WI0500406_GEO THERMAL_20160713

Permit Number WI0500406
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
David & Anne Vellenga SFR
Location Address
46 Pollyanna Rd
Henderson
Owner
Owner Name
David
Dates!Events
NC
Orig Issue
9/6/2011
App Received
5/3/2016
Regulated Ac vit1es
Heat Pump Injection
Outfall
Waterbody Name
27537
Vellenga
Draft Initiated
Scheduled
Issuance Public Notice
Central Files : APS S\NP
7/13/2016
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Bill Evangelist
1117 Batchelor Rd
Apex NC 27523
Major/Minor
Minor
Region
Raleigh
County
Vance
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David Vellenga
46 Pollyanna Rd
Henderson
Issue
NC
Effective
27537
Expiration
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
5/9/16
7/8/16
Subbasin
PAT MCCRORY
Governor
DONALD R. VAN DER V AAR T
Water Resources
ENVIRONMENTAL QUALITY
David & Anne Vellenga
46 Pollyanna Road
Henderson NC 27537
Re: Issuance of Injection Well Permit
Permit No. WI0500406
July 13, 2016
.Geothermal Heating/Cooling Water Return Well
Vance County
Dear Mr. and Mrs. Vellenga:
Secretary
S. JAY ZIMMERMAN
Director
In accordance with your permit renewal application received on May 3, 2016, I am forwarding Permit
No. WI0500406 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
September 1, 2016, (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 September 1, 2016 until August 3, 2021, 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 24, 2016. Laboratory analytical results have been forwarded to
you from Raleigh Regional Office.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Resources. If you have any questions regarding your permit or the Underground
Injection Control Program, please call me at [phone].
Best Regards,
Shristi Shrestha
Underground Injection Control (DIC)-Hydrogeologist
Division of Water Resources, NCDEQ
Water Quality Regional Operations Section
State ofNortli'Carolina I Environmental Quality I Water Resources
1611 Mail service Ccutcr I Raleigh, No,th Caroli11a 27699-1611
919 707 9000
cc: Rick Bolich-Danny Smith, Raleigh Regional Office
Central Office File, WI0500406
Vance County Environmental Health Department
Page2 of2
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
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
David and Anne Vellenga
FOR THE CONTINUED OPERATION OF ONE (I) GEOTHERMAL HEATLNGICOOLING 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 46 Pollyanna Road, Henderson, Vance
County, NC 27537, will be operated in accordance with the application submitted May 3 2016, and in conformity
with the specifications and supporting data, all of which are filed with the Department of Environmental Quality
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 September 1, 2016, (i.e., the day after the expiration date of
existing permit) until August 31, 2021, and shall be subject to the specified conditions and limitations set forth in
this permit.
d'^
Permit issued the 1.5 day of _ VL' , 2016.
tS. Jay Zimmerman, P.G.
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Perntit #WI0500406
UIC/5A7
vet-. 11/15/2015
Page 1 of 5

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 (15A 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 (l)].
4. This permit is not transferable without prior notice and approval. 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, including any supporting materials as may be appropriate, at least 30 days prior to the date of
the change [15A 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
I. The well supplying water for the geothermal heating and cooling system shall be constructed in 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 02C .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 defmed in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .0107(j)(2)].
Penuit #WI0500406 UTC/5A7
ver. 11/15/2015
Page 2 of 5
7. A completed Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 of this
permit.
PART ID-OPERATION AND 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 15A NCAC 02C .0200,
even if compliance requires a reduction or dimination of the permitted activity [ISA NCAC 02C .021 l(j)].
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface water
or groundwater resulting from the operatfon 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 [ISA 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
l. 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(t)(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(t)(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 15A 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 919-791-4200.
(B) Written notification shall be made within five days of the occurrence and submitted to the addresses
in Item #5 below.
Permit #WI0500406 UIC/5A7
ver. 11/15/2015
Page 3 of5
(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 locatio.n of the wells with the register of deeds in the county in
which the facility is located. [ISA 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
3 800 Barrett Drive
Raleigh, NC 27609
PART VI-PERMIT RENEWAL [ISA 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 I SA
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.
(C) Each well shall be thoroughly disinfected prior to sealing in accordance with rule 15A
NCAC 02C .0lll(b){l)(A), (B), and (C).
Pernut#WI0500406 UIC/5A7
ver. 11/15/2015
Page 4 of5
(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 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 Record (Form GW-30) as specified in
I SA 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.
Perm.it #WI0500406 UTC/5A7
ver. 11/15/2015
Page 5 of5
WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
Permit No. WI0500406
Date: 07/06/2016
To: Shristi Shrestha
Central Office Reviewer
County: Vance
Permittee/ Applicant: David & Anne Vellenga
Facility Name: Vellenga Geothermal Well
L GENERAL INFORMATION
1. This application is (check all that apply): D New tzl Renewal
D Minor Modification D Major Modification
a. Date of Inspection: 05/24/2016
b. Person contacted and contact information: David V cllenga, [phone]
c. Site visit conducted by: Laura Robertson & Erin Deck
d. Inspection Report Printed from BIMS attached: D Yes tzl No
e. Physical Address of Site including zip code: 46 Pollvanna Road , Henderson. NC 27537
f. Driving Directions if rural site and/or no physical address:
g. Latitude: 36.470760 Longitude: -78.411552
Source of Lat/Long & accuracy (i.e., Google Earth, GPS, etc.): Google Earth
IL DESCRIPTION OF INJECTION WELL(S) AND FACILITY
1. Type of injection system:
tzl Geothermal Heating/Cooling Water Return
D In situ Groundwater Remediation
D Non-Discharge Groundwater Remediation
D Other (Specify: _ ____._)
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system:
RECEIVED/NCDEQ/OWR
JUL O 8 2016
Water Quality Regional
Operations Section
Were samples collected from Influent/Effluent sampling ports? tzl Yes D No.
Provide well construction information from well tag: Completed 6/2/2008: depth 360 ft: casing d e pth
61 ft: diameter 6in.: yield 30gpm.
b. Does existing or proposed system use same well for water source and injection? tzl Yes D 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? D 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: tzl Good D Adequate D Poor
6. Flooding potential of site: tzl Low D Moderate D High
Rev. 6/1/2015 Page 1
WQROS REGIONAL STAFF REPORT FORM
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? D Yes D No. If No,
attach map of existing monitoring well network if applicable and recommend any changes to the groundwater-
monitoring progi;am.
8. Does the map included in the Application reasonably represent the actual site (property lines, wells, surface
drainage)? D Yes 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.
