WI0500428_GEO THERMAL_20120531

Beverly Eaves Perdue
Governor
J;;A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 31, 2012
John and Dianne Clarke
212 Cumberland Road
Sanford, NC 27330-1043
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0500428
Dear Mr. and Mrs. Clark:
Dee Freeman
Secretary
Our records indicate that you cunently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted .by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quajity. You
may view the revised rules on our website at htt p://portal.ncdenr.org/web/wq/ap s.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
/4 Jwd--·
Eric G. Smith, P.G.
Hydrogeologist
cc: urc Pennit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity\ Afiirmattve Action Employer
One
North Carolina
)Vat11rnll11
Beverly Eaves Perdue
Governor
A~A ~,,~~=~=-
NCDENR
North Carolina Department of-Environment and Natural Resources
Division of Water Quality_"'--· .. -
Charles Wakild, P. E.
Director
May 23, 2012
John and Dianne Clark
46 Fearrington Post
Pittsboro, NC 27312
Subject: Notification of Rule Revisions Affecting
Closed-Loop.Geothermal Injecti<:m_Well Permit Holders
Permit Number: WI0500428
Dear Mr. and Mrs. Clark:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May l, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at htt p://portal.ncdenr.or g/web/wg/a ps.
If you have any questions regarding your current permit or the rule revisions, -please feel free to
contact our underground injection control staff at [phone].
Sincerely,
{.) t~ b ,;;;;r
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Aclion Employer
Nirth Carolina
/Vatura/ly
,_Jiaqua drill
· wells • septic • geothermal
Commercial & Residential
February 20, 2012
To Whom It May Concern:
We did not complete a GW-1 form for the John and Diane Clark geothermal project. The Clark well
was an existing 605 ft. 6'" well. After Boer Brothers installed the 1 1/4 inch. HDPE loop pipe to the
bottom of the well, we grouted the bore hole from the bottom to top with thermally enhanced grout
consisting of 1 part Bentonite and 6 parts sand.
This well takes place of the 2 wells that were permitted with application #WI0500428. If you have any
further questions regarding this particular project, please feel free to contact us.
Billy Clayton
www.aquadrillinc.net
Office: [phone] Fax: [phone]
Permit Number WI0500428
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
John & Diane Clark SFR
Location Address
212 Cumberland Rd
Sanford
Owner
Owner Name
John
Dates/Events
NC 27330
Clark
Orig Issue
09/16/11
App Received Draft Initiated
08/26/11
Scheduled
Issuance
Central Files: APS_ SWP_
09/20/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Billy Clayton
4137 Moores Mill Rd
Spencer VA
Major/Minor
Minor
Region
Raleigh
County
Chatham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
John Clark
212 Cumberland Rd
Sanford NC
Public Notice Issue
09/16/11
Effective
09/16/11
24165
27330
Expiration
08/31/16
_R_e~g~u_la_t_e_d_A_c_t_iv_it_ie_s _______________ Re a uested/Received Events
Heat Pump Injection RO staff report requested
RO staff report received
Outfall NULL
Waterbody Name Stream Index Number Current Class
09/08/11
09/15/11
Subbasin
Permit Number WI0500428
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael .rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
John & Diane Clark SFR
Location Address
212 Cumberland Rd
Sanford
Owner
Owner Name
John
Dates/Events
NC 27330
Clark
Orig Issue App Received Draft Initiated
08/26/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Scheduled
Issuance
Central Files: APS_ SWP_
09/14/11
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Billy Clayton
4137 Moores Mill Rd
Spencer VA
MajorfMinor
Minor
Region
Raleigh
County
Chatham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
John Clark
212 Cumberland Rd
Sanford NC
Public Notice Issue Effective
Reauested/Received Events
RO staff report requested
RO staff report received
24165
27330
Expiration
09/08/11
09/14/11
Waterbody Name Stream Index Number Current Class Subbasin
AVA
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 16, 2011
John and Diane Clark
212 Cumberland Rd.
Sanford, NC 27330
Ref: Issuance of Injection Well Permits WI0500428
Issued to John and Diane Clark
Sanford, Chatham County, North Carolina
Dear Mr. and Mrs. Clark:
In accordance with the application received on August 26, 2011, I am forwarding permit number W10500428 for
the construction and operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system to
be 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, including the requirement to install
well identification tags as specified in Part II.3 and to submit well construction records as specified in Part
VIL2. Be sure to read the entire permit to ensure that you are aware of all compliance requirements of the permit.
