WI0500481_GEO THERMAL_20120523

Beverly Eaves Perdue
Governor
NA
NC DE ~R
North·Carolina Department of Environment and NaturaLRes_ources
Division of Water Quality
Charles Wakild, P. E.
Director
May 23, 2012
Ashley Pessagno
235 Buck Branch Road
Pittsboro, NC 27312
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geotherm~ Injection Well Permit Holders
Permit Number: WI0500481
Dear Ms. Pessagno:
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 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 Quality. You
may view the revised rules on our website at http ://portal.ncdenr.org/web/wq /ap s.
If you have any. questions reg~_ding your cunent permit or ~he fl:lle revisions, ple_ase. feel free to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC 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.ncwaterquality.org
An ~qual Opporlunily \ Af.irmative Action Employer
Nirth Carolina
;Vatura!l11
Permit Number W10500481
Central Files: APS SWP
03/13/12
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Primary Reviewer Permit Contact Affiliation
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Ashley Pessagno SFR
Location Address
235 Buck Branch Rd
Pittsboro
Owner
Owner Name
Major/Minor Region
Minor Raleigh
County
Chatham
NC 27312 Facility Contact Affiliation
Owner Type
Individual
Ashley Pessagno Owner Affiliation
Ashley Pessagno
Elates/Events
Orig Issue App Received Draft initiated
03/02/12 02/14/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Scheduled
issuance
PO Box 1302
Pittsboro
NC 27312
Public Notice Issue Effective Expiration
03/02/12 03/02/12 02/28/17
Re:'uestedlReceived Events
RO staff report requested 02/16/12
RO staff report received 02/28/12
Waterbody Name Stream Index Number Current Class Subbasin

L--
NCDENR
North Carolina department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
March 2, 2012
Ashley Pessagno
Post Office Box 1302
Pittsboro, NC 27312
Ref: Issuance of Injection Well Permits WI0500481
Issued to Ashley Pessagno
Pittsboro, Chatham County, North Carolina
Dear Mr. Pessagno:
In accordance with the application received on February 14, 2012, I am forwarding permit number WI0500481 for the
construction and operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system to be located
at 235 Buck Branch Road, Pittsboro, Chatham County, NC 27312. This permit shall be effective from the date of
issuance until February 28, 2017, and shall be subject to the conditions and limitations stated therein, including the
requirement to install well identification tags as specified in Part II. 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 eric.g.smithialncdenr.Yov if you have any questions about your permit.
Best Regards,
Eric G. Smith, F.G.
cc: Jay Zimmerman, Raleigh Regional Office
W1050048 I Permit File
Chatham County Environmental Health Department
James Darby, Jr.; James Darby Well Drilling, LLC; 2512 Zinker Road, Rock Hill, SC 29732
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; 919.807.6496
Internet: www.n terq &lity.org
An 'alai; Opportunity 1 Affirmative khan Employer
Non5aturaUj
thCarolina

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
Ashley Pessagno
FOR THE CONSTRUCTION AND OPERATION OF 3 (THREE) TYPE 5QM INJECTION WELL(S),
defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a
vertical closed loop geothermal mixed fluid heat pump system. This system is located at 235 Buck Branch
Road, Pittsboro, Chatham County, NC 27312, and will be constructed and operated in accordance with the
application received February 14, 2012, 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 February 28, 2017, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 2'd day of March, 2012.
klCharles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #W10500481
UIC/5QM
ver. 03/2Qi0
Page 1 of 5

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Peimittee 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 }lrotection 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 919-807-6406 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 pem1it amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3 . The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances , which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit #WI0500481 UIC/SQM
ver . 03/2010
Page 2 of 5
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. t
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 Pennittee 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 919-807~6406. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine ifit is in compliance with permit
conditions.
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, eriter 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 #WI0500481 UIC/SQM
ver. 03/2010
Page 3 of 5
PART VII — MONITORING AND REPORTING REQUIREMENTS
All required documentation shall be submitted to:
Aquifer Protection Section — UIC Program
DENR — Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Ph# 919-715-3221
and
Aquifer Protection Section
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
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 11.2 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)
(B)
(C)
(D)
Any occurrence at the injection facility that results in any unusual operating circumstances;
Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
Any loss of refrigerant in the system, regardless of the origin of the loss;
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 #tWI0500481
U IC/5QM
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.1 of this permit.
