WI0500281_GEO THERMAL_20200708

rOggtalprolina Department of Environmental Quality - Division of Water Resources
N FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
t401:6 OlCroe
EOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
In Accordance With the Provisions of 15A NCAC 02C .0224
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: _
., 20 PERMIT NO. W.1t) SD 0 2$ (leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New We1I/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as Geothermal Well ❑ Drinking Water Supply Well
❑ Other Water Supply Use- Indicate use (i.e., irrigation, etc.)
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 Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence X- 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: C 4'1, a u-(e5 Pt\ ( +coin -Pc,rd1 *B6-6 bile) /31-r1drecv5 Si-cui -fzrrc 7
Mailing Address: t if G) /4 • e,evus bor-c �+ t
City: ( 2-p e ( tom` f ( State: l'\GLZip Code: ') County: 0 rGr �,q c_
Day Tele No.: ��! - q �{ -.1-Ce LfS- Cell No.: U
EMAIL Address:5+cu'recar-cQ , b a- Jrta.i l C 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:
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: q, q' L b Lt 3 3 `f County: (3 r Gt v►.
(2) Physical Address (if different than mailing address): - a v
City: County _ Zip Code:
F 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.: Ce11 No.: Fax No..
G. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name:
NC HVAC Contractor License No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Ce11 No.: 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(4):
(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

(3)
(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.
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:
(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 1500
mg/L chloride or greater per 15A NCAC 02C .01070(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
K. 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.
L. SITE MAP — As specified in 15A NCAC 02C .0224(11)(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 nerson(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."
Signature of Pro ty wner/Ap
,..a
ant
e kt,cirte.s 5f6- C1 0 wvkcv-
Print or Type Full Name and Title
T&bbu'G drew5w�ev-
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

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
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: 20 PERMIT NO. _ (leave blark 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 grGeothermal Well ❑ Drinking Water Supply Well
❑ Other Water Supply Use- Indicate use (i.e., irrigation, etc.)
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 jNO
If yes, indicate New Owner's contact information:
Name(s)
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence X Business/Organi7Ation
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: C fr a. a-teg A t -tzar l-Po r41 B6.lobLei 6-mc:14-erv5 -1-G n-(crrc(!
Mailing Address: I ${ rD ^+mac eve S bvr t, f5s }
City: 1,1 412 e ( 1-411
Day Tele No.: I - G} 4, - 1-Ce '-ES Ce11 No.:
EMAIL Address:5fa-vr f'ar-41, ,b el- 3 rrza:4 t , Carr -Fax No.:
State:l'\GLZip Code: - �5(
County: 0 ('a.44,3c..

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: 5a-i^"L
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: q 'I d 334- County: (3 rct14r„
(2) Physical Address (if different than mailing address): r5
City:
County Zip Code:
F 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.: Ce11 No.: Fax No.:
G. HVAC CONTRACTOR INFORMATION (if different than driller)
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.:
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:

(3)
(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.
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.
.1: 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:
(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 1500
mg/L chloride or greater per 15A NCAC 02C .0107(1)41
(1 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
K. 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) o 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)

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 personls) 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."
Signature of Prop�wner/Ap 4ant
C
C ha.rte.s j� �1n.1 �� f ay.-�a r c� (� w n,Lv-
Print or Type Full Name ana Title
C Signature a Property
gabbu'Gdrew5 ,
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]

ROY COOPER
Governor
MICHAELS. REGAN
Secretary
S. DANIEL SMITH NORTH CAROLINA
Environmental Quality Director
July 8, 2020
Charles A. & Bobbie A Stanford
1800 N. Greensboro St.
Chapel Hill, NC 27516
RE: Acknowledgement of Application No. WI0500281
Geothermal Heating/Cooling Water Return Well
Orange County
Dear Mr. & Mrs. Stanford:
The Water Quality·Regional Operations Section (WQROS) acknowledges receipt
of your permit application and supporting documentation received on June 29, 20120.
Your application package has been assigned the number listed above, and the primary
reviewer is Shristi Shrestha
Central and Raleigh Regional Office staff will perform a detailed review of the
provided application, and may contact you with a request for additional information. To
ensure maximum efficiency in processing permit applications, the Water Quality Regional
Operations Section (WQROS) requests your assistance in providing a timely and complete
response to any additional information requests.
Please note that processing standard review permit applications may take as long
as 60 to 90 days after receipt of a complete application. If you have any questions, please
contact Shristi Shrestha at 919-707-3662 or email at [e-mail].
Sincerely,
For Rick Bolich, Chief
Ground Water Resources Section,
NCDEQ Division of Water Resources
cc: Raleigh Regional Office, WQROS
Permit File WI0500281
~~~ North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street I 1636 Mail Service Center I Raleigh, North Carolina 27699-1036
919.707.9000
Permit Number
Program Category
Ground Water
Permit Type
WI0500281
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Charles and Bobbie Stanford SFR
Location Addre.ss
1800 N Greensboro St
Chapel Hill NC
Owner
Owner Name
Charles Ashley
Dates/Events
Orig Issue
8/23/2010
App Received
4/21/2015
Re gulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27516
Stanford
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
6/30/2015
Permit Tracking Slip
Status
In review
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliatio.n
Charles Ashley Stanford
1800 N Greensboro St
Chapel Hill
Region
Raleigh
County
Orange
NC
Issue Effective
27516
Expiration
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
4/22/15
6/12/15
Subbasln
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
July 2, 2015
Charles and Bobbie Stanford
1800 N. Greensboro Street
Chapel Hill, NC 27516
Re: Issuance of Injection Well Permit
Permit No. WI0500281
Geothermal Heating/Cooling Water Return Well
Orange County
Dear Mr. and Mrs. Stanford:
Donald R. van der Vaart
Secretary
In accordance with your permit renewal application received April 21, 2015, I am forwarding Permit
No. WI0500281 for the continued 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, 2015, (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, 2015, until July 31, 2020,
and shall ·be subject to the conditions and limitations stated therein. ·
Please Note:
• Samples from the influent and effluent sampling ports of your geothermal well system
were collected on May 13, 2015. 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 pennit, 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,
~ f4 .~
Michael Rogers, P.G. (NC 2 FL)
Hydro geologist
Division of Water Resources, NCDENR
Water Quality Regional Operations Section
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Phone: [phone] \ Internet: http://www.ncwater.org
An Equal Opportunity I Affirmative Action Employer -Made in part by recycled paper
Charles and Bobbie Stanford
cc: Danny Smith and Rick Bolich, Raleigh Regional Office
Central Office File, WI0500281
Orange County Environmental Health Department
Page 2 of2
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENViRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE 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
Charles Ashley and Bobbie A. Stanford
FOR THE CONTINUED OPERATION OF 1 (ONE) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defined in Title 15A North Carolina Administrative Code 02C .0224(a), which will be
used for the injection of heat pump effluent. The injection well(s) located at 1800 N; Greensboro Street, Chapel
Hill, Orange County, NC 27516 will be operated in ~ccordance with the application submitted April 21, 2015,
and 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 continued operation 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 August 1, 2015, (i.e., the day after the expiration date of the
existing permit)until July 31, 2020, and shall be subject to the specified-conditions and limitations set forth in
this permit.
Permit issued this the 2nd day of July 2015.
W. S. Jay Zimmerman; P.G. ..
\) Director, Division ofWaterResources
By Authority of the Environmental Management Commission.
Permit #WI0500281 UIC/5A7
ver. 04/15/2015
Page 1 of5
PART I -PERMIT GENERAL CONDITIONS
1. The Permittee shall comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (ISA NCAC 2C .0200). 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 is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data [15A NCAC 02C .021 l(a)].
3. 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 [15A NCAC 02C .0211(1)].
4. This permit is not transferable without prior notice _and approval. In the eventthere 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, including any supporting materials as may be appropriate, at least 30 days
prior to the date of the change [ISA NCAC 02C .021 l(q)].
