WI0500157_GEOTHERMAL_20120523

A.VA
MCDENR=·--
Narth Carolina DepartmenLoLEJwironment and Natural Resources ---
Division of Water Quality
Beverly Eaves Perdue
Governor
Steven and Sujittra Martin
723 Holden Street
Raleigh, NC 27604
Charles Wakild,P. E.
Director
May 23, 2012
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0500157
Dear Mr. and Mrs. Martin:
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://p ortal.ncdenr.or g/web/wq/ap s.
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,
Eric G. Smith, P.G.
Hydro geologist
cc : UIC Permit File
AQU IFER PR OTECTION SECTION
1636 Mail Service Center, Raleigh , North Carolina 27699· 1636
Location: 512 N. Sali sbury St, Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
In ternet: www .ncwaterquality.org
An Eq ual Opportu nity\ Affi rma tive Acti on Employer
One
North Carolina
J;atura!ly
Permit Number WI0500157
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Steven and Sujittra Martin SFR
Location Address
723 Holden St
Raleigh
Owner
Owner Name
Steven
Dates/Events
NC
J
27604
Martin
Scheduled
Orig Issue
03/09/07
App Received Draft Initiated Issuance
10/26/11
Central Files: APS_ SWP_
11 /15/11
Permit Tracking Slip
Status
Active
Version
2.00
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Steven J. Martin
723 Holden St
Raleigh NC 27604
Public Notice Issue
11/10/11
Effective
11/10/11
Expiration
10/31/16
Regulated Activities Re a uested/Received Events --=------------------------
Heat Pump Injection RO staff report requested
RO staff report received
Outfall NULL
Waterbody Name Stream Index Number Current Class
11/02/11
11/07/11
Subbasin
Permit Number WI0500157
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Steven and Sujittra Martin SFR
Location Address
723 Holden St
Raleigh
Owner
Owner Name
Steven
Dates/Events
NC
J
27604
Martin
Scheduled
Orig Issue
03/09/07
App Received Draft Initiated Issuance
10/26/11
Regulated Activities
Heal Pump Injection
Outfall NULL
Central Files: APS_ SWP_
11/07/11
Permit Tracking Slip
Status
In review
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Afflllatlon
Owner Type
Individual
Owner Affiliation
Steven J. Martin
723 Holden St
Raleigh NC
Public Notice Issue Effective
Re q uested/Re<:eived Events
RO staff report requested
RO staff report received
27604
Expiration
11/02/11
11/07/11
Waterbody Name Stream Index Number Current Class Subbasin
North Carolina
Beverly Eaves Perdue
Govemor
Steven and Sujittra Martin
723 Holden St.
Raleigh, NC 27604
AK46 C-A
NCDE14 R
Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
November 10, 2011
Ref: Issuance of Injection Well Permit W10500157
Issued to Steven and Sujittra Martin
Raleigh, Wake County
Dear Mr. and Mrs. Martin:
Dee Freeman
Secretary
In accordance with the application received on October 26, 2011, 1 am forwarding permit number W10500157 for
the continued operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system located at
the above referenced address. This permit shall be effective from the date of issuance until October 31, 2016, and
shall be subject to the conditions and limitations stated therein,
Please be advised, in the event there are multiple wells with separate clusters, one well identification tag per
`cluster' of wells should be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location.
Also, please pay special attention to Part V.2. The Permittee shall retain all records of repairs, pressure
tests, maintenance, and other activities needed to maintain normal operating conditions.
In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must 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 [phone] or michael.rogerga•ncdenr.yov if you have any questions about your permit.
cc: Jay Zimmerman, Raleigh Regional Office
WI0500157 Permit File
Ware County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Rajai th, Noah CamlIna 27599-1636
Local on: 2729 Capitai Boulevard, Ralelnh. North Carolina 27604
Phone: [phone] l FAX 1: 919-715A5BB: FAX 2- 9 194, 15-6048 t Cuswma,-8eryice : I-W-s23.574E
internet www.ncwatemuallt, .ory
Best Regards,
12
/4�14wl 61�?
Michael Rogers, P.G. (NC & FL)
hOne
o&..b Carol i na
An Equal OpRorr my l AffiFmi ve Acc .oar Lmwhver

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMESSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Steven and Sujittra Martin
FOR THE CONTINUED OPERATION OF TYPE 5QM INJECTION WELL(S), defined in Title 15A North
Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed -loop
geothermal -mixed -fluid heat pump system. This system is located at 723 Holden St., Raleigh, Wake County,
NC 27604, and will be constructed and operated in accordance with the application received October 26, 2011,
and in conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for operation of an injection well and 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
constructloz and use.
This permit shall be effective, unless revoked, from the date of its issuance until October 31, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through VII hereof.
Permit issued this the I Oth day of November 2011.
I D�� - � Ll_*�
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
WI0500I i7 T11C/5QM-M.F. Renewal Pagel of 4
Version 112010

