WI0500143_GEOTHERMAL_20120518

Beverly Eaves Perdue
Governor
J...'P"'A-.a:··~~ d"---NCDENR-=~ --
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E:
Director
May 18, 2012
Kevin and Michelle Kahn
405 Lake Hogan Farm Road
Chapel Hill, NC 27516
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0500143
Dear Mr. and Mrs. Kahn
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you-that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http://portal.ncdenr.org/web/wq/aps.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
£_ ✓j)11ij~-
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity \ Aff.rmalive Action Employer
One North Carolina
;Vatttra!ly
.
Permit Number WI0500143
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Kevin and Michelle Kahn SFR 5OM
Location Address
405 Lake Hogan Farm Rd
Chapel Hill
Owner
Owner Name
Michelle
Dates/Events
Orig Issue
08/04/06
NC 27516
Simmo Kahn
ns
App Received Draft Initiated
04/20/11
Scheduled
Issuance
Central Files: APS_ SWP_
05/05/11
Permit Tracking Slip
Status
Active
Version
2.00
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Michelle Simmons Kahn
405 Lake Hogan Farm Rd
Chapel Hill NC 27516
Public Notice Issue
04/28/11
Effective
04/28/11
Expiration
03/31/16
Re o ulated Activities Re a uested/Received Events ------------------------
Heat Pump Injection Region comments on draft requested
Region comments on draft received
Outfall NULL
Waterbody Name Stream Index Number Current Class
04/28/11
04/28/11
Subbasin
..
Permit Number WI0500143
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
john .mccray
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Kevin and Michelle Kahn SFR 5QM
Location Address
405 Lake Hogan Farfn Rd
Chapel Hill
Owner
Owner Name
Michelle
Da tes/Events
Orig Issue
08/04/06
NC 27516
Simmo Kahn
ns
App Received Draft Initiated
04/20/11
Scheduled
Issuance
Central Files : APS_ SWP_
04/29/11
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Michelle Simmons Kahn
405 Lake Hogan Farm Rd
Chapel Hill NC 27516
Public Notice Issue Effective Expiration
_R_e~g'-u_la_t __ e_d_A_c_t_iv_i_ti_e_s ________________ Re quested/Received Events
Heat Pump Injection Region comments on draft requested
Region comments on draft received
c;>utfall NULL
Waterbody Name Stream Index Number Current Class
04/28/11
04/28/11
Subbasin
Mccray, John
From:
Sent:
To:
Cc:
Subject:
John,
Mccartney, Lin
Thursday, April 28, 2011 1 :15 PM
Mccray, John
Zimmerman, Jay
SQM WI0500143, Kevin Kahn
Raleigh Regional Office would like to acknowledge that we have received an application to construct a SQM well,
WI0500143. I plan on conducting an inspection during the construction.
Thanks,
Lin McCartney
Environmental Senior Technician
APS, Raleigh Regional Office
919-791-4243
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.
35° s~, .SIP"'
·7 q O oS '.SJ ,,.
1
Mccray , John
From:
Sent:
To:
Subject:
Attachments:
Mr. Zimmerman,
Mccray, John
Thursday, April 28, 2011 10:09 AM
Zimmerman, Jay
WI0500143 renewal
wi0500143application.pdf
Attached you will find a copy of the renewal application for permit WI0500143. Please let me know how your office
wishes to proceed with the renewal.
Best Regards,
John McCray
1
NA
NC DE NR
North Caroiina Department of Environment and Natural Resources
Division of Water Quality
Beveriy Eaves Perdue
Governor
Coleen H. Sullins
Director
April 26, 2011
Kevin Kahn
Michelle Kahn
405 Lake Hogan Farm Ro~d
Chapel Hill, NC 27516
Subject: Acknowledgement of Application No. WI0500143
Dr. & Mrs. Kahn SFR
Injection Mixed Fluid GSHP Well System ( SQM)
Orange
Dear Mr. & Mrs. Kahn:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on April 20, 2011. This application package has been assigned the number listed above and will be reviewed by
John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information ifnf?cessary. 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. '
Pl.ease 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 C!ln take as long as 60 -90 days after receiptof a complete
application. ·
If you have any questions, please contact John McCray at 919-715-6168, or via e-mail [e-mail]. If the reviewer is
unavailable, you may leave a message, and they will respond promptly.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
0~&-~
for Debra J. Watts
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Permit Application File WI0500143
AQUIFER PROTECTION SECTIOI~
1636 Mail Service Cenier, Raleigh, North Carolina 27699-1636
Locaiion: 2728 Capital Boulevard. Raleigti, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Serviee: 1-877-623-6748
Internet: www.ncwaterquality.org
A·1 Equal Opportun;~y \ Affirm~t:ve .A.c::c;--i Employe~
Nirth Carolina
/vaturall!I
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERAW TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP MIXED -FLUID GEOTHERMAL INJECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system
(check one) New Application Renewal* Modification
Print or Type Information and Maid to the Address on the Last Page. ]!legible Applications Will Be Returned As Incomplete_
DATE: 14-11` , 2011
RECEIVED ! DrrNFt 1 01W
PERMIT NO..WI 05 0014 3 (leave blank if New Application) RqW� Protection Sin
APR 2 0 2011
A. STATUS OF APPLICANT (choose one)
Non-Govemment: Individual Residence ✓ Business/Organization
Government: State Municipal County Federal
B. PERMIT APPLICANT — For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
Kum W AM& Y-PJAY.
Mailing Address: THE KAHNS
City. CHAPEL HILL W127516 Zip Code: County: n"
Day Tele No. 919 933-0687 Cell No.:
EMAIL Address: �' �r1 e�4►hf tT Fax No.:
C. LOCATION OF WELL SITE — Where the injection wells we physically located:
(1) Parcel Identification Number (PIN) of well site: County:
(2) Physical Address (if different than mailing address): A40
City: _ State: NC Zip Code:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No..
Company Name:
Contact Person: EMAIL Address:
Address:
city -
Office Tele No.:
Zip Code: State; County: _
Cell No.: Fax N
GPU 11C 5QM Permit Application (Revised 1/2412011)
Page i