9 . For Non-Discharge groundwater remediation systems only:
a. Are the treatment facilities adequate for the type of waste and disposal system? D Yes D No D NIA
If no, 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? D Yes D No. D N/A. Ifno, please explain: __
IIL EVALUATION AND RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? D Yes !8] 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
D Deny. If Deny, please state reasons: __
D Hold pending receipt and review of additional information by regional office
D Issue upon receipt of needed additional information
[8J Issue ( .J
5. Signature of report preparer(s): ~WI.iv ~ ·e,;/
Signature of WQROS Regional Supervisor: ~ = V ~
Date: 1--l,e ✓l[p
Rev. 6/1/2015 Page2
WQROS REGIONAL STAFF REPORT FORM
UIC Program Support
IV. ADDITIONAL REGIONAL STAFF REVIEW COMMENTS/ATTACHMENTS (If Needed)
The well is excellently maintained in a large, locked shed/building behind the house.
Rev. 6/1/2015 Page3
PAT MCCRORY
Water Resources
rNVIRPNMINTAL. cUwurV
July 6, 2016
David & Anne Vellenga
46 Pollyanna Road
Henderson, NC 27537
Subject: Geothermal Well Sampling Results
46 Pollyanna Road
Henderson, NC — Vance County
Oure'7Nrn•
DONALD R. VAN DER VAART
Scrmmru
S. JAY ZIMMERMAN
Giro.. rnr
Dear Mr. &. Mrs. Vellenga:
Groundwater sampling was conducted at the geothermal well on your property on May 24,
2016. We are forwardin, herewith the laboratory reports dated June 20, 2016, issued for the
following analyses in the influent and effluent samples: fecal and total coliform bacteria, chloride,
fluoride, sulfate, total dissolved solids, nitrate -nitrite as N, and metals.
The laboratory results indicate that several metals were detected in the groundwater
samples collected on May 24, 2016. Iron concentrations were higher in the effluent sample than
the nn#luent sample on the date collected, though still below the 15A NCAC .02L groundwater
standard. Your permit application renewal is currently processing and will be mailed to you
separately.
Please find the attached laboratory results. Feel free to contact me with any questions.
Sincerely,
Laura Robertson, L.G.
Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ
Enclosure
cc: RRO Files
Vance County Health Department
State of North Carolina I Environmental Quality I Water Resources
i 628 Mail Service Center I Raleigh, North Carolina 27699-] 62S
919 791 4200

AC29263 North Carolina Division of Water Resources Water Sciences Section Laboratorv Results
Loe. Descr .: 46 PO!,Yf\1':!1':!A B.QAD, !:fead!JrSOiJ San,ple ID: AC29263
County: VANCE Collector: LROBERTSON VisitlD PO Number#
Region: B.B.Q Report To BBQ Location ID: 5P091WI0500406INF Date Received: 05/24/2016
River Basin ROA01 Co.llect Date: 05/24/2016 Priority ROUTINE Time Received: 13:15
Emergency Collect Time: 11:00 Sample Matrix: Groundwater i..abworks LoginlD TASCENZO1
COC Yes/No Sample Depth Loe. Type: Water SUl!l!IJt Delivery Method NC Courier
Final Report Date: 6/20/16
Report Print Date: 06/20/2016
Final Re 9ort
If this report is labeled preliminary report, the results have not been validated .. Do not use for Regulatory purposes.
CAS#
7429-90-5
7440-70-2
7440-43-9
7440-47-3
7439-89-6
7440-09-7
7439-95-4
7439-96-5
7440-23-5
7440-02:.0
7439-92-1
7440-66-6
Result/ Units Method Analysis
Analyte Name PQL Qualifier Reference
LAB
Sample temperature at receipt by lab 2.3 ·c
MIC
Coliform, MF Fecal in liquid 1 B2 CFU/100ml SM 9222 0-1997
Coliform, MF Total in liquid 1 1 B2 CFU/100ml SM 9222 B-1997
NUT
N02+N03 as N in liquid 0.02. 1.8 mg/LasN EPA 353.2 REV 2
WET
Bromide 0.4 0.4U mg/L EPA300.0 rev2.1
Chloride 1.0 4.0 mg/L EPA 300.0 rev2.1
Fluoride 0.4 0.4U mg/L EPA 300.0 rev2.1
Sulfate 2.0 2.0 U mg/L EPA 300.0 rev2.1
Total Dissolved Solids in liquid 12 80 mg/L SM 2540 C-1997
MET
Al by ICP 50 50 U ug/L EPA200.7 Rev4.4
Caby ICP 0.10 6.4 mg/L EPA200.7 Rev4.4
Cd by ICPMS 0.50 0.50 U ug/L EPA 200.8 Rev5.4
Crby ICPMS 5.0 5.0 U ug/L EPA 200.8 Rev5.4
Fe bylCP 50 50 U ug/L EPA200.7 Rev4.4
Hardness by Calculation 1.0 23 mg/L SM2340BEPA200. 7
K by ICP 0.10 1.3 mg/L EPA200.7 Rev4.4
Mg by ICP 0.10 1.7 mg/L EPA200.7 Rev4.4
Mn by ICP 10 10 U ug/L EPA 200. 7 Rev4.4
Na by ICP 0.10 6.6 mg/L EPA200.7 Rev4.4
NibylCPMS 2.0 19 ug/L EPA 200.8 Rev5.4
Pbby ICPMS 2.0 2.0 U ug/L EPA200.8 Rev5.4
Znby ICPMS 10 44 ug/L EPA 200;8 Rev5.4
WSS Chemistry Laboratory>> 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone]
"Not Detected" or "U" does not indicate the sample is analyte free but that the analyte is not detected at or above the PQL
Page 1 of 1
Date
5/24/16
5/24/16
5/24/16
5/26/16
5/25/16
5/25/16
5/25/16
5/25/16
5/26/16
6/2116
6/2/16
6/13/16
6/13/16
6/2/16
6/17/16
6/2/16
6/2/16
6/2/16
6/2/16
6/13/16
6/13/16
6/13/16
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CGREEN
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MOYERMAN
ESTAFFORD1
ESTAFFORD1
ESTAFFORD1
ESTAFFORD1
ESTAFFORD1
ESTAFFORD1
ESTAFFORD1
ESTAFFOR01
ESTAFFORD1
ESTAFFORD1
ESTAFFORD1
ESTAFFORD1
ESTAFFORD1
North Carolina Division of Water Resaurces
Water Sample Collection & Submittal Form
Central Laboratory [Wader Sciences Sermon)
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Metals Parameters: _
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as CaCO3, to pH 4 5/8 3