PART I -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local; state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. In the event that there are multiple wells with separate clusters, one well identification tag per 'cluster' of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
PART II-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 III -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
WI0500157 · UIC/5QM-M.F. Renewal
Version 1/2010
Page 2 of4
PART IV -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 V -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 retain all records of repairs, pressure tests, maintenance, and other activities
needed to maintain normal operating conditions.
3. 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 919-791-4200, 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;
4. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of miy
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.
5. 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 VI-PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
WI0500157 UIC/SQM-M.F. Renewal
Version 1/2010
Page 3 of 4
PART VII -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 prQcedures 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.
3. The written documentation required in Part VII (1) and (2) (G) shall be submitted to:
WI0:500157
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/5QM-M.F . Renewal
Version 1/2010
Page 4 of4
Ro gers, Michael
From: Zimmerman, Jay
Sent:
To:
Monday, November 07, 2011 7:53 AM
Rogers, Michael
Subject: RE : Wl0500157 Martin 5QM renewal
No go ahead an process.
J
From: Rogers, Michael
Sent: Wednesday, November 02, 2011 5:16 PM
To: Zimmerman, Jay
Subject: WIOS00157 Martin SQM renewal
Attached is a SQM renewal app. Let me know if you wish to conduct a pre-permitting inspection or not.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wq/aps/qwpro/permit-applications#geothermApps
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
1
NA
NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Steven J. Martin
Sujittra T. Martin
723 Holden St reet
Raleigh, NC 27604
Dear Mr. and Mrs . Martin:
Coleen H. Sullins
Director
November 1, 2011
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI0500157
Steven Martin SFR
Injection Mixed Fluid GSHP
Well (SQM) System
Wake County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on October 26, 2011. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Raleigh Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
Sincerely, o~~J~V\v\
for Debra J . Watts
Groundwater Protection Unit Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Permit File WI0500157
AQUIFER PROTECTION SECTION
1636 Mail Serv ice Center, Raleigh , North Carolina 27699-1636
Location : 2728 Capital Boulevard, Raleigh, North Carolina 2i604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-5748
Internet: www.ncwateroualitv.org
An Eq:Jal Oppor:cni'..' \ Affirmaliv;; Acton Emrloyer
None, C li ortn aro na
"Vaturall!f
NORTH CAROLfNA DEPARTMl!NT OF ENVIRONMENT ANO NATURAL RESOURCES
Al'PUCA 1'1ON Jl"OR A PERMIT TO CONSTRUCT OR OPERA TE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
C LOSE D-LOOP MIXED-FLUID GEOTHERMAL INJECTION WELLS
111cl1c wctl!i circulate Ou ids olhcr than potable water as part of a geothennal heating and cooling system
(check one) _New Application _[}(_Renewal* _Modification
• For renewals complete Pans A-C and the signature page.
P,1,,, or 1)-pe Jnjr,rmt1/1011 ancl Mt1II lo the Address on rllc Last Page. Illegible Applications Will Be Returned As Incomplete.
DATt:: .Q£~-t2-S ____ , 2011
PERMIT NO. WIOSOOI 57
A. STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence X Business/Organization __
Government: State Municipal__ County__ Federal
B. PERMIT APPLICANT -For individual residences, list each owner on property deed. For all others,
state nnme of entity mid name of person delegated authority to sign on behalf of the business or agency:
Steven J. Mnrtin
Sujittru T. Martin
Mailing Address: 723 Holden Street
City: Raleigh Stale: NC Zip Code: 27604 County: Wake
Doy Tele No.: 919.609.S879 Cell No.: 919.609.5879
EMAIL Address: [e-mail] Fax No.: no fax
C. l.,OCATJON OF WELL SITE -Where the injection wells are physically located:
(I) Parcel Identification Number (PIN) of well site: 1714027969 County: Wake
(2) Physical Address (if different than mailing address): (same as mailing address)
City: _____________ State: NC Zip Code: _______ _
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: _______________________ _
NC Well Drilling Contractor Certification No.: ___________________ _
Company Name: _____________________________ _
Contact Person ... ; __________________ E._M=A-"'l=L""'A""'"d=d=res=s,_: __________ _
Address: _______________________________ _
City: _________ Zip Code: ____ State:_ County: ________ _
Office Tele No.: ________ Cell No.: ________ .._Fai=x~N"-'=o.=: _______ _
Ol'IJ/IIIC 5QM Penni! Application (Revised 1/24/2011) ,ii:.Gt:IVi::U / DENR / DWQ
Aquifer Protection Section
OCT 26 2011
E. HEAT PUMP CONTRACTOR INFORMATION (if different 1bnn driller)
Company Name:. ______________________________ _
Contact Person"-: ----------------!Ea!!M:!!. !.JA'""-llu.,LAU!d~d~rce..:r-~s;'--_________ _
Address: _______________________________ _
City: _________ Zip Code: ____ State: __ County: ________ _
Office Tele No.: Cell No.: Ems._._N.,_.Oa,,!'--_____ _
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: _____ Depth of each boring (feet): ______ :--:-_
• If existing water supply wells will be used tlre11 prm•icle JIit' i1,fimm1tim1 ;,, illtm (-I) 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 ,tmg (steel. PVC, plastic, etc.). m~. ~.
and extent of casing appearing above ground: ________________ _
(S) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite .. __ Other (specify) ______ _
•• By selecting bedonite grout. a variance is hereby requested to I SA NCAC 2C .0213(dX l)(A). which n:qmrcs a cement lype grout
(b) Grout depth of tubing (reference to land surface): from ___ to ___ (feet)
If well has casing. indicate grout depth: from ___ 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 featur~ clearly and jnclude n north arrow.
(1) Attach a site-specific map showing the locations of the following:
• Proposed injection wells • Buildings • Property boundaries
• Surface water bodies • 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 property lines and struC'IUres can be
obtained and downloaded from the applicable county G/S webslle. Typlca/1)•, the property can ~ starched by
owner name or address. The location of the wells In relation to property boundaries, hausa. septic tonts, other
wells, etc. can then be drawn in by hand. Also. a 'layer' can be selected shoM•lng topographic contours or
elevation data.
OPU/UIC SQM Pennit Application{Revised 1/24/2011)
H. CERTIRCATION (to be signed as required below or by that person's nulhori-/ctl agent)
15A NCAC 02C A211(b) requires that all permit applicnliolis shoal be Signed ns rollows,
1. for a corporation: by a responsible corporate officer;
2, for a partnership or sole proprietorship: by a general partner or the proprielor, respectively;
3. for a municipality or a state, federal, or other public ni*e'WY: by either it princilral executive
officer or ranking publicly elected official;
4. Far all others: by the ►veil owner (w is s n11 _'r�11<l �1i4 ���113flt.ltr[�l)�rR}'..t14'.C[i}.
U an authorized agent is signing on behalf of the applicant, then supply n lefter !rlt;ned by lite
applicant that names and Authorizes their agent to sign this applic atlen on their be+htalf.
"I hereby certify, under penalty of law, that I have personally examined and am thritilinr with the information
submitted in this document and all attachments thereto and that, Imsed on my intlidry al' Ihosc: individunts
immediately responsible for obtaining said information. I hclieve that lire inlormaliun Is Ime, mxmrute and
complete. I am aware that there: are significant penalties, including; the passibility of line'. ttntt impris-onrnenl,
for submitting false information. I agree to construct. operaw. maintain, repair. and it �rplwlienhlr, nhfnillnn Ilse
injection well and all related appurtenances in accordance with Itte approved specitientiom and conditions of
the Permit." ) �
Signature of Pup rty ownerfm knot
Steven 3_ Martin
Print or Type Feel I Name
Signature 4 Property Owner/Applicant
Stlittm TMartin
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] RECEIVECD + i;% NR 1 DWQ
Aquifer Prn"ion St:rtan
OCT 26 2011
GPt]MC 5QM I'MMI Application (RrviRd IR412011k rnr;