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: __________________________________ _
Contact Person.:...: _______________ __.E=MA=-"'I=L"--'-'A=d=d=re=s=s_,_: ___________ _
Address:--------------------------------------
City: __________ Zip Code: ____ _ State: __ County: _________ _
Office Tele No.: _________ Cell No.: __________ =-F=ax'-'--=-N-'--'o"-" . .,_: _______ _
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: _____ Depth of each boring (feet): ________ _
* If existing water supply wells will be used then provide the information in item ( 4) below.
(2) Chemical additives to be used: R-22 ___ Propylene glycol ___ Ethanol __ _
Other _________ (other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper; PVC, etc): ________________ _
(4) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, plastic, etc.), diameter, depth,
and extent of casing appearing above ground:
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** __ Other (specify) _______ _
** By selecting bentonite grout, a variance is hereby requested to ISA NCAC 2C .0213(dXl)(A), which requires a cement type grout.
(b) Grout depth of !1,lbirig (reference to land surface): from ____ to ___ (feet)
If well has casing, indicate grout depth: fr~m ____ to _____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearlv and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water-bcfdi.eg * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing p1·operty lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC SQM Permit Applicati~n (Revised 1/24/2011) Page 2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
1 SA NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer,
2_ for a partnersbip 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 (which means all persons listed on the propert%_ 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 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
iniection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Signature of Property Owner/Applicant
Am &A &M
Print or Type Full Name
Signature of Property OwnerlApplicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED I MNR l OWG
Aquit'r pMtfirA on St=c 'M
APR 2 0 z411
GPUNIC SQNt Pemut Application (Revised 1124/2011) Page 3

State of Nortli'� Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: W 10500 19 �
Permittee Name: �A A d[e, ad Kto n &—ho
Please check the selection which most closely describes the current status of your injection well system:
i 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) ❑ Weil(s) not abandoned
4) ❑ Injection weli(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping 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 ❑f material used to fill the well f fpermanentl}, 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 of the
permit. Do you wish to rescind the permit?
❑ Yes ❑ No
Certification',
T "I hereby certify, under penalty of law, that I have personalty 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."
Signature
Revised 5105 GWlUlC-68
�•�51f
Date
RECUVE❑ t GENR ► DWZJ
AgVef FlOter -on Sacbon
APR 2 0 1011

Norm Carolina
Beveriy Eaves Perdue
Governor
Kevin Icahn
Michelle Kahn
405 Lake Hogan Farm Road _
Chapel Hill, NC 27516
+r'N
-A
NCDENR
Department of Environment and Natural
Division of water Quality
Coleen H. Sullins
Director
April 26, 2011
Subject: Acknowledgement of Application No. WI0500143
Dr. & Mrs. Kahn SFR
Injection Mixed Fluid GSHP Well System (5QM)
Orange
Dear Mr. & Mrs. Kahn:
Resources
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (I)ivision) acknowledges receipt of your permit application and
supporting materials on April 20, 2011. This application package has been assigned the number listed above and will be reviewed by
John McCray.
The reviewer will perform a detailed review and contact you with a request far 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 belu A,, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days after receipt of a complete
application.
If you have any questions, please contact John McCray at 919-715-6168, or via e-mail at john.mccrayGncdenngov. If the reviewer is
unavailable, you may leave a message, and they will respond promptly.
PLEASE REFER TO TIIE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROTECT.
Sincerely,
�J �Wattsfor Debra J
Supervisor
cc, Raleigh Regional Office, Aquifer Protection Section
Permit Application File W10500143
AQUIFER PROTECTION SECTION
1636 ViajI Sanice Cente,. Raleigh, North GerolFra 27W-1636
Location, 2729 Capital Boulevard, Rabeigh. North Carolina 27604
Phone: [phone] FA. X'.- 919-715J0588. FAX 2' 919-715.6048-1 Customer Seryice . 1-877-623-6748
Intemet www,ncwale-.ualitv,or
fir• ztu,1 Cppww, i. lnfnm; ise A^Ann Emoovc
One NCraroli-na
Aaaaral`