mg/L
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Oil and Grease, HIM, Total Recoverable
mg/L
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Titanium (Ti)
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pg/t
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Bpi Biochemical Oxygen Demand, 5-day
mg/L
Residue. Total (TomlSolids)
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Arsenic (As)
pg/L
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Zinc (2n)
pg/L
cBOD Carbonaceous BOD, 5-day
mg/L
Residue Volatile/Fixed, Total
mg/L
Banum Oa)
PEA
Coliform Fecal MF
/100ml
Residue Suspended { Suspended Satrds I
mg/L
Beryllium (Bel
pg/L
Baron (El), Total
prg/L
V
Cohform Total MF
/i.00mI
Residue Volatile/Fixed, Suspended
mg/L
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Cadmium [Cd)
pg/L
Mercury 1631, tow -level
ng/L
Cohform Tube Fecal
/100m1
V
MS -Total Dissolved Solids
mg/L
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Calcium (Ca)
mg/L
Conform Tube Total
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Silica
mg/L
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chromium [CI), Total
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mg/L
Tannin & Lignin
mg/L
Copper (Cu)
pg/L
Organochlorine Pesticides
'Turbidity
NTU
V
Iron (Fe)
pg/L
Organonitrogen Pesticides
Other Parameters: ' -' •
(Pb)
I!g/L
Organophosphorus Pesticides
Wet Chemistry ParRrnetCrs:'
-
s u
_Lead
Lithium (Li)
pg/L
PCBs (polythlonnated hiphenyls)
Bromide
mg/L
• Y
`pH
Hardness, Total as CaCO3 - by titration
mg/L
I
Macnesium { Mg)
mg/L
Vf
Chloride
mg/L
V
Manganese (Mn)
pg/L
Semi -Volatile Organics [BNAs1
Fluoride
mg/L
Mercury [Hg)
ilg/L
TPH Diesel Range
Sulfate
met-
Nutrients Pararriyeters- `_,
..: '
Molybdenum (Mo)
pg/L
Chlorophyll a
p►g/L
Ammonia as N (NH3-N)
mg/L
V
Nickel (Ni)
pg/L
Volatile Organics (VOA)
Color AUMI
c u
‘-Nitrate-Nitrite
as N [NO3+NO2-N]
mg/L
Potassium (K)
m9 L
Color Platinum Cobalt
c u
Total Kleldahl Nitrogen as N [TKN)
mg/L
Selenium (5e)
pg/L
TPH Gasoline Range
COD Chemical Oxygen Demand
mg/L
Total Phosphorus as P (TP)
mg/L
Silver (All]
pg/L
Cyanide. Total
mg/L
Nitrite as N [NO2 N]
mg/L
/
V
Sodium (Na)
mg/L
' 431ologkal: •
,
Formaldehyde
mg/L
Nitrate as N (NO3-N calculatsd)
mg/L
Strontium (Sr)
pg/L
Phytaplanktoo / Alga e
Hexavalent Chromwm (CrEr+)
mg/L
Orthophosphate as P (PO4) ,
mg/t
Thallium (TI)
pg/L
LAB COMMENTS :
Field' Pa ro m eters l opti a ra ll
Water.Temp [°C]: • 1
.pH�siutl S.�`
.L
Dissolved Oxygen (roil):
• 4
-Cnriducpvrry lltmhos/eta}; �rt.t- is r. =5.71iriA1'PH = .
Revision: 2/06/7015

AC29264 North Carolina Division of Water Resources Water Sciences Section Laboratorv Results
Loe. Descr.: 4!! POLY~N!':lA ROAD, !:!endersoa Sample ID: AC29264
County: VANCE Collector: LROBERTSON VisitlD PO Number#
Region: fil!Q Report To fil!Q Location ID: 5P091WI0500406EFF Date Received: 05/24/2016
River Basin ROA01 Collect Date: 05/24/2016 Priority ROUTINE Time Received: 13:15
Emergency Collect Time: 11:30 Sample Matrix: Groundwater. Labworks LoginlD TAS!;;ENZOj
COC Yes/No Sample Depth Loe. Type: Water SU(!l!llf Delivery Method NC Courier
Final Report Date: 6/20/16
Report Print Date: 06/20/2016
Final Re 11 ort
ff thjs report Is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes,
CAS#
7429-90•5
7440-70-2
7440-43-9
7440-47-3
7439-89-6
7440-09-7
7439-95-4
7439.95.5
7440-23•5
7440-02-0
7439-92-1
7440<66-6
Result/ Units Method Anal~sis
AnaM e Name PQL Qualifier Reference
LAB
Sample temperature at receipt by lab 2.3 'C
MIC
Coliform, MF Fecal in liquid 1 B2 CFU/100ml SM 9222 D-1997
Coliform, MF Total in liquid 1 1 B2 CFU/100ml SM 9222 B-1997
NUT
N02+N03 as N in liquid 0.02 1.7 mg/Las N EPA 353.2 REV 2
WET
Bromide 0,4 0.4U mg/L EPA 300.0 rev2.1
Chloride 1.0 3,9 mg/L EPA 300.0 rev2.1
Fluoride 0.4 0.4U mg/L EPA 300.0 rev2.1
Sulfate 2.0 2.0 U mg/L EPA 300.0 rev2.1
Total Dissolved Solids in liquid 12 77 mg/L SM 2540 C-1997
MET
Al by ICP 50 50 U ug/L EPA 200. 7 Rev4.4
Caby ICP 0.10 6.6 mg/L EPA200.7 Rev4.4
Cd by ICPMS 0.50 0.50 U ug/L EPA 200.8 Rev5.4
Crby ICPMS 5.0 5.0 U ug/L EPA 200.8 Rev5,4
Fe by ICP 50 160 ug/L EPA200.7 Rev4.4
Hardness by Calculation 1.0 23 mg/L SM2340BEPA 200.7
K by ICP 0.10 1.3 mg/L EPA200,7 Rev4.4
Mg by ICP 0.10 Vi mg/L EPA200.7 Rev4.4
Mn by ICP 10 10 U ug/L EPA200.7 Rev4.4
Na by ICP 0.10 6.7 mg/L EPA 200. 7 Rev4.4
Ni by ICPMS 2.0 18 ug/L EPA 200.8 Rev5.4
Pbby ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4
Znby ICPMS 10 41 ug/L EPA 200.8 Rev5.4
WSS Chemistry Laboratory>> 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone]
"Not Detected" or "U" does not indicate the sample is analyte free but that the analyte is not detected at or above the POL
Page 1 of 1
Date
5/24/16
5/24/16
5/24/16
5/26/16
5/25/16
5/25/16
5/25/16
5/25/1.6
5/26/16
6/2/16
6/2/16
6/13i16
6/13/16
6/2/16
6/17/16
6/2/16
6/2/16
6/2/16
6/2/16
6/13/16
6/13/16
6/13/16
Validated b~
MSWIFT
ESTAFFORO1
ESTAFFOR01
CGREEN
CGREEN
CGREEN
CGREEN
CGREEN
MOVERMAN
ESTAFFORD1
ESTAFFORD1
ESTAFFORD1
ESTAFFORD1
ESTAPFORD1
ESTAFFORD1
ESTAFFORD1
ESTAFFORO1
ESTAFFORD1
ESTAFFORD1
ESTAFFORD1
ESTAFFORO1
ESTAFFORD1
North Carolina Division of Water Resources
Central laboratory (Water Sciences Section) Water Sample Collection & Submittal Form
V1sitID; !