5. 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 [15A NCAC 02C .0203].
PART II -WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed m
accordance with the requirements of rule 15A NCAC 02C .0107 except as required in Item #2 below.
2. Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC O2C
.0107 except that the entire length of the casing shall be grouted in such a way that there is no
interconnection of aquifers or zones having differences in water quality that would result in degradation of
any aquifer or zone. For screened wells, grout shall be emplaced from the top of the gravel pack to the
land surface. For open-end wells, the casing shall be grouted from the bottom of the casing to the land
surface [15A NCAC 02C .0224(d)(2),(3)].
3 . Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing
conditions. [15A NCAC .0225(g)(8)].
4. The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [15A NCAC 02C .0224(d)(4)].
5. Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal as defined in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .0107(j)(2)].
Permit #WI0500281 UIC/5A7
ver. 04/15 /2015
Page 2 of5
7. A completed Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 of this
permit.
PART 111-0PERATIONAND USE CONDITIONS
1. The Permittee shall comply with the conditions of this permit and properly operate and maintain the
injection facility in compliance with the conditions of this permit and the rules of 1 SA NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [ISA NCAC 02C
.021 lG)].
2. The issuance. of this permit shall _not relieve the Permittee of the responsibility for dan:rnges to surface
water or groundwater resulting from the operation of this facility. 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 that may be
required, such as the repair, modification, or abandonment of the injection facility [15A NCAC 02C
.0206].
PART IV -INSPECTIONS [ISA NCAC 02C .021 l(k)]
1. Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) 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. DWR 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 samples of the injection facility's activities.
PART V -MONITORING AND REPORTING REQUIREMENTS
1. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on-site and available for inspection [1 SA NCAC
02C .0224(f)(2), (4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State
and compliance with the groundwater quality standards specified in ISA NCAC 02L [ISA NCAC 02C
.0224(f)(l )].
3. The Permittee shall report any monitoring or other information that indicates noncompliance with a
specific permit condition, that a contaminant may cause a violation of applicable groundwater quality
standards, or that a malfunction of the injection system may cause the injected fluids to migrate outside
the approved injection zone or area. As specified in rule lSA NCAC 02C .021 l(r), noncompliance
notification shall be as follows:
(A) Oral notification shall be given within 24 hours of the occurrence, or first knowledge of the
occurrence, to the Raleigh Regional Office, telephone number 919-791-42.00.
Permit#WI0500281 UIC/5A7
ver. 04/15/2015
Page 3 of5
(B) Written notification shall be made within five days of the occurrence and submitted to the
addresses in Item #5 below.
(C) The written notification shall contain a description of the noncompliance and its cause; the period
of noncompliance, including dates and times; if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and any steps taken or planned to reduce, eliminate, and
prevent reoccurrence of the noncompliance.
4. The Permittee shall record the number and location of the wells with the register of deeds in the county in
which the facility is located. [15A NCAC 02C .0224(f)(3)].
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
UIC Program Staff
Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Water Quality Regional Operations Section
DWR Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699
PART VI-PERMIT RENEWAL [15A NCAC 02C .0224(c)]
As required by rule an application for permit renewal shall be made at least 120 days prior to the
expiration date of the permit. This permit condition does not apply if the Permittee chooses to
discontinue operation of the well for injection of effluent from the geothermal heating and cooling system
associated with this permit.
PART VII-CHANGE OF WELL STATUS [15A NCAC 02C .0240]
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complying with all applicable regulatory requirements.
2; If a well will no longer be used for any purpose, then it should be permanently abandoned according to
rule 15A NCAC 02C .0113(b) in order to prevent the well from deteriorating and acting as a source or
conduit of contamination, which is prohibited by General Statute 87-88(c).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well
seal that cannot be removed without the use of hand or power tools.
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose,
the Permittee shall permanently abandon that injection well in accordance with the procedures specified in
15A NCAC 02C .0113(b), which include, but are not limited to, the following;
(A) All casing and .materials may be removed prior to initiation of abandonment procedures if
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.
Perinit#WI0500281 UIC/5A7 ·
ver. 04/15/2015
Page 4 of5
(C) Each well shall be thoroughly disinfected prior to sealing in accordance with rule ISA
NCAC 02C .01 l l{b)(l)(A),(B), and (C).
(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
filied.
(E) In those cases when a subsurface cavity has been created as a result of the injection
operations, each well shall be abandoned in such a manner that will prevent the
movement of fluids into or between underground sources of drinking water.
(F) The Permittee shall submit a Well Abandonment R,ecord (Form GW-30) as specified in
15A NCAC 2C .0224(f)( 4) within 30 days of completion of abandonment.
5. The written documentation required in Part VII ( 4)(F) shall be submitted to the addresses specified in Part
V.5 above.
Permit#WI0500281 UIC/5A7
ver. 04/15/2015
Page 5 .of5
WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
Date: 06/09/2015
To: Michael Rogers
Central Office Reviewer
Permit No. WI0500281
County: Orange
Permittee/Applicant: Charles & Bobbie Stanford
Facility Name: Stanford Geothermal Well
L GENERAL INFORMATION
1. This application is (checks] that apply): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification
a. Date of Inspection: 05/13/2015
b. Person contacted and contact information:
c. Site visit conducted by: Laura Robertson & Rai Milosh
d. Inspection Report Printed from BIMS attached: ® Yes ❑ No.
e. Physical Address of Site including zip code: 1800 North Greensboro Street Chapel Hill. NC 27516
f. Driving Directions if rural site and/or no physical address: NW corner at Morningside Drive
g. Latitude: 35.921668 Longitude: -79.085974
Source of LatlLong & accuracy (i.e., Google Earth, GPS, etc.): Goode Earth
IL DESCRIPTION OF INJECTION WELL (S) AND FACILITY
1. Type of injection system: ��
El Geothermal Heating/Cooling Water Return RECE�VEDIDEKR
❑ INR
In situ Groundwater Remediation {Ll}; 12 W3
❑ Non -Discharge Groundwater Remediation t cool Re9o<at
❑ Other (Specify: ] W D48r Gana Semen
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system:
Were samples collected from Influent/Effluent sampling ports? it Yes ❑ No.
Provide well construction information from well tag: Drilled in 2009 by McCall Brothers. 6"diameter
L7alvanized casing to 63 ft bes. Total depth 640 ft bus. 2com.
b. Does existing or proposed system use same well for water source and injection? ❑ Yes 12 No
If No please provide source/supply well construction info (i.e., depth, date drilled, well contractor,
etc,) and attached map and sketch location of supply well in relation to injection well and any other
features in Section IV of this Staff Report.
3 . Are there any potential pollution sources that may affect injection? ❑ Yes ® No
What is/are the pollution source(s)? _
What is the distance of the injection well(s) from the pollution source(s)?
4. What is the minimum distance of proposed injection wells from the property boundary?
5. Quality of drainage at site: ll Good ❑ Adequate ❑ Poor
6. Flooding potential of site: ® Low
❑ Moderate ❑ High
Rev. 6/1/2015 Page 1

WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
7, For Groundwater Remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. If No,
attach map of existing monitoring well network if applicable and recommend any changes to the groundwater -
monitoring program.
8. Does the map included in the Application reasonably represent the actual site (property lines, wells, surface
drainage)? ❑ Yes ❑ 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.
9. For Non -Discharge groundwater remediation systems only:
a. Are the treatment facilities adequate for the type of waste and disposal system? ❑ Yes ❑ No ❑ N/A,
Ifno, please explain:
b. Are the site conditions (soils, topography, depth to water table, etc.) consistent with what was reported by
the soil scientist and/or Professional Engineer? ❑ Yes ❑ No ❑ N/A. If no, please explain:
IIL EVALUATION AND RECOMMENL}ATIO NS
1. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, explain.
