WI0700013_GEO THERMAL_20200508

r olina Department of Environmental Quality -Division of Water Resources
APPLICA'{lON FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
N OS tGl'l ' Y" In Accordance With the Provisions of 15A NCAC 02C .0224
~~~RMAL HEATING/COOLING WATER RETURN WELL (S}
-These well(s) inject groundwater directly into the subsurface as part ofa geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application -X-Renewal* __ Modification __ Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Sections A thru E, and MJ.signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: _______ _, 20 __ PERMIT NO. t/\/1-o it O O O 13 (leave blank if New Application)
CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application) A.
1. Current Use of Well ~
a. I wish to continue to use the well as ~ Geothermal Well D Drinking Water Supply Well
D Other Water Supply Use-Indicate use (i.e., irrigation, etc.) ________ _
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
D Yes, I wish to rescind the permit
2. Current Ownership Status ~
Has there been a change of ownership since permit last issued? D YES 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 ~ Business/Organization __
Government: State Municipal__ County__ Federal
C. WELL OWNER(S)/PERMIT APPLICANT -For single family residences, list all persons listed on the
property deed. ! or all others, ·st name of business/agency and name of person and title with delegated authority
to sign: ~
Mailing Address: •
City: ~ l:\(u1:oY State: tft_zip Code: ~]'1\19 County: a!_
Day Tele No.: l:!,o\L) SI~• (t?m; Cell No.: -
EMAIL Address: Kt5hl0:-t ~a~ Fax No.:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 1
D. WELL OPERATOR (if different from well owner)-For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
tosign: ~ ~ \1,0l\ Oll!0OY
Mailing Address: _______________________________ _
City: ____________ State: __ Zip Code: ______ County : _____ _
Day Tele No.: ---------------=E=m=at='l'--'-A-=-=d=d=r=es=s=·=------------
E. PHYSICAL LOCATION OF WELL(S) SITE
( 1) Parcel Identification Number (PIN) of well site: _______ -----= __ County: _____ _
(2) Physical Address (if different than mailing address): ~ aS roaJ. l\~
City: _____________ County _________ Zip Code: ____ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: _________________________ _
NC Well Drilling Contractor Certification No.: ____________________ _
Company Name:. _______________________________ _
Contact Person~: --------------~EMAIL Address: ___________ _
Address: _________________________________ _
City: _________ Zip Code: _____ State: __ County: _________ _
Office Tele No.: _________ Cell No.: Fax No.:. ________ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: ___________________________ _
NC HVAC Contractor License No.: ________________________ _
Company Name: _______________________________ _
Contact Person~: --------------~EMAIL Address: ___________ _
Address: _________________________________ _
City: _________ Zip Code: _____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ----------------
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
P~rson_al ,consumption?
YES ___ _ NO ___ _
YES __ _ NO ___ _
I. WELL CONSTRUCTION ·lmQUIREMENTS -As specified in l SA NCAC 02C .0224( d ):
(1)
(2)
.. _. .
Tlie wat~r sup'pfy well ~hall be constructed in accordance with the-water supply well requit'eme~ts of
ISA NCAC OlC .0107 .• ·
If a separ!lte well is, used to 'inject the he~t pump effluent, then the injection well shall be constructed
in accordance with the water sup:i,ly well requirements of ISA NCAC 02C .0107 , except that:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page2
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A samplii;ig tap-or other approveq collection equipment shall provide a functional source of water
during: system operation for the collectibn of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
____ *EXISTING WELLS ----~PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and inje"c~on well serving the geotherrnfil
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107 f0(8 J
(t) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATINGDATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP -As specified in I SA NCAC 02C .0224 (b )( 4 ), attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(I) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0 I 07(a ){2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page3
NOTE. In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand Also. a `layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211 (gi 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 persons s).listed.on the propprty 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 ofthe
Permit."
Signature of Property Owner/Applicant
( otter"�
Print or Type Full Nl ne and Title
A -
Signature of Property Cwne .rpp scant
NN
Ab"
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - [.TIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev_ 4-15-2016 Page 4

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMrr TO CONSTRUCT OR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of 15A NCAC 02C .4124
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 Renewal* _Modification Permit Rescission Re
■Aor Permit Renewals �f a R : ,� - AWWWke�yHe
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE:
A.
20 PERMIT NO. (leave blank if New Application)
CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New We1VPermit Application)
1. Current Use of Well
a. I wish to continue to use the well asbdGeothermal Well []Drinking Water Supply Well
❑ Other Water Supply Use- Indicate use (i.e., irrigation, etc.)
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
❑ Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES 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 Business/Organization
Government: state Municipal County Federal
C. WELL OWNER(S)!PERMIT APPLICANT — For single family residences, list all persons listed on the
property deed. For all others, . t name ofbusinessl envy and name of person and title with delegated authority
tD Slgn:Ar _ __
Mailin Address: A
City: LIA
State: K—Zip Code: ;" County
Day Tele No.:V� 7` Cell No.:
EMAILAddress: T Fax No.:
Geodzermaf Water Return Well Permit Application Rev. 4-15-20T6 Page I

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT DR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of 15A NCAC 02C .0?24
GEOTHERMAL HEATING/COOLING WATER RETURN WELLS
These well(s) inject groundwater directly into the subsurface as part of a geothermal beating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application Renewal* Mndificstiou Permit Rescxssiun Re nest*
,For perm Renewals t—
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete,
DATE: .20 PERMIT NO. (leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New We[UPermit Application)
1. Current Use of Well
a. I wish to continue to use the well as*eothermal Well ❑ Drinking Water Supply Well
❑ Other Water Supply Use- Indicate use (i.e., irrigation, etc.)