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Suilins
Governor Director
October 3, 2011
CERTIFIED MAIL # 7010 0780 00017057 6126
RETURN RECEIPT REQUESTED
Steven I. Martin
723 Holden Street
Raleigh, NC 27604
Subject: Notice of Expiration (NNOE)
5QM Geothermal Injection Well
Permit No. W10500157
Wake County
Dear Mr. Martin:
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
located on your property at 723 Holden Street, in Raleigh, NC, which was issued to you on March 9,
2007, and expires on February 29, 2012, is soon due for renewal. If you wish to keep this permit and
operate the injection well system, the permit must be renewed and issued in your name.
If Your Injection Well is Currenthf Inactive:
If the injection well system is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section .0214.
When each well is plugged and abandoned, the well abandonment record (Form GW-30) must be
submitted to our office to certify that the abandonment was properly conducted.
If there has been a change of ownership of the property, an Injection Well Permit Name/Ownership
Change Form must also be submitted, The GW-30 and Name/Ownership Change forms can be found at
http.- 1portal.ncdenr.or weblwg/at �gwprolreportina-forms.
If Your Injection Well is Currenth Active:
If the injection well system is still active and you wish to renew your permit, the renewal application must
be submitted within 120 calendar days of the expiration of your permit. According to our records, you
must submit your permit renewal by November 1.2011.
AQUIFER PRQTECT$0N SECTION
1636 Mail SeNiCe Center. Raleigh, North Cantina 27699-1636
Location: 2728 Capital Boulevard. Raieigh. North Caroline 275n4
Phone: [phone] FAX 1: 9 19-71 5-W88 ; FAX 2: 919-7 15-6048 1 Custotm,ServiCe: 1-€7-623-9.74e.
Intsmet: www.nwaterwuelitY.or�
nn Equal Oopnunny I Afhrmatrve Amon EmpIDM
One
Caroiir-L
akrall .

In order to comply with the regulatory requirements listed under North Carolina Administrative Code
(NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit one of the following enclosed forms:
A. Application for Permit (Renewal) to Constiwl andlor Use a Wells) for Injection with
Geothermal Heal. Pump System for Type 5QM Wells) if the injection well system on your
property is still active.
-OR-
B. Status of'Injection Well System if the injection well system is inactive or has been temporarily or
permanently abandoned.
Please submit the appropriate forms to:
Aquifer Protection Section
Groundwater Protection UDA
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 CTIC 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
htti): Hportal.ncdenr. ore/weblwo /Wsl2-a-prolnermit-an r)licati ons# t:eotherm Apes.
Thank you in advance for your cooperation and timely response. If you have any questions, please
contact me by phone at [phone] or by email at eric.g.smith(wncdenr.gnv.
Sincerely,
I
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Raleigh Regional Office - APS w/o enclosures
APS Central Files - Permit No, WI0500157 w/o enclosures