2. List any items that you would like WQROS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item;
Item
Reason
3. 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
4. Recommendation
❑ Deny. If Deny, please state reasons:
❑ Hold pending receipt and review of additional information by regional office
❑ Issue upon receipt of needed additional information
® Issue a
5. Signature of report preparer(s): jl
V7/5---
Signature of WQROS Regional Supervisor:
Date: -
Rev. 6/1/2015 Page 2

WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE QUEST FORM
Date: ApriJ 22, 2015
To: RRO-WQROS: Rick Bolich/ Danny Smith
From: Michael Rogers, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
A. Permit Number: WI0500281
B. Applicant: Charles and Bobbie Stanford
C. Facilitv Name:
D. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
D I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a com pleted W OROS Staff
Report.
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 Groundwater Protection Branch contact
person listed above.
RO-WOROS Reviewer: ___________________ Date: _____ _
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 092614 Page 1 of 1
ATTA,
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
April 22, 2015
Charles and Bobbie Stanford
1800 N. Greensboro St.
Chapel Hill, NC 27516
RE: Acknowledgement of Application No. WI0500281
Geothermal Heating/Cooling Water Return Well
Orange County
Dear Mr. and Mrs. Stanford:
Donald R. van der Vaart
Secretary
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on April 21, 2015. Your application
package has been assigned the number listed above, and the primary reviewer is Michael Rogers.
Central and Raleigh Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Water Quality Regional Operations Section
(WQROS) requests your assistance in providing a timely and complete response to any additional
information requests.
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
cc: Raleigh Regional Office, WQROS
Permit File WI0504281
Sincerely
-
rk
Debra J. Watts, Supervisor
[]� Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Phone: [phone] Internet: http:llwww.ncwaler.org
An Equal Opportunity 1 Affirmative Action Employer — Made in part by recycled paper

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 WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal creating and cooling system
CHECK ONE OF THE FOLLOW]NG:
New Application _Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Patties 1 and 4 (signature page) only
Pr nt or Type Information and Mail to the Address on the Last Page illegible Applications Will Be Returned As Incomplete.
DATE: 4,'// )
,20 /.j PERMIT NO. WE 05b0J37 (leave blank if New Application)
A. CURRENT WELL USE AND OWNERSH P STATUS (leave Blank if New Application)
1. Current Use of Well
a. Continue to use as VGeothermal Well Drinking Water Supply Other Water
Supply
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).
D Yes, l wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit Iast issued? ❑ YES ❑ NO
If yes, indicate new owner's contact information:
Name(s)
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
H. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence Business/Organization
Government: State Municipal Count3RECEederaa D �
0, . 21
C. WELL OWNER(S)IPERMIT APPLICANT — For individual residences, list owne ( Ip,property deed. For
all others, list name of entity and name of person delegated authority to sign: .VJat1,,,t
__S-Vart v-r-cQ T 1[3o b b i t- , -E r cP
Mailing Address: ( GTO - t7trrr) 6
City: C yvoi—F U[- State: t Zip Code:.) 7 ( County: b raw
Day Tete No_: '1 / q - 9 ` f - - Cell No.: Ig - - 57a /
EMS Address: 1 a.n t ,6.c1V. 3 Arta- it , COM Fax No.:
Geothernta1 Water Return Welfi'errnit Application (Revised Jan 2015) -` PageT

D. 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: ______________________________ _
Mailing Address:---------------------------------
City: ____________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: Email Address.:
E. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1)
(2)
Parcel Identification Number (PIN) of well site: __________ County: _____ _
Physical Address (if different than mailing address): _________________ _
City: ________________ State: NC Zip Code: ________ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: __________________________ _
NC Well Drilling Contractor Certification No.: _____________________ _
Company Name:. _________________________________ _
Contact Person_~: ---------------~EMAIL Address: ___________ _
Address: ___________________________________ _
City: __________ ZipCode: _____ State: __ County: _________ _
Office Tele No.: _________ Cell No.: ________ Fax No .. : _________ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
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.: _______ _
H. WELL USE.;;;...,.._Witt-the·'i'f'!J~dion well(s) also be used as the supply well(s) for the follpwing?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO
YES ___ _ NO ___ _
L WELL CONSTRUCTION REQUIREMENTS-As specified in 15A NCAC 02C .0224(d ):
(l) The water supply well shall be constructed in accordance with the water supply well requirements of
l5A 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 Pennit ApJ?lication (Revised Jan 2015) Page 2
(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.
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:
(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 1500
mg/L chloride or greater per 15A NCAC 02C .0107(f)(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
K OPERATING DATA
(1) Injection Rate: Average· (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Avera$e (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
feeto~proposed injection well(s).
(3) .. Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be loca'ted. · .._
( 4) -An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page3
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded fro►n the applicable county GIS svebsite. 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 he 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_e7 requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
1 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 personisi 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, 1 believe that the information is true, accurate and
complete. 1 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."
S gnature of Property Owner/Applic i r
__By bb � A* � T -
Print or Type Full Name
Signaturet 12- 41 ed.
��� of r perryy Own // `Applicant �
Print or Type Ettil Name
Signature of Authorized Agent, if any
Print or Type F'utl Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 4

Permit Number WI0500281
Central Flies: APS_ SWP_
09/03/10
Permit Tracking Slip
Program Category
Ground Water
Status
Active
Project Type
New Project
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Version
1.00
Permit Classification
Individual
Primary Reviewer
mi cha el. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Charles Ashley & Bobbie Andrews Stanford SFR
Location Address
1800 N Greensboro St
Chapel Hill
Owner
Owner Name
Charles
Dates/Events
NC 27516
Ashley Stanford
Permit Contact Affiliation
Mike Floyd
PO Box 668710
Charlotte
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Charles Ashley Stanford
1800 N Greensboro St
Chapel Hill
NC
NC
Orig Issue
08/23/10
App Received Draft Initiated
08/02/10
Scheduled
Issuance Public Notice Issue
08/23/10
Effective
08/23/10
_R_e_..g'-u_la_t_e_d_A_c_t _iv_it_ie_s _______________ Re q uested/Received Events
Heat Pump Injection Additional information requested
RO staff report requested
Additional information requested
Additional information received
RO staff report received
Additional information received
Outfall NULL
282668710
27516
Expiration
07/31/15
08/06/10
08/09/10
08/09/10
08/09/10
08/16/10
08/16/10
Waterbody Name Stream Index Number Current Class Subbasin
Permit Number WI0500281
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
Charles Ashley & Bobbie Andrews Stanford SFR
Location Address
1800 N Greensboro St
Chapel Hill NC 27516
Own r
Owner Name
Charles Ashley Stanford
Dates/Events
Orig Issue App Received Draft Initiated
08/02/10
Requlated Activities
Heat Pump Inject ion
Outfall JULL
Scheduled
Issuance
Central Files: APS_ SWP_
08/18/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Mike Floyd
P O Box 668710
Charlotte
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Afflliatlon
Owner Type
Individual
Owner Affiliation
Charles Ashley Stanford
1800 N Greensboro St
Chapel Hill
NC
NC
Public Notice Issue Effective
eauested/Received Events
Addi ti onal inform ation requ ested
RO staff report requested
Additional information requested
Additional information rece ived
RO staff report received
Additi onal information rece ived
282668710
27516
Expiration
08/06/10
08/09/10
08/09/10
08/09/10
08/16/10
08/16/10
Waterbody Name Stream Index Number Current Class Subbasin
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
August 23, 2010
Charles Ashley and Bobbie Andrews Stanford
1800 N. Greensboro St.
Chapel Hill, NC 27516
Re: Issuance of Injection Well Permit
Permit No. W10500281
Issued to Charles Ashley and Bobbie Stanford
Orange County
Dear Mr. and Mrs. Stanford:
In accordance with your application received August 2, 2010, I am forwarding Permit No. W10500281 for the
operation of a 5A7 geothermal underground injection control (UIC) well heat pump system located at the above
referenced address. This permit shall be effective from the date of issuance until July 31, 2015, and shall be
subject to the conditions and limitations stated therein.