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
0 Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES 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 Business/Organization
Government: State Municipal County Federal
C. WELL OWNER(S)IPERMIT APPLICANT — For single family residences, list all persons listed on the
property deed. For all others , ' t name of business/agency and name of person and title with delegated authority
to sign:\rJj _
Mailin Address: City; � V State: � P Zip Code: County: �—
Day Tele No.:u 1 Cell No.;
EMAIL Address: Fax No,:
Geothermal Water Return Well Permit Application Rev, 4-I5-2016 Fagg

D. WELL OPERATOR (if diffe~ent from well owner) -For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
tosign: ~ o;S \L~ll 01unOY
Mailing Address: _____________________________ _
City: ____________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: -----------------'E=m=ai"'""l =A=d-=dr"""e"""'ss~.:'-------------
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: __________ County: _____ _
(2) Physical Address (if different than mailing address): '50..fV\e. ~ roal l\ ~
City: ____________ County _________ Zip Code: ____ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: ________________________ _
NC Well Drilling Contractor Certification No.: ___________________ _
Company Name: ______________________________ _
Contact Person~: ______________ EMAIL Address: __________ _
Address: ________________________________ _
City: _________ Zip Code: ____ State: __ County: ________ _
Office Tele No.: ________ Cell No.: ________ Fax No.: _______ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: __________________________ _
NC HVAC Contractor License No.: _______________________ _
Company Name:, ______________________________ _
Contact Person~: ______________ EMAIL Address: __________ _
Address:---------------------------------
City: _________ Zip Code: ____ State: __ County: ________ _
Office Tele No.: Cell No.: Fax No.: ______ _
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(I) The injection operation? YES ____ NO ___ _
(2) P~rsonal,consumption? YES ____ NO ___ _
I. WELL CONSTRUCTION ·REQUIREMENTS -As specified in I SA NCAC 02C .0224(d):
I •-· •
(1)
(2)
The water suppfy well shall be constructed in accordance with the-water supply well requil'ements of
!SA NCAC OJC .. 0107 .• ·
If a separt1te well is, used to 'inject the he~t pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of I SA NCAC 02C .0107 except that:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page2
D. WELL OPERATOR (if different from wen owner) -For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
tosign: :xi.rrf. ll'.S U~l\ ou1nOY
Mailing Address: _____________________________ _
City: ____________ State: __ Zip Code: ______ County :. _____ _
Day Tele No.: ---------------=E'°'m""'a..._il ..:..A=-=d::d::...:re=s=s . .,_: __________ _
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site:. _______ ----=c __ County: _____ _
(2) Physical Address (if different than mailing address): ~ (lS roru n~
City : ____________ County _________ Zip Code: ____ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: ________________________ _
NC Well Drilling Contractor Certification No.: ___________________ _
Company Name:. ______________________________ _
Contact Person.~: ______________ EMAIL Address:. __________ _
Address: ________________________________ _
City: _________ Zip Code: ____ State: __ County: ________ _
Office Tele No.: ________ Cell No.: Fax No.:. _______ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: __________________________ _
NC HVAC Contractor License No.: _______________________ _
Company Name: ______________________________ _
Contact Person.,_: ______________ EMAIL Address: __________ _
Address: ________________________________ _
City: _________ Zip Code : ____ State: __ County: _________ _
Office Tele No.: Cell No.: _________ Fax No .: ______ _
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(I)
(2)
The injection operation?
P~rsonal ,consumption?
YES ----NO ___ _
YES ___ _ NO ___ _
I. WELL CONSTRUCTION·REQUIREMENTS-As specified in 15A NCAC 02C .0224 (d ):
(I) The wat~r sup·pty well shall be constructed in accordance with the-water supply well requir'ements of
15A NCAC OlC .. 0107 .• · .
(2) If a separ!ite well is-used to 'injeot th~ heat pump effluent, then the injection well shall be constructed
in accordance with the water supJ'ly well requirements of I SA NCAC 02C .0 l 07, except that:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page2
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap-or other approvecj. collection equipment shall provide a functional source of water
during: system operation for the collectibn of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
K.
( 1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
_____ "'EXISTING WELLS _____ PROPOSED WELLS
* For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and inje'Ction well serving the geotherm~l
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NC.AC 02C .0J07(t2f!il.
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
OPERATING DATA
(1) Injection Rate: Average (daily) __ ~gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP-As specified in 15A NCAC 2C .0224 b 4 , attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0 I 07 (a )(2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Pennit Application Rev . 4-l:S-2016 Page3
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A samplii:ig tap·or other approvecj. collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothennal heating/cooling system:
_____ ,.EXISTING WELLS _____ PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and inje-ction well serving the geotherm!il
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(!)(8)
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATINGDATA
(1) Injection Rate: Average (daily) __ ~gallons per minute (gpm).
(2) Injection Volume: . Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP-As specified in I SA NCAC 02C .0224(b)(4). attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in I SA NCAC 02C .0 l 07 (a)(2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one .-ofthe cardinal directions (north, south, west, or east)
Geothennal Water Return Well Permit Application Rev. 4-15-2016 Page 3
NOTE In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county Glii website. Typically, the property can be searched by
owner name or address. The location of the welts 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
daw
M. CERTIFICATION (to be signed as required below or by that pemon's authorized agent)
1 SA NCAC 02C .0211 Le) requires that all permit applications shall be signed as follows:
I. for a corporation: by a responsible corporate officer,
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency_ by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the person[ s )1 fisted 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 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 ofthe
Permit."
L
Signature of Property Owner/Applicant
ln[�ui 7 (O X)
Print or Type Full Name and Title
Signature of Prope-N%Aba rty Owne i pp scant LOWNUI
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIfC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (919) $07-6464
Geothermal Water Return Welk Permit Application Rev. 4-19-2016 Rage 4

NOTE: In most cases an aerial photograph of the property parcel shosving property lines and structures can be
obtained and downloaded from the applicable county GIS websrle. 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 them be drawn in by hand. Also, a 'la}per' can he selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15ANCAC 02C .0211 {e) requires that all permit applications shalt be signed as follows:
I . 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 atl the personas} listed on the prop iv- 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
iinjection well and a]I related appurtenances in accordance with The approved specifications and conditions of the
Permit."
/U
Signature of Property Owner/Applicant
Print or Type Full Name and Title
Signature of Property Owne. 7- pp scant
Nyoxt -rl U . o
Print or Type Full Name and Title
Signature of Authorized Agent. if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 2 7699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Yaffe 4

ROY COOPER
Governor
MICHAELS. REGAN
Secretary
S. DANIEL SMITH NORTH CAROLINA
Environmental Quality Director
William & Amber Tice
180 New Beach Rd.
Point Harbor, NC 27964
RE: Acknowledgement of Application No. WI0700013
Geothermal Heating/Cooling Water Return Well
Currituck County
Dear Mr. & Mrs. Tice:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt
of your permit application and supporting documentation received on May 8, 2020. Your
application package has been assigned the number listed above, and the primary reviewer
is Shristi Shrestha
Central and Washington Regional Office staff will perform a detailed review of the
provided application, and may contact you with a request for additional information. To
ensure maximum efficiency in processing permit applications, the Water Quality Regional
Operations Section (WQROS) requests your assistance in providing a timely and complete
response to any additional information requests.
Please note that processing standard review permit applications may take as long
as 60 to 90 days after receipt of a complete application. If you have any questions, please
contact Shristi Shrestha at 919-707-3662 or email at [e-mail].
cc: Washington Regional Office, WQROS
Permit File WI0700013
Sincerely,
For Rick Bolich, Chief
Ground Water Resources Section,
NCDEQ Division of Water Resources
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street I 1636 Mail Service Center I Raleigh, North Carolina 27699-1636
919.707.9000
ROY COOPER
Govemar
MICHAEL S. REGAN
Seaerary
5, DANIEL SMITH
Olmcror
NORTH CAROL?NA
Environmental Quofity
April 30, 2020
CERTIFIED MAIL # 7018 0040 0001 1449 6894
RETURN RECEIPT REQUESTED
William & Amber Tice
180 New Beach Rd.
Point Harbor, NC 27964
Subject: Notice of Expiration (NOE)
Geothermal Water RetumlOpen-Loop Injection Well
Permit No. WI0700013
Currituck County
Dear Mr. & Mrs. Tice:
The Underground Injection Control (U1C) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on July I, 2015, and expires on June 30, 2020. Per permit conditions and requirements per
15A NCAC 2C .0224(c), the renewal application must be submitted at least 120 calendar days
prior to expiration of the permit if you wish to continue operating the injection well on your
property.