You will need to notify this office at least 48 hours prior to beginning construction and operation of the injection
well system. In order to continue uninterrupted legal use of the injection facility .for the stated purpose. you must
submit an application to renew the permit 120 days prior to its expiration date. This permit is not transferable to
any person without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or michael.rosers:t encdenr.Uov if you have any questions about your permit.
Best Regards,
r
Michael Rogers, P.G. (NC & FL)
cc: Jay Zimmerman, Raleigh Regional Office
W10500428 Permit File
Chatham County Environmental Health Department
Billy Clayton, Aqua Drill Inc., 4137 Moore's Mill Rd., Spencer, VA 24165 (sent via e-mail)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Lo tion; 272Ei Capita!;3oulevard, Raleigh, North Carolina 27604
Phone [phone]i \ FAX 1:9'.9-715-4558; FAX 2 3ig-715-60451 customer Service: 1-877-023r6748
in;emet: www.ncwaternvalitv.or..
One
No fCaroliyn�a
rar,ai CrotionurvivI Affirm ira k riOT Employer

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
John and Diane Clark
FOR THE CONSTRUCTION AND OPERATION OF 2 TYPE SQM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at 212 Cumberland Rd., Sanford, Chatham
County, NC 27330, and will be constructed and operated in accordance with. the application received August
26, 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 Construction and Operation of an injection well and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its ,issuance until August 31, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 16th day of September, 2011.
~ Coleen H. Sullins, Director
~ bivision of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0500428 UIC/SQM
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 not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number 919 715-6166 and the Raleigh Regional Office Aquifer Protection Section Staff, telephone
number 919-791-4200.
2. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
3. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with ISA NCAC 2C .0213(g).
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as maybe appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit #WI0500428 UIC/SQM
ver. 03/2010
Page 2 of-S
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number 919 715-6166. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
PART VI -INSPECTIONS
1. AI].y duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Division representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
Permit #WI0500428 UIC/SQM
ver. 03/2010
·Page 3 of 5
PART VII -MONITORING AND REPORTING REQIDREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section -UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699
919-791-4200
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Raleigh Regional Office within 30 days of completion
of well construction. Copies of the GW-1 .form(s) shall also be given to the Permittee and retained on site
to be made available for inspection.
3 . A copy of the site map updated with manifold locations required in Part II.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Raleigh Regional Office within 30 days
of completion of well construction.
4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed.
5. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the 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;
(C) Any loss ofrefrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. 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.
7. 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 VIII -PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit #WI0500428 UIC/SQM
ver. 03/2010
Page 4 of 5
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
·for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l).
Notification shall be submitted to the addresses given in Part VII.I of this permit.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not l_imited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.I of this permit.
Permit #Wl,0500428 UIC/SQM
ver. 03/2010
Page 5 of 5
09/14/2011 10:12 9197807159
NCTIWQRRO
PAGE 01/07
FAX COVER SHEET
AVA
NCDENR
M.v.► � µ.+r.i�oc�a
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT
AND NATURAL RESOURCES
Raleigh Regional Office
1625 Mall Service Center
Raleigh, NC 2769E-1625
Pages, including cover sheet 6 U 4-(
TO: �litr�� poce.r5 FAX -7 —4461110
FROM: DATE: 1- 1 - Q 11 1
SUBJECT: W C S 0 C) 2, _ JCS n C! CV 1Z
MESSAGE:
If you do not receive all pages, call 9 t Q. 791, 4290 or fax back to 4 t q - 'MI- t 59
PLEASE NOTE_�!�
THE FAX NUMBER REMAINS THE SAME

09/14/2011 10:12 9197887159 NCDWQRRD PAGE 02/07
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: §!lptember 14, 2011
To: Aquifer Protection Central Office
Central Office Reviewer: Michael Ro gers
Regional Login No: __ _
County: Chatham
Permittee: John Clark
Project Name: SOM Iniection Well
Application No.: WI0500428
L GENERA L INFORMATION
1. This application is (cfi(c~ all that apply): [8] New O Renewal
D Minor Modification D Major Modificatfon
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
0 Surface Disposal
0 503 regulated O 503 exempt
D Closed-loop Groundwater Remediation 181 Other Injection Wells (including in. situ remediation)
Was a site vi.sit conducted in order to prepare this report? l&1 Yes or D No.
a. Dateofsitevisit: 9-13-2011
b. Person contacted and contact information: John Clark , 91 9~533-6090 . 919-593-5133
c. Site visit conducted by: Lin McCartne_y
d. Jnspection Report Attached: 181 Yes or O No.
