WI0500134_GEOTHERMAL_20150602

Jr.A
North Carolina Department of Environment and _Natura! Resources
Pat McCrory
Governor
Paul and Betty Poole, Jr.
5520 Watkins-Road
Wendell, NC1]591
Subject: Permit Rescission
UIC Permit No. WI0500134
June 2, 2015
Geothermal Heating/Cooling Water Return Well
Wake County
Dear Mrs. and Mrs. Poole:
Donald R. van der Vaart
Secretary
Reference is made to your request for rescission of the subject Geothermal Heating/Cooling Water Return
Well Permit issued on September 16, 2010, located at the above referenced address. Staff from the
Raleigh Regional Office has agreed that a permit is no longer required. Therefore, in accordance with
your request, Underground fujection Control (UIC) Permit WI0500134 is rescinded, effective
immediately.
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.
If it would be helpful to discuss this matter further, please do not hesitate to call Michael Rogers
at [phone].
Attachment( s)
cc: Raleigh Regional Office -WQROS
Central Files -Permit No. WI0500134
Wake County Environmental Health Dept.
Sincerely,
I
{J)µ, J, vn,t,
.k(\...Jay Zimmerman, P.G., Director tv Division of Water Resources
1636 fV!ail Service Center, Raleigh, North Carolina 27699-1636
Phone: [phone] \ Internet: http ://www.ncwater.org
An Equal Opportunity I Affirmative Action Employer -Made in part by recycled paper
AFA
CDE R
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Paul and Betty Poole, Jr.
5520 Watkins Road
Wendell, NC 17591
Subject: Permit Rescission
UIC Permit No. Wl0500134
June 2, 2015
Geothermal Heating/Cooling Water Return Well
Wake County
Dear Mrs. and Mrs. Poole:
Donald R. van der Vaart
Secretary
Reference is made to your request for rescission of the subject Geothermal Heating/Cooling Water Return
Well Permit issued on September 16, 2010, located at the above referenced address. Staff from the
Raleigh Regional Office has agreed that a permit is no longer required. Therefore, in accordance with
your request, Underground Injection Control (UIC) Permit WI0500134 is rescinded, effective
immediately.
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.
If it would be helpful to discuss this matter further, please do not hesitate to call Michael Rogers
at [phone].
Attachment( s)
cc: Raleigh Regional Office -WQROS
Central Files -Permit No. WI0500134
Wake County Environmental Health Dept.
Sincerely,
I
Obu j, vJJt-
1(\..Jay Zimmerman, P.G., Director t· Division of Water Resources
1636 f\.1ail Service Center, Raleigh, North Carolina 27699-1636
Phone: [phone] \ Internet: http://www.ncwater.org
An Equal Opportunity I Affirmative Action Employer-Made in part by recycled paper
Rogers, Michael
From: Bolich, Rick
Sent:
To:
Monday, June 01, 2015 5:02 PM
Rogers, Michael
Cc:
Subject:
Smith, Danny; Robertson, Laura R.
RE: WI0500297 Rescission Request
Michael;
The RRO inspected this site and has no concerns with rescinding the subject permit.
rb
Rick Bolich, LG.
NCDENR DWR Water Quality Regional Operations Section Assistant Regional Office Supervisor
1628 Mail Service Center
3800 Barrett Drive
Raleigh, NC 27609
[phone]
rick.bolich @ncdenr.gov
Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed
to third parties unless the content is exempt by statute or other regulation.
-----Original Message-----
From: Roge.rs, Michael
Sent: Wednesday, May 27, 2015 2:19 PM
To: Srnith, Danny; Bolich, Rick
Subject: FW: WI0500297 Rescission Request
Please find attached a permit rescission request. Mr. Poole indicates he converted the open-loop to closed-loop system
shortly after the permit was issued. I am not sure if he used the open-loop well to insert the loops or not. Please let me
know if it is OK to rescind. You can conduct a site inspection prior to recommending rescission if you wish. Let me
know. Thanks.
----Original Message-----
From: Michael Rogers [mailto:michael.rogers @ncdenr.gov]
Sent: Wednesday, May 27, 2015 1:13 PM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 05.27.2015 13:12:52 (-0400)
Queries to: robin.markham @ncdenr.gov
1
Ro gers, Michael
From:
Sent:
Robertson,· Laura R. <[e-mail]>
Monday, June 01, 2015 4:37 PM
To: Rogers, Michael
Cc: Bolich, Rick
Subject: RE: WI0500297 Rescission Request
Hi Michael,
I visited Paul Poole's property at 5520 Watkins Road in Wendell on 5/29/15. Mr. Poole currently operates one water
supply well at the site for his drinking water. The WSW is placed correctly on the Wake County iMAPS. He also operates
a separate closed-loop well system with 3 wells.
In 2005, Mr. Poole had one permitted open-loop well that cycled from the well into the house, then into the pond.
In 2010, he had the one open-loop well converted to a closed-loop well and then drilled two additional closed-loops
wells to add to the system. The permit was applied for and received. He currently has 4800 feet of piping in the closed
loop system. The wells are all below grade in his yard to the south of the house, and the system is accessible in his
basement. Everything appears to be very well maintained.
I will be happy to supply my maps and notes if you would prefer.
Thank you,
Laura
Laura R. Robertson
Hydrogeologist
Raleigh Regional Office
Water Quality Regional Operations Section Division of Water Resources
919.791.4247
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties by an authorized state official.
-----Original Message-----
From: Bolich, Rick
Sent: Thursday, May 28, 2015 9:18 AM
To: Rogers, Michael; Robertson, Laura R.
Cc: Smith, Danny
Subject: FW: WI0500297 Rescission Request
Hi Michael;
RRO would like to conduct a short site visit to confirm the conversion of this system to closed loop. We will try to
conduct this site visit ASAP and get back to you with a staff report on our findings.
Laura -could you please contact the permitee and make arrangements to do a quick inspection to verify this? I can go
with you if you'd like.
1
Thanks!
rb
-----Original Message-----
From: Rogers, Michael
Sent: Wednesday, May 27, 2015 2:19 PM
To: Smith, Danny; Bolich, Rick
Subject: FW: WI0500297 Rescission Request
Please find attached a permit rescission request. Mr. Poole indicates he converted the open-loop to closed-loop system
shortly after the permit was issued. I am not sure if he used the open-loop well to insert the loops or not. Please let me
know if it is OK to rescind. You can conduct a site inspection prior to recommending rescission if you wish. Let me
know. Thanks.
-----Original Message-----
From: Michael Rogers [mailto:michael.rogers @ncdenr.g ov]
Sent: Wednesday, May 27, 2015 1:13 PM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 05.27.2015 13:12:52 (-0400)
Queries to: robin.markham @ncdenr.gov
2
Ro gers, Michael
From:
Sent:
To:
Subject:
Mr. Poole-
Rogers, Michael
Friday, May 22 , 2015 9:40 AM
'[e-mail]' .
WI0500134 Geothermal Permit
We received the rescission request for the open-loop geothermal well permit issued in 2010. Thank you.
We just need to know what is the status of the wells that were drilled for the open-loop geotherma I permit-were the
wells/boring drilled for the open-loop geothermal system used for the closed-loop system, left open, plugged and
abandoned? Please let me know and we will close out this permit in our system.
Thanks
Michael Rogers, P.G. (NC & FL)
Hyd rogeologist
NCDENR-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
1
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 Pa2.es 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications ~Returned As Incomplete.
' ,3y~
DATE: ________ ,20__ PERMIT NO. iJj';{}fO~Oeave 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
Supply
Geothermal Well __ Drinking Water Supply Other Water
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the pennit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30 ~
~ es, I wish to rescind the permit
2. Current Own ership Status
Has there been a change of ownership since permit last issued? D YES ~O
If yes, indicate new owner's contact information:
Name(s) ----------------------------------
Mailing Address: ______ _
City: __________ State: __ Zip Code: _ _____ County: _____ _
Day Tele No.: Email Address.:
B. STATUS OF APPLICA"NT (choose one)
Non-Government: Individual Residence ✓ Business/Organization __
Government: State Municipal __ County_~ Federal
C. WELL OWNER(S)/PERMIT APPLICAN -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:---------------------------------
City: __ State: __ Zip Code: _______ County· _____ _
Day Tele No.: _________ Cell No.:
EMAIL Address: ______ -----------=-F=axc..c...a..N-'--'o'"'".:~ _____________ _
Geothermal Water Return Well Permit Application (Rev ised 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.: Cell No.: Fax No.: ________ _
G. HV AC CONTRACTOR INFORl\'.'A TION (if different than driller)
H.
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.: _______ _
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
I. WEl:..L CONSTRUCTION REQUIREMENTS -As specified in 15A NCAC 02C .0224(d):
(1)
(2)
The water supply well shall be constructed in accordance with the water supply weH requitements of
ISA NCAC 02C .0107.
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
(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 specifo;ations:
. (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(/)(fil
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATINGDATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average ( daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP -As specified in 15A NCAC 02C .0224 b 4 , attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0 I 07 1 a }(2 ) located within 250
feet of the proposed injection well(s).
(3) Prope1iy 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 (Rcvi~cd Jan 20 i 5) Page3
------.
N07'E. Inmost cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county CIS website Typically, the property ran 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 42C .02111e) 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 allothers: by all thepppgTj(sj listed on the prooerty 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
Property Owner/Applicant
v �
Print or Ty - Ful l Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division; of Wafter Resources
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application (Revised ]an 2015) Page 4

.... . .
NORTI-1 CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM
TYPE SO W WELL(S )
In Accordance With the Provisions ofNCAC Title 15A 02C.0200
Print or type the required information and mail lo address on the back page.
DATE: Se:P T" I 3 , 20...1...£
Well Type Confumation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
cJosed-loop)?
Yes ~ontinue completing this form.
No ___ Do Not complete this form. Complete other UIC application forms for installing
either a SA 7 well (open-loop well injecting potable water into the aquifer) or a 5QM well ( closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corro.sion inhibitors).
A. PROPERTY OWN.ER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): 'P4 Uh I P a D L-i!!= ~
(I) Mailing Address: , 25 2.... o ld # T l<-Int s: /?_Or
(2)
City: WC/If Oe:LL State:~ Zip Code: ;2 7.f?9 I County: W"'4 J< c
~e/Oflice Tele No.: 'k l 1 2 6 k I 3 t. 7 Cell No.: 2 / ~ 8 /D ;2 ,;?-I '1
Email Address: erPot!'J L.~ Website:
l-l~TH'ZJiJ'--CA>~
Physical Address of Well Site (if different than above): ______________ _
City: _________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: ____________ C=e=U::.cN=-=o·==-----------
B. AUTHORIZED AGENT OF OWNE~ IF ANY (if the Pennit Applicant does not own the subject property,
attach a Jetter from the property owner authorizing Agent to install and operate UlC well)
Company Name: _____________________________ _
Contact Person-: -------------~E=MA~=IL~A=ddress=~= __________ _
Address: _______________________________ _
City: _________ State: __ ZipCode: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any:. ______________ _
GPU/UIC SQW Notificalion oflntent Form (Revised 8fl008) Page 1
C. WELL DRILLER INFORMATION �)
Company Name: Xj+w Poo e a°',4'. ea
well D iller Contractor's Name:
NC Contractor Certification No.:
Contact Person: EMAIL Address: Y
Address: 0/ �' /97 -
City: 4/ Zip Code: zr county: _ w,-)-4
OfccTele No.:
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: r ? %� T =� _ �%'�Ia k—
Contact Person: EMAIL Address:
Address: 49 r ,/� � G R 2 ,_
City: }tl T17A34g Zip Code: L7_C�tr County. :.•�
❑ffice Tele No-: I ?��1'-- Cell No-:
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State_ Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONS9MUCTION DATA
(])Proposed date to he constructed: d G 7� _ __Number of borings:
Approximate depth of each boring (feet)_
(2) Type of tubing to be used (copper, PVC, etc)-
(3) Well casing. is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: _ _f gaIvanized steel black steel plastic other (specify)
Casing depth: From 7 ['J ?�—to 3 d feet (reference to Iand surface)
Casing extends to above ground _ _inches
(b) No
(4) Grout Info (material surrounding well rasing and/or piping): f
(a) Grout type: Neat Cement Bentonito Other (specify)�-
(b) Grout placement: Puznpirsgl Pressure Other
(c) Grout depth of tubing (reference to land surface): from _ to _gip (feet)
If well has casing, indicate grout depth: from -- — - to Y (feet)
CPU/UIC 5QW NatTtcation orintmt Form (Revised 812008) Page 2

Phone: BW777-7637
MECHANICAL EQUIPMENT SALES, INC.
5025 Euclid Road
Virginia Beach, VA 23452
FAX: [phone]
H. /A] r r v.V .- lZZ5 4,0 r� 0 t �Ll- I P&I 6�417'
DATE: OCTOBER 1, 2010
MGM I�ZiIi]�I0
FROM: ED FLITCH, CERTIFIED IGSHPA TRAINER AND INSTALLER
SUBJ: DESCRIPTION OF RECOMMENDED CLOSED LOOP SYSTEM DESIGN
The following is recommended for your closed loop system for the 2 ton and 5 ton geothermal
units in your house:
Three minimum 6 inch diameter vertical bore holes, each 375 feet deep, 20 feet apart and
each bore hole having two HDPE one inch pipe vertical loops for a total of six 1 inch vertical
loops in the three boreholes to maximize thermal transfer and minimize borehole depth. Each
loop should be a minimum of 385 feet one way or 770 feet total so as to provide 10 foot pigtails
for parallel flow hook up to the supply and return pipe header_ Each header (supply and return to
the house should have 5 tees as follows from start to end: one 1-114 X 1 X 1, two 1-1I4 X 1-114
X 1, one 1-112 x 1- 1/4 reducer and two 1-1 f2 X 1-112 X 1. Six inch pieces of pipe should be
between the tees. The supply and return should be 1-112 inch pipe minimum up to 100 feet in
length and 2 inch if longer. A purge station should be built outside with a meter box cover so as
to provide access for charging the system with water and purging out the air. Purging station
consists of two sets of ball valves, (one for supply and one for return) each set having three 1-1I2
inch ball valves, one 1-1/2 inch Tee and three 1-1I2 x 3 inch ripples, all brass.
Piping in the house should continue with HDPE piping and be insulated to prevent
condensate formation. Heat pumps must be piped in parallel and the pump station should be two
UPS26-116F Grundfos pumps piped in series with a six inch nipple between there if put
together. Elbows on piping should be kept to an absolute minimum.
ALL PIPING MUST BE HIGH DENSITY POLYETHYLENE (JIDPE) WITH A
MINIMUM CELL CLASSIFICATION OF PE355434C ORPE345434C WHEN TESTED
UNDER ASTM3350 AND ALL FIl'"T1NGS UNDERGROUND FUSED WITH THE
EXCEPTION OF THE PURGE STATION. ALL THREADED JOINTS MUST HAVE
REFRIGERATION GRADE JOINT SEALER (COMMONLY KNOWN AS LEAKLOCK) OR
EQUIVALENT. NO EXCEPTIONS!
Ed Futch

1L INJECTION -RELATED EQUH%0,7+IT
Attach a diagram showing the engineering layout or proposed modification of €#he injection equipment and exterior
piping/tubing associated with the injection operation. The nmufacturer's brochure may provide supplementary
information.
L LOCATfON OF WELLS)
Attach two copes of maps showing the following information:
(i) 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 200 feet of
the -geothermal heat pump well system. Label all leatures clearly and include a north arrow.
(2) The Site Map must show the subject property in rciation to the si mminding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"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 agm to constrict, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conAtions of the Permit-"
& r-' -1 -,_AaM
Signature of Property Owner/Apphc16t
Print or Type Full Name and title
Signature of Property OwnerlApplicaut
Print or Type Full Name and title
Signature of Authorized Agent; if any
Print or Type Full Name and title,
Please return two copies of the completed Applicatian package, to.
North Carolina DENR-DWQ
Aquifer Protections Seetion-UIC Program
1636 Mail Service Center
Raleigh, NC 276"-1636
Telephone [phone]
GPUfUIC 5QW Notification oflntmd Fenn (Revised WON) Page 3

AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
May 4, 2015
CERTIFIED MAIL# 70141200 000134328480
RETURN RECEIPT REQUESTED
Paul and Betty Poole
5520 Watkins Road
Wendell, NC 27591
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0500134
Wake County
Dear Mr. and Mrs. Poole:
Donald R. van der Vaart
Secretary
RECEIVED!DENR!DWR
MAY 21 2015
Water Quality Regional
Operations Section
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 September 16, 2010, and expires on August 30, 2015. 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 injectio'n well
on your property. According to our records, the permit renewal application is now past due.
Please submit your renewal application (attached) as soon as possible if you wish to continue using
the well for injection.
If Your Geothermal Water Return Well is Still Currentlv Being Used for In jection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title ISA, 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 Bein g 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
1636 Mail Service Center, Raleigh , North Carolina 27699-1636
Phone: [phone]\ Internet: http://www .ncwater.org
An Equal Opportunity\ Affirmative Actio n Emp loyer -Made in part by recycled paper
Paul and Betty Poole Page2
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
If There has been a Change of Ownershi p of the Pro pe rtv :
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 (919)
807-6406 or by email at Michael.Ro gers(a),ncdenr.gov.
Regards,
~,P.~
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Raleigh Regional Office -WQROS w/o enclosures
Central Files -Permit No. WI0500134 w/o enclosures
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
May 4, 2015
CERTIFIED MAIL# 7014 1200 00013432 8480
RETURN RECEIPT REQUESTED
Paul and Betty Poole
5520 Watkins Road
Wendell, NC 27591
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No; Wl0500134
Wake County
Dear Mr. and Mrs. Poole:
Donald R. van der Vaart
Secretary
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 September 16, 2010, and expires on August 30, 2015. 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 injectio'n well
on your property. According to our records, the permit renewal application is now past due.
Please submit your renewal application (attached) as soon as possible if you wish to continue using
the well for injection.
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 J>arj: 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 requiryments listed under NCAC Title 15A, Subchapter 2C, Section
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Phone: [phone]\ Internet: http://www.ncwater.org
ft.n Equal Opportunity I Affirmative Action Employer -Made in part by recycled paper
Paul and Betty Poole Page2
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
If There has been a Change of Ownership of the Property:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for your
cooperation and timely response. If you have any questions, please contact me by phone at (919)
807-6406 or by email at Michael.Ro gers (a),ncdenr.gov.
Regards,
~,P.~
Hydro geologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Raleigh Regional Office -WQROS w/o enclosures
Central Files -Permit-No. WI0500134.w/o enclosures
Permit Number WI0500134
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Paul and Betty Poole SFR 5A7
Location Address
5520 Watkins Rd
Wendell NC 275919235
Owner
Owner Name
Paul
Dates/Events
Orig Issue
10/25/05
T Poole
App Received Draft Initiated
06/02/10 09/15/10
Scheduled
Issuance
Central Files: APS_ SWP_
09/23/10
Permit Tracking Slip
Status
Active
Project Type
Renewal
Version
2.00
Permit Classification
Individual
Permit Contact Affiliation
Kevin Letchworth
Driller Well
PO Box 1958
Wendell
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Paul T. Poole Jr.
5520 Watkins Rd
Wendell
NC
NC
Public Notice Issue
09/16/10
Effective
09/16/10
27591
27591
Expiration
_R_e_g_u_la_t_e_d _A_c_t _iv_it_ie_s _______________ ~R~e~q=u=e=st=e~d=/R~ec~e=i~v=ed~E=v~e~n=ts~----------
Heat Pump Injection RO staff report requested
RO staff report received
Outfall NULL
Waterbody Name Stream Index Number Current Class
07/02/10
08/16/10
Subbasin
Permit Number WI0500134
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Paul and Betty Poole SFR 5A7
Location Address
5516 Watkins Rd
Wendell
wner
Owner Name
Paul
Dat es/E ve nts
NC
T
275919235
Poole
Scheduled
Orig Issue App Received . Draft Initiated Issuance
10/25/05 06/02/10 09/15/10
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files : APS_ SWP_
09/16/10
Permit Tracking Slip
Status
In draft
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Kevin Letchworth
Driller Well
PO Box 1958
Wendell
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Paul T. Poole Jr.
5520 Watkins Rd
Wendell
NC
NC
Public Notice Issue Effective
Requested/Received Eve ts
RO staff report requested
RO staff report rece ived
27591
27591
Expiration
07/02/10
08/16/10
Waterbody Name Stream Index Number Current Class Subbasin
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Paul and Bettye Poole
5520 Watkins Road
Wendelt, NC 27591
Dear Mr. and Ms. Poole:
Division cf water Quality
Coleen H. Sullins
Director
September 16, 2010
Dee Freeman
Secretary
Re: Issuance of Injection Well Permit
Permit No. WIOSOO134
Issued to Paul and Betty Poole
Wake Country
In accordance with your application received Jmie 2, 2014,1 am forwarding Permit No. WT0500134 for
the operation of a 5A7 geothennal 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 August 30.
2015, and shall be subject to the conditions and limitations stated therein.
Also attached is a summary of the laboratory sampling results from water samples collected from your
geothermal well on July 9 and 13, 2010. Laboratory analytical results of both the influent and effluent
samples indicate exceedances in the Groundwater Standard maximum contamination level (MCL) for the
following parameter(s):
Parameter
Units
MCL
Results
Flouride
mglL
No standard
2.6 (influent)
2.5 (effluent)
Magnesium
mg/L
No standard
11 (influent)
(detect)
I effluent
Sodium
mglL
No standard
24 (influent)
(detect)
24 (effluent)
The source or cause of these exceedances is unknown. It is recommended before using water from this well for
personal consumption that you consult with the Wake County Environmental Health Department.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raeegh. North Comma 27692-1636
Location: 2728 Capital Boulevard, Raleigh, North Camlba 27604
Phone' 919.733-32211 FAX 1: 919-715-028; FAX 2; 919-715-84481 CIxomer 5enice:1-877-62M748
Internet www.newatemV_aJ0.oM
4 Equal Qpport pity 1 Afrinna6ve Acion Emuloyei
onit NhCarolina
Adually

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: Jay Zimmennan -Raleigh Regional Office
Central Office File -WI0500134
Wake County Environmental Health Dept.
Attachment(s):
Permit
Sample Results
Best Regards,
A/ _a -
, -;K-K d{!;r
L John R. McCray
Environmental Specialist
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
Paul and Beth Poole
FOR THE OPERATION OF I TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(c)(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 5520 Watldns Road, Weddell, Wake Comity, NC 27591, and will be constructed and
operated in accordance with the application received June 2, 2010, and in conformity with the specifications and
supporting; data submitted, all of which are filed with the Department of Environment and Natural Resources
and are considered a part of this permit.
This permit is for operation of an injection well shall he 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 per shall be effective, unless revoked, from the date of its issuance until August 30, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
Permit issued this the y day of , 2010.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
W10500134

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 geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section -UIC Staff
1636 Mail s ·ervice Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
[phone]
GW-ls must be submitted within 30 days of completion of well construction. Copies of the GW-1
form(s) shall be retained on-site and available for inspection.
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.
WI0500134 2
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
PART III -PERFORMANCE 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 well heads shall be repaired and brought to the proper height of at least twelve inches above
land surface or a request to rescind the permit should be submitted if the system is converted to a surface
discharge system and the wells are no longer needed within 90 days of the issuance date of this permit.
2. The injection facility shall be properly maintained and operated at all times.
3. The Perrnittee 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.
WI0500134 3
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Raleigh Regional Office, telephone 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 RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension. . .
PART VIII -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
WI0500134 4
(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.
Cf) 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 Pennittee shall submit a Well Abandonment Record (Form GW-30) as specified in
ISA 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:
WI0500134
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
MEMORANDUM 16-Sep-lO
To: Paul and Betty Poole
From: John McCray [phone]
Re: Groundwater Sampling Results from July 9, 2010
Influent Water Sam l!le Effluent Water Same le
Parameter Standards Results Standards Results
Groundwater Drinking Groundwater Drinking
Coliform, total 1 per 100ml zero <1 . Coliform, total 1 per 100ml zero <1
Coliform, fecal 1 per 100ml zero <1 Coliform, fecal 1 per 100ml zero <1
pH 6.5 -8.5 7.0-8.S 7 pH 6.5-8.5 7.0-8.5 7
Hardness no standard no standard Hardness no standard no standard
Chloride, Cl 250 mg/L no standard 3.5 mg/L Chloride, Cl 250 mg/L no standard 2.3 mg/L
Flouride, F 2 mg/L 4 mg/L 2.6 mg/L Floride, F 2 mg/L 4 mg/L 2.5 mg/L
Sulfate, SO4 250 mg/L no standard 4.9 mg/L Sulfate, SO4 250 mg/L no standard 5 mg/L
Dissolved Solids 500 mg/L no standard 186 mg/L Dissolved Solids 500 mg/L no standard 190 mg/L
No2• + Nol· as N detect 10 mg/L ND mg/L NO2" + NOJ. as N detect 10 mg/L ND mg/L
Aluminum, Al detect no .standard ND ug/L Alwninum, Al detect no standard ND ug/L
Calcium,Ca detect no standard 30 mg/L Calcium,Ca detect no standard 30 mg/L
Cadmium,Cd 1.75 ug/L 5 ug/L ND mg/L Cadmium, Cd 1.75 ug/L 5 ug/L ND mg/L
· Chromium, Cr 10 ug/L 100 mg/L ND ug/L Chromium, Cr 10 ug/L 100 mg/L ND ug/L
Iron,Fe 300 ug/L no standard ND ug/L Iron, Fe 300 ug/L no standard ND ug/L
Magnesium, Mg detect no standard 11 mg/L Magnesium, Mg detect no standard 11 mg/L
Manganese, Mn 50 ug/L no standard ND ug/L Manganese, Mn 50 ug/L no standard ND ug/L
Sodiwn, Na detect no standard 24 mg/L Sodium, Na detect no standard 24 mg/L
Nickel,Ni 100 ug/L no standard ND ug/L Nickel, Ni 100 ug/L no standard ND ug/L
Lead,Pb 15 ug/L 15 ug/L ND ug/L Lead,Pb 15 ug/L 15 ug/L ND ug/L
Zinc, Zn 1 mg/L no standard 0.09 mg/L Zinc,Zn 1 mg/L no standard 0.1 mg/L
J
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 08-11-2010
To: Aquifer Protection Section Central Office
Central Office Reviewer: John McCrav .
Regional Login No: __ _
I .. GENERAL INFORMATION
1. This application is (check all that apply}: D New ~ Renewal
County: Wake
Permittee: Paul Poole
Project Name: SA 7 Geothermal Well
Application No.: WI 0500134
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals D Attachment B included D 503 regulated D 503 exempt
D Distribution of Residuals D Surface Disposal
D Closed-loop Groundwater Remediation ~ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IZ! Yes or D No.
a. Date of site visit: 07-09-2010
b. Person contacted and contact information: Paul Poole, 919-266-1369
c. Site visit conducted by: Lin McCartney
d. Inspection Report Attached: IZ! Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
)>
c:: en
"""' 0,
I'.)
c::> -=
IZ! Yes or D No . If no, please complete the following or indicate that it is correct on the current application .
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude: __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Disposal and Injection Sites:
(If multi ple sites either indicate which sites the information a pp lies to . copy and paste a new section into the
document for each site . or attach additional pa ges for each site )
a. Location(s): 5520 Watkins Road. Wendell , NC 27591
b. Driving Directions: Take 1-440 E/US-lN. Merge onto US-401 N via EXIT 11 toward wake forest fro 7.3
miles . tum ri ght onto Mitchell Mill Rd .• tum ri 2ht onto Watkins rd.
c. USGS Quadrangle Map name and number: __
d. Latitude: 35-50-56 Longitude: 78-28-9.4
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section)
Description Of Waste(S ) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
FORM: Staff.Report-Poole
f5
s; :.:0
ii~ :t? m 't:J-~E§
,;:t c
s>m :::I .
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enc,
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,:,c
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AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use inj ection
wells , including closed-loop groundwater remediation effluent injection .wells, in situ remediation injection wells, and heat
pump injection wells.)
Descri ption Of We ll(S) And Facilities -New , Renewal , And Modification
1. Type of injection system:
1:8] Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
D Other (Specify: )
2 . Does system use same well for water source and injection? D Yes 1:8] No
3. Are there any potential pollution sources that may affect injection? D Yes cgj No
What is/are the pollution source( s )? __ ....:,• _Wh"'-'--='=a~t =is:....;:t=h-=-e ,;d=is=ta=n=c=e---=o=f----"th=e=--=in"-'-je=c"-"t=io=n,__w"""e=l=l (-=s.,__) =fr=o-=m.c..t=h=e__.pc..=o=ll=u=ti=o=n
source (s)? ft.
4 . What is the -minimum distance of proposed injection wells from the property boundary? 30 ft.
5. Quality of drainage at site: cgj Good D Adequate D Poor
6. Flooding potential of site: C8J Low D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No . Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? 1:8] Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
In jection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat'pump or injection well operation (e .g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes D No. If yes, exp lain:
2 . For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If y es. explain:
3 . For renewal or modification of groundwater remediation permits (of any type ). will
continued/additional/modified in jections have an adverse impact on mi gration of the plume or management of
the contamination incident? D Yes O -No. If yes , explain:
4 . Drilling contractor: Name: Letco, Poole Well& Pump Co.
FORM : Staff.Report-Poole 4
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address: 5801 Farm Well Rd.
Ralei gh . NC 27610
Certification number:
5. Complete and attach Well Construction Data Sheet
FORM: Staff.Report-Poole 5
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet -if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? D Yes r8J No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7 . Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information; r8J
Issue; D Deny. If deny, please state reasons: __
8. Signatureofreportpreparer(s): d'~
Signature of APS regional supervisor: = = __,,
Date: :fy-/Z-/ {)
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
The result of the gr ound water sam ples met the North Carolina Ground Water Standards.
FORM: Staff.Report-Poole 6
Compliance Inspection Report
Permit: WI0500134
SOC:
County: Wake
Region: Raleigh
Effective: 10/25/05 Expiration: 10/31 /10
Effective: Expiration:
Contact Person: Paul T Poole
Directions to Facility:
Title:
System Classifications:
Primary ORC: Certification:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Owner: Paul T Poole
Facility: Poole, Paul -SFR
5516 Watkins Rd
Wendell NC 275919235
Phone:
Phone:
Inspection Date: 07/09/2010
Primary Inspector: Lin McCartney
Secondary lnspector(s):
Entry Time: 10:30 AM Exit Time: 12:00 PM
Phone: [phone]
f;:xt.4243
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well (5A7)
Facility Status: ■ Compliant O Not Compliant
Question Areas:
■Wells
(See attachment summary)
Page: 1
r r
F
County:
WAKE
Sample ID-
ARGO640
River Basin
�0F WRTER
PO Number #
10G0455
Report To
RROAP
_0
Date Received:
OVDW2010
Time Receiaed_
13:00
Collector.
L MCCARTNI=Y
Labworks LoginlD
SMAMS
Region.
art Generated:
RepSample
Matfix:
GROUNDWATER
Data
pate Reported:
08JO41
081WIl2010
Loa Type:
N[ATER SUPPLY
Emergency Yes/No
VFsdil)
COC YeslNtl
° t �• I G
V
LoC, Dascr.: PAUL AOOLE INFLUENT
Ltic 6w ID:
SP092MOSOO134
Collect Date: a710912010
CollactTime: %30
Sample Depth
Resultl
Method
Analysis
CAS # Analvte Name PCL
Units
Validated by
-
Qualifier
Reference
Date
LAB
Sample temperature at rer;eipt by lab
3.4
"C
7112110
SMAT! IS
MIC
Coliform, M>' Fecal in liquid 1
1 B2
CFU1100m1 APHA9222D-201h
7r9110
CGREEN
Coliform, MF Total in liquid 1
1 132
CFU1100m1 APHA92228-201h
719110
CGREEN
WET
Ion Chromatography
TITLE
mg1L
EPA 300.0
7128110
MOVERMAN
Chloride
1
3.5
mg1L
EPA 300.O
7128110
MOVERMAN
Fluoride
0.4
2.6
m9I-
EPA 300.0
7128110
MOVERMAN
Sulfate
2
C9
mg&
EPA 300.0
V28110
MOVERMAN
Total Dissolved Solids in liquid
12
168
mg&
APHA254OC-ISTH
7113110
MOVERMAN
NUT
NO2+NO3 as N in liquid
0.02
0.02 U
mg1L as N
Lac10-107-04-1-c
VW10
CGREEN
MET
7429-90-5
Al by ICP
50
54 U
uglL
EPA200.7
ViW10
ESTAFFORDt
7440-70-2
Ca by ICP
0.1
30
mg1L
EPA 200,7
7116110
ESTAFFORDI
7440�3-9
Cd by ICPMS
1
1-0 U
ug/L
EPA200.8
7116110
ESTAFFORDI
7440-47-3
Cr by ICPMS
10
IOU
ug/L
EPA 200.8
7116110
ESTAFFORDI
7439-89-6
Fe by ICP
50
3Q U
uWL
EPA 200.7
711WI0
ESTAFFORDI
743"5-4
Mg by ICP
0A
11
mg1L
EPA200.7
7115110
ESTAFFORDI
7439-96-5
Mn by ICP
10
IOU
ug/L
EPA 200.7
7116110
ESTAFFORD1
7440-23-5
Na by ICP
01
24
mglL
EPA 200.7
7116/10
ESTAFFORDI
7440-02-0
Ni by ICPMS
10
IOU
uglL
EPA 200.0
7116110
ESTAFFORDI
7439-92 1
Pb by ICPMS
10
10 U
ug/L
EPA 200.8
7116110
ESTAFFORDI
7440-6"
Zn by ICPMS
10
90
ug�L
EPA 2018
7116110
ESTAFFORDI
Laboratory Section- 1623 Mall Service Center, Raleigh, NC 27699-1623 19191733.3908
Pow adeieked deaerwlen or the Ejuairw codes rarer to �Hosroun�l.Sri:y7r,nm1•eOMnAgI•4+{�, nJQ1L c��s t7 lsjp C��xNFler Cixles ehrtnlman W.nr�Pn7�-o yt, l tw nr,�ursi
Page 1 of 1