If Your Geothermal Water Return Well is Still Currenth° Beine Used for In iection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
h=./lgortal.ncdenr.org/web/wcjlaps/;,), ,�■.-pro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Seine Used for Injection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (Le., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C,
Section .0240. When the well is plugged and abandoned, a well abandonment record (Form GW-
30) must be submitted to our office to certify that the abandonment was properly conducted.
1Vortb Carolina Qepa"em o F Envl =m ental Quality I DIOslo n of Water Resources
EQ W Non Sali!5bury Sweet } 163h !Nail Service Center I kaletgft North Carolina 27699-W36

If There has been a Chance of Ownership of the P_ropern :
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UTC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms 30 days before the -expiration of the permit may result in
the assessment of civil penalties in accordance with North Carolina General Statute 87-94. Thank
you in advance for your cooperation and timely response_ If you have any questions, please contact
me by phone at [phone] or by email at shristi.shresthafuncdenr-gov.
Regards,
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington- Regional Office — WQROS w/o enclosures
Central Files - Permit No. W10700013 w/o enclosures

6.2
LVX
NA
�w�
MCDGf1A
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
June 24, 2015
William and Amber Tice
180 New Beach Road
Point Harbor, North Carolina 27954
SUBJECT. Groundwater Sampling Results
UIC Permit No. W10700013
issued to William and Amber Tice
Point Harbor, Currituck County, North Carolina
Dear Mr. and Mrs. Tice:
Donald R. van der Vaart
Secretary
RECEIVEDIDERDWR
July 26 Z015
water Q alitY
Permitflni Section
Staff from the Washington Regional Office of the Water Quality Regional Operations Section collected
samples of the influent (supply well) and effluent (injection well) from your geothermal heat pump system on
April 25, 2015. The samples were analyzed for metals, nutrients, and other inorganic constituents by the
Division of Water Resources laboratory. A summary table of the analytical results, as well as the laboratory
reports, field sampling forms, and definitions of laboratory data qualifiers are attached to this letter- The
following three constituents were detected above state groundwater standards in both samples from your
system;
Parameter
Iron
Manganese
pH
Units
ug1L
ug1L
Standard Units
NC Groundwater Results
Standard
300 4500 (supply well -influent)
4100 (injection well -effluent)
50 100 (supply well -influent)
100 ,injection wail-effiuentl
6.5 to 8.5 5.5 (supply well--influent)-�
5.5 {injection well -effluent i
The exact source of these exceedances is unknown; however, Iron, Manganese, and pH exceedances
in groundwater are often due to naturally occurring conditions. These exceedances should not affect the use
of the wells for your geothermal heat pump system; however, it is recommended before using the water from
these wells for personal consumption that you consult with Albemarle Regional Health Services (local health
agency).
In addition, the following two constituents exhibited an increase in concentration between the influent
{supply well} and effluent (injection well):
Parameter Units
NC Groundwater
Results
Standard
Copper i
ug1L
1000
28 (supply well -influent)
160 tiinjection well -effluent,
Nickel -
ug/L
_
100
2.2 (supply well -influent) -
a0 'injection welkeffluenty
Division of Water Resources — Water Quality Regional Operations Section — Washington Regional Office
943 Washington Square Mall, Washington, NC 27889
Phone: [phone] F ax: 252-97 5-371 M Internet wwwncdenr.gov
An EquA OppWun41 Airirmatiw Aotlon Employer — Made in part by recyciev paper

William and Amber Tice
June 24, 2015
Page 2 of 2
While the concentrations of these constituents are still below state groundwater standards, these
results may indicate that your geothermal heat pump system is have an effect on the groundwater flowing
through the system. This information being provided to help you operate the system in the future.
If you have any questions regarding the sampling results or your permit, please feel free to contact me
at [phone].
Dwight Randy Sipe, P.G., Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources, NCDENR
Attach]en s
cc: ichael Rogers -DWR Groundwater Protection Unit, Central Office
Albemarle Regional Health Services
WaRO
Parameter Fecal Coliform
units CFU/100ml
NC MCL and/or EPA Standard NC GWS =< 1
Influent Sample Results < 1
Effluent Sample Results < 1
Parameter Nitrate
units mg/Las N
NC MCL and/or EPA Standard NC GWS=10
EPA PDWS = 10
Influent Sample Results 0.29
Effluent Sample Results 0.27
Parameter Chromium, Cr
units µg/L
NC MCL and/or EPA Standard NC GWS= 10
EPA PDWS = 100
Influent Sample Results <10
Effluent Sample Results <10
Parameter Sodium, Na
units mg/L
NC MCL and/or EPA Standard NS
Influent Sample Results 13
Effluent Sample Results 13
NC DIVISION OF WATER RESOURCES
LABORATORY ANALYTICAL RESULTS
GEOTHERMAL UNDERGROUND INJECTION CONTROL (UIC) WELL
PERMIT NO.: WI0700013
PERMITTEE(S) William and Amber Tice
SAMPLE COLLECTION DATE: 4/25/2015
Total Coliform Total Dissolved Solids Chloride, Cl
CFU/100ml mg/L mg/L
NC GWS = 1 NC GWS=500 NC GWS =250
EPA SDWS = 500 EPA SDWS = 250
< 1 122 23
< 1 126 23
Hardness as CaCO3
Nitrite (by Calculation) * Aluminum, Al
mg/Las N mg/L as CaC03 µg/L
NC GWS= 1 NS NS
EPAPDWS= 1 EPA SDWS = 50 to 200
<0.01 67.2 <50
<0.01 67.2 <50
Copper, Cu Iron, Fe Potassium, K
µg/L µg/L mg/L
NC GWS = 1000 NC GWS = 300 NS
EPA SOWS= 1000; PDWS = 1300 EPA SOWS= 300
28 4500 2.8
160 4100 2.8
Nickel, Ni Lead,Pb Zinc, Zn
µg/L µg/L µg/L
NC GWS = 100 NC GWS = 15 NC GWS = 1000
EPAPOWS= 15 EPA SOWS= 5000
2.2 3.9 32
40 3.1 24
Fluoride, FL
mg/L
NC GWS =2
EPA PDWS = 4.0
<0.4
<0.4
Arsenic, As
µg/L
NC GWS = 10
EPA PDWS = 10
<2.0
<2.0
Magnesium, Mg
mg/L
NS
3.6
3.6
pH (field)
units
NC GWS = 6.5-8.5
EPA SOWS= 6.5 to 8.5
5.5
5.5
NC GWS. = North Carolina Groundwater Standard per 15A NCAC 2L .0200 • Calculation performed by WaRO
EPA PDWS = Environmental Protection Agency Primary Drinking Water Standards
EPA SOWS = Environmental Protection Agency Secondary Drinking Water Standards
NS = No Standard
Sulfate, S04
mg/L
NCGWS=250
EPA SOWS = 250
40
40
Calcium, Ca
mg/l
NS
21
21
Manganese, Mn
µg/L
NC GWS=50
EPA SOWS= 50
100
100
0(-Jn�
North Carolina Division of Water Resources
Central LA beiratury (Water SrJences Section)
Water Sample Collection& Submittal Form
VjsIt 10,
(optional),
.4b•only.
