WI0300161_Regional Office Historical File Pre 2018

Dear Ms.
In accordance
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pump in}cctiot
€:tir'sion )..
issuance until
Plea.
CDENR
n of Environment and
Dmston Yvater
fColieen
Luecte
Subjuan+ a of Injection Well Perm'
Permit No. WIII30061'
Issued to City of Cllariottc
c t.' i.a of straw. County
h your application r eeived of rtat e 201 it. 1 am forwarding.; Perim
he construction and operation of vertical closed -loop geothermal !nixed-. heat
.em to be located at th, s.d ,:;r"[on Pol6 „° Siation
St,. (Mari ()litip`:" 18202. This permit: shall be effective from tlae date of
20. and shall be subject to the conditions and limitations stated therein,
pay special atte
on to the following se
Part [l. e At least forty -
Aquifer Protection Sectio
telephone number [phone], and the Mooresvilk Regional Office Aquifer Protection Section
Staff, telephone number itt ti'i.-lnc+ct.
etions in Part II of the permit:
(48) hours prior to constructing system, the Permittee shall notify th
Underground Injection. Control ('UIC) Program Central Office staff,.
Part Submit copies of the Well Construction Completion for
days of copletion of installation of geothermal wel
}).
hin 30 calendar
In order to continue uninterrupted legal use of this v'ell for the stated purpose, you should suhnnit 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 Quality. if you ha�rvc any questions regarding your permit or the Underground injection
Control Program please call me at (91 ca) 71. 5-6166.

Sincerely,
/
Michael. Rogers. P.O. (NC & FL)
Environmental Specialist
de: Andrew Ititner — Mooresville Regional. Office
t Central Office File -- WI03001.61.
Mccidenborg Coonly Eirivironnienta 'Health Dept,
lanice Scott Midsouth Geothermal. 1„.„liCt, (Sent via tttnerift
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
City of Charlotte
FOR THE CONSTRUCTION AND OPERATION OF 44 TYPE 5QM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at Charlotte Mecklenburg Police Station
(Providence Division), 3725 Ellington St., Charlotte, Mecklenburg County, NC 28202, and will be constructed
and operated in accordance with the application received September 23, 2010, and in conformity with the
specifications and supporting data, all of which are filed with the Department of Environment and Natural
Resources and are considered a part of this permit.
This permit is for Construction and Operation of an injection well and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and .
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until September 30, 2015, and shall
be subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 20°' day of October 2010.
OgfAc._Sw-tc
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit W10300161
U IC/5QM
ver. 03/2010
Page 1 of 5

PART I - WELL CONSTRUCTION7 GENERAL CONDITIONS
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 (I5A NCAC 2C ,0200), Any noncompliance with.
conditions of this permit constitutes a violation of the North Carolina Weil Construction Act ,and is
grounds for enforcement action as provided for in N,C.G.S, 87-94.
This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit,. the appro ed plans and specifications, and other supporting data.
Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not he located in an area generally subject to flooding. Areas that are general);
subject to flooding include those ; ith concave slope, allu Aial or colluvial soils, gullies, depresstons. and
drainage ways,
Each injection r ell shall be afforded rcasona
ai
PART II WELL CONSTRUCTION SPECIAL CONDITIONS
d.amattc during constru.ctiora and use.
At least forty-eight (48) hours prior to constructing system, the Permittee shall noti y° the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number t91ca't .l t l `, and the iviooresv:,1 Re i prt i Office Aquifer Protection Section Staff., to ephon.e
number t4 R
The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation comers) and shown on an. updated Site Map, The Permittee
shall retain a copy of this record on site.
One well. identification tag per grouping or 'cluster' of wells shall be permanently° affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 1.5A NCAC 2C .0213(g).
PART III _• OPERATION AND USE GENERAL CONDITIONS
This permit is effective only, with respect to the natk
described. in the application and other supporting data.
volume of materials and rate of injection, as
This permit is not transferable. without prior notice to, and approval ,hy# 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. he submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
The issuance of this permit sit not relieve the Perrnittee of the responsibility of nplying kith any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, tivhieh have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit W10 w>m
UIC/5QM
ver. 03/2010
Page 2 of 5

PART IV — PERFORMANCE STANDARDS
I. 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.
The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V — OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to .the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number [phone]. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
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 W10300161
UIC/5QM
ver. 03/2010
Page 3 of 5

PART VII — MONITORING AND REPORTING REQUIREMENTS
All required documentation shall be submitted to:
Aquifer Protection Section — U IC Program
DENR — Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Phi 919-715-3221
and
Aquifer Protection Section
R.cgiona', .Office
0 Easl: ,re Avenue
Mooreseilne„
704 e
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 1\10,Jr,..:svilk..' Regiona; Office within 30 days of
completion of \Yell construction,. Copies of the GW-1 'foun(s) Shall also be given to the Permittee anc'
retained on site to he made available for inspection:
A copy of the site map updated with manifold locations required. in Part .1.I.2 of this permit shall be
su.bmittedto the Aquifer Protection Section Central Office and the Rcgiona Office within 30
days of completion of well construction,
4.. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection will he established and an
acceptable sampling reporting schedule shall be followed.
5. The Permittee shall report -by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Mooresville Regional Office, telephone number (704) 663-1.699 any of the follovving:
(A)
(13)
(C)
(D)
Any occurrence at the injection facility that results in any unusual operating circumstances;
Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
Any loss ofreffigerant in the system, regardless of the origin. oftheloss:
Any recharging of the refrigerant system.,
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit applica: . of any
incorrect infomiationsubmitted in said application or in any report to the Director, the relevant and correct
facts or information shall he promptly submitted to the Director by the Permittee:
7, In the event that the 'permitted facility fails to perform satisfactorily, the Pemiittee shall take such
immediate action as may he required by the Director:
PART VIII — PERMIT RENEWAL
In order to continue 'uninterrupted legal. use of the injection facility for the stated purpose. the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit Wr3a......le,„
U1C/50M
ver. 03/2010
Page 4 of 5

