WI0500204_GEOTHERMAL_20140521

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
RECEIVED
In Accordance With the Provisions of 15A NCAC 02C .02? '
AR 2 546THERMAL HEATING/COOLING WATER RETURN WELLM
Ctftm�) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
'ertral office CHECK ONE OF THE FOLLOWING:
New Application Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Sections A thru E. and M (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 2l , 20 2.0_ PERMIT NO. �. (�2 60eave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as 0 Geothermal Well ❑ Drinking Water Supply Well
® Other Water Supply Use- Indicate use (i.e., irrigation, etc.) ,sh
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
❑ Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES ❑ NO
If yes, indicate New Owner's contact information:
Name(s)
Mailing Address:
City: State: Zip Code: County:
Day Teie No.: Email Address.: _
R. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence Business/Organization
Government: State Municipal County Federal
C. WELL OWNER(S)/PERMIT APPLICANT — For single family residences, list all persons listed on the
property deed. For all others, list name of business/agency and name of person and title with delegated authority
to sign: I�DOMO�n rf �i/jAeMP7,p C?,�i�'I�'it
Mailing Address:
City: _ Apg:�X State: rk, Zip Code: 2--So Z County: yfgk=Q
Day Tele No.: Cell No.: 71 9 K-ti2—a u,O/
EMAIL Address:% ,f'] CS w , e-J �, Fax No.: _
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 1

D. WELL OPERATOR (if different from well owner) — For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
to sign: 5J�
Mailing Address:
E.
F
G.
City:
Day Tele No.:
State: Zip Code: County:
Email Address.:
PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site:
(2) Physical Address (if different than mailing address):
City:
WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
Contact Person:
Address:
County
City: Zip Code:
Office Tele No.: Cell No.:
EMAIL Address:
State:
HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name:
County:
County: _
Fax No..
NC HVAC Contractor License No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
Zip Code: State: County:
Cell No.:
Zip Code:
Fax No.:
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO
I. WELL CONSTRUCTION REQUIREMENTS — As specified in 15A NCAC 02C .0224(d):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 2

�doo
(a) For screen and gravel -packed wells, the entire length of casing shall be grouted from the top
MPS of the gravel pack to land surface;
b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
�OpPG� to land surface.
A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTING WELLS PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
Depth of each boring below land surface
Well casing and screen type, thickness, and diameter
Casing depth below land surface
Casing height "stickup" above land surface
Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water -bearing zones with 1500
mg1L chloride or greater per I5A NCAC 02C .0107(a181
Length of well screen or open borehole and depth below land surface
Length of sand or gravel packing around well screen and depth below land surface
K. OPERATIlvG DATA
(1)
Injection Rate:
Average (daily)
gallons per minute (gpm).
(2)
Injection Volume:
Average (daily)
gallons per day (gpd).
(3)
Injection Pressure:
Average (daily)
pounds/square inch (psi).
(4)
Injection Temperature:
Average (January)
° F, Average (July) ° F.
L. SITE MAP —As specified in 15A NCAC 02C .0224(b ){4), attach a site -specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 3

NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a `layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the person(s) listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
RECEIVED
MAR 2 6 2020
idC DEQJDWR
Central Office
a'
Signature of Property Owner/Applicant
AT) Wes- G hod416.4.'
Print or Type Full Name and Title
Signature of Property Owner/Applicant
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 4

Permit Number
Program Category
Ground Water
Permit Type
WI0500204
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Hooman Ghashghaei and Annemette Olufsen SFR
Location Address
3011 Buckingham Way
Apex NC
Owner
Owner Name
Hooman Troy
Dates/Events
Orig Issue
7/31/2009
App Received
3/10/2014
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27502
Ghashghaei
Draft Initiated
Scheduled
Issuance
' )
Central Files : APS SWP
5/21/2014
Permit Tracking Slip
Project Type Status
Issued Renewal with major mod
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Hooman Troy Ghashghaei
Asst Professor
3011 Buckingham Way
Apex
Region
Raleigh
County
Wake
NC 27502
Public Notice Issue
5/9/2014
Effective
8/1/2014
Expiration
7/31/2019
Requested /Received Events
RO staff report received
RO staff report requested
Additional information requested
Additional information received
5/1/14
3/28/14
3/28/14
3/28/14
Streamlndex Number Current Class Subbasin
Permit Number W10500204
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Revlewer
michael.rogers
coastal SwPule
Permitted Flow
Facility
Facility Name
Hooman Ghashghaei and Annemette Olufsen SFR
Location Address
3011 Buckingham Way
Apex NC 27502
Owner
Central files' APS _ SVVP
51B12014
Permit Tracking Slip
Status Project Type
In review Renewal wish major mod
Version Permit Classification
Individual
Permit Contact Affiliation
MajorfMinor Region
Minor Raleigh
County
Wake
Facility Contact Affiliation
Owner Name Owner Type
Individual
Hooman Troy Ghashghaei Owner Affiiiation
Hooman Troy Ghashghaei
Asst Professor
3011 Buckingham Way
Dates/Events Apex NC 27502
Scheduled
prig issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
7/31/2009 311012D14 �Yt� �� l
Regulated Activities Requested 1Receiyed Events
Heat Pump Injection RO staff report received 511114
RO staff report requested 3/28114
Additionai information requested 3/28/14
Additional information received 3128114
Outfall
VVaterbody Name 5treamindex Number Current Class 5ubbasin

96VA
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory John E. Skvarla, III
Governor Secretary
May 9, 2014
Hooman Troy Ghashghaei and Annemette Sofie Olufsen
3011 Buckingham Way
Apex, NC 27502
Re: Issuance of Injection Well Permit
Permit No. W10500204
Geothermal Heating/Cooling Water Return Well
Wake County
Dear Mr. Ghashghaei and Ms. Olufsen:
In accordance with your permit renewal application and change of ownership request received
March 10, 2014, and additional information received March 28, 2014,1 am forwarding Permit No.
WI0504204, dated May 9, 2014, for the operation of geothermal heating/cooling water return
well(s) located at the above referenced address. Please note that this renewed permit shall become
effective on August 1, 2014, (i.e., the day after the expiration date of the existing permit), which
may differ from the date of this letter. This permit shall be effective from August 1, 2014, until July
31, 2019, and shall be subject to the conditions and limitations stated therein.
The Raleigh Regional Office collected samples from your geothermal well system on April 29,
2014. Laboratory analytical results will be forwarded to you when it becomes available.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days 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 Resources. If you have any questions regarding your permit or the Underground
Injection Control Program please call me at [phone].
Best Regards,
Michael Rogers, P.G. (N & FL)
Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources, NCDENR
1636 Mail Service Center, Inlet h, Worth Carolina 27t399-1636
Phone: 919-8V-646C Internet: www.ncdenr.gov
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Ghashghaei and Olufsen SFR
Page 2 of2
cc: Rick Bolich, Raleigh Regional Office
Central Office File, WI0500204
Wake County Environmental Health Department
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article-7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Hooman Troy Ghashghaei and Annemette Sofie Olufsen
FOR THE OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S),
defined in Title ISA North Carolina Administrative Code 2C .0224, which will be used for the injection of heat
pump effluent. This injection well is located at 3011 Buckingham Way, Apex, Wake County, NC 27502, and
will be operated in accordance with the renewal application and change of ownership request received March
10, 2014, and in conformity with the specifications and supporting data received March 28, 2014, all of which
are filed with the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for operation of an injection well shall be in compliance with Title I SA 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 August 1, 2014, (i.e., the day after the expiration date of the
existing permit) until July 31, 2019, and shall be subject to the specified conditions and limitations set forth in
Parts I through VITI hereof. -~ ~ Permit issued this the 'u day of_~------
~~ -~
~ Thomas A. Reeder, Director
\ Division of Water Resources
By Authority of the Environmental Management Commission.
Permit #WI0500204 UIC/Retum Well-RENEWAL
ver. 04/2014
, 2014
Page 1 of5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be sealed with a watertight cap or well seal, as defined in G.S. 87-85(16).
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0107(j).
8. Copies of the Well Construction Records shall be retained on-site and available for inspection.
PART II-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4 . Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
Permit #WI0500204 UIC/Return Well-RENEWAL
ver. 04/2014
Page 2 of5
-PART III-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater which will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility. ·
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility. ·
PART IV -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
PART V -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect" or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids. ·
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Raleigh Regional Office, telephone number 919-791-4200, any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
Permit #WI0500204 UIC/Retum Well-RENEWAL
ver. 04/2014
Page 3 ofS
(B) Any failure due to known or unknown reasons that renders the facility incapable of p:1:oper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VII -PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART VIII -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use· of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0240,
Abandonment and Change-of-Status of Wells.
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
.0240, 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 ari 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.
Pennit #WI0500204 DIC/Return Well -RENEWAL
ver. 04/2014
Page 4 of5
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0224(f)( 4) within 30 days of completion of abandonment.
3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
Permit #WI0500204
Water Quality Regional Operations Section-DIC Program
DENR-Division of Water Resources
1636 .Mail Service Center
Raleigh, NC 27699-1636
UIC/Return Well-RENEWAL
ver. 04/2014
Page 5 of5
MA
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
April 30, 2014
Memorandum
To: Michael Rogers
Water Quality Regional Operations, Central Office
From: EricRice ti/..
Water Quality Regional Operations, Raleigh Regional Office
Through: Rick Bolich, Assistant Regional Supervisor
Water Quality Regional Operations, Raleigh Regional Office
Subject: Geothermal Water Return-Renewal
Hooman Troy Ghashghaei
3011 Buckingham Way
Apex, N.C.-Wake County
Permit # WI0500204
John E. Skvarla, Ill
Secretary
RECEIVED/DENR/DWR
MAY O 1 2014
Water Quality Regional
Operations Section
Enclosed is the regional staff report regarding the submittal of a permit renewal application
for a geothermal water return system at the above listed site in Apex, N.C. Please contact me at
[phone] if you have any questions about the staff report.
cc: file
Attachment: WQROSR form
1628 Mail Service Center, Raleigh, North Carolina 27699-1628
Phone: [phone]\ Internet: www.ncdenr.gov
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WATER QUALITY REGIONAL OPERATIONS STAFF REPORT
Date: April 30, 2014 County: Wake
To: WQ Regional Operations CO Permittee: Troy Ghashghaei
Central Office Reviewer: Michael Rogers Project Name: Ghashghaei (Stivland)
Regional Office Inspector: Eric Rice & Mack Wiggins Permit # WI0500204
L GENERAL INFORMATION
1. This application is (check all that apply): D New [8] 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
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation [8] Geothermal Water Return
Was a site visit conducted in order to prepare this report? [8] Yes or D No.
a. Date of site visit: April 29, 2014
b. Person contacted and contact information: Troy Ghashghaei
c. Site visit conducted by: E. Rice & M. Wiggins
d. Inspection Report Attached: D Yes or [8] No.
2. Is the following information entered into the BIMS record for this application correct?
RECEIVED/OENR/DWR
MAY O 1 2014
Water Quality Regional
Operations Section
[8] Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For Dis posal and Injection Sites:
(If multi ple sites either indicate which sites the information a pp lies to . co py and paste a new section into the
document for each site. or attach additional pa ges for each site)
a. Location( s ):
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
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:
[8] Heating/cooling water return flow
D Closed-loop heat pump system
D In situ remediation (51)
FORM: WI0500204
WATER QUALITY REGIONAL OPERATIONS STAFF REPORT
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
D Other (Specify: -~)
2. Does system use same well for water source and injection? cg) Yes D No
3 . Are there any potential pollution sources that may affect injection? D Yes cg) No
What is/are the pollution source(s)?
pollution source(s)?
What is the distance of the injection well(s) from the
4. Quality of drainage at site: cg) Good
5. Flooding potential of site: cg) Low
D Adequate D Poor
D Moderate D High
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.: Total well depth is 450 feet. 65
feet of casing installed. 6 inch steel casing. An illegible well tag is the cause of limited information. Influent
and effluent samples collected for chloride, metals, and N02+N03 as N . Well operation appears to be
compliant.
2. Do you foresee any problems with issuance/renewal of this permit? D Yes cg) No. If yes, please explain
briefly. __ .
3. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
4 . 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
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
FORM : WI0500204 2
WATER QUALITY REGIONAL OPERATIONS STAFF REPORT
6. 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- sample results pending; ❑ Deny, If deny, please state reasons:
7. Signature of report preparers):
Signature of regional DWR supe
Date:
Attachments:
FORM: W10500204 3