: •(V i• sit raij
T�
1°1
•4 .~^ .7G ! j
AC29264
LctiOn LieicrFption:
!-I��{„,„7„LI,tid,,,''',
LDDaIaton
•
b2r EFF
I
`'.--" . • ; I fJ
Giuoe l0leioelrnadr • Zf ] II:
i- , t/D
p� i
County: o1 V^" • 1�%
Y wr /�
!�: waGL{Vf., �� c� - {
�lrr��`
�...,y....
�7}.�a...•'
i
WOtM.i�Y7Qt7':�=
Motile'
r,.r.,,..,... r
FM�r;f .i ��J` .�Yy..
E • .
► »eReserve�. i f I
P. :. h /
DWRR non.. i
e9 n
fbaredan county) ��
�1. , O�CE%
{o.ugeri[y rmmej
�v
❑Amhient
❑ Surface
❑
IN
/Str take
River eam
Estuary DCanal
`
RaQeivBdBy� I
River Bcsirr: v
'�
� +� _
�'1
Date! : ,
"-7 r L
i� C �+�
IRoutrne
❑�mp�
f
❑Stormwater
,i,�
❑Mun�tonng Well L1Qwater Supply
_ •
+- UState Gaoler
Dellvery'l i ` ❑Ffand Delivery
`q•= , Doter
Noses:
]ril7ie:
1' '
❑ COC
Ground
❑Waste
❑Effluent ❑Influent
•-i?.- 1
r i�`�
' • dnArrive i '
_ • , i
.
.3
[i Chlorinated 00e-chlorinated ill Field
Sampling1
'' `JYJethod:
Grail -0Composde
ILJIOther
[] Emergency
❑Blank
CFI eldBlank
❑Filter Blank
"'Trip
Mark
•
Dissolved analysts Enter 'OM'
Filtered in Field
in check -boxes for parameters
`^
Sample f�pdh
•. r
❑iIA
❑ Soiubon
❑ Other
• Colketar's ComruenL ::
' Microbiology Parameters:
MBAS (surfactants) mg/L
- . Metals Parameters:
lin (5n) pg/L
Acidity, as CaCO3, to pH 4 5/8 3 mg/L
Od and Grease. HEM, Total Recwerable mg/L
L%+
Aluminum (Al) pg/L
Titanium (Tr) pg/L
Alk-aImity, as CaCO3, to pH 4 5/8 3 met
Phenols. Total Recoverable part.
Antimony (Rd }let
.,-Vanadium
(V) pg/L
BOD Biochemical Oxygen Demand, -day mg/L
Residue Total (Tor &Solids) mg/L
Arsenic (As) pg/LV
Zinc an) {sglL
c9OD Carbonaceous BOO, 5-day mg/L
Residue Volatile/Fixed, Total mg/L
Barium (Ba) Iig/L
Vl(Coliform
Fecal MF /10DmI
Residue Suspended (suspendedsobds ) mg/L
Beryllium (Be) Ifg/L
i.
Boron (B), Total pg/L
V
Coliform Total MF /100mI
Residue Volatile/Fared. Suspended matV
Cadmium (C d) pg/L
Mercury 1631, low-level ng/L
Co&iform Tube Fecal /1.00ml
f
TDS - Total Dissolved Solids mg/L
if
Calcium (Ca) rrtglL
Coldorm Tube Total /10om1
Silica mg/L
rJ
Chromium (Cr), Total pg/L
• Organics Parameters: ' -
Specific Conductance, at 25 °C umhos/rm
Sulfide mg/L
Cobalt (Co) pg/L
Acid Herbicides
TOC- Total Organic Carbon mg/L
Tannin & Lignin mg/L
Copper (Cu) pg/L
Organochlonne Pesticides
Turbidity NTU
V'
[ran (Fe) IJg/L
Organonitrogen Pesticides
... Other Oilier Parameters:
/
Lead (Pbl IJg/L
Organophosphorus Pesticides
' .. ' Wet Cheriiis uYParameters: • ` ? -..` s °i 1 " ,
pH s u
.
Lithium( ) PEA
PCBs (payhlonnated hiphenyls)
Bromide mgjL
'
Hardness, Total as CaCO3 - by titration mg/L
v1//
magnesium (Mg) mg/L
1i
Chloride mg/L
_
i/_
Manganese (Mn) pg/L
-
Semi -Volatile Organics (BNAs)
Fluoride mg/L
Mercury Pig] Iig/L
TPH Diesel Range
Sulfate mg/L
Nutrients Parameters: . . ;' -,
Molybdenum (Mg) mg/L
Chlorophyll a yg/L
Ammonia as N {NH3-N) mgj.
1
Nickel (Ni) 14/L
Volatile Organics (VOA)
Color. ADMI c u
V
Nitrate -Nitrite as N (NO3+NO2-N) me.
Possum (K) mg/L
Color Platinum Cobalt c.0
_
Total Kleldahl Nrtrogen as N (TNN) mg/L
Selenium (Sol PR/ .
TPH Gasoline Range
COD Chemical Oxygen Demand mg/L
Total Phosphorus as P (TP) mg/L
i
Silver (Ag) iJg/l-
Cyanide, Total mg/L
Nitrite as N (NO2-N) mg/L
V
5odlum (Na) mg/L
" ' Biological: . '" 1 j
Formaldehyde mg/L
Nitrate as N (NO3-N calculated) mg/L
Strontium (5r) pg/L
' Phytoplanktan / Algae
Hexavalent Chromium (Cr6+) mg/I.
Ortho phosphate as P (PO4) mg/L
Thallium (T1) pg/L _
,
LAB COMMENTS :
Field Parameters(aptonnlit
1NajerTernn ri;: 'i• f I �� 1 pH (s.u.): !
