
-
RECEIVED
BY:
DATE
TIME
QA'Forrns\Sample Receiving\COC form GW
4/10/0ldbs

4.
COUNTY:
QUAD NO:
IREDELL
DIVISION OF WATER QUALITY
Chemistry Laboratory Report / Ground Water Quality
SAMPLE PRIORITY
ROUTINE
REPORT REPORT TO : MRO Regional Office I I CI IAIN OF CUSTODY
COLLECTOR(S) : CALDWELL
I )Al P: 21112991 n SAMPLE TYPE
1 Inn':
PURPOSE:
LABORATORY ANALYSIS
POI) 310
mg'1.
COI I ligh 340
mg/ 1.
COI) Low 335
mg/I.
X
Coliform: MP Fecal 31616
<1
/IO0nd
X
Coliform: ME Total 31504
<1
/100ml
TOC
mg/1
furbitity
NTU
Residue., Suspended 530
mg/L
Total Suspended solids
mg/1.
piI
units
Aikalinity to pH 4.5
mg/1_
Alkalinity to pll 8.3
mg.'L
Carbonate
mg/L
Bicarbonate
rag/ 1_
Carbon dioxide
mg/L
X
Chloride
2
mg/L
Chromium: Ilex 1032
ug/L
Color: True 80
c.u.
Cyanide 720
mg: L
(•U313IF:NTS :
Owner: RONALD IIOLDEN INF
Location or Site:
Description of sampling point
Sampling Method:
Remarks:
EMERGENCY
INF.
0 2 2001
t$C DEPT. OF ENVIRONMENT
AND NATURAL RESOURCES
MOOORESL`1LLE REGIONAL OFFICC.
Lab Number : 1G0162
Date Received : 2/2/2001
Time Received : 9;30
th-
Releasedved By : DS
By : AR
Date reported : 4/23/2001
X
Diss. Solids 70300
170.
mg- I.
Fluoride 951
mg/I.
X
I lardncss: total 900
89'
mg/L
Hardness: (non•carb) 902
mg/L
Phenols32730
ug/L
Specific Cond. 95
umhos/cm2
Sulfate
mg/L
Sulfide 745
mg/L
MBAS
mg/L
Oil and Grease
mg/L
Silica
mg/L
Boron
Formaldehyde
mg/ L
N1-13asN6I0
rng/L
TKN as N 625
mg/L
X
NO2 +NO3 as n 630
<0.5
mg/L
P: Total as P 665
mg/L
PO4
mg/L
*Hardness sample received rrrrpreserverl; preserve with sulfuric acid to pHQ.
Ag-Silver 46566
ug/L
X
AI -Aluminum 46557
4
56 ,.
ug/L
As -Arsenic 46551
ug/L
Ba-Barium 46558
ug/L
X
Ca -Calcium 46552
'
53
mg/L
Cd-Cadium 46559
ug/L
X
Cr-Chromium 46560
<25
ug/L
X
Cu- Copper 1042
T
<2:0
ug/L
X
Fe- Iron 1045
4
66 ug/L
llg- Mercury 71900
ug/L
X
K-Potassium 46555
2.1
mg/L
X
Mg- Magnesium '927
4.1.
mg/L
X
Mn-Manganese 1055
19 ug/L
X
Na- Sodium 929
. if
8.5
mg/L
X
Ni-Nickel
<10
ug/L
X
Pb-Lead 46564
<10
ug/L
Se -Selenium
• ug/L
X
Zn_Zinc46567
<10
` ug/L
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
Semivolatiles
TPH-Dicsel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
1G0162.sls

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COUNTY : IREDELL
QUAD NO:
REPORT TO : MRO
COI_LECTOR(S) : CALDWELL
DATE: N/I /2001
TIME:
PURPOSE:
LABORATORY ANALYSIS
Regional Office
BOD 310
mg/L
COI) I Iigh 340 -
mg/I_
COI) Low 335
mg/L
X
Coliform: Mir Fecal 31616
<1
/ 100m1
X
Conform: ME' Total 31504
<1
/ 100m1
TOC
mg/1
futbitity
NTU
Residue., Suspended 530
mg/L
fraud Suspended solids
mg/ 1.
pl I
units
Alkalinity to pl 14.5
mg/I.
Alkalinity to pl 18.3
mg' L
Carbonate
mg' L
Bicarbonate
mg/L
Carbon dioxide
mg/L
X
Chloride
2
mg/L
Chromium: Hex 1032
ug/L
Color: True 80
c.u.
Cyanide 720
mg/ I -
COMMENTS :
Owner:
Location or Site:
Description of sampling point
Sampling Method:
Remarks:
DIVISION OF WATER QUALITY
Chemistry Laboratory Report / Ground Water Quality
SAMPLE PRIORITY
nROUTINE
pi CHAIN OF CUSTODY
n SAMPLE TYPE
RONALD 1101.1)EN EFF
EMERGENCY
EFF.
„Ft, :,_ T> r
rar_ • tr 2001
NC DEPT. OF ENVlRONMEi,
AND NATURAL RESOURCE'
►iIOORESVfLLE REGIONAL OFFICE
Lab Number : 1G0163
ji Date Received : 2/2/2001
Time Received : 9;30
Received By : DS
Ce53#'
Released By : AR
Date reported : 4/23/2001
X
Diss. Solids 70300
170 ,
mg/L
Fluoride 951
mg/L
X
Ilardness: total 900
89
mg/L
Hardness: (non-carb) 902
mg/L
Phenols 32730
ug/L
Specific Cond. 95
umhos/cm2
Sulfate
mg/L.
Sulfide 745
mg/L
MBAS
nig/L
Oil and Grease
mg/L
Silica
mg/L
Moron
Formaldehyde
ntg.L
NH3 as N 610
mg/L
TKN as N 625
mg/L
X
NO2 +NO3 as n 630
<0.50
mg/L
P: Total as P 665
•
mg/L
PO4
mg/L
Ag-Silver 46566
ug/L
X
AI -Aluminum 46557
<50
ug/L
As -Arsenic 46551
ug/L
Ba-Barium 46558
ug/L
X
Ca -Calcium 46552
33,
mg/L
Cd-Cadium 46559
ug/L
X
Cr-Chromium 46560
<25,
ug/L
X
Cu- Copper 1042
4.9
- ug/L
X
Pc- Iron 1045
.
<50,‘ug/L
11g- Mercury 71900
ug/L
X
K-Potassium 46555
2.4
mg/L
X
Mg- Magnesium 927
4.4.
- mg/L
X
Mn-Manganese 1055
19 ug/L
X
Na- Sodium 929
/
9.1
mg/L
X
Ni-Nickel
<10
, ug/L
X
Pb-Lead 46564
<10
, ug/L
Se -Selenium
ug/L
X
Zn_Zinc46567
<10
ug/L
/
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
Semivolatiles
TPH-Diesel Range
Volatile Organics (VOA bottle)
TI'I1-Gasoline Range
TPII-BTEX Gasoline Range
1G0163.xls

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Division of Environmental Management
GROUNDWATER SECTION
CHAIN OF CUSTODY RECORD
For Investigation of (1.-/(7_,�� Incident No
Samples collected and GW-54 forms completed
by: 941-4-4-u-
Lab Only I Quad
No. No.
Loca .0 n\
Date
No. of
Time Containers
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Lab No.
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Relinquished by Received by 1
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•• —

MEMORANDUM
TO:
FROM:
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
February 2, 2001
Mark Pritzl
UIC Section
Groundwater, Parker Lincoln
Susie Caldwell V
SUBJECT: Ronald Holden
UIC Permit Application
Attached is Preconstruction Injection Facility Inspection Report -Form,A for the Ronald
Holden residence, 124 Tall Oak Drive, Mooresville, NC.
Please call if any questions.

