WI0500231_GEOTHERMAL_20120517

Beverly Eaves Perdue
Governor
A.TA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 17, 2012
Sarah Woodring
1513 Glasgow Street
Durham, NC 27705
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI050023 1
Dear Ms. Woodring:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http ://portal.ncdenr.om/web/wq/ap s.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our undergroun_d injection control staff at [phone] .
Sincerely,
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity \ Affirmative Action Employer
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/'Vaturall!f
Mechanical Integrity Test Record
(For 5QM Geothermal Heat Pump Injection Well System)
Owner/Pertnittee Name: Sarah Woodrine Permit Number. WI0500231
Facility Address: 1513 Glasgow Street Durham.. NC 27705
Horne Phone: [phone]
Cell Phone:
Heat Pump Contractor Name: Geo Design Group Inc. 10025 US264A POB 9 Middlesex. NC 27557
Office Phone: [phone]
Cell Phone:
Tester Name: William B. Jefferson Signature:
Date of Test:
Loop
Initial Pressure (psi)
Final Pressure (psi)
Duration (minutes)
Pass (Yes or No)
1
400
400
24 Hrs.
Yes
2
3
i
4
1/
5
Ny/
V
7
8
9
10
11
12
13
14
15
Any additional loop testing add to back of this form
Comments: All loops held 400 psi for min. of 24 hours.
Other Test Methods and Results:
Prior to install all loops held in water for 5 min.
kri' rm,zDvva/BOG
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This form must be filled out and signed by the tester. The record must be received by Aquifer Protection Section 24 hours
prior to the initiation of the operation of the facility. You can send the form by mail: UIC Program, Mail Service Center 1636,
Raleigh, NC 27699 or by fax: [phone].
Mechanical Integrity Test Form 1112007

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Project Site Owner:
Address:
(GDG) Geo Design Group Inc.
Earth Loop Equipment & Drilling Information Sheet
Sarah Woodring
1513 Glasgow Street
Durham, NC 27705
Date:
Prepared By:
WA/3 Are
Earth Loop Installer: GEO DESIGN GROUP INC POB 9 MIDDLESEX, NC 27557 PH. 252-235-2209
Driller / Excavator: GEO DESIGN GROUP INC POB 9 MIDDLESEX, NC 27557 PH_ 252-235-2209
Grout Installer: GDG - GEO DESIGN GROUP INC POB 9 MIDDLESEX, NC 27557 PH, Z52-235-2209
Earth Loop Model Number:
CPS Model Number:
Soil PH:
Earth Loop System Seal Test: (400 psi)
Triangulation Map Attached: (required)
Compressor Start Up Date:
Compressor Unit Model Number:
Compressor Unit Serial Number:
Drill Start Date: Drill Completion Date:
Bentonite Grout Used: /0
(Bags)
X-Fine Silica Sand Used: - . (Bags)
Yes gx No (circle one) No. Holes Drilled: SA —
Yes
or No (circle one)
Depth -Length Holes:
Angle Holes: 1.10 - -
Earth Formation Description For:
TOP to Bottom
Sand:
Clay:
Rock: 6 `'

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5 f -.0 4-
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3.
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5
RESIDENTIAL WELL CONSTRUCTION RECORD
ELL%
North Carolina Department of Environment and Natural Resources- Division of Water Qu,
1-A
WELL CONTRACTOR CERTIFICATION # 397��[1
1, WELL CONTRACTOR:
William B. Jefferson
Well Contractor (individual) Name
Geo Design Group Inc.
Well Contractor Company Name
10025 HWY 264A - PQB 9
Street Address
Middlesex NC 27557
City or Town
252 235-2209
Area code Phone number
2, WELL INFORMATION:
State Zip Cade
WELL CONSTRUCTION PERMIT#W I0500231
OTHER ASSOCIATED PERMIT#(it applicable)
SITE WELL ID #(lf applicable)_
3. WELL USE (Check Applicable Box): Residential Water Supply D
DATE DRILLED 1._ 2. S J (]
TIME COMPLETED _� —1 0 AIVI D mule
4. WELL LOCATION:
cITY: Durham CDUNTYDurham
1513 Glasgow Street 27705
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPc 1 RAPHIC / LAND SETTING: (check appropriate box)
❑Slope ley DFlat ❑Ridge pOther
LATITUDE 36 ' ' " DMS
LONGITUDE 75 CI " DMS
DD
Latitude/longitude source: LJ. PS Qropographic map
(location of well must be shown on a USGS topo map andattacbed to
this form if not using GPS)
5. WELL. OWNER
Sarah Woodring
Owner Name
1513 Glasgow Street
Street Address
Durham NC 27705
City or Town State Zip Code
(919 684-2527
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:7°1 + -
h. DOES WELL REPLACE EXISTING WELL? YES Q NO 1r
c, WATER LEVEL Below Top of Casing: N/A _ FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING 15 N/A FT- Above Land Surface'
"Top of casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm). N/A METHOD OF TEST
f. DISINFECTION: TypeNM Amount
11. DRILLING LOG
Top Bottomffrr
1 `i-
f
1
I
1
1
1
1
1
1
g. WATER ZONES (depth):
TopN1A Bottom. -- - -
Top Bottom
Top Bottom
7. CASING: Depth
TapN/A Bottom
Top Bottom
Top Bottom
8. GROUT: Depth
TopO Bottom70`
Tap Bottom
Top - Bottom
Ft.