-
.Dllssoived Oxygen (ppm): ^ �
• Condudiv[ry. (Prnhoa/CM)• { C-21 Salinity (pit]
• .• i
Revision 2/06/2015

WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE QUEST FORM
Date: May 9, 2016
To: Danny Smith -Rick Bolich
From: Shristi Shrestha, WQROS -Animal Fe·eding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0500406
A. Applicant: David G. & Anne L. Vellenga
B. Facility Name:
C. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
__ 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 WOROS 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: Please get a copy of GW~ 1 if possible.
FORM: WQROS-A.,"IB. vcr. 092614 Page 1 of 1
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE QUESTFORM
Date: May 9, 2016
To: Danny Smith -Rick Bolich
From: Shristi Shrestha, WQROS-Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0500406
A. Applicant: David G. & Anne L. Vellenga
B. Facility Name:
C. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
E. Comments/Other Information:
__ 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 completed 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: Please get a copy of GW-1 if possible.
FORM: WQROS-ARR vcr. 092614 Page 1 of 1
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
David & Anne Vellenga
46 Pollyanna Road
Henderson NC 27537
May 9, 2016
RE: Aclmowledgement of Application No. WI0500406
Geothermal Heating/Cooling Water Return Well
Vance County
Dear Mr. and Mrs. Vellenga:
The Water Quality Regional Operations Section (WQROS) aclmowledges receipt of your
permit application and supporting documentation received on May 3, 2016. 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 919-807-6406 or email at [e-mail].
cc: Raleigh Regional Office, WQROS
Permit File WI0500406
r
Sincerely,
s-~-
Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
State oi North Carolina ! K1vironmental Quality I Water Resources
16il Mail service Center I Raleigh, NorthCarolina27699-1611
919 707 9000
Director
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 1 5A 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 )1\ 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: 2 T 20 I G
PERMIT NO. ►erg ' p dloaleave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New WeJt/i ermit Application)
B.
1.
Current Use of Well
a. I wish to continue to use the well as IN Geothermal Well ® Drinking Water Supply Well
El 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?
If yes, indicate New Owner's contact information:
Name(s)
Mailing Address:
City:
RECEIVED(NCDEQWR
MAY 432016
Water Quality Regional
❑ YES EgRovrations Section
State: Zip Code: County:
Day Tele No.: Email Address.:
STATUS OF APPLICANT (choose one)
Non -Government: individual Residence y( Business/Organization
Government: State Municipal County Federal
C. WELL OWNER(S)IPERMIT 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: 4a r:' e.- . Ve lle n• A "FA-,- /le4 A
Mailing A ddress: 114 A. .f__/2_(.2 t1 — -
City: 'vide S#. ' State: /VC Zip Code: .Z 7. 7 County: If y vice
Day Tele No.: vL S2 -'Y y2 -,k' 7 iTa 5— Cell No.: J!_ t - ` #/& 4' $. c"
EMAIL Address: C ,)Ve /!e rr Ja /t. a) co M Fax No.:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 1

D. WELL OPERA TOR (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: .f IL Me ~ 5 w e/) p w/Vel-:
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: __________ County: __ ¼_q~v_c_e_
(2) Physical Address (if different than mailing address): ----""5'----n,.__,_,,llf,_,t"._....c~"-L.S:_L,./1...;..::;;<e,..,_,..,_J.Lj=Jf/-'J--A-----'-'~---"~'-'H!'~,s
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.: _________ Cell No.: Fax No.: _______ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
JNAC Contractor's Name: ___________________________ _
NC INAC 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)
(2)
The injection operation?
Personal consumption?
YES __ _ NO ___ _
YES ----NO ___ _
L WELL CONSTRUCTION REQUIREMENTS-As specified in 15A NCAC 02C .0224 (d ):
(1)
(2)
The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107 .
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 Page2
(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({)(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(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 ISA NCAC 02C .0107 (a )(2 l 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 Page3
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 CIS websitc 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)
A ti ".3, i _. i +_ aI 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 personts} 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 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, 1 believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fmes 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 Property OwnerfApplicarft
eiV G. 141/16,.t.
Print or Type Full Name and Title
signature of Property Owner/Applicant
Print or Type Full Name and Title
izr.ve. 1--
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 - U1C
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

GEOTHERMAL HEATING/COOLLNG WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxes. Fill in depths below land surface (BLS) and
details of well construction on the blank lines provided Use additional sheets as needed
Hpen-Hole Well Design
l Proposed 0 Existing
❑ Injection; ❑ Supply;
111 Dual Purpose
Land Surfac
Record Depths Below
Laud Surface (BLS)
on Lines Provided
1
Bottom of casing
(FL BLS)
Total Depth
(Ft. BLS)
}
(Ft-)
Screened Weil Design
❑ Proposed ❑ Existing
❑ Injection; ❑ Supply;
❑ Dual Purpose
Return or Supply Line
Casing
•
Grout
WELL DETAILS
Casing Material:
Casing Diameter (in.): _
Grout Type:
Grout Depth (BLS):
Top of Bentonite Seal (if present);
Bottom of Bentonite Seal
Screen Material:
Screen Slot Size (in.):
Sand/Gravel Pack
Material Type:
Bedrock
open Role
Bentonite Seal
(if present)
Sand/Gravel Pack
Screen
■
}
(Ft.)
Record Depths Below
Land Surface (BI.S) on
Lines Provided
l
(Ft. OILS)
(Ft_ BLS)
Bottom of casing
(Ft. BLS)
(Total Depth
Ft. BLS)
NC Certified Well Driller Name:
Certification No.:

ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Colleen H. Sullins Dee Freeman
Governor Director Secretary
October 6, 2011 p1 �k c5
ortor
OCT 11 2
Mr. and Mrs_ Vellenga
46 Pollyanna Road
Henderson, NC 27537
Subject, Permit No. WI 0500406
UIC-5A7 Geothermal Well
Vance County
Dear Mr. & Mrs. Vellenga,
Enclosed please find the analytical results of the well water which was sampled on August 17, 2011,
The analytical data indicate that all the parameters are in compliance with Groundwater Standards and
the subject well is in compliance with the permit conditions.
If you have any questions, please contact me at [phone].