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Duality
Beverly paves Perdue
Governor
Kevin and Michelle Kahn
405 Lake Hogan Farris Rd
Chapel Hill. NC 27 516
Coleen H. Sullins
Director
April 28. 2011
Ref: Issuance of Injection Well Permit W1105001.43
Issued to Kevin and Michelle Kahn
Chapel Hill.. Orange Cowity, North Carolina
Dear Dr. and M.s. KA-m.:
Dee Freeman
Secretary
In accordance with the renewal application received on April 20, 2011. I am forwarding permit number W10500143
for the operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system. This permit
shall be effective from the date of issuance until March 31, 2016, and shall be subject to the conditions and
limitations stated therein, including the requirement to install well identification tags as specified in Part 11.2.
Be sure to read the entire permit to ensure that you are aware of all compliance requirements of the permit.
You will need to notify this office at least 48 hours prior to beginning construction and operation of the injection
well system. In order to continue uninterrupted legal use of the injection facility for the stated purpose, you musk
submit an application to renew the permit 120 days prior to its expiration date. This permit is not transferable to
any person without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at (919) 715-61 G8 [e-mail] if you have any questions about your permit.
Best Regards,
John McCray
Jay Zimmerman- Raleigh Reuional Office
W1050G]43 Permit File Y
C =,-,: County Environmental Health Dept.
AQUIFER PROTECTION 5ECTLt.
1636 Mail Servip, Center, Raleigh, North Carai na 27699.1636
! aCas!orr 2728 uaphar Boulevard, Raleigh. Korth Gamkna 27W
anmw 91G 73a'2211Fk, 1.919.7155K1 r4Y, 2: 919-715-5048 ' CLlswmer SeMccg 14,Tt-6=3-HAF
Internet %Wnewatermalktv.oro
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1v orw Carohna
.An EC aai Gppor;_ ^.1 4 AffmamP you --- ipDow

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
hi accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
Kevin and Michelle Kahn
FOR THE OPERATION OF 10 TYPE 5QM INJECTION WELLS), defined in Title 15A North Carolina
Administrative Code 2C 0209(c)(3)(F), for the purpose of operating a vertical closed loop geothermal mixed
fluid heat pump system. This system is located at 405 Lake Hogan Farm Road, Chapel Hill, Orange County,
and will be operated in accordance with the application received April 20, 2011, and in conformity with the
specifications and supporting data submitted, all of which are filed with the Department of Environment and
Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation of an injection well and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until March 31, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 28th day of April, 2011_
�019-ZO •,'C L�
or-
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit UWIUS00143 UiCJSQM Page Y of 5
ver.0312010

.
PAST I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
2. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit #WI0500143 UIC/SQM
ver. 03/2010
Page 2 of 5
PARTIVTPERFORMANCESTANDARDS
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. fu 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
ground water 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.
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. Division 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. All required documentation shall be submitted to:
Aquifer Protection Section -UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Permit #WI0500143 UIC/SQM
ver. 03/2010
Aquifer Protection Section
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Ph# 919-791-4200
Page 3 of 5
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Raleigh Regional Office within 30 days of completion
of well construction. Copies of the GW-1 form(s) shall also be given to the Permittee and retained on site
to be made available for inspection.
3 . A copy of the site map updated with manifold locations required in Part II.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Raleigh Regional Office within 30 days
of completion of well construction:
4. 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.
5. 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;
(C) Any loss ofrefrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6 . 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.
7 . In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the di~continued 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, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l).
Notification shall be submitted to the addresses given in Part VII. I of this permit.
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:
Permit #WI0500143 UIC/SQM
ver. 03/2010
Page 4 of 5
(A). All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for. or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.I of this permit.
Permit #WI0500143 UIC/SQM
ver. 03/2010
Page 5 of 5
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RECEIVED/ DEN I DWQ
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Form G1iWla
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Mechanical Integrity Test Record
(For 5QM Geothermal Heat Pump l4ection Well System)
Owner/Permittee Name: tom, �r" +� : �• PermitNumber: W_i i i '� I r
_ a
Facility Address: ' t�4� , ry L
Home Phone:
1 Cell Phone.
Heat Pump Contractor Na ne:
Office Phone: 0 1 K
Tester Name:
Date of Test:
Signature:
I.oa
lwdw Pressure ul'j Final Pressure rJ)
Duration (minutes)
Pass 'es or No
2
1
t
3
4
5
6
7
i
9
10
11
12
13
14
�
15
Any additional loop testing add to bade of this form
Comments: ( ❑
Other T�st Methods and Results:
r
This fvnn must be &tied out and signed by the tester. The record must be received by Aquifer Protection Section 24 hours
prior to the initiation of the operation of the facility. You can send the form by malt: UIC Program, Mail Service Center 1636,
Raleigh, NC 27699 or by fax: [phone].
Mechanical Integrity Test Fc m 1 1/2007

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HOME
incorporated
t e
Mr. Michael Rogers,
Please find the following Mechanical Integrity Test Records and triangulation maps for the following
projects. I will be sending you another packet of the remaining 07 and 08 projects at my soonest
convenience. Thank you for your patience and help on this matter.
• WIO0800137
• WIO500157
• WIO500161
• WIO500162
• WO500169
• WlO700107
• WIO700096
• WIO500143
• WIO700093
• WIO700095
• WIO500185 -not included on permit list.
Best Regards,
/I /I;{ A/I -· I l i(,//f.// ((A../
Anna Jeffreys
Administrative Assistant
Home Energy Inc.
RECEIVED / DENR / D"(VQ
Aquifer Protection Section
JAN 2 9 2009
302 E -i Street VVendell NC 27591 • 919-366-0261
r ' '
Permit No.
W10400082
W100800137
W10500145
W10800140
W10500157
Wlf]100086
W10700105
WI0500161
W145D0162
W 10500163
W10500166
W10500169
W 10700107
W10800150
W10500171
W 10500170
W10700094
W10800136
Wf0500139
W101300135
W10700096
W10500143
W 10700093
W 10700095
W10500173
W10500174
List of issued Permits to Home Energy, Inc.
Name
Braden
Panigutti
Clark
Belanger
S. Martin
Combs
Chenill
Stein V
Lauer
6lachowicz
-Mffff mw-�-
Maloneyy
Latta
Duan
ENT Audiology
Griffin
Harris
Jefferson
Essick
Wilson
Stolar x
Kahn /
Young
Tumer
Bell
Wilson Community College
November 20, 2007
Heat Pump Contractor
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Mont: Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Date Permit Issued
11 /20/2006
11/22/2006
101912006
2/13/2007
3/9/2007
4/1812007
5/17/2007
5/27/2007
7/612007
8/2012007
8f17/2007
l0/1212007
9/21/2007
9/20/2907
9/2012007
10/11 /2007
7130/2006
9/12/2006
1/6/2006
9/1212006
9/22/2006
8141200E
7/312006
9122/2006
not permitted as of 11/20/07
t 1/20/2007
RECEIVED 1 DENR / DVYG
Aquifer Protection Secticr;
JAN 2 9 2009

