WI0600057_GEO THERMAL_20150506

AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Edward and Jennifer Hickman
.5104 White Oak Drive
Lumberton, NC 283 52
Subject: Permit Rescission
UIC Permit No. W10600057
May 6, 2015
Geothermal Heating/Cooling Wate1eturn Well
Robeson County "'
Dear Mrs. and Mrs. Hickman:
Donald R. van der Vaart
Secretary
/
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 Fayetteville Regional Office has
agreed that a permit is no longer required. Therefore, in accordance with your request, Underground
fuje~tion Control (U1C) Permit W10600057 is rescinded, effective immediately.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 Michael Rogers
at [phone].
Attachment( s)
cc: Fayetteville Regional Office -WQROS
Central Files -Permit No. WI0600057
Robeson County Environmental Health Dept.
Sincerely,
~j_.LJ"is <t'\ Jay Zimmerman, P.G., Director
'{ Division of Water Resources
1636 Mail Service Center, Raleigh , North Carolina 27699-1636
Phone: [phone] , I Internet: http://www.ncwater.org
An Equal Opportunity I Affirmative Action Employer -Made in part by recycled pap er
Permit Rescission Form
Information to be filled out bv Central Office:
Facility Name: Edward and Jennifer Hickman (SA 7 geothermal injection well)
Permit Number: WI0600057
Regional Office: Fayetteville
County: Robeson
Date Rescission Requested: Letter from Edward Hickman, homeowner, dated 28 April 2015 and permit
rescission application, received in Fayetteville via email on 28 April 2015.
Permit Expiration: 06/30/2015
Received Original Request: Central Office XX Regional Office
Form of Received Request: [Rj Letter Signed Annual Fee Invoice Other
Information to be filled out by Re gion:
Please Check Appropriately:
~ite Visit Performed D Groundwater Concerns Addressed
Render Decision for Rescission of the Above Referenced Permit:
~pproved D Denied
Note: If approved this permit will become inactive in the BIMS database and will not be billed
through the division billing system.
~ Rtffi9EIVED/DENR/DWR
Complete if Approved: l_y1 Rescind Immediately
M~~A\ O 5 2015
Reason for A pp roval: The Hickman residence installed two wells for use with the " tt 'io/~onal
installed. Both wells were drilled to 103 ', with screens set at 86' to 100'. The injectio · ~8flffiiion
accept the volume of water (approx .. 20 to 25 gpm for three units) discharged to it due to the confined
aquifer (Black Creek) and the groundwater table being at 12' below ground surface at time of boring.
There is approximately 13' of storage volume in the injection well and once the system was operational,
water was flowing out of the well. The driller and HV AC contractor received approval from the City of
Lumberton to discharge the effluent water to the White Oak drive stormwater system and operate the
groundwater source HVAC system as a "pump and dump". It's the regional office's understanding that
the injection well received water from the HV AC system for approximately two days (most of it flowing
out of the well onto the yard), until a underdrain was installed to discharge the water to the curb (see
photo from site visit on 29 April 2015).
1
The proposed injection well is currently being used for irri atian of the yard and landscaping at the
Hickman residence; hence there are no wells to be aban oned at this time.
Based upon site visits to the Hickman residence on 29 April 2015 and the request for rescission letter
provided to the Division by Edward Hickman; permit W10600057 should be rescinded.
1f you need additional information don't hesitate to contact Jim Barber at 910-433-3340.
Reason for Denial; Not Applicable
Signature of Certifier: � L, f �t
Date Certified • '5- ,, S
Return Completed and Signed Form to Groundwater Protection Unit, Aquifer Protection Section
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NdN RESIDENTIAL wELL CONSTRUCTION RECORD
'arolina Department of Environment and Nuturai Resources- Division of Water Quality
,L CONTRACTOR CERTIFICATION # •_ 11
1. WELL Q00TRACTOR'
Well Contractor (indiOd t) Name
�' .fir �-/sf�.;✓ ,��r.! �.�
Well Con actor Company Name
Street Address
Lj E .y 1 F_ru ()
City or Tc*n State Zip Coda
1110 6 73 - Zi ?- i
Area code Phone number
2, WELL INFIORMATION:
WELL CONSTRUCTION PERMITS
OTHER.ASSQCIATED PERMIT#(9 apptic�be)
3. WELL USE (Check One Box) Monitoring ❑ NEunicipallPublico
industrialiCpmmeraal p Agricultural Q Recovary ❑ Injedion
IrrigafionQ -der Q {fist use
DATE DPJ4F-D
4. WELL LOCATION:
LA",fe-
(Street ?Jame. wmbers. Cornmun$y. SubdM,ion, Ed No., Pan7ei, Zip Code)
CITY: L f/ n-�i+r' e COt1NTY sl} 5 r
TOPOGRAPHIC I LAND SETTING. (check appropriate pox)
❑Slope CIVailey ❑Flat 013009a t7Other
LATITUDE ' DMS OR 3x.Xxx7Cx) XXX DO
LONGITUD4 75 " ❑MS OR 7x-x]WOcx) XX DID
Lathudellongjtude source: E13PS 01"opographic map
pocaffon of WO must be shown on a USGS ropo rasp andattached to
this firm if nor using GPS)
6. FACILITY (Name of ft buskress where the well Is located.)
Facility Nartre Facility Id: (it applicable)
Street Address
4/G
City or Towh State ZIP Cade
`] — V 4! L F_
Con ct Name
Mali N Addraiss
CHy or Town ' - - a - State 7Jp Code
'li i o 1 Z -7 7 '1 0
Area Code Phone number
6. WELL. OETA(L.S:
a. TOTAL DEPTH: t03 r
b, DOES WELL R9PLACE MST] NO WELL? YF-5 CI NQ tf
C- WATER LEVEL Below Top of Casing: _ 13 _ FT.
(Usa •*' if Above Top of Casing)
/`11 c Ak)
d. TOP OF CASING IS - - -41- - FT. Above Land Surface'
'Top of rasing terminated actor below land surface may require
a varianca In accordance with 15A NCAC 2C .0116.
e. YIELD fgpmj: METHOD OF TEST A,("
f. 131SINFECTION: Type �T�— Amount ' L
g. WATER ZONES (depth):
Topes 5ottom-_,&Ja_ ToP Bottum
Top Bottom Top Bottom
Top Bottom Top Bottom^ _
Thlcknoss/
7, CASING: Depth diameter Welght Material
Top
Top Bottom Ft.
S. GROUT: Depth Material Method
Tops 0 SotLam ,Ko
Top Bottom Ft. -
Top Bottom Ft. - --
9_ SCREEN: Depth ❑iarneter Slot Size Material
YflP_ im Bettorn__,�+�-In. - -5�- , In -
Top Bottom FL in- in-
i qp Bottom FI. in. In.
fit. SANDIGRAVEL PACK
Depth Size Material
Top_lo—Bottam-,?'M Ft.�ef,,?, A"ed
. Top Bottom Fl.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Fohnatfort description
/,.
1�
A& �w h
1
_.�1.
r — -
12, REMARKS'
I po HEREBY CERTIFY THAT TMIS YVELL WAS CONSTRUCTED W ACCORDANCE YM-H
15A HCAC 2C. WELL CONSTRLCn0N STANDARD$, AND TMT A COPY OF THIS
REDORD W DEENP137ADED TO THE WELL OWNER,
SIG NAT E�R fifE�f C W CDiJTRACT4R t]A7E
PRINTED NAME OF PER50N .,ANSTRUCTING THE WELL
Form � t 3; j iDX1-13F W Fir u liljl lllfolrn�tivn Praee fs7,g; vb
. 2 g'1
Re
Ptshrib : (1919) 407430D
r'

