WI0500424_GEO THERMAL_20160802

Permit Number WI0500424
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Dean & Christine Sawyer SFR
Location Address
2501 Laurel Ford Ln
Wake Forest
Owner
Owner Name
Dean A
Dates/Events
NC
Orig Issue
9/22/2011
App Received
8/23/2011
Re ulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27587
Sawyer
Draft Initiated
Scheduled
Issuance
Central Files: APS SWP
8/2/2016
Permit Tracking Slip
Status
/Active
~ \I-
-~
Version
1.00
"2?/31/I~
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Public Notice
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Dean A. Sawyer
2501 Laurel Ford Ln
Wake Forest
Region
Raleigh
County
Wake
NC
Issue
9/22/2011
Effective
9/22/2011
Requested /Received Events
27587
Expiration
8/31/2016
RO staff report received
RO staff report requested
9/14/11
9/2/11
Streamlndex Number Current Class Subbasin
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
Water Resources
ENVIRONMENTAL QUALITY
S. JAY ZIMMERMAN
Dean & Christine Sawyer
2501 Laurel Ford Lane
Wake Forest NC 27587
Subject: Permit Rescission
UIC Permit No. WI0500424
August 1, 2016
Geothermal Heating/Cooling Water Return Well
Wake County
Dear Mrs. and Mrs. Sawyer:
Director
Reference is made to your request for rescission of the subject Geothermal Heating/Cooling Water Return
Well Permit located at the above referenced address. Staff from the Raleigh Regional Office has agreed
that a permit is no longer required. Therefore, in accordance with your request, Underground Injection
Control (UIC) Permit WI0500424 is rescinded, effective immediately.
If in the future, you wish to operate a Geothermal Heating/Cooling Water Return Well injection system,
you must first apply for and receive a new permit. Operating a geothermal heat pump injection system
without a valid permit may result in the assessment of civil penalties and/or the use of other enforcement
mechanisms available to the state.
If it would be helpful to discuss this matter further, please do not hesitate to call Shristi Shrestha
at [phone].
Attachment( s)
cc: Raleigh Regional Office -WQROS
Central Files -Permit No. WI0500424
Wake County Environmental Health Dept.
f
Sincerely,
Jay Zimmerman, P.G., Director
Division of Water Resources
State ofNoi1:h Carolina I Environmental Quality I Water Resources
1611 Mail service Cc11tcr I Raleigh, No,tli Camlu1a 27699-1611
919 707 9000
P-ekM to til A,41
Ili/ fq,5� 03�
DmSION OF WATER RESOURCES
WQROS
June 28, 2016
MEMORANDUM
To: Danny Smith — Rick Bolich?
I
Raleigh Regional Office
z
From: liristi Shrestha 5.5
:
s
W ROS
u
Re: Rescission Request
5A7 Geothermal Heating/Cooling Water Return Well
Permit No. W10500424
Dean & Christine Sawyer
Wake County
The WQROS Central Office has received a permit renewal Form indicating the permit be
rescinded. A Permit Rescission Form is attached. Please determine if a rescission should be
issued for this permit and return the completed Permit Rescission Form to this office.
If you have any questions, please contact me at [phone].
Thank you for your cooperation.
Attachment(s)
RECEIVE D/NCDEQIpwR
JUL 2 5 2016
Water Ouaiity Regional
Operations Secuon

Well tag for WI0500424
Surface completion for W/0500424
Com pliance Inspection Re p ort
Permit: WI0500424
SOC:
Effective: 09/22/11
Effective:
Expiration: 08/31/16 Owner: Dean A Sawyer
County: Wake
Region: Raleigh
Contact Person: Dean A Sawyer
Directions to Facillty:
System Classiflcatlons:
Primary ORC:
Secondary ORC(s):
On-Site Representative(&):
Related Permits:
Inspection Date: 07/22/2016
Primary Inspector: Rick Bolich
Secondary lnspector(s):
Expiration: Facility: Dean & Christine Sawyer SFR
2501 Laurel Ford Ln
Wake Forest NC 27587
Title: Phone: [phone]
Certification: Phone:
Entry Time: 09:00AM Exit Time: 09:25AM
Phone: [phone]
Reason for Inspection: Other Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Retum Well
Facility Status: ■ Compliant D Not Compliant
Question Areas:
■ Wells ■ System Operations
(See attachment summary)
Page: 1
Permit: WI0500424
Inspection Date: 07122/2016
Owner -Facility: Dean A Sawyer
Inspection Type : Compliance Evaluation Reason for Visit_: Other
Inspection Summary:
Well and system inspected as part of owner-requested permit rescission request. Geothermal system discharge is no
longer re-injected into well. Well appears to be properly grouted at surface and well maintained. Recommend rescinding
geothermal injection well permit.
,.._._
Page: 2
Permit: WI0500424
Inspection Date: 07/22/2016
System O peration
Is same well used as source well and injection well?
Is injection well capable of assimilating injected fluid?
Injection flow rate at time of inspection (gpm)
Owner. Faclllty: Dean A Sawyer
Inspection Type : Compliance Evaluation
Has system owner/operator noticed any abnormalities (turbidity, air in system, poor heating/cooling, etc) in
system operation?
Comment on system operation
Is system operation and construction consistent with that described in application?
Describe Inconsistencies between application and observed operation/construction
Reason for Visit: Other
Yes No NA NE
□■□□
■□□□
120
□■□□
□■□□
■□□□
Comment: Ins pection for permit rescission re quest. Return water is not re-in iected into well .
Page: 3
Compliance Inspection Report
Permit: W10500424 Effective: 0912 I l Expiration: 08/31/16 Owner: Dean A Sawyer
SOC: Effective: Expiration: Facility! Dean & Christine Sawyer SFR
County: Wake 2501 Laurel Ford Ln
Region: Raleigh
Wake Forest NC 27587
Contact Person: Dean A Sawyer Title: Phone: [phone]
Mrections to Facility:
Systern Classifications'
Primary ORC: Certitication: Phone:
Secondary ORC(s):
On -Site Representativa(s):
Related Permits'
Inspection date: 0712212016 Entry Time: 09:OOAM Exit Time: 09:25AM
Primary Inspector: Rick Bolich Phone: [phone]
Secondary Inspectors):
Reason for Inspection: Other inspection Type: Gomplianee Evaluation
Permit Inspection Type: injection Heating/Cooling Water Return Well
Facility status: Compliant Ej Not Compliant
Question Areas;
Wells System Operations
(See attachment suminaryy
Page: 1