V fV-Y7
tk'S -T
WI: 07 0 0 0 1
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C] Waste
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Osolution
tc, bx,hfd
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hr
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05tormwater
UMarikorific Well E]Watersupply
FjEffl-eng Elln(luent I
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Notes.
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❑ Chlorinated L—]1)e-cWoTina1Od in Field
Grab 'Cornposile
Jx ElOft,
Dissolved analysis: Eroef "DIS'
❑ Filtered in Field
In check-bmms for parameters9
C. M 511
ccUerA-,
5 r CC k cf5,
MRAS(5urfactants)
mg/L
Metals Para M;etze es:
Tin (Sn)
Acidity, as lraOD3, to pH 4.5193
mg/L
Oil and Grease. HEM, Total Recoverable
moo.
><j
Aluminum (All
461L
TlimAlurn M)
Alkarulky, as QCO2, to pH 4m5183
rrLg/L
Phenols, Total Recoverable
P&A
Antimony (5b)
OF,/L
Vanadium (V)
BCD: Slwh emica I OWn Demand, 5-day
mg/L
Residue: TataL(TotolSolids)
mg/L
:)<
Arsenic (As)
Vg/L
Zinc (Zn) ")L
cBOD: Carbcnace=5 BOD, 5-day
mg/L
Residue: Volarile/Fixed, Tonal
mg/L
Eloolum (82)
Coliform. Fecal MF
/100ml
Residue: Suspended t5uspended-Solids)
Beryllium (80
v gA
Baron (14), Total WL
Coliforrnm.lotal MF
1100MI
Residue: VolattWFIxed. Suspended
me/L
Cadmium (Cd)
P811
Mercury 1631, low-level ng/L
CoRtafm: Tube Fecal
1100mi
TD5 - Total Dissolved Solids
mg/L
Calcium (Cal
(nqIL
Cotdo rm; Tube Totpl
/1DOm1
silica
mg/L
chromium (Cr], Total
IJAA
oigaAics`
5 pecHic Cond uctanw. at 25 X umhosycm
sulfix1a
mg/L
Cobalt (cc)
1JOA
AcId Herbicides
70C - T-dt2J43r82r1lC CaTbon
mg/L
Tarkri In & Ligefin
mg/L
Copper(cu)
VS/L I
OrzaporhWn8 9esticides
Tueaidity
NTU i
==
iron (Fe)
P&A
Organcoltrogen Pesticides
sOiher rs: - -
Lead (Pb)
PSA
Organophosp horus P esUcides
Wet Ch,6;M!&W Rz�'D-n ftmm-%-.m-
ply
lithium (U)
P&A
PCBs (polychlorinated biph"11)
Bromide
mg/L
Hardness, Total as QC03 - by O"tion
mg/L
rMaertemurn
(Mg)
mq1L
Chloride
mg/L
Manganese (Mn)
pg/L
Semi -Volatile Grpn7= (ON Asl
Fittodde
MCIL
Mercury (Hg)
IjgA
TPH Diesel Range
Sulfate
Maiyhrienurn (Me]
pgjL
Chlorophyll
PgA
Arn monla as N (NH 3 -N 1.
Nickel (Ni)
lig/L
VblaUle Organia (VOA)
Color: ADMI
c.u.
N itriTtem Nitfite W N I riC3+NO2-Nj
mg/L
PiXaSPUM (K)
mg/L
Color; Platinum Cobalt
-Total —Xle Jda hi Nitrogen as N (TKN I
mj1L
Selenium (Sel
pg/L
TfPF Gasoline Range
COD: C hemkAt crgen Demand
mg/L
7Total Phosphorus as P (TP)
m
Silver (Ag I
ijg/L
Cyanide, —T-i-I
mg/L
Nitrite as N (NO2mN)
m WL
Sodium (Na)
mqIL
siologicarmm+':
Formaldehyde
mg/L
Nitrate as N (Ko3mN catculaled)
mg/L
jStroifflufn
(Sr)
pg/L
I
I PhyEoplonkc on I Algae
ftr.rvalent ChMmIum (Gr6+)
rag/L
Orthophow hate LS P (PC41
mg/L
PS/L
LAB CO M ME NTS
Field F-ArziheTersJO'M'(cri9rQW te pH is, Oussolved Oxygen (OpmY, C66d,,�� (VMhoSjCFn)-
r7erip I - Q,

AC18772 :N"C <DWa( Water Sciences Section-Cfiemistry £a6oratory ~su(ts
County : CURRITUCK Sample ID : AC18772
River Basin PASQUOTANK DWR PO Number# 15G0188
Report To WARO Date Received : 04/29/2015
Collector: RSIPE Time Received: 08:00
Region: WARO Division of Water Resources
Labworks LoginlD TASCENZO1
Sample Matrix: GROUNDWATER Final Report Date: 6/11/15
Loe. Type: Final Re Qort Report Print Date: 06/11/2015
Emergency Yes/No VisitlD
COC Yes/No
Loe. Descr.: TICE 1801 NEW BEACH ROAD
I Location ID: WI0700013 I Collect Date: 04/28/2015 I Collect Time: 10:10 I Sample Depth I
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
CAS#
LAB
MIC
WET
NUT
MET
7429-90-5
7440-38-2
7440-70-2
7440-47-3
7440-50-8
7439-89-6
7440-09-7
7439-95-4
7439-96-5
7440-23-5
7440-02-0
7439-92-1
7440-66-6
Anal yt e Name PQL Result/ Units Method Analysis
Qualifier Reference Date
Sample temperature at receipt by lab p.7 ·c 4/29/15
Coliform, MF Fecal in liquid 1 1 B2Q1 CFU/100ml APHA9222D-20th 4/29/15
Coliform, MF Total in liquid 1 1 B2Q1 CFU/100ml APHA9222B-20th 4/29115
Ion Chromatography _TITLE mg/L EPA300.0 rev2 .1 5/5/15 -
Fluoride 0.4 0.4U mg/L EPA 300.0 rev2.1 5/5/15
Chloride 1.0 23 mg/L EPA 300 .0 rev2.1 5/5/15
Bromide 0.4 0.4 U mg/L EPA 300.0 rev2 .1 5/5/15
Sulfate 2.0 40 mg/L EPA 300.0 rev2.1 5/5/15
Total Dissolved Solids in liquid 12 122 mg/L SM 2540 C-1997 5/1115
NO2+NO3 as N in liquid 0.02 0.29 mg/Las N EPA 353.2 REV 2 4/30/15
Nitrate as N in liquid 0.02 0.29 mg/Las N EPA 353.2 REV 2 5/4/15
Nitrite as N in liquid 0.01 0.01 U mg/Las N EPA 353 .2 REV 2 4130/15
Al by ICP 50 50 U ug/L EPA200.7 5/1/15
As by ICPMS 2.0 2.0 U ug/L EPA200.8 5/4/15
Ca by ICP 0.10 21 mg/L EPA200.7 5/4/15
Crby ICPMS 10 10 U ug/L EPA200.8 5/4/15
Cu by ICPMS 2.0 28 ug/L EPA200.8 5/4/15
Fe by ICP 50 4500 ug/L EPA200.7 5/1115
K by ICP 0 .10 2.8 mg/L EPA200.7 5/4/15
Mg by ICP 0.10 3.6 mg/L EPA200.7 5/4/15
Mn by ICP 10 100 ug/L EPA200.7 5/1115
Na by ICP 0.10 13 mg/L EPA200.7 5/4/15
Ni by ICPMS 2.0 2.2 ug/L EPA200.8 5/4/15
Pb by ICPMS 2.0 3.9 ug/L EPA200 .8 5/4/15
Zn by ICPMS 10 32 ug/L EPA200.8 5/4/15
WSS Chemistry Laboratory» 16~3 Mail Service Center, Raleigh, NC 27699-1623 [phone]
For a detailed doscriotion of the Qualifier codes refer to <htto ://oortal.ncdenr. orn./web/wq/ oos/methods-and-oq ls>
Page 1 of 1
Validated by
MSWIFT
ESTAFFORD 1
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North Carolina Division of Water Resources
Water Sample Collection & Submittal Form Vlsitti]''
Central LSizat&buty{WaterSciences Sectran] �apGorrG7].