Please notify Lin McCartney with the Raleigh Regional Office at 919-791-4200 after the geothermal
injection well becomes operational in order to collect influent and effluent samples.
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 meat [phone].
Best Regards,
Michael Rogers, P.G. C & FL)
Environmental Specialist
cc: Jay Zimmerman — Raleigh Regional Office
Central Office File — WI0500281
Orange County Environmental Health Dept.
Mike Floyd - McCall Brothers, Inc.
Attachment(s)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27690-1636
Location: 2728 Capital Boulevard. Raleigh, North Carolina 27604
Phone' 919.733-3221 I FAX 1: 91 S-715-056B; FAX 2: 919-715-5048 i Customer Service: 1--877-623-6746
Internet; yrww.ncwatervualitv.ora
An Equal pc ruin iy l Atfirmaiive Action Employer
1V orthCarol,ina
VQ' raiiij

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
Charles Ashley and Bobbie Andrews Stanford
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title ISA 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 1800·N. Greensboro St., Chapel Hill, Orange County, NC 27516, and will be
constructed and operated in accordance with the application received August 2, 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 operation of an injection well shall be in compliance with Title l 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 the date of its issuance until July 31, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
Permit issued this the 23 rd day of August 2010.
\<'4 Coleen H. Sullins, Director
\j . Division of Water Quality
By Authority of the Environmental Management Commission.
WI0500281
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-1) 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 -Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
[phone]
GW-1 s must be submitted within 3 0 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.
WI0500281 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.
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.
PART ID-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 .
WI0500281 3
PART VI -MONITORING AND REPORTING REQUiltEMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Raleigh Regional Office, telephone number [phone], any of the following:
(A) Any occurrence at the injection facility that results 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 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 Pennittee.
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 RENEW AL
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 .0213(h)(l), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
WI0500281
(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.
4
•·
(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 injeqtion operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
WI0500281
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 07-19-2010
To: Aquifer Protection Central Office
Central Office Reviewer: Michael Rogers
Regional Login No: __ _
L GENERAL INFORMATION
1. This application is (check all that apply): IZ! New D Renewal
County: Orange
Permittee: Charles Standford
Project Name: Injection SA 7 Well
Application No.: WI0500281
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 IZ! Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IZ! Yes or D No.
a. Date of site visit: 08-12-2010
b. Person contacted and contact information: Charles Stanford, [phone]
c. Site visit conducted by: Lin McCartney
d. Inspection Report Attached: 1:2] Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
]>
C en -en ,..._,
c::, a
IZ! Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Disposal and Injection Sites:
(If multiple sites either indicate which sites the information applies to, copy and paste a new section into the
document for each site, or attach additional pages for each site)
a. Location(s): 1800 North Greensboro St.. Chapel HilL NC 27516
b. Driving Directions: From I-40 . Merge onto NC-54 W via EXIT 273A. Merge onto US-15 S/US-501 S.
US-15 S/US-501 S becomes NC-54 BYP W. Tum right onto W Main St. Turn left onto Simpson St.. Turn
right onto Hillsborough Rd. Stay straight go onto N Greensboro St.
c. USGS Quadrangle Msf name and number: Chapel Hill
d; Latitude:35-55-~ / Longitude: 79-5-7.6
II. NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section)
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
FORM: Staff.Report-Standford 1
~ g
JPI Ji ;:I-
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z
AQUIFER PROTECTION 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 of injection system:
[8J Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
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 [8J No
3. Are there any potential pollution sources that may affect injection? D Yes [8J No
What is/are the pollution source(s)?
4. What is the minimum distance of proposed injection wells from the property boundary? 41 ft.
5. Quality of drainage at site: [8J Good D Adequate D Poor
6. Flooding potential of site: [8J 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: NI A
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? IZ! 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 . explain:
3. For renewal or modification of groundwater remediation permits (of an y typ e), will
continued/additional/modified in jections have an adverse impact on mi gration of the plume or mana e.ement of
the contamination incident? D Yes D No. If yes . explain:
4. Drilling contractor: Name:
FORM: Staff.Report-Standford 4
AQUIFER PROTECTION REGIONAL STAFF REPORT
Address:
Certification number:
5. Complete and attach Well Construction Data Sheet.
V . EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet -if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? D Yes IZI No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
FORM: Staff.Report-Standford 5
AQUIFER PROTECTION REGIONAL STAFF REPORT
7. Recommendation: D Hold, pending receipt and review of additional informati~n by regional office; D Hold,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information; ~
Issue; D Deny. If deny, please state reasons: __
8. Signature ofreport preparer(s): _d:_· ___L_) Y\:......,___/~--'m'-----=C~'-'--·-'-'~-"'-~..,.....:~-_:-------
Signature of APS regional supervisor: ____ _,ffe.....~~,'-,;,-l~~~'---F-c~~~~,..--c=~=-,,____ ________ _
Ec?'Z-/' (/ Date:
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
The owner pro poses to convert an irri e ation well to a geothermal in jection well. This site visit was a pre-
p ermittinl! ins pection. Based u pon the result of this ins pection. The Central Office may issue the p ermittee a
permit to install the heat pump to the well. The result of the ins pection indicated that the location and the
construction of the well met the requirements of North Carolina Well Construction Standards . U pon installation
of the heat pum p, there will be a follow-u p ins pection and a samp lin g of the well.
FORM: Staff.Report-Standford 6
Permit: WI0500281
SOC:
County: Orange
Region: Raleigh
Effective:
Effective:
Contact Person: Mike Floyd
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 08/12/2010
Primary Inspector: Lin McCartney
Secondary lnspector(s):
Reason for Inspection: Routine
Compliance Inspection Report
Expiration:
Expiration:
Title:
Owner: Charles Ashley Stanford
Facility: Charles Ashley Stanford SFR
1800 N Greensboro St
Chapel Hill NC 27516
Phone: [phone]
Certification: Phone:
Entry Time: 11 :00 AM Exit Time: 11 :30 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
AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: August 9. 2010
To: ❑ Landon Davidson, ARO-APS
❑ Art Barnhardt, FRO-APS
❑ Andrew Pitner, MRO-APS
® Jay Zimmerman, RRO-APS
From: Michael Rogers Groundwater Protection Unit
Telephone: S 919) 715-6166
E-Mail: Michael.Rogers: a ncmail.net
❑ David May, WaRO-APS
❑ Charlie Stehman, WiRO-APS
❑ Sherri Knight, W-SRO-APS
Fax: [phone]
A. Permit Number: WI 0500281
B. Owner: Charles Ashley Standford
C. Facility/Operation:
❑ Proposed ® Existing
❑ Facility ❑ Operation
D. Application:
1. Permit Type: ❑ Animal ❑ SFR-Surface Irrigation❑ Reuse ❑ }I R Infiltration
❑ Recycle E I/E Lagoon ❑ GW Rernediation (ND)
• UIC — 5A7 Geothermal well
For Residuals: ❑ Land App, ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2 Project Type: ® New ❑ Major Mod. ❑ Minor Mod.. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: E I would like to accompany you on a site visit.