Beverly Eaves Perdue
Governor
BA NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
October 3, 2011
CERTIFIED MAIL# 7010 0780 0001 7057 6126
RETURN RECEIPT REQUESTED
Steven J. Martin
723 Holden Street
Raleigh, NC 27604
Subject: Notice of Expiration (NOE)
SQM Geothermal Injection Well
Permit No. WI0500157
Wake County
Dear Mr. Martin:
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
located on your property at 723 Holden Street, in Raleigh, NC, which was issued to you on March 9,
2007, and expires on February 29, 2012, is soon due for renewal. If you wish to keep this permit and
operate the injection well system, the permit must be renewed and issued in your name.
If Your Ini ection Well is Currentlv Inactive:
If the injection well system is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section .0214.
When each well is plugged and abandoned, the well abandonment record (Form GW-30) must be
submitted to our office to certify that the abandonment was properly conducted.
If there has been a change of ownership of the property, an Injection Well Permit Name/Ownership
Change Form must also be submitted. The GW-30 and Name/Ownership Change forms can be found at
htt p ://portal.ncdenr.or£!/web/wg/aos/!!Wp ro/rep01ting-fonns.
If Your Injection Well is Currentlv Active:
If the injection well system is still active and you wish to renew your permit, the renewal application must
be submitted within 120 calendar days of the expiration of your permit. According to our records, you
must submit your permit renewal by November 1. 2011.
AQUiFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard. Raleigh. North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Cusiomer Service: 1-877-623-574£.
lniernet: www.ncwaterauali v.oro
An Equal Opportunity\ Aifirm~iive Act;on Employe r
N 0nc 1 C .. ort 1 · ·aro11na.
JJ,1tutnll!f
In order to comply with the regulatory requirements listed under North Carolina Administrative Code
(NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit one of the following enclosed forms:
A. Application for Permit (Renewal) to Construct andlor Use a Well(s) for Injection with
Geothermal Heat Pump System. for Type 5QM Well(s) if the injection well system on your
property is still active.
m
B. Status of Injection Well System if the injection well system is inactive or has been temporarily or
permanently abandoned.
Please submit the appropriate forms to:
Aquifer Protection Section
Groundwater Protection Unit
LTIC 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 LUC well system status form are attached along with a self-addressed envelope. The above referenced
forms arealso available on-line at the DWQ website at
htip://portaLncdenr.ore/web/wg/anslawpro/permit-aapiications#geothprglA_Ms.
Thank you in advance for your cooperation and timely response, If you have any questions, please
contact me by phone at [phone] or by email at eric.e.smith dmcdenr.P_ov.
Sincerely,
Z ' 0-
Eric G. Smith, P.G.
Hydrogeolog-ist
Enclosures
cc: Raleigh Regional Office - APS w/o enclosures
APS Central Files - Permit No. W10500157 w/o enclosures

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to { FTON To 723 Holden St.
p j"sr"(get 4pr'F Raleigh, NC 27604
or FD Sox N
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- PS Form 3800. August zuun I
• Complete items 1, 2, and 3. Also complete
Item 4 If Restricted Delivery Is desired.
■ Print your name and address on the reverse
SO that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Arddfe Addressed to:
Steven J. Martin
723 Holden St.
Raleigh, NC 27604
2. Article Number
(Ransfer from service label}
PS Form 3811, February 2004
A. Skk ature
�-�� �1- - o Agent
x 0 Addressee
13. Received tly (PrIaWNa—) G Date of Delivery
D. Is delivery address dffrerent from item 14 ❑ Yes
It YES, enter dellvery address below. ❑ No
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Cl certmed Mall ❑ Evress Mall
0 Registered 0 Return Receipt fnr Memhandise
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7010 0780 0001 7057 6126
Domestic Return ReOW 1a 5Vj4Zf&1S40

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https://tools.usps.com/go/TrackConfirmAction _input?qtc _tLabelsl =70100780000170576... 10/18/2011
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suet to Brie farm ff no mmm IGPM
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S. WELL DETAfLs:
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b. DOES RNIKACE OXMIM
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1017 Melf Service Center - ft "ft, MC 2TOW1617 Phone Nlo. (M9)733 7d1$ ext 5M
RECEIVED / DENR 1 DVVQ
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Farm GW '1a
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Mechanical Integrity Test Record
(For 5QM Geothermal Heat Pump Injection Well System)
OwneriPermittee Name: Lf
'_Permit Number: WI b L71 7 -
Facility Address:_.____
Home Phone: — ;f� ` ��� Cell Phone:
r-
Heat Pump Contractor Name:
Office Phone-.f Cell Phone:
Tester Name: 1$dg, Signature:
Date of Test: --9-A C-1
fI
:- -
r-
Lao TWtial
Pressure di
Flnal Pres um jj
Dwmfian (minutes)
Pass es or No
2
3
4
F
5
6
7
8
9
10
11
12
13
14
15
Any additional loop testing add to back of this form
Comme©ts: - 1 L L Q
f
Other Tt Methods and Results:
. - _ - —, -
r A
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 mad: UIC Program, Mail Service Center I636•
Raleigh, NC 27699 or 5y fax: [phone].
Mechanical Integrity Test Fonn 1 Ir-7007