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tiMic'ri36Salagy;Parrimeters'
MSA5 {surfactants} mg/L
Metais pxrarrreters: ; ::_ '= _' ;� '_ -
-
Tin (So) µgJ1
Acidity, as CaMa, to pH 4.5/8-3 mg/L
Oil and Grease, HEM, To ( Recoverable mg/L
Aluminum W) µg/L
Titanium M) µg/L
Alka&nity, as CaCO3, to pH 4,518.3 mg/L
Phenols, Total Recoverable pg/L
Antimony [Sb} Ng/L
Vanadium (V) p8/L
BOO. sixhem.6=1 Omyzen Demand, 5-day mg/L
Residue: Total (/atal5oltds) 1net.
Arsenlc (As) Ng/L
Zinc (2n)
CBOD: Carbonaceous 600, 5-day mg/L
Residue- Volatile/Fixed, Total mg/L
Barium Teal µg/L
Colifnrm- Feral MF IIODmI
Residue -Suspended [5uspen6edSolidsl mg/L
Beryglurn (Be) pg/L
Baron (6}, Total µglL
Coliform: Total MF /106ml
Residue: Volatile/Fixed, Suspended mg/L
Cadmium (Cdl pg/L
Mercury 1631, law -level ng/L
Coffform: Tube Fecal /lODm!
TD5 -Total 9molved Solids mg/L
<
Calcium (C3) mglL
Cohform: Tube Total /100ml
'silica mg/L
Chromium (Cr), Total pgjL
;prgantcs Rararreters:
Specific Conductance, at 25 aC umtws/cm
Sulfide mg/L
Cobalt (Col µg/L
I
Acid Herbicides
TOC- rorml ❑rgook Carbon _ nWL
Tannin & Ugnin mg/L
.
Copper (Cv) lig/L
Organochlvrine Pesticides
Turbidity NTU
Iron (Fe) µg/L
Organorittrollen Pesticides
r '-Kltiie[paratneters: ` _
'
Lead (Pb) pg/L
OfganaphosphorusPesticides
<wetChcmisl,y Ppi,20 t6s- _ �;;
PH s.u,
Lithium (U) }Jgj1
PCBs (paiychlonnated biphenyfs).
Bromide mg/L
Hardness, Totals C403 - byirtration mg/L
Magnesium (Mg) mgA .
Chipride mg/L
Manganese (Mn] µg11
Semi -Volatile Organics (BNAs)
Fluoride mg/L
Mercury (Hg) pg/L
TPH Diesel Range
Selifate mgll
. Nutrleiit3l'aramerers' - '`•'
Molybdenum IMoj pg/L
Chiarophyll a µfill
Ammonia as N (NH3-N) mg/L
Nickel (Ni) Ng/L
Votatile Crganic�s (VOA}
Color: ADM c i.
as N [NO3+NO2-N] mg/L
Potassium (li) mglL
Color. Platinum Cobalt C-u.
Total Kje(dahi Nitrogen as N (TKN} rng/L
Selenium (Se) µg/L
TPK Gasoline Range
CCD: Chemlad oxygen Demand mglL
Totai Phosphorus as P (TP) mg/L
Silver (Ag) µg/L
Cyanide, Total mg/L
Nkrite as N (NO2 -NJ mg/L
Sodium (Nal mg)L
.; _ -SluloglRb _
Formaldehyde mg/L
Nitrate as N (NO3-N ralcuiated) mg/L
Strontlum (Sr} 119/L
Phytoplankton/ Algae
Hsxavalent Chromium (Cr6+j mg/L
Orthophosphate as P IP04} mg/L
Tflaliium (Tl) +✓gIL
LAB COMMENTS :
Re1d Paiarilebersravo-o' roll : Water Temp (Cj: , ; pH {s.li:j: 57_ I : Cnnduc[liiity [ltmhos/ *m Salinity (pptk'

AC18773 NC aYWQ{. Water Sciences Section-Cliemistry £a6oratory <R§su[ts
County:
River Basin
Report To
Collector :
Region:
CURRITUCK
PAS QUOTANK
WARO
RSIPE
WARO
Sample Matrix: GROUNDWATER
Loe. Type :
· Emergency Yes/No
COC Yes/No
I Location ID: WI0700013
DWR
Division of Water Resources
Final Re port
Visit!D
Loe. Descr.: TICE 1801 NEW BEACH ROAD
J Collect Date: 04/28/2015
Sample ID:
PO Number#
Date Received:
Time Received:
Labworks LoginlD
Final Report Date:
Report Print Date :
J Collect Time : 10:15
AC18773
15G0189
04/29/2015
08 :00
TASCENZO1
6/11/15
06/11/2015
I Sample Depth
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
CAS#
LAB
MIC
WET
NUT
MET
Anal yt e Name
Sample temperature at receipt by lab
Coliform, MF Fecal in liquid
Coliform, MF Total in liquid
Ion Chromatography
Fluoride
Chloride
Bromide
Sulfate
Total Dissolved Solids in liquid
N02+N03 as N in liquid
Nitrate as N in liquid
Nitrite as N in liquid
7429-90-5 Al by ICP
7440-38-2 As by ICPMS
7440-70-2 Ca by ICP
7440-47-3 Cr by ICPMS
7440-50-8 Cu by ICPMS
7439-89-6 Fe by ICP
7440-09-7 K by ICP
7439-95-4 Mg by ICP
7439-96-5 Mn by ICP
7440-23-5 Na by ICP
7440-02-0 Ni by ICPMS
7439-92-1 Pb by ICPMS
7440-66-6 Zn by ICPMS
PQL
0.4
1.0
OA
2.0
12
0.02
0.02
0.01
50
2.0
0.10
10
2.0
50
0.10
0.10
10
0.10
2.0
2.0
10
Result/
Qualifier
0.7
Units Method
Reference
Analysis Validated by
Date
4/29/15 MSWIFT
1 B2Q1 CFU/100ml APHA9222D-20th 4/29/15 ESTAFFORD1
1 B2Q1 CFU/100ml APHA9222B-20th 4/29/15 CGREEN
_TITLE_ mg/L EPA 300 .0 rev2.1 5/5/15 CGREEN
0.4U mg/L EPA 300.0 rev2.1 5/5/15 CGREEN
23 mg/L EPA300.0 rev2.1 5/5/15 CGREEN
0.4U mg/L EPA 300.0 rev2.1 5/5/15 CGREEN
40 mg/L EPA 300 .0 rev2.1 5/5/15 CGREEN
126 mg/L SM 2540 C-1997 5/1/15 CGREEN
0.27 mg/Las N EPA 353.2 REV 2 4/30/15 CGREEN
0.27 mg/Las N EPA 353 .2 REV 2 5/4/15 CGREEN
0.01 U mg/Las N EPA 353.2 REV 2 4/30/15 CGREEN
50U ug/L EPA200.7 5/1/15 ESTAFFORD1
2.0 U ug/L EPA200.8 5/4/15 ESTAFFORD1
21 mg/L EPA200.7 5/4/15 ESTAFFORD1
10 U ug/L EPA200.8 5/4/15 ESTAFFORD1
160 ug/L EPA200.8 5/4/15 ESTAFFORD1
4100 ug/L EPA200.7 5/1/15 ESTAFFORD1
2.8 mg/L EPA200 .7 5/4115 ESTAFFORD1
3.6 mg/L EPA200.7 514/15 ESTAFFORD1
100 ug/L EPA 200.7 5/1/15 ESTAFFORD1
13 mg/L EPA200.7 5/4/15 ESTAFFORD1
40 ug/L EPA200.8 514/15 ESTAFFORD1
3.1 ug/L EPA200.8 5/4115 ESTAFFORD1
24 ug/L EPA200.8 5/4/15 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
For a detailed description of the oualifier codes refer to <httu ://portal.ncdenr. onr/web/wq/oos/methods-and-oals>
Page 1 of 1
Symbol
A
B
BB
C
G
J
Definition
Value reported is the mean (average) of two or more determinations. This code is to be used if the results of two or more discrete
and separate samples are averaged. These samples shall have been processed and analyzed independently (e.g., field duplicates,
different dilutions of the same sample). This code is not required for BOD or coliform repmting since averag ing multiple
dilutions for these parameters is fundamental to those methods .
Results based upon colony counts outside the acceptable range and should be used with caution. This code applies to
