WI0500170_GEOTHERMAL_20120514

Beverly Eaves Perdue
Governor
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 14, 2012
Bruce Griffin
11239 S NC 581
Bailey, NC 27807
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WIOS00l 70
Dear Mr. Griffin:
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 Jong 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,
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit Fil e
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
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RESIDMYIML WE4L CONSTRUCTION RECORD
North Camliss Dcpatunm of $nvisantowd and Nemow Resoumes- Di vwon of Wainr Que&ty
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3. WELL LtW (Check Appk=ble Boxy: R I Wafer Supply 0 r
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4. WELL LOCATION:
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8. WELL DETAILS:
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10. 5A1AXORAVEL PACK:
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1017 Mall Service Center— fRaielgh, NC 276984817 Phan No. (919)?33 7015 ext 588. Rev. 3M7

Mechanical Integrity Test Record
(For SQM Geothermal Heat Pump L-j ection Well System)
OwnerlPermittee Name:_ Permit Number: WI�C�� eta
Facility Address: Sol_t_� } �C' . "on -4 7igD t
Home Phone: �ORSII-� r s)TS-1 - 51 q I Cell Phone:
Heat Pump Contractor Name:
Office Phone: � 1-4 - _-�
Tester N ame: la(i A U x '&SQ Siguature:
Date of Test: 11 A
S_[
Loop
Initial Pressure(psi)
Final Pressure sly
Duration minutes)
Patsy Yes or No
-
2
3
4
5
6
-
7
8
9
10
1I
12
13
14
l5
Comments:
Any additional loop testing add to back of this form
CO 47 1
Other Test Methods and Results:
rA
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 forth by mail: UIC Program, Mail Service Center 1636,
Raleigh, NC 27699 or by fax: [phone],
Mechanical Integrity Test Form 11,12007

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C l 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 .
• WIO400082
• WIO800140
• WIO100086
• WIO700105
• WOP800150
• WIO500171
• WIO500170
• WIO700094
• WIO500139
Regards, a~
Anna Jeffreys
Administrative Assistant
Home Energy Inc.
302 E Third 1 : • \/Vende!l , NC ::7591 •
.. - t f ~ •;t If l
List of Issued Permits to Home Energy, Inc.
Permit No. Name
Wl0400082 Braden
WI00800137 Panigutti
Wl0500145 Clark
WJ0800140 Belanger
WJ0500157 S . Martin
Wl0100086 Combs
Wl0700105 Cherrillo
WI0500161 Stein
Wl0500162 Lauer
WI0500163 Blachowicz
WI0500166 Manning
WI0500169 Maloney
WI0700107 Latta
WI0800150 Duan
Wl0500171 ENT Audiology
WI0500170 Griffin
WI0700094 Harris
Wl0800136 Jefferson
WI0500139 Essick
W10800135 Wilson
WI0700096 Stolar
W10500143 Kahn
WI0700093 Young
WI0700095 Turner ·
WI0500173 Bell
WI0500174 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
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 Pennit Issued
11/20/2006
11/22/2006
10/9/2006
2/13/2007
3/9/2007
4/18/2007
5/17/2007
6/27/2007
7/6/2007
8/20/2007
8/17/2007
10/12/2007
9/21/2007
9/20/2007
9/20/2007
10/1112007
7/30/2006
9/12/2006
1/612006
9/12/2006
9/22/2006
8/4/2006
7/3/2006
9/22/2006
not permitted as of 11 /20/07
11/20/2007
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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina 13cpzi1ment of Environment and Natural Resources
Coleen suIiins. Director
Division of Water Quality
November 27, 2007
Monte Jefferson
Home Energy, Inc.
PO Box 238
Wendell, NC 27591
Subject: Geothermal Wcll 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
• 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_�.GX
Debra J. Watts
Environmental Supervisor
Groundwater Protection Unit
Attachments)
cc: APS Central Files (copy to each permit file on attached list)
Aquii'er Protection Section 1636 Mail service Center
Internet: www.acwateryualir�.On' Location: 2728 Capital Souleverd
An Equal Oppork.,nttylAffirmative Adorn Employer— 50 %Recycled110% Post Caasumer Paper
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❑rlhCamlina
N97A AY
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1. [phone]
Fax 2: (9i9)715.6048
Customer 5ervicc: [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: -----------------~=-"'-"=="---------------
Tester Name: _______________ Signature: _______________ _
Date of Test: --------
Loop Initial Pressure (o si) Final Pressure (nsi) Duration (minutes) Pass (Yes or No)
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: ----------------------------------
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 or by fax: [phone].