Cc: RRO-APS Files
APS Central Files
Aquifer Protection Section
1628 Mail Service Center, Raleigh, North Carolina 27699-1628
Location: 3800 Barrett Ur., Raleigh, Worth Carolina 27609
Phone: [phone] FAX. [phone]S 'kCa1s6.1mer Service. 1-K77-623-6741
I]iItrnetoLncw terquaiirv.urg
an Equal t )ppurfisnity ! Aflirmative Aatoon lintplo\er
Sincerely,
61(61/4(4Y-oly
Lin McCartney
Environmental Senior Tech
One
North Carolina
Naturally

Permit Number WI0500406
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
David & Anne Vellenga SFR
Location Address
46 Pollyanna Rd
Henderson
Owner
Owner Name
David
Dates/Events
NC 27537
Vellenga
Orig Issue
09/06/11
App Received Draft Initiated
07/29/11
Scheduled
Issuance
.. Central Files : APS_ SWP_
09/02/11
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Bill Evangelist
1117 Batchelor Rd
Apex
Major/Minor
Minor
Region
Raleigh
County
Vance
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David Vellenga
46 Pollyanna Rd
Henderson
NC
NC
Public Notice Issue
09/06/11
Effective
09/06/11
27523
27537
Expiration
08/31/16
_R_e ... a'--u_la_t_e_d_A_c_t_iv_i_ti_e_s ________________ .:.cR=e=a=u=e=s=te=d=/-=-R=e=c=e"-iv;:;..:e=d=-=E'-'-v=e.,_,n=tsc...._ __________ _
Heat Pump Injection RO staff report requested
Outfall NULL
Waterbody Name
RO staff report received
Additional information requested
Additional information received
Stream Index Number Current Class
08/05/11
08/25/11
08/29/11
08/30/11
Subbasin
Permit Number WI0500406
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
David & Anne Vellenga SFR
Location Address
46 Pollyanna Rd
Henderson
Owner
Owner Name
David
D ates/Events
NC 27537
Vellenga
Orig Issue App Received Draft Initiated
07/29/11
Requlated Activities
Heat Pump Injection
Outfall NUL!..
Scheduled
Issuance
Central Files: APS_ SWP_
08/30/11
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Bill Evangelist
1117 Batchelor Rd
Apex
Major/Minor
Minor
Region
Raleigh
County
Vance
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David Vellenga
46 Pollyanna Rd
Henderson
NC
NC
Public Notice Issue Effective
Reo uested/Received Events
RO staff report requested
RO staff report received
Additional information requested
Additional information received
27523
27537
Expiration
08/05/11
08/25/11
08/29/11
08/30/11
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
September 6, 2011
David and Anne Vellenga
46 Pollyanna Rd.
Henderson, NC 27537
Re: Issuance of Injection Well Permit
Permit No. WI0500406
Issued to David and Anne Vellenga
Vance County
Dear Mr. and Mrs. Vellenga:
In accordance with your application received July 29, 2011. I am forwarding Permit No. W10500406 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 August 31, 2016, and
shall be subject to the conditions and limitations stated therein.
Please Note: The injection rate, injection volume, and injection pressure for the injection well was left
blank on the permit application. After the system becomes operational, please provide this information.
Your beat pomp contractor and/or well driller contractor can provide this information. You can, if you
like send it via e-mail to Michaei.Roaersfwncdenr.aov.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date_ As indicated in the permit, this permit is
not transferable to any person without prior notice to, and approval by, the Director of the Division of Water
Quality. If you have any questions regarding your permit or the Underground Injection Control Program
please call me at [phone].
Best Regards,
/1//,,/,-)&4
6
�t
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
cc: Jay Zimmermann, Raleigh Regional Office
Central Office File — WI0500406
Vance County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699.1636
Location: 2728 Capital Boulevard. Raleich. North Carolina 27604
Prrone: 919-733-3221 t FAN t: 919-715-05B8: FAX [phone] Customer berme: 1-877.623-6748
Ihtemet: www.fl atervualitv.or •
C)n�
NorthCarotina
lu, cccrpaon..-;;: +hrnvma::rt ,Aman Smo,oyeF

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
David and Anne Vellenga
FOR THE OPERATION OF A TYPE SA7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 46 Pollyanna Rd., Henderson, Vance County, 27537 , and will be constructed and
operated in accordance with the application received July 29, 2011, and in conformity with the specifications
and supporting data submitted, all of which are filed with the Department of Environment and Natural
Resources and are considered a part of this permit.
This permit is for operation of an injection well shall be in compliance with Title 1 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 August 31, 2016 , and shall be
subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
Permit issued this the 3tY day of ~ , 201 I.
O&ej_~ t Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0500406 UIC/5A7
ver . 03/2010
Page 1 of 5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be sealed with a water-tight cap or well sealed, as defined in G.S. 87-85(16).
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
PART II -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
Permit #WI0500406 UIC/SA7 Page 2 of 5
ver. 03/2010
PART III-PERFORMANCE STANDARDS •
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART IV -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
PART V -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
Permit #WI0500406 UIC/SA7 P.age 3 of 5
ver. 03/2010
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Raleigh Regional Office, telephone number 919-791-4200 , any of the following :
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(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 Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VII-PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
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:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to , the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing , if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
Permit #WI0500406 UIC/SA7 Page 4 of 5
ver. 03/2010
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet , and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a 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 :
Permit #WI0500406
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/SA7
ver. 03/2010
Page 5 of 5
Jr-A
NCDE R
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Division of Water Quality
Coleen H. Sullins
Director
August 23, 2011
MEMORANDUM
To:
Through:
From:
Michael Rogers, The Central Office, APS
Jay Zimmerman ~
Lin McCartney
Dee Freeman
Secretary
Subject: Staff Report,. WI0500406, David Vellenga, SA 7 Geothermal Well
Vance County
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.ncwaterquality.org
An Equal Opportunity \ Affirmative Action Employer
RECEIVED/ DENR / DWQ
AQUIF!=R·PROTFr.TJ()~J SECTION
AUG 2 ii 2011
NirthCarolina
/Vaturallu
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: Au gust 24 , 2011
To: :A quifer Protection Central Office
Central Office Reviewer: Michael Ro gers
Regional Login No: __ _
i GENERAL INFORMATION
1. This application is (check all that apply): ~ New D Renewal
County: Vance
Permittee: David Vellen ga
Project Name: ln iection SA7 Well
Application No.: WIOS00406
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 ~ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ~ Yes or D No.
a. Date of site visit: 08-17-2011
b. Person contacted and contact information: David Vellen ga & Anne Vellen ga, 1-252-492-8745
c. Site visit conducted by: Lin McCartney
d. Inspection Report Attached: ~ Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
~ Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
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 Disp osal and In jection Sites:
(If multiple sites either indicate which sites the information a pp lies to, co py and paste a new section into the
document for each site . or attach additional p a ges for each site)
a. Location(s): 46 Polly anna Road. Henderson . NC 27537
b. Driving Directions: Take US-1 N for 39 miles . take NC-39 exit toward Henderson . turn left onto E
Andrews Ave/NC 39 . turn ri ght onto Plum Nutty Rd, tum ri ght onto Pollvanna.
c. USGS Quadrangle Map name and number:
d. Latitude: 36-20-35 Longitude: 78-23-20
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed fo r 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-Vellenga 1
RECEIVED / DENR / DWQ
AQUIFl=R·PROT!=f.TION 8ECTION
AUG 2 5 2011
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.)