1y DN RESIDENTIAL w,,LL coNsTRucnoni REcowo
trolina Department of Environment and Natural Resources- Division of Water Quality
L, CONTKACTOR CERTIFICATION # �
1. WELL CONTRACTOR:
Well ntraclor (IndW I) Name
Well Contractor Company Name r
Street Address -
t-1`'S1 F.-� 10 NL Z 7S 16
City or Town state Zip Code
it 14, 673 7-1F
Area code Phone number
2. WELL INFORMATION: Vj 10 L(� S 7
WELL CONSTRUCTION PERMrT#
OTHER ASSOCIATED PERMIT#(dapplicable)
srm WELL ID *(If applicable)
3, WELL USE (Check One Box) Monitoring D Municipal/Public C1
IndustrtalrCommerdal EI Agricutturai Q Recovery M Injection t-
Irrigation❑ Other ❑ (list rise
DATE DWLLED t% I 10
4. WELL LOCATION:
(Street Narm Mmrbam. Cornmanity, Subdivision, Cvl Nm, Parcel, Zip Cade]
CITY: L V "h s-: At n COUNTY . a i e 5
TOPOGRAPttIC l LAND SETTING- (0a* appropriate boo
❑ Slope C Valley ❑ Flat CI Ridge ❑ Other
LATITUDE 36 w " Dms oR 3x.x)=xxXXX DO
LONGITUDE 75 " DM3 oR 7x.xxx xxr(xx DO
Lafitudellong'rtude source; IDGPS !]Topographic map
{IvooVon of well must be shown an a USG fcpo reap and$dfached to
this form ff not uainq GFSj
5. FACILITY (Name of the business where the well Is located.)
Facility Name Facility IDtlt (if applicable)
.510& -)" auk D=
Street Address
1 cal-%W,r 466-
City or Towh Stale Zip Code
Sir L.F
Ca cl Name r
I T TO MLCott #4-k
M ItIng Address r + { l 7
City or Town State Zip Cade
LL1,ca _y •� -7� - 2 ?' 0
Area code Phone number
6. WELL DETAJLS:
a. TOTAL DEPTH:_ j03
b. DOES WELL REPLACE gUSITNG WELL? YES ❑ NO t1
c, WATER LEVEL 8efow Top of Ciraing; ! 3 FT_
(Use'+' if Above Top of Casing)
d. TOP OF CASING 15 ^ { FT. Above land Surface'
'Tap of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118,
e. YIELD {gpmj:. w METHOD OF TEST _ A. e-
f, DISINFECTION; Type � f� __ Amount r �
: 9, WATER LOVES (depth):
Top Bottom- -ia_ Top Bottom
Tap Bottom Top Bottom
Top Bottom Top Bottom
ThlaknesW
7. CASING: Depth Diameter W010111 Material
Top 0 Boftom� Ft. I
Top l�t3 _ Battom—&,�Ft._�
Top Uottom Ft.
8, GROUT: Depth Material Method
To d Bottom Z40 Ft. �t �
Top Bottom Ft.
Tap Bottom Ft.
9, SCREEN: Depth Diameter Slot Size Material
Tap firs 9atiom- Ay - 4—i—ln. _jo­ in. RW "36
Tap Bottom Ft_ in. in.
Top Bottom Ft. in. in.
10. SANDrGRAVEL PACK:
Depth Size Material
TopYrBattom IraS- Ft_ IYve�
- Tap Bottom Ft_
Top bottom Ft.
11. DRILLING LOG
Top Mtom Formation Description
112+ REMARKS: r
i DO HJ:REBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCOR DANCE 'IMP I
15A NCAC 7C, WELL CMTRUCT*N STANDARDS. AN07MT A COPY Of 7+05
RECORD HAS OEEVRCP DED TO THE WELL OWNER.
SiGNATZKE`0Fr CER FLED VVEK CONTRACTOR DATE
1�Ai" 1! r -
PRINTEO NAME OF PERSOIJNSTRUCTING THE WELL
�[p� 11i�S.�f111 of°1t1(B T�$ll� Inf4TfitAtion f�rOCeS,^In Form CWtb
. n 9, Rev, 2/09
ail 61, phone' ; W*410743 0

Ro gers, Michael
From:
Sent:
To:
Subject:
Attachments:
Rogers, Michael
Tuesday, April 28, 2015 3:25 PM
Henson , Belinda; Barber, Jim
WI0600057 Edward Hickman, Geothermal Well
Geothermal Water Return Well.pdf
Please find attached a permit rescission request. Please let me know if it is OK to rescind. You can conduct a site
inspection prior to recommending rescission if you wish. Let me know. Thanks.
From: sally.richardson [mailto:evhdentall @bellsouth.net]
Sent: Tuesday, April 28, 2015 3:08 PM
To: Rogers, Michael
Subje(:t:: Edward Hickman, Geothermal Well
Mr. Rogers,
I am sending the attached information per Dr. Hickman's request.
Sally Richardson
Office Manager
Edward Hickman, DDS, PA
720 Oakridge Blvd
Lumberton, NC 28358
Office: 910-738-8444 .
Fax: [phone]
Confidentiality Notice: This e-mail transmission may contain confidential or legally privileged information that is
intended only for the individual or entity named in the e-mail address. If you are not the intended recipient, you are
hereby notified that any disclosure, copying, distribution or reliance upon the contents of this e-mail is strictly
prohibited. If you received this e-mail transmission in error, we apologize for the error. Please reply to the sender so that
arrangements can be macle for proper delivery, and then please permanently delete this message from your e-mail
system. Thank you.
1
EDWARD V. IDCKMAN, D.D.S., P.A.
720 Oak Ridge Boulevard
Lumberton, N.C. 28358
April 28, 2015
NC DENR -Division of Water Quality
Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Attention: Michael Rogers, P.G. (NC & FL)
Hydro geologist
Division of Water Resources
Water Quality Regional Operations Section
Dear Mr. Rogers,
I am sorry about the delay responding to your notice. I have talked with the HV AC
company that put the geothermal system in and the well in question is not being used.
There evidently was too much water pressure in the aquafer to discharge the water back
into the ground. With the city's permission we are discharging the waJer into the storm
drain.
This well is no longer being used as a geothermal injection well and I wish to rescind the
permit.
I was told to write an explanatory letter to you. If there are any questions please contact
me at 910-258-1867. For any technical questions I would recommend you contact Steve
Cole, President of Simmons Heating and Cooling, at 910-610-3363.
Sincerely, __ ./ /
~~=:l
Edward Hickman, DDS
THEOAKS
OFFICE [phone] FAX [phone]
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 1 SA NCAC 42C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELLS]
These'well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application JKModification �rinit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages l and 4 (signature page) only
Print or hype Information and Mail to the Address on the Last Page. Illegible Applications Will Be ReturnedAs Incomplete.
DATE: --I , 14 _20 PERMIT NO. -tV. MoW j_7 (leave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave blank if New Application)
I. Current Use of Well
a. Continue to use as 40
eothermal Well Drinking Water Supply Other Water
Supply
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below- If abandoned, attach a copy of the Well Abandonment
Record (GW-30)_
`es, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES J% NO
If yes, indicate new owner's contact information:
Name(s) ---- — --
Mailing Address: _
City: _ State: Zip Code:-- _ County.
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence T Business/Organization
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: __ fir# ;.-.2,,J f/, if,�„�
Mai l ing.Address: / C�'r?_ tlkki
City: L: _ _ _ State: it`!C_Lip Code:.„es_J _ County:
Day Teie No.:. Qju_--'7 3�:- _' Y' `�—l1 Cef1 No._ 10 _ 12-5 1<' - z
E1WJi,, A3d[ess:.ilh�I�� �T� y.� Fax No.:
Geothermal Water.Retm-n Welt Permit Application (Revised Jan 2015) Page l

N
NOTE, Inmost cases an aerial photograph of the properly parcel snowing properly limes and structures can be
obtained and downloaded from the applicable costnty GIS website 1ypkafly, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tacks: other
wells, err- can then be drawn in by hared Also, a `layer' can be selected showing topographic contours or
elevation data
M. CERTMCATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(e requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer,
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by all the person(silisted on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their Behalf
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I art► aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. r agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit_"
Signature of Property Owner/Applicant
..,Print of Type Full Name
Si re of Pr a rty Owner AppIidant
V1, - Ar "I
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Hull Name -
Submit two copies of the completed application package to:
Division of Water Resources
Water- Quality Regional Operations $gtion (WQRQS)
1636 Mail Service Center
Raleigh, NC 27699-1E636
Telephone (91:9) 807-6464
Geothermal Water Return Wel[ Permit Application (Revised Jan 22015) Page 4

rn:Tarrell Graham (19198076496)
13.27 0210111 2G M T-05 Pg 01•03
To:
Fax: [phone]
Re;
Flrorn: Tarrell Graham
Pages: 3
Dais; Feb 01, 2012
Urgent For Review Please Comment Please Reply For Information
Comments:
To Whom It May Concern,
My office recently received a letter from your department requesting GW1s for'
Pmt W10600057 Edward & Jennifer Hickman SFR
Pmt W10400130 Kimball Hall Building, Charlotte Hawkins
Our records show that the GW1 forms for Hickman were sent on 8I18110 but I have
attached them to this fax. I am not sure why you didn't receive them but
appreciate the opportunity to resubmit.
do not show any customer history under the name Hawkins and will require more
information to locate that form. Our billing and accounts system does not sort
projects by permit number so I need other details. If you would email me additional
information about the Hawkins request I will be glad to assist and locate the request
information asap. Thank you.
Tarreii Graham
Graham and Currie Well Drilling
[e-mail]
www.myfax.com
RECEIVED 02-01-' 12 13:12 FROM- FAX TO- NC DENR P&S P001/003