NOTE:
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within, please take the following actions:
• Return a Completed APSARR Form and attach laboratory analytical results, if applicable.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer:
Date:
FORM: APSARR 07/06 Page 1 of 1

AUG-49-2010 MOH 10:54 AM McCall Brothers
FAX NO. 7043982605 P. 01/02
ilicOLL PO BOX E68710 " CHARLOTTE, NC " TELEPHONE [phone]CE " FAX {700-398.2645
BROINERSC4FACSIMILE TRANSMITTAL
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DATE: ) q/ 70/0 FAX NO. 49 ''j - 7/5 -
TO:
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ATTENTION:
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FROM: 6- t‘Yi6
NO. PAGES Z (Including This One)
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AUG-09-2010 MON 10;55 AM McCall Brothers FAX NO, 7043982605
P, 02/02
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NON RSIDS+ VTIAL WELL CONSTRUCTION RECOIL]
North CarolinaDepeentten! al2nviratInc sand Natural Imo row Division GFWatet Quality
WELL CONTRACTOR CERTIFICATION # 3 S 5
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L CONTRACTOR:
ne F"'n:Ci r
elt Contractor (Indhl el) Name
t'i r f X Cf= 'S
Wd Carnraclor CommName
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WELL INFORMATION: ,{
SITE WELL ID tut appticablaar�
STATE WELL PERM)Ti{1[apmicibtd) W '0. OM 7
l]WQ or OTHER PERMIT it(If applicable) A./A
WELL USE [Chock Appltcable Oa) MoriTlpfng ❑ Munlolpal1Puia1tc
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DATE DitILLEi 6"27(;)•-cg
TIME COMPLETED • AM LI PM Ei
3. WELL LOOA'f ION:
CITY: C',r>.f { tit COW1TY onD
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t9Vaet Name, NurRkaar, Carnmunni Subdrdalen, Lot4m, Parses. Zip Cade)
TOPOGRAPHIC f LAND SEI TING:
t Stapt3 ClYuitey L4iat QRldgo f=I other
(Os* eppreprlsta bet4
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stinuteci whin rant Inot rattle
4. PACILtTY• le the nano or 1hr doing' shove eVewetl Ir1a Oa.
FACILITY ID Cif eppfioehi
NAIAR OF FACILITY
STREET ADDRESS
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minutes. eecnnds m
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CONTACT PERSON 51Ify S-1: 41-at ei
MAILING ADDRESS Ni. 6 sit r. 5
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alp Code
t;ll or Town SIM
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& WELL DETAILS:
a, TOTAL DEPTH
b. DOES WELL.. REPLACE EXISTING WELL?( YES C1 NO ti
a, WATER LEVEL saint Tap of Casingl 16 _FT.
(ilea "r' If Above Top of Casing)
d. TOP of CASING IS 1. FT, Ab4vs LeM Surface'
"Top or mho terminated atior *kw lend aurfara mey require
a variance in accordance Milt t5A MCA° 2G -Slit f+
a. YICLtO farm*ter. • MgTHQD OF TEST 0+�i P
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p, WA, ERZQNES (dap1h
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ATA
NCDE1P
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Goleen H. Sullins Dee Freeman
Governor Director Secretary
August 6, 2010
Charles Ashley Stanford
Bobbie Andrews Stanford
1800 North Greensboro St.
Chapel Hill. NC 27516
Subject: Acknowledgement of Application No. W10500281
Charles Ashley Stanford SFR
Injection Heating/Cooling Water Return Well (5A7)
Orange
Dear Mr. and Mrs. Stanford:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on August 2, 2010. 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 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 hue:Nh2o.enr.state.nc.usldocumentsldwo orechart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
SincerQy,
for Debra J. Watts
Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Mike Floyd (McCaI1 Brother, Inc., P.O. Box 668710, Charlotte, NC 28266)
Brian Boer (Boer Brothers, 113 E. Union St., Hillsborough, NC 27278)
Permit Application File W10500281
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location' 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] l FAX 1: 919-715-D588; FAX 2: 919-715-60481 Customer Service; 1-877-623-6748
Internet: www.nowaterquaMy.orp
An Equal O porilnity I Affirmative Aaron Employer
N0orthCarolina
7atu"aI1ij

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
Willi A GEOTHERMAL HEAT PUMP SYSTEM
TYPE 5A 7 "OPEN LOOP" INJECTION WELL{S )
(check one) ✓ New Permit Application Renewal ---Modification --
DATE: ----'~rm;'""".· ..... · __ 20 ;o
PERMIT NO.: ...,_WI=-=----------'(leave blank if NEW permit application)
A. PROPERTY OWNER/PERMIT APPLICANT
Name of each owner listed on property deed. For a business or government agency, state name of entity and
name of person delegateq authority to sign application on behalf of the business/agency: ______ _
cicu--le.s /2/4/~.,, e ,6oJ/.;c /lnc/re~,s .:Srn1-l['1.>fi..D l I
(1) Mailing Address: I /106 !1/4R-rll UR.1:-r: A/..s/&t~ o 5 rR :f e,
City: (!A¥el /(!// State: ll.f_Zip Code: ~ ':fS-I Ca County: ,'Jran r t_·. @-
Home/Offi~e Tele No.: f/Jr) f't~ -7~ 'IS" Cell No.: q I °J -~q..._g ;}.-~ h" 1
Fax No. __________ Email Address: ____________ _
(2) Physical Address of Well Site (if different than above): _ _____.,.:i._/.J_!Y,_?=E _________ _
City: _________ State : __ Zip Code: ______ County: ____ _
Home/Office Tele No.: Cell No.: -----------="-=--"'~----------
Fax No. __________ Email Address: _____________ _
B. PROPERTY OWNERSHIP DOCUMENTATION
··-...
Provide legal documentation of property ownership, such as a contract, dee<(' article of incorporation, etc. and
a PLAJmap showing the property. This information may be obtained from the county GIS w<&site;:.
·-· .
C. AUTHORIZED AGENT, IF ANY
If the property owner/permit applicant wants to authorize someone else to sign the permit on their behalf, then
attach a signed letter from the property owner/permit applicant specifying and authorizing their agent (well
driller, heat pump contractor, or other type of contractor/agent) to sign this application on their behalf.
Company Name: ___________________________ _
ContactPerson,....: _____________ =E=m=ail=· ....,A=ddr=ess==--:-·_·-_/ _________ _
Address: ______________ -"'------------------
City: _________ State: .-.. -rZ11,·Code: ---~--'-County: _______ _
Office Tele No.: Fax No. Cell No.:
Website Address of Company, if any: _____________ -.....-n..-,..,,....,......,.,......,,,.,...,..,......,.. __
RECEIVED I DENR / DWQ
AQUIFFR·PROTECTION SECTION
AUG O 2 2010
D. WELL DRILLER INFORMATION
Company Name: -'
Well Drilling Contractor's Name:
NC Contractor Certification No.:
Company Website: WWW.
Address: le. eok , :- : g .7, ^
Contact Person: 4J) r) G
1 L r F:t.V Email Address:
City: c .,-/ ),e State: A/C Zip Code: County:
Office Te1e No.:6a Yg a G Fax No.: Cell No.:
E. HEAT PUMP CONTRACTOR INFORMATION (if different than Driller)
Company Name: e . W'o,.I,.
Company Website: WWW.
Address: 13
Contact Person: L o
Email Address:
City: r/Z`9rf ve.O f1 State: /t'C Zip Code: 76 County:
Office Tele No.: (91t) 6 3 �e f 5 Fax No. Celt No.
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
1t.; 7'i2ly
-1 is fi
`fr./_'2:.� -. .I .4' d f 2 e-i -
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES 7 NO
(2) Personal consumption? YES NO
adg-
EL WELL CONSTRUCTION DATA
PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(7) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
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 the Well Construction Record (Form
GW- l) if available.
(1) Well Construction Date: 1 ar Number of borings:
Depth of each boring (feet): -• -Jd
(2) Well casing. Is the well(s) cased?
(a) YES / If yes, then provide the casing information below.
Type: Galvanized steel / Black steel Plastic Other (specify)
Casing thickness: �� diameter (inches): 6" depth: from ;a r"r to •3 feet (relative to land surface)
Casing extends above ground ,..2 O ` inches Al'° q` ('
(b) NO
(3) Grout material surrounding well casing:
(a) Grout type: Cement / Bentonite* Other (specify) //E.17
*By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .02 13(dX1XA), which requires a cement type grout,
r
(b) Depth of grout around well casing (relative to land surface): from Ir /to 020 feet
Q6"e eha.