Page 1 of 2
North Carolina Department of Environment and Natural Resources
Division of Water Quality.
Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTION
REPORT -FORM A
INJECTION WELL PERMIT NO. WI DATE ,Q - ,/- n /
NAME OF OWNER / a a Ld -
ADDRESS OF OWNER j ,Q L{ 1 Ct, (I Ca-kc aprt
I .00re$vi l le 1C
(7? ' 1. 1 7
(Street/ road or lot and suddivision, county, town)
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable)
r a -u o---f d (00 v' -S uutte- A3C a F 11 "Z - /it-tLP Zia_ a_ -
c w'✓.--€ — v ' h�� _e a 11,,-m !ry' —
' U
(Street/ road or lot and suddivision , county, town, if different than owner's address, plus description of location on site)
Potential pollution source . JJ-ry Distance from well 5J
Potential pollution source Distance from well
Potential pollution source Distance from well
u�c_e. �„te.� � /av
Minimum distance of proposed well from property boundary 7Lti„(�GQ, ,v�U
, am n��. —
Quality of drainage at site ' -i ' Flooding potential of site it- --& a—, -/time / r
(goali,adequate,poor) (high,moderate,low) v$ La„.o! 'tz.—
vim, "..-6-tt vM Larr-e!
DRAW SKETCH OF SITE
(Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and north arrow.)
n
March 98

FPI
Page 2 of 2
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cont.)
COMMENTS
vJ¢u Lcwalr' — CwV UrI (LQ/-41:..4 ' I ✓LC ay b 'L ` VLb f^2 CaA, d yr, (ck Mat)
4.1±AI ,A4,0 %v ! r1 cev 2.-tI
��cih GZta ('2G(1�t..�J /D ft% ' e_A. G ���,.�r
r
41%1/J 4 /4/4 ITS 7/7 9 /D / •
INSPECTOR L`'� OLL
Office /?%
WITNESS 'nu 1eo-)'i 44-zde
Address
/a « A4
WITNESS
Address
March 98

Beverly Eaves Perdue
Governor
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
March 1, 2011
Ronald Holden
124 Tall Oak Drive
Mooresville, NC 28117
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WI0300051
Iredell County
Dear Mr. Holden:
MAR- 2011
MRO
DWCI Aouift r ProteeCt?O1l
Dee Freeman
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Quality (DWQ) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for
the underground injection well system, which was issued to you on July 3, 2006, and expires on
July 31, 2011, is soon due for renewal. If you wish to keep this permit and operate the injection
well system, the permit must be renewed and issued in your name.
If Your Injection Well is Currently Inactive:
If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed under NCAC Title 15A, Subchapter
2C, Section .0214. When each well is plugged and abandoned, the well abandonment record
(Form GW-30) must be submitted to our office to certify that the abandonment was properly
conducted.
If there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form must also be submitted. The GW-30 and Name/Ownership
Change forms can be found at httn://nortal.ncdenr.ora/web/wq/aps/Lnvpro/reporting-forms.
If Your Injection Well is Currently Active:
If the injection well system is still active and you wish to renew your permit, the renewal
application must be submitted within 120 calendar days of the expiration of your permit.
According to our records, you must submit your permit renewal by April 2, 2011.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2726 Capital Boulevard. Raleigh, North Carolina 27604
Phone: [phone] FAX 1: 919-715-0588; FAX 2: 919-715-6048'\ Customer Service: 1-877-623-6748
Internet: www.ncwaterqualitv.orq
An Equal Opportunity 1 Affirmative Action Employer
ilne
N
orti1 Carolina
t Tali

In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit one of the following
enclosed forms:
A. , :Application for Permit (Renewal) to Construct and/or Use a Well(s) for Injection with
Geothermal Heat Pump System for Type 5A7 Well(s) if the injection well system on your
property is still active.
-OR-
B, : Status of Injection Well :System if the injection well system is inactive or has been
temporarily or permanently abandoned.
Please submit the appropriate forms to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may .result in the assessment of civil penalties
, in accordance with North Carolina General Statute. 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
http://h2o.ermstate.nc.us/aps/gpu/forms.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please contact me by phone at [phone] or by email at eric.g.smithicb,ncdenr.gov.
Sincerely, ,�y1 d
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: t _Moores vine_Regional_-Office_- APS w/_o_enclosur_esj
APS Central Files - Permit No. WI0300051 w/o enclosures

DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
1/17/2006
MEMORANDUM
To: Andrew Pitner
Mooresville Regional Office
From: Jesse Wiseman
Central Office UIC Program
Re: Notification of Regulatory Requirement
UIC Permit No. WI0300051
E EWIE F-1
JAN 2 4 2006
NC DEAR MRO
DWQ - A• uifer Protection
UIC Pennit No. WI030005 1 (Type 5A7) issued to Ronald L. Holden is due to expire on February 28,
2006. A Notice of Regulatory Requirement regarding this permit was sent by this office to Ronald
Holden on 1/17/2006. This letter is attached for your record. No regional action is necessary at this
time.
Attachment

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 17, 2006
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7002 2410 0003 0274 9847
Ronald Holden
124 Tall Oak Drive
Mooresville, NC 28117
Ref: Notice of Regulatory Requirement
North Carolina Well Construction Standards
Applicable to Injection Wells - Subchapter 2C
UIC Permit No. WIO300051 Issued to Ronald L. Holden
Dear Mr. Holden:
The Underground Injection Control (UIC) Program of the Division of Water Quality is
responsible for the regulation of injection well construction and operation activities within the
state of North Carolina. The purpose of this letter is to inform you, as the current property
owner, of your responsibilities pertaining to injection well rules.
The permit referenced above was issued for the construction and operation of an injection well at
124 Tall Oak Drive in Mooresville, North Carolina. This permit will expire on February 28,
2006. This office attempted to bring your injection well into compliance by sending you a
notification of expiration, a blank application for permit renewal, and an injection well status
form in December 5, 2005. To date the UIC Program has not received either the renewal
application or the status form. Please note that, as stated in PART VIII of your permit, a renewal
applications should have been submitted at least 3 months prior to the expiration of this permit.
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must take one of the following.
actions:
A. Submit the form RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION
WITH A HEAT PUMP SYSTEM (form GW/UIC-57 HPR) if the injection well on your
property is still active;
B. Submit the form STATUS OF INJECTION WELL SYSTEM (form GW/UIC-68) if the injection
well is inactive or has been temporarily or permanently abandoned.
NorthCarolina
A2atlrrally
Aquifer Protection Section 1636 Mail Service Center • Raleigh, NC 27699-1636 Telephone: [phone]
Internet: http://h2o.enr.state.nc.us 2728 Capital Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper Customer Service: [phone]

Ronald Holden
January 17, 2006
Page 2 of 2
If the well is no longer being used for any purpose, it must be permanently abandoned according
to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section .0214. If
the injection well is to be permanently abandoned, a well abandonment record must be submitted
to our office to certify that the abandomment was properly conducted.
Again, we have provided you with the appropriate materials to update your UIC permit. You
must respond within 15 days of the receipt of this letter, or a Notice of Violation will be issued to
you, which carries the -possibility for an assessment of fines or cessation of operation of the
injection well system. Please contact Thomas Slusser at [phone] or myself at (919) 715-
6182 if you have any questions about this correspondence, the UIC Program, or the enclosed
forms.
Sincerely,
Evan O. Kane, L.G.
UIC Program Manager
Enclosures
cc: (Dw = Mooresville`Regional-Office w/o enclosures''
CO-UIC Files w/o enclosures

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: Apri17.2011
To: ❑ Landon Davidson, ARO-APS
❑ Art Barnhardt, FRO-APS
® Andrew Pitner, MRO-APS
❑ Jay Zimmerman, RRO-APS
From: John McCraw , Groundwater Protection Unit
Telephone: [phone]
E-Mail: jolm.mccray(&,ncdenr.aov
❑ David May, Wa
Charlie Stelunan, WiRO-APS
❑ Sherri Knight, WSRO-APS
Fax: [phone]
A. Permit Number: WI0300051
B. Owner: Anne Holden
C. Facility/Operation: Anne Holden SFR 5A7
❑ Proposed ® Existing
Facility
❑ Operation
D. Application:
1. Permit Type: ❑ Animal ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ JIE Lagoon ❑ GW Remediation (ND)
UIC (5A7). open loop geothermal
❑ Land App. n D&M ❑ Surface Disposal
'❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type: New n Major Mod. ❑ Minor Mod. ® Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
• For Residuals:
APR 1 1 2011 10
DENR MRO
;W© - A• uifer Protection
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
® Return a Completed Form APSARR.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO*.
* Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: Date:
FORM: APSARR 02/06 Page 1 of 1

Beverly Eaves Perdue
Governor
Anne Holden
124 Tall Oak Drive
Mooresville. NC 28117
NCDEN
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins Dee Freeman
Director Secretary
Apri14, 2011
Subject: Acknowledgement of Application No. WI0300051
Holden, Ronald - SFR
Injection Heating/Cooling Water Return Well (5A7)
Iredell
Dear Ms. Holden:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on March 30, 2011. This application package has been assigned the number listed above and will be reviewed by
John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications,.the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days after receipt of a complete
application.
If you have any 'questions, please contact John McCray at 919-715-6168, or via e-mail at [e-mail]. If the reviewer is
unavailable, you may leave a message, and they will respond promptly.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
EGOI`.
for Debra J. Watts
Supervisor
cc: 01ooresuiUle Regional Office;quiFfe-aP,ratectQn cetto
Permit Application File WI0300051
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.ncwateraualitv.ore
Nt one
hCarolina
An Equal Opportunity t Affirmative Action Employer