Descri ption OfWell(S) And Facilities-New, Renewal, And Modification
1. Type of injection system:
1:8] Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (SQM/SQW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (SL/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? 1:8] Yes D No
3. Are there any potential pollution sources that may affect injection? C8J Yes D No
What is/are the pollution source(s)? The septic tank. The septic tank is approximately 128 feet distance from
the well.
4. What is the minimum distance of proposed injection wells from the property boundary? 10 U1
5. Quality of drainage at site: 1:8] Good D Adequate D Poor
6. Flooding potential of site: 1:8] 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)? C8J Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes 1:8] 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. ex plain:
3. For renewal or modification of groundwater remediation permits (of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or mana gement of
the contamination incident? D Yes D No. If yes , explain:
FORM: Staff.Report-Vellenga 4
AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Drilling contractor: Name: Davis Well Drilling
Address: 702 W. Green St., Franklin, NC 27525
Certification number:
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 ~ 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-Vellenga 5
AQUIFER PROTECTION REGIONAL STAFF REPORT
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
8. Signature of report preparers):
Signature of APS regional supervisor:
Date: ./ 17,:
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
A well construction inspection and well water sampling were conducted on August 17, 2011.
An existing water supply well has been proposed for use as a 5A7 geothermal injection well.
The following comments are highlighted as a result of the inspection.
A review of the construction data indicates that the subject geothermal injection well has been
constructed in accordance with N.C. State Regulations (Title 15A NCAC 2C), Well Construction
Standards.
The following items were checked:
1. Well Casing
• Casing depth: 60 ft, Casing extends above ground 12 inches.
2. Grout
• Grout type- Cement
• Grout surface and grout depth- around well casing from 0 to 20 feet.
3. The location of the well
• The septic tank (potential pollution source) is approximately 128 feet distance from
the well.
• The minimum distance of the well from property boundary is about 101 feet.
• The minimum distance of the well from the building is about 72 feet.
Over all, this geothermal injection well is in compliance with well construction standards.
However, we are awaiting the analytical results of the well water to complete this application
process.
FORM: Staff.Report-Vellenga 6

Permit: WI0500406
SOC:
County: Vance
Region: Raleigh
Effective:
Effective:
Contact Person: Bill Evangelist
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 08/17/2011
Primary Inspector: Lin McCartney
Secondary lnspector(s):
Reason for Inspection: Routine
Compliance Inspection Report
Expiration:
Expiration:
Owner: David Vellenga
Facility: David & & Anne Vellenga SFR
46 Pollyanna Rd
Henderson NC 27537
Title: Heat Pump Contractor Phone: [phone]
Entry Time: 10:00 AM
Certification:
Exit Time: 12:00 PM
Phone:
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:
(See attachment summary)
Page: 1
Permit: WI0500406
Inspection Date: 08/17/2011
Owner -Facility: David Vellenga
Inspection Type: <;ompliance Evaluation Reason for Visit: Routine
Inspection Summary:
A well consruction inspection and well water sampling were conducted on August 17, 2011.
An existing water supply well has been proposed for use as a 5A7 geothermal injection well.
The following comments are highlighted as a result of the inspection.
A review of the construction data indicates that the subject geothermal injection well has been constructed in accordance
with N.C. State Regulation (Title 15A NCAC 2c), Well Construction Standards.
The following items were checked:
1. Well Casing
Casing depth: 60 feet, casing extends above ground 12 inches
2. Grout
Grout type-cement
Grout surface and grout depth-around well casing from surface to 20 feet
3. The location of the well
The septic tank (potential pollution source) is approximately 128 feet distance from the well.
The minimum distance of the well from the property boundary is about 101 feet.
The minimum distance of the well from the building is about 72 feet.
Over all, this geothermal injection well is in compliance with well construction standards.
However, we are awaiting the analytical results of the vvell water to complete this application process.
Page: 2
Rogers, Michael
From:
Sent:
To:
Subject:
Mccartney, Lin
Tuesday, August 30, 2011 2:52 PM
Rogers, Michael
RE: WI 0500406 Vellenga
A
The well certification number for the driller for Vellenga is 2386. Durwood Davis
From: Rogers, Michael
Sent: Monday, August 29, 2011 2:36 PM
To: Mccartney, Lin
Subject: WI 0500406 Vellenga
Lin-
~ l ( ·---
Do you have the well certification number for the driller for the well you inspected. The certification number should have
been on the well tag. I know Davis Well Drilling was the company, but there are several certified drillers with this
company.
Thanks
Michael Rogers, P.G. {NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section {APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http ://portal.ncdenr.org/web/wq/aps/qwpro/permit-applications#geothermApps
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
1
AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: August 5. 2011
To: □ Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS
0 Andrew Pitner, MRO-APS
IZ! Jay Zimmerman, RRO-APS
□ David May, W aRO-APS
0 Charlie Stehman, WiRO-APS
0 Sherri Knight, W-SRO-APS
From: Michael Rogers Groundwater Protection Unit
Telephone: (919 ) 715-6166 Fax: (919 ) 715-0588
E-Mail: Michael.Ro gers~. ,ncmail.net
A. Permit Number: WI 0500406
B. Owner: Vellenga.
C. Facility/Operation: _
D Proposed IZ! Existing 0 Facility D Operation
D. Application:
1. Permit Type: 0 Animal D SFR-Surface Irrigation□ Reuse O H-R Infiltration
D Recycle D I/E Lagoon D GW Remediation (ND)
IZI UIC -:SA7 Well
For Residuals: D Land App.
0 503
0 D&M
0 503 Exempt
D Surface Disposal
D Animal
2. Project Type: IZ! New D Major Mod. D Minor Mod. D Renewal D Renewal w/Mod ..
E. Comments/Other Information: D
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:
IZ! Return a Completed APSARR Form and attach laboratory analytical results, if applicable.
D Attach Well Construction Data Sheet.
0 Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: -------------------Date: _____ _
FORM: APSARR 07/06 Page I of I
NA
~CDEMR
North Carolina Department of Environment an d Natural Resources
Division of Water Quality
Beverly Eaves Perdu e
Governor
David G. Vellenga
Anne L. Vellenga
46 Pollyanna Road
Henderson, NC 27537
Dear Mr. and Mrs. Vellenga:
Cole en H. Sullins
Directo r
August 5 , 2011
Dee Free man
Secretary
Subject: Aclmowledgement of
Application No. WI0500406
David & Anne Vellenga SFR
Injection Heating/Cooling
Water Return Well (5A7)
System
Vance County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on 7/29/2011. Your application package has been assigned the number listed
above, and the primary reviewer is Michael Rogers.