&9A
C E R
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Hooman Troy Ghashgaei -Owner
Annemette Sofie Olufsen
3011 Buckingham Way
Apex, NC 27502
March 31, 2014
John E. Skvarla, Ill
Secretary
Subject: Acknowledgement of
Application No. WQI0500204
Heating/Cooling Water Return
Geothennal Injection Well
System
Wake County
Dear Mr. Ghashgaei and Ms. Olufsen:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your pennit
application and supporting documentation received on March 10, 2014. Your application package has
been assigned the number listed above, and the primary reviewer is Michael Rogers.
Central and Raleigh Regional Office staff will perfonn a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing pennit applications, the Water Quality Regional Operations Section (WQROS)
requests your assistance in providing a timely and complete response to any additional infonnation
requests.
Please note that processing standard review pennit 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].
cc: Raleigh Regional Office, WQROS
Permit File WI0500204
sf;;, /¢L
for Debra J. Watts, Supervisor
Division of Water Resources
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Phone: [phone] I Internet: http://portal.ncdenr.org/web/wq_
An Equal Opportunity\ Affirmative Action Employer-Made in part with recycled paper
Division of Water Resources
APPLICATION REVIEW REQUEST FORM
Date: March 28 , 2014
To: D Landon Davidson, ARO-APS
0 Michael Parker, FRO-APS
□ Andrew Pitner, MRO-APS
IZI Rick Bolich, RRO-APS
0 David May, WaRO-APS
□ Morella Sanchez King, WiRO-APS
0 Sherri Knight, W-SRO-APS
From: Michael Ro gers -Water Quali ty R egional O perations Section
Telephone: [phone] Fax: [phone]
E-Mail: Michael.Ro gers @ncdenr.gov
A. Permit Number: WI0500204
B. Owner: Ghashghaei
C. Facility/Operation: --.. -.-....
D Proposed
D. Application:
I. Permit Type: D Animal
D Recycle
fZI Existing D Facility D Operation
D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D 1/E Lagoon D GW Remediation (ND)
IZI UIC -Geothermal Heating/Cooling Water Re.turn Well
For Residuals: D Land App. D D&M D Surface Disposal
D 503 D 503 Exempt D Animal
2. Project Type: D New D Major Mod. D Minor Mod. IZI Renewal D Renewal w/ Mod.
E. Comments/Other Information:
NOTE: During the site ins pection, please obtain well construction from well tag(s) on all existing well(s) and put
on the staff re port. Thanks!
IZI Return a completed APSARR after the site inspection. At a later date, after sampling & the lab
results are received, please send us a copy of the letter you send to the Permittee containing
laboratory analytical results.
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 wiH 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: --------------------Date: _____ _
FORM: APSARR 07/06 Page 1 of 1
Rogers, Michael
From:
Sent:
To:
Troy Ghashghaei [tghashg@ncsu .edu]
Friday, March 28, 2014 1 :58 PM
Rogers, Michael
Subject: Re:FW:
Attachments: 20140328113941725-tg.pdf
Thank you Michael!
On Fri, Mar 28, 2014 at 1:50 PM, Rogers, Michael <michael.ro gers @ncdenr.gov> wrote:
Please have both parties sign and return via email. Thanks.
-----Original Message-----
From: Michael Rogers [mailto:michael.ro gers mcdenr.gov]
Sent: Friday, March 28, 2014 12:40 PM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNP AC7DD0" (Aficio 2075).
Scan Date: 03.28.2014 11:39:41 (-0500)
Queries to: [e-mail]
Troy Ghashghaei, Ph.D
Assistant Professor of Neurobiology
Department of Molecular Biomedical Sciences
Center for Comparative Medicine and Translational Research
College of Veterinary Medicine
North Carolina State University
1060 William Moore Drive
Raleigh, NC 27607
Phone: [phone]
Website: h ttp ://www.cvm.ncsu.edu/mbs/personnel/ghash ghaei tro .html
1
Rogers, Michael
From:
Sent:
To:
Subject:
Attachments:
Rogers, Michael
Friday, March 28, 2014 1:50 PM
'Troy_ [e-mail]'
FW:
20140328113941725.pdf
Please have both parties sign and return via email. Thanks.
-----Original Message-----
From: Michael Rogers [mailto:[e-mail]]
Sent: Friday, March 28, 2014 12:40 PM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 03.28.2014 11:39:41 (-0500)
Queries to: robin.markha m@ ncdenr.gov
1
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELLS
These wells inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
(check one) __ New Application j Renewal* Modification
* For renewals complete Parts A-C and the signature page.
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: __ ~h_b~2--_1-_~, 20-lt RECEIVEDIDENRIDWR
MAR 1 0 2014 PERMIT NO. L\.} ID >OD 20 4 (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence -L
Woater Q':'ality Regional
. . . peratrons Sectio Busmess/Orgamzatlon __ n
Government: State Municipal __ County__ Federal
B. WELL OWNER/PERMIT APPLICANT -For individual residences, list owner(s) on property deed. For all
1
) others, list name of entity and name of person delegated authority to sign on behalf of the business or agency: _
tfTXJ/1\1,;J U oy {3 /-IASH6HAE /
,ANNWE-TT£ OLu B/=1
Mailing Address: 3 V II Bu ck,1'."j bov,, IJlt)
City: .A.f <!...x State: ..!iL_Zip Code: 2--"tS-oi-County: U) Ake
DayTeleNo.: 9 /q 5 /3 fo f"'/-L/ CellNo.:_ 9/Cf 02-;?..05"2--J
EMAIL Address: ---rfL oY _ 6-,JJ,<}JJ.J~NAtli,$, .. 0 5"<A tf"J)l-1.
" ~
C. WELL OPERATOR (if different from well owner) -For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the
business or agency: S tNIN... IA., 'f a..bo M.-•
Mailing Address: _____________________________ _
City: ____________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: Cell No.:
EMAIL Address: Fax No.: -------------------------------
D. LOCATION OF WELL SITE-Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: __________ County: _____ _
(2) Physical Address (if different than mailing address): _______________ _
City: _______________ State: NC Zip Code: ________ _
GPU/UIC 5A 7 Permit Application (Revised 8/8/2013) Page 1
E. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: __________________________ _
NC Well Drilling Contractor Certification No.: _____________________ _
Company Name: ________________________________ _
Contact Person~: _______________ EMAIL Address: ___________ _
Address: ___________________________________ _
City: _________ Zip Code: ____ State: __ County: ________ _
Office Tele No.: Cell No.: Fax No.: ________ _
F. HV AC CONTRACTOR INFORMATION (if different than driller)
G.
HVAC Contractor's Name: ____________________________ _
NC HVAC Contractor License No.: _________________________ _
Company Name: ________________________________ _
Contact Person~: _______________ EMAIL Address: ___________ _
Address: ___________________________________ _
City: __________ Zip Code: _____ State: __ County: _________ _
Office Tele No.: _________ Cell No.: __________ Fax No.: _______ _
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
H. WELL CONSTRUCTION REQUIREMENTS -As specified in 15A NCAC 02C .0224(d ):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
GPU/UIC 5A 7 Permit Application (Revised 8/8/2013) Page 2
L WELL CONSTRUCTION SPECIFICATIONS
J.
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
_____ *EXISTING WELLS ----~PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 15 00
mg/L chloride or greater per 15A NCAC 02C .0107(0(8 )
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
OPERATING DATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average ( daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
K SITE MAP-As specified in 15A NCAC 02C .0224(b )(4 ), attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107 (a )(2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located. ·
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner .name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5A 7 Pennit Application (Revised 8/8/2013) Page3
L. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211 a requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respective
�allrlers.
miipira state, federor other public agency: by either a pri'"oceranking publicly elected official;
4. by the well owner (person(s) listed on the property deed).
If an authdfiied agent is signing on behalf of the applicant, then supply a Ie er signed by the
applicant tha names and authories their agent to sign this application on their ehalf.
" i hereby certify. NRder penalty of law, that 1 have personally examined and am fas liar with the information
submitted in this d ument and all attachments thereto and that, based a/my 'quiry of #hose individuals
immediately responsi for obtaining said information, i believe that thation is true, accurate and
complete. 1 am aware t t there are significant penalties, including the poof fines and imprisonment,
fnr submitting false infnrr tion. 1 agree #o construct, operate, maintain, re if applicable, abandon the
injection well and all relate appurtenances in accordance with the appm�4ed specifications and conditions of
the Permit.,, �
Submit two copies of the co
Signature of Property 0(%nerlApplirant
of Property Owner/Applicant
PCO or Type F`ulI Name
Signature of Authori
I Agent, if any
or Type Full Name
eted application package to:
DWR - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUIUIC 5A7 Permit Application (Revised a1a12013) Page 4