(4)
I
Well Screen or Open Borehole depth (relative to land surface): from _6_3_. __ to 6 '-/0 feet
(5) N.C .. State Regulations (Title 15A NCAC 2C .0200) require -the Permittee to make provisions for
monitoring wellhead 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) Influent line? Yes~No__ (b) Efiluentline? Yes__L_No __
(6) Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Form GW-1). If Form GW-1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment units will the groundwater be withdrawn? (e.g .
granite, limestone, sand, etc.)
Depth: _______ Formation: ______ Rock/sediment unit: ______ _
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHERWISE UNAVAILABLE.
I. OPERATING DATA
(1) Injection Rate:
(2) Injection Volume:
(3)
(4)
Injection Pressure:
Injection Temperature:
J. INJECTION-RELATED EQUIPMENT
Average (daily) 5.:-t3 gallons per minute (gpm).
Average (daily)?zro -1;s20 gallons per day (gpd). r,Jp,n:/CA;Se
Average (daily) ,,.., dl.O pounds/square inch (psi).
Average (January) ,1 :,; M •'. ° F, Average (July) '.'/a r •! .. ° F.
Attach a schematic diagram or cross-section of the well construction that shows the total depth, length of casing,
extent of grout, stickup, location of influent/efiluent sampling ports, etc. If this is a modification, show 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 if needed .
K. LOCATION OF WELL{S)
(1) Attach a site map (can be drawn) showing: houses and other structures, property lines, surface water bodies,
potential sources of groundwater contamination, and the orientation of and di stances between the proposed
injection well(s) and any other 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) Attach a scaled topographic map of the area extending 1/4 mile from the property boundary that indicates
the facility's location, a north arrow, and the map name . '
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. Typlcally, the property can be searched by owner
name or address. The location of the wells in relauon 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 elevatwn data.
L. CERTIFICATION (to be signed as required below or by that person's authorized agent)
NCAC 15A 2C .0211(b) 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.
If an authorized agent is signing on behalf of the applicant, then submit a letter signed by the
applicant that names and authorizes their agent as specified in Part C of this permit application.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted in
this document and all attaclunents 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 tines 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."
Signature of Propf v Own /Applicant
r 4S�F�
Print or Type Full Name —'
L..L'(C-r
Signature of Properih Owner/Applicant
f1/V.r'?ie4-4,1
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit TWO signed copies of the completed application package and all attachments to:
131C Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVFt /DENR /DWQ
AOUIFFR p r,rrnrw PFC;
AUG 4 2 2010

7.107.B.9
mr40,„..
4
7.104.A.1.
ONDO

Orange County Environmental Health
r...w� � YwY. wrrR ..
r
1 inch = 50 feet

am225O no 7
oaulas tvnrrr It OV Q/wot
$430.8G
Real Etta la
Excise Tex
Exoira Tex 8430.00
FLLED
30 APR 2301, at O2:33:23pm
Book 2250, Page 7 —
Joyce H. Pearson
Register of seeds,
Orange County, N. G.
lieeordlt Time. Buck anal Page
Tax Loth Na 7.108..12 Parcel Identifier Number 9779-40-4334
Verified by County on the dry of 19.
b�.
Mail after recording to: Grantee at address listed below
Ibis instrument was prepared by James C. Stanford, Atty.
Brief description for the index 1800 N. Greensboro Street
NORTH CAROLINA GENERAL WARRANTY DEED
THIS DBED made this 30' claw of April, 2001, by and between
GRANTOR
GAYLE LATFA CLARiS
and
I. WOODWARD CLARIS
(wife & husband)
GRANTEE
CHARL__S ASHLEY STANFORD
and
BOBBIE ANDREWS S A.N ORD
(husband & wife)
1800 N. Greensboro Street
Carrbora, NC 275L0
num. h appeor Auto Work ford ,. rt.: name, addeesa. aed. ire, ppmpdatl. chaeteletr or emit,. Fa. parwrrtion or pn,iearal[p.
The designation Grantor and Grantee as used heroin DWI include said parties, their heirs, au;.c s ors, and assigns, Trod shall include
singular, plural, masculine, feminine or Pouter se required by context.
WITNPSSETH., that the Grantor, for a valuable consideration paid by the Qreoreo. the receipt of which ie hereby acksvawSadZod,
has and by these manta does grant, bargain, sell and convey unto the grantee in fee Dimple, ail that certain for or parcel of land
mtuated in the City of Carrboro. Chapel Ma Township, Orange County, North Carolina and more particularly described as
follows:
Being all that certain lot or parcel of land situated, lying and being on the north side of OW
Greensboro Road in the Town of Carrburo, Chapel Hill Township, Orange County North Carolina being
the major portion of Lot 1, Block B of the Callahan Property and more particularly described as;
Beginning at an control corner iron found which iron is located in the north property line of Old
Greensboro Road at its interseetton with the western property line of Morningside Drive (formerly
Callahan Street); running thence along the north property line of said road North 70 38' 00" West
253.53 feet to an control corner iron (Aubrey D. Ilarward's southeast corner; see DB 165-651); running
thence (with the said Harward's line) North 34° 37' 49" East 244.44 feet to an iron found; running thence
South 63° 02' 45't East 218.53 feet to an iron found in the west property fine of Morningside Drive;
running thence along the west property line of the said drive South 26° 55' 08' West 208.77 feet to the
beginning, according to the plat of survey prepared by William Jerry Autry, BLS, dated 4-24-01..
This tract of land is all that property conveyed to J.M. Latta and wife Frances Latta in Deed Book
L65, at Page 650, Orange County Registry LESS AND EXCEPT the triangular tract of land located
along the western property tine conveyed to Aubrey D. Hatward and wife Pauline 'forward by J.M.
Latta and wife, Frances M. Latta in Deed Book 165, Page 651. Set also 95-E411 and 00-E-70, Orange
County.
me. a r...a . kate Na. 3 • MC f W iwi ° 973

VENT
GIOUT
20"
ioIo'
WILL CM•LSTR
1'
/20
G3'
1
500/
nit
5/7'1
EA) HT 7-r
EFFLOE:i
f3LEED__

July 30, 2010
To whom it may concern:
Our current air conditioning system is no longer functioning. I hope the worst of the high
temperatures is past for this summer. Anything that could be done to expedite this permit
would be greatly appreciated.
This is my first time applying for a permit like this, and my hope is it has been completed to
your satisfaction, but if not please let me know that is lacking and I will rectify it as soon as
possible. Thank you very much for your effort.
Sincerely,
~h~:~1
(9/V 732 -9-5~ l,tlt>AA
(q IC/J C/4,) -=f-& <-15"° home.
RECEIVED / DENR / DWQ
AQUIFFR·PROTECTION SECTION
AUG O 2 2010
HA
NCDENR MAR O 2 2011
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Mr. Charles Stanford
1800 N Greensboro St.
Chapel Hill, NC 27516
Dear Mr. & Mrs. Stanford,
Division of Water Quality
Coleen H. Sullins
Director
March l, 2011
Subject:
Dee Freeman
Secretary
Permit No. WI 0500281
UIC-5A 7 Geothermal Well
Orange County
Enclosed please find the analytical results of the well water which was sampled on February 03, 2011.
The influent manganese concentration was 250 micro gram per liter (ug/1) while the effluent manganese
concentration was 260 ug/1. These results indicate that the manganese concentration was in excess of the
2L Groundwater Quality Standards of 50 ug/1. The zinc concentrations were 1.0 part per million (ppm)
for influent and 0.96 ppm for effluent. These results indicate that the zinc concentration was slightly
elevated and was close to the 2L Groundwater Quality Standards of 1.05 ppm. However, these zinc
concentrations are not considered to be unusual for wells which have a galvanized steel casing.
Based on the results of the dissolved solids and hardness, it is unlikely that the quality of the well water
would cause a severe scaling problem.
If you have any questions , please contact me at [phone].