2. Is the following information entered into the BTh1S record for this application com~ct?
[8J Yes or O No. Ifno, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions: _
c. USGS Quadrangle Map name and number: __
d. Latitude: _ Longitude: __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Disposal and Injection Sites:
(If multip le sites either indicate which sites the information app lies to . CODY and past.e a new section into the
document for each site . or attach add:i,tional pages for each site )
a. Location(s); 212 Cumberland Rd., San ford. NC 27330
b. Driving Directions: Take US-1 S for 39 miles . t.ake the US-l-business/US-15 N/US-5·1/US-1 BR for 6
miles . tum ri gh t onto River Forks Rd .. tum left to stay on River Forks rd., tum ri gh t onto Cumberland.
c. uso·s Quadrangle Map name and number: NIA
d. Latitude: 35~36-45 Longitude: 79-11-13
I[.. NEW AND MAJOR MODIFICATJON APPUCATIONS (this section not needed for renewals or minor
modi(!cations, skip to next section )
Descri pti on OfWaste (S) And Fac.ilities
1. Please attach completed rating sheet. Facility Classification: _
FORM: Staff.Report-Cla:rk-.SQM
09/14/2011 10:12 9197887159 NCDWQRRO PAGE 03/07
AQUIFER PROTECJ'.ION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use: injection
wells, including closed-loop gro1D1dwater remediation effluent iujection wells, in situ. remediatioJJ. it1jection. wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
D Heating/cooling water return flow (5A7)
l8l Closed-loop heat pump system (5QM/5QW)
0 In situ remediation (SI)
0 Closed-loop groundwater remediation effluent injection (SL/''Non-Discharge")
0 Other (Specify; ___J,
2. Does system use same well for water sow.ce and injection? 0 Yes 181 No
3. Are there any potential pollu.tion sources that may affect injection? 0 Yes [8J No
What is/are the pollution source(s)?
4. What is the minimum distance of proposed injection wells from the property boundary? 114 ft.
S. Quality of drainage at site: ~ Good O Adequate D Poor
6. Flooding potential of site: 12:1 Low D Moderate O High
7. For groundwat.er remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, mon1toring parameters, etc.) adequate? 0 Yes D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundw.\lter monitoring program: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? t8J Yes or O 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 pUIIlp 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 ~No. If yes, explain:
2. For closed-loop beat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes 181 No. If yes, expJain:
3. For renewal or modification of groundwater remediation permits (of any type), wlll
continued/additional/modified injections have an adverse impact on xni&1:ation of the plume or management of
the conta.mination incident? D Yes O No. If ves. exQlain:
4. Drilling contractor: Name: Billy Clayton
FORM: Sta.ff.Rcport-Clai:k:-5QM 4
09/14/2011 10:12 9197887159 NCDWQRRD
AQUIFER PROTECTION REGIONAL STAFF REPORT
Address:
413 7 Moores Mill Rd., Spencer , VA 24165
Certification number: 2839-A
5. Complete and. attach Well Constnicti.on Data Sheet.
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the app1ication.:
2. Attach Well Construction Data Sheet -if needed information is available
PAGE 04/07
3. Do you foresee any problems with issuance/renewal of this permit? D Yes CEJ No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional infonhation request.
Make sure that you provide a reason for each item:
Item Reason
S. List specific Permit conditions that you recommend to be removed from the pennit 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 pennit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
FORM: Staff.Report-Clark-SQM s
09/14/2011 1e:12 9197E97159 NCDW❑RR❑ PAGE 05/07
AQUIFER PROTECTION REGIONAL STAFF REPORT
7. Recommcr lotion: ❑ .Hold, pending receipt and review of additional information by regional office; E Hold,
pcndiszg review of draft permit by regional office; Q Issue upon receipt of needed additional information;
Issue; Deny, If deny, please state reasons:
,
8. Signature of report preparer(s): r+
Signature of APS regional supervisor;
Date: `i/, q2I[
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
A pre -permitting inspection was conducted on September 13, 2011.