Permit: WI0500424
Inspection Date: 07/22/2016
Owner -Facility: Dean A Sawyer
Inspection Type : Compliance Evaluation Reason for Visit: Other
Inspection Summary:
Well and system inspected as part of owner-requested permit rescission request. Geothermal system discharge is no
longer re-injected into well. Well appears to be properly grouted at surface and well maintained. Recommend rescinding
geothermal injection well permit.
Page: 2
Permit: Wl0500424
Inspection Date: 07/22/2016
System O peration
Is same well used as source well and injection well?
Is injection well capable of assimilating injected fluid?
Injection flow rate at time of inspection (gpm)
Owner -Facility: Dean A Sawyer
Inspection Type : Compliance Evaluation
Has system owner/operator noticed any abnormalities (turbidity, air in system, poor heating/cooling, etc) in
system operation? .
Comment on system operation
Is system operation and construction consistent with that described in application?
Describe Inconsistencies between application and observed operation/construction
Reason for Visit: Other
Yes No NA NE
□■□□
■□□□
120
□■□□
□■□□
■□□□
Comment: Ins pection for permit rescission re quest. Return water is not re-in jected into well.
Page: 3
Well tag for WI0500424
Surface completion for W/0500424
DivFsToN OF WATER RESOURCES
WQROS
June 29, 2016
MEMORANDUM
To: Danny Smith — Rick Bolich
Raleigh Regional Office
From: Shristi Shrestha }- S
WQROS
Re: Rescission Request
5A7 Geothermal Heating/Cooling Water Return Well
Permit No. W10500424
Dean & Christine Sawyer
Wake County
The WQROS Central Office has received a permit renewal form indicating the permit be
rescinded. A Permit Rescission Form is attached. Please determine if a rescission should be
issued for this permit and return the completed Permit Rescission Form to this office.
If you have any questions, please contact me at [phone].
Thank you for your cooperation.
Attachment(s)

Permit Rescission Form
Information to be filled out by Central Office:
Facility Name: Dean & Christine Sawyer
Permit plumber: WI0500424
Regional Office: Raleigh
County: Wake
Date Rescission Requested: 06/27/2016
Received Original Request: Central Office ❑ Regional Office
Form of Received Request: 0 Letter 0 Signed Annual Fee Invoice 0 Other farm
Information to be filled out bv Re2ion:
Please Check Appopriately:
MSite Visit Performed
Recommendations
❑ Groundwater Concerns Addressed
❑ Require Renewal with Suspended Actions
Recommended Actions to be Taken
❑ Do Not Rescind/Recommend Renewal
Reason For Denial

Signature of Certifier (WQROS Section):
Date Certified: ____ ___,_+---+-+~---------------------
Re tum Completed and Signed
NORTH CAROLINA D~PARTMENT OF ENV_IRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION: WELLS
' : . . '. -· ., .
In Acco~darice With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundw~tei: directly into the substirface as part of a geothermal heating ~d cooling system
CHECKONEOF THE FOLLOW~:
__ New Application .. ·.· Renewal* _Modification --✓----;:ermit Rescission Request*
+For Permit Renewals or .Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Inforfnation and Mail to the'A~dress on the Last Page. Illegible Applications WiUBe .Returned As Incomplete.
DATE: ~k.NL . Z.I 20 t fD PERMIT NO. WJ:()50042-4 _ (leave blank ifNew Application)
A. CURRENT WELL USE AND OWNERS~ STATUS {leave Blank if New Application)
B.
1. Current Use of Well / • . . . . .
a. Continue to u~s _L Geothermal Well __ Drinking Water Supply __ Other Water
Supply ~T A!. --ru.."t1o\.P ' l)u.w.f" -NO eo,.lt.lti.cT"ION St\Q(. " WR.LL .
/Jts 1aJE.. \.lN~ ""Tke.._ iu..U!,., W£-t>Q 1-l•T" ~ ~ ~rr(~tOOJQCCc~)
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish'tb-..-
re_ scind the permit, ~e~k the __ box below. If. ab~doned, attach a copy of the. Well Abandonment
Record(GW.:30). ~ _uJEu. .W~ ~lNltu..'f ~Sl6tJeb As ~. ~--~ ~aJ.dC. To
. . WE.le-··ec,a-· WAS INSO\U.a). ~ ~ t bu.MP. ~M& ti,,w-'\~
•D Yes, I wish to rescind the permit · . . · · · _ ·
. . . . •. . . . _11t€f-~ieo Sb IM,I.I..Cf'\ i.lJATeR. "1\-0\T "TKEY Ceo..(.{) NOT
2. Current Ownership Status .t>i2.tfi . Peer-,. ~ ~-~ l.eQ P. · _11,cu,s__ P~E.c..T Wl\5
Has th~re ~een a change of ownershi~ since p_ermit last issued? D YES Q. NO . _
If yes, md1catenew owner's contact information: ~~ To RuA.-lP ~ ~~
Name(s) _____________________________ _
Mailing Address: ___________________________ _
City: ________ State: __ Zip Code: _____ ~VED/NC0EOfDWR
Day Tele No.: -------------=E=m=;a;=ilo...:.A-=d=dr=-=e=ss=.: ____ -d-<jLJf+IIN-2 ........ 7J-2-.40.....,16---
STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence d
Government: State Municipal __
. Water Q~cillity Regional
Operations Section
Business/Organization __
County__ Federal
C. WELL OWNER(S)/PERMIT APPLICANT -For individual residences, list owner(s) on property deed. For
all others, list name of entity and name of person delegated authority to sign: __________ _
Mailing Address: ____________________________ _
City: ____________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: Cell No.:
EMAIL Address: Fax. No.:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 1
i
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) Parcel Identification Number {PIN} of well site: County:
(2) Physical Address (if different than mailing address): 21 Cam. Lt& . -
City: Wa .,e_ F&y e, si- State: NC Zip Code: 2-750
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.
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 TeIe 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
1. WELL CONSTRUCTION REQUIREMENTS — As specified in 15A NCAC ()2C .0224id1:
(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:
Creothermal Water Return Well Permit Application (Revised Jan 20 i 5) 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 ~:used for the_ geothermal heating/cc>0ling 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 froin one another.
Each diagram shall demonstrate compliance with the well construc,tion requirements specified in Part
H above and shaUincluqe,· at a minimuin,.the follow~g well construction specifications:
Depth of each boring below Jand surface
Well casing and screen type, thickness, and diameter
Casing depth below land surface
Casing he_ight "stickup" above land surface
(a)
(b)
(c)
(d)
(e) Grout material( s) surrounding casing and depth below land surface
N;tei bentonite gf~uts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater pef 15A NCAC02C .0107(()(8 )
Length of well screen or open borehole and depth below land surface (f)
(g)
K. OPERATING DATA
Length of sand or gravel packing around well screen and depth below land surface
(1) Injection Rate: A vetage ( daily) aallons per minute (gpm).
(2) Injectio_n Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average .( daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP-As specified in 15A NCAC 02C .0224(b)(4 ). attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s). ·
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothennal Water Return Well Permit Application (Revised Jan 2015) 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 .021 H e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking publicly elected official; ·
4. for all others: by all the person{s) listed on the prop erty 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 specificatiQns and conditions of the
Permit."
--::~,--·a-nt~-
J:2M"'"1 A. 814ut~
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
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) Page4
Permit Rescission Form
Information to be filled out by Central Office:
Facility Name:
Permit Number:
Regional Office:
County:
Date Rescission Requested:
Dean & Christine Sawyer
W10500424
Raleigh
Wake
06/27/2016
RECEIVEDINCDEQIDWR
JUL 2 5 2016
Water Quality Regional
Operations Section
Received Original Request:
0 Central Office ❑
Regional Office
Form of Received Request:
Letter
Signed Annual Fee Invoice
Other form
❑
0
Information to be filled out by Redon:
Please Check Appropriately:
❑ Site Visit Performed
Recommendations
Rescind Permit Immediately
Reason for Approval ti� io 0
2P (Hn r`a', r1 L4 e4e i Ar) Le 1 l f" �
❑ Groundwater Concerns Addressed
❑ Require Renewal with Suspended Actions
Recommended Actions to be Taken
❑ Do Not Rescind/Recommend Renewal
Reason For Denial
k