Ft.
Ft.
Top Bottom
Top Bottom
Top Bottom
Thickness)
Diameter Weight Material
Material
FLMIX Thermex
FiBentonite
Ft.Sand
Method
Grout
& Silica
9. SCREEN: Depth Diameter Slot Size Material
TopN/A Bottom Ft. in. in.
Top Bottum Ft. in. in.
Top Bottom Ft. in. - in.
10. SAND/GRAVEL PACK:
Depth
TopNJA Bottom Ft.
Top Bottom Ft.
Size Material
Tap Bottom Ft.
F6nition Description
E q BAR 3 Z010
welts bur Ir end 4'-5' below grade n grroo�ltedPbottarn•- t
mart rot. •
0WQraoG
I D0 HEREBY CE
ACCORDANCE
STANDARDS,
PROVIDED T
SIG A ' OF CEF
William B. Jefferson
WELL WAS CONSTRUCTED IN
WELL CONSTRUCTION
THIS RECORD HAS BEEN
LL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09

Permit Number
Program Category
Ground Water
Permit Type
WI0500231
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Sarah Woodring SFR
Location Address
1513 Glasgow St
Durham ·
Owner
Owner Name
Sarah
Dates/Events
NC 27705
Woodring
Orig Issue
01/08/10
App Received Draft Initiated
12/08/09
Scheduled
Issuance
Central Files: APS_ SWP_
01/07/10
Permit Tracking Slip
Status
In review
Version
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor ·
Region
Raleigh
County
Durham
-FacUity-Contact Affiliation
Owner Type
Individual
Owner Affiliation
Sarah Woodring
Owner
1513 Glasgow St
Durham NC 27705
Public Notice Issue
01/08/10
Effective
01/08/10
Expiration
12/31/14
-'--R'-'e_,.a'-'-u"-la"-t:C.Ce-'-d'--'A-'c.c..t=iv_i-'-ti_ce_s ________________ ""'R=e=g=u=e=s=te""'d=/-'-'R=e=c=e"'"'iv'""e""d=-=E-=-ve=.a.a.nt=s....._ __________ _
Heat Pump Injection Additional information requested
Outfall f\!UL L.
Waterbody Name
RO staff report requested
Additional information received
RO staff report received
Stream Index Number Current Class
12/14/09
12/18/09
12/21/09
01/04/10
Subbasin
ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Pardue
Governor
Sarah Woodring
] 513 Giasvow Street
Durham.. NC 27705
Re: Issuance of Injection Well Permit
Permit No. %'I0500231
Issued to Sarah Woodring
Durham County
Dear Ms. Woodring:
Division of Water Quality
Coleen H. Sullins Dee Freeman
Director Secretary
January 8.2 010
In accordance with your application received December 8. 2009, l am forwarding Permit No. Wi0500231 for
the operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system located at the
above referenced address. This permit shall be effective from the date of issuance until December 3 ! , 2014,
and shall be subject to the conditions and limitations stated therein.
Please pay special attention to the following bolded language in the permit:
Per Part II, paragraph 2, notify the Raleigh Regional Office at [phone] at least 48 hours
prior to starting drilling.
Per Part II, paragraph 1.3, one well identification tag per scluster' of wells shall be permanently
affixed to the heating and cooling unit or other nearby permanently fixed Location in a clearly
visible location.
Per Part LrII, paragraph 2, please submit copies of the Well Construction Completion form (GW-
1) after construction.