Two borings were proposed to construct with depth of 330 feet. The permittec proposed to use the
existing dry well, which previously was intended to be used as a water supply well, as one of the
two borings.
A review of the construction data indicates that the proposal to construct the well meets the
infection well construction criteria in accordance with N.C. State Regulations (Title 15A NCAC
2C), Well Construction Standards.
The following items were checked:
Type of tubing: HDPE
Existing well —cased with PVC, grouted to 60 feet with cement
The other well will not be cased, grouted to 330 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
The well driller is waiting for a permit to start construction. The driller's name:
Billy Clayton, phone: [phone]
FORM: Staff Report-Clark-SQM. 6

09/14/2011 10:12
Permit:· WI0500428
SOC:
County: Chatham
Region: ~leigh
9197887159
Effective:
Effective:
Contact Person: Billy Clayton
Directions to FacJJlty:
Systam Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Represantatlva(s):
Rolalad Pennlts:
NCDWQRRD
Compliance Inspection Report
Expiration:
Expiration:
Tltla:
Certification:
Owner: John Clark
Facility: John & Diane Clark SFR
212 Cumberland Rd
Sanford NC 27330
Phone: [phone]
Phone:
Inspection Data: 09/13/2011
Primary Inspector; Lin Mccartney
Secondary lnspec:tor(s):
Entry Time: 02:00 PM Exit Time: 03:30 PM
Phone: [phone]
Ext.4243
Reason for Inspection: Routine Inspection Typo: Compliance Evaluation
Permit Inspection Type: Injection Mixed Fluid GSHP Well System (5QM)
Faclllty Status: ■ Compliant D Not COmpllant
Question Areas:
■Other
(See attachment summary)
PAGE 06/07
Page: 1
09/14/2011 10:12 9197887159 NCDWQRRO
Permit: WI0500428
Inspection Dato: 09/13/2011
lr11sper;tlon Summary:
Owner • F111Cllfly: JQhn Cl8fk
Inspection Typ•: Compliance EvaJ1.13tlon
A Pre-permitting inspection was conducted on September 13, 2011.
PAGE 07/07
Raason for Visit: Routlnl!I
Two borings were proposed to construct with depth of 330 feet. The permittee will use the existing dry well, which
previously was intended to be used as a water supply well, as one of the two borings.
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. S~te Regulations (Title 1'5A NCAC 20), Well Construction Standards.
The following items were checked:
Type of tubing: HDPE
Existing well-cased with PVC, grcuted from surface to 60 feet with cement
The other well will not be cased, grouted to 330 feet with cement.
Other
Comment;
Yes No NA NE
Page: 2
Rogers, Michael
From:
Sent:
To:
Aqua Drill/Dana Clayton [aquadrill@hughes .net)
Wednesday, September 07, 2011 9:30 AM
Rogers, Michael
Subject: Re : Clark geothermal construct app
John Clark's cell phone number is 919-593-5133 and his home number is 919-533-6090. Thanks again.
Dana Clayton
----Original Message ---
Fro111:. Roqers . M ichael
To: A q ua Drill/Dana Clayton
Sent: Friday, September 02, 2011 4:09 PM
Subject: Clark geothermal construct app
Okay thanks. Also, we just received an application for Clark. What is the phone number for the Clarks?
Also, just to confirm-there will be 2 closed loop geothermal wells utilizing ethanol as an additive, and one proposed
water supply well. One of the geothermal Wells is cased to 60 feet and the other will not be cased. But, both will be
grouted top to bottom-is that correct?
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/wg/aps/gwpro/penn it-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
From: Aqua Drill/Dana Clayton [mailto:[e-mail]]
Sent: Friday, September 02, 2011 9:06 AM
To: Rogers, Michael
Subject: 11 Prentiss Pl, geothermal construct app
Mr. Rogers,
I am resending the geothermal permit application for 11 Prentiss Place/Godrich Home. I am not sure what happened
during the faxing process but I apologize for the inconvenience. Hopefully the scanned copy will be more legible. Thank
you for your help with this matter. If there are any further questions, please feel free to contact me.