m:Tarrell Graham (19199076490)
13:27 02101112GMT-06 PQ 02-03
1 r aN1 R—ESID ENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Depamncnl of Environment and Neluml Resources. Division of WacerQuality
WELL CONTRACTOR CERTIFICATION #
1. WELL CrONTRACTOR:
-,Vile! n�clor (Indiuid n Name
%�
ell Cordrtactor Company Name
Street Addireas
City or Toon State tp Coee
iq 6 73 2V I
Area code Phone number
2. WELL INFIPIRWTiON: j„ 1 L V
wELLC0N3 RVCTTON PERMITS -�
OTHER A$S(PCIATE❑ PERMITI(It appikabte)
SFTE WELL Ilp xM ap04-.wa) W r. L.L.
]. WELL USE (Check One Box) Monitanng ❑ MurflcipsYPublic 0
industnaVOOMmerdal ❑ Agricultural p Recovery 0 Infection
IrrigsfionD Other 0 (list use
DATE DRILLED /`i Ito
4. WELL LDCATION:
61 3Y,; ie-
(tlO" Nmre. NWbere. Colrlmurily, 5uttd+Ase0, . ot Na., Parcel, Zp Code(
CITY: fY U Mill If ^ COUNTY_ It] e5 r I
TOPOGRAPHIC I LAND SMING; (awe appropriate boxy
❑Slope ❑Valey ❑Flat ❑Ridge ❑ether
LATITUDE 36• DMS aR 3x.xxXxxxxxx DD
LONGITLICIE r3 ° �' " t7AA5 OR 7 .x7 xxxxx% Do
t-alitudellongftude source: UPS propographlc map
(lacaUan of well must be shown on a USGS lopo map andaltached to
this form if not using GPSJ
S. FACLfTY (Name of the business where the well Is located,)
C1. w � la , � Z .. ,V%
Fac ty Namet
Facllity ID# (if appitcable)
.1i
Street Address
L,f6N► 44r
City or Town
Stale
Zip Code
�F v� e
Con at Name
i? 8`'0 l l f"'',
MailirgAddralsa ------ �y, -
J
j
Z
City or Town
State
Zip Code
tA ;,, .
Area code thane number
S. WELL DETA4L S-.
a. TOTAL DEPTH: 103
b. DOES WELL REPLACE EXISTINO WELL? YE5 LI
NO
c. WATER L-VEL Below TDp pf Casing: _ 3 FT.
(Il,tse •+' if Above Top of Casing(
d. TOP OF CASING IS _ ft _ FT. Above Lao Surface'
'Top of casing terminated attor below land surface may require
a variance in accordance with 15A NCAC 2C D118.
e. YIELD igpml- METHQQ OF TEST— �_r -
f. DISINFECTION: Type— Jy Amount ' r.
g. WATER ZONES (deplh):
Topes Bottarn�bp Top Bottom
Top 89llonf_ — _ i Top Batlarrl
Top Bottom Top Bottom
Thlrkrmssl
T. CASING: Depth Diameter Weight malarial
Tap 0 8odom--Ve— FI.-
Tup� t3ot om- Ft-
Top Bottom Ft.
8. GROAT; Depth Material Method
Tap— Bottom Z0 Ft.—Aty a
Top Bottom Ft.
ToF BollorrFt. _ ^�
9. SCREEN: Depth Diameter Slot Size Material
Topes_ Bottom_ Ft.-ln- ­ja_ in.
Top Bottom Ft. in. In. --
Top Bottom Fl. in- In-
10. SANDIGRAVEL PACK:
Depth Size Material
oP.�LLBottorn� Ft.1 Yt ve r
Top Bottom Ft.
Top Sodom Ft.
11, DRILLING LOG
Top Bottom Formation Description
Q 1��
_1 Ala_
- I _ dead —
—-1 �d — --
.,��I_zax
12, REMARKS:
I PC MEREW CERTIFY THAT TRS WELL WAS CONSTRICTED IN ACCORDANCE MTN
13R NCAC 7C. WELL CONSTRUCTION STANW03. AND THAT A Wit OF 7lO
RECORD MS SEENPA VICED TO THE WELL OWNER.
SIGNAT E O CER FIED —CONTRACT—OR DATE
PRINTED NAME Or PERSON IO STRUCTING THE WELL
Form GW 1 b
il��wweryltrtilnn•;in_.i]Ivt4lrsn At' WAtar {3rrality . tnfmrregiinn prmraadlnn ..__
CEIVED 02-@1-' 12 13 J2 FROM- FAX 'TO- NC DENS P&5 ' P002/003

rrr:Tarrell Graham (ISI B076486) 13:27 0=1112GMT-05 Py 03-03
NUN RESIDENTIAL wELL CONSTRUCTION RECORD
North Caroliaa Department of £n►•ironment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. VYIELL CDHTiiACTOR:
�, _-
Twep waft (1�f& e- 11di AD N �
1�e;
-uteri Centraclor Company Name
c V4L Y r 5
Street dress
z 75 16
City or Town State ZIP Code
11_0J 613 - Z I I �
Area code Pkme number
2. WELL INFORIIWTION: �►! l t: ` L' i
VVELL CONSTRUCTION PERMITS
OTHER ASSOCIATED PERMFT#t'dappFmble)
SrTE WELL ID #cif epplicew) W t, t,t_ tt 2
3. WELL USE (Check One Box) MoMoring ❑ Municipa1/Pubfs'c0
IndustriatlCommerdal 0 Agriculturat 0 Recovery 0 injection > r
IrrVat}onlD Other ❑ [list se
DATE DRILLED
4. WELL LOCATION:
(SImet Name. Nw►bera, Commuriiy. Su6d union, Ns., partaal, 2)p Cndel
CriY: _ t- u rt n C• � e n COUNTY _ - a� e S r'1
TOPOGRAPHIC r LAND SETTING: (check sppropfte b�kx)
E)Skt w (2Valley OFIM ❑Ridge 00ttrer
LATfTUDE 3$ -OMSOR 3x.XXXXxxxxx DD
LONGITUDE 75 • DMS OR 7x..xxxxxxxxx DD
L.atiludellangitLde sources BPS OTopographic map
(1901ion o(well must be sf+own on a USGS lopo map andah'ached to
mis form V not using GPS)
6. FACELM (Name of the business where the well is located.)
FaclltyName
Facility Ira# (if applicable)
Steel Address
Lti,n bexlar
City or Town
State Zip Code
Conrad Name
11-7 ro ""l`G
ARaiNng Address
Z X �5
City or Town
Stale Zip Code
Ito ,L -7
Area code Phorm number
IL VALL VETAA-S:
a. TOTAL, DEPTH: 103
b. OM WELL REPLACE E)USTiNG WELL? YES 0 NO I�
e. WATER LM Below To of Casing: �FT.
{Use'*' if Above Top of Ca3ing=
d. TOP OF CASING IS 4,1-- FT. Above Land Surface'
'Tap of casing terminated ayor below land surface may require
a Va►isr►ee in accordance with I SA NCAC 2C ,0118.
@. YIELD jgIsmj:. k _ METHOD OF TEST : r
C DISINFECTION: Type Amount ' c
q, WATER ZONES Idept4
. Top_ !SJ2 - BottomTop Bottom
Top BOHOM Top BUdOrn
Top Bottom Top Bottum
Tttickneesl
7, CASING: Depth Diameter weigh materiel
Top D Bottom 5' -- Ft.`
Top /Gd - Botlom-,j&3 Ft.�
ToA Bottom Ft.
8. GROUT: Depth
maleriat Method
Tope t3attam .y
Ft
Top Bottom
Ft.
Top Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top Sodom_& L Ft.—a.Lin. -*Jd. in. Ae—
Top_ Bottom
FI. in. in-
Top— Bottom
Ft. in. in,
10. SANDIGRAVEL PACK:
Depth Sine Materlal
Top_2,CL_Boltem-,&j_FI. /YJ __Z;mtet
Top Bottom Ft.
Top Bottom Ft-
11. DRILLING LOG
Tap Bottom Formations Description
12. REMARKS_
DO HER ENY CERTIFY 1HAT THIS WELL WAS CONSTRICTED IN ACOORQALvCE +mT H
I5A WAC 2C,'4YELL CO%TRt1CTION STANWDS. AND TiIAT A COPY OF THIS
REODRD HAS MVFtqVI0ED TO THE WELL DANER,
SIGNAA E'O CER PIED W G CONTRACTOR DATE
LAW;dr 11010el
PRINTED NAME OF PERSON 111ONSTRUCTING lI• EWELL
Pi- RiiF7dilo73f%eYfririit►flnntn.l!1iv[clran of Hralnre].,arlfi. _ I�Fn..n a#i,yn Dm�eeetiri. Form W-lb
_ ECEIVED 02-01-' 12 AJ2 _ FROM- _ FAX __ _ TO- NC DENS P&5 P003/003