1�

oMEe il
ncorporated
a 1 0
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
• WIO700107
• WIO700096
• WIO500143
• WIO700093
• WIO700095
• WIO500185-not included on permit list.
Best Regards,
/l /J/11 111 ,.., I 1.A. .. /l / i._t/',.--/
Anna Jeffreys
Administrative Assistant
Home Energy Inc.
302 E ~ 11 :· Street \f\fendeH,
RECEIVED / DENR / D'['/Q
Aquifer Protection Section
JAN 2 9 2009
yeqk � V V- rr'urA [- d t ~-2-73,rC:x3
List of Issued Permits to Home Energy, Inc.
Permit No. Name
W1040OG82 Braden f
WIOOBG0137 Panigutti V
W10500145 Clark
W10800140 Belanger
W10500157 S. Martin
W10100086 Combs
W10700105 Chen -ill 0 f
W10500161 stein ,.
W10500162 Lauer
W10500163 Blachowicz
W10500166
W10500169 Malone
W10700107 Latta
W10800150 Duan
W10500171 ENT Audiology
W 10500170 Griffin
W10700094 Harris
W10800136 Jefferson
W10500139 Essick
W10800135 Wilson
W10700096 Stotarx
W10500143 Kahn V
W10700093 Young'X
W10700095 Turner
W10500173 Bell
WiO500174 Wilson Community College
fly i`1 L•t' � � � r°��� 1� r t �� ��. � �1 r � 1 L {'"`'�
November 20, 2007
Heat Pump Contractor
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
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Monte Jefferson
Date Permit Issued
11120=06
11 /2212006
101912006
2/13/2007
3/9/2007
4/18/2007
5/17/2007
6/27/2007
7/612 007
812012007
8/17/2007
10/12/2007
9121 /2007
9/20/2007
9/20/2007
10/11/2007
7/30/2006
91121200fi
1/6/2006
911212006
912212OG6
81412M
7/3/2006
912212W6
not permitted as of 11/20/07
11/2012007
RECEIVED 1 ❑ENR I DWa
Agiisfar Protection Section

Di War [� V U 3 0 J-T Michael P. Easley, Gavemor
QQ Wiliiam G. Ross Jr., secretary
North Carolina Dgririment of Environment and ivatvral Resources
7
5tRe Colmn 5uHins, Director
Division of Water Quality
November 27, 2007
Monte Jefferson
Home Energy, Inc.
P4 Box 238
Wendell, NC 27591
Subject; Geothermal Well Installation Data
Dear Mr. Jefferson:
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
• Well ID plate installation date
a 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 have any questions regarding this
letter, please call me at [phone] or Michael Rogers at [phone].
Sincerely,
a'_� Lzt
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: WWW.ncwateNuaiitv.org Location: 2778 CapitaI Boulevard
An Equal opportunitylRlfrrmallve Acton Employer- 50% RecyclWi10 ro Post Consumer Paper
Cie
Nx CuohDa
Aturrr!!y
Raleight NC 27699-1636 'telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: 5 919) 715-6048
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
Wl0500157 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
Wl0700094 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 Co 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
Michael F. Easley, GUVernor
William G. Ross Jr., Secretary
North Carolina Department of Environment And Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
March 9, 2007
Mr. Steven Martin
8231 Allyns Landing Way, Unit 002
Raleigh, NC 27615
Re: Issuance of Injection Well Permit
Permit No. W10500157
Issued to Steve Martin
Dear Mr. Martin_
In accordance with your application received February 7, 2007, I am forwarding Permit No.
W10500157 for the operation of a vertical closed -loop geothermal mixed -fluid heat pump
injection well system to be located at 723 Holden Street, Raleigh, Wake County, North Carolina
27604. This permit shall be effective from the date of issuance until February 29, 2012, and
shall be subject to the conditions and limitations stated therein.
Pay. special attention to the well construction standards in Parts 11 and V of your permit.
You must notify this office (Raleigh Central Office) and the Raleigh Regional Office at least
forty-eight (48) hours prior to constructing the system, and forty-eight (48) hours prior to
initiation of the operation of the system.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit
an application to renew the permit three months prior to its expiration date. As indicated in the
permit, this permit is not transferable to any person without prior notice to, and approval by, the
Director of the Division of Water Quality. If you have any questions regarding your permit or
the Underground Injection Control Program please call Mr. Qu Qi at [phone] or me at
[phone].
Best Regards,
/t_r� 4xovr_��
Michael Rogers
Hydrogeological Technician 11
cc: Jay Zimmerman — Raleigh Regional Office
Central_ Office File — W10500157
Monte Jefferson — Home Energy, Inc.
Attachment(s)
Aquifer Protection Scainn 1636 ,%flail Service Center Raleigh, NC 27699-1636
Internet; htt•//WWW.newater uali .or 2728 Capital Boulevard Raleigh, NC 276G4
An Equal opportunilylAffitmalive Aclion Employer— 50% Recycled110% Post Consumer Paper
leorcthCare I i a a
Naturally
Telephone: [phone]
Fax l: [phone]
Fax [phone]
Customer service: [phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 2I, Chapter 143, and other
applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
STEVEN MARTIN
FOR THE CONSTRUCTION AND OPERATION OF 15 TYPE 5QM 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 723 Holden Street in Raleigh, Wake County, North Carolina, and will be
constructed and operated in accordance with the application received February 7, 2007. 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 Actor any other applicable Laws, Rules, or Regulations. Operation and use of an injection well
shall be in compliance with Title 15A North Carolina Administrative Code 2C _0100 and .0200, and
any other Laws, Rules, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until February 29, 2012
and shall be subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the day of Vr�, 2007.
Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0500157 PAGE 1 OF 7