Dana Clayton
1
Rogers, Michael
From:
Sent:
Aqua Drill/Dana Clayton [[e-mail]]
Sunday, September 04, 2011 9:51 AM
To: Rogers, Michael
Subject: Re: Clark geothermal construct app
Everything you typed below is correct regarding the Clark Site . I will forward the Clark's phone number to you soon.
Thank you again for all your help . Hope you have a great Labor Day.
Dana Clayton
----Original Message --
From: Ro g ers . Michael
To: A qua Drill/Dana Clayt on
Sent: Friday, September02, 2011 4:09 PM
Subject: Clark geothermal construct app
Okay thanks. Also, we just received an application for Clark. What is the phone number for the Clarks?
Also, just to confirm-there will be 2 closed loop geothermal wells utilizing ethanol as an additive, and one proposed
water supply well. One of the geothermal Wells is cased to 60 feet and the other will not be cased. But, both will be
grouted top to bottom-is that correct?
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Rale igh , NC 27699-1636
Direct Line [phone] ; Fax [phone] (put to my attn on cover letter)
http ://portal .ncdenr.org /web/v:;q/aps/tjwpro/permit-applications#qeothermApps
E -mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Aqua Drill/Dana Clayton [mailto:aq uadrill @hu g hes.net]
Sent: Friday, September 02, 2011 9:06 AM
To: Rogers, Michael
Subject: 11 Prentiss Pl, geothermal construct app
Mr. Rogers,
I am resending the geothermal permit application for 11 Prentiss Place/Godrich Home. I am not sure what happened
during the faxing process but I apologize for the inconvenience. Hopefully the scanned copy will be more legible. Thank
you for your help with this matter. If there are any further questions, please feel free to contact me.
Dana Clayton
1
Ro g ers, Michael
From: Rogers, Michael
Sent:
To:
Friday, September 02, 2011 4:10 PM
'Aqua Drill/Dana Clayton'
Subject: Clark geothermal construct app
Okay thanks. Also, we just received an application for Clark. What is the phone number for the Clarks?
Also, just to confirm-there will be 2 closed loop geothermal wells utilizing ethanol as an additive, and one proposed water
supply well. One of the geothermal Wells is cased to 60 feet and the other will not be cased. But, both will be grouted
top to bottom-is that correct?
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/gwpro/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
From: Aqua Drill/Dana Clayton [mailto:[e-mail]]
Sent: Friday, September 02, 2011 9:06 AM
To: Rogers, Michael
Subject: 11 Prentiss Pl, geothermal construct app
Mr. Rogers,
I am resending the geothermal permit application for 11 Prentiss Place/Godrich Home. I am not sure what happened
during the faxing process but I apologize for the inconvenience. Hopefully the scanned copy will be more legible. Thank
you for your help with this matter. If there are any further questions, please feel free to contact me.
Dana Clayton
1
'JJ;A
NCDE MR
North Carolina Department of Environment and Na tural Resources
Division of Water Quality
Beve rly Eaves Perdue
Governor
John Clark
Diane Clark
212 Cumberland Road
Sanford, NC 27330
Dear Mr. and Mrs. Clark:
Co leen H. Sullins
Director
September 7, 2011
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI0500428
John & Diane Clark SFR
Injection Mixed Fluid GSHP
Well (SQM) System
Chatham County
The Aquifer Protection Section acknowledges receipt of your pennit application and supporting
documentation received on August 26, 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] or [e-mail].
Sincerely,
for~~•~
Groundwater Protection Unit Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Billy Clayton-Aqua Drill, Inc -4137 Moores Mill Road, Spencer, VA 24165
Bryan Boer -Boer Brothers Heating & Cooling -104 R Hwy 54W #333 , Carrboro, NC 27510
Pennit File WI0500428
AQUIFER PROTECTION SECTlrnJ
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www .ncwate mualitv.om
An Equ;:.i Oppofii;ni:1 \ A'iirma:ive Action Ern ployer
NOnel c· J' ortn aro .ma
Jvatural!y
2011-08-26 09;35 AQUA DRILL 2769571705»
P 1/11
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Aceorttanca With the Provis[ons of 1 SA NCAC 02C .0200
CLOS L.OQP ht1 -FLUID GEOTHERMAL INJECTION WELLS
These wells circulate other than potable water as pe,r t of 5 otherntal heating and mating system
(check one) Now Application Ronowai* Modification
' For renewals (*mptete Parts A-C and the sigtnaccnrz page.
print or 7)7pe Information and .kfaI( to the ,4ddret1 on Our La si Page. II e e pplrcarlasa Will Be Returned AS incomplete.