2. When operations have ceased at the facility and a well will no longer be used · for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in ISA NCAC 2C
.0214, including but not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water. ·
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(E) In: the case of gravel-packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII. I of this permit.
Permit #WI0S00481 UIC/SQM
ver. 03/2010
Page 5 of 5
Smith, Eric
From: Smith, Eric
Sent:
To:
Monday, February 27, 2012 9:32 AM
Mccartney, Lin
Subject: RE: Geothermal Inspection for WI0500481
Un:
Did you send over the site inspection report?
-Eric G. Smith
Eric G. Smith, P.G.
Hyd rogeologist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
919-807-6407
919-807-6496 Fax
http://portal.ncdenr.org/web/wq/aps
DISCLAIMER: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties.
From: Mccartney, Lin
Sent: Monday, February 27, 2012 9:14 AM
To: Smith, Eric
Subject: RE: Geothermal Inspection for WIOS00481
Eric,
Yes, l did the site inspection.
Lin
From: Smith, Eric
Sent: Monday, February 27, 2012 8:46 AM
To: Mccartney, Lin
Subject: Geothermal Inspection for WI0500481
Lin:
Have you performed the site inspection for geothermal permit WI0500481 (Pessangno)?
-Eric G. Smith
1
Smith, Eric
From: Zimmerman , Jay
Sent:
To:
Thursday , February 16 , 2012 4 :47 PM
Smith, Eric
Subject: RE: WI0500481 5QM Application
1111 ask Un McCartn ey to conduct a pre-permit inspectio n and submit a staff report.
From: Smith, Eric
Sent: Thursday, February 16, 2012 1:S4 PM
To: Zimmerman, Jay
Subject: WIOS00481 SQM Application
Jay:
Since Mike Rogers is out for a few weeks, I'll be assisting with SQM permits. This is my first email of this type, so if you
need anything else, let me know.
Attached is a SQM application we received 2/14/12. Do you want to do a pre-permitting inspection?
-Eric G. Smith
Eric G. Smith, P.G.
Hyd rogeo logist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
919-807-6407
919-807-6496 Fax
http://portal.ncdenr.org/web/wq/aps
DISCLAIMER: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties.
1
41,4
MCDEMR
North Carolina Department of Environment and Natural Resources
Governor
Ashley Pessangno
PO Box 1302
Pittsboro, NC 27312
Dear Ms, Pessangii :
Director Secretary
February 14, 2012
Subject: Acknowledgement of
Application No. W10500481
Ashley Pessangno SFR
Injection Mixed Fluid GOP
Well (5QM) System
Chatham County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on February 14, 2012. 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 hi
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 michael.rogers[a7ncdenr.gov.
Sincerely,
for Debra J. Wat{s
Groundwater Protection Unit Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
James Darby — James Darby Well Drilling, LLC
Permit File W10500481
l i1v;-
1636 hda[I Service Center, Raleigh. North Carolina 27689.1636
Location: 512 N. Salisbury St., Raleigh, Norlh Carolina 27604
Phone: 919$e7.64641 FAX 919.8Q7.6496
Internet www.ncwaternua[Ity.org
An Equal Opportunity 1 Affirmativs Action Employer
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NorthCarolina
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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 .0200
CLOSED-LOOP MIXED-FLUID GEOTHERMAL INJECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system
(check one) _X_New Application Renewal* ---Modification
* For renewals complete Parts A-C and the signature page.
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete .
DATE: 1/30 20 12
PERMIT No.~Q5Qn--f5/ (leave blank if New Application)
'-)
-q
1
J
A. STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence X Business/Organization __
Government: State Municipal__ County__ Federal
B. PERMIT APPLICANT -For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
Ashley Pessangno ______________________________ _
Mailing Address: PO Box 1302 __________________________ _
City: Pittsboro State: _NC_ Zip Code:27312 County: Chatham
Day Tele No.: -----=9--=1~9--=-2~7-=-0--=-0"""1""'1=---5 -----------=C"""e=ll-=-N"""o'"".:'--_~S=am=e ______ _
EMAIL Address: __ ~A~s~h_le~y~f@._. . ._pc~e_a~ss~o~c1~·a~te~s _.c_o=m'-----------~F~ax~N~o~.: _____ _
· C. LOCATION OF WELL SITE -Where the injection wells are physically located:
(I) Parcel Identification Number (PIN) of well site __ 2001-3 IO __ County: Chatham
(2) Physical Address (if different than mailing address): ----=2=3=5--=B=u=c=k'----"B=r=a=nc=h=---R:..a.=d ______ _
City: Pittsboro State: NC Zip Code: ~2~73~1~2'-----
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: __ __._J=am=es"-'D=ar=b--'--=--J=---r _________________ _
NC Well Drilling Contractor Certification No.: ---~2=6~0~6 _______________ _
Company Name: James Darbv Well Drilling LLC
Contact Person."-: ---=J am=e=s"-'D==ar=b_,_v-=-J=---r ------=E=MA=-=cIL=cA~d=dr=e=ss"-'-: i=a=m'-"e""sd:::ar:e.b""-'--'w'-'-e=l~l@;;:,~!!=moo:a=il.:.::.cc.:a:co=m
Address: ______ 2=5~1=2~Z=i=n=ke=r~R=d~-----------------------
City: Rock Hill Zip Code: 29732 State: SC County: ___ Y~o=r=k'--
Office Tele No.: 803-329-2424 Cell No.: 803-415-1853 __ Fax No.: 803-329-4935
GPU/UIC 5QM Permit Application (Revised 1/24/2011) Page I
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: __________________________________ _
Contact Person . .,_: -------'P'-'r,..,,o"'pc:,:e-'--'rt'-'-v....::O::..w.:..:..::n=er"--------------'E=MA==IL~A'--=-=d=d=-cre=s=s '-: ___________ _
Address: ___________________________________ _
City: Zip Code: ____ State: __ County:
Office Tele No.: _________ Cell No.; __________ ~F=ax~N~o~.'-: _______ _
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: ___ 3 ___ Depth of each boring (feet): __ 335 ____ _
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Chemical additives to be used: R-22 __ _ Propylene glycol _x __ Ethanol __ _
Other _________ (other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): _HDPE Plastic (Black Pipe) ________ _
(4) Well casing. If the well(s) will use casing then provide the !Yill?, (steel, PVC, plastic, etc.), diameter, depth,
and extent of casing appearing above ground: __ NIA __
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** _x_ Other (specify) _______ _
** By selecting bentonite·grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from _O __ to _335 __ (feet)
If well has casing, indicate grout depth: from _O __ to __ 335 __ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearl v and include a north arrow.
(I) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. 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.
GPU/UIC 5QM Permit Application (Revised 1/24/201 I) Page 2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .02ll(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3 . for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the pro pe rtv deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law , that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit" ~ /47, _
Si gnatureof.perty Owner/;e pplicant
_Ashley Pessagno ---------------
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:
DWQ -Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU /UIC SQM Permit Application (Revised 1/24/2011) Page3
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
February 23, 2012
MEMORANDUM
To: Michael Rogers, The Central Office, APS
Through: Jay Zimmerman
From: Lin McCartney
Subject: Staff Report for Ashley Pessangno, W10500481, Chatham County
Aquifer Protection Section
1628 Mail Service Center, Raleigh, North Carolina 27699-1628
Location: 3800 Sairett Dr., Raleigh,, North Carolina 27609
Phone: 919-79 i-42001 FAX: [phone] Customer Service: I-g77-623-6748
Inien,et: www.ncwaterquality.ora
An Equal Opportunity 1 Affirmative Action Employer
NorthCarolina
Naturally

AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: Februarv 22 , 2012
To: A quifer Protection Central Office
Central Office Reviewer: Michael Ro gers
Regional Login No: __ _
County: Chatham
Permittee: Ashley Pessangno
Project Name: SQM Injection Well
Application No.: WI0500481
L GENERAL INFORMATION
1. This application is (check all that apply): ~ New D Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation ~ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ~ Yes or D No.
a. Date of site visit: 11-07-2011 r \
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b. Person contacted and contact information: Ashle y Pessan gn o , 919-270-0115 ,",.)
c. Site visit conducted by: Lin McCartne y -.J
d. Inspection Report Attached:~ Yes or D No. ....