Cc : RRO-APS Files
The Central Office-APS Files
Aquifer ·Protection Section
1628 Mail Service Center. Raleigh, North Carolina 27699-1628
Location: 3800 Barrett Dr., Raleigh, North Carolina 27609
Phone: [phone] \ FAX: [phone] \ Customer Service: 1-877-623-6748
Internet: www.ncwatergualitv.org
An Equal Opportunity\ A ffirrnative Action Employer
Sincerely, J:: ~ Yr\ ((jx{ }y0,'),--
Lin McCartney V
Environmental Senior Tech
Nirth Carolina
Jvaturall!f
GROUNDWATER FIELD/LAB FORM
Location code _ 3 p 01:w C 2 l - E �
County _G ran j
Quad No Serial No.
Lot- - - Long.
Report To: ARO. FRO, MRO,WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other._
Shipped by: Bus, Courier, and Qel. Other:
Coilector(s): t, . P1 CCc-f
FIT LD ANALYSES
pH 4r19
Ternp.,4 I_. °C
Appearance
Field Analysis By:__
North Carolina
Department of Environment and Natural -Resources
D}VISION OF WATER QUALITY -GROUNDWATER SECTION
Lab Number
Date Received 0245 ' / 1 Time: ! i,S-S-
Rec'd By: From:Bus, Courier rand Del.,
Other. dl
r` ti -l#Data Entry By: _ Ck: _
Date Reported:
Date ;J -11
Spec Cond.94_2 at 25°C
Odor
LABORATORY ANALYSES
BOD 31 ❑
COD High 340
COD Low 335
,. Conform: MF Fetal 31616
mgfL
mglL
1100mi
Coliform: MF Total 31504
1100m1
TOC 680 mgiL
Turbidity 76 NTU
Residue. Total Suspended 530 mglL
pH 403
Purpose: 9-,411
Time / G.) Baseline, Complaint, tompliance,iLUST, Pesticide Study, Federal Trust, Other.
Owner (l'1 W J 4- .S a 1�['tir+k- 1) C? lorrxe one}
Location or Stte /V C7,s-•e. Q►-i 5 Pc. rC C 1r. W r 14 r-.'1 t L
Description of sampling point W V Zt) !-'l .et- ` E f `- /
Sampling Method_L-7 .,, t �Tg eta Sample Interval
Remarks �= � I u - _
f f 9;7 f% f
Alkalinity to pH 4,5 410
Alkalinity to pH 6.3 415
Carbonate 445
Bicarbonate 440
Carbon dioxide 405
Chloride 940
Chromium: Hex 1032
Color: True BO
Cyanide 720
Lab Comments
units
mgIL
mglt.
mg./
mg/L
mg&L
ug✓l.
< Diss. Solids 70300
mgil.
Fluoride 951
mgfL
eY Hardness: Total 900
Hardness (nonxarh)902
Phenols 32730
wfl
Specific Cond. 95
NMtoslcm
Sulfate 945
m
Sulfide 745
m92
Oil and Grease
NHS as N 610
TKNasN625
mail
X NO2 , NO, as N 630
P: Total as P 665
Nitrate (NOS as N)620
mgfL
CU
Nitrite (Ng as N) 615
mak
GW-54 REV. 7f03 For Dissolved Analysis -submit filtered sample and write MIS' in block
[Pumping time. air temp . eit
Ag-Silver 46566
u2fi-
x.
At-Alurninnml46557
-
As -Arsenic 46551
ug/L
-
Ba-Barium 46558 -
-- -
-
Ca -Calcium 46552
L
.
Cd-Cadmium 46559
uSift-
pm
Cr-Chromium 46559
INA-
Cu-Copper 46562
yyL
Fe -Iron 46563
41,
Hg-Mercury 71900
uvf .
K-Potassium 46555
mg&
Mg -Magnesium 46554
mgfl-
Mn-Manganese 46565
46556
rngA_
IINa-Sodium
Ni-Nicket
ugL
Ph -Lead 46564
ufgl-
Se-selenium
141
111
Zn-Z'snc 46567
ugA.
❑rg_anochforine Pesticides
Orr�anopt+osphorus Pesticides
Nitrorn Pesticides
--— — _ -
Acid Herbicides
PGBs
Semivolarile Organics
TPH-diesel Range
a
Valable Organics (VOA bolUe.1
TPH-Gasoline Range _
TPH-BTEX Gasoline Range
LAB USE ONLY
Temperature on arrival (°C):

Ar cEfl 1.'O La orrory Nett ion (Resuf
County: ORANGE
River Basin
Report To RROAP
Collector: L MCCARTNEY
Region. RRO
Sample Matrix; GROUNDWATER
Loc, Type: WATER SUPPLY
Emergency YeslNo
COC Yes/No
VisitID
Loc. Oescr.: CHARLES STANFORD
Sample ID -
PO Number #
Date Received:
Time Received:
Labworks LoginlD
Report Generated'
Date Reported.
AB 67971
11 G0075
02/03/2011
11:55
HMORGAN
2123111
02/23/2011
11+ 2IZ3l14
Location ID: 5P068W10500281-EFF
Coiiect Date: 02/0312011
Collect Time: 10:30
Sample Depth
CAS # Analyte Name
LAB
Sample temperature at receipt by lab
PCL
Result/
Qualifier
Units
3.8 °C
Method Arj.y Validated by
Reference Date
213111 HMORGAN
MIC
Coliform, MF Fecal in liquid
1 1 B2
CFU1100ml APMA9222❑-20th 213/11 MOVERMAN
Coliform, MF Total in liquid
1 1 B2
CFU1100m1 APHA9222B-20th 2/3/11 MOVERMAN
WET
Ion Chromatography
TITLE mg/L EPA 300.0 2/14/11 CGREEN
Chloride
1 8.7
mglL EPA 300.0 2114/11 CGREEN
Fluoride
0.4 0.4 !J mg/L EPA 300.0 2/14/11 CGREEN
Sulfate
2 3.8 mg/L EPA 300.0 2/14/11 CGREEN
Total Dissolved Solids in liquid
12 251 mglL APHA2540C-18TH 2/7/11 MOVERMAN
NUT
NO2+NO3 as N in liquid
0.02 0.02 U mg/L as N Lac10-107-04-1-c 214/11 CGREEN
MET
7429-90-5 Al by ICP
50 50 LJ ug/L EPA 200.7 2/10/11 ESTAFFORDI
7440-70-2 Ca by 1CP
0.1 65 mg/L EPA 200.7 2/11/11 ESTAFFORD1
7440-47-3 Cr by ICPMS
10 10 U ug/L EPA 200.8 2/4/11 ESTAFFORDI
7440-50-8 Cu by ICPMS
2
150 ug/L EPA 200.8 2/4111 ESTAFFORD1
7439-89-6 Fe by ICP
50 130 ug/L EPA 200.7 2/10/11 ESTAPFORD1
Hardness by Calculation
1 200
mg/L SM2340BEPA 200.7 2111/11 ESTAFFORDI
7440-09-7 K by ICP
0,1 4.7 mg/L EPA 200.7 2/11/11 ESTAFFORD1
7439-95-4 Mg by ICP
0.1 8.5 rng1L EPA 200.7 2J11/11 ESTAFFORD1
7439-96-5 Mn by ICP
10 260 ug/L EPA 200,7 2/10/11 ESTAFFORD1
7440-23-5 Na by 1CP
0.1 14 mg/L EPA 200.7 2/11/11 ESTAFFORDI
7440-02-0 Ni by ICPMS
10 51 ug/L EPA 200.8 2/4/11 ESTAFFORD1
7439-92-1 Pb by ICPMS
10 10 U ug/L
EPA 200.8 2/4/11 ESTAFFORD1
7440-66-6 Zn by 1CP
10 960 ug/L EPA 200,7 2110/11 ESTAFFORDI
FER 2 2011
Laboratory Section'a 1623 Mail Service Center, Raleigh, NC 27699-1623 t919I 733.3908
r•]r a !Qi3liGO lr'e 1'.ia'•''er rq dla3 rarer :O ',!laPr pi l r; r:a7 nr FY�Ne1L+7:Yri1l7rflstrl hr �rv�r:G1•: rsi��:a r]irl r�:.l� ru {[�IY:Qs -I!:1 ]�llt 7rt 71. r'_��a ryr _±. . _fph2R ll{ -rge7fii 1r,V19rr,:4x5•S[,
Page 1 of 1

GROUNDWATER FIELD/LAB FORM 1,, f
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Location code fJ 0/791 t:.-1 r p j G; • f
County O rC'r e
❑ued No Serial No.