Please submit the data within 30 calendar days of completion of the geothermal wells to the following address:
Aquifer Protection Section (APS)
Underground Injection Control (UIC) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
in order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application
to renew the permit three months prior to its expiration date. As indicated in the permit, this permit is not
transferable to any person without prior notice to, and approval by, the Director of the Division of Water
Quality. If you have any questions regarding your permit or the Underground Injection Control Program please
call me at [phone].

Best Regards,
AA-~.4f:_D (!_~ ~·
/ )
Michael Rogers, P.O. (NC & FL)
Environmental Specialist
cc: Jay Zimmerman -Raleigh Regional Office
Central Office File -WI0500231
Durham County Environmental Health Dept.
Geo Design Group, Inc -A1arie Jvf eiton (sent USPS and.faxed)
Attachment( s)
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
Sarah Woodring
FOR THE CONSTRUCTION AND OPERATION OF TYPE SQM INJECTION WELLS, defined in Title 15A
North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a "direct expansion" type
vertical closed-loop geothermal-mixed-fluid heatpump system. This system is located at 1513 Giasgovv Street,
Durham, Durham County, NC 27705, and will be constructed and operated in accordance with the application
received December 8, 2009, and in conformity with the specifications and supporting data submitted December
21, 2009, all of which are filed with the Department of Environment and Natural Resources and are considered
a part of this permit.
This permit is for Construction and Operation of an injection well and shall be in compliance wi:th Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until December 3 L 2014, and shall
be subject to the specified conditions and limitations set forth in Parts I through IX hereof.
-\,'-> ;-..'.}a\ 0
Permit issued this the ,~ day of ,-:.~~ v:>i -.,2009.
u
U~vl!::.. ~ l ;0,~
JtA Coleen H. Sullins, Director
\ Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0500231 UIC/SQM-DX
ver. 10/2009
Page 1 of 6
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 (l SA NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. Soil from a depth of at least three feet at the planned well location shall be tested for pH prior to
constructing the injection well system. The well system shall be equipped with a compatible cathodic
protection system if the soil pH is less than 6 standard units or greater than 11 standard units. All testing
results shall be kept on site to be made available for inspection.
2. At least forty-eight ( 48) hours prior to constructing system, the Pennittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone] and the Raleigh Regional Office Aquifer Protection Section Staff, telephone
number [phone].
3. All underground tubing shall be refrigeration-grade copper tubing.
4. Prior to installation, all tubing to be placed in boreholes shall be checked for leaks by pressurizing the loop
to a gauge pressure of at least 350 pounds per square inch (psig), immersing the loop in water and
examining it for leaks. Loops with leaks shall not be installed.
'
5. Prior to installation, all tubing shall be visually inspected for damage such as kinks, dents, and scrapes.
Each tubing "loop" shall be checked to verify that the nitrogen charge applied to the loop by the
manufacturer before shipping is still present at a pressure of at least 300 psig. The manufacturer shall be
notified in the event of damage or pressure loss, and the manufacturer's instructions shall then be
followed. The nitrogen charge may be released only when the tubing is installed and ready to be
connected to the manifold.
6. Boreholes shall be large enough to allow insertion of the tubing plus a tremie pipe for grouting.
7. After insertion of the tubing into the boreholes, an approved grout (as defined in Title 15A North Carolina
Administrative Code 2C .0100) shall be pumped via tremie pipe into the annular space of each borehole so
as to completely fill it from bottom to top.
Permit #WI0S00231 UIC/SQM-DX
ver. 10/2009
Page2 of 6
8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material shall have a
galvanic potential as close as practicable to that of the tubing material.
9. Dry nitrogen shall be circulated through the tubing during brazing to prevent oxidation.
10 . After installation and prior to operation of the system, a mechanical integrity test shall be conducted by
pressurizing the injection well system to 400 psig with dry nitrogen and monitoring for leaks using an
ultrasonic or other leak detector of equal sensitivity and monitoring pressure in the system for at least 2
hours. Alternatively, an equivalent vacuum test is acceptable. Any pressure fluctuation other than that due
to thermal expansion and contraction of the testing medium shall be considered a failed mechanical
integrity test. Any leaks shall be located and repaired prior to charging the system with refrigerant.
11 . The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation corners) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
12. Boreholes shall not connect separate aquifers or zones that have differences in water quality (e.g., shallow
surficial aquifers, saprolite, fractured bedrock, etc.) as specified in 15A NCAC 2C .0213(d)(8)(C) and
shall be filled with hentonite grout from the lowermost water bearing zone to land surface as specified in
the permit application.
13. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the
heating and cooling unit in a clearly visible location in accordance with ISA NCAC 2C .0213(g).