Permit Number WI0600057
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
Edward & Jennifer Hickman SFR
Location Address
5104 White Oak Dr
Lumberton
Owner
Owner Name
Edward
Dates/Events
NC
V
28358
Hickman
Orig Issue
07/15/10
App Received Draft Initiated
05/12/10
Scheduled
Issuance
Central Files: APS_ SWP_
07/19/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Tarrell Graham
4532 Hwy 73
West End NC
Major/Minor
Minor
Region
Fayetteville
County
Robeson
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Edward V. Hickman
5104 White Oak Dr
Lumberton NC
Public Notice Issue
07/15/10
Effective
07/15/10
27376
28358
Expiration
07/30/15
_R_e~g'-u_la_t_e_d_A_ct_iv_i_ti_e_s ________________ -'-'R=e=a=u=e=s=te=d=/-'-'R=e=c=e-'-'iv'--'e=--=d=----=Eco_v=e=-=-nt=s"'-------------
Heat Pump Injection Additional information requested
Outfall NULL
Waterbody Name
RO staff report requested
Additional information rece ived
RO staff report received
Stream Index Number Current Class
06/04/10
06/18/10
06/18/10
07/09/10
Subbasin
Pe r mit Number WI0600057
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
Edward & Jennifer Hickman SFR
Location Address
5104 White Oak Dr
Lumberton
Owner
Owner Name
Edward ·
Dates/Events
NC
V
Orig Issue App Received
05/12/10
Reg ulated Activities
Heat Pump Injection
Outfall NULL
28358
Hickman
Draft Initiated
Scheduled
Issuance
Central Files: APS_ SWP_
07/14/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Tarrell Graham
4532 Hwy 73
West End NC
Major/Minor
Minor
Region
Fayetteville
County
Robeson
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Edward V. Hickman
5104 White Oak Dr
Lumberton NC
Public Notice ·11iij lo Effective
Re o uested/Received Events
Additional information requested
RO staff report requested
Additional information received
RO staff report received
27376
28358
Expiration
7/3115
06/04/10
06/18/10
06/18/10
07/09/10
Waterbody Name Stream Index Number Current Class Subbasin
A~A -..~--~-~-NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beveriy Eaves Perdue
Governor
Edward and Jennifer Hickman
5104 White Oak Dr.
Lumberton, NC 28358
Re: Issuance of Injection Well Permit
Permit No. WI0600057
Coleen H. Sullins
Director
July 15, 2010
Issued to Edward and Jennifer Hickman
Robeson County
Dear Mr. and Mrs. Hickman:
Dee Freeman
Secretary
In accordance with your application received May 12 , 2010, and additional information received June 18, 2010,
I am forwarding Permit No. WI0600057 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 June 30 , 2015, and shall be subject to the conditions and limitations
stated therein.
Please notify Jim Barber with the Fayetteville Regional Office two business days prior to construction of
the geothermal well. ·
Also, per permit condition Part 11.5, the injection, well must be constructed to a depth such that it is
injecting water into the same aquifer that the source well is drawing from.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application
to renew the permit four months prior to its expiration date. As indicated in the permit, this permit is not
transferable to any person without prior notice to, and approval by, the Director of the Division of Water
Quality. If you have any questions regarding your permit or the Underground Injection Control Program please
call me at [phone].
Best Regards,
~a~
'Michael Rogers, P .G . (N"::: FL)
Environmental Specialist
cc: Art Barnhardt-Fayetteville Regional Office
Central Office File -WI0600057
Robeson County Environmental Health Dept.
AQUIFER PROTECT ION SECTION
i636 Mail Service Cente r, Raleigh , North Carolina 27699-1636
Location : 2728 Capital Bou levard, Raleig h, North Carolina 27604
Phone : [phone] I FAX 1: 919-715-0588 ; FAX 2: 919-715-6048 I Customer Service : 1-877-623-6748
Interne t: www.ncwaterauality.org
An Equ al Opportunity I Affirm aliv e Action Employ er
None C 1. orth aroma
J\)aturall!f
NORTH CAROLINA
1 �1�►►� f ;Z�1►fu I ��� 1� f���I1�311'►1 �►ff I[K�]� fu' !_1�X� [��►�
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
Edward and Jennifer Hickman
FOR THE CONSTRUCTION AND 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 5104 White Oak Dr.. Lumberton, Robeson County come NC 28358,
and will be constructed and operated in accordance with the application May 12, 2010, and conformity with the
specifications and supporting data received June 18, 2010, 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 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 constructs on and use.
This permit shall be effective, unless revoked, from the date of its issuance until June 30, 2015, and shall be
subject to the specified conditions and limitations set forth M' Parts 1 through IX hereof.
Permit issued this the day of �U-4.q .2010
Z'10-r'Ztl� -9-7 Z-611,
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
WI0600057