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES`
P: l A 0 f; 21111
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A GEOTHERMAL HEAT PUMP SYSTEM
(check one)
TYPE 5A7 "OPEN LOOP" INJECTION WELL(S)
New Permit Application V Renewal Modification
DATE: , (a-{, a; 'Z ( 20 % I
PERMIT NO.: WI (`; 3 E-t'() 51 (leave blank if NEW permit application)
A. PROPERTY OWNER/PERMIT APPLICANT
Name of each owner listed on property deed. For a business or government agency, state name of entity and
name of person delegated thopty to sign application on behalf of the business/agency:
11 f? A. (.1]Neten
(1) Mailing Address: ?• //cP(/ 7c7 V i
City: / I t/0 rE 5 V1 %�/ 0 State:A)C Zip Code:'2 8f/ / County: Ire eh,'
,/I
Home/ef'free Tele No.: %D 40: 3 5-3( Cell No.:
Fax No. Email Address:
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County:
Home/Office Tele No.: Ce11 No.:
Fax No. Email Address:
B. PROPERTY OWNERSHIP DOCUMENTATION
Provide legal documentation of property ownership, such as a contract, deed, article of incorporation, etc. and
a PLAT map showing the property. This information may be obtained from county Register of Deeds or GIS
website.
C. AUTHORIZED AGENT, IF ANY
If the property owner/permit applicant wants to authorize someone else to sign the permit on their behalf, then
attach a signed letter from the property owner/pennit applicant specifying and authorizing their agent (well
driller, heat pump contractor, or other type of contractor/agent) to sign this application on their behalf.
Company Name:
Contact Person: Email Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Fax No. Ce11 No.:
Website Address of Company, if any:
Type 5A7 In.action Well Permit Application (Rev. August 2009) Page I of 4

(
D. WELL DRILLER�[NFORMATION
Company Name: �'
Well Drilling Contractor's Name:
f NC Contractor Certification No.: Contact Person:
Company Website: WWW. Email Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Fax No.: Ce11 No.:
E. HEAT PUMP CONTRACTOR INFORMATION (if different than Driller)
Company Name: Contact Person:
Company Website: WWW. Email Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Fax No. Cell No.
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The infection operation? YES - NO
(2) Personal consumption?- YES ✓ • NO
•
H. WELL CONSTRUCTION DATA
qg 61 /PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
9 u (7) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
1 EXISTING Well(s) 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 the Well Construction Record (Form
GW-1) if available. -
(1) Well Construction Date: Number of borings:
Depth of each boring (feet):
(2) 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 thickness: diameter (inches): depth: from to feet (relative to land surface)
Casing extends above ground inches
(b) NO
(3) Grout material surrounding well casing:
(a) Grout type: Cement Bentonite* Other (specify)
*By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(1)(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from
to feet
Type 5A7 Injection Well Permit A=+plication (Rev. August 2009)
Pane 2 of 4

(4) Well Screen or Open Borehole depth (relative to land surface): from to feet
(5)
N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Will there be a faucet on:
(a) Influent line? Yes No (b) Effluent line? Yes No
(6) Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Form GW-1). If Form GW-1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment units will the groundwater be withdrawn? (e.g.
granite, limestone, sand, etc.)
Depth: Formation: Rock/sediment unit:
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHERWISE UNAVAILABLE.
I. OPERATING DATA
(1)
(2)
(3)
(4)
Injection Rate:
Injection Volume:
Inj ection Pressure:
Injection Temperature:
Average (daily)
Average (daily)
Average (daily)
Average (January)
gallons per minute (gpm).
gallons per day (gpd).
pounds/square inch (psi).
° F, Average (July) ° F.
J. INJECTION -RELATED EQUIPMENT
Attach a schematic diagram or cross-section of the well construction that shows the total depth, length of casing,
extent of grout, stickup, location of influent/effluent sampling ports, etc. If this is a modification, show the
engineering layout or proposed modification of the injection equipment and exterior piping/tubing associated with
the injection operation. The manufacturer's brochure may provide supplementary information if needed.
K. LOCATION OF WELL(S)
(1)
Attach a site map (can be drawn) showing: houses and other structures, property lines, surface water bodies,
potential sources of groundwater contamination, and the orientation of and distances between the proposed
injection well(s) and any other 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 al' features clearly and include a
north arrow.
(2) Attach a scaled topographic map of the area extending 1/4 mile from the property boundary that indicates
the facility's location, a north arrow, and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county 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.
. Type 5A7 Injection Well Permit Application (Rev. August 2009) Page 3 of4

L. CERTIFICATION (to be signed as required below or by that person's authorized agent)
NCAC 15A 2C .0211 (b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner.
If an authorized agent is signing on behalf of the applicant, then submit a letter signed by the _
applicant that names and authorizes their agent as specified in Part C of this permit application.
"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."
MAR U 0 2011'
,01A4,6
Signature of Property Owner/Applicant
1-/o(de �7
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit TWO signed copies of the completed application package and all attachments to:
TJIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Type 5A7 Injection Well Permit Appi. ation (Rev. August 2009) Page =: of4

�'iiij.
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor . Director Secretary
March 15, 2011
Anne Holden
124 Tall Oak Drive
Mooresville, NC 281.17
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection. Well
Permit No. W10300051
Iredell County
Dear Ms. Holden:
As per our phone conversation on March 15, 2011, please complete and return the enclosed form for
renewal of your 5A7 Geothermal Injection Well system. Your permit number is listed in the subject
line above. Please complete the form with the information that you know then submit the completed
form to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
For your convenience, a self-addressed envelope has been enclosed. The enclosed form is also
available on-line at the DWQ website at httn://h2o.enr.state.nc.us/ans/gnu/forms.htni.
Thank you in advance for your cooperation and timely response. If you have any questions, please
contact me by phone at [phone] or by email at eric.u.smith(ir).ncdem.aov.
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
Enclosure
cc: APS Central Files - Perrnit No. WI0300051 w/o enclosures
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 [phone] Customer Setiice: i-87; -323-6748
Internet www.ncwaterqualitv,orq
An =oual Opportunity Affirmative Action Employer
one
o trig r itna

GROUNDWATER FIELD/LAB FORM
Location code WI0300051-Well
County_Iredell
Quad No Serial No.
Lat. Long.
Report To: ARO, FROR0; RRO, WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other:
Shipped by: Bus, - Hand Del., Other: Purpose: UIC System Inspection
Collector(s): Maria Schutte Date: 05/04/2011 Time M:0Q Baseline, Complaint, Compliance, LUST, Pesticide Study, Federal Trust, Other:
FIELD ANALYSES q Owner: Anne Holden (circle one)
pH 400 t. t ' Spec. Cond�4 l r �t at 25°C Location or Site: 124 Tall Oak Drive, Mooresville
10 Description of sampling point: Influent
pp A earance c1e t- ci- 1'.S5 Sampling Method: Pump- (2ii c—
Field Analysis By: Maria Schutte Remarks rPum°. Bauer. etc.)
(Pumping time, air temp., etc.)
SAMPLE TYPE� ' Water
❑ Soil
Di Other
El Chain of Custody
SAMPLE PRIORITY
Routine
El Emergency
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Temp 13 ` °C Odor" c'cl
Lab Number
Date Received Time:
Rec'd By: From:Bus, Courier, Hand Del.,
Other:
Data Entry By: Ck:
Date Reported:
Sample Interval
LAUUKA I UKY HIN/-HL T JCJ
Organochlorine Pesticides
BOD 310
mg/L
X
Diss. Solids 70300
mg/L
Ag-Silver 46566
ug/L _
Organophosphorus Pesticides
COD High 340
mg/L
Fluoride 951
mg/L
X
AI -Aluminum 46557
ug/L
Nitrogen Pesticides
COD Low 335
mg/L
X
Hardness: Total 900
mg/L
X
As -Arsenic 46551
ug/L
Acid Herbicides
X
Coliform: MF Fecal 31616
/100m1
Hardness (non-carb) 902
mg/L
X
Ba-Barium 46558
ug/L
PCBs
X
Coliform: MF Total 31504
/100m1
Phenols 32730
ug/I
X
Ca -Calcium 46552
mg/L
X
Cd-Cadmium 46559
ug/L
•
TOC 680
mg/L
Specific Cond. 95
pMhos/cm
.
Turbidity 76
NTU
X
Sulfate 945
mg/L
X
Cr-Chromium 46559
ug/L
Residue, Total Suspended 530
mg/L
Sulfide 745
mg/L
X
Cu-Copper 46562
ug/L
X
Fe -Iron 46563
ug/L
Semivolatile Organics
Oil and Grease
, mg/L •
Hg-Mercury 71900
ug/L
TPH-Diesel Range
pH 403
units
X
K-Potassium 46555
mg/L
Alkalinity to pH 4.5 410
mg/L
X
Mg -Magnesium 46554
mg/L
Alkalinity to pH 8.3 415
mg/L
X
Mn-Manganese 46565
ug/L
Volatile Organics (VOA bottle)
X
Na-Sodium 46556
mg/L
TPH-Gasoline Range
Carbonate 445
mg/L
NH3 as N 610
mg/L
Bicarbonate 440
mg/L
TKN as N 625
mg/L
X
Ni-Nickel •
ug/L
TPH-BTEX Gasoline Range
Carbon dioxide 405
mg/L
X
NO2 + NO3 as N 630
mg/L
X
Pb-Lead 46564
ug/L
X
Chloride 940
mg/L
P: Total as P 665
mg/L
X
Se -Selenium
ug/L
X
Nitrate (NO3as N) 620
mg/L
X
Zn-Zinc 46567
ug/L
Chromium: Hex 1032
ug/L
Color: True 80
CU
X
Nitrite (NO2 as N) 615
mg/L
LAB USE ONLY
Temperature on arrival (°C):
Cyanide 720
mg/L
Lab Comments
GW-54 REV. 7/03 For Dissolved Analysis -submit filtered sample and write "DIS" in block.