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable 'without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore. the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit #WI0500231 UIC/SQM-DX
ver, 10/2009
Page 3 of 6
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The PermiUee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Pemiittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number (919) 71 S-(, 166. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
PART VI-INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Division representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
Permit #WI0500231 UIC/SQM-DX
ver. 10/2009
Page 4 of 6
.
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section -UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Raleigh Regional Office
3800 Barrett Drive
l<..aleig.h~ ·Ne.~ 27609
(919J 791-4200
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Raleigh Regional Office within 30 days of completion
of well construction. Copies of the GW-1 form(s) shall aiso be given to the Permittee and retained on site
to be made available for inspection.
3. Mechanical integrity testing data required in Part II.IO of this permit shall be recorded on the attached
Mechanical Integrity Test Record form and submitted to the Aquifer Protection Section Central Office and
the RaL3igh Regional Office at least 24 (twenty-four) hours prior to initial operation of the injection
facility. A copy of this form shall also be retained on-site for inspection.
4. A copy of the site map updated with manifold locations required in Part II.11 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Raleigh Regional Office within 30 days
of completion of well construction.
5. Documentation for change of well status as described in Parts IX.1 and IX.2(G) of this permit.
6. 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.
7. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Raleig11 Regional Office, telephone number [phone] any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
8. 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.
9. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
Permit #WI0500231 UIC/SQM-DX
ver. 10/2009
Page 5 of 6
PART VIII -PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Pem1ittee shall
submit an application to renew the permit 120 days prior to its expiration date.
----PARTIX-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, then that well must be permanently abandoned according to 15A NCAC 2~ .0213(h)(l ).
Notification shall be submitted to the addresses given in Part VII.1 of this permit.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for, or contribute to , the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when , as a result of the injection operations, a subsurface cavity has been created ,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.I of this permit.
Permit #WI0500231 UIC/SQM-DX
ver . 10/2009
Page 6 of 6
Mechanical Integrity Test Record
(For SQM Geothermal Heat Pump Injection Well System)
Owner/Permittee Name : ________ Permit Number: __ W __ I _____ _
Facility Address: ____________________________ _
Home Phone: Cell Phone:
Heat Pump Contractor Name:
Office Phone: _________________ C_e_ll _P_h~on_e~: _________ _
Tester Name: ______________ Signature: ____________ _
Date of Test: ______ _
Loop Initial Pressure (psi) Final Pressure (psi) Duration (minutes) Pass (Yes or No)
1
2
3
4 I
5
6
7
8
9
10
11
12
13
14
15
Add any additional testing data to back of this form
Comments: ___________________________________ _
Other Test Methods and Results:
This form shall be completed and signed by the tester. The record shall be received by Aquifer Protection
Section 24 hours prior to the initiation of the operation of the facility. You can send the form by fax.to 919-
715-0588 or by mail to the following address:
SQM Mechanical Integrity Test Record
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Page 1 of 2
Loop Initial Pressure {psi) Final Pressure (psi) Duration (minutes) Pass (Yes or No}
I
I
I
I
I
I
I
I
SQM Mechanical Integrity Test Record Page 2 of 2
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Beverly Eaves Perdue, Governor
Dee Freeman, Secretary
Coleen Sullins, Director
Division of Water Quality
Aquifer Protection Section
Location: 2728 Capital Blvd.
Raleigh, NC 27604
Mailing Address: 1636 Mail Service Center
Raleigh, N.C. 27699-1636
FAX: [phone]
[phone]
Date: /%//-0
FAX TO: 4/I�
FAX NUMBER:
FROM: z1
PHONE:
NO. OF PAGES INCLUDING THIS SHEET:
It you receive this fax by mistake call: Aquifer Protection Section @ 919-733-3221

. Rogers , Michael
From: Zimmerman, Jay
Sent:
To:
Monday, January 04, 2010 1 :33 PM
Rogers, Michael
Cc: Fleahman, Matthew
Subject: RE: Woodring SQM WI0500231
Michael,
Matt sent me this and I looked at the original email. We have no plans to conduct a pre-permit inspection as it appears
to be located in an area served by city sewer and water.
Jay
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to
third parties.