Mechanical Integrity Test Form 11/2007
P.�rrnit Number W10500170
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Permitted Flow
[-'!-IV
Facility Name
Bruce Griffin SFR
Location Address
11239 S NC Hwy 581
Bailey
NC 27807
Central Files: APS 5WP
10/11/07
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliatiorl
MajorlMinor Region
Minor Raleigh
county
Nash
Facility Contact Affiliation
Owner Name Owner Type
Individual
Bruce Griffin Owner Affiliation
Bruce Griffin
11239 S NC Hwy 5581
Bailey NC 27807
_v
Scheduled
069 issue App Receivod draft Initiated Issuance Public Notice Issue Effective Expiration
10/09/07 09/05/07 10/09/07 10/09/07 09/30/12
P.pUlatEtt - nC�,� I:i'•(-�tv[?.r r=..
Heat Pump Injection RO staff report requested 09/13/07
RO staff report received 10/05/07
Rc staff report received 1011 1 J07
❑utfall r•1LJLL
Waterbody Name Stream Index Number Current Class 5ubbasin

Michael F. Ruloy, Govemor
William G. Ross Jr.. Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
October 9, 2007
Bruce and Dorothy Griffin
11239 South NC 581
Bailey, NC 27807
Re: Issuance of Injection Well Permit
Permit No. W10500170
Issued to Bruce and Dorothy Griffin
Dear Mr. and Mrs. Griffin:
In accordance with your application received September 6, 2007,1 am forwarding Permit No.
W10500170 for the operation of a vertical closed -loop geothermal mixed -fluid heat pump
injection well system to be located 11239 South NC 581, Bailey, Nash County NC 27807. This
permit shall be effective from the date of issuance until September 30, 2012, and shall be subject
to the conditions and limitations stated therein.
Pay special attention to the well construction standards in Parts H 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 (3) 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,
Michael Rogers
Environmental Specialist
cc: Jay Zimmerman — Raleigh Regional Office
Central Office File — W10500170
Monte Jefferson — Home Energy, Inc.
Attachment(s)
�ura!!;
ai
Aquifer Protection Section 1636 Mail Service Center Raleigh, TIC 27699-1636 Telephone: [phone]
Internet: bM-./lwww.newaten uelihy.nrp 2729 Capital Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2: (919) 715-6a48
An Equal OpportunitylAtfinnative Action Employer— 50%Rerycledll0% Post Consumer Paper Customer Service: [phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT l\ND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other
applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
BRUCE AND DOROTHY GRIFFIN
FOR THE CONSTRUCTION AND OPERATION OF 7 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 11239 South NC 581, Bailey, NC 27807, and will be
constructed and operated in accordance with the application received September 6, 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 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 September 30 ,
2012 and shall be subject to the specified conditions and limitations set forth in Parts I through
IX hereof.
Permit issued this the /l Kday of ~ , 2007.
_ ____;Qk~-lli-=---------: ---~
Coleen H. Sullins, Director
Division of Water Quality
ByAuthority of the Environmental Management Commission.
Permit No. WI0500170 Page2
PART I-WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that
are generally subject to flooding include those with concave slope, alluvial or colluvial
soils, gullies, depressions, and drainage ways.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled,.with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each injection well shall have permanently affixed an identification plate.
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection
well to: DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1636
Mail Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well
construction.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
l. 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 tu.bing shall be refrigeration grade copper tubing.
Permit No. WIOS00l 70 Page3
4. Prior to installation, all tubing to be placed in boreholes ("loops") shall be checked for leaks
by pressurizing the loop to a gage pressure of at least 350 pounds per square inch (psig),
immersing the loop in water and examining it for leaks. Loops with leaks shall not be
installed.
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 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 post-installation pressure or vacuum test record {i nitial pressure readin g, final pressure
readin g, and the duration of the test) shall be submitted to the Aquifer Protection Section.
The test records must be received b y the A quifer Protection Section at least twenty-four (24)
hours prior to the initiation of the op 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 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 r eq uired in Part II , p ara gr aphs (1 0) and (11) shall be submitted to:
Permit No. WI0500170
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Page4
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.