microbiological tests and specifically to membrane filter (MF) colony counts. It is to be used if Jess than 100% sample was
analyzed and the colony count is generated from a plate in which the number of colonies exceeds the ideal ranges indicated by
the method . These ideal ranges are defined in the method as:
Fecal coliform or Enterococcus bacteria: 20-60 colonies Total coliform bacteria: 20-80 colonies
I. Countable membranes with less than 20 colonies. Reported value is estimated or is a total of the counts on all filters
reported per 100 ml.
2. Counts from all filters were zero . The value reported is based on the number of colonies per I 00 ml that would have
been reported if there had been one colony on the filter representing the largest filtration volume (reported as a less
than "<" value).
3. Countable membranes with more than 60 or 80 colonies. The value reported is calculated using the count from the
smallest' volume filtered and reported as a greater than ">" value. ·
4. Filters have counts of both >60 or 80 and <20. Reported value is estimated or is a total of the counts on all filters
reported per 100 ml.
5. Too many colonies were present; too numerous to count (TNTC). TNTC is generally defined as >150 colonies. The
numeric value represents the maximum number of counts typically accepted on a filter membrane (60 for fecal or
enterococcils and 80 for total), multiplied by I 00 and then divided · by the smallest filtration volume analyzed. This
number is reported as a greater than value.
6. Estimated Value. Blank contamination evident.
7. Many non-coliform or non-enterococcus colonies or interfering non-coliform or non-enterococcus growth present. In
this competitive situation, the repo1ted value may under-represent actual density.
Note: A "B" value shall be accompanied by justification for its use denoted by the numbers listed above (e .g., B 1, B2 , etc .).
Note: A "J2" should be used for sp ikin g failures.
This code applies to most probable number (MPN) microbiological tests.
1. No wells or tubes gave a positive reaction. Value based upon the appropriate MPN Index and reported as a less than
"<"value.
2. All wells or tubes gave positive reactions . Value based upon the MPN Index and repmted as a greater than">" value.
Note: A "BB" value shall be accom oanied by justification for its use denoted by the numbers listed above (e.g., BBi, BB2, etc.).
Total residual chlorine was present in sample upon receipt in the laboratory; value is estimated . Generally applies to cyanide,
phenol, NH3, TKN, coliform, and or~anics.
A single quality control failure occurred during biochemical oxygen demand (BOD) analysis . The sample results should be used
with caution .
I. The dissolved oxygen (DO) depletion of the dilution water blank exceeded 0.2 mg/L.
2. The bacterial seed controls did not meet the requirement of a DO depletion of at least 2.0 mg/L and/or a DO residual of
at least I . 0 mg/L.
3 . No sample dilution met the requirement of a DO depletion of at least 2 .0 mg/L and/or a DO residual of at least 1.0
mg/L.
4. Evidence of toxicity was present. This is generally characterized by a significant increase in the BOD value as the
sample concentration decreases. The reported value is calculated from the highest dilution representing the maximum
loading potential and should be considered an estimated value.
5 . The glucose/ glutamic acid standard exceeded the range of 198 ± 30.5 mg/L.
6 . The calculated seed correction exceeded the range of0.6 to 1.0 mg/L.
7. Less than I mg/L DO remained for all dilutions set. The reported value is an estimated greater than value and is
calculated for the dilution using the least amount of sample.
8. Oxygen usage is less than 2 mg/L for all dilutions set. The reported value is an estimated less than value and is
calculated for the dilution using the most amount of sample.
9. The DO depletion of the dilution water blank produced a negative value.
Note: A "G" value shall be accom panied by justification for its us e denoted by the numbers listed above (e.g., GI, 02, etc.).
Estimated value; value may not be accurate. This code is to be used in the following instances:
I. Surrogate recovery limits have been exceeded.
2. The reported value failed to meet the established quality control criteria for either precision or accuracy.
3 . The sample matrix interfered with the ability to make any accurate determination .
4. The data is questionable because of improper laboratory or field protocols (e .g., composite sample was collected
instead of grab, plastic instead of glass container, etc.).
5. Temperature limits exceeded (samples frozen or >6°C) during transport or not verifiable (e.g., no temperature blank
provided ): non-reportable for NPDES com oliance monitorin g.
J 6. The laboratory analysis was from an unpreserved or improperly chemically preserved sample. The data may not be
accurate .
7. This qualifier is used to identify analyte concentration exceeding the upper calibration range of the analytical
instrument/method. The reported value should be considered estimated.
8. Temperature limits exceeded (samples frozen or >6°C) during storage, the data may not be accurate.
9. The rep01ted value is determined by a one-point estimation rather than against a regression equation. The estimated
concentration is less than the laboratory practical quantitation limit and greater than the laboratory method detection
limit.