Signature of Certifier (WQROS Section):
Dean A. Sawyer, P.E.
2501 Laurelford Ln.
Wake Forest, NC 27587
919-523-3929
RECEIVE01NCOEOWR �-'awyereriggr 44 (]C'rr'com
JUN 2 7 2016
Water Quality Regional
Operations Section
Ms_ Shristi Shrestha
Hydrogeologist
Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
Dear Ms. Shrestha:
Based on our conversation on Wednesday, June 22, 2016 and a subsequent conversation with
Mr. Michael Rogers, I have confirmed that a LTIC permit is not required for our geothermal well.
Thank you for your time and please let me know if you have any comments or quesitons.
Sincerely,
Dean A. Sawyer

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 heating and cooling system
CHECK ONE OF THE FOLLOWINx :
__ New Application ___ Renewal* __ Modification _(_ ;:ermit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pa ges 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
---DATE: Jkl'J£ Z.I ,20 l lo PERMIT NO. WI.oS'0042.4 (leave blank ifNew Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave Blank if New Application)
B.
1. Current Use of Well / ~
a. Continue to u ~s __ Geothermal Well __ Drinking Water Supply __ Other Water
Supply ~T As. "ru..11\P ' ~" -NO ~f.l{ic::rleN SA«-~ w£-LL . '\
As WE. \}...N~ -rKL ~U!,..J u.l'£.. I>C> ,-,h,-r tJriil> It ~rT"( ~I.OOJQOO c_p&J
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish 'tf:,
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30). ~ oJeu.. WAS °"-tblNlrU..'f ~S1e...lel> As A,-J ~ ~ 51\ck To
WEU.... ~ w,\t, IN~ A ~ f bl.lW\P. i>wlJN6 tlfllW~6 D Yes, I wish to rescind the permit
1"J.tef ~~ ~ ~ i.uATeR. 1\-0\T "TKE'f C'ct.Ltl) N cT
2. Current Ownership Status ~u Peet~ ~ i-"o(., ~ LeQP. 11,u,c,s Pto.TE.c:..T Wl\5
Has there been a change of ownership since permit last issued? D YES c;J NO
If yes, indicate new owner's contact information: ~u:rED Tb Pc.uM..f> ~ ~ ~
Name(s) _____________________________ _
Mailing Address: ____________________________ _
City: ________ State: __ Zip Code: _____ BQVED/NCDEO/OWR
Day Tele No.: Email Address.: JU N .2 7 2016
STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence J
Government: State Municipal __
Water Quality Regional
Operations Section
Business/Organization __
County__ Federal
C. WELL OWNER(S)/PERMIT APPLICANT-For individual residences, list owner(s) on property deed. For
all others, list name of entity and name of person delegated authority to sign: __________ _
Mailing Address: _____________________________ _
City: ____________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: Cell No.:
EMAILAddress: ______________ F_a_x_N_o_.: _____________ _
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 1
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.: ---------------~E=m=a=i~l A~d=d=re=s=s-~: ___________ _
E. LOCATION OF \\'ELL 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): 25 1Sl I ~~ /..;v,..
.>
City: Wa,lle.. F~ ~+ State: NC Zip Code: _Z_7'_5_8_c _____ _
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. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: ____________________________ _
NC HV AC 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 __ _
I. 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
15ANCAC 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 (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 an_d 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)(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. OPERATINGDATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP-As specified in 15A NCAC 02C .0224(b )(4 ), attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
( 1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107 (a )(2 } located within 250
feet of the proposed injection well(s). ·
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page3
NOTE. In n=ost cares 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 NQAC 02C_.0211(eI requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer,
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the person(s) listed on the property deed,
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicani that naives 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, l 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. 1 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_"
Signa of Property Own / icant
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type: Full Naive
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 20l Sy Page 4

DIVISION OF WATER RESOURCES
WQROS
June 28, 2016
MEMORANDUM
To:
From:
Re:
Danny Smith -Rick Bolich
Raleigh Regional Office
Shristi Shrestha S-.S .
WQROS
Rescission Request
SA 7 Geothermal Heating/Cooling Water Return Well
Permit No. WI0500424
· Dean & Christine Sawyer
Wake County
The WQROS Central Office has received a permit renewal form indicating the permit be
rescinded. A Permit Rescission Form is attached. Please determine if a rescission should be
issued for this permit and return the completed Permit Rescission Form to this office.
If you have any questions, please contact me at [phone].
Thank you for your cooperation.
Attachment( s)
Permit Rescission Form
Information to be filled out by Central Office:
Facility Name: Dean & Christine Sawyer
Permit Number: W10500424
Regional Office: Raleigh
County; Wake
RECEIVED/NCDE{OWR
JUL 2 5 2016
Water QuMiry Regional
Operations section
Date Rescission Requested: 06/27/2016
Received Original Request: 0 Central Office Regional Office
Form of Received Request: ❑ Letter 0 Signed Annual Fee Invoice Other form
Information to be filled out by Reiion:
Please Check Apprdpriately:
❑ Site Visit Performed ❑ Groundwater Concerns Addressed
Recommendations
❑ Require Renewal with Suspended Actions
Recommended Actions to be Taken
ElDo Not Rescind/Recommend Renewal
Reason For Denial