From: Fleahman, Matthew
Sent: Monday, January 04, 2010 9:38 AM
To: Zimmerman, Jay
Subject: FW: Woodring SQM WIOS00231
From: Rogers, Michael
Sent: Monday, December 28, 2009 2:47 PM
To: Fleahman, Matthew
Subject: FW: Woodring SQM WIOS00231
Matt-
Attached is a SQM App. According to Jay's VM you are the acting Super. Jay reviews these Apps and decides whether to
conduct a pre-permitting inspection or not and responds via email. Let me know if you wish to inspect. If you are not
comfortable and would rather wait until Jay returns to make a decision on this, let me know.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Rogers, Michael
Sent: Friday, December 18, 2009 4:02 PM
To: Zimmerman, Jay
Subject: Woodring SQM WI0500231
Attached is a SQM App. Let us know if you wish to conduct a pre-permitting inspection or not.
Michael Rogers, P.G. (NC & FL)
1
Enviro~\hen~"'' Specialist
NC Div of Wacer Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
2
Rogers, Michael
From:
Sent:
To:
Marie Melton [mmelton@geodesigngroup .net]
Monday, December 21, 2009 9:06 AM
Rogers, Michael
Subject: Re: Woodring 5QM wi0500231
Mr. Rogers,
good morning, 10' from the house is a bare min. that we put on site map but we always bore as far off as possible.
think her yard is not that large but we do plan on boring as far away from the house as possible. Please let me know if
you will need any additional information.
Regards,
Marie
On 12/18/09 3:30 PM, "Rogers, Michael" <michael.rogers @ncdenr.gov> wrote:
Marie-
We rec'd the App for the above. In reviewing the site map, is the.lot large enough for the nearest boring to be a
minimum of 25 feet from the house instead of 10 feet?
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
Marie
Marie Melton I Resource Manager
Geo Design Group Inc. I www.geodesigngroup.net
1900 Campus Commons Drive I Suite 100 I Reston, VA 20191
703.766.6551 Main I 866.975.4434 Toll Free I 866.929.8150 Fax
"Energy & Technology Simplified"
The information transmitted is intended only for the person or entity to which it is addressed and may contain
confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any
action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you
received this in error, please contact the sender immediately and delete the material from any computer. Any views or
opinions expressed in this email are those of the author and do not represent those of the Geo Design Group Inc.
Warning: Although precautions have been taken to make sure no viruses are present in this email, the company cannot
accept responsibility for any loss or damage that arise from the use of this email or attachments.
1
Please consider the environment before printing this email.
2
Rogers, Michael
From:
Sent:
To: .
Subject:
Attachments:
Rogers, Michael
Friday, December 18, 2009 4:02 PM
Zimmerman, Jay
Woodring SQM WI0500231
Woodring 5QM wi0500231.pdf
Attached is a SQM App. Let us know if you wish to conduct a pre-permitting inspection or not.
Michael Rogers, P.G. (NC & FL).
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspondence to and from this address may be subject to the North Carolfna Public Records Law and may be disclosed to third parties
1
Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Subject:
Friday, December 18, 2009 3:30 PM
'm [e-mail]'
Woodring 5QM wi0500231
Marie-
We rec'd the App for the above. In reviewing the site map, is the lot large enough for the nearest boring to be a
minimum of 25 feet from the house instead of 10 feet?
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
1
Ro gers, Michael
From:
Sent:
To:
Sarah Woodring [[e-mail]]
Wedr,esday, December 16, 2009 10:05 AM
Rogers, Michael
Subject: RE: application# W10500231
Thank you Michael for following up. I am now following up with Home Energy to see what has happened/what is going on
now.
Sarah
"Rogers, Michael" <[e-mail]> To Sarah Woodring <sarah.woodrinq@ duke.edu>
cc
12/16/2009 09:49 AM Subject RE: application# W10500231
Hello-
We rec'd your App on December 8, 2009. However, the App did not include well construction info. We are waiting on additional
information from Home Energy.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Sarah Woodring [mailto:sarah.woodring@ duke.edu ]
Sent: Tuesday, December 15, 2009 8:09 AM
To: Rogers, Michael
Subject: application# W10500231
Dear Michael,
I received a letter of acknowledgement in the mail yesterday ... .! was just wondering-It says it " ... acknowledges receipt of
your permit application and supporting materials on December 8, 2009."
Is 12/8 the day it actually arrived in the NCDENR office, or did it arrive earlier and just not get assigned till then? - I
signed the papers to get the ball rolling for drilling/installing my new system on 11/5 and was told they were to be filed
immediately. That it could take 4-6 weeks for the approval to come through. Then drilling could start/I should be up and
running before the cold weather set in. So this letter surprised me quite a bit.