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section -UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Fayetteville Regional Office
Systel Building
225 Green St., Suite 714
Fayetteville, NC 28301-5094
[phone]
GW-1s must be submitted within 30 days of completion of well construction. Copies of the GW-1
form(s) shall be retained on-site and available for inspection.
PART II-WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing each injection well, the Permittee shall notify the
Aquifer Protection Section-Underground Injection Control (UIC), Central Office staff, telephone number
[phone] and the Fayetteville Regional Office Aquifer Protection Section (APS) Staff, telephone
number [phone].
2. Within 30 days of injection well completion, Permittee must contact the Fayetteville Regional Office APS
Staff in order to have samples collected at the source well and injection well.
WI0600057 2
3. Continued operation of the injection system will be c!ontingent 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.
4. The injection well system must be constructed with sampling ports so that system influent and effluent
may be sampled.
5. The injection well must be constructed to a depth such that it is injecting water into the same
aquifer that the source well is drawing from.
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 may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Perrnittee 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.
PART IV -PERFORMANCE ST AND ARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater which 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 Perrnittee of the responsibility for damages to surface or
groundwater 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.
WI0600057 3
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-Underground Injection Control (UIC),
Central Office staff, telephone number [phone] 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. 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 pennit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART VII -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.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Fayetteville Regional Office, telephone number [phone], any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the 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 VIII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
WI0600057 4
PART IX -CHANGE OF WELL STATUS ..
1. The Pennittee 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 Pennittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealin~ 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.
(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 IX (1) and.(2) (G) shall be submitted to:
WI0600057
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: 07/02/10
To: A quifer Protection Section Central Office
Central Office Reviewer: M. Ro gers
Regional Login No: ??
County: Robeson
Permittee: Mr. Edward Hickman
Project Name: Hickman Residence
Application No.: WI00600057
L GENERALINFORMATION
1. This application is (check all that apply): IZI 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 Attachment B included D 503 regulated D 503 exempt
D Distribution of Residuals D Surface Disposal
D Closed-loop Groundwater Remediation IZI Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IZI Yes or D No.
a. Date of site visit: 07/01/10
b. Person contacted and contact information: NI A
c. Site visit conducted by: Jim Barber
d. Inspection Report Attached: Ill Yes or~ No"J~
2. Is the following information entered into the BIMS record for this application correct?
IZI 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 Injection Sites:
(If multiple sites either indicate which sites the information a pp lies to . co pv and paste a new section into the
document for each site , or attach additional pa ges for each site)
a. Location(s): 5104 White Oak Drive . Lumberton NC 28358
b. Driving Directions: From the Fayetteville Re gional Office travel to Lumberton on 1-95 South. U pon
enterin g Lumberton ci ty limits , take exit 33 (H wy 301/Fayetteville Road) into Lumberton pro per. Drive
app rox. 2 miles and tum left onto Oakridge Blvd. (Oakrid ge subdivision). Turn left onto White Oak Drive
and 5104 is on the ri ght, just past Red Oak Court.
c. USGS Quadrangle Map name and number: Northeast Lumberton . NC O-23-NW )
d. Latitude: 34.663896 N Longitude: -78.989532 W (a pp rox. location of in jection well in front vard)
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section)
Description Of Waste (S) And Facilities
FORM: APSARRHickmanResidenceLumberton WI0600057July201 0.doc 1
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
1. Please attach completed rating sheet. Facility Classification: __
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No D N/ A. If no, please explain: __ ._
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No D N/A. Ifno, please explain: __
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes D No D N/ A. If no, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes 0No0
NI A. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D N/ A. If no, please explain: __
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No D N/A. If yes, please attach a niap showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part N: __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit: __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEW AL AND MODIFICATION APPLICATIONS (use previous section fo r new or maior modification
systems)
Descri ption Of Waste{S) And Facilities
1. Are there appropriately certified ORCs for the facilities? D Yes or D No.
Operator in Charge: __ Certificate #: __
Backup-Operator in Charge: __ Certificate #: __
2. Is the design, maintenance and operation ( e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D No.
If no, please explain: __
FORM: APSARRHickmanResidenceLumberton WI0600057July201 O.doc 2
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? 0 Yes or O No. If no, please explain: __
4. Has the site changed in any way that may affect permit ( drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain: __
5. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
D Yes or D No. Ifno, please explain: __
6. Are the existing application rates (hydraulic or nutrient) still acceptable? D Yes or D No. If no, please
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Will seasonal or other restrictions be required for added sites? 0 Yes O No ON/A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there arty buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, please attach a
map showing conflict areas or attach any new maps you have received from the applicant to be incorporated
into the permit: __
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? D
Yes or D No. Ifno, please explain: ____ _
11. Were monitoring wells properly constructed and located? D Yes or D No D N/A. If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? [8J Yes or
0 No ON/A. Please summarize any findings resulting from this review: __ _
13. Check all that apply: D No compliance issues; D Notice(s) of violation within the last permit cycle; 0
Current enforcement action(s) 0 Currently under SOC; 0 Currently under JOC; D Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc): ____ _
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? 0 Yes
D No D Not Determined D N/ A.. If no, please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? 0
Yes or D No D N/A. If yes, please explain: __
FORM: APSARRHickmanResidenceLumberton WI0600057July201 0.doc 3
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Descri ption OfWell(S) And Facilities-New, Renewal, And Modification
1. Type of injection system:
[8l Heating/cooling water return flow (5A 7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5L/"Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes [8l No
3. Are there any potential pollution sources that may affect injection? D Yes [8l No
What is/are the pollution source(s )? ___ ._Wh __ a_t _is_th_e _d_is_tan_c_e_o_f~th_e_in..,.ie~c~t~io_n_w~e~l~l{=s~) =fr~o=m~t=h~e_.p~o~ll~u~ti~on
source(s )? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 15' +/-ft.
5. Quality of drainage at site: D Good 12:1 Adequate D Poor
6. Flooding potential of site: [8l 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)? [8l 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.
In jection 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 y es , explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes, explain:
3. For renewal or modification of groundwater remediation permits (of anv tvp e ). will
continued/additional/modified in jections have an adverse im pact on migration of the plume or management of
the contamination incident? D Yes D No. If yes, explain:
4. Drilling contractor: Name: __
FORM: APSARRHickmanResidenceLumberton WI0600057July201 0.doc 4
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address:
Certification number: __
5. Complete and attach Well Construction Data Sheet.
FORM: APSARRHickmanResidenceLumberton WI0600057July2010 .doc 5
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
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 [8J 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
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; [8J
Issue; D Deny. If deny, please state reasons: __
~,~R~-/J 8. Signature ofreport preparer(s): ----~-""'-""'+--------+~-,,J<--U--"--'C-"'=:;,,c___ '---__________ _
c:r;,.__ ~ ForL A,z.,r BAQ»/#lfUJT Signature of APS lgional supervisor:
Date: 7/ (Q ID ~ :.
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
A brief site visit was made to the site on 1 July 2010 to determine if the information provided b y Graham &
Currie Well Drillin is a reasonable re resentation of the ro osed site for the installation of a water su
FORM: APSARRHickmanResidenceLumberton WI0600057July201 0.doc 6
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
well (for a geothermal heating/cooling system) and a in jection well for the return of said water back to the
formation that it was pum ped from.
The pro ject site is in a residential neibhorhood in the City of Lumberton. Houses in the vicini ty of the pro ject
site are of like construction with no unusual uses or features (i.e. auto body shop. mechnical re pair sho p. oil
change station. etc.).
It doesn't a pp ear that the proposed activi ty will have a adverse impact to the surrounding area. Groundwater
flow would a pp ear to be toward Fivemile Branch that is located a pproximately 300' north of the proposed
proiect site . with the supp ly well being located outside of the 500 ear flood plain and the in jection well being in
the 500 year flood plain. In reviewing the NC Flood plain Mapp ing website. the outermost extent of the 100 year
flood plain a pp ears to be in White Oak Drive. The injection well is in the y ard of the Hickman residence
(landscaped area) and will be a pprox. 20' +/-outside of the the indicated 100 year flood plain. If the in jection
well is pro perl y constructed b y Graham & Currie; there should be no im pacts to groundwater resources if
floodwaters where to reach the injection well. Greater im pacts would come from landscape activities at the
residence. i.e. a pplication of fertilizer, herbicides. pesticides and landscaping activities that involve excavation.
FORM: APSARRHickmanResidenceLumberton WI0600057July201 0.doc 7
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AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: June 18. 2010
To: D Landon Davidson, ARO-APS
l:8J Art Barnhardt, FRO-APS
0 Andrew Pitner, MRO-APS
D Jay Zimmerman, RRO-APS
0 David May, W aRO-APS
0 Charlie Stehman, WiRO-APS
0 Sherri Knight, W-SRO-APS
From: Michael Ro!!ers Groundwater Protection Unit
Telephone: {919) 715-6166 Fax: {919 ) 715-0588
E-Mail: Michael.Ro [e-mail]
A. Permit Number: WI 0600057
B. Owner: Edward and Jennifer Hickman
rt 11~-Pity(Qp~t~ii~n;: 0::: : : .. ·.·
fZI Proposed D Existing D Facility D Operation
D. Application:
I. ?.~i#!it:7'fj,~: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D L'E Lagoon D GW Remediation (ND)
'l:8J UIC -SA 7 Geothermal well
For Residuals: □ Land App. 0 D&M
D 503 0 503 Exempt
D Surface Disposal
D Animal
2. fr~)e.ci 1'ype: l:8J New O Major Mod. 0 Minor Mod. 0 Renewal O Renewal w/ Mod.
E. Comments/Other Information: D I would like to accompany you on a site visit. I NOTE:
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within, please take the following actions:
l:8J Return a Completed APSARR Form and attach laboratory analytical results, if applicable.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above. ~ /J _ /. / _
RO-APS Reviewer: ~ / ""-,~ W?_Jy-;:::/1 Date: ~
FORM: APSARR 07/06 Page 1 of 1
NORTH·•CAROLINA
DEPARTMENT.OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATIONFORPERMIT TO CONSTRUCT AND/OR USEA WELL FORINJECTION
WITH A GEOT:BERMALIIEATPUMP SYSTEM
TYPE SA 7 "OPEN LOOP" INJECTION WELL {S)
( check one) __ New Permit Application Renewal ---Modification
oAIB: S / 1 f lo 20 __
PERMIT NO.: ~~~~?f: {leave blank if NEW permit application) ..
A. PROPERTY OWNER/PERMIT APPLICANT
Name of eacbowner listed on property ·deed •. for.a business.or government c:tgency, state name of entity and
name of person delegated authority to sign application on behalf of the business/agency: ______ _
1:::;.fu ✓1 ·-ad . t,~. llu k/1,,,, ,-1 b/-,, IE:/J,•: .. Fe-:-£ r2 • Ai£ c,.t,.:Mn;v
{l) Mailing Address:. 57tJ <./ l1)H ;re 1/.4-1< )a
City: /4-A-<1/2tN'f'>u£& State:,M__ Zip Code: J:-8·3 S-¥ County: h u k.t,.,,:,-,
Home/OfficeTe1eNo.: CJ/tJ-739-.";r'¥</t/ CeUNo.: 91',1 c2 s"]5/S&' 7
Fax No. /t/11-EmailAddress:£J(IIDtf:/l,ir'/ft..Pf!?bcll5oerft-.': &:<1
i
(2) Physical Address of Well Site (ifdifferenttban above):_. "'::? .... .,-... &: .... --T .... ,_~_----------..--
City: _________ State: __ Zip Code: ______ County: ___ _...._
Home/Office TeleNo.: ----------~Ce=ll~N~· o~.: _________ _
Fax No. __________ Email Address: _____________ _
B. PROPERTY>OWNERSHIP.DOCUMENTATION
Provide legaldecumentation of prQperty ownership, such as a ~ct, deed, article of incorporation, etc .. and
aPLAT map showing the property. This infonnation may be obtained from county Register of Deeds or:01s
website.
C. AUTHORIZEllAGENT, IF ANY
If the property owner/permit applicant wants to authorize someone·else· to sqpi the permit on their behalf. then
attach a signed letter from the property. owner/permit applicant. specifying and authorizing their .igent (well
driller, •heat pmnp contractor, or other type of contntctor/agent) to sign this application on their behalf.
CompanyName: ~> 5LM17,yv.s /k-"'°,..v? c :,alaa: HCcfte,.,-/ T ,vC::•
ContactPerson~t'/4 .... w u!C ~mail Address: <ct1/c <2 '>a,,&,;4 ,,,.._ C a~
Address; // 7:5"0 · tu re I / tl:1 '
City: ,/41:rtt,lflJlL6 u L/;_, State: M'.:.zip Code: .21f; $-2. County: _:iu t2-&v?'
OfficeTeleNo.: :Vd'.J-?iG cJ-7'$".t-Fax No. 71/1'.1 ,'.? 77 S'7Z:¥CellNo.: 71/v t;:_;/o ~ )G ~
Website Address ofCompany; if any: _____________________ _
06/07/2010 16:05 9106718251 DR. HI Cl<MANS CFFI CE PAGE 01
Dr. Edward Hickman and Jennifer Hickman, wife
5104 White Oak Drive
Lumberton NC 28358
May 4, 2010
To whom itmay concern:
RECEIVED/ DENR / D'hO
Aquifer Pro\edmn Section
JUN 1s ao.JA
Ott, st Nnr
uo,io;s UOfJ09J0Jd .18J!Jlb\f
")MO I ~N30 / 03Al303ij
Simmons Heating Cooling Electrical, Inc. witl represent me, Dr. Edward
Hickman, as my agent forthe sole purpose of instiiHing a geothermal
HVAC and hot water systems. Stephen W. Cole, President of Simmons'
or Tarrefl Graham with Graham and Currier Welt Drillers, is authorized
to repr-esent my interests and to s,gn ap.propriate documents for this
project.
Sincerely,
D. WELL DRILLER INFORMATION
C❑mpany Name: + L U lr-a 1�
k.�l�y- -
Well Drilling Contractor's Name: N f�o& 0 G_ gA 14fA
NC Comractor Certification No.: k-< ? 3 A Contact person: SAME
Company Website: WWW. n ra-k••, .4rr1: (L . LvM Email Address: OaNTVILO.� C+ +C40k-W
V
Address: � 5 3 Z �J L 4 w X 13
City: LJ�IST- EAW State: NL Zip Code:
Office Tele NoA0-C -7 3 - Z I �-i FaxNo.`�16'6
-L't 5 7 �
? 3 -Vl
_County. /0,1-00A£
Cell NO 10-6 * 18 T
E. HEAT PUMP CONTRACTOR INFORMATION (if different than Driller)
Company Name, v •-- _ -- - s?,:: � C ... /",Z". Contact l?erson:�
Company Webske: WWW. - - s.� ; • - Eanail Address: ! L - t.cr�
Address:
City: -__, ram .. �.�._ - State [dip Code: ' S— County:
Office Teie No., : L G FaxNo. :�� rrs ��cr Cell Na. - - -:'. 4,-5
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
C. WELL USE Will the injection wells) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO �-
(2) Personal consumption? YES NO
0
x
WELL CONSTRUCTION DATA
_PROPOSED Well(s) to be constructed for use as wi injection well. Provide the data in (1) through
(7) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (7)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
OW-1) if available.
61 fib Z
Well Construction Date.: t- � Number of
Depth of each boring (feet): V N 1:Iu0,-.+hj
Well casing. Is the wells) eased?
YES 1�-� If yes, then provide the raging information below.
b -7 Type: Galvanic steel Slack steel
Plastic V Other (specify)
Casing thickness: diameter (inches): _LaCdepth: from C)� to__LQ6 feel (relative to land surface)
Casing extends above ground _ inches
S (b) NO
(3) Grout material surrounding well casing:
(a) Grout type., Cement Bentonite* _1L Other (specify)
413v setwring bentonite omut a vmiance is hereby requtxted to 15A NCAC 2C: ,0213fdwl)tA), which requires a content grout.
~ (b) Depth of groat arotmd well casing (relative to land surface): from C) to ZQ feet