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the North
Carolina Well Construction Act and is grounds for enforcement· action as provided for in
N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4.
5 .
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.
Each injection well shall be secured to reasonably insure against unauthorized access and use.
Eachwell shail 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 ofWater Quality, Aquifer Protection Section UIC-Staff, 1636 Mail
Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well construction.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. Prior to constructing the injection well system, the permittee or his agent shall test the pH of the
soil at a depth of three feet at the planned well location. If the resulting soil pH is less than 6
standard units or greater than 11 standard units, the well system shall be equipped with a
compatible cathodic protection system. All testing results shall be kept on site available for
inspection.
2. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff,
telephone number [phone] and the Raleigh Regional Office Aquifer Protection Section
Staff, telephone number [phone].
3. All underground tubing shall be refrigeration grade copper tubing.
PermitNo. WI0500157 PAGE 2 OF 7
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 50 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 15A North
Carolina Administrative Code 2C .0100) shall be pumped via tremie pipe into the annular space
of each borehole so as to completely fill it from bottom to top.
8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material shall
have a galvanic potential as close as practicable to that of the tubing material.
9. Dry nitrogen shall be circulated through the tubing during brazing to prevent oxidation.
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 psigwith 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 expansi.on 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 co py of the p ost-installation pressure or
vacuum test record (initial pressure readin g, final p ressure reading. and the duration of the tes t)
shall be submitted to the A quifer Protection Section. The test records must be received b v the
A quifer Protection Section at least twenty-four (24) hours prior to the initiation of the o p eration
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 corners). The permittee shall retain a
copy of the triangulation records. The permittee shall also submit a copy of the triangulation
records to the Aquifer Protection Section within 30 days of completion of well construction.
12. The written documentation required in Part II , p ara graphs (1 0) and (11) shall be submitted to :
Permit No. WI0500157
Aquifer Protection Section-DIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PAGE30F7
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 ofthe
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 havejurisdiction .. 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 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 (24) 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)
715-6166. 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.
Permit No. WI0500157 PAGE40F7
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. WI0500157 PAGE 5 OF 7
PART VIII -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 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.
(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. WI0500157 PAGE 6 OF 7
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
PermitNo. WI0500157
Aquifer Protection Section-VIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PAGE 7 OF7
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 02/20/2007
To: Aquifer Protection Section Central Office
Central Office Reviewer: Micheal Ro gers
Regional Login No: 05
I . GENERAL INFORMATION
1. This application is (check all that apply): ~ New D Renewal
County: Wake
Permittee: Steven J. Martin
Project Name: UIC-5 QM Wells
Application No.: WI0500157
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 Distribution of Residuals
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
~ Closed-loop Groundwater Remediation D Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? [8J Yes or D No.
a. Date of site visit: 02/20/2007
b . Person contacted and contact information: Steven J. Martin, Ph# 9196095879
c. Site visit conducted by: JGreer . RRO-APS
d. fuspection Report Attached: !ZI Yes or D No.
2 . Is the following information entered into the BIMS record for this application correct?
!ZI 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): NIA
For Dis posal and Injection Sites:
(If multi ple sites either indicate which sites the information a pp lies to , copy and paste a new secti gn into the'
document for each site . or attach additional pages for each site ) · :
a . Location(s): 723 Holden Street , Ralei gh NC 27604
b. Driving Directions: See Map Quest ,
c. USGS Quadrangle Map name and number: Ralei gh West. D24SW
d. Latitude: 35.47.27 Longitude: 78.37.38 --,
I
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IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed fo r renewals or minor
modifi cations . skip to next section)
Descri ption Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: _
FORM: WI0500157.SJM 1
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 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 D N/A. If no, 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. 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 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 N/A If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEW AL AND MODIFICATION APPLICATIONS (use previous section for new or maior modification
systems)
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, 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:
FORM: WI0500157.SJM 2
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?
D Yes or D No. ffno, 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 of waste(s) as written in the existing permit correct? D
Yes or D No. If no, please explain:
11. Were monitoring wells properly constructed and located? D Yes or D No IZJ NIA. 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 pennit 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: WI0500157.SJM 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.)
Description Of W ell(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
D Heating/cooling water return flow (SA 7)
C8J Closed-loop heat pump system (5QM/5QW)
D In situ remediation (SI)
D Closed-loop groundwater remediation effluent injection (5L/''Non-Dischai-ge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes D No
3. Are there any potential pollution sources that may affect injection? C8J Yes D No
What is/are the pollution source(s)? House at 721 Holden Street is less then 25' away .. What is the distance of
the injection well(s') from the p ollution source(s )? 15 ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 10 ft.
5. Quality of drainage at site: C8J Good D Adequate D Poor
6. Flooding potential of site: [gl 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)? C8J 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 Onlv :
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. 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 C8J No. If yes, explain:
3. For renewal or modification of groundwater remediation permits (of any typ e ). will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes D No. If v es . explain:
4. Drilling contractor: Name: Home Engery/ David Boyd
FORM: WI0500157.SJM 4
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address: Bo yd Well & Pump Company
2462 Caroll Rd, Chocowinty NC 27817 . Ph# 2529468912
Certification number: 2106
5. Complete and attach Well Construction Data Sheet.
FORM: WI0500157.SJM 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:
Item _ _ _-I- 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
b. 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:
f Condition I Reason
7 recommendation: ❑ Hold; pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
S. Signature of report prepar(As)
Signature of APS regional sup
Date: ? lo
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
�5