GROUNDWATER FIELD/LAB FORM
Location code W10300051-IN
CountyIredell
Quad No Serial No.
Lat. Long.
Report To: ARO, FRO, TCD, RRO, WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other:
Shipped by: Bus Coo n . , Hand Del., Other:
Collector(s): Maria Schutte
FIELD ANALYSES ',
pH 400 6, 4(5- Spec. Cond.94 ; i' at 25°C
Temp.io /7/c °C Odor ddt,t t c
Appearance .(i' r- 4- 6.(nv-( t
Field Analysis By: Maria Schutte
SAMPLE TYPE
.'Water
❑ Soil
❑ Other
❑ Chain of Custody
SAMPLE PRIORITY
I
Routine
❑ Emergency
Date: 05/04/2011
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Lab Number
Date Received
Rec'd By:
Other:
Time:
From:Bus, Courier, Hand Del.,
Data Entry By: Ck:
Date Reported:
Purpose: UIC System Inspection
Time / S lt) Baseline, Complaint, Compliance,(LUS°T, Pesticide Study, Federal Trust, Other:
circlene)
Owner: Anne Holden
Location or Site: 124 Tall Oak Drive, Mooresville
Description of sampling point: Influent (-a? (—ilk-PeSampling Method: Pump
Remarks
IYumo. bailer. etc.)
Sample Interval
(Pumping time, air temp., etc.)
LAI3UKAIUKY ANALYJCJ
Organochlorine Pesticides
BOD 310
mg/L
X
piss. Solids 70300
mg/L
Ag-Silver 46566
ug/L
Organophosphorus Pesticides
COD High 340
mg/L
Fluoride 951
mg/L
X
AI -Aluminum 46557
ug/L
Nitrogen Pesticides
COD Low 335
mg/L
X
Hardness: Total 900
mg/L
X
As -Arsenic 46551
ug/L
Acid Herbicides
X
Coliform: MF Fecal 31616
/100m1
Hardness (non-carb) 902
mg/L
X
Ba-Barium 46558
ug/L
PCBs
X
Coliform: MF Total 31504
/100m1
Phenols 32730
ug/I
X
Ca -Calcium 46552
mg/L
x
Cd-Cadmium 46559
u./L
TOC 680
mg/L
Specific Cond. 95
pMhos/cm
Turbidity 76
NTU
X
Sulfate 945
mg/L
X
Cr-Chromium 46559
uglL
Residue, Total Suspended 530
mg/L
Sulfide 745
mg/L
X
Cu-Copper 46562
ug/L
X
Fe -Iron 46563
ug/L
S
Semivolatile Organics
Oil and Grease
mg/L
Hg-Mercury 71900
ug/L
TPH-Diesel Range
pH 403
units
X
K-Potassium 46555
mg/L
X
Mg -Magnesium 46554
mg/L
Alkalinity to pH 4.5 410
mg/L
Alkalinity to pH 8.3 415
mg/L
X
Mn-Manganese 46565
ug/L
Volatile Organics (VOA bottle)
NH3 as N 610
mg/L
X
Na-Sodium 46556
mg/L
T
TPH-Gasoline Range
Carbonate 445
mg/L
Bicarbonate 440
mg/L
TKN as N 625
mg/L
X
Ni-Nickel
ug/L
T
TPH-BTEX Gasoline Range
Carbon dioxide 405
mg/L
X
NO2 + NO3 as N 630
mg/L
X
Pb-Lead 46564
ug/L
X
Se -Selenium
ug/L
X
Chloride 940
mg/L
P: Total as P 665
mg/L
Chromium: Hex 1032
ug/L
X
Nitrate (NO3 as N) 620
mg/L
X
Zn-Zinc 46567
ug/L
LAB USE ONLY
Color: True 80
CU
X
Nitrite (NO2 as N) 615
mg/L
Temperature on arrival (°C):
Cyanide 720
mg/L
Lab Comments
GW-54 REV. 7/03 For Dissolved Analysis -submit filtered sample and write "DIS" in block.

GROUNDWATER FIELD/LAB FORM
Location code WI0300051-Out
County_Iredell
Quad No Serial No.
Lat. Long.
Report To: ARO, FRO,10 RRO, WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other:
Shipped by: Bus, C° , Hand Del., Other:
Collector(s): Maria Schutte
FIELD ANALYSES
pH 400 4. (- Spec. Cond.94
Temp.10 A °C Odor
Appearance Q.% r- 4- C.. ®r tzcr
Field Analysis By: Maria Schutte
SAMPLE TYPE
❑ Water
❑ Soil
❑ Other
❑ Chain of Custody
SAMPLE PRIORITY
❑ Routine
❑ Emergency
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Lab Number
Date Received
Rec'd By:
Other:
Time:
From:Bus, Courier, Hand Del.,
Data Entry By: Ck:
Date Reported:
Purpose: UIC System Inspection
Date: 05/04/2011 Time (51Baseline, Complaint, Compliance, LUST, Pesticide Study, Federal Trust, Other:
(circle one)
Owner: Anne Holden
at 25°C Location or Site: 124 Tall Oak Drive, Mooresville
Description of sampling point: Efffluent C -gv`" - (.,(,LT' -( — Ot`(
Sampling Method: Pump Sample Interval
U-'umo. bailer. etc.)
LABORATORY ANALYSES
BOD 310
mg/L
COD High 340
mg/L
COD Low 335
mg/L
X
Coliform: MF Fecal 31616
/100m1
X
Coliform: MF Total 31504
/100m1
TOC 680
mg/L
Turbidity 76
NTU
Residue, Total Suspended 530
mg/L
pH 403
units
Alkalinity to pH 4.5 410
mg/L
Alkalinity to pH 8.3 415
mg/L
Carbonate 445
mg/L
Bicarbonate 440
mg/L
Carbon dioxide 405
mg/L
X
Chloride 940
mg/L
Chromium: Hex 1032
ug/L
Color: True 80
CU
Cyanide 720
mg/L
Lab Comments
Remarks
X
Diss. Solids 70300
mg/L
Fluoride 951
mg/L
X
Hardness: Total 900
mg/L
Hardness (non-carb) 902
mg/L
Phenols 32730
ug/I
Specific Cond. 95
pMhos/cm
X
Sulfate 945
mg/L
Sulfide 745
mg/L
Oil and Grease
mg/L
NH3 as N 610
mg/L
TKN as N 625
mg/L
X
NO2 + NO3 as N 630
mg/L
P: Total as P 665
mg/L
Nitrate (NO3 as N) 620
mg/L
Nitrite (NO2 as N) 615
mg/L
(Pumping time, air temp., etc.)
Ag-Silver 46566
ug/L
X
Al -Aluminum 46557
ug/L
X
As -Arsenic 46551
uglL
X
Ba-Barium 46558
ug/L
X
Ca -Calcium 46552
mg/L
X
Cd-Cadmium 46559
ug/L
X
Cr-Chromium 46559
ug/L
X
Cu-Copper 46562
ug/L
X
Fe -Iron 46563
ug/L
Hg-Mercury 71900
ug/L
X
K-Potassium 46555
mg/L
X
Mg -Magnesium 46554
mg/L
X
Mn-Manganese 46565
ug/L
X
Na-Sodium 46556
mg/L
X
Ni-Nickel
ug/L
X
Pb-Lead 46564
ug/L
X
Se -Selenium
ug/L
X
Zn-Zinc 46567
ug/L
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCBs
Semivolatile Organics
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
LAB USE ONLY
Temperature on arrival (°C):
GW-54 REV. 7/03
For Dissolved Analysis -submit filtered sample and write "DIS" in block.