• Lat. _ Long.
Report To: ARO, FRO, MRO, WaRO, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Oft., Other:
Shipped by: Bus, Courier Viand Oela Other:
Collector(s): _...- j 1 i-CoLY t-'i ' i Date /- 3
FIELD ANALYSES
��}} 0 cif
pH 400 '/` Spec. Cond.y4'
Temp.,.1- /•°~ ' °C Odor + c
SAMPLE TYPE
0 Water
❑ Soil
❑ Other
IDChain of Custody
Appearance LL
Field Analysis By: : rt F ,=r i1
f
LABORATORY ANALYSES
Bap 310 mg&L
COD High 340
COD
Low 335
Coliform: ME Fee -al 31015
X
Calirorm: ME Total 31504
mgfL
mg&
1100m1
1100ml
TOC 680 mg/L
Turbidity 76 NTU
Residue. Total Suspended 530 mg/L
pH 403
A+ka1irrity to pH d.5 410
Alkalinity to pH 8.3 415
Carbonate 445
Bicarbonate 440
Carbon dioxide 405
Chloride 9d0
TChromium: Hex 1032
Color: True 80
Cyanide 720
Lab Comments
CW-54 REV. 7/0:3
Purpose:
SAMPLE PR1ORiTY
❑ Routine
❑ Emergency
Pt(r D°-q /B 0-6P0
Lab Number
Date Received
Rec'd By:
Other: _
Data Entry By:
Date Reported:
07- 03 I I Time: l
From:Bus, Courie Hand Del
Ck:�
-1 f Time / I ` f } c .'Baseline, Complaintlpompliancei LUST, Pesticide Study. Federal Trust, Other:
by ner kyc. r (E sa tan L t. �' (nude n )
at 25°C Location or Site i SC, C' C 54 - C' r>r r- 1 J -L r / iff� C._ � S
Description of sampling point ;.t>e r / '- t• F { - / -F
Sampling Method
Remarks —n.0 4r-
piss. Solids 70300
mg/L
Fluoride 951
mg/L
Hardness: Total' 900
mg&
Hardness (non- arb) 902
mg&L
Phenols 32730
ugll
Specific Cond. 95
WMhoslcm
Sulfate 945
Sulfide 745
mg/L
m
rr-vmo_ n2ITer_ erc.
AgSllver 46565
; At -Aluminum 46557
As -Arsenic 46551
$a -Barium 46558
X; Ca -Calcium 46552
Cd-Cadmium 46559
Sample Interval
(Pumping time. al 9emp elc.I
uyfL TOrinnochlorine Pesticides
Cr-Chromium 46559
X Cu-Copper 46562
X Fe -Iron 46563
Oil and Grease
units
mg/L
mg&
mg/L
mglL
mg/1.
mg&L
ug/L
cu
mg/L
mg&
Hg-Mercury 71900
ug/L
ug&L
ug/L
uo1L
NHaasN610
TKN as N 625
1' NO2 + NO3 as N 630
P: Total as P 665
mg1L
mglL
mg/L
mg!L
3( K-Polassiurn 46555
X Mg -Magnesium 46554
)( Mn-Manganese 46565
){ Na-Sodlum 46556
Ni-Nickel
Ph -Lead 46564
Nitrate (NO3 as N) 620
Nitrite (NO2 asN)615
mg&
rng7L
mult-
mgrt
SJL ,
rngll
ug/L.
ua1L
Se -Selenium ug/L
Zn-Zinc 46567
• Or;anophose,horus Pesticides
Nitro3en Pesticides_
Acid Herbicides
PCBs
Sermvotatde Organics
TPH-! osel Range
Volatile Organics (VOA bottle)
TPH-Gasoline Range
TPH-BT1 X Gasoline Range
LABUSE ONLY
Temperature on arrival (°C):
For Dissolved Analysis -submit filtered sample and write "015' in block.

0'61,0 LLl6omtorv.SeLtrott Rcsufts
County:
River Basin
Report To
Collector:
Region:
Sample Matrix:
Loc. Type:
ORANGE
RROAP
L MCCARTNEY
RRO.
GROUNDWATER
WATER SUPPLY
Emergency Yes/Na
COC Yes/No
OS}01. wARQG
� r
FEB 2 5 201`-
VisitlD
Loc. Descr.: CHARLES STANFORD
FEB
Sample ID-
PO Number #
Date Received:
Time Received:
Labworks LvgintD
Report Generated:
Date Reported:
AB67970
11G0074
02/03/2011
11:55
HMORGAN
2/23/11
02/2312011
Fmk -1/23)1�
Location fO:
5P068W10500281-INF
Collect Date: 02/03/2011
Collect Time: 10:00
Sample Depth
CAS* Analyte Name
LAB
Sample temperature at receipt by lab
PQL
Result!
Qualifier
3.8
Units
Method Analysis Validated by
Reference Date
2/3/11 HMORGAN
MIC
Coliform, MF Fecal in liquid
1
1 B2
CFU1100mi APHA92220-20th 213111 MOVERMAN
Coliform, MF Total in liquid
1 B2
CFU1100m1 APHA9222B-20th 213111 MOVERMAN
WET
Ion Chromatography
T1TLE�
mg1L
EPA 300,0
2/14/11 CGREEN
Chloride
9.2
mg/L
EPA 300.0
2/14/11 CGREEN
Fluoride
0.4 0,4 U mg/L
EPA 300.0
2/14/11 CGREEN
Sulfate
2
3.8
mg/
EPA 300.0
2114/11 CGREEN
Total Dissolved Solids in liquid
12
246
mg/L
APHA2540C-18TH 217/11 MOVERMAN
NUT
NQ2+NO3 as N in liquid
0.02 0.02 U mg/L as N Lac10.107-04-1-c 2/4/11 CGREEN
MET
7429-90-5 AI by ICP
50
55
ug/L
EPA 200.7
2/10/11 ESTAFFORDI
7440-70-2 Ca by ICP
0.1
65
mg/L
EPA 200.7
2J11/11 ESTAFFORDI
7440-47-3 Cr by ICPMS
10 10 U ug/L
EPA 200.8
2/4/11 ESTAFFORDI
7440-50-8 Cu by ICPMS
2
180
ug/L
EPA 200.8
2J4111 ESTAFFORDI
7439-89-6 Fe by ICP
50.
160
ug/L
EPA 200.7
2/10I11 ESTAFFORDI
Hardness by Calculation
1
200 mg1L SM234DBEPA 200.7 2/11/11 ESTAFFORD1
7440-09-7 1< by 1CP
0.1 4.9 mg/L EPA 200,7
2<111/11 ESTAFFORD1
7439-95-4 Mg by 1CP
0.1
8.7
mg/L
EPA 200.7
2111/11 ESTAFFORD1
7439.96.5 Mn by 1CP
10
250
ug/L
EPA 200.7
2/10/11 ESTAFFORDI
7440.23-5 Na by iCP
0.1
15
mg/L
EPA 200.7
2111111 ESTAFFORDI
7440-02-0 Ni by ICPMS
10
59
ug/L
EPA 200.8
214111 ESTAFFORDI
7439-92-1 Pb by ICPMS
10
10U
ug/L
EPA 200.8
214/11 ESTAFFORDI
7440.66-6 Zn by 1CP
10
1000
ug/L
EPA 200,7
2/10/11 ESTAFFORD1
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
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