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environmentand Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
Location code ~ {2-0 '!j_ 2. ii,) J; O 5_ 0 b 13 4-SAMPLE TYPE SAMPLE PRIORITY 0 /ovi,4st; Bb_~ovi'-f O County vJ 0-~-e ¥1._ Water t Routine Lab Number
Quad No Serial No. □'Soil Emergency Date Received J . CJ ' f O Time: Jo~
Lat. Long. D Other
D Chain of Custody
Rec'd By: Hp, From:Bus,e and De
Other: · r'
Re art To: ARO FRO MRO RRO WaRO WiRO Data Ent 8 Ck: ~ ry y. ___ _ p
WSRO, Kinston FO, Fed. Trust Central Off., Other:.__________ Date Reported :. _____________ _
Shipped by: Bus, Courier, and Del., Other: Purpos~ · _____ · .
Collector{s): ·· C • Date 7-Cj --u'l Time / (; <::;;:C) l'B~e, Complaint, Compliance LUST, Pesticide Study, Federal Trust, Other:. ____ _
FIELD ANALYSES Owner ; ('.l...u · ooi e -(cl eonel ""J:rr{I"' l'i-J--:J-
pH 400 7 ' 0 Spec. Cond.94 :.) ..:l O at 25°C Location or Site <::: .s:: ;J. D \.V~ r g / n S'. cX2 0 f w -end e II ' fl) c_, .). rz
Temp.10 .... _::::.. 0 °C Odor (V Oh P Description of sampling point._~½:1..l~R.....:....I :....I _....1/2--l-_,t::~~,!.A:::_,,:d::::..· · _________________ _
Appearance C, I --<? C-,r Sampling Method c:74.-,; .... h Sample Interval. _______ _
FLAie
8
IdOARAnalyTsOisRBYy:ANAL-LYSE)11S C (' o-( 4-h-e ,.,1 Remarks ____________ 1P_um_o_. b_a_11e_,._e1_c ._, __________________ _
/ (Pumping time, air temp., etc.)
'9 I
BOD310 mg/L '>( Diss. Solids 70300 mg/L Ag-Silver 46566 ua/L Oroanochlorine Pesticides
COD High 340 mg /L Fluoride 951 mg/L x Al-Aluminum 46557 ua/L O roano chos oh!,rus Pesticides
COD Low335 mg/L 'X. Hardness: Total 900 mg/L As-Arsenic 46551 uq/L Nitrooen Pestic ides
){_ Coliform : MF Fecal 31616 1100ml Hardness ( non-carb) 902 mg/L Ba-Barium 46558 uc/L Acid Herbicides
)(. Coliform : MF Total 31504 1100ml Phenols 32730 ug/1 ')( Ca-Calcium 46552 mail PCBs
TOG 680 mg/L Specific Cond . 95 µMhos/cm )<' Cd-Cadmium 46559 uo/L
Turbidity 76 NTU Sulfate945 mg/L v Cr-Chromium 46559 uo/L
Residue, Total Suspended 530 mg/L Sulfide 745 mg/L Cu-Copper 46562 ua/L
><.. Fe-Iron 46563 uo/L Semivolatile Oraan lcs
Oil and Grease mg/L Hg-Mercury 71900 uo/L TPH-Diesel Ran ae
pH403 units K-Potassium 46555 moil
Alkalinity to pH 4.5 410 mg/L X Mg-Magnesium 46554 mall
Alkalinity to pH 8.3 415 mg/L )( Mn-Manganese 46565 uo/L Volatile Oroan ics !VOA bottle l
Carbonate 445 mg/L NH3 as N 610 mg/L X Na-Sodium 46556 mall TPH-Gasoline · Ran oe
Bicarbonate 440 mg/L TKN as N625 mg/L X Ni-Nickel uc/L TPH-BTEX Gasoline Ran ae
Carbon dioxide 405 mg/L X. N02 + N03 as N 630 mg/L X Pb-Lead 46564 uo/L
·../ Chloride 940 mg/I., P: Total as P 665 mg/L Se-Selenium ua/L
Chromium : Hex 1032 ug/L Nitrate (NO:i as NJ 620 mg/L X. Zn-Zinc 46567 uoJ L
Color : True BO cu
Cyanide 720 mg/L
Nitrite (N02 as N) 615 mg/L LAB USE ONLY S.t/ Temperature on arrival (°C):
Lab Comments. ______________________________________________________________ _
GW-54 REV . 7/03 For Dissolved Analysis-submit filtered sample and write "DIS" in block .
County:
WAKE
River Basin
Report To
RRQAP
Collector-
L MCCARTNEY
Region:
RRR
sample Matrix:
GROUNDWATER
Loc. Type:
WATER SUPPLY
Sample i ❑r
OF wRtrE,Q PO Number It
_Q� P Date Received:
Time Received:
❑ n�.� Labwoft Login!❑
• Report Generated:
Date Reported:
A86073O
10G0461
0711312010
12.45
SMATHIS
712311 ❑
0712312010
Emergency YeslNo visitla
COC Yes/No
Loc.Oescr.: PAUL POOLE
Location ID: SP097MOSOO137-IN> Cniterx Date: 07/13/2010 Collect T:me: 00:30 sample Depth
Result! Method Analysis Validated by
sis
CAS # Anal +ate Name PQL Units
uaffier Reference . D�
LAB
Sample temperature at receipt by lab 2.9 °O 7113M 0 SMATHIS
WET
Total Dissolved Solids in liquid 12 i9Q mglL APHA2640C-18TH 7113110 MOVERMAN
Laboratory Section» 1823 Mail Servico Center, Raleigh, NC 27699-1623 (912) 7333908
For 0 0MUM de5cnpllGn of the quPIWer wdv5 mfef fo I�. o' Irortal.Maem oruwah&ymfmhN f1C kM-h—'09Nj9 QyaliAer GdflS �hpy.7ippn9t.RW.gnGP19MS'h34[I.�9bIz Inthn.9A.N0.Zvi S1312
Page 1 of 1

GROUNDWATER FIELD/LAB FORM Nonh caro1ma
Department al Environment and Natural Resources ,.. DMSION OF WATER QUAUTV-GROUNDVVATER SECTION
·Location code r, ,(,,) 0 CJ ;) w 'J. 0 5 C>O / ~ h -~fl SAMPl,E lm_ SAMPL£ PRIORITY 0 J,~~"' 1 Pf!M_o1 JO County Wo-~e ,S:w.r l;ii{. Routne
Quad No Serial No. D Soil □ Emergency Date Received :/:· /8 · /o llme: /J)./S-
Lat. Long. Don. = By. 'Jtf l'I From:Bus, Courier,~ D Chai'I of Custody :'."'"\
T :AR FRO MRO RO aRO WiRO Report o 0, .~ l Y\.f Data Entry By: ______ Ck .. ___ _
WSRO, Kinston FO, Fed. ~Trust Central Off., Other:.________ Date Reported:
Shipped by: Bus, Courier, Hand . Other: __________ ~:J\1
Colleclor(s): L ,M C( e ,.j Date 7-13-1() Tnne Jk3i9 /(ftl8Seine, Complajnt. Compliance, ~UST, Pesticide Study, Federal Trust, Other: ___ _
FIE LD ANAL vses 1 _ OMkir oa,-u J D Do I § 1
c:ida-
1 ,
pH .QI 7 , o Spec. Cond.!M :3 o 6' at 258C Location cir Site :+t j o w!' i .t .. \.-1 ~ k ,1 Cv -e YI ~ -e, , ,. JV c 5 7 ,s; :v
Temp.1 0 2 3 , °C Odor (1 O }-1.C Desaiplion of smnpfing~-\ _.e \ l rl e c_a
r' l ..f' r -V Appearance Method _ ,b Sample Interval
Field Analysis Q,)..,_· ,._.<,,._,...,:,--'-"-· ......,.-'-"'""'....-d:-t-1 _''?t_..,.-"-· .... 'f-+1---------::::::::::::::::::~::_: LAB ORATO ' . ~nme. •-. .. -.,
8ampling
By: / .n1 ( ( r-. "+-n 0-.,. Remarks
RY ANALYSES (T
0 B0031
COD High
CODLDW
CoHrorm
ColiJonn
TOC880
Tulbldily
Residue
340
335
: MF Fecal 31818
: MF Total 31504
78
, Tolal Sulpended 530
fDpH4.5410
pH403
AlkallnHy
Alcallnity
carbanatllt
Biclirbanale
C8rbor1
Chloride
Clvomium
Color:T
Cyallda
topHB.3415
445
440
dloxlde405
940
: Hex 1032
rue BO
720
mg/L 'X DilLSolds70300
mgll ' Fu:irtde951
mg/L Hanlnea:Tatal900
1100ml Hardnel8{~)902
1100ml flhllm32730
mg/L st,ec:ilicCond.95
NTU &Jlfalll45
mgll &jftde745
Olllld619818
units
mgll
mg.IL
mgll NHJaN810
mgll TICNasN825
mglL N0.z + N0a a N 830
mg/I. P:Talll•P885
ug/L --{NOa. N) 820
cu .... {NOi.N)815
mg/L
mglL Ao-Sher~ uan.. Pai ..
mglL AI-Alllnlnum48557 uill Peslicidas
mg/L ~48551 ua/1.. N-Pedcides
mglL aa:a.tum 48558 uall AcldllerllicQel
ui;i ca.calclllm-48552 mnll PC8a
.-...,an Cd-Cadmium 48559 un/1
mglL Cr-Cmlmlum 485511 uall
rng/L CII-Copper,48582 un/1
Fe-lran48!583 uall 8enWI I Ill Ornann
mglL Hg-MIR:ury71800 ..,,. TPH-Dlelal Ranae
K-Pdaslun48555 mall.
llg-Mignelun 48554 mn/1
Mr>Mallgll-48585 un/1 VOlllll9 Oraanlal ~ ballle)
mg/L Na-Sodiln 48558 mall TPH-Gaahl Ra nge
mglL NI-Nlckel un/1 TPK-8lEX GemlsM, Ranal!I
mg/L Pb-leal486&4 ..,,.
mg.'L Se-&illnllln UWl
mwL Zn-Zinc~ ua/1.
mg/L LM !,Sil; ONLY J~°! Temperature on anlval (9C):
Lab Comments'---------------------------------------------------
GW-54 REV . 7/03 For OillcMld Anllyals-submit tlll9nld umple ........ "DIS" In blad(.
-
County,
1NAKE
Sample ID;
AB60641
River Basins
wAR
PO Number 9
10G0456
P
Report To
RROAP
Date Received:
0710912010
�O�
vi
Tuna Received;
13:00
Collector.
L MCCARTFlEY
p
Labworks LoginlD
SMATHIS
Region:
RRO
Report Generated;
514110
Sample Matron
GRGUNDWATER
Date Reported;
1)810412t110
Loc. Type:
WATER SUPPLY
Emergency YestNo
\Aside
r� 5} "tr f . j
COC Yes1ND
Loc. Descr.: PAUL POOL EFFLUENT
Location ID:
5PD92WIQSGD134
Collect Date: 071091Z010
Collect Time: MOD
Sample Depth
CAS #
LAB
AnalYte Name
-
Sample temperature at receipt by lab
PQL
Result/
Qualifier
3.4
Units
'C
Method
Reference
Ana sis
Date
7112n0
Vg�ated by
SMATHIS
MIC
Coliform, MF Fecal in liquid
1
1 B2
CFUr100rn1
APHA92220-20th
719116
CGREEN
Coliform, MP Total in liquid
1
1 62
CFUI100m1
APHA92229-20th
719110
CGREEN
WET
Ion Chromatography
_TITLE
mgn-
EPA 300.0
7MI10
MOVERMAN
Chloride
1
2.3
mg1L
EPA 300.0
712B110
MOVERMAN
Fluoride
0.4
2.5
mg1L
EPA 3OD-0
712800
MOVERMAN
Sulfate
2
5.0
mglL
EPA 300-0
7128110
MOVERMAN
NUT
NO2+NQ3 as N in liquid
0.02
0.02 U
mg/L as N
Laoi0-107-04-1c
718110
CGREEN
MET
7429-90-5
Al by ICP
50
50 U
ug1L
EPA 200.7
7116110
ESTAFFORDt
7440-70-2
Ca by ICP
0.1
30
mglL
EPA 200.7
711WI0
ESTAFFORDi
7440-43-9
Cd by ICPMS
1
1.0 U
uB1L
EPA 200.8
7/16110
ESTAFFORD7
7440-47-3
Cr by ICPMS
10
IOU
ug/L
EPA 200.8
7116110
ESTAFFORD1
7439- "
Fe by ICP
50
SOU
uglL
EPA 200,7
7116110
ESTAFFORD1
7439-95-4
Mg by ICP
0.1
11
mglL
EPA 200.7
7116110
ESTAFFORD7
7439-96-5
Mn by ICP
10
IOU
u$/L
EPA 200.7
7116110
ESTAFFORD1
7440-23-5
Na by ICP
0.1
24
mgfL
EPA 2007
7116110
ESTAFFORD1
7440-02-0
Ni by ICPMS
10
IOU
ug(L
EPA 200.8
7116/10
ESTAFFORD1
743M2-1
Pb by ICPMS
10
10, U
ugtL
EPA 200.8
7116110
ESTAFFORoI
7440-66-6
Zn by ICPMS
10
98
v91L
EPA 2MB
7116110
ESTAFFORDI
Laboratory Sectlon>> 1623 Wl Service Center, Raleigh, HC 27699.1623 [phone]
For a WAIM 1 Mrlplioq or ljlc gUAtiRAr Mies reke ftl �Jp-+loun9f enr. oru+wgp7s dl,h'xlr bin }jV0.oj oi!a�iae� cndas<ntta:+`cansL ernrnromhxehnt❑ryk4 frfwp rd R=t
Page 1 of 1