10. Unidentified peak; estimated value.
11. The reported value is determined by a one-point estimation rather than against a regression equation. The estimated
concentration is less than the laboratory practical quantitation limit and greater than the instrument noise level. This
code is used when an MDL has not been established for the analyte in question.
12. The calibration verification did not meet the calibration acceptance criterion for field parameters.
Note: A "J" value shall be accompanied by justification for its use denoted by the numbers listed above (e.g., JI, J2, etc.). A "J"
value shall not be used if another code app lies (e.J,,., N, V, M ).
M Sample and duplicate results are "out of control". The sample is non-homogenous (e.g., VOA soil). The repo1ted value is the
lower value of du plicate anal yses of a sam ple .
N Presumptive evidence of presence of material; estimated value. This code is to be used if:
I. The component has been tentatively identified based on mass spectral library search.
2. There is an indication that the analyte is present, but quality control requirements for confirmation were not met (i.e .,
presence ofanalyte was not confirmed by alternate procedures).
3. This code shall be used if the level is too low to permit accurate quantification, but the estimated concentration is less
than the laboratory practical quantitation limit and greater than the laboratory method detection limit. This code is not
routinely used for most analyses.
4. This code shall be used if the level is too low to permit accurate quantification, but the estimated concentration is less
than the laboratory practical quantitation limit and greater than the instrument noise level. This code is used when an
MDL has not been established for the analyte in question.
5. The component has been tentatively identified based on a retention time standard.
Q Holding time exceeded. These codes shall be used if the value is derived from a sample that was received, prepared and/or
analyzed after the approved holding time restrictions for sample preparation and analysis . The value does not meet NPDES
requirements.
I. Holding time exceeded prior to receipt by lab.
2. Holding time exceeded following receipt by lab.
p Elevated PQL* due to matrix interference and/or sample dilution.
s Not enough sample provided to prepare and/or analyze a method-required matrix spike (MS) and/or matrix spike duplicate
(MSD).
u Indicates that the analyte was analyzed for but not detected above the reported practical quantitation limit*. The number value
re oorted with the "U" Qualifier is equal to the laboratory's practical Quantitation limit*.
X Sample not analyzed for this constituent. This code is to be used if:
I. Sample not screened for this compound.
2. Sampled, but analysis lost or not performed-field error.
3. Sampled, but analysis lost or not performed-lab error.
Note: an "X" value shall be accompanied by j ustification for its use by the numbers listed.
V Indicates the analyte was detected in both the sample and the associated method blank. Note: The value in the blank shall not be
subtracted from the associated sam ples.
y Elevatecj PQL * due to insufficient sample size.
z The sample analysis/results are not reported due to:
I. Inability to analyze the sample.
2. Questions concerning data reliability.
The presence or absence of the analyte cannot be verified .
*PQL The Practical Quantitation Limit (PQL) is defined and proposed as "the lowest level achievable among laboratories within
specified limits during routine laboratory operation". The PQL is about three to five times the calculated Method Detection Limit
(MDL) and represents a practical and routinely achievable detection limit with a relatively good certainty that any reported value
is reliable".
3/10/2011
Permit Number WI0700013
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael .rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
William and Amber Tice SFR
Location Address
180 New Beach Rd
Point Harbor
Owner
Owner Name
William C
Dates/Events
NC
Orig Issue
5/11/1992
App Received
3/31/2015
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27964
Tice
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
5/12/2015
Permit Tracking Slip
Status Project Type
In review Renewal with major mod
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
William C. Tice
180 New Beach Rd
Point Harbor
Region
Washington
County
Currituck
NC
Issue Effective
27964
Expiration
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
4/1/15
5/8/15
Subbasin
A�
�.:;r gA
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Gavemor
May 15, 2015
William and Amber Tice
184 New Beach. Road
Point Harbor, NC 27964
Re: Issuance of Injection Well Permit
Permit No. W10700013
Geothermal Heating/Cooling Water Return Well
Currituck County
Dear Mr. and Mrs. Tice:
Donald R. van der Vaart
Secretary
In accordance with your pen -nit renewal application and change of ownership request received March
31, 2015, I am forwarding Permit No. W10700013 for the continued operation of geothermal
heating cooling water return well(s) located at the above referenced address_ Please note that this
renewed permit shall become effective on July 1, 2015, (i.e_, the day after the expiration date of the
existing permit), which may differ from the date of this letter. This permit shall be effective from
July 1, 2015, until June 30, 2020, and shall be subject to the conditions and limitations stated therein.
Please Note:
Samples from the influent and effluent sampling ports of your geothermal well system
were collected on April 28, 2015. Laboratory analytical results will be forwarded to you
when it becomes available.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this
permit is not transfetable to any person without prior notice to, and approval by, the Director of the
Division of Water Resources, If you have any questions regarding your permit or the Underground
Injection Control Program please call the at [phone].
Best Regards,
Michael Rogers. P.G. (N & FL)
Hydrogeologist
Division of Water Resources, NCDENR
Water Quality Regional Operations Section
1636 Wil 5enfice Center, Raleigh, }forth Carolrrna M99-1636
Phone: [phone]Internel: hltp:l�u'w'v:.ncv'ater.grc
? rn }:IUA C3N400: Y s �FiIr AVID ;dOn EMPIW-er - h4ade ir. PV1 L f EGydF.; fj4; E'

William and Amber Tice
cc: David May and Robert Tankard, Washington.Regional Office
Central Office File, WI0700013
Currituck County Environmental Health Department
Page 2 of2
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT ANDNA'fURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
In '3.ccordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
William and Amber Tice
FOR THE CONTINUED OPERATION OF 1 (ONE) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defined in Title 15A North Carolina Administrative Code 02C .0224(a), which will be
used for the injection of heat pump effluent. The injection well(s) located at 180 New Beach Road, Point
Harbor, Currituck County, NC 27964 will be operated in accordance with the application and name change
request submitted March 31, 2015, and conformity with the specifications and supporting data, 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 continued operation of an injection well shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from July 1, 2015, (i.e., the day after the expiration date of the
existing permit) until June 30, 2020, and shall be subject to the specified conditions and limitations set forth in
this permit.
Pennit issued this the 15th day of May 2015.
S. Jay Zimmerman, Director
Division of Water Resources
By Authority of the Envirom11ental Management Commission.
Permit #WI0700013 UIC/5A7
ver_ 04/15/2015
Page 1 of5
PART I -PERMIT GENERAL CONDITIONS
1. Tue Permittee shall comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94
2. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data [15A NCAC 02C .021 l(a)].
3. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data [15A NCAC 02C .0211(1)].
4. This permit is not transferable without prior notice and approval. In the event there is a desire for the
facility to change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted, including any supporting materials as may be appropriate, at least 30 days
prior to the date of the change [15A NCAC 02C .021 l(q)].
5. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met [15A NCAC 02C .0203].
PART II -WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed in
accordance with the requirements of rule 15A NCAC 02C .0107 except as required in Item #2 below.
2. Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC 02C
.0107 except that the entire length of the casing shall be grouted in such a way that there is no
interconnection of aquifers or zones having differences in water quality that would result in degradation of
any aquifer or zone. For screened wells, grout shall be emplaced from the top of the gravel pack to the
land surface. For open-end wells, the casing shall be grouted from the bottom of the casing to the land
surface [15A NCAC 02C .0224(d)(2),(3)].