Permit Rescission Form
Information to be filled out by Central Office:
Facility Name:
Permit Number:
Regional Office:
County:
Date Rescission Requested:
Received Original Request:
Dean & Christine Sawyer
WI0500424
Raleigh
Wake
06/27/2016
X I Central Office D Regional Office
Form of Received Request: D Letter ~~I Signed Annual Fee Invoice I X · I Other (form)
Information to be filled out by Region:
Please Check Appropriately:
D Site Visit Performed D Groundwater Concerns Addressed
Recommendations
D Rescind Permit Immediately
Reason for Approval ____________________________ _
D Require Renewal with Suspended Actions
Recommended Actions to be Taken ------------------------
□ Do Not Rescind/Recommend Renewal
Reason For Denial -----------------------------
Signature of Certifier (WQROS Section):
Signature of Certifier: ________________ _
Date Certified: -::--------:------::-:------:-:=----:--:=-::-::-::---------------------
Re tum Completed and Signed Form to the WQROS Section
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 heating and cooling system
CHECK ONE OF THE FOLLOWIN :
New Application Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pat;es I and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 1141 Zl ,20 1 (a PERMIT NO. WT.056n4Z4 _(leave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave Blank if New Application)
1.
Current Use of Well
n1
a. Continue to us - �S V Geothermal Well Drinking Water Supply Other Water
Supply T A5, "FWAtp I Nvm ` 90 `l's
N
- 54,CX LALLL .
A5 bJE lAN�1� I E �'....." u-�E Do i t aT- 9M A L��►NICr�; �O�CQO
ig
Qc►+
b. Terminate Use: If the well is no longer being used as a injection well
N
geothermal and you wish
G
rescind the permit, ��c check the box below. If abandoned, attach a copy of the Well Abandonment
0
Record (GW-30). (No WSU- WAS &9460►%LLy t`�. estc.40 AS W 4&4 IMIP, bAc4c To
7
m
WELD. &Vr WAS 1A5Tj4,EA A RLMP * lxtMP >AOJ96 DR►UAo
n
❑ Yes, I wish to rescind the permit
�y
G
3;
1TW-V EI. "WTW Sa mwcA L4ATtR -Dbkr `rKEY Cag►-cD N o T'
2.
Current Ownership Status M V_ Peep. C4q f-mt, cfct 1 Loop 174u s P&�Trmc-T WAS
Has there been a change of ownership since permit last issued? ❑ YES y NO
If yes, indicate new owner's contact information: eqovegmD T't7 RA JAAP b t q `t
Name(s)
Mailing Address:
City: State:
zip Code:
REWMINCDEOMR
Day Tele No.:
Email Address.:
J4N-$7_ ?&,Fr—_
B. STATUS OF APPLICANT (choose one)
Water Quality Regional
Operations Section
Non -Government: Individual Residence
Business/Orgauization
Government: State Municipal
County
Federal
C. WELL OWNER(S)IPERMIT APPLICANT - For individual residences, list owner(s) on property deed. For
all others, list name of entity and name of person delegated authority to sign:
Mailing Address:
City_ State:
Zip Code:
County:
Day Tele No.:
Cell No.. -
EMAIL Address:
Fax No.:
Geothermal Water Return Well Permit Application (Revised Ian 2015) Page l

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 Teie No.: Email Address.:
E. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PrN) of well site: County:
(2) Physical Address (if different than mailing address): 2 1 L4462LAN
F
City: WAy'.- FcTo,+ State: NC Zip Code: Z750
WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
Contact Person:
Address:
City -
Office Tele No.:
EMAIL Address:
Zip Code: State:
Cell No..
County: T
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:
Otiice Tele No.: Cell No.: Fax No.:
H. WELL USE Will the injection wel(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 92C .02241 dl:
(I) The water supply well shall be constructed. in accordance with the water supply well requirements of
15ANCAC 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 (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(/)(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. OPERATINGDATA
(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 l SA 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 (Revised Jan 2015) Page3
NOTE. Inmost cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and dow."loaded from the applicable county CIS wehsite. 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 Band 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 periuit applications shall be signed as follows:
1. for a corporation_ by a responsible corporate officer;
I for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking; publicly elected official;
4. for all others: by all the person(s) listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant thai names and authorizes their agent to sigh 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. 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."
f7
Signs ure ofProperty Own 1.Wicant
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Nance
Signature of Authorized Agent, if any
Print or Type Full 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 Waier Return Well Permit Application (Revised Jan 2015) Page 4

PAT MCCRORY
Governor
C
DONALD R. VAN DER VAART
Secrerarr
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY
Di+"Eoor
June 16, 2016
CERTIFIED MAIL # 7015 1520 0000 7838 3903
RETURN RECEIPT REQUESTED
Dean & Christine Sawyer
2501 Laurel Ford Lane
Wake Forest NC 27587
Subject: Notice of Expiration (NOE)
Geothermal Water RetumlOpen-Loop Injection Well
Permit No. W10500424
Wake County
Dear Mr. and Mrs. Sawyer:
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well -construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on September 22, 2011, and will expire on August 31, 2016. Per permit conditions and
requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior to expiration of the permit if you wish to continue operating the injection well
on your property.
If Your Geothermal Water Return Well is Still Currenth Being Used for Iniection:
In order to comply with, the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
l4eating/Cooling Water Return Wells). The form is also available on-line at our website
http://poilal.nedenr.org/web/wqlaps/gwpro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Bein= Used for Iniection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box. in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be pennanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
Slatc of North Caroline I EayimnmaaW Quality j Watcr Resources
1619 NW aw'vi4u Cuutur i McigSI, Nuah CkuvIlpw 27699-1611
919 707 9(W

i
Page 2 of 2
If There has been a Chanae�of Ownership of th_e_Prvperty:
If there has been a change of ownership of the property, an "injection Well Permit
Name/Ownership Change" Farm must also be submitted in addition to the renewal application.
This farm is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable farms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. if you have any questions, please contact me by phone at
[phone] or by email at shristi.shresthatri n_edenr.gov.
Retards,
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Raleigh Regional Office — WQROS w/o enclosures
Central Files - Permit No. W10500424 w/o enclosures

S.
Postal
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ERTIFIED
MAIL°
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War
s Dean & Christine Sawyer
sen 25O1 Laurel Ford Lane
� Wake Forest NC 27587
e
■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the hack of the mailpiece,
or on the front If space permits.
1. Article Addressed to:
Dean & Christine Sawyer
2501 Laurel Ford Lane
Wake Forest NC 27587
A. 5i wat
��
A9
x Addressee
B. RvV by=� 0. D!ate of Deliv_� �] - 2x3 -eery
D. is dowery address differsm from Item 17 E3 Yes
If YES, enter delivery address below: © No
3. Service Type
[I Priority Mae? EWeesO
❑ Adult signature
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❑ Registered Melt
D Adult signature HeWftted DeiWry
0 g istered Mall Restricted
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❑ Cernfled Mail Restricted Delivery
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Domesbc Return Rpcelpt