VW 0 �_0 0
November 27, 2007
Monte Jefferson
Horne Energy. Inc.
PO Box 238
Wendell, NC 27591
Subject: Geothermal Well Installation Data
Dear Mr. Jefferson:
Michaal F. Easley, Governor
William G. Ross Jr.. Secretary
North Carolina Department oFEnvironment and Natural Resources
Coleen Sullins, Director
Division of Water Quality
In review of our records concerning closed -loop geothermal mixed -fluid injection well systems,
classified as 5QM type permits, we have found the following records have not been submitted
for permits where your company is listed as the heat pump installers:
• Well Construction Record (GW-1)
■ Triangulation Data
r Well ID plate installation date
■ Mechanical Integrity Pressure testing data (if available)
In order to assist your clients (those who hold 5QM permits) in meeting the condition of their
permits, Home Energy, Inc. (specifically Brad Scheel) has agreed to provide the above
information no later than December 27, 2007. For future reference, as we discussed November
14, 2007, we recommend you provide this information to your clients as soon as construction is
complete to assist them in meeting the condition of their permits. Also, please remember their
permits require them to keep this information on -site as well.
To assist you, we have attached a list of permits where you are listed as the heat pump installer.
We have also attached a form to fill out the results of your mechanical integrity tests. Thank you
in advance for your cooperation and timely response. If you leave any questions regarding this
letter, please call me at [phone] or Michael Rogers at [phone],
Sincerely,
Debra J. Watts
Environmental Supervisor
Groundwater Protection Unit
Attachment(s)
cc: APS Central Files (copy to each permit file on attached list)
Aquifer Protection Section 1636 Mail Service Center
Internet: wwwmwatergu ahimig Locution: 2728 Capital Boulevard
An Equal Qppartunf ylAflirrnaiive Action Empbyer— 50% Recydedll0%Post Consumer Fa per
Nonce Carolina
�Xatttr,741
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: (919) 71 S-p588
Fax 2: [phone]
Customer Service: [phone]

List of Issued Permits to Home Energy, Inc.
Permit No. Name Heat Pump Contractor Date Permit Issued
WI0400082 Braden Monte Jefferson 11/20/2006
WI00800137 Panigutti Monte Jefferson 11/22/2006
WI0500145 Clark Monte Jefferson 10/9/2006
WI0800140 Belanger Monte Jefferson 2/13/2007
WI0500157 S. Martin Monte Jefferson 3/9/2007
WI0100086 Combs Monte Jefferson 4/18/2007
WI0700105 Cherrillo Monte Jefferson 5/17/2007
WI0500161 Stein Monte Jefferson 6/27/2007
WI0500162 Lauer Monte Jefferson 7/6/2007
WI0500163 Blachowicz Monte Jefferson 8/20/2007
WI0500166 Manning Monte Jefferson 8/17/2007
WI0500169 Maloney Monte Jefferson 10/12/2007
WI0700107 Latta Monte Jefferson 9/21/2007
WI0800150 Duan Monte Jefferson 9/20/2007
WI0500171 ENT Audiology Monte Jefferson 9/20/2007
WI0500170 Griffin Monte Jefferson 10/11/2007
WI0700094 Harris Monte Jefferson 7/30/2006
WI0800136 Jefferson Monte Jefferson 9/12/2006
WI0500139 Essick Monte Jefferson 1/6/2006
WI0800135 Wilson Monte Jefferson 9/12/2006
WI0700096 Stolar Monte Jefferson 9/22/2006
WI0500143 Kahn Monte Jefferson 8/4/2006
WI0700093 Young Monte Jefferson 7/3/2006
WI0700095 Turner Monte Jefferson 9/22/2006
WI0500173 Bell Monte Jefferson not permitted as of 11 /20/07
WI0500174 Wilson Community College Monte Jefferson 11/20/2007
November 20, 2007
Mechanical Integrity Test Record
(For SQM Geothermal Heat Pump Injection Well System)
Owner/Permittee Name: Permit Number: WI --------------------'---'---'"--------
Facility Address: _______________________________ _
Home Phone: Cell Phone:
Heat Pump Contractor Name: ___________________________ _
Office Phone: Cell Phone: -----------------~~~~~------------
Test er Name: _______________ Signature: _______________ _
Date of Test: --------
Loop Initial Pressure (p si) Final Pressure (p si) Duration (minutes)
1
2
3
4
5
6 .
7
8
9
10
11
12
13
14
15
Any additional loop testing add to back of this form
Comments:
Pass (Yes or No)
----------------------------------
Other Test Methods and Results:
This form must be filled out and signed by the tester. The record must be received by Aquifer Protection Section 24 hours
prior to the initiation of the operation of the facility . You can send the form by mail: UIC Program, Mail Service Center 1636,
Raleigh, NC 27699 orby fax: [phone].
Mechanical Integrity Test Form 11/2007
5arg5 �
�� [►�� G� r�� wit !�[ �c - ���

lt
-·
-·
,.
Michael F. Easicy, Governor
William G. Ross k , Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E- Director
Division of Water Quality
August 3, 2006
Kevin & Michelle Icahn
405 Lake Hogan Farm Road
Chapel Hill, NC 27516
Subject. Permit Transmittal Letter
Injection Mixed Fluid GSHP Well System (5QM)
Permit No. WI0500143
Dr. & Mrs. Kahn SFR
Orange County
Dear Dr. & Mrs. Kahn:
In accordance with your application received on rune 13, 2006, the Division of Water Quality's
Underground Injection Control ([]IC) Program is forwarding Permit No. W10500143 for the construction
and operation of a geothermal heat pump injection system at 405 Lake Hogan Farm Road in Chapel Hill,
North Carolina. This permit shall be effective from the date of issuance until August 31, 2011, and shall
be subject to the conditions and limitations stated therein. Please read your permit carefully to make sure
you thoroughly understand its requirements and your responsibilities.
Post -construction inspection of this geothermal heat pump system is necessary to complete the permitting
process. You must contact the Division of Water Quality's Raleigh Regional Office at [phone] 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. Additionally. as specified in
Part 11. Section 10 of vour permit. a copy of the post -installation nressurelyacuum test record must be
received by the_Aguifer Protection Section at least tw=y_four (24) hours prior to time initiation of the
operation of your injection system.
Please call me at [phone], or email rue atgu._ i &,ncmail.net, if you have any questions regarding
your permit, the [.UIC Program, or injection rules and regulations.
Sincerely,
Qu Qi, P.G.
UIC Program Manager
Aquifer Protection Section
Enclosures
cc. biome Energy, Inc. - Monte Jefferson
Raleigh Regional Office
APS Central Files
Aquifer Protection section 1636 Mail Service Center
]n[ernet: wwW.ncwatcxquality.org Location: 2728 Capital Boulevard
An Equal OppoduniWAfirmative Action Employer— 5D% Recycled110% Post Consumer Paper
Nw` Carolina
Xatxrally
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service- [phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OFA 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
Kevin and Michelle Kahn
FOR THE CONSTRUCTION AND OPERATION OF TEN (10) TYPE SQM INJECTION WELLS,
defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of
operating a "direct expansion" type vertical closed-loop geothermal-mixed-fluid heat pump system.
This system is located at 405 Lake Hogan Fann Road in Chapel Hill, Orange County, North
Carolina, and will be constructed and operated in accordance with the application submitted June 13,
2006, and in conformity with the specifications and supporting data submitted, all of which are filed
with the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation only and does not waive any provisions of the Water
Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an injection well
shall be in compliance with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and
any other Laws, Rules, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until July 31, 2011, and
shall be subject to the specified conditions and limitations set forth in Parts I through X hereof.
r RrvY.v.<qr-, Permit issued this the 4 day of_~~ ............. --~~~• 2006.
£k~----j . cNSl:s r-Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
PennitNo. WI0500143
GW/UlC-5QM ver. 7/06
PAGE 1 OF7
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 (ISA 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. Injection wells shall have a permanently affixed identification plate.
8. A completed Well Construction Record (Form GW-1) must be submitted for injection wells
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 constmction.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. Prior to constructing the injection well system, the permittee or his agent shall test the pH of the
soil at a depth of three feet at the planned well location. If the resulting soil pH is less than 6
standard units or greater than 11 standard units, the well system shall be equipped with a
compatible cathodic protection system. All testing results shall be kept on site available for
inspection.
2. At least forty-eight ( 48) hours prior to constmcting system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff,
telephone number [phone] and the Raleigh Regional Office Aquifer Protection Section
Staff, telephone number [phone].
3. All underground tubing shall be refrigeration grade copper tubing.
PennitNo. WI0500143
GW/UIC-5QM ver. 7/06
PAGE2 OF7
4. Prior to installation, all tubing to be placed in boreholes ("loops") shall be checked for leaks by
pressurizing the loop to a gage pressure of at least 3 5 0 pounds per square inch (psig), immersing
the loop in water and examining it for leaks. Loops with leaks shall not be installed.
5 . Prior to installation, each loop shall be visually inspected for damage such as kinks, dents, and
scrapes. Each loop shall be checked to verify that the nitrogen charge applied to the loop by the
manufacturer before shipping is still present at a pressure of at least 300 psig. The loop
manufacturer shall be notified in the event of damage or pressure loss, and the manufacturer's
instructions shall then be followed. The nitrogen charge may be released only when the loop is
installed and ready to be connected to the manifold.
6. Boreholes shall be large enough to allow insertion of the loop plus a tremie pipe for grouting.
7. After insertion of the tubing into the boreholes, an approved grout (as defined in Title ISA North
Carolina Administrative Code 2C .0100) shall be pumped via tremie pipe into the annular space
of each borehole so as to completely fill it from bottom to top.
8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material shall
have a galvanic potential as close as practicable to that of the tubing material.
9. Dry nitrogen shall be circulated through the tubing during brazing to prevent oxidation .
•
10. After installation and prior to operation of the system, a mechanical integrity test shall be
conducted by pressurizing the injection well system to 400 psig with dry nitrogen and monitoring
for leaks using an ultrasonic or other leak detector of equal sensitivity and monitoring pressure in
the system for at least 2 hours. Alternatively, an equivalent vacuum test is acceptable. Any
pressure fluctuation other than that due to thermal expansion and contraction of the testing
medium shall be considered a failed mechanical integrity test. Any leaks shall be located and
repaired prior to charging the system with refrigerant. A copy of the p ost-installation pressure or
vacuum test record (initial p ressure reading, final pressure reading, and the duration of the test )
shall be submitted to the A quifer Protection Section. The test records must be received by the
A quifer Protection Section atleast twenty -four (24) hours prior to the initiation of the o peration
of the facility for injection.
11. The location of each of the system manifolds shall be recorded by triangulation from two
permanent features on the site (e.g., building foundation comers). The permittee shall retain a
copy of the triangulation records. The permittee shall also submit a copy of the triangulation
records to the Aquifer Protection Section within 30 days of completion of well construction.
12. The written documentation required in Part II. p ara gra phs (1 0 ) and (11) shall be submitted to:
Permit No. WI0500143
GW/UIC-SQM
Aquifer Protection Section-IBC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
ver. 7/06
PAGE 3 OF7
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to change
ownership, or there is a name change of the Permittee, a formal permit amendment request
must be submitted to the Director, including any supporting materials as may be appropriate, at
least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying
with any and all statutes, rules, regulations, or ordinances which may be imposed by other
local, state, and federal agencies which have jurisdiction. Furthermore, the issuance of this
permit does not imply that all regulatory requirements have been met.
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is
no contamination of groundwater that will render it unsatisfactory for normal use. In the event
that the facility fails to perform satisfactorily, including the creation of nuisance conditions or
failure of the injection zone to adequately assimilate the injected fluid, thePermittee 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 REQUIREMENrs
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of
any planned physical alterations or additions in the permitted facility or activity not
specifically authorized by the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section's
Underground Injection Control (UIC) Program Central Office staff, telephone number (919)
715-6935. 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.
PennitNo. WI0500143
GW/UIC-5QM ver. 7/06
PAGE4 OF7
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 that results m any unusual operating
circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of
proper injection operations, such as mechanical or electrical failures;
(C) Any loss ofrefrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report to the
Director, the relevant and correct facts or information shall be promptly submitted to the
Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
PermitNo. WI0500143
GW/UIC-5QM ver. 7/06
PAGES OF7
PART VIII -PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an
extension.
PART IX-CHANGE OF WELL STATUS
1. The Pennittee 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.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have not
been removed, the casing shall be perforated opposite the gravel pack, at
intervals not exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner that
will prevent the movement of fluids into or between underground sources of
drinking water and in accordance with the terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as
specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion of
abandonment.
Permit No. WI0500143
GW/UIC-5QM ver. 7/06
PAGE 60F7
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X-PERMIT SPECIAL CONDITIONS
None.
Permit No. WI0500143
GW/UIC-5QM ver. 7/06
PAGE7OF7
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 07/1412006 County: Orange
To: Mulifer Protection Section Central Office Permittee: Kevin & Michelle Kahn.
Central Office Reviewer: Debra Watts Project Name: UIC 5QMClosed Loots
Regional Login No: 05 Application No.: W1050OW143
L GENERA! INFORMATION
I. This application is (check all that apply): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration
❑ Land Application of Residuals ❑ Attachment B included
❑ Distribution. of Residuals ❑ Surface Disposal
EvaporationlIrLfiltration Lagoon
❑ 503 regulated ❑ 503 exempt
❑ Closed -loop Groundwater Remediation ® Other Injection Wells (including in situ rernediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
a. Date of site visit: 06/27/2006
b. Person contacted and contact information: MonIN Jefferson Home Energy lnq.
c. Ph. # 252-2051251
cd. Site visit conducted by: JGreer
d:e. Inspection Report Attached: ® Yes or ❑ No.
2. Is the following information entered into the BIMS record for this application correct?
❑ Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location: 405 Lake Hogan Farm Road, Chanel Hill_ NC 27516
b. Driving Directions: I40 to 54W to old 86N_to HomesteadRd. R ga one mile on L lake Hogan Farm Rd. goo
112 mi on L -
c. USGS Quadrangle Map name and number: D22NE Chapel Hill
d. Latitude: 35.57.03 Longitude: 79.05.54
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): NIA
For Disposal and Iniection 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 sites
a. Locations};
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
II. NEWAND MAJOR MODIFICATIONAPPLICATIONS (this section not needed !or reneivak or miltor
mods rcatrons skip to next section
Description Of Waste(And_ Facilities
1. Please attach completed rating sheet. Facility Classification:
FORM: W105000143.K.K