PARTIV-PERFORMANCESTANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater that will render it unsatisfactory for normal use. In the
event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART V -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
[phone]. Notification is required so that Division staff can inspect or otherwise
review the injection facility and determine if it is in compliance with permit conditions.
Permit No. WI0500170 Page5
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 (919) 791-
4200, 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.
Permit No. WI0500170 Page 6
PART VIII-PERMIT RENEWAL
The Permittee shall, at least 90 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 1 S 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 ISA 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 ISA 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.
Permit No. WI0500170 Page 7
(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 IX (1) and (2) (G) shall be submitted to:
Permit No. WI0500170
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Page 8
Permit Number WI0500170
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Permitted Flow
Facilit
Facility Name
Bruce Griffin SFR
Location Address
11239 S NC Hwy 581
Bailey
Owner
Owner Name
Bruce
Dates/Events
NC 27807
Griffin
Orig Issue App Received Draft Initiated
09/06/07
Scheduled
Issuance
Central Files: APS_ SWP_
10/09/07
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Nash
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Bruce Griffin
11239 S NC Hwy 581
Bailey NC
Public Notice Issue Effective
27807
Expiration
Re g ulated Activities Re q uested/Received Events -----------------------
Heat Pump Injection RO staff report requested
RO staff report received
Outfall NULL
Waterbody Name Stream Index Number Current Class
09/13/07
10/04/07
Subbasin
· AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 10/04/2007 County: Nash
To: Aquifer Protection Section Central Office Permittee: Mr. Bruce Griffin
Central Office Reviewer: Micheal RogersProject Name: UIC-5OM Heat Exchange/Closed Loop
Regional Login No: 05 Application No.: W 00
L GENERAL INFORMATION
1. This application is (checkallthatapply): ~ New D Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
0 Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation ~ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ~ Yes or D No.
a. Date of site visit: 10/04/2007
b. Person contacted and contact information: B. Griffin Ph.# 252 235-3191
c. Site visit conducted by: JGreer, RRO-APS
d. Inspection Report Attached: ~ Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
C, v ~~Yes or D No. Ifno, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions: ~
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): NIA
For Disposal and Injection Sites:
{If multiple sites either indicate which sites the information applies to, copy and paste a new section into the
document for each site. or attach additional pages for each site)
a. Location(s): 11239 S NC Hwy. 581, Bailey NC 27807
b. Driving Directions: See Map Quest. 1440 EL on 64BP Ron 264S Lon 581N second house past the
church on the R.
c. USGS Quadrangle Map name and number: Bailey D26SE.
d. Latitude: 35.47.45 Longitude: 78.06.56
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section)
Description OfWaste{S) And Facilities
1. Please attach completed rating sheet. Facility Classification:_
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
2. Are the new trea1ment 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 NIA. Ifno, please explain: __
7. Are the new trea1ment 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 trea1ment facilities or new disposal sites)? D Yes or D No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No D NIA. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D NIA If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or maior modification
systems)
Description OfWaste(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. ls the design, maintenance and operation (e.g. adequate aeration, sludge wasting, sludge storage, effiuent
storage, etc) of the trea1ment 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. Ifno, please explain: __
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
4. Has the site changed in any way that may affect pennit (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. Indicate the review and compliance boundaries. If No, explain and recominend 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 pennit: __
10. Is the description of the facilities, type and/or volume ofwaste(s) as written in the existing permit correct? 0
Yes or D No. Ifno, please explain: ___ _
1 1. 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; 0
Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc): ____ _
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? D Yes
D No D Not Determined D N/A.. Ifno, please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? 0
Yes or D No D N/ A. If yes, please explain: __
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 OfWell(S) And Facilities-New, Renewal, And Modification
1. Type of injection system:
D Heating/cooling water return flow (5A7)
~ Closed-loop heat pump system (SQM/SQW)
D In situ remediation (5I)
D Closed-loop groundwater remediation effluent injection (SLf'Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes ~ No
3. Are there any potential pollution sources that may affect injection? D Yes ~ No
What is/are the pollution source(s)? Septic Sy stem. What is the distance of the injection well(s) from the
p ollution source(s)? 100' ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 60' ft .