GROUNDWATER FIELD/LAB FORM North Carolina
Department of Environment and Natural Resources
DMSION OF WATER QUALITY-GROUNDWATER SECTION
Lucation code $ :12 C) '1 .;>. ~\) r O ,2 oo 13 LJ.. SAMPLE n:eg SAMPLE PRIORITY fvv bl.f% ~(.Qo{cJ'i( County W°')C C2. ~Water ~Routine lab Number
Quad No Serial No. □Sou D Emergency Date Received 1 ff • ! D Time: /36b D Other 0 Lat. Long. Rec'd By: From:Bus, Courier,~ -
D Chain of Custody Other:
Re rt To: ARO FRO MRO RRO WaRO. WiRO, .., po /_@ ,:--l''Clu<,J DalaEnlry ~-----Ck. ___ _
WSRO, Kinston FO, Fed. Trust, Central Off., Other:._________ c. \ 1' Date Reported:. ___________ _
Shipped by: Bus, Courier,\Hand oef/. Other: __________ , Purpose: .
Collector(s): / kl CC 0:, r f n e ✓ Date 7 ,,q d'D Time//. '2Z? Baseline, Complaint, Com_pliance, L,UST, Pesticide Study, Federal Trust, Other:
FIELD ANALYSES r , ? . Owner I2r1.,u l ,P L'> OJ e.. 1:K-t I u ~...:4~-1 ·----
pH 400 q : 0 Spec. Cond.94 . ?. ~ V at 25°C Locati~n. ol-site f>" 5✓2 D \ \J'O.. t /l > n $ f.i. of , w e ..,, d ~ > ) ,, ;J C ;? ? .5 q J
Temp.10 ~ J7 °C Odor 1--) o n -e.... DesaiptiOn of sampling point~\Alt"" .... 1:1-s ... i __ l __ H......__;~'""o--~c:\..,__ ____ --=_-:-~--,--------
Appearance G \ & , , r::: SampUng Method 6z (tJ..-b Sample Interval ______ _ Field Analysis By: L l'ri L L o.-✓-t n. .R y Remarks __ __.__....._ ___ ,PiiNI,._,.,._ w....,._...,iic....,,r-----
LABORATORY ANALYSES
BOD 310
CODHigh340
CODLow335
31616
otal 31504
Coliform: MF Fecal
1-._ Coliform: MF T
TOC6B0
Turbidity 76
Residue, Total SIIIPl!llded·530
pH403
.4.5 410 Alkalinity 10 pH
Alkalinity ID pH
C&rbonate 445
Bicarbonate 44
carbon diOxlde
8.3 415
0
405
"' Chloride 940
Chromium: He X 1032
Color: True 80
Cyanida720
mg/l
mg/l
mg/L
/10Dml
1100ml
mg/l
NTU
mg/I.
units
mgll
mg/I.
mg/L
mg/L
mg/I.
mgll.
ug/L
cu
mg/I.
' y . '\"['\ .
-· -.. --~N h mg/l ---
Fluoride 951 I mg/L
X. HanSness: Tola! 900 mg/l
Hardness (non-aab) 902 mg/l
Phenols 32730 ugll
Specific Cond. 95 jM,os/cm
Sutrate945 ff9L
Sulfide 745 mg/I.
Oil and Grease mg/l
NH3asN810 mg/I..
TKNasN625 mg/l
·f.._ NOz+ ~asN830 mg/l
P : Total as P 885 ff9L
Nilratll (NOias N) 820 mg/I.
Nllrilll (NOz as N) 815 mg/l
(F'l.rnpircJ llme, Bi' tame, .• Ille.)
Ag-Silver 48588 ug.ll. 0 Pellicldes x Al-Aluminum 48557 ua/1 0 Pestlc:idas
As-ArNnk:48551 UQ/l Nltmooin Pes11cides
Ba-Barium 48558 ua/L Acid Herbicides
-x. ca.calclum 48552 ma/L PCBa x Cd-Cadmium 48559 ua/L
)< Cr.Chromium <185511 ua/1
Cu-Copper 46582 ua/1
;<., Fa-Iron 46583 UII/L Semlwlatlla Omanlc:a
Hg-Meralry 71900 ua/l TPH-Dlaul Range
K-Polasalum 48555 mall
?' Mg-Magnaklm48554 ma/L
X Mn-Manganese 48585 ua/1. Volatile OmaricS {VOA bottle!
')( Na-sodium 48558 ma/I TPH-Guoline Ranae
·,( Ni-Nickel ua/l TPH-8TEX Gasollria R..nn,,
X Pl>-l,ead48564 UQ/1.
Se-se&anlum ua/L
X Zn-Zinc 46587 ua/1
LAB !.!SEO~LY 3,~ Temperature on arrival ("C):
L,ab Comments. __________________________________________________ _
GW-54REV. 7/03 For Dissolved Analysis-submit filtered sample and write "DIS" In blOck.
rN� sD'i�Gb �a6nraLvrv.S'e�tr'crrt �7��su��s
County:
WAKE
Sample ID_
ABS0731
River Basin
Report To
RROA PO
0F WAr�9
PO Number #
Date Received:
1QG0462
0711312010
+
Time Received:
12:45
Collector_
L MCCARTNEY
t
n 17
Region:
HMOReport
Labworks Loginit)
Generated:
SMATHIS
7MI10
Sample Matrix:
GROUNDWATER
Date Reported:
07/2312010
Loc, Type:
WATER SUPPLY
Emergency Yes1No
vtsitlo
COG YeSJN0
Loc. Descr.: PAUL POOLS
Location 10:
5P69ZMf)509137-EFF
Collect Date: 0711312010
Collect Time: 09:46
Sample Depth
CAS # Analyte Name PQL Result/ Units Method Analysis Varidated kr
Qualifier Reference Date
LAB
Sample temperature at receipt by lab 2.9 'C 7/13110 SMATHIS
WET
Total Dissolved Solids in liquid 12 186 rng1L APHA254QC-18TH 711310 MOVERMAN
i
Laboratory Section;- 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
Fpr a �Iolaletl d65cf�tlop a[Ille quallriK W404 Rfer SD �ju7:1 !QHal.nr3lenr.nrMunhnruAuh�nN� fortxchtissniCORfa [S�ia!]flPr Ca�n�SrMrrfLPoflBCnWrnr.CrnrMehAvaau Nxtalf nfollnchassLst+
Page 1 of 1

GROUNDWATER FIELD/LAB FGRM�
Limon code
County_ Lj " E �-
Serial No.
Long.
�TYK
�Sol
❑ Otlrer
❑ Chain ei Cratody
o Ernwr9ancy
Report To: ARO, FRO, MRO WaRO, WiRO.
WSRO, Kinston FO, Fed. TnvAt CCegtral OR., Other.
Shipped by: Bus, Courier,Mand Deis Other; Purpose:
Colledof(s): L 3y'1 Cf_ ; . -� -- - _ Dater =� Time `-� c r EM
FIELD ANALYSES \ Owner 01
pH .no - CJ Spec. Cond. at 2b-C Locakm Site
Temp., o J_ �-2 °C Odor - t L -� I % Description of &
Appearance =-1 c 7 Sampling Mettx
Field Anakysis By: _ ] { �' . i ? _ s Remarks C4 -
1 AR(IRATnPY AKIAI YSF.R
$00 310 MS&
COD High 340 mg&
COO Law 335 rtgrL
Camorm W Fecal318T$ 1i00nd
Cdffo m: MF Total 31504 1100"t
Toe 580 nv&
-tUft ft 76 NM
Residue, TOW Sresperided 530 "V&
PH 403 Unb
AtlrWh* 1a pH 4.5 410 rng1L
Alkalklity ih pH 9.3 415 fnQfL
C4r4ona* 445 mgk
Bk*rhanrg7 440 nvq-
Carbon dkodde 405 rrglL
Chloride 940 ffwL
ChromRim: Max 1032 uglL
Color. True 8o Cu
Cyanide 720 MWL
n
North Carolim
Departrnerlt of EnvkwmW and Natural Remrm
i7NWON OF WATER QUALITY-GRMNOWATER SECT}DN
Lab Number
Date Received -13 L Time: jAT
Reed By. Frcm:Bus. Courier, 1�1'n--d
Other.'i-
f' Data Entry By. Ck:
Daie Reported:
Aa plWnce,�. 'Pesticide Study, Federal Trust, Other:
Sample Interval
[v+rvrq em.. w fa�p.. ale y
Duns. Scads 70300 MWL
AR Saver 48586 DLL
Fkwfkle 951 rn0 L
Ak&Jurslinun 46W UWL
HOWE= TOW 900 MWL
As-Arserdc 48551 LKVL
Hwdr a (non cart) 902 mglL
Ba-Bsrkxn 455M
Phwwl6 32730 tw
Cs-G8kAm 46652
Spedit Conti 95 dawn""
Cd-Cadmkm 48559
Sultan 945 "wL
Cif-cuairlkllrl 1655 UIA
&Wide 745 moll
Cu-Copper 40W
Fe -kw 4D58S
09 rod Gnaw ffg&
Hg Alum" 71900
IC Dahmaldfn40555 noz
Mg4bVWWksn 45554
Mi-IKrngariese 4eW
Nty as N 010 MWL
NO -Soften 48M TgLt
TKN as N 875 "wL
N144ftei
No, + Nos as N 630 MOL
Ptsl.erd 4$ vi
R Ted as P Dag MVL
Se-SrMrdrm
Hware (Ho3m H) M ngrL
LiZ=45W7 Ugk
N ft (N% as N) 615 MWL
Lab Comments
GVII54 REV- 7103 for DFssotrW Analyaia.-subrrit fiitred ur" sod rKlire TU in CiocL

Cr
400 800 1600 Feet
Feld
Valeta .
PIN
1756733747
Real Estate 10
0142114
Map Name
175004
Owner
POOLE. PAUL T JR
TRUSTEE
Malling Address 1
5520 WATKINS RD
Malling Address 2
WENDELL NO
27591-9235
Malling Address 3
Deed Book
13947
Deed Page
2635
Deed Date
(35)2112010
Deeded Acreage
9.22
Assessed Building
Value
$386,254.00
Assessed Land Value
$276,704.00
Tote! Assessed Value
$662,958.00
Billing Class
INDIVIDUAL
Property Description
L06B POOLE &
HARRIS
BM2009-01366
Heated Area
3384
Site Address
5520 WATKINS RD
City
Township
ST. MATTHEWS
Year Built
2004
Total Sale Price
$24,0DOAD
Sale Date
5121I2010 12:00:00
AM
Type and Use
Single Famlly
Design Style
Log
Land Class
RESIDENCE-<10
ACRE$-kDME SfTE
CA Parcel Number
415--
�°
WAKE
COUNTY
K011'A

NCDENR
North Carolina Department of Environment and
Division of Dater. Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
June 23, 2010
Paul T. Poole, Jr.
Retry H. Poole
5520 Watkins Road
Wendell. NC 27591
Subject: Acknowledgernent of Application No. WI0500134
Poole, Paul - STR
Injection Heating/Cooling Water Return Well (5A7)
Wake
Dear Mr. & Mrs. Poole:
Natural Resources
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on June 2, 2010. 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 compute
application.
If you have any questions, please contact John McCray at 919-715-6168, or via e-mail at john.mccray c�Z nadenr.gov. If the reviewer is
unavailable, you may leave it message, and they will respond promptly. Also note that the Division has reorganized. To review our
new organizational chart, go to httt):llh3o.enr,state.nc.us/documents/dwq or_chart.l-,df.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
CW
for Debra J. Watts
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Permit Application File W10500134
AQUIFER PROTECT ION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard. Raleigh, North Carolina 27604
Phone: [phone] l FAX 1: 919-715aH. FAX 2, 919.715-60481 Gustamer Service, 1-677-623-6748
Intemal; www.ncaaterwalitv.Qrm
No thCarolina
An Equai Ovportu@lly 1 AiGrmatme .Action Empbpr

. . . .. .. . .
. At:9rA
~;;1--~
MCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Paul Poole
Coleen H. Sullins
Director
May 24, 2010
5516 Watkins Road
Wendell, NC 27519
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection W~ll
Permit No.-WI0500134
Wake County
Dear Mr. Poole:
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 October 25, 2005, and
expires on Octobert 31, 2010, has not been renewed. If you wish to keep this permit and operate
the injection well system, the permit must be renewed and issued in your name. Our records do
not indicate that the well system has been plugged and abandoned.
In order to comply with the-regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title ISA, Subchapter 2C, Section .0211, you must submit one of the following
~s: .
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.
If there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form must also be submitted.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, N9rth 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 : 1-877-623-6748
Internet: www .ncwaterguality.org
An Equal Opportuntiy \ Affirmative Action Employer
RECEIVED / DENR / DWQ
AQUIFJ:R'PROTEr.nnN SECTION
JUN O 2 2010
1J:!ft3!J}};a
If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed under NCAC Title 15A, Subchapter
2C, Section .0214. When each well is plugged and abandoned, the well abandonment record
(Form GW-30) must be submitted to our office to certify that the abandonment was properly
conducted. If the injection well system is still active and you wish to renew your permit, the
renewal application must be submitted within 30 calendar davs of the receipt of this letter to:
Aquifer Protection Section
Groundwater Protection Unit
UICProgram
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://b2o.enr.state.nc.us/aps/gpu/forms.btm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call me at [phone].
Sincerely,
L )} J,,w1,t
Eric G. Smith, P.G.
Hydrogeologist
Attachments
cc: Raleigh Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0500134 w/o enclosures
2
RECEIVED / DENR / DWQ
AQUIFl=R·PRnTEr.TION SECTION
JUN t 2 2010
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A GEOTHERMAL HEAT PUMP SYSTEM
TYPE 5A7 "OPEN LOOP" INJECTION WELL(S)
(check one) New Permit Application ,I Renewal Modification --
DATE: ,ttAY 6 7 20 I (?
PERMIT NO.: WI O £1) 0 I 3 ± (leave blank if NEW permit application)
A.-PROPERTY OWNER/PERMIT APPLICANT
l
--
Name of each· owner listed on property deed. For a business or government agency, state name of entity and
name of person delegated authority to sign application on behalf of the business/agency: ______ _
p ,9:e,a_ /. Pool.£ ~ 8 t::JTY l+N/LJ'LI J P'tPDLe'
(1) Mailing Address: .'ir,lo IV/f T t< IN.> /l...O
City: k/t=l()/)t=4 L State:.&_ Zip Code: ,t 7.S7f I County: W A-/.::.€
Home/Office Tele No.: ., I ? ,,Z. f-& I 7 t z Cell No.: V '? 1§ I tJ .2 2 / 7
FaxNo. ___________ EmailAddress: PTP e>oL r=:@ L~-r #UI/L.-. C..Olk.
(2) Physical Address of Well Site (if different than above): ______________ _
City: _________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: ____________ C=e=ll=-=N~o=.-'-: _________ _
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/permit 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: ------------0-------------------
Contact Person~: ----------t---~E=m~a~il~A~d~dre~ss_: __________ _
Address:
City: _________ State: __Jj ~ e: ______ County: _______ _
Office Tele No.: Fax No. Cell No.:
Website Address of Company, if any: ______________________ _
Type SA 7 Injection Well Permit Application (Rev. August 2009)
RECEIVED / DENR / DWQ
AQUIFl=R'PRnTFr.T1nN SECTION
. JUNO 2 lOto Page 1 of4
1 1)-"A.1.1W6).5i a I C61 Llu ► V 0.COTi7
E.
Company Name: cv, G o
Well Drilling Contractor's Name: my g n
NC Contractor Certification No.: 3 -1 A Contact Person: Zi4Qr2 YY _ x- jErC « ei a.¢ r/4
Company Website: W W W. M w P o o tic wC A� L . c p mg Email Address: g,ETc,& wd 8,T $V La
P o as W� • Gpxfs-
Address: 1� a 0 � bC I I 5'f3
City, ld g�Z�y 09E.9 L. State: &C, Zip Code: ,Z7,5-- g 1 I County:
Office Tele No.: 9 f 9 ,2 f G 2�U Fax No.: gl! g6 C 2 5-,o :7 Cell No.:
HEAT PUMP CONTRACTOR INFORMATION (ff different than Driller)
Company
Company
Address: _3 o-c 1/f L e. A rz e 122 . 1N Q, "z w--
City: k ►/ G .y T ,�� z C _ State: AL�:_ Zip Cade:: _= Z j = .County: r.-,e�
� &
Office Tele No_: �l `1 / Fax No.G
_ 119 =�Vp -/??�p Cell No.
F. INJECTION PROCEDURE {briefly describe how the injection well(s) will be used)
2 -r" ^1 c
G. 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 d NO
H. WELL CONSTRUCTION DATA
PROPOSED Well(s) 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,
- 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 (Force
GW-1) if available.
(1) Well Construction Date: 4 - z 3 q- Number of borings: J - -
Depth of each boring (feet): n /
(2) Well casing. Is the wells) cased?
(a) YES � Z If yes, then provide the casing information below.
Type: Galvanized steel +� Black steel Plastic Other (specify)
Casing thickness:.t iameter (inches): depth: from -_to AW"' feet (relative to land surface)
Casing extends above ground _ � f inches + !
DJ iW
(3) Grout material surrounding well casing:
(a) Grout type: CementJ/ Bentonite* Other (specify)
*By selecdug bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(dx1)(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from o to 2_ feet
Type 5A7 Injection Well Permit Application (Rev. August 2009) Page 2 of