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No D N/A. 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 N/A. Ifno, please explain: __
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes D No D N/ A. If no, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No D
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. If no, please explain: __
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No D N/ A. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? 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 N/A. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or maior modification
s vstems)
Description Of Waste(S) And Facilities
1. Are there appropriately certified ORCs for the facilities? D Yes or D 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 D No.
If no, pl~ase explain:
FORM: WI05000143.KK 2
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
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: __
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?
D Yes or D No. Ifno, 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. fudicate 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 of waste(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 D No D 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: D No compliance issues; D Notice(s) of violation within the last permit cycle; D
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? D
Yes or D No D N/A. If yes, please explain: __
FORM: WI05000143.KK 3
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Descri ption OfWell(S) And Facilities-New, Renewal , And Modification
1. Type of injection system:
D Heating/cooling water return flow (5A7)
cg] Closed-loop heat pump system (5QM/5QW)
D In situ remediation (SI)
D Closed-loop groundwater remediation effluent injection (SL/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes cg] No
3. Are there any potential pollution sources that may affect injection? D Yes cg] 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~1=·n=-je=c~ti=·o=n~w~e=l=l(=s)~fr==om~t=h~e ....,p~o=ll=u=ti~on
source(s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 50' ft.
5. Quality of drainage at site: cg] Good D Adequate O Poor
6. Flooding potential of site: ~ Low D Moderate O 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)? cg] 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 Onl v:
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)?
0 Yes O No. If y es , 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 yes , explain:
3. For renewal or modification of groundwater remediation permits (of any cvp e ). will
continued/additional/modified in jections have an adverse imp act on mi gr ation of the plume or management of
the contamination incident? D Yes O No. If yes. exp lain:
4. Drilling contractor: Name:
FORM: WI05000143.KK 4
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT .
Address:
Certification number:
5. Complete and attach Well Construction Data Sheet.
FORM: WI05000143.KK 5
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVALUATIONAND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, please explain
briefly.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
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
G. 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:
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
8. Signat
Signat
Date:
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
Country water & Sewers
FORM: W105000143.KK 6