L. CER'I IfICATION (to be signed as required below or by that person's authorized agent)
ISA NCAC 02C .0211(e).requires that all permit applications shall.be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (person(s) listed on the property deed).
l_f an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit ,
Hooman Try, Ghashghaei
Signature of Property Owner/Applicant
Hooman TrovGhashgbaei
Print or Type Full Name
Annemette Olufsen
Signature of Property Owner/Applicant
Annemette Olufsen
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
"". -
t" Submit two copies of the completed application package to
DWR - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
" OPUAJIC 5A7 Permi( AppIication (Revised 91812013)
FWA

North Carolina Department of Environment and Natural Resources
Division of Water Resources
PERMIT NAME/OWNERSHIP CHANGE APPLICATION FORM
I. INSTRUCTIONS
1. Complete this form in its entirety as follows:
(a) Change of Ownership-Provide the information in Parts II and III and submit legal documentation of
the transfer of ownership such as a contract, deed, article of incorporation, etc. The certifications in part
IV.must be signed by both the current permit holder and the new applicant(s).
(b) Name Change Only -Provide the information in Parts II and III. Sign the certification for the new
applicant in part IV.2.
2. Submit the properly completed form to the address on bottom of Page 2.
II. CURRENT PERMIT INFORMATION
1. Permit number: W .:Z:: 0 5' 00 VO Y
2. Permit holder's name(s): __ do.,--=,__r 0 _ __.<;;.,,_.,_.-h_..'·v_·lu.,='-'r'l-=d=--------------------
3. Permit signing official's name and title: _____________________ _
(Person legally responsible for permit)
{Title)
4. Mailing address: ____________________________ _
City: _____________ State: ______ Zip: _________ _
Telephone number: L__) _______ _ Facsimile number: L__) ______ _
III. NEW OWNER/ NAME INFORMATION
1. This request for a permit change is a result of:
~ a. Change in ownership of property/company
_b. Name change only
_ c. Other (please explain):
f-/ooNlP.-N 1Ay GM~-H61-M£,{
AN/v£MEIT£ ()lJJf'J~
FORM: GPU-PNOC 8/5/2013 Page 1 of2
2. New owner's name(s) as listed on the property deed (Please Print/or -Type):
'A.[ 1 _-1 -L)R jr111 -
3. New owner's or signing official's name and title: J
f(Perso 1 lly responsible rpermit)
(Title)
5
4. Mailing, Address: ,} d ? � �� ^'��`� � ° ;1
City: State: Zip: SD _
Day/Cell Phone No- (11 I &I Fax number: ( }
EMAIL. Address:
IV. CERTIFICATION
Current Permittee's Certification
I, - attest that this application tier name/ownership change has been
reviewed and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting information and attachments are not
included, this application package will be returncd as incomplete. I understand I will continue to be
responsible for compliance with the current permit until a new permit is issued.
2. New Applicant(s)'s Certification: t
IIWe, j6f, , l k l�[rR �_ _ MA J�7AE7rF— Li LUr,;0A attest that this application
for name/ownership change has been reviewed and is accurate and complete to the best of my knowledge. I
understand that if all required parts of this application are not completed and that if all required supporting
information and attachments are not included, this application package will be returned as incomplete. I
f n-tber certify that I will operate and maintain the permitted facility in accordance with the perrnit and
related regulatory requirements. J r�
Signature:: Date: _ 21 r
Signature: _ Date: _
SUBMIT THE COMPLETE APPLICATION PACKAGE V[A ONE OF THE FOLLOWING METHODS:
U.S. Postal Service:
Aquifer Protection Section
NC Division Of Water Resources'
1636 Mail Service Center
Raleigh, NC 27699-1636
Courier 1 Special Delivery I In Person:
Aquifer Protection Section.
NC Division Of Water Resources
512 North Salisbury Street
Raleigh, NC 27604
TELEPHOW NUMBER. (919) 807-646d
FORM: GPU-PNOC 8151201 a Page 2 of 2

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
STATUS OF INJECTION WELL SYSTEM
Permit Number: �;. 1 T: 0 S C,C L i , 9 _
Pernittee Name:
Address:
Please check the selection which most closely describes the current status of your injection well system:
1) J ( Well(s) still used for injection activities. -
2) ( Well(s) not used for injection but used for other purposes: a) ( Water Supply
b) ( Recovery
c) ( Monitoring
3) ( Injection discontinued and: a) ( Well(s) temporarily abandoned
b) ( Well(s) permanently abandoned
c) ( Well(s) not abandoned
4) ( Injection well(s) never constructed
Well Abandonment
If you checked (3)(a) or (3)(b), attach a copy of the GW-30 We][ Abandonment Record. If not available, then describe the
method used to abandon the injection well, including a description of how the well was sealed and the type of material
used to fill the well if permanently abandoned:
Permit Rescission:
If you checked (2), (3), or (4) and will not use a well for injection on this site in the future, you should request rescission
of the permit_ Do you wish to rescind the permit?
( Yes ( No
Certification:
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted in
this document, and that to the best of my knowledge the information is true, accurate, and complete."
r
y- -+ �
S3gnarlire
2/
Date
Revised 8150013 GW/UIC-88

WAKE COUNTY. .NC 5Lj1
LAuRA." RIDDrcK
REGISTER OF DEEDS
PRESENTED 8 RECORDED ON
86r63?36-13 AT 15 : 81:13
STATE OF NORTH CAROL I NA
REAL ESTATE EXCISE TRM: sBes
BOK:015300 PAGE: e2397 - ee3se
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: j $Old . *•
.Parcel Identifier No. 0113030 Verified by
By:
MaiVBox
Countyon the day of , 20
This instrument was prepared by: Lynch & Eatman, LLP without title examination
Brief description for the Index: Lot 15 Buckingham _
THIS DEED made this .3 1 cf day of May, 2013, by and between
GRANTOR GRANTEE
Gary H. Stivland and wife, Judith H. Stivland Hooman Troy Ghashgaei, and wife, Anmemette Sofie Olufsen
3011 Buckingham Way 3011 Buckingham Way
Apex, NC 27502 Apex, NC 27502
Enter in appropriate block for each Grantor and Grantee: name, mailing address, and, if appropriate, character of entity, e.g.
corporation or partnership.
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and assigns, and shall include
singular, plural, masculine, feminine or neuter as required by context.
WITNESSETH, that the Grantor, Fora valuable consideration paid by the Grantee, the receipt of which is hereby acknowledged, has and
by these present's does grant, bargain, sell and convey unto the Grantee in fee simple, all that certain lot orparcel of land situated in the
City of , White Oak Township, Wake County, North Carolina and more particularly described as follows;
Being all of Lot 15, Phase Two of Buckingham, according to map recorded in Book ofMaps 1980, Page 135 and rerecorded in
Book of Maps 1980, Page 169, Wake County Registry
The property hereinabove described was acquired by Grantor by instrument recorded in Book 2847, Page 200.
Ali o, a portion of the property herein conveyed ® includes or ❑ not include the primary residence of a Grantor
A map showing the above described property is recorded in Plat Book 1980, Page 169
NC Bar Association Norm No. 3 Q t976, Revised 0 1/1/2010
Printed by Agreement with the NC Bar Association

AVA
NCDENR
North Carolina Department of Environment and Natural Resource
Division of Water Quality
Pat McCrory
Governor
Thomas A Reeder
Acting Director
February 18, 2014
CERTIFIED MAIL# 7010 0780 000170573347
RETURN RECEIPT RE QUESTED
Hooman Troy Ghashgaei
Annemette Sofie Olufsen
3011 Buckingham Way
Apex, NC 27502
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WI0500204
Wake County
Dear Mr. Ghashgaei and Ms. Olufsen:
John E. Skvarla, Ill
Secretary
RECEIVED!DENR!DWR
MAR 1 0 2014
Water Qua/i,,, R .
Operationis eg_1ona1 ' ection
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state, Our records indicate that the above-referenced permit was issued to
Gary and Judith Stivland on July 31, 2009, and expires on July 31, 2014.
This permit was issued for the operation of a Heating/Cooling Water Return Geothermal
Injection Well on your property located at 3011 Buckingham Way in Apex, North Carolina. As
the new property owners, you are responsible for maintaining this permit. Therefore, it is
important that you submit a Change of Ownershi p form within thirty (30) days of receipt of this
letter.
Since the permit is set to expire shortly and in order to comply with the regulatory requirements
listed under North Carolina Administrative Code (NCAC) Title 15A, Subchapter 2C, Section
.0211, you must also submit one of the following forms:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for Injection
with Geothermal Heat Pump System for Type 5A7Well(s) if the injection well
system on your property is still active.
-OR-
B. Status of Injection Well System if the injection well system is inactive or has been
temporarily or permanently abandoned.
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location : 512 N. Salisbury St., Raleigh, North Carolina 27604
Phon e: 919-<'307-6464 I FAX: 919-<'307-6496
Internet: www.ncwaterquality.org
An Equal Opportunity\ Affirmati ve Action Employer
Please submit the forms to:
Division of Water Resources
Groundwater Protection Branch
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 97-94. For your convenience, a Change of
Ownership form, a renewal application, and a UIC Well System Status form are attached along
with a self-addressed envelope. The above referenced forms are also available on-line at the
DWQ website at http:Ilporlal.ncdenr.orglweblwglapslgwprolpermit-applications#geolherrnA]2p
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. �.srnith`ji ��cdenr, ay.
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Raleigh Regional Office - WQROS w/o enclosures
Central Files - Permit No_ WI0500204 w/o enclosures