/
(4) Well Screen or Open Borehole depth (relative to land surface): from 1--.3 to S1o 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 injection1-
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.)
I
Depth: +so Formation: ~A/IN/ 715 Rock/sediment unit: --------
NQJE: _THE ~LL PRJ:LLIN9 QR JmAJ PUMP CONTRACTOR. CAN HELP SUPPLY THE DAT A.IF THIS
INFORMATION IS OTHERWISE UNAVAILABLE.
I. OPERATING DATA
(I)
(2)
(3)
(4)
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
J. INJECTION-RELATED EQUIPMENT
Average (daily) 7 gallons per minute (gpm).
Average (daily).t,fl o gallons per day (gpd).
Average ( daily) / I> pounds/square inch (psi).
Average (January) ,£1> ° F, Average (July) 7S-0 F.
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 all 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 count:y 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 are 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.
"1 hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted in
this document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible for
obtaining said information, 1 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."
_ r.
Signature of Property Owner/ApplicapV -- --
Pf3III= T, T t, c 1 OL
Print or Type Full Name
Signature roperty 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:
LiIC Program
Aquifer Protection Section
North Carolina DENR-DWQ AQ�j F � � �►i1 pyy�?
1636 Mail Service Center
Raleigh, NC 27699-1.636 JUAI ¢ 2 Cora
Telephone [phone]
Type 5A7 injection Well Permit Application [Rev. August 2009) Page 4 of 4

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: h! 0 a &
Permittee Name: Pf u 1 -- pma--
Address: r o Jeht7fie I&!-
�
Please check the selection which most closely describes the current status of your injection well system:
1) E� Well(s) still used for injection activities, or may be in the future.
2) ❑ Well(s) not used for injection but is/are used for water supply or other purposes.
3) ❑ Injection discontinued and: a) ❑ Well(s) temporarily abandoned
b) ❑ Well(s) permanently abandoned
c) ❑ Well(s) not abandoned
4) ❑ Injection well(s) never constructed
Current Use of Well
If you checked (2). describe the well use (potable water supply, irrigation, monitoring, etc), including purnping rate and other
relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description of how the well
was sealed and the type of material used ta, fall fhe well if perm❑nently abandoned] -
Permit Rescission:
If you checked (2). (3), or (4) and will not use a well for injection on this site in the future, you should request rescission ofthe
permit. Do you wish to rescind the permit?
❑ Yes ❑ No
Certification:
"I hereby certit,, under penalty of law, that I have personally examined and am familiar with the information submitted
in this document. and that to the best of my knowledge the information is true, accurate, and complete."
Revised 5/05
Signature % Date
G WItJIC-S8 RECEIVED I []ENS i QWQ
AQUI► 41)9nir n; ON
3Ut4 0 2 Qin

WAKE COUNTY DEPA flMIENT OF ENVIRONMENTAL SERVICES WHJ_AND SEMGE SITE LOCATION PERMIT
..�-.FT� - rid. �i.i�-- : Irr■+� +AFT oil
iZ. .F3 i!T• - ri f r. -r �wT1� 'i. 19i
PERMIT#_ 00274fi9 STATUS: A APP. DA'f E wrIlDrA nJ BLDG. PE W". OMM
PIN, 1756.04 73 2951 000 TAX MAP: "IS 0024 RECORDED. Y ORIG. PERRMITW
TCONSHIP: 17 ST MAT THEWS JURISDICTKx- WC ZONIPCI R30
APPLICANT: POOLF- PAUL T JR
5619 WATKINS RD
WENDELL, NC 278M
[phone]
USE: HD USE 0002 VERIFYAE7C TANG SYSTEM
EXIST' USE.101 ONE-FAWL.Y HOUSE
DISPOSAL: BEDROOMS: 3 BASEMENT: Y #EMPLOYEES_ 0 FOUND DRAIN: N
SITE: ADDRESS: 5516 WATKINS RD
SUBDWION: POOLE. PAUL LOT: 2 ACRES: 7.80
:PIREC71ON' US 64 r= TU LT ON OLD MILBURNiE TU RT ON WATKINS
PROPERTY ON THE RT
IMPROVEMENT PERMIT
'ANKSIZE:10W pal. PUMP rank gal, SO FT: 1200 STONE DEPTH: 12 in. MAX DEPTH LINE: 18 in.
VASTEWATER: INDIVIDUAL SEWAGE: DOMESTIC TYPE SYSTEM: II A PUMP: N PIM: N
)AILY FLOW: 300 g0day DESIGN FEE REQ?: PAID7: WATER: INDIVIDUAL
:OMIu ENS:
*Jr ISSUED? Y DATE GVZW2W3 BY:
Ew:[a .1�3�'3YGIc' :9
:or&actws shall install system on conwurs, see attached sate plan forwasb water system design and wail location. No
ndeMround ulffifts, wafer tines or sprintder systems may be located In the or%inal system or repair areas. A septic tank filter
,dh a rises for access is requ'aed. The waste mler system shA not be covered or placed irda use urn wtspected by the Wake
aunty Oepariment of Emr nmem tel Services and an Operation Pam* issued. OTHER CONDMONS:
VITAL SYSTEM 3135/ CONVENTIONAL LINES. CONTRACTOR TO FOLLOW LAYOUT IN FIELD SKETCH ON CA SrM PLAN IS
PPROXIMATE FOLLOW GIVEN SETBACKS. KEEP TANK 1.7 OFF SAS IIIE i T FOUNPA71ON CALL OFFS WI TH,ANY
UESTIONS.
kNK SQ7 f000 gal. PLIMP TANK: gal. SOFT- 1200 S ONE DEFCH:12 itL MAX DEPTH LINE 18 irL
AWN OPER N MY TRENCHk. 3 LENC'Ti : 1361L WIDTH: 36 in- DESIGNED _
SUBFIEL.DS: _ DESIGN HEAD PRESSURE:- DESIGN OW gaYmm DOSE VOLUME gal.
k ISSUED? Y DATE: 09A2912003 BY: (SCR)Kgma=1'tl%w: 857--9355

WAIF COUNTY GE`PAITiMENT OF EKVHVONN8TAL SER%NCES VNELL AND SEWAGE SrFE LOCATION P8tWr
NO PERIJI {S] FOR CONSI'RUCTM LOCATION OR RELOCATION AC7NITY SHALL BE ISSLEED
UffM AN AJAWRIZAiiQN FOR VWASTEMTER SYSTEM HAS BE@+I ISSUED
*PEM f Win IF N= IN C01111PtIJANCE WITH ZQ1tM RLGULATHM ANW OR 1F SITE IS ALTO OR INTENDED USE CHANGED'
PERMIT: 0027M STATUS: A APP. WATE 040012003 BLDG. PST#. 004MA9
PIN: 1756M 73 2W DOD TAX WUP- iWtS 0024 REDORIX0. Y ORIG. FE' 2MTTtE
TCANNSHIP: 17 ST UATTFIEM JLFOSL]ICTKW WC ZONING: R30
APPLICANT-- POOLF- PAUL T JR
6516 WATMNS RD
WENDELL, NC 27691
(910 )2ti@ -1369
USE HD USE 000 VERWYAvawn G SYSTu
EXIST USE:101 ON!E-FiWLY HOUSE
DISPOSAL: BLOOMS` 3 B Y XEMPLiQYEES: a
SITE: ADDRESS: WIG WAT3iM RD
SUBDIVISION: POOLF, PAtUL LOT: 2 ACRES: 7.80
DIRECTtM US 64 E TU LT ON OLD IYgLBURNIE: TU RT ON WATIONS
PROPERTY ON THE RT
►A1e8 Syamm: M1t WDNMQAL - TYPE: NEW
WELL LOG INFORMATION: DGPTF-t ^ CASING DBgW " YlEll7 STATIC LEVEL. _
WELii CONTRACiOJt FtEG-# PUNW CON7RACTOlk
Consuuc*m Contphance GROIITAPPROVED © IDA7E EM
IAIB_IBEAD APPROVED El DATE EM
SYSTEM FTNAUZED ❑ nATE EMS
DESIGN FLOW. gat/min- ACTUAL FLOW:
INSTALLED BY:
PROPRIETARY SYSTEM:
COMMENTS:
Opor�upnp�tmlt
INNOVATIVE LETTER N
INSTALLATION APPROVED BY:
FILTER NO:
OPERATIONS PEFi11ATr ISSiUEM OP ELATE BY:
This permit is based in peat on inforumfion provided by tic howcomar or hWh r n*m senwive in the application submitted far ilsi:s permit
The Environmental HeaM Speasliat is mot xcspp mole tbr false of misleading mfaFinatian oanmed is the applient iots. The Environmcutal
HcaIth Spedalist is also not ale far concealed cry co the property or for swcmem in this tgxwt dw may Lave resulted from
False or mzleKrmg statements provided to him in tie applicaftm Ndltw Wake County nor tie Emirowntatal HcoM Spctasla wmmis
that the SCOC Owk system will continue to funcdan wisllmrgy fort tine future mr that the wafer supply will remain potable.
As Built Information:
Date: Benchmark- Rod reading.
ST-. gals M#: D.0-M.: Elev.:
PT: gals ED#: D.0,X: EIev :
❑-hoxlFDf?M elev.: z Supply Line: & Pura! Pagel
Line l: Date.
Line 2: Date:
.ine 3: Date:
vine 4: Dsae
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June 17, 2005
Paul T. Poole, Jr.
5516 Watkins Road
Wendell, NC 27591
Ref.- Nection Well Application Receipt
Dear Mr. Poole:
William 0. Ross Jr., 5sxretary
Noah Cnvlina Department of Faviroarnent and Natwal Rmouf=
Alan W. Klimek, P.E. Director
Division of water Quality
Your application for a permit to construct and 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 Raleigh Regional
Office staff will be contacting you to arrange an inspection of the injection well site as part of the review.
Please contact me at 919-715-6166 or Evan Kane at 919-715-6182 if you have any questions regarding the
Underground Injection Control Program or injection well rules and regulations.
Best Regards,
--Tjltr� Vl i-
Thomas Slusser
Hydrogeological Technician 11
UJIC Program
Cc: Jay Zimmerman, Raleigh Regional Office
CO-UIC Files
Aquifer Protection Section 1636 Mail Seance Center Raleigh, NC 27699-1636 Piume [phone]
Internet: hap;/ h2o.enr.st=.nc.us 2729 Capital Boulevard Raleigh, NC 276" Fax {919} 715-0588
Fax [phone]U
An Equal OpportunitylAttirmativa A on Employer --W% Recycledll09/, Pest Consumer Paper
ta
tCaroliiia
urdlil
Customer service
1-877-623-6748

LETCQ, tne- dba N.W. Poole Well & Pump Co.
5 801 Farm Well Rd.
Raleigh, NC 27610
919-266-9223 Office
919-266-7507 Fax
Paul Poole
5516 Watkins Rd_
Wendell, NC 27591
Invoice
Date Invoice #
09123Y2004 010009
Description ! Amount
Drilled Well: Lot 2, 5516 Watkins Rd_
Wake County Pennat #D027065
570 feet deep @ $9.00 per foot
25 feet of S" galvanized steel casing @ $22.00 per foot
Cement grout
Diameter: 6 114"
Depth: 570 feet
Pipe: 25 feet
Rock Type: Granite
Water Income: 15 gpm
Water Level: 20 feet
Driller: Jamie Jones
Well #4330
Harry Letchworth/bgl
4
' N
h&LAI 7
5�3Q- 00
5,130.00
550.00
250.00
Due upon Receipt - Past due accounts will he assessed a finance charge of
1.5% per month I Total $5,930.00

LETCO, Inc. dha N.W. Poole Well & Pump Co.
Post Office Box 1958
%WOti Wendell, N.C. 27591
919-266-9223 ice
9I9-266-7507 Fax
Bill To
Paul Poole -- — -
5516 Watkins Rd.
Wendell, NC 27591
Descripiii
Pump Service:
Drilled 8" tole down to 43' and installed 6" ;
shoe down to 43', chlorinated well, misc. fits
No charge..
Completed By: Kevin Letchworth & Marty ]
bgl
Thank you for your business.
Invoice
Da#e�n o:oi #
10/15/2007 I 14840
Total $4.00

Beverly Eaves Perdue
Governor
Paul Poole
~A =-=--"-"-· -NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
May 24, 2010
5516 Watkins Road
Wendell, NC 27519
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WIOS00 134
Wake County
Dear Mr. Poole:
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 October 25, 2005, and
expires on Octobert 31, 2010, has not been renewed. If you wish to keep this permit and operate
the injection well system, the permit must be renewed and issued in your name. Our records do
not indicate that the well system has been plugged and abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit one of the following
forms:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for Injection with
Geothermal Heat Pump System for Type 5A 7 Well(s) if the injection well system on your
property is still active ..
-OR-
B. Status of Injection Well System if the injection well system is inactive or has been
temporarily or permanently abandoned.
If there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership-Change Form must also be submitted.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location : 2728 Capttal Boulevard. Raleigh . North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-604B I Customer Service: 1-877-623-6748
Internet: www.ncwaterauality.org
An Equal Opponun ity \ Affirmaiive Action Employer
NOnethC 1· or aro 1na
/vatura!lg
If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed under NCAC Title 15A, Subchapter
2C, Section .0214. When each well is plugged and abandoned, the well abandonment record
(Form GW-30) must be submitted to our office to certify that the abandonment was properly
conducted. If the injection well system is still active and you wish to renew your permit, the
renewal application must be submitted within 30 calendar days of the receipt of this letter to,
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 DWp website at
httl2://h2o.enr.state.ne.us/aps1!-mu/forms.htm,
Thank you in advance for your cooperation and timely response. If you have any questions,
please call me at [phone].
Sincerely,
00
Eric G. smith, P.G.
Hydrogeologist
Attachments
cc: Raleigh Regional Office - APS w/o enclosures
APS Central Files - Permit No_ W10504134 w/o enclosures