5. Quality of drainage at site: ~ Good D Adequate D Poor
6. Flooding potential of site: IZJ 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: N/ A
8. Does the map presented represent the actual site (property lines, wells, surface drainage)?~ Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes 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 D No. If yes, explain: NIA New System
3. For renewal or modification of groundwater remediation permits ( of any type), will
continued/additional/modified injections have an adverse imp act on migr ation of the plume or manag ement of
the contamination incident? D Yes D No. If yes, explain:
4. Drilling contractor: Name: David Boyd
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address: Bo d Well & Pump Comp any
2462 Carroll Road.Chocowinity NC27817
Certification number: 2106
5. Complete and attach Well Construction Data Sheet.
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application..
2. Attach Well Construction Data Shut - if needed information is available
3. Do you foresee any problems with issuancelrenewal 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:
S. 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
' ReBsee
5. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued Make sure that you provide a reason for each special condition:
Condition
Reason
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional. office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If decay, please state reasons;
S. Signat
Signals
Date:
ADDITIONAL REGIONAL STAFF REVIEW ITEM
New System not yet constructed Pending WI number.

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* 11239 S Ne Highway 581
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10/4/2007 10:16 AM
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Page 1 of 2
North Carolina Department of Environment and Natural Resources
Division of Water Quality -Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTION
REPORT -FORM A
INJECTION WELL PERMIT NO. WI
DATE /. 4
NAME OF OWNER_Ll r. ,L Yy\p 5 C" i
ADDRESS OF OWNER
(Street/ road or lot and suddhision, county, town)
MON OF PROPOSED INJECTION WELL ( ), if applicable) 4-
(4" -r , _ _ "i — S"a t 1 6 a ' Fes,
(Streed road or lot and suddivrsion , coun),, town, if differenl than owner's address; plus description of location on site)
Potential pollution source i c_R __r_ Distance from well f &--1v
Potential pollution source Distance from well EV
Potential pollution source r f= a Distance from well d- r
Minimum distance of proposed well from property boundary 6 a
Quality of drainage at site Flooding potential of site
((f 5dA dequalepoor) (high,modera
DRAW SKETCH OF SITE
(Show property boundaries. buildings, wells, potential pollidion sources, roads, approximate scale, arrd north arrow.)
R
?� C3
D� Meech 98

Page 2 of x
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cant.)
CDlI'Il MNTS
WITNESS
Address
WITNESS
Address
March 98

Pennit: V\/10500170
SOC:
County: Nash
Region: Raleigh
Effective:
Effective:
Contact Person: Bruce Griffin
Directions to Facility:
Compliance Inspection Report
Expiration:
Expiration:
Title:
Owner: Bruce Griffin
Facility: Bruce Griffin SFR
11239 S NC Hwy 581
Bailey NC 27807
Phone:
From Raleigh take I440E to US64 By pass. Tum R on US264S. Tum Lon 581 N. Property is second house past the church on R.
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Pennits:
Inspection Date: 10/04/2007
Primary Inspector: Jimmie W Greer
Secondary lnspector(s):
Entry Time: 10:00 AM
Certification:
Exit Time: 10:30 AM
Phone:
RECEIVED/ DENR / OWQ
AQUIFER·PPOTFCTION RECTION
OCT ll 2007
Phone: [phone]
Reason for Inspection: Routine Inspection Type: Compliance Assistance
Permit Inspection Type: Injection Mixed Fluid GSHP Well System (SQM)
Facility Status: 0 Compliant O Not Compliant
Question Areas:
■Other
(See attachment summary)
Page: 1
Permit: WI0500170
Inspection Date: 10/04'2007
Inspection Summary:
Owner -Facility: Bruce Griffin
Inspection Type: Compliance Assistance
This system is yet to be installed ..
Other
Comment:
Reason for Visit: Routine
Yes No NA NE
Page: 2
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 10/04/2007
To: Aquifer Protection Section Central Office
Central Office Reviewer: Micheal Rogers Project Name:
Regional Login No: 05
L GENERALINFORMATION
1. This application is (check all that apply): [8J New D Renewal
County: Nash
Permittee: Mr. Bruce Griffen
Closed-Loop 5OM WelJ System
Application No.: WI0500170
0 Minor Modification O 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 O 503 exempt
D Closed-loop Groundwater Remediation ~ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? [8J Yes or O No.
a Date of site visit: 10/04/2007
. . . RECENEO / DENR / DWQ
b. Person contacted and contact mformation: Mr. Bruce Griffen Ph.# 252 235-3191 AQUIFER·PROTECTION SECTION
c. Site visit conducted by: JGreer. RRO-APS 10CT l 1 2007
d. Inspection Report Attached: [8J Yes or O No.