( 4) Well Screen or Open Borehole depth (relative to land surface); from 5 0 to 1 0 feet
(5) N.C. State Regulations (Title 15A NCAC 2C .0200) require the Pennittee to make provisions for
monitoring wellhead processes. A faucet on both Influent (groundwater ent.ering heat pump) and Effluent
( water being injected back into the well) lines is required. Will there be a faucet on:
(a) lnfluentline? Yes V,No__ (b) Effluent line? Yes~ No __
(6) Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Fonn GW-1). If Form GW-l is not available, provide
the following data:
From what depth. formation, and type of rock/sediment wits will the groundwat.er be withdrawn? (e.g.
granite, lim~one, sand, etc.)
Depth: S O -] D Formation: $ I). r' 0 Rock/sediment unit: ________ _
NOTE; THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATAIF THIS
INFORMATION IS OTHERWISE UNA VAJLABLE.
L OPERATING DATA
(])
(2)
(3)
(4)
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
J. INJECTION-RELATED EQUIPMENT
Average (daily) /</, gallons per minute (gpm).
Average (daily)/)., 'lGiegauons per day (gpd).
Average (daily) 6'.D pounds/square inch (psi).
Average (January) '-1(1.. Q F. Average (July)~° F.
Attach a schematic diagram or cross--section of the well construction that shows the total depth, length of casing,
extent of grout, stickup, location of influent/effluent sampling ports, etc. If this is a modification, show the
engineering layout or proposed modification of the injection equipment and exterior piping/tubing associated with
the injection operation. The manufactmer's brochure may provide supplementary infonnation if needed.
K. LOCATION OF WELL(S)
(1) Attach a site map (can be drawn) showing: houses and other structures, property lines, surface water bodies,
potential sources of groundwater contamination. and the orientation of and distances between the proposed
injection welt(s) and any other existing well(s) or waste disposal facilities such as septic tanks or drain fields
located within l 000 feet of the geothenna1 heat pump well system. Label all featw-es clearly and include a
north arrow.
(2) Attach a scaled topographic map of the area extending l/4 mile from the property boundary that indicates
the facility's location, a north arrow, and the map name.
NOTE: In most cases, an aerial photogn,ph of the property parcel showing property lines and struelllr~ can be
ob'llliMd and downloadea from tire applicabl.e cOUllty GIS website. 1ypically, the property can be setUC•ell b_v owner
nmne or address. The location of the wells in relatwn to property boulldalit!s, houses, septic tanks, other wdls, etc.
can then be drawn in by hand. Also, a 'layer' C/111 be st!lectnl showing topographic contollrs or t!levatitm dl1III.
L. CERTIFICATION (to be signed as required below or by that person's authorized agent)
NCAC 1 5A 2C A? 11(b) requires that all permit applications shall be signed as fellows:
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 ofcial;
4. for all others. by the well owner.
If an authorized agent is signing on behaff of the applicant, then submit a letter signed by the
applicant that names sod authorizes their agent as specified in Part C of this permit application.
"1 hereby certify. under penalty of law, that I have personally examined and am. familiar with the information submitted in
this document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible for
obtaining said information, t [relieve that the information is true, accurate and complete. 1 am aware that there are significant
penalties, including the possibility of fines and imprisonment, for submitting false information. 1 agrve to construct, operate,
maintain, repair, and if applicable. abandon the injection. well and ail related appurtenances in accordance with the approved
specifications and conditions of the Permit." --�
Si tore mperty OwmerlApplicant
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Fu11 Name
t�
Signature of Authorized Agent, if any
Print or Type Full Name
Submit TWO signed copies of the completed application package and all attachments to:
WC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]

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,8 tg,-dl ofLotNumber TRIitTY-SEVEN (37), as sbown on m mD safl0ed, "Osktidge Subdwitaon,
Section II," prnisarod by Andmon Bngiaeer M & Auocixtca;'P.A. defted SeptestMs 1, 1993, and
rzoordedin Book aOffimW Maps 33, LLpage23. Robeson CoudyRegistry, rcftmFwe to which asap
in hereby madefor a moreportiwLr description ofaid lot toed for the purpaaaof inwxporxling the
Mm in.this dteeriptian as tfft mictne wwaAiUy sa forth.twein.
The %boon described a aoavgcd subjetx to boat certain Doclarabon of Restrictive Covenants and
CQaffitiaea, dated March 4, 1992aad mem io" Book7$5, at p4e793. Robmw County RqOst►y,
and tMt sxaiaia Firal SupplenmW Oecia[tt m of Restrictive Ltd Protective Covenants and
Conditioaa, dated Seplarnber 1, 1993 sad rct4ordcd in Book $06, at page 127, Mbc* a Cotetty
Registry.
Imo:
1,ying and beirsg in the City ofIssmberton, Robeson Comty, North C rolina, about 53 feel west of
WiDow OADri m:huts. 150•feat south of Whits Oak Drive, bounded by col 37 Oakndge on The
wakti by:LnL 54 on the muth4 Lot 40 on the went and the: remainder of Lest 52 an the e+SL
BEGfhlNWG at an adating iron stake, the-mustean=- orm of Lot 37 OakridgFSubdivision
Stxcdoa II(MapBook 39,PmV 25), the southwest wrnw ofLut 47 Oakridge5ubdivision Ststaimt 111
(map -Book 33, Pige 96) and a emir of the original I -at 52 Omslt i Subdiviaion Sectiorrtll, and
runem from Wd paint ofbegkwwsg is a new line South 4 degrees 24 mimetes 49 seovnds west 146,25
feet to as iron stake set in tc soother, ks+e of i.ot 52, the northern am of Lat S4; thw= with the
comnm h t: of J ma 52 and 54 'North 79 dagsars 57 ad uaoa 03 moottda weal 97,0I fmi to an
t dong iram stake its as eaarm Iim Qf L4t 40, a anwoon comer of Lots 52 and 54; therm with and
tsaumu !unto€Lot 40-Noah 11 dq pm 02 m mrtm 57 at condaFast=00 erect to an exmtiingirmtt
azlM themes agaittwithan coMem Lot ofl of 40 North 4 dry 58rrtim#a49 scmnds Wear 59.80
fea to ut *dding iron Lske in eke southtmt I m of Lot 37. a cretmm corner of Lots 40 and 52.
thmw wath the sovtwm lint. of Lot 37, the adtthom time omot. 52, North 63 dgp-aw FAst 110 00
fee[ to the point of hegimung, co=Mng 0,24 oar, more of less -
Bring a portion of Lot 52 OakrWV Subdivision, Sedioa Ill.as ahavm oa a plat recorded in Map
Book 33, Page 96, Robeson Cmity Reglury,
ibia let, beng tewhalf (%) of a lot in theOakiidgo Subdivistsn,.shall be m bycd to orm4mX4VAI of
the lam assnsartwmLu e*Med from time to tune by ThcOakttdgo Awoaaiion of i umbmm Ltd-
Subjem to that certain Dcdatttion ofRest►ictiveand Pmtcvtivc Covenants. and Cooditiona, dated
October 26, 1994, sad rmovicd-io Book MY. LL page I31, $abeann.Couoty R*wy, aud.subjw
to eammerttz shorn an the plat hereinafter refuted to.