Central and Raleigh Reg ional 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 Aquifer Protection Section 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].
Sincerely,
()~A-~
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Davis Well Drilling
Evangelist Service Company (William Evangelist)
Permit File WI0500406
AQUiFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Locaiion: 2728 Capital Boulevard, Raieigh. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Cusiomer Serviee : 1-877-623-6748
Internet: www.ncwateraualitv.oro
A, Equcl Oppo~ur·'_: \ Affirrn2'·ve .A.ct10'l Ernp \oye:
Nirth Carolina
Jvaturnllll
NOR1H CAROLINA
DEPAR1MENT OF ENVIRONMENT AND NATURAL RESO.URCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
/ TYPE 5-A7 WELL(S)
__ ......;;V_ Ne, w Permit Application OR ____ Renewal (check one)
DATE: (/4vtrui-;; JJ . 20 / i
PERMIT NO. l)JTO,SQ)'t:Q{p (leave blank if NEW permit application)
A. PROPERTY OWNER(S}/ APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/autbority for signature): _ _.()~a=~-v~'Z~---I/-... ,-._· •-~Ye_e_/_~_e_--0_,,,,,,.,.-t~a-_,
7
._, ___ _
AM/1/e L, ½/levq <-
V
(I) Mailing Address: 3/ & /4 )/ V <? .,v v -'f'. / t?;:f ✓ ;
City: 1/r IY tie 1-;; A/ State:# C Zip Code: t:1 7 5"" -1 7 County: ½ .vce
Home/Office Tele No.: )... 5=..<.. -t/9' ol. -R71/.s Cell No.: 71/"?-5'.t::? ,)-6 3 &' ~-
EMAIL Address: d_p v e /Je!vJ'""' & ,?( tp /, C t?M
(2) PhysicalAddressofSite(ifdifferenttbanabove): S o l'V1 e u ( a~11ve
City: _________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: ----------~C=e=ll -=--N=o'--'-.: _________ _
EMAIL Address: _______________ .
B. AUTHORIZED AGENT OF OWNER, IF ANY (iftbe Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: ___________________________ _
Contact Person._: ---------------=E=MA=-==IL~A=d=c:w=-=e=ss.,.: _________ _
Address: _____________________________ _
City: ________ State: __ ZipCode: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: _____________ _
GPU/UIC 5A7 Well Permit Application (Revised 912007)
RECEIVED/ DENR / DWQ
Aquifer ProtAt-tion Sec:tion
JUL 2 9 2011
Page I
C. WELL DRILLER INFORMATION
Company Name: U4"? i.1 s �� �J ��• •'r
Well Drilling Contractor's Nance:
NC Contractor Certification No.:
Contact Person:
Address: 7Q.2 �'d/r G /��c'r✓
EMAIL Address:
City: i;-,e ,-/%wvFv'V A/C Zip Code: -a 7,�� S� County: ' v"r2.,'
Office Te1e Na:: q/7- 9 - y5`-6 Ce11 No.:
D. HEAT PUMP CONTRACi'OR INFORMATION (if different than driller)
Company Name: eilp NG ects i S'enR u°'67. Cr)" ti$Ps/
Contact Person: + et ► a ►ti • &Al A 6 a's ► - EMAIL Address: e e 1 w el hefirosi L -"
Address: 1 I t 7 13 fl Cf4 ec oft. lea A()
City: Ae E'>< Zip Code: 21f 23 County: Ct-1 wry I1 $1
Office TeieNo.: a14-362- 7gl0 cell No.: ?f4- 2►tr 7y4a
E. STATUS OF APPLICANT
Private:
State:
x
Federal: Commercial:
Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describeri.how the injection well(s) will be used)
(Arc- y
.10
G. WELL USE Will the injection welle sup s) also be used as thply weil(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES NO
YES NO
H. WELL CONSTRUCTION DATA (Skin to Section I if this is a Permit RENEWAL
PROPOSED Well(s) to be constructed far use as an injection well. Provide the data in (1)
through (7) below as PROPOSED construction specifications. Submit Form GW- I after
construction,
EXISTING Well(s) being proposed for use as an injection well. Provide the data in (I) through
(7) below to the best of your knowledge. Attach a copy of Form GW- 1 (Well Construction
Record) if available. -
(I) Date to be constructed: _ Number of borings:
Approximate dep)h'of each boring (feet):
(2) Well casing. the well(s) y:ased? (check either (a.) YES or (b.) NO below)
(a) YES If ye; en provide the casing information below.
Type: Galvanized steel V Slack steel Plastic Other (specify) __
Casing thickness: diameter (inches): _depth: from 0 to & / ft. (reference to land surface)
Casing extends above ground _ inches
GPU/UIIC 5A7 Well Permit Application (Revised 9/2007) Page 2

L
(b) NO
(3) Grout (material surrounding wel!µsing and/or piping):
(a) Grouttype: Cement_✓_ Bentonite__ Other(specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
___ Around closed-loop piping; from ___ to __ (feet).
/ Around well casing; from ~ to l-=> (feet).
(4) Well(s) Screen Information
Depth of Screen: From ____ to ____ feet below land surface
(5) N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead water quality and processes. A faucet on both Influent (groundwater entering heat
pump) and Effluent (water being injectefl'!ck into the well) lines is required. Wi11 there be a faucet on:
(a) Influentline? Yes __ No__ (b) Effluentline? Yes_✓_No __
(6) Source Well Construction Information (if the water source well is a different well than the injection well)
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available, provide the
following data:
GroW1dwater Source. 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: TuE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR PRO.POSED WELLS IF
THIS INFORMATION IS UNA VATLABLE BY OTHER MEANS.
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) rs ° F, Average (July) 6 0 ° F.
J. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supp]ementary
information.
K. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(I)
(2)
Include a site map (can be drawn) showing: buildings, property lines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name. · 1~
GPU/UIC 5A7 Well Permit Application (Revised 9/2007) Page3
L. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"1 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.
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 Property Owner/Applicant
fP d--J 4 tie :rr; 2
Print or Type Full Name
Z=i ! //
Signature of Property Owner/Applicarft
tide
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Pull. Name
Please return two copies of the completed Application package to;
North Carolina DENR DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUIUIC 3A7 Well Permit Application (Revised 9/2007)

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