Michael F. Easley, Govemor
cfr \N H r&-9QG
ti
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
July 3, 2006
Anne and Ronald Holden
124 Tall Oak Drive
Mooresville, NC 28117
Ref: Injection Permit Issuance
Permit # WI0300051
Issued to Anne and Ronald Holden
Dear Mr. and Mrs. Holden:
In accordance with the application submitted on March 20, 2006, the Division of Water
Quality's Underground Injection Control (UIC) Program is forwarding permit number
WI0300051 for the continued operation of a geothermal heat pump system located at 124 Tall
Oak Drive in Morrisville, Iredell County, NC.
This permit shall be effective from the date of issuance until July 31, 2011 and shall be subject to
the conditions and limitations stated therein. Please read your permit carefully to make sure you
thoroughly understand its requirements and your responsibilities.
If you have any questions regarding your permit please contact Qu Qi at [phone] or
Debra Watts at [phone].
Best Regards,
Thomas Slusser, L.G.
Environmental Specialist III
cc: �Aridrew Pifner_1Vlooresvi11e Regional' Office
CO-UIC files
Enclosure
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636
Internet: http://www.ncwaterquality.org 2728 Capital Boulevard Raleigh, NC 27604
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper
One
NorthCarolina
Naturally
Telephone: [phone]
Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE 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
ANNE and RONALD HOLDEN
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent.
This injection well will be located at 124 Tall Oak Drive in Mooresville, Iredell County, North
Carolina, and will be operated in accordance with the application received on March 20, 2006, and in
conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Operation only and does not waive any provisions of the Water Use Act or any
other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be in
compliance with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and any other
Laws, Rules, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until July 31, 2011, and
shall be subject to the specified conditions and limitations set forth in Parts I through IIX hereof.
Permit issued this the 3 4 day of TT .. ty , 2006.
Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0300051 PAGE 1 OF 5
GW/UIC-5 ver. 7/05

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.
PART II - OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances which may be
imposed by other local, state, and federal agencies which have jurisdiction. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
Permit No. WI0300051 PAGE 2 OF 5
GW/UIC-5 ver. 7/05

PART III - PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted- activity.
The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART IV - OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
PART V - INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
Permit No. WI0300051 PAGE 3 OF 5
GW/UIC-5 ver. 7/05

PART VI - MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary
by the Division of Water Quality to insure surface and ground water protection, will be
established and an acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Mooresville Regional Office, telephone number (704)
663-1699, any of the following:
(A) Any occurrence at the injection facility which results in any unusual
operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report to
the Director, the relevant and correct facts or information shall be promptly submitted to •
the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
PART VII - PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an
extension.
PART IIX - CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinuation of use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(1), Well Construction
Standards.
Permit No. WI0300051 PAGE 4 OF 5
GW/UIC-5 ver. 7/05

2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel -packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
(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 IIX (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. WI0300051 PAGE 5 OF 5
GW/UIC-5 ver. 7/05

v77 DINO Laboratory Section 1ResuCts
County: IREDELL
River Basin
Report To MROAP
Collector: M SCHUTTE
Region: MRO
Sample Matrix: GROUNDWATER
Loc. Type: WATER SUPPLY
Emergency Yes/No
COC Yes/No
VisitlD
Loc. Descr.: ANNE HOLDEN 124 TALL OAK DRIVE
Sample ID: AB71032
PO Number# 11G0356
Date Received: 05/05/2011
Time Received: 08:30
Labworks LoginlD HMORGAN
Report Generated: 5/20/11
Date Reported: 05/20/2011
Location ID: WI0300051-WELL
Collect Date: 05/04/2011
Collect Time: 14:00
Sample Depth
CAS # Analyte Name
LAB
Sample temperature at receipt by lab
PQL
Result/
Qualifier
Units
0.4 °C
Method Analysis Validated by
Reference Date
5/5/11 DLEAVITT
MIC
Coliform, MF Fecal in liquid 1 1 B2Q1 CFU/100m1 APHA9222D-20th 5/5/11 CGREEN
Coliform, MF Total in liquid
1 3 Q1
CFU/100m1 APHA9222B-20th 5/5/11 MOVERMAN
WET
Ion Chromatography _TITLE_ mg/L EPA 300.0 5/17/11 CGREEN
Chloride 1 1.7 mg/L EPA 300.0 5/17/11 CGREEN
Fluoride 0.4 0.4 U mg/L EPA 300.0 5/17/11 CGREEN
Sulfate 2 • 7.6 mg/L EPA 300.0 5/17/11 CGREEN
Total Dissolved Solids in liquid 12 96 mg/L APHA2540C-18TH 5/5/11 MOVERMAN
NUT
NO2+NO3 as N in liquid
0.02 0.54 mg/L as N Lac10-107-04-1-c 5/6/11 CGREEN
mg/L as N Lachat107-04-1-c 5/17/11 CGREEN
Nitrate as N in liquid
0.02 0.54
Nitrite as N in liquid 0.01
0.01 U mg/L as N Lachat107-04-1-c 5/5/11 CGREEN
MET
7429-90-5 Al by I C P
50 50 U ug/L EPA 200.7 5/6/11 ESTAFFORD1
7440-38-2 As by ICPMS
2
2.0 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
7440-38-3 Ba by ICP
10 72 ug/L EPA 200.7 5/9/11 ESTAFFORD1
7440-70-2 Ca by ICP
0.1 18 mg/L EPA 200.7 5/9/11 ESTAFFORDI
7440-43-9 Cd by ICPMS 1 1.0 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
7440-47-3 Cr by ICPMS 10 10 U ug/L EPA 200.8 5/9/11 ESTAFFORDI
7440-50-8 Cu by ICPMS 2 22 ug/L EPA 200.8 5/9/11 ESTAFFORDI
50 50 U ug/L EPA 200.7 5/6/11 ESTAFFORD1
7439-89-6 Fe by ICP
7440-09-7 K by ICP 0.1 2.1 mg/L EPA 200.7 5/9/11 ESTAFFORD1
7439-95-4 Mg by ICP 0.1 4.4 mg/L EPA 200.7 5/9/11 ESTAFFORD1
10 10 U ug/L EPA 200.7 5/6/11 ESTAFFORD1
7439-96-5 Mn by ICP
7440-23-5 Na by ICP
0.1 9.4 mg/L EPA 200.7 5/9/11 ESTAFFORDI
7440-02-0 Ni by ICPMS 2 2.0 U ug/L EPA 200.8 5/9/11 ESTAFFORDI
2 2.0 U ug/L EPA 200.8 5/9/11 ESTAFFORDI
7439-92-1 Pb by ICPMS
7782-49-2 Se by ICPMS 5 5.0 U ug/L EPA 200.8 5/9/11 ESTAFFORDI
10 15 ug/L EPA 200.8 5/9/11 ESTAFFORD1
7440-66-6 Zn by ICPMS
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
For a detailed description of the qualifier codes refer to htto:lloortal.ncdenr.oro/web/wellab/slaffinfo/techassisl#Data Qualifier Codes<http://portal.ncdenr.orofweblwq/lab/staffinfo/lechassist>
Panes 1 of 1

GROUNDWATER FIELD/LAB FORM
Location code WI0300051-Well
CountyIredell
Quad No Serial No.
Lat. Long.
Report To: ARO, FR• RI, RRO, WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other:
Shipped by: Bus, ourier Hand Del., Other:
Collector(s): Maria Schutte
FIELD ANALYSES
pH 400 (', .r Spec. Cond. (5_r -1 at 25°C
Temp.io 13,S °C Odor c c
Appearance C,LoA- ci- fi t- (e,5c,
Field Analysis By: Maria Schutte
SAMPLE TYPE
Water
❑ Soil
❑ Other
E Chain of Custody
SAMPLE PRIORITY
Routine
❑ Emergency
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Purpose: UIC System Inspection
Date: 05/04/2011 Time /L/r Q Baseline, Complaint, Compliance, LUST, Pesticide Study, Federal Trust, Other:
(circle one)
Owner: Anne Holden
Location or Site: 124 Tall Oak Drive, Mooresville
Description of sampling point: Influent
Sampling Method: Pump - tt'e \t 4e.sasp.cl
Remarks umo. bailer. etc.r.
(Pumping time, air temp., etc.)
Lab Number
Date Received 5 5 ' I I Time: Io3 C�
Rec'd By: ,/ From:Bus, .wrier, Hand Del.,
Other:
Data Entry By:
Date Reported:
C k:
BOD 310
mg/L
X
Diss. Solids 70300
mg/L
Ag-Silver 46566
ug/L
COD High 340
mg/L
Fluoride 951
mg/L
X
Al -Aluminum 46557
ug/L
COD Low 335
mg/L
X
Hardness: Total 900
mg/L
X
As -Arsenic 46551
ug/L
X
Coliform: MF Fecal 31616
/100m1
Hardness (non-carb) 902
mg/L
X
Ba-Barium 46558
ug/L
X
Coliform: MF Total 31504
/100m1
Phenols 32730
ug/I
X
Ca -Calcium 46552
mg/L
TOC 680
mg/L
Specific Cond. 95
pMhos/cm
X
Cd-Cadmium 46559
ug/L
Turbidity 76
NTU
X
Sulfate 945
mg/L
X
Cr-Chromium 46559
ug/L
Residue, Total Suspended 530
mg/L
Sulfide 745
mg/L
X
Cu-Copper 46562
ug/L
X
Fe -Iron 46563
ug/L
Oil and Grease
mg/L
Hg-Mercury 71900
ug/L
pH 403
units
X
K-Potassium 46555
mg/L
Alkalinity to pH 4.5 410
mg/L
X
Mg -Magnesium 46554
mg/L
Alkalinity to pH 8.3 415
mg/L
X
Mn-Manganese 46565
ug/L
Carbonate 445
mg/L
NH3 as N 610
mg/L
X
Na-Sodium 46556
mg/L
Bicarbonate 440
mg/L
TKN as N 625
mg/L
X
Ni-Nickel
ug/L
Carbon dioxide 405
mg/L
X
NO2 + NO3 as N 630
mg/L
X
Pb-Lead 46564
ug/L
X
Chloride 940
mg/L
P: Total as P 665
mg/L
X
Se -Selenium
ug/L
Chromium: Hex 1032
ug/L
X
Nitrate (NO3 as N) 620
mg/L
X
Zn-Zinc 46567
ug/L
Color: True 80
CU
X
Nitrite (NO2 as N) 615
mg/L
Cyanide 720
mg/L
Lab Comments
Sample Interval
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCBs
Semivolatile Organics
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
LAB USE ONLY
Temperature on arrival (°C):
GW-54 REV. 7/03 For Dissolved Analysis -submit filtered sample and write "DIS" in block.