The reason I ask is because this is for a new heating system and as my present one isn't working properly, I am anxious
to get the new system in, but it appears to me that between my signing papers in Nov and your receiving a request for a
permit in Dec, a whole month has lapsed in which nothing was happening at all and I'm trying to figure out what
happened/why it happened as based on your letter, getting the permit is still 2-3 months away ... by then winter will be over
and if my present system goes out I'm up a creek.
Any help would be appreciated.
1
Thank you ,
Sarah
Sarah Woodring
Duke University Medical Center
Phone: [phone]
Fax: [phone]
2
Rogers, Michael
From: Rogers, Michael
Sent:
To:
Subject:
Tuesday, December 15, 2009 9:23 AM
'[e-mail]'
wi0500213 Woodring
Monte-
Here we go again-we rec'd an incomplete SQM App. The App lacked proposed date of construction, number and depth
of borings, grout depth, type of tubing, and a map showing the proposed borings distance in relation to the house,
property boundaries, and septic tank and other wells, if present. This impedes our processing your Apps and issuing
permits in a timely manner when we have to ask for additional info.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
1
ATLI
P4CDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Gee Freeman!
Governor Director Secretary
December 11, 2009
Sarah Woodring
1513 Glasgow St.
Durham, NC 27705
Subject: Acknowledgement of Application No. WI0500231
Sarah Woodring SFR
Injection Mixed Fluid GSHP Well System (5QM)
Durham
Dear Ms. Woodring:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on December 8.2009. This application package has beenassignedthe 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 clays after receipt of a complete
application.
If you have any questions, please contact Michael Rogers at 919-715-61 fib, or via e-mail at michael.rogers@,ncdenr.gov. 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 hnr://h2o.enr.state.nc.us/documents/dwt, oruchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
-1 i f
for Debra J , tts
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
William B. Jefferson (Home Energy Inc„ P.O. Box 238, Wendell, NC 27591)
Permit Application File W10500231
AQUIFER PROTECTION SECTION
1636 Mail Service Center. Raleigh. North Carolina 27699-163n
Location 2728 Capital Boulevard, Raleigh, North Carolina 27664
Phone: [phone] FAX 1' 919-715-0588: FAX 2: 919-715.64451 Customer Service-'-877.G23-S748
Internet WWW.nCWatergUatirV•afq
ar, Equal Clpparlunilp 1 Athrmarrve Aaron Errria-w
One
Nth Caro hna
aturaij

12/113/200D 13:21 FAX
U1002
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (Napti 3�C4
APPLICATION FOR PERIVI.IT TO CONSTRUCT AND/OR USE
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTE
TYPE 5QM WELL(S)
New Permit Application OR
DATE: I l C�
20 O`I
Renewal (check one)
PERMIT NO. -_ (leave Munk if NEW permit application)
A. PROPERTY OWNERS)/APPLICANT(S)
List each Property Owner fisted on property deed (if owned by a business or government agency, state name of
entity and a representative wlautharity for signature): 5 S]y.�, i�►.1 co ayai*s
(1)
Mailing Address: 151 a GI s qcA0
City:. ,i 1,I! State: Zip Code1-7 O 5 [runty: utll tr►"1
Name ffe_e_Ts! o.! 4:111 • pv-_.2.5,--7 Cell 110_
EMAIL Address: S Y .1 W.Q4.4. C eL kA a,. C'tem
(2) Physical Address of Site (i£ different than above):
City: State: Zip Cade: County;
Home/Office Tele Na.: Cell No.:
EMAIL Address:
D. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a Ietter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address
City: State : Zip Code: County:
Office Tele No.1+I0,:
Website Address of Company, if any:
C. STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands: Kttictvtl) r uOan+ uv�U
ACIVCR pRO 11 RECTO
DEC 11 24a9
D. WELL DRILLER INFORMATION
GPLIIUIC 5QM Well ronnu Application (Reviled woos)
PAP I

12/16 /2009 1~:21 FAX il]003
Company Name: Home Eue. SY fl,e-:-e e..,o ""D 1!1. "ci ii(\ ~ JD· c..,
Well Drilling Contractor's Name: William B. Jefferson
NC Contractor Certification No.: 3971-A
Contact Pe~1t~~~~ Addtess: M~J1tt.~~(4gl~~eZ~~;;1 Or'"O"t>f> ~ ~
Address: PO BOX 238/ ~ei £i 'fl1hd 6ffliet V c.\
City: W-endell Zip Code: 2~ County: ~\~er t~
('r\'\Ao.\e..S~~ a., S-S'l 1'10-~ .>
Office Tele No.: 919.366.8261 Cell No.: n/a
6)-S~-AM-~~9
E. HEAT PIJ MP CONTRACTOR INFORMATION (It different than driller)
F.