NCDENR
North Carolina Department of Environment and Natural
Division of Water Quality
Pat McCrory Thomas A. Reeder
Governor Acting Director
February 18, 2014
CERTIFIED MAIL # 7010 0780 0001 7057 3347
RETURN RECEIPT REQUESTED
Hooman Troy Ghashgaei
Annemette Sofie Olufsen
3011 Buckingham Way
Apex, NC 27502
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WI0500204
Wake County
Dear Mr. Ghashgaei and Ms. Olufsen:
Resource
John E. Skvada, ill
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina., and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced permit was issued to
Gary and Judith Stivland on July 31, 2009, and expires on July 31, 2014_
This permit was issued for the operation of a Heating/Cooling Water Return Geothermal
Injection Well on your property located at 3011 Buckingham Way in Apex, North Carolina As
the new property owners, you are responsible for maintaining this permit. Therefore, it is
important that you submit a Change of Dwnershio form within thirty (30) days of receipt of this
letter.
Since the permit is set to expire shortly and in order to comply with the regulatory requirements
listed under North Carolina Administrative Code (NCAC) Title 15A, Subchapter 2C, Section
-0211, you must also submit one of the following forms:
A- Application for Permit (Renewal) to Construct andlor Use a Well(s) for Injection
with Geothermal Feat pump System for Type 5A7Well(s) if the injection well
system on your property is still active.
12
B. Status of Injection Well System if the injection well system is inactive or has been
temporarily or permanently abandoned.
1635 Mail Service Center, Raleigh. North Caralino 27699-1636
Locatwrc 512 N. 5alisbary St., Raleigh, North Cantina 27604
Phone: 91"07-641 FAX91 MD7-6496
lnlewel: M".rmaterau_arirt .om
An Equal Opportunity 1 AfrinwlWe Action Employer

Please submit the forms to:
Division of Water Resources
Groundwater Protection Branch
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 Change of
Ownership form, a renewal application, and a UIC Well System Status form are attached along
with a self-addressed envelope. The above referenced forces are also available on-line at the
DWQ website at http:llportal.ncdenr_aT3.lwgblw4/ap5l 'iApro1.17erm_ it-aprlications#peeo hexmA�)ys,
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.smithiujncdenr. ,ov_
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Raleigh Regional Office - WQROS w/o enclosures
Central Files - Pcrmit No. W10500204 w/o enclosures

B'A
NCDENR
North Carolina Department of Environment and Natural Resource
Division of Water Quality
Pat McCrory
Governor
Thomas A. Reeder
Acting Director
February 18, 2014
CERTIFIED MAIL# 7010 0780 0001 7057 3347
RETURN RECEIPT REQUESTED
Hooman Troy Ghashgaei
Annemette Sofie Olufsen
3011 Buckingham Way
Apex, NC 27502
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WI0500204
Wake County
Dear Mr. Ghashgaei and Ms. Olufsen:
John E. Skvarla, Ill
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above-referenced permit was issued to
Gary and Judith Stivland on July 31, 2009, and expires on July 31, 2014.
This permit was issued for the operation of a Heating/Cooling Water Return Geothermal
Injection Well on your property located at 3011 Buckingham Way in Apex, North Carolina. As
the new property owners, you are responsible for maintaining this permit. Therefore, it is
important that you submit a Change of Ownership form within thirty (30) days of receipt of this
letter.
Since the permit is set to expire shortly and in order to comply with the regulatory requirements
listed under North Carolina Administrative Code (NCAC) Title ISA, Subchapter 2C, Section
.0211, you must also submit one of the following forms:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for /refection
with Geothermal Heat Pump System for Type 5A7Well(s) if the injection well
system on your property is still active.
-OR-
B. Status of Injection Well System if the injection well system is inactive or has been
temporarily or permanently abandoned.
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: 919~07-6464 I FAX: 919~07-6496
Internet www .ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
Please submit the forms to:
Division of Water Resources
Groundwater Protection Branch
U1C 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 Change of
Ownership form, a renewal application, and a UIC Well System Status form are attached along
with a self-addressed envelope. The above referenced forms are also available on-line at the
DWQ website at hqp://VorW.nedenr.orL,/web/wq/M/LNvpro/Nn-nit-4pplications#ueothermApvs.
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.&.smith4 cdenr.s-ov.
Sincerely,
Eric G. Smith, P.G_
Hydrogeologist
Enclosures
cc: Raleigh Regional Office - WQROS w/o enclosures
Ventral Files - Permit No. W10500204 w/o enclosures
2

U.S.
Postal
Service,,,
CERTIFIED
MAIL,?.,
RECEIPT
(Domestic
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For delivery
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visit our
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0 Postage S
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P5 Farm 3800, August 20A Sec Reverse for in&trueGans
s Complete items 1, 2, and 3. Also complete
item 4 K 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. ArUcle Addressed to:
V� M W e� & fi S NOX, X4
,3611 4txb) M
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C. Date of Delivery
D. Is delivery`addmss dffferent from ftem 17 ❑ yes
If YES, enter dellveras below: ❑ No
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3. 'ce Type
Ceftod Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
© Insured Mail © C.O.D.
4. Restrkkted Delivery? Pdre Fee} ❑ Yes
2. Article Number7010 0780 0001 7057 3347
fTiamansier iromservice label)
PS form 3811, February 2004 Domestic Return Receipt 1025W02-M-1540

Permit Number
Program Category
,Ground Water
Permit Type
WI0700204 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Karen Fulcher SFR
Location Address
505 Antioch Dr
New Bern
Owner
Owner Name
Karen
Dates/Events
NC 28560
Fulcher
Orig Issue
01/19/11
App Received Draft Initiated
01/14/11
Re g ulated Activities
Heat Pump Injection
Outfall N JLI .
Scheduled
Issuance
Central Files: APS_ SWP_
01/19/11
Permit Tracking Slip
Status
Active
Project Type
New project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Mike Smith
Contractor Heat Pump
102 Middle St
Jacksonville
Major/Minor
Minor
NC
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Karen Fulcher
505 Antioch Dr
New Bern
Public Notice Issue
01/19/11
NC
Effective
01/19/11
28546
28560
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Karen Fulcher
505 Antioch Drive
New Bero, NC 2 8560
JF-"A -!'"-~ MCD-EN-R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
1/19/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0700204
505 Antioch Drive, New Bern, NC 28560
Dear Ms. Fulcher:
Dee Freeman
Secretary
On 1/14/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-
only geothermal injection well system for the operation of a ground-source heat pump located at the address referenced
above. An individual permit is not required for the construction and operation of this type of geothermal injection well
system as long as the following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction st!llldards specified
in North Carolina Administrative Code Title ISA Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely 'and accurately.
submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and
North Carolina Administrative Code Title ISA Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the
Craven County Health Department as they may have additional requirements for this type of system. Noncompliance
with applicable state, county, or municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Roi!ers@ncdenr.!!ov if you have any questions.
Sincerely, (o,S?ra~~
cc: W ashiugton Regional Office -APS
APS Central Files -Permit No. WI0700204
Craven County Health Dept.
Supervisor
Coastal Geothermal / Climate Control Heating & Cooling Co. (Mike Smith)
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 -71 5-0588: Ff.:X. 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
NirthCarolina
Jvaturall!f
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTEICATiON OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLS)
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or TW information).
DATE: January 12, 2011 W:r' d,-+ cyj r�09
A.
R
WeU Type Cvnfrn"on: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
clased-loota)?
Yes ____X— Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well Copen-loop well iWectin potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): wren Fulcher
(2)
Mailing Address: 505 Antioch Drive
City: New Bem State: NC Zip Code: 28550 County: Craven
Home/Office Tele No.: [phone] Cell No.:
Email Address: tonvwoiter(disuddenlink.net Website:
Physical Address of Well Site (if different than above):
City:
State: Zip Code:
Horce/Office Tele No.: Cell No.:
County:
AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate MC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
State: Zip Code:
Website Address of Company, if any:
County:
E,411t,x
iVED 1 DENR I DVVQ
i1yuifer Proteclion Section
GPU/WC 5QW Notification ofhtent Form (Revised 8/2008) JAN 14 2011 PW I

C. WELL DRILLER INFORMATION
Company Name: Coastal Geothermal
Well Driller Contractor's Name: -=S=ann=ord=-=S:..:w=e=e=tin=g.,___ _________________ _
NC Contractor Certification No.:N ~=C'-"2=-=0=82=----------------------
Contact Person~: =Mik=·=e=-=Smi=·th=-------~E=MA-=-==IL:..:Aa,.;.=-ddre=s=s~: __ ~ms=m.t=·=th@"""""'b=ize=c=.rr=.c=o=m=----
Address: 102 Middle St _________________________ _
City: Jacksonville Zip Code: 28546 _____ County: --~Ons=l=ow~---
O:ffice Tele No.: 910-353-9040 Cell No.: 910-376-1101 ~~~~-----------
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Climate Control Heating and Cooling Company Inc.
Contact Person: Mike Smith EMAIL Address: msmith@ bizec.rr.com
Address: 102 Middle St
City: Jacksonville Zip Code: 28546 County: __ Ons==lo"""w ________ _
Office Tele No.: -----"-'91"'"'0'""'-3=-=5-=3~-9~0~40"---------Cell No.: 910-376-1101
E. STATUS OF APPLICANT
Private: _X_
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be. used)
Closed Loop Geothermal
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: January · 2011 Number of borings: i
Approximate depth of each boring (feet): 250
(2) Type of tubing to be used (copper, PVC, etc): High Density Polyethylene ____ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes m: (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: ___galvanized steel __ black steel___plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No .~
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite X Other (specify) ______ _
(b) Grout placement: Pumping X Pressure__ Other __
( c) Grout depth of tubing (reference to land surface): from _O __ to --=25=-=0'----(feet)
If well has casing, indicate grout depth: :from ___ to ____ (feet)
GPU/UIC SQW Notification of Intent Form (Revised 8/2008) Page2
H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
L LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(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 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and· am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurterumoes in accordanoe with & specifications and conditions of the Pennlt" ~ ~~
Signature of Property Owner/Applicant
)< t.{rr ~E /V a E W-c:«£/<...
Print or Type FullName and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authoriz.ed Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh NC 27699-1636 REC_EIVED / D~NR I DWQ
Telepho;e [phone] Aquifer Protectron Section
JAN 14 2011
GPU/UIC SQW Notification of Intent Form (Revised 8/2008) Page 3.
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Permit Number WI0500204
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Gary & Judith Stivland SFR
Location Address
3011 Buckingham Way
Apex NC
Owner
Owner Name
Gary
Dates/Events
27502
Stivland
Orig Issue
07/31/09
App Received Draft Initiated
05/14/09
Scheduled
Issuance
Central Files: APS_ SWP_
08/20/09
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Gary Stivland
3011 Buckingham Way
Apex NC 27502
Public Notice Issue
07/31/09
Effective
07/31/09
Expiration
07/31/14
_R_e .... a_u_la_t_e_d_A_c_t_iv_i---'--ti_e_s ________________ -'--'R=e=a=u=e=s=te=d=/-'---'R=e=c=e-"--'iv'---"e=d=----=E-=--ve=n,_,_t=sc.__ __________ _
Heat Pump Injection RO staff report requested
Outfall NULL
Waterbody Name
Additional information requested
RO staff report received
Additional information received
Stream Index Number Current Class
05/21/09
05/21/09
07/21/09
07/21/09
Subbasin
Central Files. AP5 5WP
08/11 /09
Permit Number W10500204 Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Facility
Facility Name MajorlMinor Region
Gary & Judith Stivfand SFR Minor Raleigh
Location Address County
3011 Buckingham Way Wake
Apex NC 27502 FaclIIty Contact Affiliation
Owner
Owner Name Owner Type
Individual
Gary
Stivfand
Owner Affiliation
Gary Stivfand
3011 Buckingham Way
Apex NC 27502
Datesl€vets - - -- — - _
Scheduled
trig Issue App Received Draft Initiated Issuance Public Notice tssue Effective ExpiratFLj
05/14/09 -"3log -1131
Rea ulated Activities Re iiestedfRe ; c: i �- -1 Ev e
Heat Pump Injection RO staff report requested 05121/09
Additional information requested 05/21109
RD staff report received 07/21109
Additional information received 07/21 /09
Guitfall
Waterbody Name Stream Index Dumber Current Class Subbasin