(' <1?WO Laboratory Section Results
County: IREDELL
River Basin
Report To MROAP
Collector: M SCHUTTE
Region: MRO
Sample Matrix: GROUNDWATER
Loc. Type: WATER SUPPLY
Emergency Yes/No
COC Yes/No
r,
? t :-
ti^, AY 2 4 2011
VisitlD
Loc. Descr.: ANNE HOLDEN 124 TALL OAK DRIVE
Sample ID: AB71033
PO Number# 11G0357
Date Received: 05/05/2011
Time Received: 08:30
Labworks LoginlD HMORGAN
Report Generated: 5/20/11
Date Reported: 05/20/2011
Location ID: W10300051-IN
Collect Date:
05/04/2011
I Collect Time: 14:40
Sample Depth
CAS # Analyte Name
LAB
Sample temperature at receipt by lab
PQL
Result/
Qualifier
0.4
Units
°C
Method Analysis Validated by
Reference Date
5/5/11 DLEAVITT
MIC
Coliform, MF Fecal in liquid 1 1 B2Q1 CFU/100m1 APHA9222D-20th 5/5/11 CGREEN
Coliform, MF Total in liquid 1 1 Q1 CFU/100m1 APHA9222B-20th 5/5/11 MOVERMAN
WET
Ion Chromatography TITLE mg/L EPA 300.0 5/17/11 CGREEN
Chloride
1
1.7 mg/L EPA 300.0 5/17/11 CGREEN
Fluoride
0.4 0.4 U mg/L EPA 300.0 5/17/11 CGREEN
Sulfate 2 7.7 mg/L EPA 300.0 5/17/11 CGREEN
Total Dissolved Solids in liquid 12 96 mg/L APHA2540C-18TH 5/5/11 MOVERMAN
NUT
NO2+NO3 as N in liquid
0.02 0.54 mg/L as N Lac10-107-04-1-c 5/6/11 CGREEN
mg/L as N Lachat107-04-1-c 5/17/11 CGREEN
Nitrate as N in liquid
0.02 0.54
Nitrite as N in liquid 0.01
0.01 U mg/L as N Lachat107-04-1-c 5/5/11 CGREEN
M ET
7429-90-5 Al by 1CP
50 50 U ug/L EPA 200.7 5/6/11 ESTAFFORD1
7440-38-2 As by ICPMS
2
2.0 U ug/L EPA 200.8 5/9/11 ESTAFFORDI
7440-38-3 Ba by ICP
10 75 ug/L EPA 200.7 5/9/11 ESTAFFORDI
7440-70-2 Ca by ICP
0.1 19 mg/L EPA 200.7 5/9/11 ESTAFFORD1
7440-43-9 Cd by ICPMS 1 1.0 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
7440-47-3 Cr by ICPMS 10 10 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
7440-50-8 Cu by ICPMS 2 10 ug/L EPA 200.8 5/9/11 ESTAFFORDI
50 50 U ug/L EPA 200.7 5/6/11 ESTAFFORD1
7439-89-6 Fe by ICP
7440-09-7 K by ICP
0.1 2.2 mg/L EPA 200.7 5/9/11 ESTAFFORD1
7439-95-4 Mg by ICP
0.1 4.4 mg/L EPA 200.7 5/9/11 ESTAFFORD1
7439-96-5 Mn by ICP 10 10 U ug/L EPA 200.7 5/6/11 ESTAFFORD1
0.1 9.6 mg/L EPA 200.7 5/9/11 ESTAFFORD1
7440-23-5 Na by I C P
7440-02-0 Ni by ICPMS -2 2.0 U ug/L EPA 200.8 5/9/11 ESTAFFORDI
7439-92-1 Pb by ICPMS 2 2.0 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
7782-49-2 Se by ICPMS 5 5.0 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 10 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 {919) 733-3908
For a detailed description of the qualifier codes refer to httplfoortal.ncdenr.orQANeb/wq/lab/staffinfo/techassist,'#Data Qualifier Codes <http:dportal.ncdenr.orgfweb/wa/labfstaffinfo/fechassist>
Panto 1 of 1

GROUNDWATER FIELD/LAB FORM
Location code WI0300051-IN
CountyIredell
Quad No Serial No.
Lat. Long.
Report To: ARO, FRO, CO, RRO, WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other:
Shipped by: Bus, Hand Del., Other:
SAMPLE TYPE
. }"Water
❑ Soil
❑ Other
❑ Chain of Custody
SAMPLE PRIORITY
Routine
LI Emergency
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION .
11G- 035-
Lab Number
A1).7-In33
Date Received 5' 5 ' 1 j Time: • 0
Rec'd By: From:Bus, 'ourier, Hand Del.,
Other:
Data Entry By: Ck:
Date Reported:
Purpose: UIC System Inspection
j i, O Baseline, Complaint, Compliance, LUST Pesticide Study, Federal Trust, Other:
Owner: Anne Hoiden
pH 400 (n, Spec. Cond.g4 �P�: rV at 25°C Location or Site: 124 Tall Oak Drive, Mooresville
Temp.lMt o 7r c °C Odor t C ;�, Description of sampling point: Influents t uk' 4 Lr -
et o Pump Sample Interval
(Puma bailer. etc.)
Collector(s): Maria Schutte
FIELD ANALYSES
Date: 05/04/2011 Time
(circle one)
Appearance C.,(/'r �- �(��(R� Sampling Method: d ,P b ter t t S I l t I
Field Analysis By: Maria Schutte Remarks
LABORATORY ANALYSES
BOD 310 mg/L
COD High 340 mg/L
COD Low 335 mg/L
Coliform: MF Fecal 31616 /100m1
Coliform: MF Total 31504 /100m1
TOC 680 mg/L
Turbidity 76 NTU
Residue, Total Suspended 530 mg/L
Diss. Solids 70300
mg/L
Fluoride 951
mg/L
Hardness: Total 900 mg/L
Hardness (non-carb) 902 mg/L
Phenols 32730 ug/I
Specific Cond. 95 pMhos/cm
Sulfate 945 mg/L
Sulfide 745 mg/L
Oil and Grease mg/L
pH 403 units
Alkalinity to pH 4.5 410 mg/L
Alkalinity to pH 8.3 415 mg/L
Carbonate 445 mg/L
Bicarbonate 440 mg/L
Carbon dioxide 405 mg/L
NH3 as N 610 mg/L
TKN as N 625 mg/L
NO2 + NO3 as N 630 mg/L
Chloride 940 mg/L
P: Total as P 665 mg/L
Chromium: Hex 1032 ug/L
Nitrate (NO3as N) 620 mg/L
Color: True 80 CU
Cyanide 720 mg/L
Nitrite (NO2 as N) 615 mg/L
(Pumping 'me, air temp., etc.)
Ag-Silver 46566
ug/L
X
AI -Aluminum 46557
ug/L
X
As -Arsenic 46551
ug/L
X
Ba-Barium 46558
ug/L
X
Ca -Calcium 46552
mg/L
X
Cd-Cadmium 46559
ug/L
X
Cr-Chromium 46559
ug/L
X
Cu-Copper 46562
ug/L
X
Fe -Iron 46563
ug/L
Hg-Mercury 71900
ug/L
X
K-Potassium 46555
mg/L
X
Mg -Magnesium 46554
mg/L
X
Mn-Manganese 46565
ug/L
X
Na-Sodium 46556
mg/L
X
Ni-Nickel
ug/L
X
Pb-Lead 46564
ug/L
X
Se -Selenium
ug/L
X
Zn-Zinc 46567
ug/L
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCBs
Semivolatile Organics
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
LAB USE ONLY
Temperature on arrival (°C): �.
Lab Comments
GW-54 REV. 7/03
For Dissolved Analysis -submit filtered sample and write "DIS" in block.