Page 1 of 2
North Carolina Department of Environment and Natural Resources
Division of Water Quality -Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTION
REPORT -FORM A
INJECTION WELL PERMFF NO. WI 7D rVA7i-5-7 MATE r> Z- 7- a o� �
NAME OF OWNER 4 .
ADDRESS OF OWNER
(Streetl road or lot and suddivision, county, town)
LOCATION OF PROPOSED INJECTION WEI X (and source well(s), if applicable)
/ - i= - -
(Street/ road or lot and suddh4sion , caunty, town, !f different than owner's address, plus descripdion of location on site)
Potential pollution source 3 e Distance from wells
Potential pollution source Distance from wells
Potential pollution source k _ Distance from well -
Minimum distance of proposed well from property boundary
Quality of drainage at site Flooding potential of site
ood adequate poor) (high,moderaie lqo t� .
DRAW SKETCH OF SITE
(Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and north arrow.)
g- "j 7�_
;Ole 5,
Mamb 9a

v
Page 2 of 2
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cant.)
CoAMrtTS
INSPECTOR.
office -
WITNESS
Address
WITNESS
Address
Mmrcb 98

Pennit: WI0500157
SOC:
County: Wake
Region: Raleigh
Effective:
Effective:
Contact Person: Steven J Martin
Directions to Facility:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Pennits:
Inspection Date: 02/20/2007
Primary Inspector: Jimmie W Greer
Secondary lnspector(s):
Reason for lnspeetion: Routine
Compliance Inspection Report
Expiration:
Expiration:
Owner: Steven J Martin
Facility: Steven Martin SFR
723 Holden St
Raleigh NC 27604
Phone: [phone]
Certification: Phone:
Entry Time: 09:00 AM Exit Time: 09:30 AM
Phone: [phone]
Inspection Type: Compliance Evaluation
Pennit Inspection Type: Injection Mixed Fluid GSHP Well System (SQM)
Facility Status: ■ Compliant O Not Compliant
Question Areas:
■Other
(See attachment summary)
Page: 1
Permit: WI0500157
Inspection Date: 02!20!2007
Inspection Summary:
Other
Comment:
Owner -Facility: Steven J Martin
Inspection Type: Compliance Evaluation
tDe-1I!> I-½+ .::Oe.1'1W ~-
l-v+-j3, O#d k-lJ 0 ~
Reason for Visit: Routine
Yes No NA(@)
Page:2
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type SA7 and 5QM Wells
In Accordance with the provisions of NCAC Title I5A: 02C.0240
Complete application and mail to address on the back page.
TO: DIRECTOR, NORTH CAROL.INA DIVISION OF WATER QUALITY
DATE:-nw�__. . 20 D27-
A_ SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1) Type SA7 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 circulate~ a fluid other than potable water.
This includes systems that circulate additives such as antifineres 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 complete form GW-57 Cl., Nodjrcalron Of I►rtent To
Construct A Closed -Loop Geothermal -Water Only Injection Wet! System.
ffl�'MAIU I.il11f Q"COMMZvi
Name:�UP.y1
Address: a 3 �_�t �_t1_x - :
City: RPU-, tk h State: —L�,Zip Code%2�A County:
Telephone:.�� i ` 1 C f i'-'
C. PROPERTY OWNER (if different from applicant)
Name:
Address:
City: _ — Sate: Zip Code: County: —
Telephone:
D. STATUS OF (PPLICANT
Private: Federal- Commercial.
State: Municipal: Native American Lands:
Revised 5105 GW/LIIC-57 HP Page I of 4

E. FACILITY (SITE) DATA
(Bill 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 PUP" CONTRACTOR DATA
Name: i 1urr\o_ . , � Trc-
Address: �t YD-
City: « rrZip Code: County.
Telephone: UA � ,;Wa � L Q _ Contact Person: �-\Cy�t" 2slh�
a
o���
G. INJECTION PROCEDURE (Briefly describe how the inection 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 NO_—
(2) Personal consumption? YES NO
t. CONSTRUCTION DATA (check one)
EXISTING WELL being proposed for use as an injection well. Provide the data in
(1) through (7) below to the best of your knowledge. Attach a copy of Form GW-
1 (Well Construction Record) if available.
_ PROPOSED WELL to be constructed for use as an injection welL Provide the
data in (1) through (7) below as PROPOSED construction specifications. Submit
Form GW-1 after construction.
(1 ) Well Drilling Contractor's Name: ` 1' P
NC Contractor Certification number: r�l
(2) Date to be constructed: Number of borings: S
Approximate depth of each boring (feet):s�
(3) Well casing: 1s the well(s) ? Q
(a) YES if yes, then de the casing information belvlt.
Type: Galvanized st Black s I Plastic Other (sic ify)
t ,f1 Casing depth: Fro _.to ft. (reference h, land surface)'•..
Casing extends above 91Tuttd inches
(b) NO
Revised 5105 GWIMC-57 HP Page 2 of 4