HCDENR
North Carolina Department of Environment and
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
July 31, 2009
Gary and Judith Stivland
3011 Buckingham Way
Apex, NC 27502
Re: Issuance of Injection Well Permit
Permit No. W10500204
Issued to Gan, and Judith StIvIand
Wake County
Dear Mr. and Mrs. Stivland:
Natural Resources
(Dee Freeman
Secretary
In accordance with your application received May l 4, 2009, I am forwarding Permit No. W10500204 for the
operation of a 5A7 geothermal underground injection control (UIC) well heat pump system located at 30J.1
Buckingham Way, Apex, Wake County, NC 27502. This permit shall be effective from the date of issuance
until July 31, 2014, and shall be subject to the conditions and limitations stated therein.
Also attached is a summary of the laboratory sampling results from water samples collected from your
geothermal well on June 9, 2009. Laboratory analytical results of both the influent and effluent samples
indicate exceedances in the maximum contamination level (MCL) for several parameters:
Parameter
Units
MCL
Results
Total Dissolved
milligrams per
500
1500 (influent)
Solids (TDS)
liter (mg/L)
I580 (effluent)
Sulfate
mglL
250
1100 (influent)
1000 (effluent)
Zinc
micrograms per
1050
1900 (influent)
liter (µglL)
1800 (effluent)
Manganese
µglL
So
140 (influent)
120 (effluent)
Additionally, although the value for fluoride was below laboratory detection level (<8 mg/L), the practical
quantitation limit (PQL) for fluoride was elevated and, therefore, an exceedances may he possible for this
parameter. The source or cause of these exceedances is unknown. It is recommended that you consult with the
Wake County Environmental Health Department and not use water from this well for personal consumption
until the well is re -sampled and tested.
AOUIFER PROTECTION SECTION
1636 Mail Service Center, Rale�h, North Carolina 27699.1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] l FAX V 818.715-0588; FAX Z 919-715.60481 Customer Servim 1-877-i23-6748
Internet w►wwxwaternuaft-pm
An Equal QWoqumly f Aff matge AWIao Emcby :
Nne
orthCalxolina
NaAmally