~le-~ ~ ?jpo?'/ -::,= === I
7 ,-P75' E :=;).
AQUIFER PROTECTION SECTION REGIONAL STA°1!F REPORT
Date: 02/14/2007 County: Wake
To: Aquifer Protection Section Central Office Permittee: Paul T. Poole Jr.
Centra~ Office Reviewer: Micheal RogenProject Name: Heating & Cooling 5A 7Source & Supply
Regional Login No: 05 Application No.: WI0500134
L GENERAL INFORMATION
1. Tiris application is (check all that apply): D New ~ Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals D Attachment B included D 503 regulated D, 503 exempt
D Distribution of Residuals D Surface Disposal
D Closed-loop Groundwater Remediation O Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ~ Yes or D No.
a. Date of site visit: 02/14/2007
b. Person contacted and contact information: Paul T. Poole Jr., Ph.# 9192661369
c. Site visit conducted by: JGreer, RRO-APS
d. Inspection Report Attached: ~ Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
~ Yes or D No. Ifno, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location: __
b. Driving Directions: __
c. USGS Quadrangle Map name and number: _
d. Latitude: Longitude: _
RECEIVED/ DENR / DWQ
AQUIFER'PROTECTION SECTION
EEB 2 7.. 20_0~
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): J I/A
For Disposal and lniection Sites:
(If multiple sites either indicate . which sites the information applies to, copy and paste a new section into the
document for each site, or attach additional pages for each site)
a. Location(s): __
b. Driving Directions: See Map Quest ,
c. USGS Quadrangle Map name and number: __
d Latitude: __ Longitude: __
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section)
Description Of Waste{S} And Facilities
1. Please attach completed rating sheet. Facility Classification:_
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
0 Yes D No D NIA. Ifno, please explain: __
3. Are the new site conditions (soils, topography, depth to water table; etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No D NIA. Ifno, please explain: __
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes D No O NIA. Ifno, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No0
NI A. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D N/A. Ifno, please explain: __
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No D NIA If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No D NIA. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D NIA If yes, attach list of sites
with restrictions (Certification B?)
Ill RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or maior modification
~ysterm·)
Descri ption OfWaste{S) And Facilities
1. Are there appropriately certified ORCs for the facilities? D Yes or O No.
Operator in Charge: __ Certificate#: __
Backup-Operator in Charge: __ Certificate #: __
2. Is the design, maintenance and operation ( e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or O No.
If no, please explain: __
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? D Yes or D No. If no, please explain: __
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
4. Has the site changed in any way that may affect permit (drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain: __
5. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
0 Yes or O No. If no, please explain: __
6. Are the existing application rates (hydraulic or nutrient) still acceptable? D Yes or D No. If no, . please
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Will seasonal or other restrictions be required for added sites? D Yes D No D N/ A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, please attach a
map showing conflict areas or attach any new maps you have received from the applicant to be incorporated
into the permit: __
10. Is the description of the facilities, type and/or volume ofwaste(s) as written in the existing permit correct? D
Yes or D No. Ifno, please explain: ___ _
11. Were monitoring wells properly constructed and located? D Yes or O No ll:;l N/ A If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? D Yes or
D No D N/A. Please summarize any findings resulting from this review: __ _
13. Check all that apply: 0 No compliance issues; 0 Notice(s) of violation within the last permit cycle; 0
Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc): ____ _
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? D Yes
D No D Not Determined D N/ A. If no, please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? 0
Yes or D No O N/ A If yes, please explain: __
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPUCATIONS (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 h~t
pump injection wells.)
Descri ption Of Well(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
[8] Heating/cooling water return flow (5A7)
0 Closed-loop heat pump system (5QM/5QW)
D In situ remediation (5I)
D Closed-loop groundwater remediation effluent injection (5Lf'Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? [8] Yes D No
3. Are there any potential pollution sources that may affect injection? 0 Yes [8] No
What is/are the pollution source(s)? --~· _Wh~=at~i=s~th=e~di=·=st=an=c=e~o=f~th=e~in"'"je=c=ti=o=n~w~e=ll=(s=)c....=fr=o=m=-=th=e=--.Jp""'o=ll=u=ti=on=
source(s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 75 ft.
5. Quality of drainage at site: [8] Good O Adequate O Poor
6. Flooding potential of site: ~ Low D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable. If No, exRlain and recommend any changes to the
groundwater monitoring program: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? [8] Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal And Modification Only :
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes IZJ No. If yes. explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes . D No. If yes, explain:
3. For renewal or modification of groundwater remediation permits (of any type ), will
continued/additional/modified injections have an adverse impact on migration of the p lume or manag ement of
the contamination incident? 0 Yes O No. If yes, explain:
4 . Drilling contractor: Name: Letco DBA NWPoole Well & Pump Company. Inc.
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address: PO Boxl 958
3500 Rolesvilles Rd, Wendell NC 27591
Certification number: 3122
5. Complete and attach Well Construction Data Sheet.
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet-ifneed.ed information is available
3. Do you foresee any problems with issuance/renewal of this permit? D Yes IZl No. If yes, please explain
briefly. __
4. List any items that you would like APS Central Office to obtain through an additional infonnation request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7. Recommendation: 0 Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; 0 Issue upon receipt of needed additional infonnation; IZl
Issue; 0 Deny. If deny, please state reasons: __
8. Signatureofreportpr~ ~ = JA...,_____ ~---z..1,f P)
Signature of APS regi~or: -~--.... ~~-----------------
Date: z/z ,fa-1
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
Compliance Inspection Report
Permit: WI0500134
SOC:
Effective: 10/25/05 Expiration: 10/31 /1 0 Owner: Paul T Poole
Effective: Expiration: Facility: Poole, Paul -SFR
County: Wake
Region: Raleigh
Contact Person: Paul T Poole
Directions to Facility:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 02/14/2007
Primary Inspector: Jimmie W Greer
Secondary lnspector(s):
Reason for Inspection: Routine
Entry Time: 09:00 AM
Certification:
5516 Watkins Rd
Wendell NC 275919235
Phone:
Phone:
Exit Time: 10:00 AM
Phone: [phone]
Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well (5A7)
Facility Status: ■ Compliant D Not Compliant
Question Areas:
■Wells ■ System Operations
(See attachment summary)
Page: 1
Permlt:WI0500134
Inspection Date: 02/14'2007
Inspection Summary:
Owner -Facility: Paul T Poole
Inspection Type: Compliance Evaluation Reason for V1111t: Routine
Page:2
Permit: WI0500134
Inspection Date: 02/14/2007
owner -Facility: Paul T Poole
Inspection Type: Compliance Evaluation Reason for Visit: Routine
System Operatlo~
Is same well used as source well and injection well?
Is injection WE)II capable of assimilating injected fluid?
Injection flow rate at time of inspection (gpm)
Has system owner/operator noticed any abnormalities (turbidity, air in system, poor heating/cooling, etc) in
system operation?
Comment on system operation
Is system operation and construction consistent with that described in application?
Describe inconsistencies between application and observed operation/construction
System is operating normally
Comment: System is on line and OK.
BIMS000905
Location
Distance from septic tank & dralnfield (feet)
Distance from other waste disposal/collection
Comment
+ 100 from septic system+ Horse Bam
Distance from other pollution source (feet)
Comment
Pond, Horse Sam, ,§eptic system all Plus 100'
Is well location subject to flooding?
Minimum distance to property boundary (ft)
(feet)
Comment: Near a creek, small creek not subject to flooding
Casing
Type
Depth (ft b.f.s)
Weight/thickness
Weight/thickness
.(Oecimal range. e.g. 15.5 to 25.5 ft)
Height (A.L.S)
Comment: about 75feet from creek
Grout
Type
Yes No NA NE
•□□□
•□□□
□•□□
□•□□
•□□□
Yes No NA NE
100
100
100
□•□□
75
Yes No NA NE
. Galvanized Steel
2
25
2
Yes No NA NE
Concrete Grout
.. Page: 3
Permit: Wl0500134
Inspection Date: 02/1412007
owner -Facility: Paul T Poole
Inspection Type: Compliance Evaluation
Thickness
Depth
Comment:
ID Plate
(Decimal range, e.g. 15.5 to 25.5 fl)
2 to 3 inches around the casing
ID Plate present & properly completed?
Well Contractor indicated on ID Plate?
Comment:
Comment:
Reason for Visit: Routine
2
2
20
Yes No NA NE
■ODO
•□□□
Page:4
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
I
INJECTION WELL PERAUT NO. WI CZ-o) DATE VC;,' _f _m
NAME OF OWNER G� /
ADDRESS OF OWNER /G r,! _ .
{Street/ road or lot and suddh lion, caamty, town)
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable) LLjj
y: e ,J-4- r1 e'a/ Y /i %r .7 c� f -�i. �: _?^: � .�.-.�. I� �j i� � a-t 7 •. � r .�. _ � 1�t►auir
(Street road nr lat and suddivisim , county, town, ifdoea mt dwn owner's address, plus desmplian of location on site)
Potential pollution source Distance from well 1 L>
Potential pollution source 1-21F Distance from well 7s-'
Potential pollution source C1 Distance from well
Minimum distance of proposed well from property boundary
Quality of drains a at site Flooding potential of site
�r ,( o��equate poor} (high,mad e
DRAW 5 CH OF srrE
(Show pro k liatvtdaries, buildings, wells potential pollution sources, rvttd� a prositnate scale, aqd north arrow.)
Aj
Bl
P
J
M
4�kl 14�-
j !Il
`'� Merch 98
OU

Page 2 of 2
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (coat)
i ►AE►T.fi
INSI ECTQR - '
Once Z,
WITNESS
Address
W DYESS
Address
March 98

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 a S� f 3_ DATE
NAME OF OWNER
ADDRESS OF OWNER
U P
(Street/ road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL (anal source well(s), if applicable)
(Streetl road or lot and subdivision , county, town, if different than owner's address, plus description of location on site)
Potential pollution source 2-, r} � Distance from well t��t.
Potential pollution source -► , -. Distance from well -7 5-
Potential pollution source t_�AAz-_ Distance from well rt5
Minimum distance of well from property boundary f 1� 5
Quality of_drainage at site
ft4dequate,poor}
Flooding potential of site
(high, moderate,low})
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and
north arrow.)
.4i
DESCRIBE INJECTION SYSTEM (vertical closed loop, encased borehole or cased water well; separate source well and
injection weyl combination source and injection well, or other description as applicable)

I r
INJECTION FACILITY INSPECTION REPORT -FORM B (CONTINUED)
WELL CONSTRUCTION
Date constructed r � 3
Drilling contractor: Name
Ge_-Ar_y .1 .�
�,Iia��
1�7�►! '�.�, -C? _ r�
Address —�f T�'►s-
i'�
�t��-,,�-:Y
11e F�j
Registration numbers a_
fr�'3 ��+,�.-�•4 .
_�
Total depth of well S- 7 ;�, Total depth of source well
(f applicable)
Inspection point
Measurement
Meets minimum
standards Comments
Yes
No
Casing
Depth
7 5'�
+f
Diameter
4),
Height (A.L.S.)
77,1
Grout
Depth
Screens
Depth(s)
Length(s)
—
r
I.D. Plate
Static water level
i J
Well yield�<�,•�
— -T
Enclosure
Enclosure floor
(concrete)
Sampling port
(labeled)
Water tight pipe entry
Well enclosure entry
Vent
Functioning of heat pump system (Determine from the owner if heat pump functions properly.)
INSPECTOR Office
i
WITNESS J, Address
WITNESS Address March 1998

91
r
16L -I
North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources =
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
County
❑uad No Serial No
Lat
Long
SAMPLE TYPE SAMPLE PRIORITY
Water Routine
[] Soil ❑ Emergency
❑ Other
Report To: ARO, FRO, MRO,4EDWaRO, WiRO, JIL ❑ Chain of Custody
WSRO, Kinston FO, Fed. Trust, Central Off., Other:
Shipped by: Bus, Courier and De ., Other- Purpose:
Collector(s): J Date 0-')- J 27 Time Af c zr z> $aline,
0
Lab Number
Date Received 49' Time
Rec`d by: From: Bus, Courier,
Other:
Data Entry By: Ck:
Date Reported:
LUS �, Pesticide Study, Federal Tr ss. OthaE: C C " -yl v
FIr.LD ANALYSES Owner ■ - :ems
pH4DD Spec. Cond'94 1 -?.6 at 250 C Location or site et 7 J
Temp.10 I z oC Odor ^�1�� its Description of sampling point _
Appearance ' A - Sampling Method Sample Interval -S7 c) �
Field Analysis By: Remarks
LABORATQRY ANALYSES oor1piN t6me. of tgrt� IMP,)
1301)310 m Il
piss. Solids 70300 m A
A - Silver 46566 u 1
COD High 340 mgll
Fiouride g51 m
Al - Aluminum 46557 ugA
COD Low 335 mgA
Har ne s: Total 900 l
As - Arsenio 46551 u p
Coliform: MF Fecal 31616 11oom1
Hardness Mon-carbj 902 mqA
Ba - Barium 46558 ugA
Coliform: MF Total 31504 1100MI
PhOnrjlS 73
Ca - CalClum 46552 m
La Comments:
b4 ,
24 Z
' Z
For Dissolved Analyssubmit filtered sample and write "DM" in bN
�J
!I
O anochlorine Pesticides
Organophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCB's
Semivolatile Organics
TPH - Diesel Range
Volatile Organics (VOA bottle)
TPH - Gasoline Range
r—tI TPH - BTEX GasollrB Ronne
rt

WO La6orator4 _' --
Sample ID:
AB13481
Loc. Descr,:
f
PAUL T POOLE JR
�� �u e.� f
PO Number #
VisitlD
7GO07i5
-'x:aton ID:
RROAPNLC
County.
River Basin
WARE
T
WA
Collect Date:
0211442007
Report To
RROAP
�F
�7
Collect Time::
10:30
Region:
Collector:
RRO
.] GREER
RECZVEp j DENR / DWO
Ao(ffF;Q DRt1i'Ft'il1'fWsK110t'z
Date Received:
Time Received:
02/14/2007
11:55
Sample Matrix:
GROUNDWATER
t� ��yyn 77
MA{` �• � �UV1, �
Lahwarks Lvginl❑
i1flMA
Loc. Type:
WATER SUPPLY
Date Reported:
03112J2007
Sample Depth
Sample Comment
Emergency Yes/No
C n .. -1-
CDC Yng)Nn
Analyte dame -�
LAB
Sample temperature at receipt by lab I
MIC
Coliform, MP Fecal in liquid I 1
Coliform, MF Total in liquid 1
WAR❑
Result Qualifler Units Approved By
3.4 °C MMATHIS
1 32 CFUJI00ml CGREEN
1 52 CFU1100ml CGREEN
Alkalinity4.5
26 mg/L as CaCO3 ESTAFFORD
Alkalinity8.3
1 U mgIL as CaGO3 ESTAFFORD
Bicarbonate
26 mg1L as CaCO3 ESTAFFORD
Carbonate
1 t1 mg/L as CaCO3 ESTAFFORD
pH
6.0 mglL as CaCO3 ESTAFFORD
WET
Chloride in liquid 5 13 mg1L MOVERMAN
Sulfate in liquid 5 12 mg1L MOVERMAN
Total Dissolved Solids in liquid Ila 151 mglL MOVERMAN
NUT
NH3 as N in liquid
0.02
0.02 (1
mg/L as N
CGREEN
Total Kjeldahl N as N in liquid
0.2
0.20 U
mg1L as N
CGREEN
NO2+NO3 as N in liquid
0.02
8.1
mg/L as N
CGREEN
Phosphorus_total as P in liquid
0.02
0.02
mg1L as P
CGREEN
Nitrate as N in liquid
0,01
7.98
mg/L as N
CGREEN
Nitrite as N in liquid
0.01
0.12
mg)L as N
CGREEN
MET
7440-70-2 Ca by ICP 0.10 116 mg1L ESTAFFORD
t_abcratory Section>> 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone] Page 1 of 2