Permit Number WI0500424
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
Dean & Christine Sawyer SFR
Location Address
2501 Laurel Ford Ln
Wake Forest
Owner
Owner Name
Dean
Dates/Events
NC
A
27587
Sawyer
Scheduled
Orig Issue
09/22/11
App Received Draft Initiated Issuance
08/23/11
Re a ulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
09/28/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Dean A. Sawyer
2501 Laurel Ford Ln
Wake Forest NC
Public Notice Issue
09/22/11
Effective
09/22/11
Reauested/Received Events
RO staff report requested
RO staff report received
27587
Expiration
08/31/16
09/02/11
09/14/11
Waterbody Name Stream Index Number Current Class Subbasin
Permit Number W10504424
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael.rogers
Coastal 5W Rule
Permitted Flow
Central Files: AP5 5WP
09/15/11
Permit Tracking Slip
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Facilit
Facility Name Major/Minor Region
(Jean & Christine Sawyer SFR Minor Raleigh
Location Address County
2501 Laurelfvrd Ln Wake
Wake Forest NC 27587 Faclifty Contact Affiliation
Owner
Owner Name
Owner Type
Individual
Dean A Sawyer
Owner Affiliation
Dean A. Sawyer
2501 Laurel Ford Ln
Wake Forest INC
27587
Dates Events
Scheduled
Orig Issue App Received ❑raft iniliated Issuance
08/23111
Public Notice 1 ue Effective
Ctil
E ira on
��
[
R,Duvlate:` Activities
7;-a,-,`:ec!;7 -,-
Heat Pump Injection
Ra staff report requested
09/02/11
RQ staff report received
09/14/11
Gutfall OULL
Waterbody Name Stream Index Number Current Glass Subbasin

A~A .a:··:,.~ ;;-;;-..,,. __
MCDE R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Dean and Christine Sawyer
2501 Laurelford Ln.
Wake Forest, NC 27587
Re: Issuance of Injection Well Permit
Permit No. WI0500424
Coleen H. Sullins
Director
September 22, 2011
Issued to Dean and Christine Sawyer
Wake County
Dear Mr. and Mrs. Sawyer:
Dee Freeman
Secretary
In accordance with your application received August 23, 2011, I am forwarding Permit No. WI0500424
for the construction and operation of a SA 7 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.
Per Permit Condition Part 11.2, please notify Jay Zimmerman with the Raleigh Regional Office
(919-791-4200) within 30 days after the well becomes operational in order for water samples can be
collected from the geothermal system.
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, -~~-
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
cc: Jay Zimmerman, Raleigh Regional Office
Central Office File, WI0500424
Wake County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1635
Location: 2728 Capital Boulevard , Raleigr1, North Carolina 27604
Phone: [phone] FAX 1: 919-715-0588: FAX 2: 919-715-6048 \ Cusiomer Service : 'i-877-623-6748
Internet: www.ncwateraualitv.o rg
A:1 Eq:ial Cpportcnl:; \ Affirrna'ive Act;o'.1 Employt.:
.NOnethC 1· .or . aroma
JVaturnflg
NORTH CAROLINA
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
Dean and Christine Sawyer
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina
Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent. This
injection well is located at 2501 Laurelford Lane, Wake Forest, Wake County, North Carolina 27587, and will
be constructed and operated in accordance with the application received August 23, 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 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until August 31, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through VIlI hereof.
rz
Permit issued this the 2I, day of , 2011.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #W1050004 UICr5A7 Page 1 of 5
ver. 03/2010

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. Within 30 days of the well(s) becoming operational, Permittee must contact the Aquifer Protection
Section at the Raleigh Regional Office (919-791-4200) in order for staff to collect samples from the
influent and effluent sampling ports.
3. 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.
4. 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.
5. 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 #WI0500424 UIC/5A7 Page 2 of 5
ver. 03/2010
PART Ill-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 reiated 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 #WI0500424 UIC/SA7 Page 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 RENEW AL
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 ISA 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 #Wl0500424 UIC/5A7 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 #WI0500424
Aquifer Protection Section-VIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/SA7
ver. 03/2010
Page 5 of 5
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 8, 2011
MEMORANDUM
To: Michael Rogers, The Central Office, APS
Through: Jay Zimmerman
From: Lin McCartney"
Subject: Staff Report- WI0500424, Dean Sawyer, 5A7 Geothermal Well
Wake County
Aquifer Protection Section
1628 Mail 5ervioe Center, Raleigh, North Carolina 27699-1628
Location: 3800 Barrett Dr., Raleigh, North Carolina 27609
Phone. [phone] FAX: [phone] Customer Service: 1-977-623-6749
Internet:: www wwaternualitv.org
An Equal Opportunity 1 Affirmative Action Employer
RECEIVED I DENR 1 DWd
Aquifer Protection Section
SEP 14 2011
One
Nor(hCarolina
;W111rally
�4,

AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: September 8.2011
To: Aquifer Protection Central Office
Central Office Reviewer: Michael Rogers
Regional Login No:
County: Wake
Permittee: Dean and Christine Sawver
Project Name: Iniection 5A7 Well
Application No.: W10500424
L GENERAL INFORMATION
1, This application is (check all that appjy): ® New ❑ Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ Nigh Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 ragttlated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation ® Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
a. Date of site visit: 09-08-2011
b. Person contacted and contact information, Dean Sawver, 919-488-4044. 919-494-3470
c. Site visit conducted by: Lin McCartney
d. Inspection Report Attached; ® Yes or ❑ No.
2. Is the following information entered into the BIMS record for this application correct?
® Yes or ❑ 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 Iniection_Sites:
If multiple sites either indicate which sites the information ap1L s_ Co. co aLy and paste a new section intothe
document for each site, or attach_ additional pis for each site)
a, Locations): 2501 Laurelford Lane, Wake Forest. NC 27587
b. Driving Directions: Take US-1 N for 12 rnile -tt" Jeft on HAvv 98 turn right onto Thompson Mill Rd.
turn right to Laurelford Rd. t
c. USGS Quadrangle Map name and number: _5
d. Latitude:35-58-59 Longitude: 78-33-�9
H. NEW AND MAJOR MODIFICATION APPLICATIONS this section not needed for renewals or minor
modifications, skin to new section)
Description Of Waste(S) And Facilities RECEIVED I ❑ENR 1 DM
1. Please attach completed rating sheet. Facility Classification: Aquifer Protedion Serlion
SEP 14 2011
FORM: Staff.Report-Sawyer-2011 1