DATE: ,fia C 2- 7-- 20 if
PERMIT NO. V L S W 902, $ (leave blank if New Application)
A. STATUS OF APPLICANT (Cheese one)
Non -Government Individual Residence Business/Organization
Government: State Municipal County Federal
& PERMIT APPLICANT - For individual residences, list ogb owner on property deed. For all ethers,
state name of entity tllid name of person delegated autherity to sign on behalf of the business or agency:
1f o (fee
Mailing Address: 2- 1 Z' C u ed-4 Ad/4e ie.4
City: F7'- ' State:N4-. Zip Code: 2.73JO county:_cAlew I
Day Tele No.: - — 609 Ceti No,: Cif
EMAIL Address: Fax No
C. LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel identification Number (MN) of wall site: 7 S 350 county: C i' f i"1
(2) Physical Address (if different than mailing address): , . ( I.Att4ig .e -/ /21
City. � r. �cti: Lir
State: Zip Code: 9 -
D, WELL DRILLER INFORMATION
Well Chilling Contractor's Name: 434-SAI L'6Y
NC Well Drilling Contractor Certification No,: 2--b 3 /9
Company Name: /9621/4, tC( r..IC,
Colttaci Perion: /4-C: > Ce.'7u4rf EMAIL Addtrsss: a -a o feagle,t.tt� "S! 'UCr`
Address: 4/ 1 1 /11h (f 00.if t a ,E
City: 5,61/C64- ZIP Code: 2-29'05- Stew VI County: '7Ert.'4'
Office Tele No.: ?3 -767' 1074 7 cell No.: d = 3 r -o S` Dix No.; (7C) -- 9)'6/
MIMIC 3QM Parmit Application (Revlted 1r2412011) Papa I
1u CAR- 77 17• J n
Paco 1

2011-08-26 0935 AQUA D9II-L 2769571705 »
P 2111
a HEAT PUWPCONTRACTORINFORNIATKIN (if different than driller)
Cowley Marna:_ Q e,r t5,l 7+ J 6 - Co'' 1;
Contact Paean: 'NI�a �.J EMAIL AA ess:
Adders:8fic,:(6,...
ikW y 5 Li k4
City: ili�`f'l a+I G Zip Code: `7 l�'� . : County: (� t�Rr.> t �.
Office Tele No.: 11 - 1 & - 9 R Cei l No,: q G 11- / 7 Fax No.: 3
I . WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: Depth of each boring (het): . 30
' If existing water wells will be used Oren provide the ir{forr►rarforr f►r ROM {ail below.
(2) Chemical additives to be used: R-22 Propylene glycol Ethanol a%'
Other (other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): de/t
(4) Well casing. If the well(s) will use casing then provide the tam (steel, PVC, plastic, ate.), themmer. sleg,
and MO of casing appeering above ground: CLIrT/11WELL- - C#Jere ir 6/7c 601
Of� ESL vtfa Gw� C AX'? C ffe
(5) Grout (material surrounding well casing and/or piping):
(a) [trout type: Cement 4"/ $erttonita tester (specify) f yr:; -41i
" By oleo int wanamb goat, a his hereby ngoaea Icci l01 iA NCAC 2C .42I3(4X ! KA , which squn.i i cocoa type grwt
(b) Grout depth of tubing (reference to land surface): from to 3.10 (font)
If wel l has casing. indicate grout depth: from .10 FC _ (fret)
G. WELL LOCATIONS - Maps must be soled or otherwise accurately indicate (Wane and nricntaations of
filatures ures located within 1000 feet of the Injection wel I(s). Label all features 9Jearir and include a MTh .a!