X(DWO Laboratory ,section vLesyh
Loc. Descr.: PAUL T POOLE JR
Location ID: RROAPNLC 35�
County: WAKE -o��F NNA7- R;9
River Basin
Report To RROAP - l�
Region: RRO iQ�w QENR i DWQ >
-^l
Collector: J GREER A(yjIPg1Mr)ir-fYifnN fi>"CTtdN
Sample Matrix: GROUNDWATER
Lac. Type: WATER SUPPLY
Sample Depth �`fy
Sample Comment
Sample ID:
AB13480
PO Number #
7G00T4
VtsittD
Collect Date:
0211412007
Collect Time:-
10:00
Date Received:
02J1412007
Time Received:
11:55
Labworks Loginl❑
MMA
Date Reported:
03112J2G07
Emergency Yes/Na
COC Yes/No
CAS r*1 Anaiyte Name PQL Result Qualifier Units Approved By
LAB
Sample temperature at receipt by lab 3.9 °C MMATHIS
MIC
Coliform, MF Fecal in liquid `1 I i B2 CFU1100ml CGREEN
Coliform, MF Total in liquid 1 1 B2 CFL)1100mI CGREEN
WARD
Alkalinity4.5
23 mg/L as CaCO3 ESTAFFORD
Alkalinity8,3
1 U mg1L as CaCO3 ESTAFFORD
Bicarbonate
23 mg1L as CaCO3 ESTAFFORD
Carbonate
1 mg1L as CaCO3 ESTAFFORD
PH
8.0 mg/L as CaCO3 ESTAFFORD
WET
Chloride in liquid 5 14 mg1L MOVERMAN
Sulfate in liquid 5 12 mg1L MOVERMAN
Total Dissolved Solids in liquid 110 159 mglL MOVERMAN
NUT
NH3 as N In liquid
0.02
0,02 u
mg1L as N
CGREEN
Total Kjeldahl N as N in liquid
0.2
0.20 U
mg/L as N
CGREEN
NO2+NO3 as N in liquid
0.02
7.8
mg?L as N
CGREEN
Phosphorus total as P in liquid
0.02
0.03
mg/L as P
CGREEN
Nitrate as N in liquid
0.01
7.67
mg1L as N
CGREEN
Nitrite as N in liquid
0.01
0.13
rnglL as N
CGREEN
MET
7440-70-2 Ca by 1CP 10.10 16 mglL ESTAFFORD
Laboratory -Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone] Page 1 of 2

'M , <D'WO Laborato rv .,ection <R.esu[ts
Loe. Descr.: PAUL T POOLE JR
Sample ID: AB13480
PO Number# 7G00it4
Location ID : RROAPNLC VisitlD
County: WAKE
River Basin
Report To RROAP
Region: RRO
Collector: J GREER
Sample Matrix: GROUNDWATER
Loe. Type: WATER SUPPLY
Sample Depth
o~~ Collect Date: 02/14/2007
ci3 y Collect Time :: 10:00
> C Date Received: 02/14/2007 --i 0 -,;;
Time Received: 11:55
Labworks LoginlD MMA
Date Reported: 03/12/2007
Sample Comment
Emergency Yes/No
COC Yes/No
I CAS# Analyte Name PQL Result Qualifier Units Approve d By I
7440-43-9 Cd by ICPMS 1.0 1.0 u ug/L EST AFFORD
7440-47-3 Cr by ICPMS 10 10 u ug/L ESTAFFORD
7440-50-8 Cu by ICPMS 2.0 12 ug/L EST AFFORD
7440-48-4 Fe by ICP 50 50 u ug/L ESTAFFORD
7439-95-4 Mg bylCP 0.10 2.9 mg/L EST AFFORD
7439-96-5 Mn bylCPMS 10 29 ug/L ESTAFFORD
7440-23-4 Na by ICP 0.10 11 mg/L ESTAFFORD
7440-02-0 Niby ICPMS 10 10 u ug/L ESTAFFORD
7439-92-1 Pb by ICPMS 10 10 u ug/L EST AFFORD
7440-66-6 Zn by ICP 10 7000 ug/L ESTAFFORD
Laboratory Section» 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone] Page 2 of 2
Loc. Descr.:
PAUL T POOLE JR
Location ID:
RROAPNLC
County:
WAKE
River Basin
Report To
RROAP
Region:
RRO
Catlectar-,
J GREER
Sample Matrix:
GROUNDWATER
Loc. Type:
WATER SUPPLY
Sample Depth
Sample Comment
Sample ID:
Ag13481
PO Number #
7GO075
Visitio
VNATF���
QF
Collect Date:
02114/2007
OtCollect
r
Time::
10:30
RECE ED IOEM J DWO
a �
Date Received:
O?J141200T
A0UFM W--7s fW.qFC"
Time Received:
11:55
MAR 16 20071
Labworks LoginlD
MMA
Date Reported:
03/12/2007
Emergency Yes/No
COC Yes/No
CAS H
Analyte Name
PQL
Result
Qualifier
Units
Approved By
7440-i3-9
Cd by ICPMS
1.0
1.0
U
uglL
ESTAFFORD
7440.47-3
Cr by ICPMS
10
10
U
ug/L
ESTAFFORD
744D-5M
Cu by ICPMS
2.0
25
ug/L
ESTAFFORD
7440-48-4
Fe by ICP
50
50
U
uy1L
ESTAFFORD
7439-95-4
Mg by ICP
0.10
2.8
mg1L
ESTAFFORD
7439-96-5
Mn by ICPMS
13
29
ug/L
ESTAFFORD
7440-23-4
Na by ICP
DAD
11
mg1L
ESTAFFORD
7440-02-0
Ni by ICPMS
10
10
U
ug/L
ESTAFFORD
7439-92.1
Pb by ICPMS
10
10
U
ug/L
ESTAFFORD
7440-66-6
Zn by ICP
10
7100
ugh-
ESTAFFORD
Laboratory Sectlon» 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone] Page 2 of 2

GROUNDWATER FIELD/LAB FORM
County
Quad No Serial No.
Lat.
Long.
SAMPLETYPE
® Water
❑ Sall
❑ Other_.
Report To: ARO, FRO, MR '�,g�Q.�WaRO, WiRO,
WSRO, Kinston FO, Fed, Trust, Central Off., Other:
Shipped by: Bus, Courier and Dei Other-
Collector(s): Date L71 L ) Y o_2 Time
SAMPLE PRIORITY
® Routine
❑ Emergency
❑ Chain of Custody
Purpose:
North C a r o I I n a z7j l
Department of Environment and Natural R ' 6urces
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
01
Lab Number 2 r
Date Received0 ` Time
Reed by From: Bus, Courier, an ,
Other:
Data Entry By: -
Date Reported:
Ck:
, Pesticide Study, Federal Trus<�1 G " ��4
FIELD ANALYSES Owner y'I Ac'
pEi400 Spec. Cond.94 at 250 C Location or site X � j Alef
Temp.,, oC Odor r--1y pl-e Description of sampling point _ G��' I I
Appearance C P, r— Sampling Method Sample Interval /� o
Field Analysis By: Remarks �' _ 72—� �—
LABQRATQRY NALYSES t".ak1WWetc:}
BOp 3ic m if
piss.Solids 70300 m
A - Silver 46566 uQn
COD High 34o mgA
Flouride 951 m
Al - Aluminum 46557 u I
COD Low 335 m A
: Total m
As - Arsenic 46551 U
Coliform: MF Fecal 31616 /100MI
Hardness non -cart 902 m A
Ba - Barium 46558 ugA
Coliform: MF Total 31504 1100ml
p n
Ca - Calcium 46552 mqA
TOG 680 m
j
Cd - Cadmium 46559 u
Turbidity 76 NTU
Sulfate 945 mqji
Cr - Chromium 46560 uqA
Residue., Suspended 530 mgA
Sulfide 745 mco
Cu - Copper 46582 ugA
Fe - Iron 46563 ugA
Olt and Grease m 11
N - Mercury 71900 ugA
pH 403 unit
K - Potassium 46555 m I
Alkalinity to pH 4.5 410 mgA
M - Magnesium 46554 m rl
Alkalinity to pH 8.3 416 mgA
Mn - Manganese 46565 u q
Cafbanat6 445 mgA
NH as N 610 m 4
Na - Sodium 46556 m 11
Bicarbonate 440 m
>
Carbon dioxide 405 mgfl
NO + NO as N 630 m I
Pb -Lead 46564 u I
Chloride 94o mgA
P: Total as P 665 m 11
Se - Selenium u I
Chromium: Hex 1032 u 11
Zn - Zinc 46567 uQA
Color: True 8o CU
Iq [l ►�! .d
Cyanide 720 mgll
LI!
L
Lab Comments:
,l `1 rE
GW-54 REV.12t7�
rn
z
7
Y-.L Al df%.
For Dissolved Analysis - submit filtered sample and write "DIS" in bit.
IrJ
Pesticides
rus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCBs
Semivolaiile Organics
TPH - Diesel Range
Volatile Organics (VOA
TPH - Gasoline Range
TPH - BTEX Gasolfre I

DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
October 19, 2005
MEMORANDUM
TO: Debra Watts ~~ \iJ@
THROUGH: Evan Kane ~
FROM: Thomas Slusser1J3 _
RE: Issuance of a Type 5A7 Injection Well Permit
Paul T. Poole, Jr.
Wendell, Wake County
I recommend that the attached permit WI0500134 be issued to Paul T. Poole, Jr. for the operation of a
Type SA 7 injection well for the injection of heat pump effluent. Mr. Poole submitted his application
for an injection well permit on 30 June 2005 and Mr. Jim Greer conducted a pre-construction
inspection on 18 October 2005. Mr. Poole intends to use an existing well as a combination household
water supply and injection well, and the injection well system is expected to be completed by 1 April
2006. Mr. Greer's inspection revealed that the proposed injection well is 50 feet down gradient of a
septic system repair area. Mr. Greer recommends issuance of this permit with the special condition
that the permittee install a 100-foot PVC liner inside the injection well casing if this septic repair area
is ever used in order to prevent a potential health risk to anyone who may drink water from this well.
Mr. Poole will contact Mr. Greer once the injection system is fully operational so that Mr. Greer may
perform the post-construction inspection and sampling of influent and effluent. Please let me know if
you have any questions regarding this submittal.
Attachment
;;ve I( /:r1 -er -Pel, f-JL -2-
( ce ht WeL I ~
A we/( ~fc{:fc/S -.Jr_
Michael F. Easley, Governor
WiIIiarn C. Ross Jr., Secretary
North Carolina Departmcat of Environmentand Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
27 October 2005
Paul T. Poole, Jr.
5516 Watkins Road
Wendell, NC 27591
Ref: issuance of Injection Permit W10500134
Dear Mr. Poole:
In accordance with your application submitted 30 June 2005, the Division of Water Quality's Underground
Injection Control (UIC) Program is forwarding Permit WI0500134 for the construction and operation of a
geothermal heat pump injection system at 5516 Watkins Road, Wendell, North Carolina, in Wake County. This
permit shall be effective from the date of issuance until 31 October 2010 and shall be subject to the conditions
and limitations stated therein. Please read your permit carefully to make sure you thoroughly understand its
requirements your and responsibilities, especially Item #2 of Part If — Well Construction Special Conditions.
Post -construction inspection and sampling of this geothermal heat pump system is necessary to complete the
pennitting process. You must contact the Division of Water Quality's Raleigh Regional Office at (919) 791-
4200 to schedule the post -construction inspection once the injection well system becomes operational: Please
note, if the 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-
Please contact me at [phone] or Evan Kane at [phone] if you have any questions regarding your
permit, the UIC Program, or injection rules and regulations.
Best regards,
Thomas Slusser
Hydrogeological Technician II
UIC Program
Cc: Jay Zimmerman, Raleigh Regional Office
CO-UIC Files
XataroI-
raly
Aquifer Protection Seetion 1636 Mail service Center Raleigh, NC 27699-1636 Phone [phone] Customer Service
Internet: http:llhzo.cnr.state.nc.us 2728 Capital Boulevard Raleigh, NC 27604 Fax [phone]
Fax [phone]M
An Equal opporturtltylAfilnnafive Action Employer — 50% Recyciedl10% Post Consumer Paper

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
PAUL T. POOLE, JR.
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5A7 INJECTION WELL, defined in
Title 15A North Carolina Administrative Code 2C .0209(e)(3)tA), which will be used for the
injection of heat pump effluent. This injection well will be located at 5516 Watkins Road, Wendell,
Wake County, North Carolina, and will be operated in accordance with the application submitted on
30 June 2005 and in conformity with the specifications and supporting data submitted, all of which
are filed with the Department of Environment and Natural Resources and are considered a part of
this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the Water
Use Act or any other applicable Laws, Rules, or Regulations. Operation and use ofan 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 31 October 2010,
and shall be subject to the specified conditions and limitations set forth in Parts I through X hereof.
Permit issued this the S day of 05L&V— 2005.
Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No, WI0500134 PAGE 1 OF 6
GWfWC-5 ver. 7105

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface
cannot migrate into the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each injection well shall have permanently affixed an identification plate.
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection
well to, DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1636
Mail Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well
construction.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall
notify the Aquifer Protection Section-Underground Injection Control (UIC), Central Office
staff, telephone number [phone] and the Raleigh Regional Office Aquifer
Protection Section Staff, telephone number [phone].
2. This injection well also serves as a household water supply well and is located 50 feet
down-gradient of the septic system repair area. The permittee shall have installed a 100-
foot PVC liner into the injection well casing if ever the septic system repair area is used in
order to avert a potential threat to the health of those who may drink water from this well.
PennitNo. WI0500134
GW/UIC-5 ver. 7/05
PAGE20F 6
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a naine 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
complyiii.g 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, ihe
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
3. At least forty-eight ( 48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section-Underground
Injection Control (UIC), Central Office staff, telephone number [phone]. Notification
is required so that Division staff can inspect or otherwise review the injection facility and
determine if it is in compliance with permit conditions.
PermitNo. WI0500134
GW/UIC-5 ver. 7/05
PAGE30F6
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 Raleigh Regional Office, telephone number [phone], any of
the following:
(A) Any occurrence at the injection facility which results in any unusual
operating circumstances;
(B) Any failure due to known or unlgiown 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.
PermitNo. WI0500134
GW/UIC-5 ver. 7/05
PAGE40F6
PART Vlll -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an
extension.
PART IX-CHANGE OF WELL STATUS
1. The Pennittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinuation of use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including 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 atiunderground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
Permit No. WI0500134
GW/UIC-5 ver. 7/05
PAGE50F6
(G) The Pennittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion of
abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X-OPERATION AND USE SPECIAL CONDITIONS
None.
PennitNo. WI0500134
GW/UIC-5 ver. 7/05
PAGE60F6
q 1UNDWATER SECTION STAFF "'SPORT
DATE aF SLTE VISIT: ,a / COUNTY:
F4GLM NbmE LM TION: _
Ae
nA—T9 R RESENTATIVES•
Sire a s es mes-
NAMES-
�so appicabwo
TIMEOP ARRIVAL: S Z>
TIMEOFOEPARTURE: D
WEATHER CONDrnONS: p �
MR,
T TLES: e_
PHONE
PHONEW.
:2 / !2- ��% -7 z�
REASON FOR visrz�CAMPLIANC COIImPLAINT. UST RELEASE, AST RELEASE, SOIL STOCKPILE,
TYPE OF SAMPLE9TJkEN: SOIL tGR1AR. COLP=M. GW, SURFACE WATER, OTHER
NO. OF SAMPLES:�
TYPE -OF CDWAM SUSPECTED: GAS. DIESEL KERO, FUEL OIL, WASTE,'1.,15ED OIL~ SOLVENTS,
PESTICIDES, OTHER
SUSPECT® SOURC t {� r r aZ) A
PHOTOS TA MC- YES NO NUMBER OF PHOTOS
SUMMARY OF-fjNQjt1GS & C. 4;( aw a additional ah"ta if nwms=q) Jr17 -5E;V57'� I,kd—
e-4C�v
rs
ATTACH A 5KETCH OF SITE (show r[ Ah arrow, egos. rasds, wall �. sa�mPIG kxmtlons, lo�atage, d landmarl
This farm not needed for initfai visit it PIRF f zsad; This farm should be used for all !allow -up visits_
SIGNATURE(S): GW STAFF PERSn L -
REVIEWED BY: DATE
SUPERVISOR: RECEIVED IE�SION NECT
_ NOTEL BATE:
COPY: FILE OCT 19 2005 FX4DRPv i-45