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 OfWell(S) And Facilities-New, Renewal, And Modification
1. Type of injection system:
IZ! 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--~!g e")
D Other (Specify: ) 0 All fJ:/
2. Does system use same well for water source and injection? pi Yes j!No
3. Are there any potential pollution sources that may affect injection? IZ! Yes D No
What is/are the pollution source(s)? Septic tanks
4. What is the minimum distance of proposed injection wells from the property boundary? 12111
5. Quality of drainage at site: IZ! Good D Adequate D Poor
6. Flooding potential of site: IZ! 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 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 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 y es , explain:
3. For renewal or modification of groundwater remediation permits (of any typ e ). will
continued/additional/modified injections have an adverse imp act on mi gr ation of the plume or management of
the contamination incident? D Yes D No. If yes. exp lain:
4. Drilling contractor: John Boyette
FORM: Staff.Report-Sawyer-2011 4
AQUIFER PROTECTION REGIONAL STAFF REPORT
Address: 1109 W Nash St., Wilson, NC 27893
Certification number: 2505
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 [8l 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-Sawyer-2011 5
AQUIFER PROTECTION REGIONAL STAFF REPORT
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information; [gl
Issue; D Deny. If deny, please state reasons: __
8. Signature ofreport preparer(s): _£_· _f _t"\~-c----1),-J .,,._~_l _{_o,...,_· _{_~_----H--------
C]j n:: '~ /)
Signature of APS regional supervisor: -~~'--+-/ .... r-J-~--~--------------
Date: --~-~=.,/1-"'b~(I_
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
The pre-construction inspection was conducted on September 8, 2011.
A review of the construction data indicates that the proposal to construct the well meets the
injection well construction criteria in accordance with N.C. State Regulations (Title 15A NCAC
2C), Well Construction Standards.
The following items were checked:
1. Well Casing
• Casing thickness: SDR 21 (0.632 inches), Diameter: 6.25 inches
• Casing depth: from surface to 49 feet, Casing extends above ground 18 inches.
2. Grout
• Grout type-Bentonite
• Grout surface and grout depth-around well casing from surface to 22 feet.
3. The location of the well
• The distance of the well from the septic tanks is 121 feet.
• The minimum distance of the well from the building is about 80 feet.
• The minimum distance of the well to the property line is 40 feet.
We recommend that the Central Office proceed to issue the applicant a permit for geothermal
well construction so that the contractor could start construction. However, once the system is
constructed, the permittee shall notify the Raleigh Regional Office so that a post construction
inspection and sampling of the well water can be performed.
FORM: Staff.Report-Sawyer-2011 6
Permit: WI0500424
SOC:
County: Wake
Region: Raleigh
Effective:
Effective:
Contact Person: John H Boyette
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 09/08/2011
Primary Inspector: Lin McCartney
Secondary lnspector(s):
Reason for Inspection: Routine
Compliance Inspection Report
Expiration:
Expiration:
Title:
Owner: Dean A Sawyer
Facility: Dean & Christine Sawyer SFR
2501 Laurel Ford Ln
Wake Forest NC 27587
Phone: [phone]
Certification: Phone:
Entry Time: 10:30 AM Exit Time: 12:00 PM
Phone: [phone]
Ext.4243
Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well (5A7)
Facility Status: ■ Compliant O Not Compliant
Question Areas:
■Wells
(See attachment summary)
Page: 1
Permit: WI0500424
Inspection Date: 09/08/2011
Inspection Summary:
Owner -Facility: Dean A Sawyer
Inspection Type: Compliance Evaluation
A pre-construction inspection was conducted on September 8, 2011
Reason for Visit: Routine
A review of the construction data indicates that the proposal to construct the well meets the injection well construction
criteria in accordance with N.C. State Requlation (Title 15A NCAC 2C), Well Construction Standards.
The following items were checked:
1. Well Casing
Casing thickness: SOR 21 (0.632 inches), Diameter: 6.25 inches
Casing depth: from surface to 49 feet, casing extends above ground 18 inches.
2. Grout
Grout type: Bentonite
Grout surface and grout depth: around well casing from surface to 22 feet.
3. The location of the well
The distance of the well from the septic tanks is 121 feet.
The minimum distance of the well from the building is about 80 feet.
The minimum distance of the well to th!;! property line is 40 feet.
We recommend that the Central Office proceed to issue the applicant a permit for geothermal well construction so that the
contractor could start construction. However, once the system is constructed, the permittee shall notify the Raleigh
Regional Office so that a post construction inspection and smpling of the well can be performed.
Page: 2
NA
NCDEN R
North Carolina Department of Environmen t and Natura l Resources
Division of Wate r Quality
Beverly Eaves Perdue
Governm
Dean Sawyer
Christine Sawyer
2501 Laurel Ford Lane
Wake Forest, NC 27587
Dear Mr. and Mrs. Sawyer:
Coleen H. Sullins
Directo r
September 1, 2011
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI0500424
Dean & Christine Sawyer SFR
Injection Heating/Cooling
Water Return Well (5A7)
System
Wake County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on August 23, 2011. 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 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] [e-mail].
Sincerely,
a~_f\-~
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Boyette Well & Septic, Inc. -John H. Boyette, Jr
Raleigh Heating & Air -Brian Barber
Permit File WI0500424
AOL!:"ER PROTECTION SECTION
1636 Ma;I Service Center, Raleigti. North Carolina 27699-1636
Location: 2728 Capital Boule11arc:. Raleigh, Nort-, Caroiina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FA\ 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet www.ncwateraualitv.oro
r-.n E:cua! Oppor:iJrit.: \ Affirmative .k.c:1C',:1 Ernolover
One . North Carolma
/Vaturall!I
Ro gers, Michael
From:
Sent:
Brian Barber [[e-mail]]
Wednesday, August 24, 2011 9:29 AM
To: Rogers, Michael
Attachments: geo1.pdf
Let me know if you need anything else.
Thanks
Brian Barber
Service Manager
Raleigh Heating And Air
2800 Rowland Rd
Raleigh, NC 27615
919-878-0008
1
Aug, 23 2011 9: QGAM RALE I GH HEATING AND AIR 9198788515 P.
__.02/00/2007 21:00 FAX 2$22930955 BOYETTE WELL
W4n1
FORTS CAROLrNA DEPART'MFM OF ENVIRONMENT AND NA7VRAL RESOURCES
APPLICATION FOR A PEANUT TO CONSTRUCT OR OPERATC INJECTION WELLS
In Accordance With the Ncvisions of 15A NCAC 02C .0200
OPEN —LOOP GEOTHERMAL INJECTION WELLS
Them wells diuharso grouredwatsr directly into the subsurflsce as part of a goothcrm l heating arc) cooling syrtesm
(chock one} New Application Renewal* Modification
Pr
DATE: , 24
�y
PEANT NO. T�I (leave Mink if Now Application)
A. STATUS OF APPLICANT (choose one)
Non-Govermnent: Individual Rea=dance Businewch-Ranization
Govrrnmerrt: State Municipal County Federal
B. PEPMIT APPLICANT - Far individual residwicos, list exit owner on VWcr ty detd. For all otters,
state name of rntity ld name of persons delegated authority to sign on bdinJf afthe business or asency:
Mai:itag Address: ^ A 50 1 W>PL- l �� r]W Gf
City: - 450'Le EA&A State: ill Lzip Code:2 3 5 �i I _ Cauitty:
Day Tale No.: %�- y tAl3q q Csll Ng., - 4y � A� 10
EMAIL Address: No..
C. LtI "TION OF WELL 9ITIEi, - Wherc the Waction wells are physically located,
(1) Parcel identification Numbar (PIN) of well site: _ County:
(2) Physical Address (if different Chart meilmil address):
D.
Ciry: _ _
State: MC Zils Code: -.-
WELL DRIti.I.dEER INFORMAMN r
wou i?rillinu Coxwuetor's Nam: T1 AA w ���I � � •
NC Well Drilling Cvrstn dff Certificoon Na-- _� -
Company Name. 1?U C LAG '?t-'�L. a 17C ■■���
Coma
Address:
City: tnl r �y r- Lill Code: _ ?- 613 State -Pk Conmtw thrf
Offica Tale No,: �i � Z ! _ CeN N o. 51 % - 0 1 Fax I . rZ,S'Z)
GPVMC 5A7 Pa rsst Applioahft (Revised 3nalmll) Pees l