(t)
Attach a site -Specific map shim Mg the locations of the following:
• Proposed Injection wells
* Surface water bodies
' Buildings * Property boundaries
* Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
' Existing or potential sources of groundwater contamination
Attach e topographic map of the area extending t14 mile from the injection well site that indicates the
facility's Location and the map name,
NOTE: I wort maw, nee aerial of to property parcel showhrg property fibres surd sttbtakre3 cam be
obtah,ed need download* frost the ppplksbto away GL4 webalte. lyplaally, rti: praalpsrty can be searched by
maw same err address. The loci** of the walls la relation a!v property 6eatardarier, home, septic may, other
welt& m cam Ikea be drown in by kool Abel, a ley"' Car be selected sbo rtrg topogruphk c iitoors or
eiewirksw dal&
PIY l IC 5QM remit Application (Rowland 1/24/201 I) Page 2
701i.ayL?7 19'A1
Panda 717

2011-08-26 0135 AQUA DRILL 2769571705 »»
P 3111
H. CERTIFICATION (to be signori as required below or by that per on's authorized agent)
I SA NCAC 02C .1211(b) s cquires that all perrnk 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 s municipality or s stele, federal, or oth r public agency: by either a principal executive
officer or ranking publicly sleeted official;
4, for all others: by the well owner listed oo13>ell-mew deed),
If as astborksd Kart is sigaist Of behalf of the applicant, ties supply a tatter signed by the
applkast that anises sad authorises their agent to alp this application on their behalf.
"t hereby certify, under penalty of law, that I have personalty examined and am familiar with the information
wbmltted in this document and all attachments thereto and that, based on my Inquiry of those individuals
immediately responaibie for obtaining said infrmadon, t believe that the information is nue, acouratc and
complete. I am aware that there sae siganiflcant penalties, including the possibility alines 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."
of Property Owner/Applicant
Print or Tyne Pull Name
,dAL-
Signature of Property Owncr/Applicant
Ja
Print or Typo Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mali Service Center
Raleigh, NC 27699.1636
7550
Telepbone [phone]
GPU/IJ C 5QM Patel[ Awplicathors (Rented V2401011) Pin 3
'011_15_11 11.11

2011.4$-25 09:35
AOUA DRILL 2759571705 ?>
P 4111
V f
go 4-
-1,(6'g-mob
L

2011-08-26 09:36
AQUA DRILL 2769571705 >a
P 5111
rww
;f'��:?ice
CHATHAM COUNTY, NC
Property Map
•n en rn RPM hi I. Fen% eeefa•TO na c Mn
alIMIC c_• _ev
01.1C al wWng1.4 +else-emsnr mw perm .e•
rM im 71sb e4rnteml ni FrFMLre,..1 wadi rr Y MAMMA.
be atae.wv Fier WW *W1, e.w rrgweueen
Ore Inch = f0l?feci
RECEIVED 1 DENR 1 DWQ
AOUIFPR
AUG 262011

DATE,TIME
FAX NO./NAME
DURATION
PAGE(S)
RESULT
MODE
TRANSMISSION VERIFICATION REPORT
09/15 14:03
913367679761
00:01:46
04
OK
STANDARD
ECM
TIME 09/15/2011 14:05
NAME
FAX
TEL
SER.# BROL0J225274
A.TA
NCD ENR
RECEIV~D / DENR / DWQ
Aquifer Protection Seetion
SEP 16 2011
Nmih Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Division of Water Quality
Coleen H. Sullins
Director
September 14, 2011
MEMORANDUM
To:
Through:
From:
Michael Rogers, The Central Office, APS
Jay Zimmerman
Lin McCartney
Dee Freeman
Secretary
Subject: Staff Report-WI0500428, John Clark, SQM Geothermal Well
Chatham County
Aquifor Protection Section
1628 Mail Service Center, Raleigh, North Carolina27699-1628
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
Oneh 1. N art Caro 1na
;vaturalllf
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: Se ptember 14 , 2011 ReGEIV~U I OENR / OWQ Aquifer ~rotectlon S . ~ounty: Chatham
To: Aq uifer Protection Central Office
Central Office Reviewer: Michael Ro gers
erm1ttee: John Clark
SE:PpAA ea : ame: SO M In iection Well
Regional Login No: __ _ Application No.: WI0500428
L GENERAL INFORMATION
1. This application is (check all that apply): IZJ New D Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
□ 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 IZJ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IZJ Yes or D No.