In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application
to renew the permit four months prior to its expiration date. As indicated in the permit, this permit is not
transferable to any person without prior notice to, and approval by, the Director of the Division of Water
Quality. If you have any questions regarding your permit or the Underground Injection Control Program please
call me at [phone].
Best Regards,
~ . /) ,,JAt-c/~J;, v4,c-----
-Michael Rogers, P.G. (NC & FL)
Environmental Specialist
cc: Jay Zimmennan -Raleigh Regional Office
Central Office File -WI0500204
Wake County Environmental Health Dept.
Attachment(s)
LABORATORY ANALYTICAL RESULTS
5A7 GEOTHERMAL UNDERGROUND INJECTION CONTROL (UIC) WELL
PERMIT NO.: WI 0500204
PERMITTEE: Gary and Judith Stivland
SAMPLE COLLECTED DATE: 6/9/09
Coliform, total Co liform, fecal pH
1 CFU/100ml 1 CFU/100ml units
MCL= 1 MCL= 1 MCL = 6.5-8.5
I Influent <1 <1 7
I Effluent <1 <1 7
N02 + N03 as N Phosphorus Nitrate
mg/L mg/L mg/L
MCL= 10 MCL= nss MCL= 10
I Influent <.02 <.02 na
I Effluent <.02 <.02 na
Calcium, Ca Cadmium, Cd Chromium, Cr
mg/L µg/L Li o/L
MCL= nss MCL= 1.75 MCL=50
I Influent 420 <1 <10
I Effluent 420 <1 <10
Manganese, Mn Sodium, Na Nickel, Ni
µg/L mg/L µg/L
MCL= 50 MCL= nss MCL= 100
I Influent 140 26 28
I Effluent 120 26 36
MCL = Maximum Contamination Level per NCAC 2L .020 0 (GA Standards)
nss = no slate standard
na = nol analyzed
*Elevated POL due to matrix Interference and/or sample dilution
Total Dissolved Solids Chloride, Cl
mg/L mg/L
MCL= 500 MCL=250
1600 <20*
1580 <20*
Nitrite Silver, Ag
mg/L ua/L
MCL=1 MCL= 17.5
na na
na na
CODDer, Cu Iron, Fe
uo/L uafl
MCL= 1000 MCL=300
na <50
na <50
Lead,Pb Selenium, Se
µgfl ua/L
MCL= 15 MCL=50
<10 na
<10 na
Sulfate
mg/L
MCL=250
1100
1000
Aluminum, Al
ua/L
MCL= nss
<50
<50
Mercury, Hg
uo/L
MCL= 1.05
na
na
Zinc, Zn
µg/L
MCL=1050
1900
1800
Ammonia, NH3 TKN
mg/L mg/L
MCL= nss MCL= nss
<.02 <.2
<.02 <.2
Arsenic,As Barium, Ba
ua/L µg/L
MCL= 50 MCL= 2000
na na
na na
Potassium, K .Magnesium, Mg
mg/L mg/L
MCL= nss MCL=nss
na 5.2
na 5.1
Flouride, F
mg/L
MCL=2
<8*
<8*
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Gary and Judith Stivland
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 3011 Buckingham Way, Apex., Wake County, NC 27502, and will be constructed
and operated in accordance with the application submitted May 14, 2009, 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.
Thi~ permit is for operation only, and does not waive any provisions of the Water Use Act or any other
applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be in compliance with
Title 15A North Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations
pertaining to well-construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until July 31, 2014, and shall be
subject to the specified conditions and limitations set forth in Parts I through VIII hereof .
...\V'-
Permitissued this the I'\ day of ~f-, 2009.
~~~
hi' Coleen H. Sullins, Director Q Division of Water Quality
By Authority of the Environmental Management Commission.
WI0500204
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall .become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications , and other supporting data.
3 . Each injection well shall not hydraulically connect separate aquifers.
4 . Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be secured with a locking cap;
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
8. A completed Well Construction Record (Form GW-l)'must be submitted for each injection well to:
Aquifer Protection Section-UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Ralei gh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
(919 ) 7 9 1-42 00
GW-1 s must be submitted within 30 days of completion of well construction. Copies of the GW-1
form(s) shall be retained on-site and available for inspection.
PART II-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2 . This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
WI0500204 2
3. The issuance of this permit shall not relieve the Pennittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
PART III-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will . render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART IV -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
PART V -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. 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 VI-MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
WI0500204 3
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Raleigh Regional Office, telephone number [phone], any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Pennittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VII -PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART VIII -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a qhange would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Pennittee 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 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.
WI0500204 4
(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 conditi0ns of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
ISA NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part VIIT (1) and (2) (G) shall be submitted to:
WI0500204
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 07-17-2009
To: Aq uifer Protection Section Central Office
Central Office Reviewer: Michael Ro gers
Regional Login No: __ _
L GENERAL INFORMATION
County: Wake
Permittee: Gary Stivland
Project Name: UIC-SA 7 Geothermal Well
Application No.: WI0500204
1. This application is (check all that apply): ~ New D Renewal
0 Minor Modification O Major Modification
D Surface Irrigation O Reuse D Recycle D High Rate Infiltration O Evaporation/Infiltration Lagoon l
D Land Application of Residuals D Attachment B inc luded D 503 regul ated D 503 exempt
0 Distribution of Residuals D Surface Disposal
0 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: 06-09-2009
b. Person contacted and contact information: Ga ry Stivland , (919 )-362-8781
c. Site visit conducted by: Lin McCartney
d. Inspection Report Attached: ~ Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
~ Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location: 3011 Buckingham Way, A pex, NC 27502
c__
C: ,.
N., ......
r"-.)
c:l
c:l
u:)
b. Driving Directions: Take US-1 S, Merge onto US-64 W via EXIT 988, Turn left onto Lake Pine Dr .. Lake
Pine Dr. becomes Old Raleigh Rd., Turn left onto Buckingham Way.
c. USGS Quadrangle Map name and number: __
d. Latitude: 35-43-55 Longitude: 78-49-25
e. Regulated Activities I Type of Wastes (e.g., subdivision, food processing, municipal wastewater): In jection
Well Discharge
For Disposal and In jection Sites:
(If multip le sites either indicate which sites the information a pp lies to , co py and p aste a new section into the
document for each site, or attach additional pa ges for each site)
a. Location(s): Same as above
b. Driving Directions: __
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this seed.on not needed fo r renewals or minor
modifications, skip to next section)
Descri ption Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
FORM: Staff.Report-Stivland 1
> D
S;;c -nm :no :um :g< :::, rn
'.j:j:: --~ ·-i -:z ~~
.n CJ
,"Tl :z:
~o
2
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 Well(S) And Facilities -New. Renewal, And Modification
1. Type (?f injection system:
IZJ Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation (5I)
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes IZJ No
3. Are there any potential pollution sources that may affect injection? IZJ Yes D No
What is/are the pollution source(s)? Septic Tanlc 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? 40 ft.
5. Quality of drainage at site: IZJ 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: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? IZJ 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 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 D No. If yes , exp lain:
3. For renewal or modification of groundwater remediation permits (of any typ e ), will
continued/additional/modified in jections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes D No. If yes , explain:
4. Drilling contractor: Name:
FORM: Staff.Report-Stivland 4
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Y 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"? ❑ 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.
Mahe 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:
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
8. Signature of report preparers):
Signature of APB r anal : per
Date:
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: Staff.Report-Stivland 6

Permit: WI0500204
SOC:
County: Wake
Region: Raleigh
Effective:
Effective:
Contact Person: Bill Evangelist
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 06/09/2009
Primary Inspector: Lin McCartney
Secondary lnspector(s):
Reason for Inspection: Routine
Compliance Inspection Report
Expiration:
Expiration:
Title:
Owner: Gary Stivland
Facility: Gary & Judith Stivland SFR
3011 Buckingham Way
Apex NC 27502
Phone: [phone]
Certification: Phone:
Entry Time: 09:00 AM Exit Time: 11 :00 AM
Phone: [phone]
Ext.4243
Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well (5A7)
Facility Status: ■ Compliant O Not Compliant
Question Areas:
■Wells
(See attachment summary)
Page: 1
Permit: WI0500204
Inspection Date: 06/09/2009
Inspection Summary:
Owner • Facility: Gary Stivland
Inspection Type: Compliance Evaluation Reason for Visit: Routine
Page: 2
county:
WAKE
River Basin
Report To
RRQAp
Collector:
L MCCARTNEY
Region:
RRO
�y �yx�
I DVR ! NQ
Sample Matrix:
GROUNDWATER
RECEIVED y;��
�yn
�F.�I IUIW
Lac. Type:
WAFER SUPPLYAQUI����¢�n�
Emergency YesNo
1�l�fn�
JUL 2
CDC YesdNo
{ Locatfon 0: SP092MOS002M
4 ' OM Laboratory, Section fWesutts
=
Sample iD:
AM297
4F *AT!c•4
PO Number #
Date Received:
SG0731
06/0912009
���
O] 7
Time Recwved:
11:20
¢ •: Y
Labworks LaginlD
HPARKER
❑ate Reported'
711109
Ill
Report Generated:
07101120109
V1010
Loc. Descr.: GARY STIVLAND INFLULNi
` J
�A
Called Date: 0610912009 Collect Time:: 10:00 Sample Depth
Sample Qualifiers and Comments
Routine Qualifiers
For a more detailed description of these qualifier codes refer to www.dwglab.org under Staff Access
A Value reported is the average of two or more determinations
143-Estimated concentration is < PQL and >Mt]L
81-Countable membranes with <20 colonies; Estimated
NE-Na established PaL
92- Counts from a rLiters were zero.
P-Elevated PQL due to matrix interference andror sample dilution