Company Name: Heme-E!k:1&) l:ne. G(ee>--c,e.S:.J~n Gn,v-p, \l'\<:r..
Well Drilling Contr.lctor's Name: William B. Jefter!lon
NC Contractor Certification No.: 3971-A
Contact~ Am1fl{HiWJMAIL Address; ,ann0@IbeHeR1eE:BC.1g:,Co1~.com n,....:t'
Adcb"ess: PO BOil38/ a~2 E 11,hdsneet ('('\N\e-\~f\ ~-Geo de~·,t,I\ ~YVU-f'
City: Wemeil ~ t Zip Code: ~ County: Wftke.. µ·n.,.Q. ~ <'l';. ~d. 1..-e !:.-<-7 a,.1S-S'"7
Office Tele No.: 919.366':0'2.61 q Cell No.: n/a
~~-B-.'3,,.S-~~,
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Geothermal HY .AC with closed loo p copp er p i ping
G. WEU, CONSTRUCTION DATA (Ski p to S~tion H If this is a Perm it R ENEW AL)
(1) Proposed date to be constructed: \'li"'2:i.,t)G\ Number of borings: --2..
Approximate depth of each boring (feet): 'l O Q/J. ,
(2) Chemical additives to be used in clOied•loQp system (only those chemicals indicated have been approved):
_x_ R~407C propylene glycol __ ethanol ----·••"'~---other (other additives will need prior
approval by NCDENR before use)
(3) Type of tubing to be used (copper, J>VC, etc): _ft _~C~~=-----._..i).,._ef=-"--------
(4) Well casing, Is the well(s) cased? (check either (a.} YES Jc t½ NO below)
(a) YES ___ if yes, then pl'ovide easing information such as~ (steel, PVC, plastic, etc.), diameter,
depth, and~ of casing appearing above ground: _________ _
(b) NO · ____.X.,__
(5) Grout (material surrounding well casing and/or piping):
(a.) Grout type; Cement__ Bentonite J_ Other (specify)~•----
(b) Grout depth of tubing (reference to land surface): fto1n fd' to 7 0 (feet)
If well has casing, indicate grout depth; from __ na)p_ to 70 ml __ (feet)
H. INJECTION-RELATED EQUIPMENT
Attach a diagram wowing the engineering lnyout or proposed modification of the injection equipment und exterior
piping/tubing associated with the injection operation. The manufactu1·e1·'s brochure may provide supplementary
information.
I. LOCATION OF WELL(S)
GPUIUIC SQM Well Perrnir Application (Rcvis1:cl 712m11:1) P11gc2
12/16/2009 1~:22 FAX @004
.-· -.,
Attach two copies of maps showing the following infonnation:
(J) 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
e:(isting well(s) or waste disposal facilities such as septic tanks or ,fr.iin fields located within 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a notth a1·row,
(2) Include II topographic map of the area extending one 1nile from the property boundaries and
indicate the facility's location and the map name.
J. POTABLE WATERWELL(S)
Arc there any potable water well(s) on the subject property 01· adjacent properties'? ~ YES -1(NO
If Yes, than indicare location 011 attached map(s}.
K. CERTIFICATION
Note: This Permit Application mbst be signed by each person appearing on the recorded legal p1·operty deed •
.. I h~reby certify, under penally of law, that I have personally examined and am familiar with the information
subinittcd in this document and all attacb111ents thereto and that, based 011 my inquiry of those individunls
irrunediately responsible for ·obtaining said information, I believe that the information i!I true, accumte at,d co1nplete.
I am aware that there are significant penalties. including the possibility of fines and impri!!onmcnl, for submitting
false information. l agree to constrnct, 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."
·-.A ·-'~ ~z~» ~ \; s.:.-0 ····• ......
Signahlr~ otProperty Ow~cr/App1icant. .