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NAMES OF ALL[PanES TO THE ORIGINAL INTRUMEW:
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GRANTEES.
STATE OF NORnJCARQL24A
COUNTY OF _ Ag&jjtl_
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.yFax - Tarrell Graham To: Michael Rogers (19197150588)
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Ro gers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Mr. Rogers,
Tarrell Graham [[e-mail]]
Friday, June 18, 2010 9:56 AM
Rogers, Michael
[e-mail]
5A7 Permit Application
Hickman Simmons HVAC 5A7 Permit.pdf; Simmon HVAC Site Plan 8 x 11.pdf
Per our phone conversation J have attached a 5A7 Permit application. Thank you.
Tarrell Graham
Project Manager
Graham & Currie Well Drilling
(0) 910.673.2921
(F) 910.673.2747
(C) 910;638.8955
www.gr ahamcurrie.com
tarrell@,gr ahamcurrie.com
Please visit our website at www.m-ahamcurrie.com for information on our services.
This electronic message and its attachments are forwarded to you for convenience and "for information only." Them•
with limitations, conditions and further explanations omitted in the interest of brevity and time constraints. The conte
any attachments may be preliminary and incomplete, subject to review and revision. This electronic message and a
are the property of Graham & Currie Well Drilling Co., Inc. and may contain information that is confidential or other
information this electronic message contains is intended solely for the use of the one to whom it is addressed, and an)
electronic m~ssage and destroy all copies.
E-mail message checked by Spyware Doctor (6.1.0.447)
Database version: 6.14880
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1
A QUIFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: June 18 . 2010
To: □ Landon Davidson, ARO-APS
IZI Art Barnhardt, FRO-APS
□ Andrew Pitner, MRO-APS
D Jay Zimmerman, RRO-APS
□ David May, WaRO-APS
0 Charlie Stehman, WiRO-APS
□ Sherri Knight, W-SRO-APS
From: Michael Ro!!ers · · Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E-Mail: Michael.Rogers@ ncmail.net
A. Permit Number: WI 0600057
B. Owner: Edward and Jennifer Hickman
C. Facjlity/Operation: __ ._.
IZI Proposed D Existing □ Facility D Operation
D. Application:
1. Permit Type: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D 1/E Lagoon D GW Remediation (ND)
IZI UIC-5A7 Geothermal well
For Residuals: D Land App. D D&M
D 503 D 503 Exempt
D Surface Disposal
D Animal
2. Project Type: IZI New D Major Mod. D Minor Mod. D Renewal D Renewal w/ Mod.
E. Comments/Other Information: D I would like to accompany you on a site visit.
I NOTE:
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within, please take the following actions:
IZI Return a Completed APSARR Form and attach laboratory analytical results, if applicable.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification.· Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: -------------------Date: _____ _
FORM: APSARR 07/06 Page 1 of 1
Beverly Eaves Perdue
Governor
A.VA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
June 2 , 2010
Edward Hickman
Jennifer Hickman
5104 White Oak Drive
Lumberton, NC 28358
Subject: Acknowledgement of Application No . WI0600057
Edward & Jennifer Hickman SFR
Injection Heating/Cooling Water Return Well (SA 7)
Robeson
Dear Dr. & Mrs. Hickman,:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on May 12, 2010. This application package has been assigned the number listed above and will be reviewed by
Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing P!!rmit applications, the Division requests your a~sistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 -90 days after receipt of a complete
application. · ·
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at [e-mail]. If the
reviewer is unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To
review our new organizational chart, go to http ://h2o.enr.state.nc.us/documents/dwg ornchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
~~
for Debra J. Watts
Supervisor
cc: Fayetteville Regional Office, Aquifer Protection Section
Simmons Heating Cooling Electrical, Inc (Stephen Cole -11780 McColl Rd, Laurinburg, NC 28352)
Permit Application File WI0600057
AQUIFER PROTECTION SECTION
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 I Customer Service: 1-BTT-623-6748
Internet: www.ncwaterguality .org ·
An Equa l Opportunity I Affirmaiive Action Employer
N°~i..c 1· 01u1 aroma
/Vatura!ly
NORTH CAROLINA
DEPARTMENTOF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A GEOTHERMAL HEAT PUMP SYSTEM
TYPE 5A7 "OPEN LOOP" INJECTION WELL S
(check one) New Permit Application Renewal Modification
DATE:
PERMIT NO.: WI
►I4]
(leave blank if NE permit application)
A. PROPERTY OWNF"ERMIT APPLICANT
Name of each owner listed on property deed. For a business or government agency, state name of entity an
name of person delegated authority to sign application orbehalf of the busineWagency:..
} T C ��•.
(1) Mailing Address: r� D z �. �•r Tc fiat -- r-�
City: /-64r2.•AvState:4d__ ip Code: County: G ��s � • -
Home/Office Tele No.: Cell No.: 91Z 2,;YJgi `i
Fax No. E m a i I Address: ,!!F J1I-1-L�G
(2) Physical Address of Well Site (if different than tbove):
City: State; lip Code: County:
Home./Office Tele No.: Celt No.:
Fax No. _ -Email Address: _
B. PROPERTY OWNERSHIP DOCUMENTATION
Provide legal documentation of property ownership, sulh as a contract, deed, article of incorporation, etc, and
a PLAT map showing the property. Ttris information rr}ay be obtained from county Register of Deeds or GI5
website.
C. AUTHORIZED AGENT, IF ANY
If the property owner/permit applicant wants to authori someone else to sign the permit on their behalf, then
attach a si eded letter from the property owner/permit tpplicant specifying and authorizing their agent (well
driller, heat pump contractor, or other type of contractor agent) to sign this application on their behalf.
Company Name.: 5 y
Contact Person: ::5, y . Em ' 1 Address:
Address: ` U ce 1,
t,
City: Z,*,4,aZZ Z State: Zip Cod z County:
Office Tele No.. f _.-� 7 S' Fax No. t `� Cel! No. 'r.fD (�fG
Website Address of Company, if any:
REC&VED / VENR / 0VV0
A4UlF�R a�4n�xr�Fi�,y SFC710N

D. WELL DRILLER INFORMATION
Company Name:Well Drilling Contractor's Name: t� EN 6rA Q G
NC Contractor Certification No.: k-C Z313 A Contact Person. SJAtotg
Company Website: WWW. +S r s-�, v, ++_Lwrri G , LwM Ernail Address_ 131?wf6&0Q C&46Ao+co01i.w
Address: q 3 3 Z N 4 w� Z 3
City: we,- 51- FJw14 � - State: NL Zip Code: IA County: 1"`846
Office Tele No.10"C 1 3- Z I Z t Fax No. RI# - 6 7 3- Z 71 Z Cel i No 1 io-4 *M-1$ T
E. HEAT PUMP CONTRACTOR INFORMATION (if
Company Name.
d' erect than Driller)
C'nniart Aprenn• ---
Company Website: W W W. _ - - '- - - r . !J.`" Email Address:
Address: --�-� •1...,�
City: �;_ , r��'ct�T G, State:,&:�'-Zip Code: :2=EE6 County;
Office Tele No.:�yy : ? G Fax No. %G� Cell No. 'f1; J 7
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. 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 y-
Nr
WELL CONSTRUCTION DATA
PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(7) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (7)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
GW-1) if available.
Iz—
(1) Well Construction Date: (J Number of borings:
Depth of each boring (feet): V N K Na w �J
(2) Well casing. Is the well(s) cased?
(a) YES if yes, then provide the casing information below.
Type: Galvanized steel Black steel Plastic Other (specify)
Casing thickness; diameter (inches): depth: from
Casing extends above ground inches
(b) NO
to feet (relative to land surface)
(3) Grout material surrounding well casing:
(a) Grout type: Cement f Bentonite* Other (specify)
,-,,*By selecting beaunite grout, a variance is hereby requested to I5A NCAC ZC .D213(d)(l)(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from to feet