2. Is the following information entered into the BIMS record for this application correct?
[8J 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 Disposal and lniection Sites:
Of multiple sites either indicate which sites the information applies to, copy and paste a new section into the
document for each site, or attach additional pages for each site)
a . Location(s ): 11239 South NC Hwy. 581, Bailey NC 27807
b. Driving Directions: See Map Quest:
c. USGS Quadrangle Map name and number: D26SE Bailey
d. Latitude: 35.47.45 Longitude: 78.06.56
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section)
Description OfWaste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification:_
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No D NI A. If no, 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 NIA. Ifno, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No0
NI A. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D NI 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 NIA. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: _. __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, please
attach a map showing conflict areas or attach arty new maps you have received from the applicant to be
incorporated into the permit: __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No D NIA. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D NIA If yes, attach list of sites
with restrictions (Certification B?)
Ill RENEWAL AND MODIFICATION APPLICATIONS (u se previous section fo r new or maior modifi cation
systems)
Description OfWaste(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, eftluent
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. Ifno, please explain: __
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
4. Has the site changed in any way that may affect pennit (drainage added, new wells inside the compliance
boundmy, 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? 0 Yes or O No. If no, please
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes O No O 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 O No O 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 O 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 pennit: __
10. Is the description of the facilities, type and/or volume ofwaste(s) as written in the existing pennit correct? D
Yes or D No. If no, please explain: ___ _
11. Were monitoring wells properly constructed and located? 0 Yes or O No O N/ A If no, please explain:
12 . Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? 0 Yes or
0 No D N/ A. Please summarize any findings resulting from this review: __ _
13. Check all that apply: 0 No compliance issues; D Notice(s) of violation within the last permit cycle; D
Current enforcement action(s) 0 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 pennit, (SOC, JOC, etc.) been complied with? D Yes
0 No D Not Determined ON/A.. Ifno, please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before. issuing this permit? D
Yes or O No D N/A. If yes, please explain: __
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 effiuent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description OfWell(S) And Facilities-New, Renewal, And Modification
1. Type of injection system:
D Heating/cooling water return flow (5A7)
t8J Closed-loop heat pump system (5QM/5QW)
0 In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5L/"Non-Discharge")
0 Other (Specify: )
2. Does system use same well for water source and injection? D Yes t8J No
3. Are there any potential pollution sources that may affect injection? D Yes [8J No
What is/are the pollution source(s)? . What is the clistance of the injection well(s) from the p ollution
source{s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 60' ft.
5. Quality of drainage at site: [8J Good D Adequate D Poor
6. Flooding potential of site: [8J 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? 0 Yes t8J 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)? [8J Yes or O No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
In jection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
0 Yes [8J No. If y es, explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? 0 Yes [8J No. If y es, e x:p lain:
3. For renewal or moclification of groundwater remediation permits (of any type ), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? 0 Yes O No. If yes, explain: N/A
4. Drilling contractor: Nmne: David Boyd-Boyd Well & Pump
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address: 2462 Carroll Road
Chocowinity, NC 27817
Certification number: 2106
5 . Complete and attach Well Construction Data Sheet.
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet-if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? 0 Yes ~ No. If yes, please explain
briefly. __ .
4. List any items that you would like APS C~tral Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
.
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; 0 Issue upon receipt of needed additional information; ~
Issue; 0 Deny. If deny, please state reasons: __
8. Signatureofreportprepar~ L-J ~
Signature of APS regional supervisor: ____________________ _
Date: -------
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
This System is y et to be installed.
A OIDFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: Se ptember 13 . 2007
To: D Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS
0 Andrew Pitner, MRO-APS
[8J Jay Zimmerman, RRO-APS
0 David May, WaRO-APS
0 Charlie Stehman, WiRO-APS
0 Sherri Knight, WSRO-APS
From: Michael Rogers Groundwater Protection Unit
Telephone: [phone] Fax: (919 ) 715-0588
E-Mail: Michael.Rogers @ncmail.net
A. Permit Number: WI 0500170
B. Owner: Bruce Griffin
C. Facility/Operation: __
C8J Proposed D Existing D Facility D Operation
D. Application:
1. Permit Type: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D I/E Lagoon D GW Remediation (ND)
C8J UIC -(SQM) closed loop mixed fluid geothermal __
For Residuals: D Land App. D D&M D Surface Disposal
D 503 D 503 Exempt D Animal
2. Project Type: C8'.I New D Major Mod. D Minor Mod. D Renewal D Renewal w/ Mod.
E. Comments/Other Information: D I would like to accompany you on a site visit.
NOTE: The requested days for the submittal of the staff re port (SR) has changed. Per the request of
Debra Watts , the requested dates for the submittal of the SR have been changed to 2 weeks for a UIC
rep ort, and 4 weeks for a SFR report.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 14 calendar days, please take the following actions:
C8J Return a Completed APSARR Form.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: --------------------
FORM: APSARR07/06 Page I of I
^�
Michael F. Easley. Governor
Q
0
William G. Ross Jr., Secretary
North Carolina 17epartment of Environment and Natural Resources
Coleen H. Sullins Director
Division of Water Quality
September 12, 2007
BRUCE GRIFFIN
11239 S NC HWY 581
BAILEY, NC 27807
Subject: Acknowledgement of Application No. WI0500170
Bruce Griffin
Injection Mixed Fluid GSHP Well System (5QM)
Nash County
Dear MR GRIFFIN:
The Aquifer Protection Section of the Division of Water Quality (the Division) acknowledges receipt of
your permit application and supporting materials on September 6, 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 by phone at [phone] or by email at
[e-mail]. If the reviewer is unavailable, you may leave a message, and they will
respond promptly. Also note that the Division has reorganized. To review our new organizational chars,
gotob.tli)-.//h2o.enr.state.nc.us/documents/dwq orLtchart.vdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAEING INQUIRIES
ON THIS PROJECT.
Sincerely,
For Debra J. Watts
S upervisor
ec: Raleigh Regional (Wice, Aquifer Protection Sectlon
Permit Application File W10500170
_ S1ln1cth�4F�} is
rtcydm I;
Aquifer Protection Section 1636 Mail service Center Raleigh, NC 27699-1636 Tclephow. . [phone]
Internet: www.ncwatertrualitv.nre Location: 2729 Capitol Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal ❑pportunitylAllirmaheAcfmn Employer— 50%Recycladl90%Post Consumer Ps per Customer Service: [phone]

NORTH CAROLINA
DEPARTMENT OF ENVIRONM13NT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type 5A7 and 5QM Wells
In Accordance with the provisions ofNCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
TO: DIRECTOR ORTHS�AROLiNA DIV ION OF WATER QUALITY
DATE: — d,LJ 20
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
(I) Type 5A7 wells inject water used to provide heating or cowling for structures.
(2) Type 5QM wells contain a subsurface system of continuous piping, that is
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes and/or corrosion
inbibitors.
(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, Notification Of Intent To
Construct A Closed -Loop Geothermal Water Only Injection We11 Sys lem.
B. PERMIT APPLICANT
Name: ! 01 e-
Address: l 1 - L'�j 1
City: e: Zip Code: 2 7&"� County:
Telephone:
C. PROPERTY OWNER {if different from leant}
Name:�'t
Address: 1
City: �" ► �_V► Sate. (—\( ip Coder ounty:
Telephone`
D. STATUS Ol� LICANT
Private: V Federal:
State: Municipal:
4(7 J>/ e A �>� �-,> 1�4-�
Commercial:
Native American Lana
t �0 # -�
P
Home Energy Inc.
P.U. Box 238
Wendell NC 27591
Revised 5/05 OWIMC-57 HP Page 1 of

E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility:
Address:
City: FZip Cod County:
Telephone: oataet Person:
F. HEAT PUMP CONTRACTOR DATA ------
Name: ff
Address: 7
City: Zip Coder County: �� (1.JC
va
Telephone: 5 Lq — �!)G 7 0 Contact Person: n8 t .[Ae
G, INJECTION PROCEDURE Briefly describe bow the injection well(•ll be used.)
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following`(
( 1) The injection operation 7n YES NO
Personal consumption? �, YES NO
I_ CONSTRUCTION DATA (check one)
(2)
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 he constructed for use as an injection well. Provide the
data in (1) through (7) below as PROPOSED construction specigcations. Submit
Farm GW-1 after constructi
Ir
Number of borings:
1�'4-
Approximate depth of each boring (feet): 1 S
(3) Well casing: Is the well(s) cased?