-Aug 23 2011 S:OGRM RALEiGH HEATING ANL AIR 9198788518
02/09/2007 21:00 FAX [phone] BOYME SELL
E. EOFAT PUMP COkTRACTOR iINFORMAMON . (ifdifferc nt than drills')
0002
Compao?' Name:
Contact Eersan: � �f'L B. L A. �
Address: ' &es114-Sci Z11
City: Zip Code: -i r4p State. 'SILCbeutty: 4Lt•#e
Office Tele No.:L- �78-069--e Cell No.: 8f�/ Fox No4-flY- A 7 6
F. WELL USE Will the koction well(s) also be used as the 7ply well(s) fix the fbilowinS7
(1) The injection ope ation7 YES NO _ �-
(2) Pemonal corimmption? YES NO
G. WItLL CSTRUCTION DATA
PROPOSED Well(a) to be corlatructM for use as an injccr�m well. Provide the data in (1) ftougb
(6) below as PROPOSED eoraw=tion specifications. Submit Form GW-1 aftcr wnitruction.
P.XX1SM0 WOW$) baieg proposed for use as an injection well. Provide the data in (1) through (6)
below to the best of your knowledge. Attach a copy of the We11 CflnaWuction Rccard (Form
GW-1) if aveilab
(1) Well Constrlxtion Date: �i� 1 � N`L nbex of boring s:
Depth of each baring (feet): S
(2) We11 caving typo: Galvantwid stw1_ D1Ack steel
Plastic �00= {spactfy)
Casing thiekneas (in.): ff Diame � {in.): �p I'f'
Well *th' from: ff, to. Lis feel below land suriaoe
Casumg extends above Xmid inches
(3) Grout material surrounding weal casing:
(a) Grnfet type: Cement nmonit '* Qt1tw Opemfy)
*By PrJe L1mk% hmWrj11: uvu , s ++mia= is herct{v mgmmd to 5A NC:AC ZC 21l7[d Yf 1!U1J. rrpiait requires a aaanail f} P+ �aa!
(b) Depth of grout around well casing (relative to Wand surface): from D to 2, 2, felt
f
(4) Wall 5creelt or Open Boss hole depth (reNttive to land stxf'ace): from �o to - feet
(5) N.C. State Mguiations (Title 15A NCAC 2C .0200) require the Parmittee to make provisions for
monitoring wellhead processes, A faucet an both Wluent (g undwster enterin heat ptunp) and Effluent
(wwcz-beirtg irgeaM back into ell) limns i9 requires. is there a faucet on:
{g} iztiiu�tt liruGT Yes No 14107 Yos V/ No
(6) Source Well Commnwtitm information, If the water sow-ca wmll is a differt_nt wall than the injection
well, attach a copy of the well construct# rcoord (Form GW-1), IF Form GW-1 is not available, provide
the foilowins data:
Pfom what depth, formation, a*d type of rock/sedimeat smite Will the WCaidwator be wi*4MwA1 (a.g,
granite, l imeatote, sand, etc-)
Depth: Formation: Rock sediment unit
NOTE: IIE WELL. BRII.LING DR HEAT PUMP CGINTWTOR CAN HELP 3LIAMLY TJ-M bA'rA 1P-MUS
TNnRMATiOH IS OTRBRWISE UNAVAILABLE.
QPL7IM SA7 Pom it Appllutkw {Revised 311&02011) Prty 2
p.3

-Aug 23 2011 9: ❑68M RRLEI GH HEATING FIND FI I R 9198788519 p° 4
02YO012007 21:00 FAX [phone] BOYETTE WELL Zeal
S. OPU RUNG VATA
(1)
tnjechm Reba
(2)
wection voiume.
(3)
Injection Prowrc
(4)
Injection Tcmperauue:
Avwwo (daily) r n Mons per u izutc (jpm).
Avarlsgp (daily).S j°v l pUons Pw d8y (gpd).
Average (daily) _ pounds/square inch {psi).
Average (]antwry) ° F, Avetags (July) °fir " F.
L WILL LOCATIONS— Maps must be scaled w athe-visa accurately mdicato distances and or'ift%xtions of
features located within 1000 fret of tiro injection wc11(s). LabcI RU fgahn§ elegly nd include e. north -- --.
(2) Attach u site-speoitm snap showing the )ocmions of the fallewimg:
+ Proposed inj"tion Wells • Buildirtga * Psopcaty bumdaries
* Surface water bodies " Water swply wells
" Septic tanks and associated spray in*tk n sites, drain fields, or repok areas
' Exietiag Of potential souses of WOUndWRIOt coMninatiOn
(2) Attach it bopagrepbic map of the area extending 114 milt from the *action well Site that indicates the
faOiiily's ioebtion and the map namc,
NOTE.• !a efoN tallest an amul phaev#Wh of Ik* prapnV parcel sr owlegjpropdWX i bmt sad ArwrAwwm MR be
o8tairsed w d &W"raaded fro,w the appliesble county GIs Wb&4,L 7yPwalk the proprlfy can be searched by
ewow naAw nr addrus, TAW location of the walk in raradon So pr+opmy boandapfas, ✓ A wag, septic tank, Odw
weft, eft aim tarn be drawn la by hand Afsvy a 'rqyer' can be seeded ■hvwiWg wpegmphlc eom ours 9r
dfemvio s darn
GPt7AW W Pamft APOmtiiaa (Knaed VISIOt 1) ftv 3