Page] oft
North Carolina Department of Environment and Natural Resources
Division of Water Quality -Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTION
REPORT -FORM A
INJECTION WELL PERWF NO. WI v 5V P-9j q3 DATE p a 7 a
NAME OF OWNER • -- v:.�1 ,�- �i .� Ili �i �1
i 1 ; r .►a ,
r I I--- a.. -
L 0Oz-
'�
(Street/ road or /at and suddivWon, county, tmm)
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicab e) Z g ar'
(Streetl road or lot and suddivision , county, town, if doerew than owner's address, plus descrip&n of locution on site)
Potential pollution source Distance from well
Potential pollution source Distance from well
Potential pollution source Cj Z Distance from well -r S`V
Nfinimum distance of proposed well from property boundary So "
Quality of drainage at site Flooding potential of site
geed degttatepnvr) (high,moder ,low
DRAW SKETCH OF SITE
(Show property bamdades, buildings, wells, potential pollution sources, roads,
—�- el
1
:5�-Iavc - -
L-,, Jn",4 l=Ac, a
le, and north arrow.)
L
Ivj �IMI3

Page 2 of 2
PRECUNSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cons.)
CONEWENTS
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1 of 1 6/27/2006 M

TopoZane - Lake Hogan, USGS Chapel Hill (NQ Topo Map http://www.topozone.com/map.asp?z=17&n=3980156&e=671'.
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Statement.
:):�) -2--Z- �Ij C
7/6/2006 1

Michael F. Easley, Governor
William; &Floss Jr., Secretary
North Caroilna Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
June 16, 2006
Ott. & MRS. KAHN
405 LAKE. HaGAN FARM ROAD
CHAPEL HILL, NC 27516
Subject Acknowledgement of Application No. WI0500143
Dr. & Mrs. Kahn SFR
Closed -Loop Geothermal -Mixed -Fluid Heat Pump System (5QM)
orange County
Dear Dr. & Mrs. Kahn:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your
permit application and supporting materials on June 13, 2006, This application package has been assigned
the number listed above and will be reviewed by Thomas Slusser.
The reviewer will perform a detailed review and contact you with a request for additional information if
necessary. To ensure the maximum efficiency in processing permit applications, the Division requests
your assistance in providing a timely and complete response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior
to final action by the Division. Please also note at this time, processing permit applications can take as
long as 60 - 90 days after receipt of a complete application.
If you have any questions, please contact Thomas Slusser at 919-715-6629, or via e-mail'at
thamas.slusser@,ncmail.net. If the reviewer is unavailable, you may leave a message, and they will
respond promptly.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES
ON THIS PROJECT.
Sincerely,
for Debra J, Watts
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Monte Jefferson - Home Energy, Inc.
U1C Central Files
Aquifer Protection Section 1636 Mail Service Center
Internet: Www.ncwateroualltv.oro Location: 2728 Capital Boulevard
An Equal Opportunity/Affirmative Adon Employer- 50% Recyded110% Post Consumer Paper
14,�rottflfhCaroiina
rI atural
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: (919) 71 "048
Customer Service: [phone]

vL IDS ,O IL3
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RE Q[ : ZyES
APPLICATION FORPERMIT 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 NC:AC Title 15A: 02C.0200
Complete application and mail to address on the back page.
TO. DIRECTOR, NORTH CAROLINA DIVISION OF WArER-QUALITY
DATE: (+ --- (-0 , 20Q�_
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1) Type 5A7 wells inject water used to provide heating or cooling for structures.
(2) X Type 5QM wells contain a subsurface system of continuous piping, that is
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes and/or corrosion
inhibitors.
(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 comol_ete form GW-57 C:L, Notification Of Intent To
Construct A Closet! -,Coop Geother►nat- Water Only Injection Well System.
13. PERMIT APPLICANT
Name: _ )f` ] . "`k` � V `�� -V-
Address: Ll �t t'Y� -
City: f 1iState: 9C Zip Coder;6149 CountyQy,
Telephone: ��r� T a3 —0(OF —1-
C. PROPERTY OWNER (if Tifferent from applicant)
Name:
Address:
City: Sate: Zip Code: County:
Telephone:
D. STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American bands:
Revised 5/05 GWMC-57 HP Page 1 of