Well Drilling Contractor's Nance: _ L _ k
NC Contractor Certification number: _ _ 01 —3
�T-
Date to be constructed:
(a) YES if yes, then provide the casing information below.
Type: Galvanized steel
Casing depth: is • _ Plastic other (specify)__
d the From tt €t, [reference to land surface)
Casing extends above grou inches
(b) NO
Revised $105 GWARC-57 HP Page 2 of

K-
L
(4) Grout (material surrounding well casing andlor ing)
(a) Grout : Cement
� Bentomte
Other (specify)
GroutO-surface and gout depth (reference to la d
-V around closed loop piping; from ' to
around well casing; from to (feet).
(5) Screens (for Type 5A7 wells)
(a) Depth: From to A. -et below ground surface,
(6) N.C. State Regulations (Title 15Mno
.0200) require the permittee to make provisions
for monitoring wellhead process on both influent (fluid entering heat pump) sad
effluent (fluid being injected int,es is required. Will there be a faucet on:
(a) the influent tine? yes (b) the efflucat line? yes lio
(7) SOURCE WELL CONSTRUCTION INFORMATION (if different Prom Injection well),
Attach a copy of Farm GW-1 (Well. Construction Record), if Form GW-1 is 110t evallabla,
provide the data in part K (1) of this application form to the best of your knowledge.
NOTE: TuE WELL ❑R11-L.ING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELt.S IF THIS [NF0RMA'n0N is UNAVAR AFiLE BY OTHER 1vlEANS,
PROPOSED OPERATING DATA (for Type 5A7 wells)
(l) Injection rate: Aver { 11 igallons per minute (gpm).
(2) Injection Volume: Ave (d ) gallons per day (SPd)•
(3) Injection Pressure: Ave ge (da iy) pounds/square inch (psi).
(4) Injection Temperature: Average (January)
INJECTION FLUID DATA
n F, Average (July) ° F.
(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:
RocklsWiment unit:
(2) Chemical Analysis of Source Fluid (for Type 5QM wells)
Provide a compl a listing of all chemicals ad&d circulating he t transfer fluid: 7-t
113
INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
M. LOCATION OF WELL(S) Attach two maps.
Revised 5/05 GWIMC-57 RP
Page 3 of 4

(1) Include a site map (can be drawn) showing: buildings, property, lines, surfliae water bodies,
potential sources of groundwater contamination and the orientation of and distances betwoctt
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tams or
drain fields located within 1000 feet of the geothermal heat pump well system. Label all
features clearly and include a north amour.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
❑. 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 appurte oces in
accordance with the approved specifications and conditions of the Permit." 11
(Signature of Well Owx►er or Z Wo6ed Agcnt)
If authorized agenrt is acting on behalf of the well owner,
please stopply 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 o►itlined in this application and that it shall be
the responsibility of the applicant to ensure that the injection well(s) confbnns to the Well
Construction Standards (Title 15A NCAC 2C .02{}0)
_ ,6AUIV,,_
(Signature Of Property er It 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 5105 GWMC-57 HP Page 4 of

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11239 S Nc Highway 581
Bailey NC
27807-9339 US
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Parcel Print Page 1 of2
Parcel Print Display
Parcel lnfor-mation
Parcel Number 276400265253
Owner Name 1 GRIFFIN BRUCE E & DOROTHY W
Owner Mailing Address 11239 SOUTH NC 581
City, State BAILEY NC
Zip Code 27807
Parcel Address 11239 SOUTH NC 581
Total Taxable Value $108,156.00
Municipality 0
Township BAILEY
I I '! ,/;
I .
' tn&
J I
·* l \
Visible Layers:
Major Roads, Parcels
Date/Time Th·e data This map is prepared for the inventory of real property found within
Stamp effective date is: this jurisdiction, and is compiled from recorded deeds, plats and
other public records and data. Users of this map are hereby notified
September 13, Tuesday, January
that the aforementioned public primary information sources should
be consulted for verification of the information contained on this
2007 17, 2007 at 12:00 map. The County assumes no legal responsibility for the information
http://www.gis.co.nash.nc.us/sdx/parcelprint.htm 9/13/2007