3. CERTI€rICATION Ito bt_ signed as required below' car by that persons authorized agent)
1 SA NCAtr OX .021 1{b1 requires thai all permit applications shall be signed as PoiloAVS'.
l - for a corporation- by a responsible corporate officer.
2. for a partnership or SOIL proprietorship: b} a general partner or the proprietor. respectively,
3 for a municipality or a -state. federal, or other public agency: by either a principal executive
off cor or tanking publicly o► med official.
Y. for all others: h% the well owner (which _means_all i)ersonslilisted .wi the provers 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 hehalf.
1 hereby certify under penalty of lay+, that .' have personally examined and am familiar with the information
submitted in this decuinent anl..: all anaehtttents thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate an4
complete. I mn aware that therw are significant penalties- including the possibility of fines and impriscttimem
for submitting Use information. I ag7ce to construct. operate, maintain_ repair. and if applicable_ abandon the
injection well arn: all rclatea appummances in accordance with the approved specifications and conditions of
the Pcmii..
L
Signature of Property F 1'+vn_r/-',.pplicant
Print or Type Full Narne
Signature of Property Owners.ex,rant
1'rinl o Type Full Najne _ +!
Signature of Authorized Agent_ if any
Print or i'vpe Full Name
Submit two c-pies m the enmpletLd appac ition package to:
DWQ - Aquifer Protection Section
16346 Mail Service Center
Raleigh, _NC 27699-1636
Telephone (9I9) 733-3221.
UP t'. tIIC 5.k7 Permit , trj h"Itiin1 (tt 4'!'f'Wj 3rt K'•?011 ) ]':l Li -i

I Are then: any i.:xisting sepiic systems (surface or subsurface) on this property?
I Are there ar:y e.:iscmems or right of ways on this property'?
Are therr an:: existing wells or water lines on this property?
Are there any surface water bodies or designated wetlands on this property?
Arc thrr.: any bdow gt0und chemical or petroleum storage tanks on this
nro ~ertv':
.Are there m~y known landfills. waste storage on this property?
1s tnere any knovn Subsu;face contamination on this property? -----------~
Arc there ary fields on this or adjacent property that are used for industrial,
________ m_u_n_ic_i,_P~! .;ludge spreading or wastewater-irrigation sites9
Estimated Demand:
' Estimated daily wal~~;St; in gallons per day (excludfng private well)
0 LEASE ATTACH A S1 TF. PLAN (TO SCALE) OF YOUR PROPERTY
Site plan must show: oroperty boundaries with dimensions, easements, existing and proposed
structures with dimensions, ~xisting l\'ells. septic/sewer lines, all other potential sources of
contamination.
Site plan scale· should be 1" = 20, 30, 40, 50, 60, 80 or 100'
: have read this application untl certify that the information provided herein is tme, complete am:
correct. J\uthoriz;;:J represcmath c~ of th(: V-/ake County Department of F nYironmental Services
are granted right of i.!ntr), t0 ...;or.due :. nt.:cessary inspections to determine compliance witt
aoplicahk bws and ruk~. T understand that I am solely responsible-for the proper identification
anti labding of a[ property line~ and comers and ensuring site accessibility so that a pennitting
::..c:ivities can b£.Q__erfom1.:d . . --C .; i--., -. ) , /
"7 ·' . -I "..-, r ,;;;1 /.-.,,, , t I ·.-_ .... ~. --~ .. ~·~ ••. '.,,.(-~-•·--.,.; , .f;.!,;> , ,
------J.-_,, ~ -. _._._:.\.;;--' ----,,--------.
Property ownei>~ or owner's iegat"repies~_utaiive signature Date '
(Must prnviclL documentation hi supm,n claim as ow11er's legal representative)
Required minimum scnaratinn distance~ between newly p(!rrnitted wells and sources of pollution: ---,-·--.
___ 100 feet I Septic _ta_1_1~_: _a_nc._l_d_r_ai_n_f _1e_ld _________________ _
:;e fort I Watei' tig~1t sc\v;;;:--lin;;-
1 OU foet I Other s.::{~,;ge_;:;_o_ll_c_~_ti-c,-n-1-in-i;;--~~------------------------
------
l :JO (~et I l\ni ma: fediot or I!!a:mre pi ks
I 00 fe-:t \ F e1ilizer, pesticidt, herbicicic: or other d1t:mical storage areas
l 00 fee1. I-Non hazardous waste storage. treatment or disposal _lagoons --------
500 i'eet I Sanitar~-land;1Hs
l 00 r~~~ Iner, debris lilrn: ti Us -----
---
i 00 fee~ i\nima! barn5
50 feet Build.inf, foundations -------------------------------
5(• fe~t I Po1.1<.is lakes ~:ml! resen oirs ( surface water bodies that provide groundwater
1 re'char~-~)
25 ,eel , Creeks. streams and ri ,-crs
50 reei I Chemical 0r fui:. underground storag: tanks v·ith secondary containment
J 1.Kl .~eet Cne~ical o:· fue: underground storage tanks \Vithout secondary containment
5(l kel All o.i1cr i1ot~ntial sources
. -----------
Well .\ppiicati(-►11 0:::1.olx::-; :•. 2ur: Page
,Aug 23 2011 9: 069 M RRLE I GH HEATING AND €i I R 9Ige788519 y
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i COR* thef =hs loft nn of Aianned or twist►nc
atruttturOW are aeewetW shown. I Undantane '
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pLM' AWft May require the relnaaman a+ !
srxileulMW rsprdkm degrle 6f carrpleuan,
heretw gram ow"ifton rD Martocipel/Tou"
Aepr"w*M*U " 09hr of entry to maks
•ve1W Of +nsasellmisM Uvon =hit prrooeriy.
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Rug 23 2❑11 9:06RM RALEIGH HEATING AND AIR 9198788519.
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RALEIGH HEATING & AIR
2800 Rowland Rd.
Raleigh, NC 27615
919-878-0008
919-878-8519 fax
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