83• Countable membranes with mare than 60 or $0 calantes; Estimated
01-Holding lime exceeded prior to receipt at tab,
04-Filters have counts of bath >60 or 80 and K 20; Estimated
02- Holding time exceeded fallowing receipt by lab
MJoc many colonies were present; too numerous to count (TNTC1
PQL- Practical Quantitation Limit-rwbject to change due to Instrument sensitivity
J2- Reported value failed to meet QC criteria for efther precision or accuracy; Estimated
U- Samples analyzed for this compound Out not detected
J3-The sample matrix interfered with the ability to make any accurate determination: Estimated
X1- Sample not anatyzod for this compound
J6-The lab analysis was from an unpreserve d orimproperty chemlcelly preserved sample; Estimated
Ni-The ccmponent has been tentatively Idant>red based on mass spectral library warm and has an estimated value
W'Ej
Laboratory Sectionaa 1623 Mail Service Center, Raleigh, NC 27699.1623 (9191 733-3908 Pape 1 of 3
jj! 9

NC £JYWQ, La6oratory Section ~su{ts Sample ID AB45297
Location ID: 5PD92WID5D0240I Collect Date: 06/09/20D9
Loe. Descr.: GARY STlVLAND INFLUENT Collect Time:: 1D :DD
Visit ID
CAS# AnalyteName PQL Result Qualifier Units Analyst/Date Approved By /Date
Sample temperature at receipt by lab 2.3 ·c DSAUNDERS SMATHIS
Method Reference 619/09 6/9/09
MIC
COllfonn, MF Fecal In liquid B2 CFU/100ml NDEO CGREEN
Method Reference APHA9222D-20th 6/9/09 6/16/09
COllfonn, MF Total In lquld B2 CFU/100ml NDEO CGREEN
Method Reference APHA9222B·20th 619/09 6116/09
Alkalinity to pH 4.5 d liquid _TTTLE_ mg/Las C8C03 ADEXTER CGREEN
Method Reference APHA2320B-20th 6/18/09 6/24/09
Alkallnlty4.5 73 mg/Las C8C03 ADEXTER CGREEN
Method Reference APHA2320B-20th 6/18/09 6/24/09
Alkallnlty8.3 u mg/Las CaC03 ADEXTER CGREEN
Method Reference APHA2320B-20th 6/18/09 6/24/09
Bicarbonate 73 mg/Las CaCO3 ADEXTER CGREEN
Method Reference APHA2320B-20th 6/18/09 6/24/09
Carbonate u mg/Las CaC03 ADEXTER CGREEN
Method Reference APHA2320B-20th 6/18/09 6/24/09
pH_Alkallnky 7.5 mg/Las CaC03 ADEXTER CGREEN
Method Reference APHA2320B-20th 6/18/09 6124/09
WET
Ion Chromatography _TITLE_ mg/I.. AWILLIAMS MOVERMAN
Method Reference EPA300.0 6117/09 6122/09
Total Dissolved Solids In liquid 12 1600 mg/L ADEXTER MOVERMAN
Method Reference APHA2540C-18TH 6115109 6122/09
Chloride 20 U,P mg/L AWILLIAMS MOVERMAN
Method Reference EPA 300.0 6117/09 6/22/09
Fluor1de 0.4 8.D U,P mg/L AWILLIAMS MOVERMAN
Method Reference EPA300.0 6/17/09 6122/09
Sulfate 2 1100 mg/L AWILLIAMS MOVERMAN
Method Reference EPA300.0 6/17/09 6/22/09
NUT
NH3 8S N In liquid 0.02 0.02 u mg/lasN MAJAYI CGREEN
Method Reference Lacl0-107-06-1-J 6/10/09 6/12/09
Total Kjeldahl N es N In liquid 02 0.2 u mg/LasN MOVERMAN CGREEN
Method Reference Lachat107-06-2-H 6111/09 8/12/09
NO2+NO3 as N In llquld 0.02 0 .02 u mg/LasN MAJAYI CGREEN
Method Reference Lac10·107-04·1-c 6110/09. 6/12/09
Laboratory Section» 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone] Page 2 of 3
' NC ©UIQ La6oratory Section (R§su[ts Sample ID AB45297
Location ID: &P092WI0&00240I Collect Dare: 06/09/2009
Loe. Descr.: GARY STIVLAND INFLUENT Collect Time:: 10:00
Visit ID
CAS# Analyte Name PQL Result Qualifier Units Analyst/Date Approved By /Date
Phosphorus_total as p In Qqukl 0 .02 0 .02 u mg/LasP GBELK CGREEN
Method Reference Lac10-115-01-1 EF 6/11 /09 6/12/09
MET
7429-90-5 AJ bylCP 50 60 u ug/1.. SGOSS ESTAFFORD
Method Reference EPA200.7 6/16/09 6/30/09
7440-70-2 ca bylCP 0 .1 420 mg/L SGOSS EST AFFORD
Method Reference EPA200.7 6/16/09 6130/09
744~3-9 CdbylCPMS 1.0 u ug/1.. PGAUTH!ER EST AFFORD
Method Reference EPA200.8 6/16/09 6/30/09
7440-47-3 CrbylCPMS 10 10 u ug/1.. PGAUTHIER ESTAFFORD
Method Reference EPA200.8 6/1 6/09 6130/09
7439-89-6 FebylCP 50 50 u ug/1.. SGOSS EST AFFORD
Method Reference EPA200.7 6/16/09 6/30/09
7439-95-4 MgbylCP 0.1 5.2 mg/I. SGOSS EST AFFORD
Method Reference EPA200.7 6/16/09 6130/09
7439-96-5 MnbylCP 10 140 Ug/L SGOSS EST AFFORD
Method Reference EPA200.7 6/16/09 6130/09
7440-23-5 Na bylCP 0 .1 26 mg/L SGOSS ESTAFFORD
Method Reference EPA200.7 6/1 6/09 6/30/09
7440-02-0 NlbylCPMS 10 2 8 ug/L PGAUTHIER ESTAFFORD
Method Reference EPA200.8 6/16/09 6/30/09
7439-92-1 PbbylCPMS 10 10 u ug/1.. PGAUTHIER ESTAFFORD
Method Reference EPA200.8 6/16109 6/30/09
7440-66-6 Zn bylCPMS 10 1900 ug/L PGAUTHIER EST AFFORD
Method Reference EPA200.8 6/16/09 6130/09
Laboratory Section» 1623 Mail Service Center, Raleigh. NC 27699-1623 (9191733-3908 Page 3 of 3
GROUNDWATER FIELD/LAB FORM
North Carolina
00POtnerd of Envimment and Na ral Resources
DIVISION OF WATER QUAt N-GROt1NDYYATER SECTION
4�
�
County fa.? r� �-
r Lab Number
Quad No Serial No.
7�."
❑Fs*rgenc1 Date Received TimeLot.
Long.
Reed B :Eus, Cou r, Bandof
Custody C*mr.
Report To: ARO, FRO, MRO,RO, WiRO,
T T Data Entry By: Ck:
WSR*O, Kinston FO, Fed. Trust, Central Off., Other.
Date Reported:
Shipped by: Bus, Courier, nd el , Other, Purpose• i1
Coiladar{sj: L_M WA r * Date�0 Tune r � : d o " l�line, Complai[rt, canoe LUST:}Pe�sticide Study, Federal
.. - -
Trust. Other.
FIELD ANALYSES
Owner c r v 1 z� (LU
PH 4W F. Spec. Cond.
t Z56C a
Location or Site qckrn c A r4m G. 1V G
y
Temp.ia °C Odor J7 []
Description of sampling point
Appearance eG a
Sampling Method �G• Sample Interval
Fieid Analysis By. JYI ec ri
Remarks ka±� roc 61 .vim _
LABORATORY ANALYSES
{P�tar+at�r. drse+ev.:•+]
BOD 310 ffsk
cob High w MWL
Cob LOW 335 wk
coworm:NF FMW 31640 noomi
COMM: MF ToW 31504 1100m1
TOC 600 ffq&
Turbidity 76 HTu
RAaidrre, TOW Sugaided 530 nrgll
pH 403 urn
AlkWhhy to pH 4.6 410 mprL
Alitsvr* t0 PH 6.3 415 ffo&
CarbMs4s 445 nV&
Hk bonaie 440 mgrL
Carbon d107dda 4M mpfL
f" tdoride wo mgA-
trhr0rrOn: Hex 1032 ug/L
Cdor Tare Bo cu
Lj wmo T20 mg►L
Lab Comments
Din. salt 703M my1
Ftupide 851 mg11
Hsrdnearr: Tots) 900 nwL
i�
HardrmM (non-awb) 902 mpiL
Phpnds 32M w
Spatft Coed- 95 o t w=
j4
Sutlers so M L
Sulfide 745 nV&
Oi end Graeae Ma[L
NHs M N e10 Mwt
TMasNO2<5 WOPX
Ncl + Nos 4a N 030 Us&
P: TOW as P on not
Nbafe (NOsaa Nf an MAL
Muff (NO2 as N) 515 MV&
GWS4 REV. 7103 For DLlsohW Arsaty�i Mered sm, nA wrfW TW In bkKk
Ag4%rer4ffiM
NAkar wm i65" Vk
Aogkrj * 46551
ea-Bariiarr 4695a UMrL
Ca-caiaun 40552
C&Cwhft n 40M
Cr-CluMan 46M
Cu-C'xr{tpar�
)( Fit W 46li6S
"?- , 7190o
K-PO WW 4e5ss nlak
M&&tKnNWM 4UM TNYL
flsr#�e 4M5 UWL
Hl•Nldopt
Ph -Ls 46W
Zr►Znc 48W

County:
WAKE
River Basin
Report To
RROAP
Collector.
L MCCARTNEY
Region:
RRO
Sample Matrix
GROUNDWATER
Loc, Type:
WATER SUPPLY
Emergency YeslNo
COC Y1961NO
Location ID: 5P092WI0500240E
��++
J r� of WArF9
T{Z.CjIVED f DENR I' DA Ot* -..PC
cis '
Aoul�Vp ��;1TF� Ttf1�1 F(:TiQ } 1
JUL 2 x
-`� VsWD
Loc. pescr.: GARY STIVLAND EFFLUENT
Collect Data: 0610912009 Collect Time:: 10.30
Sample Qualifiers and Comments
Sample ID:
AB45298
PO Number #
9GO732
Date Received:
0510912009
Time Received;
11:20
Labwcrks Loginl❑
HPARKER
Date Reported:
711/99
Repor, Generated: 07101120"
go- �I,;/6Z�
Sarnp!e Depth
Routine Qualifiers
For a more detailed description of these qualifier codes refer to www.dwglab. ofg Lander Staff Access
A Value reported Is the average of two or more determinations
N3-Estimated concentraton is c PQL and 7MDL
8i-CvuntaWe membranes with r34 wlonies; Estimated
NE -No established PQL
132- Counts from all Titers were zero.
P-Elevated PQL due to matrix interference and/or sample dilution
B3-Countable membranes with mare than 60 or 80 natcnies; Estimated
84-Filters have counts of both 760 or a and s 20: Estimated ❑1-Hold ing time exceeded 0rior to receipt at lab.
85-Tac many colonies were present; too numerous!n count (TNTC) Q2- Holding time exceeded following fceipt by lab
J2- Reported value failed to meet QC criteria for either preC[SiOn.Oi aCCUCdey; Estimated PQL- Practical Quantitat on Limit -subject to change due to instrument sensitivity
J3-The sample matrix interfered with the -ability to make any accurate determination; Estimated U- Samples analyzed for this compound but not detected
X 1 - Sample not analyzed for this compound
JB-The lab -analysis was from an unpreserved or improperly chemically preserved sample; Estmated
Ni-The component has been tentatively identified based on mass spectral library search and has an estimated value
LAB
Lnboretory section» 1623 Mail Servlco Center, Raleigh, NO 27699.1523 [phone] Page 1 of 3
W

:NC CJYWQ La6oratory Section 1?.gsu{ts Sample ID AB45298
Location IU: 5P092WI0500240E Collect Date: 06/09/2009
'Loe. Descr.: GARY S11VLAND EFFLUENT conect Time:: 10:30
Visit ID
CAS# AnalyteName POL Result Qualifier Uni1s Analyst/Date Approved By /Date
Sample temperature at receipt by lab 2.3 ·c DSAUNDERS SMATHIS
Method Reference 619/09 6/9109
MIC
Coliform, MF Fecal In liquid 82 CFU/100ml NDEO CGREEN
Method Reference APHA9222D-20th 6/9/09 6/16/09
Coliform, MF Total In liquid 82 CFU/100ml NDEO CGREEN
Method Reference APHA92228-20th 6/9/09 6116/09
AlkaUnlty to pH 4.5 al liquid _TITLE_ mg/Las CeC03 ADEXTER CGREEN
Method Reference APHA2320B-20th 6118/09 6/24/09
Alkallnlty4.5 73 mg/Las caco3 ADEXTER CGREEN
Method Reference APHA2320B-20th 6/18/09 6/24/09
Alkallnlty8.3 1 u mg/L as CeCO3 ADEXTER CGREEN
Method Reference APHA2320B-20th 6118/09 6/24/09
Bicarbonate 73 mg/Les CeC03 ADEXTER CGREEN
Method Reference APHA2320B-20th 6118/09 6/24/09
Cerbonate u mg/LBS CeC03 ADEXTER CGREEN
Method Reference -APHA2320B-20th 6/18/09 6124/09
pH_Alkellnlty 7.6 mg/LBS CeC03 ADEXTER CGREEN
Method Reference APHA2320B•20th 6118/09 6/24/09
WET
Ion Chromatography _TITLE_ mg/L AWILLIAMS MOVERMAN
Method Reference EPA300.0 6117109 6/22/09
Total Dissolved Solids In liquid 12 1580 mg/L ADEXTER MOVERMAN
Method Reference APHA2540C-18TH 6115109 6/22/09
Chloride 20 U,P mg/L AWILLIAMS MOVERMAN
Method Reference EPA300.0 6117109 6/22/09
FIUO!lde 0.4 8.0 U,P mg/L AWILLIAMS MOVERMAN
Method Reference EPA300.0 6/17/09 6/22/09
Sulfate 2 1000 mg/L AWILLIAMS MOVERMAN
Method Reference EPA300.0 6/17/09 6122/09
NUT
NH3 as N In liquid 0.02 0 .02 u mg/LasN MAJAYI CGREEN
Method Reference Lac10-107·06·1·J 6110/09 6/12/09
Total Kjeldahl N as N In liquid 0.2 0.2 u mg/LasN MOVERMAN CGREEN
Method Reference Lachat107-06-2-H 6111109 6/12/09
NO2+NO3 es N In liquid 0.02 0.02 u mg/LasN MAJAYI CGREEN
Method Reference Lael 0-107-04-1-c 6110/09 6/12/09
Laboraklry Section>> 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone] Page 2 of 3
:NC <DWQ £a6oratory Section ~su{ts Sample ID AB45298
Location {D: 5P092WI0500240E Collect Date: 06/09/2009
"Loe. Oescr.: GARY S11VLANO EFFLUENT Collect Time:: 10 :30
Visit ID
CAS# Analyte Name PQL Result Qua li fier Units Analyst/Date Approved By /Date
Phosphorus_total as P In Hquld 0.02 0.02 u mg/LasP GBELK CGREEN