• q
'NC TE 42O Laboratory Section 1?esufts
County:
River Basin
Report To
Collector:
Region:
Sample Matrix:
Loc. Type:
Emergency Yes/No
COC Yes/No
IREDELL
MROAP
z.
M SCHUT 'E;
MRO
GROUNDWATER
WATER SUPPLY
{ AV
rt
A7 9
Qatl
2 LI 9_011
VisitID
Loc. Descr.: ANNE HOLDEN 124 TALL OAK DRIVE
Sample ID: AB71031
PO Number# 11G0355
Date Received: 05/05/2011
Time Received: 08:30
Labworks LoginlD HMORGAN
Report Generated: 5/20/11
Date Reported: 05/20/2011
-340 5-da.
Location ID: W10300051-OUT
Collect Date: 05/04/2011
Collect Time: 15:00
Sample Depth
CAS # Analyte Name
LAB
Sample temperature at receipt by lab
PQL
Result/
Qualifier
Units
0.9 °C
Method Analysis Validated by
Reference Date
5/5/11 DLEAVITT
MIC
Coliform, MF Fecal in liquid 1 1 Q1 CFU/100m1 APHA9222D-20th 5/5/11 CGREEN
Coliform, MF Total in liquid
1
1 B2Q1 CFU/100m1 APHA9222B-20th 5/5/11 MOVERMAN
WET
Ion Chromatography TITLE_ mg/L EPA 300.0 5/17/11 CGREEN
Chloride
1 1.7
mg/L EPA 300.0 5/17/11 CGREEN
Fluoride 0.4 0.4 U mg/L EPA 300.0 5/17/11 CGREEN
Sulfate
2 7.9 mg/L EPA 300.0 5/17/11 CGREEN
Total Dissolved Solids in liquid 12 122 mg/L APHA2540C-18TH 5/5/11 MOVERMAN
NUT
NO2+NO3 as N in liquid
0.02 0.53 mg/L as N Lac10-107-04-1-c 5/6/11 CGREEN
MET
7429-90-5 Al by ICP 50 50 U ug/L EPA 200.7 5/6/11 ESTAFFORD1
7440-38-2 As by ICPMS 2 2.0 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
10 95 ug/L EPA 200.7 5/9/11 ESTAFFORD1
7440-38-3 Ba by ICP
7440-70-2 Ca by ICP
7440-43-9 Cd by ICPMS 1 1.0 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
7440-47-3 Cr by ICPMS 10 10 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
7440-50-8 Cu by ICPMS 2 440 ug/L EPA 200.8 5/9/11 ESTAFFORD1
7439-89-6 Fe by ICP 50 50 U ug/L EPA 200.7 5/6/11 ESTAFFORD1
7440-09-7 K by ICP 0.1 2.1 mg/L EPA 200.7 5/9/11 ESTAFFORD1
7439-95-4 Mg by ICP 0.1 4.4 mg/L EPA 200.7 5/9/11 ESTAFFORD1
10 10 U ug/L EPA 200.7 5/6/11 ESTAFFORD1
0.1 19 mg/L EPA 200.7 5/9/11 ESTAFFORD1
7439-96-5 Mn by ICP
7440-23-5 Na by ICP
0.1 9.4 mg/L EPA 200.7 5/9/11 ESTAFFORD1
7440-02-0 Ni by ICPMS 2
7439-92-1 Pb by ICPMS 2 2.0 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
7782-49-2 Se by ICPMS 5 5.0 U ug/L EPA 200.8 5/9/11 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 71 ug/L EPA 200.8 5/9/11 ESTAFFORD1
12 ug/L EPA 200.8 5/9/11 ESTAFFORD1
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
For a detailed description of the qualifier codes refer to http://noital.ncdenr.ora/web/woflab/sfaffinfoltechassist#Data Qualifier Codes <httpl/portal.ncdenr.orcifweb/v:q/lab/staffinfo/techassist>
Pape 1 of 1

GROUNDWATER FIELD/LAB FORM
Location code WI0300051-Out
CountyIredell
Quad No Serial No.
Lat. Long.
Report To: ARO, FRO,RRO, WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other:
Shipped by: Bus, ' ouri- , Hand Del., Other:
Collector(s): Maria Schutte
FIELD ANALYSES
pH 400 rC-74 Spec. Cond.94
Temp.io °C Odor L/r]
Appearance (' Qs8 {— `.- (FA C ''
Field Analysis By: Maria Schutte
SAMPLE TYPE
❑ Water
❑ Soil
❑ Other
❑ Chain of Custody
SAMPLE PRIORITY
❑ Routine
❑ Emergency
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Purpose: -UIC System Inspection
Date: 05/04/2011 Time r5.'4,0 Baseline, Complaint, Compliance, LUST, Pesticide Study, Federal Trust, Other:
Owner: Anne Holden (circle one)
r , / at 25°C Location or Site: 124 Tall Oak Drive, Mooresville
Description of sampling point: Efffluent lWSampling Method: Method: Pump Sample Interval
(Puma bailer. etc.)
I I(- ()35 At+031
Lab Number
Date Received 5 ' 5 ' I I
Rec'd By:
Other:
Data Entry By:
Date Reported:
Time: o`630
From:Bus,
urie)Hand Del.,
C k:
Remarks
(Pumping time, air temp., etc.)
Li -MD
Vr\P\ 1 VI\ 1 Pl1 Vi-,- 1 v1...v
BOD 310
mg/L
X
Diss. Solids 70300
mg/L
Ag-Silver 46566
uglL
COD High 340
mglL
Fluoride 951
mg/L
X
AI -Aluminum 46557
ug/L
COD Low 335
mg/L
X
Hardness: Total 900
mg/L
)(
As -Arsenic 46551
ug/L
X
Coliform: MF Fecal 31616
/100m1
Hardness (non-carb) 902
mg/L
x
Ba-Barium 46558
ug/L
X
Coliform: MF Total 31504
/100m1
Phenols 32730
ug/I
X
Ca -Calcium 46552
mg/L
TOC 680
mg/L
Specific Cond. 95
pMhoslcm
x
Cd-Cadmium 46559
ug/L
Turbidity 76
NTU
X
Sulfate 945
mg/L
X
Cr-Chromium 46559
ug/L
Residue, Total Suspended 530
mg/L
Sulfide 745
mg/L
X
Cu-Copper 46562
ug/L
X
Fe -Iron 46563
ug/L
Oil and Grease
mg/L
Hg-Mercury 71900
ug/L
pH 403
units
X
K-Potassium 46555
mg/L
X
Mg -Magnesium 46554
mg/L
Alkalinity to pH 4.5 410
mg/L
Alkalinity to pH 8.3 415
mg/L
X
Mn-Manganese 46565
ug/L
Carbonate 445
mg/L
NH3 as N 610
mg/L
X
Na-Sodium 46556
mg/L
Bicarbonate 440
mg/L
TKN as N 625
mg/L
X
Ni-Nickel
uglL
Carbon dioxide 405
mg/L
X
NO2 + NO3 as N 630
mg/L
X
Pb-Lead 46564
ug/L
X
Chloride 940
mg/L
P: Total as P 665
mg/L
X
Se -Selenium
ug/L
Chromium: Hex 1032
ug/L
Nitrate (NO3as N) 620
mg/L
X
Zn-Zinc 46567
ug/L
Color: True 80
CU
Nitrite (NO2 as N) 615
mg/L
Cyanide 720
mg/L
Lab Comments
Organochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCBs
Semivolatile Organics
TPH-Diesel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BTEX Gasoline Range
LAB USE ONLY
Temperature on arrival (°C):
GW-54 REV. 7/03 For Dissolved Analysis -submit filtered sample and write "DIS" in block.

L.
es.
D
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Anne Bolden
1.24 Tall Oak Dr.
Mooresville, NC 28117
Dear Ms. Holden:
Division of Water Quality
Coleen H. Sullins
Director
May 11, 2011
Y� reeman
cretary
MAY 1 8 2011
Re: Issuance of Injection Well Permit
Permit No. WI0300051.
Issued to Anne Holden
Iredell County
In accordance with your application received March 30, 2011,.I am forwarding Permit No. WI0300051
for the continued operation of a 5A7 geothermal underground injection control (UIC) well heat pump
system located at the above referenced address. This permit shall be effective from the date of issuance
until April 30, 2016, and shall be subject to the conditions and limitations stated therein.
Regional Office staff collected water samples from your geothermal well on May 4, 2011. Laboratory
analytical results will be sent to you once they are completed along with any explanation that may be
necessary. Also during the visit Regional Office Staff explained the need to repair the water supply
well pipe vent. Proper maintenance of the facility is required in Part IV.1 of the permit.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application to
renew the permit four 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].
cc: tkl citaw.Pttncr- :;Mooresv.tllf Regional:Office
Central Office File - WI0300051-L—'
Iredell County Environmental Health Dept.
Attachment(s):
Permit
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: 919-715-6048 \ Customer Service: 1-87 7-623 6748
Internet: www.ncwateraualitv.orq
An Equal Opportunity t Affirmative Action Employer
Best Regards,
27
John R. McCray
Environmental Specialist
One.,
NorthCarol1na
-Vrtv1V

•
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
Anne Hoiden
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 124 Tall Oak Dr, Mooresville, Iredell County, NC 28117, and will be operated in
accordance with the application received March 30, 2011, and in conformity with the specifications and
supporting data submitted, all of which are filed with the Department of Environment and Natural Resources
and are considered a part of this permit.
This permit is for operation 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 30, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
Permit issued this the 1 lth day of May, 2011.
3,(aH n.V
91
V\`
A, Coleen H. Sullins, Director
Division of Water Quality
u
By Authority of the Environmental Management Commission.
Permit #W10300051
UIC/5A7
ver. 03/2010
Page 1 of 5