(4) Grout (material surrounding well casing andlor pipin ): �f s pef-L� L
e: Cement Rentonite Other (s ) SPW%D— fi
(a) Grout I { 1
type. P��y 1Q.
(b) Grou ¢d surface and grout depth (reference to land surface):
around closed loop piping; from to (feet).
around well casing; from to (feet).
(5) Screams (for Type 5A7 wens)
(a) Depth: From to feet below ground surface.
(b) N.(\State Regal'gtions (Title 15A CAC 2C .fl ) require tl a permittee to make provisions
for ri nitoru w [head processes, faucet on th influent fluid enjering heat pump) and
Nyj� efflue t (fluid bein injected into the et1) lines is uired. MI:beerela fauceton:
(a) influenth ? yesno (b) efflu? s no
(7) SOURCE WELT. CONSTRUCTION INFORMATTON (if different from injection well).
Attach a copy of Form GW-1 (Weill Construction Record). If Form GW-I is not available,
provide the data in part K (1) of this application form to the best of your knowledge_
NOTE: THE WELL oRu-LrNG cON7R.ACTM CAN SUPPLY'rHE DATA FOR ErMER MSTiIVG OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
1. PROPOSED OPERATING DATA (for Type 5A7 wells)
(1) Injection rate: Average (damn) gallons per (gpm).
(2) 'ection Volume: Average (daily gallons per�mute
(gpd).
(3) in [inn Pressure- Average (daily) poundslsquare ch (psi).
J �. p
(4) Injn n Temperature: Average (January) F, Average (July) a F.
K. INJECTION FLUID DATA
(1) Fluid source (for Type 5A7 wells) If underground, from what depth, formation and type of
rock/sediment unit will the fluid be drawn (e.g., granite, limestone, sand, etc.).
Depth: Formation: Rocklse&n=t unit-
(2) Chemical Analysis of Source Fluid (for Type SQM wells)
Provide a complete listing of all chemicals added to the circulating heat transfer fluid.
L. iNJMMON-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
M. LOCATION OF WELL(S) Attach two reaps.
Revised 5105 GW/MC-57 HP Page 3 of 4

(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 Haile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LEST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
O. CERT]F`iCATION
"I hereby certify, under penalty of Iaw, 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 tote, accurate and complete. I am aware that there are significant penalties, including
the possibility of fines and imprisonment, for subrnitting false information. I agree to constrict,
operate, maintain, repair, and if applicable, abandon the injection well and all related appurtenances in
accordance with the approved specifications and conditions of the
,"
� -
r ernait A:7;:� �
(Signature'j)f 'ell Owner or Authorized Agent)
Uauthorized agent is acting on behalf of the well owner,
please sapply a Letter signed by the owner authorizing the above Agent
R CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the injection well(s) conforms to the Well
Construction Standards (Title 15A NCAC 2C .0200)
(Signature Of Property Owner if Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Revised 5/05 OWMC-57 HP Page 4 of 4

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Permit Number WI0500157
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Permitted Flow
Facilit
Facility Name
Steven Martin SFR
Location Address
723 Holden St
Raleigh
Owner
Owner Name
Steven
Dates/Events
NC 27604
J Martin
Central Files: APS_ SWP_
03/08/07
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Steven Martin
8231 Allyns Landing Way
Raleigh
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Steven Martin
8231 Allyns Landing Way
Raleigh
NC 27615
NC 27615
Orig Issue App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective Expiration
02/07/07
_R_e_..g_u_la_t_ed_A_c_t_iv_it_ie_s _______________ Re q uested/Received Events
Heat Pump Injection RO staff report requested
RO staff report received
Outfall , ';J:...1.
Waterbody Name Stream Index Number Current Class
02/13/07
02/22/07
Subbasin
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Departrnont of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
February 9, 2007
Steven Martin
723 Holden Street
Raleigh. NC 27604
Subject: Acknowledgement of Application No, WI0500157
Steven Martin SIR
Injection Mixed Fluid GSHP Well System (5QM)
Wake
Dear Mr. Martin:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on February 7, 2007. This application package has been assigned the number
Listed above and will be reviewed by Michael Rogers.
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 Michael Rogers at 919-715-6166, or via a -mail at
[e-mail]. If the reviewer is unavailable, you may Ieave a message, and they will respond
promptly. Also note that the Division has reorganized. To review our new organizational chart, go to
httr://h2o.=.state.pLc.us/documents/dwg_nrnchat df.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS
PROJECT.
Sincerely,
for Debra atTs
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Permit Application File W10500157
�o Nrtbcawlina
aturu!!�
Aqu'rfer Protection Secbon 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone: [phone]
Internet; www.ncwateryualitv.a_rg Location: 2728 Capital Boulevard Raleigh, NO 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal Opportunity/Afrmative Action Ernployer-50%Recycied11D%Post Consurner Paper Customer Service: [phone]