PART IX — CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(1).
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)(1) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit W10300161
UIC/5QM
ver. 03/2010
Page 5 of 5

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEO rIiERMAL HEAT PUMP SYSTEM FOR:
TYPE 5QM WELL(S)
m New Permit Application OR Renewal (check one)
DATE: 9/13 , 2010
PERMIT NO. \V C O310o 1 1 (leave blank if NEW 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 representative w/authority for signature):
City of Charlotte
(I) Mailing Address: 600 East Fourth Street
(2)
City: Charlotte State: NC Zip Code: 28202 County: Mecklenburg
Home/Office Tele No.: 704-336-3654 (Michelle Haas) Cell No.:
EMAIL Address: mhaas()a,ci.charlotte.nc.us
Physical Address of Site (if different than above): 3725 Ellington
City: Charlotte
Home/Office Tele No.:
State: NC Zip Code: 28202 County: Mecklenburg
n/a Cell No.: n/a
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: EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Ce1I No.:
Website Address of Company, if any:
C. STATUS OF APPLICANT
Private: Federal:
State: Municipal: xx
GPU/UIC 5QM Well Permit Application (Revised 7/2008)
Commercial:
Native American Lands:
RECEIVED / DENR i DWQ
Aquifer Protection Section
SEP 23 2010
Page 1

WELL DRILLER INFORMATION
Company Name: MidSouthw Geothermal, LLC
Well Drilling Contractor's Name:
NC Contractor Certification No.:
Contact Person: Janice Scott MAIL. Address: [e-mail]
uthgepthermal.com.-
Address: 8275 Tournament Dr, Ste 185
City: Memphis Zip Code: 38125 County: Shelby
Office Tele No.: 9(1)-748-9Q95
Cell No.: n/a
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: MidSouth Geothermal, LLC
Contact Person: (nice Scott
Address: 8275 Tournament Dr, Ste 185
City: Memphis
Office Tele No.: 901-748-9095
CIA IL Address
Zip Code: d8125 County: Shelby.
Cell No.: n!
id
INJECTION PROCEDURE (briefly describe how the injection rvel1(s) will be used)
WELL CONSTRUCTION DATA (Skip to Section 111 if tltis is a Permit RENEWAL)
(l) Proposed date to be constructed: 10/15/10 Number of borings: 44
Approximate depth of each boring (feet): :3 Q'
(2) Chemical additives to be used in closed -loop system (only those chemicals indicated have been approved):
R-22 propylene glycol _xx (10°.ia ethanol
+will treed prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): 1''" I HDPE plastic pipe
other (other additives
(4) Well casing. Is the well(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES if yes, then provide casing information such as type (steel, PVC, plastic, ate.), diameter,
depth, and extent of casing appearing above ground:
(b) NO x
) Grout (material sounding well casing and/or piping):
(a
Grout type: Cement
Bentonite x Other (spec'
(b) Grout depth of tubing (reference to land surface): from 0 to
If well has casing, indicate grout depth: from Q
II. 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,
GPUIUIC 5QM Well Permit Application (Revised 7/2008) Page 2

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 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.
J. POTABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties? YES x NO
If Yes, than indicate location on attached map(s).
K. 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 spec-fications and conditions of the Permit."
yYi,oullp, (ap, (,-(,)tp.(,)ctoISPlattOtti-
Signature of Property Owner/Ap cant
hd Ukkc
` 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]
RECEIVED I DENR I DWQ
,aquifer Protection Section
SEP 2 3 2010
GPU/UIC SQM well Permit Application (Revised 712008) Page 3

Charlotte Mecklenburg Police Dept.
Providence Division

9N16,V4 3 tt Q). _.

Mecklenburg County, NC POLARIS
Page 1 of 1
Mecklenburg County, North Carolina
POLARIS
Property Ownership Land Records Information System
Date Printed: Tue Oct 12 14:43'17 EDT 2010
Charlotte Police Ellington Contour Map
Legend
0 Selected Features
Charlotte -Douglas
Airport
TEXT
1'
This map is prepared for the inventory of real property within Mecklenburg County and is
compiled from recorded deeds, plats, tax maps, surveys, planimetric maps, and other
public records and data. Users of this map are hereby notified that the aformentioned
public primary information sources should be consulted for verification. Mecklenburg
County and its mapping contractors assume no legal responsibility for the information
contained herein.
Lot Dimensions
t 0 Foot Contours
County Boundary
Utility ROW
Railroad ROW
Tax Parcel
Easements
Miscellaneous
Parcel Limes
Ffirrat a Ri x
NcreiirteX
Corntto Outlines
Condo OtitNnts
county
*VI% 3f Way in o#h4r
county
AirPamets
Streets
krtsrmaeea
Map, Roads
Minor Kart* s
Greenways
Water Quality
Buffers
http://polaris.mecklenburgcountync,gov/servlet/com.esri.esrimap.Esrimap?ServiceName=overview&Clie... 10/12/2010