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3 Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be sealed with a water -tight cap or well seal, as defined in G.S. 87-85(16).
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
PART II — OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
Permit #WI0300051
UIC/5A7
ver. 03/2010
Page 2 of 5

PART III — PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of, groundwater 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 IV — 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.
PART V - INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Depaitnient representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART VI — MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
Permit #W10300051
U I C/5A7
ver. 03/2010
Page 3 of 5

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 Permittee shall take such
immediate action as may be required by the Director.
PART VII — PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
PART VIII — CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(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.
Permit #W10300051
UIC/5A7
ver. 03/2010
Page 4 of 5

(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 VIII: (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
Permit #W10300051
UIC/5A7
ver. 03/2010
Page 5 of 5

•
To: Susie Caldwell
Fax:
Plieie-hervat,atyddl
f-.7yr ? Al. a Jr1 rti
I.
r
704-663-6040
From: Ron Holden (704-662-3530) Date: 6/24/2001
Re:
Injection well for geothermal heat Pages: 2
pump
CC: [Click here and type name]
x Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
• • • • ® o • •
l
Notes: Attached is the plumbing detail for the entire system using a second well as an injection (or /
: return) well. Can you possibly arrange to inspect the system including a new well early this week.
I must return to Ohio by this next weekend. (6/30/2001). We are not planning to return until
Oitolier and I what to test the system thoroughly prior to this time close,to thee heating season.
-
I'd S69E-299-f►0/. uaPloH '1 phenol dOE:60 TO irZ un'

NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
P.O BOX 29578, RALEIGH, NC 27626-0578 - 2728 CAPITAL BLVD., RALEIGH, NC, 27604
PHONE [phone] FAX [phone]
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED/10% POST -CONSUMER PAPER

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989.E-299-COL

NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
P.O BOX 29578, RALEIGH, NC 27626-0578 - 2728 CAPITAL BLVD., RALEIGH, NC, 27604
PHONE [phone] FAX [phone]
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED/1 O% POST -CONSUMER PAPER

Water Resources
ENVIRONMENTAL QUALITY
March 29, 2016
CERTIFIED MAIL # 7014 1200 0001 3432 6578
RETURN RECEIPT REQUESTED
Anne Holden
124 Tall Oak Dr.
Mooresville, NC 28117
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Director
PCMVED/NCD Atr /D{NIA
) 42016 •
M p Svc, i�o
G:r rlfll 1 t S
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0300051
Iredell County
Dear Ms. Holden:
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on May 11, 2011, and expires on April 30, 2016. Per permit conditions and requirements
per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120 calendar days
prior to expiration of the permit if you wish to continue operating the injection well on your
property.
If Your Geothermal Water Return Well is Still Currently Being Used for Injection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http ://portal. ncdenr.org/web/wq/aps/gwpro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Being Used for Injection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter. 2C, Section
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
State of North Carolina I Environmental Quality I Water Resources
1611 Mail service Center I Raleigh, North Carolina 27699-1611
919 707 9000

Page 2 of 2
If There has been a Change of Ownership of the Property:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email at shristi.shrestha(a,ncdenr.gov.
Regards,
C
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: l !,QczzesvirTIGNRegtonfl OVV/ ffice QR®_ S w/o enclos�utes
Central Files - Permito. WI0300051 w/o enclosures

North Carolina Division of Water Resources
Water Sample Collection & Submittal Form
Central Laboratory (Water Sciences Section)
Visit ID:
(optional)
Tag
ID
Lab Use
',,,,,Laboratory , `
Sample Number:
Only: '
Location Description: Ronald and Anne Holden, 124 Tall Oak Dr., Mooresville, NC
Location Code:"
WI0300051-INF
` Date Received:
County: Iredell
Collector:iE
Watson/ M. Schutte
Priority,
Water Matrix:
Location Type:
;,
Time Received:
�
❑
❑
❑
❑
Surface
Ground
Waste
Blank
Solution
❑
❑Estuary
❑Effluent
❑Field
❑Filter
River/Stream ❑ Lake
❑Canal
Stormwater
Monitoring Well Water Supply
❑Influent
Blank Trip
❑ Blank
Blank
Other: Efluent Port
DWR Region: 9 MRO
bosedoncounty)
{RecervedBy:
D,WR Officer
(or agency name,
MRO
❑Ambient
,
.
''
z
RiverBasln: Catawba
' Date
4/21/2016
❑
'i
Routine
Compliance
'(
Delivery Method:
UState Courier
Hand Delivery
Other:
Notes: UIC System inspection
Time:
❑ COC
Temperature (°C)
on Arrival:
❑ Chlorinated ❑ De -chlorinated in Field
Sampling_
•, Method:
4
Grab❑❑Composite
Other: Pump
❑ Emergency
Dissolved analysis: Enter"DIS"
❑ Filtered in Field
in check -boxes for parameters
Sample Depth: `
❑QA
ColiectorsComments Lat._35.566661 Long._80.919812 **Analyze Bacteria samples regardless of hold time.**
Microbiology Parameters:,. "-:_
MBAS (surfactants) mg/L
Metals Parameters: _' _; "
Tin (Sn) µg/L
Acidity, as CaCO3, to pH 4.5/8.3 mg/L
Oil and Grease, HEM, Total Recoverable mg/L
X
Aluminum (Al) pg/L
Titanium (Ti) µg/L
A
Alkalinity, as CaCO3, to pH 4.5/8.3 mg/L
Phenols, Total Recoverable pg/L
Antimony (Sb) µg/L
Vanadium (V) µg/L
BOD: Biochemical Oxygen Demand, 5-day mg/L
Residue: Total (Total Solids) mg/L
X
Arsenic (As) µg/L
X
Zinc (Zn) µg/L
cBOD: Carbonaceous BOD, 5-day mg/L
Residue: Volatile/Fixed, Total mg/L
X
Barium (Ba) pg/L
x
Coliform: Fecal MF /100m1
Residue: Suspended (Suspended Solids) mg/L
Beryllium (Be) µg/L
Boron (B), Total µg/L
x
Coliform: Total MF /100m1
Residue: Volatile/Fixed, Suspended mg/L
X
Cadmium (Cd) pg/L
Mercury 1631, low-level ng/L
Coliform: Tube Fecal /100m1
• X
TDS - Total Dissolved Solids mg/L
X
Calcium (Ca) mg/L
Coliform: Tube Total /100m1
Silica mg/L
X
Chromium (Cr), Total pg/L
= Organics,Parameters:'-='
Specific Conductance, at 25 °C umhos/cm
Sulfide mg/L
Cobalt (Co) • pg/L
Acid Herbicides
TOC - Total Organic Carbon mg/L
Tannin & Lignin mg/L
X
Copper (Cu) pg/L
Organochlorine Pesticides
Turbidity NTU
X
Iron (Fe) pg/L
Organonitrogen Pesticides
Other Parameters:`'"+
X
Lead (Pb) pg/L
Organophosphorus Pesticides
'`
Wet Cherr lstry Parameters: ^
pH s.u.
Lithium (Li) pg/L
PCBs (polychlorinated biphenyls)
Bromide mg/L
X
Hardness, Total as CaCO3 - by titration mg/L
X
Magnesium (Mg) mg/L
x
Chloride mg/L
X
Manganese (Mn) µg/L
Semi -Volatile Organics (BNAs)
x
Fluoride mg/L
Mercury (Hg) pg/L
TPH Diesel Range
x
Sulfate mg/L
Nutrients Parameters'
Molybdenum (Mo) µg/L
Chlorophyll a pg/L
Ammonia as N (NH3-N) mg/L
X
Nickel (Ni) pg/L
Volatile Organics (VOA)
Color: ADMI c.u.
X
Nitrate -Nitrite as N (NO3+NO2-N) mg/L
X
Potassium (K) mg/L
Color: Platinum Cobalt c.u.
Total Kjeldahl Nitrogen as N (TKN) mg/L
X
Selenium (Se) pg/L
TPH Gasoline Range
COD: Chemical Oxygen Demand mg/L
Total Phosphorus as P (TP) mg/L
X
Silver (Ag) pg/L
C
Cyanide, Total mg/L
X
Nitrite as N (NO2-N) mg/L
X
Sodium (Na) mg/L
°, Biological: '
Formaldehyde mg/L
X
Nitrate as N (NO3-N calculated) mg/L
Strontium (Sr) pg/L
Phytoplankton / Algae
Hexavalent Chromium (Cr6+) mg/L
Orthophosphate as P (PO4) mg/L
Thallium (TI) µg/L
LAB COMMENTS :
Field Parameters(optional):
Water Temp ("C):,
pH (s.u.
DissoIved.Oxygen (ppm): •
�E
ConductivityJ1Jmhos/cm):
Salinity (opt):
Not measured
Revision: 2/06/2015