(4)
(5)
Well Screen or Open Borehole depth (relative to land surface): from ____ to ___ feet
N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Will there be a faucet on:
(a) Influentline? Yes No __ (b) Effluent line? Yes No
(6) Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Form GW-1). If Form GW-1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment ·units will the groundwater be withdrawn? (e.g.
granite,·limestone, sand. etc.)
Depth: Formation: ______ Rock/sediment unit: _______ _
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHERWISE UNAVAILABLE.
L OPERATING DATA
(l)
(2)
(3)
(4)
Injection Rate:
Injection Volume:
Injectioa Pressure:
lnjectiom Temperature:
J. INJECTION-RELATED EQUIPMENT
Average (daily) /<j gallons per minute (gpm).
Average (daily) IJ, 'IG,Ogallons per day (gpd).
Average (daily) &..CJ pounds/square inch (psi).
Average (January) l/ ;)._ ° F, Average (July)~° F .
Attach a schematic diagram or cross-section of the well construction that shows the total depth, length of casing,
extent of grout, stickup, location of influent/effluent sampling ports, etc. If this is a modification, show the
engineering layout or proposed modification of the injection equipment and exterior piping/tubing associated with
the injection operation. The manufacturer's brochure may provide supplementary information if needed.
K. LOCATION OF WELL(S)
(1) Attach a site map (can be drawn) showing: houses and other structures, property lines, surface water bodies,
potential sources of groundwater contamination, and the orientation of and distances between the proposed
injection well(s) and any other existing well(s) or waste disposal facilities such as septic tanks or drain fields
located within 1000 feet of the geothermal heat pump well system. Label all features clearly and include a
north arr0w.
(2) Attach a scaled topographic map of the area extending 1/4 mile from the property boundary that indicates
the facility's location, a north arrow, and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. 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.
L. CERTEFICATION (to be signed as required below or by that person's authorized agent)
NCAC 15A 2C .021 1(b) requires that all permit applications shall be signed as follows:
I . for a corporation: by a responsible corporate officer;
z. 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 ail others- by the well owner.
If an authorized agent ks signing on behalf of the applicant. then submit a letter signed by the
Applicant that names and authorizes their agent as specified in Part C of this permit application.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted in
this document and all 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."
Sigi tore - roperty Owner/Applicant
Print or Type Full Name
rSignature of Property Owner/Applicant
Print or Type Full Name
J
�G Signature of Authorized Agent, if any
Print or Type Full Name
Submit TWO signed copies of the completed application package and all attachments to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIV01 DENR I DW4
A0 UJFFR-PRf1TFrTI0N SECTION
MAY 12 2019

Dr. Edward Hickman
5104 White Oak Drive
Lumberton NC 28358
May 4, 2010
To whom it may concern:
Simmons Heating Cooling Electrical, Inc. will represent me, Dr. Edward
Hickman, as nay agent for the sole purpose of installing a geothermal
HVAC and hot water systems. Stephen W. Cole, President of Simmons'
is authorized to represent my interests and to sign appropriate
documents for this project.
Sincerely,
Dr. Edward Hickman
Witness: Date: f�
RECEIVFD I DENR 1 ON
AQUIRM aanTprTiniq �FCTION
MAY 12 2010

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This ltsrCanmr was prgkgtad by xw H. StricWsad
NORTH CAROLINA GENERAL WARRANTY DEED
MISDM node Dmmnber f, =& by and bxsrcca
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nw dwlgrcpiiun Crmwr and Crams r mW bmen dmU tadudr oriel puuM their herT, >ax»>. aM -p* and shall iW%ift singalar,
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WMQMW f, do the Gramm, for awahoble cmp*wmdon pud by the Grantee, die m o of wbwh is hadry m*wwWlpd, has and by
bm presL— ryas grog bargain, sell and carry unto fhe GrmMin fat *npfc, all lira[ cartain IN or patsd of land situ" irk ft csly of
Immberron , [araberfaa i mndkrA Robam C4wW. Nash Carolina and unre Nrtsadahy dasnibed as fulloua
See Sdicdulc ilaltWW, incorparated herein by mfemnce-
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0 The pkopmW humnabow dmm'bW was ea7 pared by UmnWr by inamtsrmt raawded in Book. Page, RohmDrt Ca>ily RegimY
A I.ap rhrwiRg the 9M 6OUbdd pr OWY it9MXvdad in Hook , P■ta
TAD HAVE AND TO HOLD the ap rmW lot or pawl of land lad ail VMkges W app otenUm= Ihaeta belonghg to the Oramw in fee
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AM the ❑rakgnr vwmm SwUh the Gnudx, rtM [mrdor iSteivad oftdc p=axnn fa.ompk has the nj�kttn axwey the same ht fix Uftoc,
Wu ttlk ii mui Wbk aad One and dm of all uiam aka Bad" Grardor sn•St warr■nt ad dcfesd the tick agtioo the hnrha efatm of all
pawm wbwmcva amp fug[ lht: cg=pwm Geteauanrt stains
Title to the preputybumbabove dexrtbed is ujbpa to Ih61r117uwW exoVba r
RJ W[FI�i9 wfII+RF.�F, the l.x�lrs has htsn�ses hia 4mdbkd saal, er i[wtperate, i]n Quad This iasWxr:nt m he aged in W oxpaate nine
by its miy ui otirmand>b mal to behmvL b aMW byudmityof* Ogre! of Dkt mm dwdry and ym fau sbdm watned
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Being all of1,ut Number THIRTY-SEVEN (37), as shown on snap entitled, "Oakridge Subdivision,
Section II," prepared by Anderson Engirmwing ,& Axwoatea, P.A. dated September 1, 1993, and
recorded "ook ofpfficiai Maps 33, at page 25, Robeson County Registry, reference to which map
is hereby made for a n►m particular description of ald lot and for the purpose of inoorporat* the
same in this description as if the tune ware rally set forth herein.
The above described is conveyed subject to that certain Federation of Restrictive Covemmu and
Conditiona, dated March 4, 1992 and recorded in Book 735. at page 783, Robeson Canty Registry,
sod that certain F orat Supplernen 3 Declaration of Restrictive wo Prolc aive Covenants and
Conditions, dated September 1, 1993 and recorded in Book W. at page 127, Robeson County
Regialry,
Trad.22
Lying and being in the City of Lumberton, Robeson County, North Carolina, shod 63 fact west of
WilIow Oak Drive, about l50 feet south of White Oak Drive, bounded by Lot 37 Oakridge on the
nortit, by Lot 54 on the youth, Lot 40 on the west and the remainder of Lot 52 on the vast.
BEGINNING at an existing iron stake, the mast restem wrrw of Ix 37 O&Mdge Subdivision
Section f1(Map Book 33,Page 25), the southwest corner ofLot 47 Oakridge Subdivision Section FII
(Map Book 33, Page 96) and a corner of the origins! Lot 52 Oalaidgo subdivision Soctian Ut and
runs from said point of beoning" a ntnv line South 4 degrees 24 minutes 49 uconds west 146.25
feet to an iron stake sal is to southern line of Lot 52, the northern line of Lot 54, thence with the
common line of Lots 52 and 54 !North 78 degrees 57 nfsnutes. 03 sacoads west 87.01 Feet to an
47isting iron stake is an eMem fine afLot 40, a common corner oftots 52 and 54, thence with and
eastern life ofiLot 40 N&& I deffees 02 minutes 57 saeonds East 20.00 feet to sn existing iron
slake thaueagain with an auertr lineofLot 40 North 4 degrees $8 minutes 49 seconds West 59.80
feet to in todWq inn stake in the southern fine of Lot 37, a common corner of Lots 40 and 52;
thence with the aouthcm tiro of Lot 37; the northern, line of Lot 52, North 63 degrees East t 10.00
feet to the poira of heg'vuting, containing 0,24 acre, mare or tern.
Bring it portion of Lot 52 Dakridge Subdivision, Section W as shown on a plat recorded in Mop
Book 33, Page 96. Robeson County Registry,
i his lot, being ono -half (14) of a tot in the Waidge 5ubt ivisioq shag be subject to one-half ('h) of
the tot ammmenu t hergcd from time to time by The Oaicridge Association of Lumberton, l.td.
Subject to that certain X3eeiaration of AeaOctive and Prateotiva Covenants and Conditions, dated
Datobrr 26, 1994. and recorded in Soak 849, at page S31, Robeson County Registry, and subject
to aasemertts shown on the plat hereinafter: referred to.

0
�/,3
EXi.: dFrl0Sl-1
EXPLANATION STATEME14TTO CORRECT OBVIOUS MINOR ERROR(5) MADE
RV AN INSTRLRCPI'T AS ORIGINALLY RECORDED
RE: BOOK �.
RECORDED IN THE _ _ �� 6r COUNTY REGISTRY
NAMES OF ALL PAR71ES TO THE ORIGINAL ZrFRUMENT: 1
GRANTORS:d-
GRANTEES: L.s'"srr� Y, .+mod +/ dr a
STATE OF NOR CAROLINA
COUNTY OF feu
UWE. The Lhtdmigned, hereby certify that the Cvilowing correctiuus are made is dm above named
recorded uutrummt m accordance with the provisions of G.S- 47.36.1 ratified June 30, I986,
OFSCRM'nON OF CORRECTION (S):
Z2
THIS, '[YI£AY OF 2fl�
($FAL)
i51~AL]
E
($EAL)
This expLamAk is =Cemmt eogedter witb the attach u+sttuEneM duly arded at
o'clock Mthisthe dayof- 2v4a�
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Register of feeds /Assistant Rillisier of Deeds
1

Retum Well disposal of VYIateffumace Well Water
Supply
Potable
Water Line
Well Ratum
Pressure
y.. - Tank -1
Welt
Pump' —a--
Corte of
'
-- - - Discharge Line
1
Depression
Injection Head o--i
,r Cone at Impression
— — —. —. — — — — — --Static Water Level— — —
#
Drop Pipe Extending
Backpressure Vaive TD
1
Below Static Water Level
Keep Discharge Line
Submersible
Under Prepsure
Pump
well Screen
F
�
Screen Area Mml
Minimum $0' lsolatlon Between Supply or Return Well end Septic -rank. Drainfiefd, Rry We
be Tice that of
Supply well
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