. 5_ C!,<'"-.:1 ~ \✓. '(:) ,)J.1'1 '/\½·-:~-... ___ ... ·,·-·---
Print or Type Full Name )
Sig;ature of Property Owner/Applicant
Print ·o"°i Type Full Name
-----------------· . ···--·---·--Signature of Authorized Agent, if any
Print or Type Full Name
Please return two copi~s 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]
C/PU/UIC SQM Well Pe1·111it A11plic:ation (Revis~d 7/2008) !'age 3
12/16/2009 1322 FAX
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12/18/2009 13:21 FAX
a0o1
FAX CO VRRSHEET
DATE: 1,2116/09
TO: Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
FROM: Marie Melton
Middlesex, NC
RE: Sarah Woodring site 1513 Glasgow St, Durham, NC
Mr. Rogers,
Per your request, 1 have enclosed the correctly completed SQM form as well
as the proper back up documents, I apologize for any inconvenience this
may have caused. I am new with Geo Design Group and am trying to get up
to speed on completing the permits and applications. I thank you for your
understanding, Please let me know if you will require any additional
information.
Kind Regards,
Marie

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Friday, October 16 2009

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 HEAT PUMP SYSTEM FOR:
TYPE 50M WELL(S1
New Permit Application OR Renewal (check one)
DATE: 1 1 — I C, , 20 Oct
PERMIT NO.
(leave blank if NEW permit application)
A. PROPERTY OWNER(S)! PLICANT(S)
List each Property Owner liste n property deed (if owned by a business or goy ment agency, state name of
entity and a representative wlautho 'ty for signature): ') Cocci
(1) Mailing Address: 15 / 3 q. il W
City: DA) {� c• ,,,� _ Stat Zip Cod ' 77 fl S ' County:0 t+11/c+14'1
Homeqfice TeI o.: 91 9 - b 2 `f • Cell No.:
EMAIL Address: St ; rc
(2) Physical Address of Site (if different than ab e):
City: State: Zip Co : County:
Home/Office Tele No.: -'ell No.:
EMAIL Address:
B. AUTHORIZED AGENT OF OWrNI R, IF ANY (if the Permit Applicant dt •s not own the subject property,
attach a letter from the property o‘yher authorizing Agent to install and operate well)
Company Name:
Contact Person:
Address:
City:
Office Tele No.:
EMAIL Address:
State: Zip Code:
County:
Cell No.:
Website Addre~ of Company, if any.
C. STATU, F APPLICANT
PnvatFederal: Commercial:
5 . Municipal: Native American Lands:
D. WELL DRILLER INFORMATION
GPUNIC 5QM Well Permit Application (Revised 7/2008)
RECEIVED 1 DENR 1 DW►
Aquifer Protection Section
DEC 0 8 Z009
Page l

Company Name: Home Energy Inc.
Well Drilling Contractor's Name: WilliamB. Jefferson
NC Contractor Certification No.: 3971-A
Contact Person: Anna Jeffreys EMAIL Address: [e-mail]
Address: PO BOX 238/ 302 E Third Street
City: Wendell Zip Code: 27591 County: Wake
Office Tele No.: 919.366.0261 Cell No.: n/a
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Home Energy Inc.
Well Drilling Contractor's Name: WilliamB. Jefferson
NC Contractor Certification No.: 3971-A
Contact Person: Anna Jeffreys EMAIL Address: [e-mail]
Address: PO BOX 238/ 302 E Third Street
City: Wendell Zip Code: 27591 County: Wake
Office Tele No.: 919.366.0261 Cell No.: n/a
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Geothermal HV AC with closed loo p co pp er pi ping
G. WELL CONSTRUCTION DATA (Ski p to Section H if this is a Permit RENEWAL )
(1) Proposed date to be constructed: ________ Number of borings: ____ _
Approximate depth of each boring (feet): _______ _
(2) Chemical additives to be used in closed-loop system ( only those chemicals indicated have been approved):
.JL_ R-407C propylene glycol ___ ethanol _________ other (other additives will need prior
approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): _______________ _
(4) Well casing. Is the well(s) cased? (check either (a.) YES QI. (b.) NO below)
(a) YES ___ if yes, then provide casing information such as~ (steel, PVC, plastic, etc.), diameter,
depth, and extent of casing appearing above ground:
(b) NO X
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite _x_ Other (specify) _______ _
(b) Grout depth of tubing (reference to land surface): from ___ to ____ (feet)
If well has casing, indicate grout depth: from __ na __ to __ na __ (feet)
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.
I. LOCATION OF WELL(S)
GPU/UIC SQM Well Permit Application (Revised 7/2008) Page2
J.
K.
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 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.
POTABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties? YES NO
If Yes, than indicate location on attached map(s).
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 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false infonnation. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
Signature o! Property Owner/Appnemit
Print or Type Full Name -
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print 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]
GPU/UIC 5QM Well Permit Application (Revised 7/2008)
RECENED I ❑ENR 1 DWCI
Aquifer Protection Section
DEC 082009
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