!. --90 ...
GROUNDWATER SECTION SITE' 'SIT REPORT
SKETCH OF SITE
DAT€-°OF SITE VISIT: _________ _
FACILlTY NAME & LOCATION:
SCALE: ______ _
(NOTE: 0UIGIW6 SH0UU) 11 TO SCM.L D&SIGNA'M Nc«tM CIAecTION, ETC.)
' I I
I
I I
I I I
I
I
. I
; i
I '
• I
l \ t
I I
:
I
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I
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IV\
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RECEIVEo / DENPJ DWO
AQUIFER PROTECTION SECTION
OCT 19 2005
1 Of 1 10/18/2005 11:09 AM

{
JI
I �
AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: rune 17. 2005
To: ❑ Landon Davidson, ARO-APS ❑ David May, WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Charlie Stehman, Wilk -APS
❑ Andrew Pitney, MRO-APS ❑ Sherri Knight, WSRO-APS
- ® Jay Zimmerman, RRO-APS
a �T>7onnas Slusser, , Groundwater Protection Unit
Telephone; OM 715-6166 �AT Fax: [phone]
E-Mail: [e-mail]
A. Permit Number: W10500134 =
B. Owner: PAUL T. POOLE, JR_
C. Facility/Operation: HOME
❑ Proposed ® Existing ❑ Facility ❑ Operation
D. Application:
1. Permit Type: ❑ Animal ❑ Surface irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ TIE Lagoon ❑ GW Remediation (ND)
® UIC - (5A7) open loop geothermal
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type: ❑ New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: ❑ 1 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.
❑ 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 forth, 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.
F � �
RO-APS Reviewer: 1� Date• �S
FORM: APSARR 09/04 Page 1 of 1

w'4 Michael F. Easley, Governor
�o +!i William G. Roas Jr.. Secretary
Z r North Carolina Departtncnt of Eavironmeat and Natural Rmurces
." Alan V Klimek, P.E. Director
Division of Water Quality
.tune 17, 2005
Paul T. Poole, Jr.
5516 Watkins Road
Wendell, NC 27591
Ref: Injection Well Application Receipt
Dear Mr. Poole:
Your application for a permit to construct and 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 Raleigh Regional
Office staff will be contacting you to arrange an inspection of the injection well site as part of the review.
Please contact me at 919-715-6166 or Evan Kane at 919-715-6182 if you have any questions regarding the
Underground Injection Control Program or injection well rules and regulations.
Best Regazds,
Azgw-4
Thomas Slusser
Hydrogeological Technician H
UIC Program
CC- Jay Zimmerman, Raleigh Regional Office
CO-UIC Files
tv
Carolina
ut�lC�
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Phone [phone] Customer Service
Internet: http:llh2o.eur.state,ne.us 2728 Capital Boulevard Raleigh, NC 27604 Fax (9I9) 715-0588 1-877-623.6748
Fax [phone]M
An Equal opportunlVAffirmafive Anion Employer — 50% 8ecycledll0% Past Consumer Paper

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERNUT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type 5A7 and 5QM Wells
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and :nail to address on the back page_
DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: rttftec!--- l — , 20 °,-T--
SYSTEM CLASSIFICATION Please check column which matches proposed system. care
(1) Type 5A7 wells inject water used to provide heating or cooling for structures.
(2) Type 5QM wells contain a subsurface system of continuous piping, that is
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes and/or corrosion 1%)
inhibitors. �-
ao
(3) Type 5QW wells contain a subsurface system of continuous piping, that is
isolated from the environment and only circulates potable water. If you selected
this well type, then complete form GW 57 GL, Notification Of Intent To
Construct A Closer[ Loop Ceotkeronat-Water Only Injection Well System.
PERMIT APPLICANT
Name: Iwac_ t�l�� cc - -
Address: ^�16 Lr1�`�'►�%+rf _ ll
City: State: /A&= Zip Code:,g= County:
Telephone: RG1e G ! 3� -- ce-L-z- ?1 ? i92o
PROPERTY OWhTER (if different fram. a�plidanit)
Name:
Address:
City:
Sate: Zip Code: County'
Telephone:
STATUS OF APPLICANT
Private: Federal:
State: Municipal:
Commercial:
Native American Lands:
BIMs
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GW/UIC-57 HP July 28, 2004 Page I of 4

FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Dame of Business or Facility:
Address:
City: _ _ Zip Code: County:
Telephone: Contact Person:
HEAT PUMP CONTRACTOR DATA
Name: _ : �, T�t��Y ? W/�I5 : c.` i-ly C-_
Address: - - o t.'I LG � 07.7- - - - -
City: ' & ve - &Z.0A"-� Zip Code: pA z E� 5 County:
Telephone: Z6 61/-S— Contact Person: MA TT au p21 r7,
INJECTION PROCEDURE (Briefly describe how the injection.well(s) will be Used.)
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES e-` NO
(2) Personal consumption? YES ^V 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-
i (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: C o_Z 11 _C. f a a LE
NC Contractor Certification number: 3 ! a Z_
(2) Date to be constructed:-,Z - c+- Number of borings:
f
Approximate depth of each boring (feet): 62
(3) Well casing: Is the well(s) Cased?
(a) YES a'- If yes, then provide the casing information below,
Type: Galvanized steel Black steel Plastic _ Other (specify)_ w
Casing depth: From a to?.— ft. (reference to land surface)
Casing extends above ground inches
(b) NO
IAC-57 HP July 28, 2004 Page 2 of 4

(4) Grout ((material surrounding well casing and/or piping):
(a) Grout type: Cement r/ Bentonite Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
around closed loop piping; from to (feet).
tf around well casing; from , � _ to .Z- (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 provision
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) an(
effluent (fluid being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? yes ✓ no - - (b) Lthe 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 Forin GWA is not available
provide the data in part K (1) of this application form to the best of your knowledge,
NUI'E: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IFTHIS INFORMATION IS UNAVAfLABLE BY OTHER MEANS.
J. PROPOSED OPERATING DATA (for Type 5A7 wells)
(1) Injection rate: Average (daily) -: -gallons per minute (gptn).
(2) Injection Volume: Average (daily} 5�0 gallons per day (gpd).
(3) Injection Pressure: Average (daily) Co poundslsquare inch (psi).
(4) Injection Temperature: Average (January) .`- - OF, Average (July) F.
K. INJECTION FLUID DATA
(I) Fluid source (far Type 5A7 wells) If underground, from what depth, formation and type of
- - - rocktsediment-unit-will-the fluid-be-drawn-(e.g ,.granite.-l-imestone., sand. etc. i.
Depth: Formation:— _ - Rock/sediment unit: .
(2) Chemical Analysis of Source Fluid (for Type 5QM wells)
Provide a complete listi1.,
of all chemicals added to the circulating heat transfer fluid.
I1 V-lye r r�"' ur, 4
L. FNJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/cubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.

LOCATION OF WELL(S) Attach two maps.
(1) Include a site map (can be drawn) showing. buildings, property lines, surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks or
drain fields located within 1000 feet of the geothermal heat pump well system. Label all
features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
PERMIT LIST. Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Nan -Discharge permits
(3) Sewage Treatment and Disposal Permits
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 faise 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."
7�
(Signature of Well Owner or Authorized gent)
If awhori: ed agent is neting on heha f of the well ❑i->>ner,
please supply a letter signed 6y the cmier authorizing the above agent.
CONSENT OF PROPERTY OWNER (Owner means any parson 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 Itereby 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
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
JJC-57 HP July 29, 2004 Pagc 4 of

WAKE COUNTY DEPARTMENT OF ENVIRONMENTAL SERVRVK= WELL AND SEWAGE SITE LOCATION PERMIT
NO PERMIT(S) FOR CONSTRUCTION, LOCATION OR RELOCATION ACTIVITY SHALL BE ISSUED
UNTIL AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION HAS BEEN ISSUED
IT VOID IF NOT IN COMPLIANCE Y1itTH ZONING REGULATIONS ANDI OR IF SITE IS ALTERED OR INTENDED USE CHANGED'
': D027065 STATUS: A APP. DATE: 0H3W2003 BLDG. PERMiTC. 0040249
W04 73 2961 000 TAX MAP: 0416 0024 RECORDED: Y ORIG. PERMITf:
HIP: 17 ST fAAT THEWS JURISDICTION: WC ZONING: R30
ANT: POOLE, PAUL T JR
5516 WATKINS RC
WENDEL , NC 27S51
(919) 256 -1369
HD USE 0002 VERIFYIEXISTING SYSTEM
EXIST USE: 101 ONE -FAMILY HOUSE
DISPOSAL BEDROOMS: 3 BASEMENT: Y *EMPLOYEES: 0 FOUND DRAIN. N
ADDRESS: 5516 WATKINS RD
SUBDIVISION: POOLE, PAUL LOT: 2 ACRES: 7.80
ON: US 64 E TU LT ON OLD MILOURNIE TU RT ON WATKINS
PROPERTY ON THE RT
LE: 1000 gal. PUMP Tank: gal. SO FT: 1200 STONE DEPTH: 12 in. MAX DEPTH LINE: iS in.
DATER: INDIVIDUAL SEWAGE: DOMESTIC TYPE SYSTEM,11 A PUMP: N PIM: N
OW: 380 gal/day DESIGN FEE RE4?: PAID?: WATER: INDIVIDUAL
ITS:
D? Y DATE; OW2912003 BY:
PHObW: 857 9355
VOID =TY (60) MONTHS FROM BATE OF ISSUANCE
AUTHORIZATION CONDMONS:
7r5 shall install system on contours, see attached site plan far wastewater system design and well location_ No
and utilities, water lines or sprinkler systems may be located in the original system or repair areas. A septic tank filter
er for access is required. The wastewater system shall not be covered or placed into use until inspected by the Wake
epartment of Environmental Services and an ❑perabon Permit issued. OTHER CO3VOMNS:
YSTEM 3135' CONVENTIONAL LINES. CONTRACTOR TO FOLLOW LAYOUT IN FIELD. SKETCH ON CA SITE PLAN IS
MATE. FOLLOW GIVEN SETBACKS. KEEP TANK 15' OFF BASEMENT FOUNDATION. CALL OFFICE WITH ANY
YS.
1000 gal. PUMP TANK 9W. SO FT: 1200 STONE DEPTH: 12 in. MAX DEPTH LINE: 18 in.
OPEfR: N L/O: Y TRENCH#: 3 LENGTI i 135 R WIDTH: 36 in. DESIGNER: —
.DS: _ DESIGN HEAD PRESSURE _ DESIGN YLOW. gatWnin DOSE VOLUME: _ gal.
]? Y DATE: 09/2912003 BY: (SCR)�_ PHONFA: 857-9355

WAKE COUNTY DEPARTMENT OF ENVIRONMENTAL SERVICES WELL AND SEWAGE SITE LOCATION PERMIT
NO PERMIT(S) FOR CONSTRUCTION, LOCATION OR RELOCATION ACTIVITY SHALL BE ISSUED
UNTIL AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION HAS BEEN ISSUED
*PERMIT VOID IF NOT IN COMPLIANCE WITH ZONING REGULATIONS AND/ OR IF SITE IS ALTERED OR INTENDED USE CHANGED*
PERMIT#: D027065 STATUS: A
PIN: 1756.04 73 2951 000
TOWNSHIP: 17 ST MATTHEWS
APPLICANT: POOLE, PAUL T JR
APP. DATE: 04/30/2003
TAX MAP: 0415 0024
JURISDICTION: WC
BLDG. PERMIT#: 0040249
RECORDED: Y ORIG. PERMIT#:
USE:
5516 WATKINS RD
WENDELL, NC 27591
( 919) 266 -1369
HD USE: 0002 VERIFY/EXISTING SYSTEM
EXIST USE: 101 ONE-FAMILY HOUSE
ZONING: R30
DISPOSAL: BEDROOMS: 3 BASEMENT: Y #EMPLOYEES: 0
SITE: ADDRESS: 5516 WATKINS RD
SUBDNISION: POOLE, PAUL LOT: 2
DIRECTION: US 64 E TU LT ON OLD MILBURNIE TU RT ON WATKINS
PROPERTY ON THE RT
Well System: WATER: INDMDUAL
ACRES: 7.80
TYPE: NEW
WELL LOG INFORMATION: DEPTH: __ CASING DEPTH:_ YIELD:___ STATIC LEVEL: __ _
WELLI CONTRACTOR:______ REG.# PUMP CONTRACTOR: _____ _ REG.#
Construction Compliance GROUT APPROVED O DATE ___ EHS _______ _
WELLHEAD APPROVED O DATE ___ EHS _______ _
SYSTEM FINALIZED O DATE ___ EHS _______ _
COMMENTS:
Operation Permit
DESIGN FLOW: __ gal./min. ACTUAL FLOW:____ INNOVATIVE LETTER: N
INSTALLED BY: ___________ _ INSTALLATION APPROVED BY: ___________ _
PROPRIETARY SYSTEM: FILTER NO: _______ _
COMMENTS :
OPERATIONS PERMIT ISSUED? OP DATE: BY: ...................................................................... ,. .................................. ,. ............................................................................................ .
This permit is based in part on information provided by the homeowner or his/her representative in the application submitted for this pennit
The Environmental Health Specialist is not responsible for false or misleading information contained in the application. The Environmental
Health Specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from
false or misleading statements provided to him in the application. Neither Wake County nor the Environmental Health Specialist warrants
that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable.
As Built Information:
Date: ---Rod reading: __ _ Benchmark: ___ _ Distance to Structure:
ST: ___ gals ID#: ____ _ D.O.M: ______ Elev.: __ _ Distance to Well: __ _
PT: ____ gals D.O.M.: _____ Elev.: __ _ ID#: -----D-box/FD/PM elev.: ____ _ Supply Line: ft. Pump/Control Panel: _______ _
Line I : __ _ Date: ---
Line 2: ---Date: __ _
:..ine3: __ _ Date: __ _
:..ine4: ---Date: __ _
Jine5: __ _ Date: __ _
)istance to P/L: ___ _ Notes: __________________________ _
r
structurejs) are accurately yngmm, V understand—
gib • • :.,, �..
failure to locate strticturesin aaaordance with this
plot plan. rriay requirio, the relmtion ..of
structur"i regardless degree of completion. I
hereby ant permission fu 'MunicipAi/County
tatives
Sill .
Rapresc the right of Oniry to make
evskcations or inspactions upgr this property.
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