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2. Is the following information entered into the BIMS record for this application correct? • . .J
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~ Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Disposal and Injection Sites:
(If multi ple sites either indicate which sites the information a pp lies to . co py and paste a new section into the
document for each site . or attach additional pa ges for each site)
a. Location(s): 235 Buck Branch Road , Pittsboro . NC 27312
b. Driving Directions: Take US-1 S for 11.6 miles . merge onto US-64 W via 98B toward Pittsboro for 22
miles . merge US-15 N/US-501 N via Exit 383 for 4 miles , turn left Hamlets Chapel Rd., Tum ri ght onto
Buck Branch.
c. USGS Quadrangle Map name and number: NI A
d. Latitude: 35-48-17 Longitude: 79-07-44
e. II. NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section)
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
FORM: Staff.Report-Ashley Pessangno-2 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)
~ Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5L/"Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes ~ No
3. Are there any potential pollution sources that may affect injection? D Yes ~ No
What is/are the pollution sotirce(s)?
4. What is the minimum distance of proposed injection wells from the property boundary? 150 feet
5. Quality of drainage at site: ~ Good D Adequate D Poor
6. Flooding potential of site: ~ 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)?~ Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal And Modification Onlv:
1. For heat pump systems, are there any abnormalities in ,heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes ~ No. If y es . exp lain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes ~ No. If v es, ex plain:
3. For renewal or modification of groundwater remediation permits (of any typ e), will
continued/additional/modified injections have an adverse imp act on migration of the plume or management of
the contamination incident? D Yes D No. If y es , exp lain:
1. Drilling contractor: Name: James Darby
FORM: Staff.Report-Ashley Pessangno-2 4
AQUIFER PROTECTION REGIONAL STAFF REPORT
2. Address:
2512 Zink.er Road , Rock Hill , SC 27932 , 803-329-2424
Certification number: 2606
3. Complete and attach Well Construction Data Sheet.
V . EVALUATION AND RECOMM:ENDATIONS
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 C8J 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-Ashley Pessangno-2 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; ~
Issue; D Deny. If deny, please state reasons: __
8 . Signature of report preparer(s): d.· n. oY\ l {.._ { ./--~
Signature of APS regional supervisor: ~
Date: i/z.1/2,,-, /k:
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
A pre-permitting inspection was conducted on February 22, 2012.
Three borings were proposed to construct with depth of 335 feet. Borings will be vertically drilled.
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:
Grout type: bentonite; grout depth: from O feet to 335 feet
Chemical additives to be used in closed-loop system: Propylene glycol
We recommend that the Central Office proceed to issue the applicant a permit for geothermal well
construction so that the contractor could start construction.
FORM: Staff.Report-Ashley Pessangno-2 6
Permit: WI0500481
SOC:
County: Chatham
Region: Raleigh
Effective:
Effective:
Contact Person: James Darby
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative( s ):
Related Permits:
Inspection Date: 02/22/2012
Primary Inspector: Lin McCartney
Secondary lnspector(s):
Reason for Inspection: Routine
Compliance Inspection Report
Expiration:
Expiration:
Title: Well Driller
Certification:
Owner: Ashley Pessagno
Facility: Ashley Pessangno SFR
235 Buck Branch Rd
Pittsboro NC 27312
Phone: [phone]
Phone:
Entry Time: 10:30 AM Exit Time: 11 :30 AM
Phone: [phone]
Ext.4243
Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Mixed Fluid GSHP Well System (5QM)
Facility Status: ■ Compliant D Not Compliant
Question Areas:
■Other
(See attachment summary)
Page: 1
Permit: WI0500481
Inspection Date: 02/22/2012
Inspection Summary:
Owner• Facility: Ashley Pessagno
Inspection Type: Compliance Evaluation
A Pre-permitting inspection was conducted on February 22, 2012.
Reason for Visit: Routine
Three boring were proposed to construct with depth of 335 feet. Borings will be vertically drilled.
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:
Grout type: bentonite; grout depth from O feet to 335 feet
Chemical Additives to be used in closed-loop system: Proylene glycol
We recommend that the Central Office proceed to issue the applicant a permit for geothermal well construction so that the
contractor could start construction.
Other
Comment:
Yes No NA NE
Page: 2