E- FACILITY (SITE) DATA
(Fitt out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility:
Address:
City: Zip Code: County:
Telephone: Contact Person:
F_ HEAT PUMP CONTRACTOR DATA
Name: rf �,
Address: --
city: M zip Code: County:
Telepltone: Contact Person: YA& (50 C)
G. INJECTION PROCEDURE (Briefly describe how the 'i jection well(s) wiV be used.
H. WELL USE Will the 'injection welI(s) also be used as the supply well(s) for the folft1wing?
(1) The injection operation? YES _ NO
(2) Personal consumption? YES _ NA'_ 1 �_
I_ 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 Iaiowledge. Attach a copy of Form GW-
1 (Well Construction Record) if available.
PROPOSED WELL to be constructed for use as an injection well. Provide the
data in (1) through (7) below as PROPOSED construction specifications. Submit
Form GW-1 after construction,
(1) Well Drilling Contractor's Name:
NC Contractor Certification number:
(2) Date lobe constructed: G d ❑ —Q (, Nvrnbcr of borings: 10
Approximate depth of each boring (feet):
(3) Well casing: Is the well(s) cased? ND
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel"I 1 II k steel-- Plastic Other (specify)
Casing depth. From �t ►' to ft. (reference to land surface)
Casing extends above ground inches
(b) NO
Revised 5105 GWIUIC-57 HP Page 2 of

(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Sentonite Other (speci 11A_ . t
(b) Gr2",
surface and grout depth (reference to land surface): 44--rA� Q4;A,_
ound closed loo i in from L {
PPP g; � ko��' (feet).
r L-oun well casing, from _ to (feet).
(5) Screens (for Type 5A7 wells)
(a) Depth: From tfeet below ground surface.
(6) N.C. State Regulations ('Title 15A NCAC 2C .0204) require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent (fluid being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? yes_ no (b) the effluent line? yes_. no
(7) SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well).
Attach a copy of Form GWA (Well Construction Record). If Fors GW-1 is not available,
provide the data in part K (1) of this application form to the best of your knowledge.
NOTE: THE WELL ORILLLYG CONTRACTOR CAN SUPPLY THE DATA FOR EI'M R EX19r1NG oR
PR0K)SED WELt S IF THIS INFORMATION IS UNAVAlLA3LEBY OMER MEANS.
.1. PROPOSED OPERATING DATA (for Type 5A7 wells)
(1)
injection rate:
Ave (d. ti }
gallons per minute (gpm)_
(2)
Injection Volume:
AW ge it r
gallons per day (gpd).
(3)
Injection Pressure:
Average (daily)
pounds/square inch (psi).
(4)
Injection Temperature:
Average ( January) 4
F, Average (July) ° F.
K. INJECTION FLUID DATA
(1) Fluid source (fur Type 5A7 wells) If underground, from what depth, formation and type of
rock/sediment unit will the fluid be drawn (e.g., granite, limestone, sand, etc.).
Depth: Formation: Rock/wdiutent unit:
(2) Chemical Analysis of Source Fluid (fur Type 5QM wells)
Provide a compiete listing of all chemicals added to the circulating heat transfer fluid:
L. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout ofthe injection equipment and exterior piping/tubing
associated with the injection operation, Tice manufacturer's brochure may provide supplementary
information.
M. LOCATION OF WELL(S) Attach two maps.
Revised 5/05 GW/iJIC-57 11P
Page 3 of

(1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks or
drain fields located within 1000 feet of the geothermal heat pump well system. Label all
features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(I) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
0. CERTIFICATION
"I hereby certify, under penalty of law, that 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."
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner authorizing the above agent.
P. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the injection well(s) conforms to the Well
Construction Standards (Title 15A NCAC 2C .0200)
Revised 5/05
~_)
roperty Owner IfDifferevt 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
Telephone [phone]
GW /UIC-57 HP Page4 of4
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Directions to Kahn Residence-Chapel Hill / Carboro
Take I-40 West and take exit 266. Go left at the top of the exit ramp and go to the 3rd or
4th light to make a right on Homestead Road.
Once on Homestead Rd go 2. 7 miles and make a right on Lake Hogan Farm Rd. We're at
405 Lake Hogan Farm which is about 0.4 miles up on the left. There are 3 homes up on a
hill across from the neighborhood pool/playground. We're the home on the left.
Permit Number WI0500143
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
thomas.slusser
Permitted Flow
Facilit
Facility Name
Dr. & Mrs. Kahn SFR
Location Address
405 Lake Hogan Farm Rd
Chapel Hill NC 27516
Owner
Owner Name
Michelle
Dates/Events
Orig Issue
Simmo Kahn
ns
App Received Draft Initiated
06/13/06
Scheduled
Issuance
Central Files: APS_ SWP_
06/16/06
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Michelle Kahn
405 Lake Hogan Farm Rd
Chapel Hill NC
Public Notice Issue Effective
27516
Expiration
_R_e_g_u_la_t_ed_A_c_t _iv_it_ie_s _______________ Re q uested/Received Events
RO staff report received
RO staff report requested 06/16/06
Outfall N i } _l,
Waterbody Name Stream Index Number Current Class Subbasin