a. Date of site visit: 9-13-2011
b. Person contacted and contact information: John Clark, 919-533-6090, 919-593-5133
c. Site visit conducted by: Lin McCartney
d. Inspection Report Attached: IZJ Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
IZJ 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 Dis posal and In jection Sites:
(If multiple sites either indicate which sites the information a pp lies to . copy and paste a new section into the
document for each site. or attach additional pa ges for each site)
a. Location(s): 212 Cumberland Rd .• Sanford, NC 27330
b. Driving Directions: Take US-1 S for 39 miles . take the US-l-business/US-15 N/US-5-1/US-l BR for 6
miles . turn right onto River Forks Rd .• turn left to stay on River Forks rd., turn ri ght onto Cumberland.
c. USGS Quadrangle Map name and number: N/A
d. Latitude: 35-36-45 Longitude: 79-11-13
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed fo r renewals or minor
modifi cations1 skip to next section )
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
FORM: Staff.Report-Clark-SQM 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:
D Heating/cooling water return flow (5A7)
[gl Closed-loop heat pump system (SQM/SQW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes
3. Are there any potential pollution sources that may affect injection? D Yes
What is/are the pollution source(s)?
[gj No
[gjNo
REC_EIVED I DENR / DWQ
Aquifer Protection Section
SEP 15 20ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 114 ft.
5. Quality of drainage at site: [gl Good D Adequate D Poor
6. Flooding potential of site: [gl 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: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? [8] 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 Onl y:
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 [gl 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 [gl No. If yes . exp lain:
3. For renewal or modification of groundwater remediation permits (of any typ e). will
continued/additional/modified in jections have an adverse impact on mi gration of the p lume or management of
the contamination incident? D Yes D No. If yes . ex plain:
4. Drilling contractor: Name: Billy Clayton
FORM: Staff.Report-Clark-SQM 4
AQUIFER PROTECTION REGIONAL STAFF REPORT
Address:
4137 Moores Mill Rd., Spencer, VA 24165
Certification number: 2839-A
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 IZ! 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-Clark-SQM 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: q/, ofI
ADDITIONAL REGIONAL STAFFREVIEWITEMS
A pre -permitting inspection was conducted on September 13, 2011.
Two borings were proposed to construct with depth of 330 feet. The permittee proposed to use the
existing dry well, which previously was intended to be used as a water supply well, as one of the
two borings.
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:
Type of tubing: HDPE
Existing well —cased with PVC, grouted to 60 feet with cement
The other well will not be cased, grouted to 330 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
The well driller is waiting for a permit to start construction. The driller's name:
Billy Clayton, phone: [phone]
FORM: Staff.Report-Clark-5QM 6

Permit:· WI0500428
SOC:
County: Chatham
Region: Raleigh
Effective:
Effective:
Contact Person: Billy Clayton
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 09/13/2011
Primary Inspector: Lin McCartney
Secondary lnspector(s):
Reason for Inspection: Routine
Compliance Inspection Report
ExplraUon:
Expiration:
Title:
Owner. John Clark
Facility: John & Diane Clark SFR
212 Cumberland Rd
Sanford NC 27330
Phone: [phone]
Certification: Phone:
Entry Time: 02:00 PM Exit Time: 03:30 PM
Phone: [phone]
Ext.4243
Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Mixed Fluid GSHP Well System (5QM)
Facility Status: ■ Compliant O Not Compliant
Question Areas:
■Other
(See attachment summary)
Page: 1
Permit: WI0500428
Inspection Date: 09/13/2011
Inspection Summary:
Owner -Facility: John Clark
Inspection Type: Compliance Evaluation
A Pre-permitting inspection was conducted on September 13, 2011.
Reason for Visit: Routine
Two borings were proposed to construct with depth of 330 feet. The permittee will use the existing dry well, which
previously was intended to be used as a water supply well, as one of the two borings.
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 1'5A NCAC 2C), Well Construction Standards.
The following items were checked:
Type of tubing: HOPE
Existing well-cased with PVC, grouted from surface to 60 feet with cement
The other well will not be cased, grouted to 330 feet with cement.
Other
Comment:
Yes No NA NE
Page: 2