Method Reference Lac10-115-01-1EF 6/11/09 6/12/09
MET
7429-90-5 AJbylCP 50 50 u ug/L SGOSS EST AFFORD
Method Reference EPA200.7 6/16/09 6/30/09
7440-70-2 CebylCP 0.1 420 mg/L SGOSS EST AFFORD
Method Reference EPA200.7 6/16109 6/30/09
7440-43-9 CdbylCPMS ,.o u ug/L PGAUTHIER ESTAFFORD
Method Reference EPA200 .8 6/16/09 6/30/09
7440-47-3 CrbylCPMS 10 10 u ug/L PGAUTHIER EST AFFORD
Method Reference EPA200.8 6/16/09 6/30/09
7439-89-6 FebylCP 50 50 u ug/L SGOSS EST AFFORD
Method Reference EPA200.7 6/16/09 6/30/09
7439-95-4 MgbylCP 0.1 5.1 mg/L SGOSS EST AFFORD
Method Reference EPA200.7 6/16/09 6/30/09
7439-96-5 MnbylCP 10 120 ug/L SGOSS EST AFFORD
Method Reference EPA200.7 6/16/09 6/30/09
7440-23-5 NabylCP 0.1 26 mg/L SGOSS EST AFFORD
Method Referef\Ce EPA200.7 6116109 6/30/09
7440-02-0 NlbylCPMS 10 36 ug/L PGAUTHIER EST AFFORD
Method Reference EPA200.8 6/16109 6/30/09
7439-92-1 PbbylCPMS 10 10 u Ug/L PGAUTHIER EST AFFORD
Method Reference EPA200.8 6/16109 6/30/09
7440-66-6 ZnbylCPMS 10 1800 ug/L PGAUTHIER EST AFFORD
Method Reference EPA200.8 6/16/09 6/30/09
Laboratory Section» 1823 Mall Service Center, Ralelgh, NC 27699-1623 [phone] Page 3 of3
GROUNDWATER FIELDMB Fa � ofE end moral Resources-- DMSION OF WATER OLIALIlY-GROUNDWATER SECTION
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County w2w Routine
❑uad No Serial No. ❑ sail ❑ Emergen y
Lat. Lang. ❑ ott of
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Report TQ. ARO, FRO, MRO RO aRO. WiRO.
WSRO, KinstDn FO, Fed. Tn Central Off., Other.
Shipped by: Bus, Courier, Other. - Purpose js1
Collector[sj:_ L- )11 CC'n r► a Date I.� "' r7 i lime (9 - 3 n �asefirle, Complaint, �c
FIELD ANALYSES L Owner- 4 ► L+ jtat r+ G�
PH Spec. Cond.g,, at 25°C Location or Site u C
Temp.to °C Odor 40 Description of sampHm paint
Appearance Sampling Method
Feld Analysis By. ine Re
marks (fi e
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BOD 310 moll
COD wgh 340 MWL
COD Low 335 "l/L
Cd ftm: W FeCaf 31915 1100m1
CpilarRr MF TOW 31MM 1100ml
TOC no We&
Tlnbift 76 NTU
Residue, ToW Suspended 530 MAIL
PH 403 urft
A&sHr* to pH 4.5 410 moll
Aloeir * to pH 3.3 415 moll
Carbonate 446 mall
BIN� 440 MAIL
Carbon dlmdda 405 mall.
ChtwwB 940 MAIL
Chmmium: Hex 1032 u91L
Color True 60 Cll
Cjranida 720 mWL
Dies. Soft 70300 m6l&
Fluoride 951 WAIL
Fhlsdrteaa: Total 900 MAIL
Hardneea (non4;sro) W2 moll
Phsnaia W30 upA
spscft COWL its Ilan
suff me 945 11IWI.
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NF. as N 610 RWL
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A QUIFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: May 21 , 2009
To: D Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS
D Andrew Pitner, MR.O-APS
[8] Jay Zimmerman, RRO-APS
From: Michael Rogers Groundwater Protection Unit
Teleplione: [phone]
0
E-Mail: [e-mail]
A. Permit Number: WI 0500204
B. Owner: Gary and Judith Stivland
C. Facility/Operation.: --· ·-·····
D Proposed
II
[8] Existing
D. Application:
0 David May, WaRO-APS
0 Charlie Stehman, WiRO-APS
0 Sherri Knight, W-SRO-APS
Fax: [phone]
D Facility D Operation
1. Permit Type: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D 1/E Lagoon D GW Remediation (ND)
[8] UIC -SA7 Geothermal well
For Residuals: □ Land App. 0 D&M
-" D 503 D 503 Exempt
D Surface Disposal
D Animal
2. Project Type: [8] · New D Major Mod. 0 Minor Mod. D Renewal D Renewal w/ Mod.
E. Comments/Other Information: [8] I would like to accompany you on a site visit.
NOTE: Well 1drilled as irrigation well proposed to be used as SA 7 injection well.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or a°ction. Within, please take the following actions:
[8] Return a (gompleted APSARR Form and attach laboratory analytical results, if applicable.
0 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 Review&r: -------------------Date: _____ _
FORM:APSARR0A~6 Page 1 of 1
NA
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
May 20, 2009
Gary Stivland
Judith Stivland
3011 Buckingham Way
Apex, NC 27502
Subject: Acknowledgement of Application No. WI0500204
Gary & Judith Stivland SFR
Injection Heating/Cooling Water Return Well ( SA 7)
Wake
Dear Mr. & Mrs. Stivland:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on May 14 , 2009. 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 e-mail 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 chart, go to h ttp ://h2o.enr.state .nc.us/documents/dwg orgchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
0~ A. l)QQ0J-
for Debra J. Watts
Supervisor
..
cc: Raleigh Regional Office, Aquifer Protection Section
Bill Evangelist (1117 Batchelor Rd, Apex, NC 27523)
Pennit Application File WI0500204
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: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity \ Affirmative Achn Employer
N~1¥thCarolina
J\7aturall!f
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL BEAT PUMP SYSTEM FOR:
TYPE 5-A 7 WELL{S)
New Permit Application OR ----____ Renewal (check one)
DATE: _ ____;:5~-----'-b __ ___,.200q
PERMIT NO. (leave blank ifNEW permit application) --------
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representativew/authority for signature): c_.::,tfR,y f/ SV// L ~.A/ lJ
Juo1r1-1 E-/. Srt//?/14/-D
(1) Mailing Address: -------']C.-O_I_I __ B_u_C_l<._,~-----"(,~/.l"'"'ll---'-"1_,___W_lll_"'(........__ _______ _
City: -~N~-E.....,:,c;~---State: t'II C. Zip Code: 2,s () z. County: t...>141< £
Home/Office Tele No.: _Cf~lq_-_i_b_:l_-_,_7_9_f_~C=el~l N~o=·~= ________ _
EMAIL Address: _______________ _
(2) Physical Address of Site (if different than above): _______________ _
City: _________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: ___________ C=e=ll~N=o=·~: _________ _
EMAIL Address: _______________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: ____________________________ _
Contact Person~: -------------=E=MAIL==..:..A=d=d~:.,:ess==.: _________ _
Address:-------------------------------
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: ______________ _
GPU/lJIC 5A 7 Well Permit Application (Revised 9/2007) RECEIVED / DENR / DWQ Page 1
Aquifer Protection Section
MAY 14 2009
C. WELL DRILLER INFORMAT>lON
Company Name: 18A 21LL 11DOI LL) w 6- - 4
Well Drilling Contractor's Name: , 13sm 2z[ i _
NC Contractor Certification No_: 2 7 2 3
Contact Person: 19 10.4 EMAIL Address:
Address: '7_2 We9T x 4jILL", _
City: Rumo Zip Code: 2ZSb8 County: !l ey rw�L►x. _
Ofrce Tele No_: 914— "6 - o 3 93 - Cell No-: 1111- -72. 8 — Vy 9 3
D. HEAT PUMP CONTRACTOR INF ORIVIATION [if different than driller)
Company Name:_ EVANG61CAr TCAUIC6 Co.
Contact Person: 19ILt l�J��► 6 t 1 SC EMAIL Address_ e+04n0e I W A be/NVfA . ;te+
Address: 1<11 -7 9A- C ItE%6 * ROS+ p
City: AeFir Zip Code: Wf- County: cHom 1 46"
Office Tele No.: 91i- 362- 7910 Celt No.: 9J q- 3 '- Pi►S- 7 YZ t
E. STATUS OF APPLICANT
Private. )(-- Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
.�ea�keK+»►Fc k�� Pti �... _
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) 'Me injection operation? YES -_ Y NO
(2) Personal consumption? YES ND )t
f. WELL CONSTRUCTION DATA (Skiftto_Section I if this is a Peri nitRENEWAL)
PROPOSED Well(s) to be constructed for use as an injection well_ Provide the data is (1)
through (7) below as PROPOSED construction specifications. Submit Form GW-1 after
construction.
EXISTING Well(s) being proposed for use as an injection well_ Provide the data in (1) through
(7) below to the best of your knowledge, Attach a copy of Form GW-I (Well Construction
Record) if available.
(1) Date to be constructed: V-21-0 9 Number of borings: —
Approximate depth of each boring (feet): y$
(2) Well casing. Is the well(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES )e — ifyes, then provide the casing information below.
Type: Galvanized steel
Casing thickness:
x Black steel Plastic Other {specify)
diameter (inches):
6 depth: from 3 to
Casing extends above ground __ 1, S inches
& (reference to land surface)
GPUAJIC 5A7 Well Permit Application (PeviW 912007) Page 2

(b) NO
(3) Grout (material surrounding well casing and/or pip_igg):
(a) Grouttype: Cement__ Bentonite_X_ Other(specify) _______ _
(b) Grouted surface and grout depth (reference to land surface):
___ Around closed-loop piping; from ___ to ___ (feet).
Y Around well casing; from O to '2.> (feet).
(4) Well(s) Screen Information
Depth of Screen: From ____ to ___ feet below land surface
(5) N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wel1head water quality and processes. A faucet on both Influent (groundwater entering heat
pump) and Effluent (water being injected back into the well) lines is required. Will there be a faucet on:
(a) lnfluentline? Yes_LNo__ (b) Effiuentline? Yes~No __
(6) Source Well Construction Information (if the water source well is a different well than the injection well)
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available, provide the
following data:
Groundwater Source. From what depth, formation, and type of rock/sediment units will the groundwater
be withdrawn? (e.g. granite, limestone, sand, etc.)
Depth: --r S 11 Formation:. ______ Rock/sediment unit::__ ______ _
THE WELL DRILUNG a~CTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR PROPOSED WELLS IF
THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
NOTE:
L OPERATING DATA
(1) Injection rate:
(2) Injection Volume:
Average (daily) 8 gallons per minute (gpm).
Average (daily).:f?~og~ns per day (gpd).
(3) Injection Pressure: Average (daily) ___ pounds/square inch (psi).
(4) Injection Temperature: Average (January)~° F, Average (July) 65"° F.
# 6s~~ B<:rfM.<i!l2kflL1/[),H -
J. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
K. LOCATION OF WELL{S)
Attach two copies of maps showing the following information~
(1) IncJude a site map ( can be drawn) showing: buildings, property lines, surface water bodies, potential sources
of -groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
GPU/UIC 5A7 Well Permit Application (Revised 9/2007) Page3
L. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
`I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete.
I am aware that there are significant: penalties, including the possibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and cflnditions of the Permit."
J
Signatu of Property Owner/Applicant
G S4 1 VAN
Print orype Full Name
)i4pature of Property OwnerlAppIicant
1Ad4,
Print or Type Full Name
Signature of Authorized Agent, if any
Prim or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEivED I DENR I OWU
Aqukfw Pml+oian ss-ctlon
MAY 14 Z009
aPUAJlC 5A7 well Permit Appiicat;prr (rtamod 9/2007) r sa 4

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