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing
conditions. [15A NCAC .0225(g)(8)].
4. The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [15A NCAC 02C .0224(d)(4)].
5. Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal as defined in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .01070)(2)].
Permit #WI0700013 UIC/5A7
ver. 04/15/2015
Page 2 of5
7. A completed Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 ofthis
permit.
PART III-OPERATION-AND USE CONDITIONS
I. The Permittee shall comply with the conditions of this permit and properly operate and maintain the
injection facility in compliance with the conditions of this permit and the rules of 15A NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C
.021 IG)].
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface
water or groundwater resulting from the operation of this facility. In the event that the facility fails to
perform satisfactorily, including the creation of nuisance conditions or failure of the injection zone to
adequately assimilate the injected fluid, the Permittee shall take immediate corrective actions that may be
required, such as the repair, modification, or abandonment of the injection facility [15A NCAC 02C
:0206].
PART IV -INSPECTIONS [15A NCAC 02C .021 l(k)]
I. Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation of credentials, enter and inspect any property, premises, or place on or related to the
injection facility at any reasonable time for the purpose of determining compliance with this permit, may
inspect or copy any records that must be maintained under the terms and conditions of this permit, and
may obtain samples of groundwater, surface water, or injection fluids.
2. DWR representatives shall have reasonable access for purposes of inspection, observation, and sampling
associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary samples of the injection facility's activities.
PART V -MONITORING AND REPORTING REQUIREMENTS
1. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on-site and available for inspection [ 15A NCAC
02C .0224(£)(2), (4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State
and compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
.0224(f)(l )].
3. The Pennittee shall report any monitoring or other infom1ation that indicates noncompliance with a
specific pennit condition, that a contaminant may cause a ·violation of applicable groundwater quality
standards, or that a malfunction of the injection system may cause the injected fluids to migrate outside
the approved injection zone or area. As specified in rule 15A NCAC 02C .021 l(r), noncompliance
notification shall be as follows:
(A) Oral notification shall be given within 24 hours of the occunence, or first knowledge of the
occurrence, to the Washington Regional Office, telephone number 252-946-6481.
Pem1it #W !0700013 UIC/5A7
ver. 04/15/2015
Page 3 of 5
(B) Written notification shall be made within five days of the occurrence and submitted to the
addresses in Item #5 below.
(C) The written notification shall contain a description of the noncompliance and its cause; the period
of noncompliance, including dates and times; if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and any steps taken or planned to reduce, eliminate, and
prevent reoccurrence of the noncompliance.
4. The Permittee shall record the number and location of the wells with the register of deeds in the county in
which the facility is located. [15A NCAC 02C .0224(f)(3)].
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
UIC Program Staff
Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Water Quality Regional Operations Section
DWR Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
PART VI-PERMIT RENEWAL [15A NCAC 02C .0224(c)]
As required by rule an application for permit renewal shall be made at least 120 days prior to the
expiration date of the permit. This permit condition does not apply if the Permittee chooses to
discontinue operation of the well for injection of effluent from the geothermal heating and cooling system
associated with this permit.
PART VII-CHANGE OF WELL STATUS [15A NCAC 02C .0240]
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complying with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to
rule 15A NCAC 02C .0113(b) in order to prevent the well from deteriorating and acting as a source or
conduit of contamination, which is prohibited by General Statute 87-88(c).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well
seal that cannot be removed without the use of hand or power tools.
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose,
the Permittee shall permanently abandon that injection well in accordance with the procedures specified in
15A NCAC 02C .0113(b), which include, but are not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
Permit #WI0700013 UIC/5A7
ver_ 04/15/2015
Page 4 of5
(C) Each well shall be thoroughly disinfected prior to sealing in accordance with rule 15A
NCAC 02C .011 l(b)(l)(A),(B), and (C).
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In those cases when a subsurface cavity has been created as a result of the injection
operations, each well shall be abandoned in such a manner that will prevent the
movement of fluids into or between underground sources of drinking water.
(F) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0224(f)( 4) within 30 days of completion of abandonment.
5. The written documentation required in Part VII (4)(F) shall be submitted to the addresses specified in Part
V.5 above.
Permit #WI07000l3 UIC/5A7
ver. 04/15/20 I 5
Page 5 of5
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: 5/4/15 Permittee(s): William & Amber Tice
Permit No.: WI0700013
To: APS Central Office County: Currituck
Central Office Reviewer: Michael Ro gersProject Name: Geothermal Heating/Coolin g Return Well
Regional Login No: __ _
L GENERAL INFORMATION
1. This application is (check all that apply): D SFR Waste Irrigation System IZ! UIC Well(s)
D New IZ! Renewal
D Minor Modification IZI 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 IZ! 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: 4/28/15
b. Person contacted and contact information: William Tice (336 ) 817-6234
c. Site visit conducted by: R. Si )e & A. Clark
d. Inspection Report Attached: IZ! Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
IZ! Yes or D No. If no, please complete the following or indicate that it is correct on the current application .
For SFR Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d . Latitude: Longitude: __ Method Used (GPS, Google™, etc.); __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For UIC 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 l
a. Location(s): 180 New Beach Rd .. Point Harbor. NC 27964
b. Driving Directions: No chan g.e since permit issuance
c. USGS Quadrangle Map name and number: __
d . Latitude: 36.094960N Longitude: 76.802141 W
Earth
RECEIVED!DENR/DWR
MAY -8 2015
Water Quality Region 1 APS-GPU Regional Staff Report (Sept 09) Operations Section a
Method Used (GPS, Google™, etc.); Google
Page I of 4 Pages
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
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 of Well(s) and Facilities -New, Renewal, and Modification
1. Type of injection system:
C8] Heating/cooling water return flow (SA 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 C8J No
3. Are there any potential pollution sources that may affect injection? D Yes C8J No
What is/ are the po II uti on source( s)? __ _,.------'-W'-'h=a=t-'-i =---s =th-'--'e'---d=i=st=a=n=c-=--e ---=o-=--f ---"th=e=-----=in"'"j =ec'--'t-'--'i o'--'-n"----w-'---'-"-e=II "'""( s'-'-)-'-f""'ro"""m"--"----'t~h"""e --<=p=o-=11-"u=ti -=--on=
source (s )? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 24 ft.
5. Qua! ity of drainage at site: D Good C8J Adequate D Poor
6. Flooding potential of site: C8J 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: NA
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? C8J Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal and Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes C8J No. If )es . ex plain: Previous 2" ln j. well was re placed in Dec 2013 with 6" Inj . well in same
location and to a pp rox. same de pth. 2" in j. well was re p laced because ofrecurrin !!. foulin g problems.
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 es ex lain: NA
3. For renewal or modification of g roundwater remediation permits (of an y tvp e ). will
continued/additional/modified in jections have an adverse im pact on mi aration of the plume or mana gement of
the contamination incident? D Yes D No. If , es . ex p lain: NA
APS-GPU Regional Staff Report (Sept 09) Page 2 of 4 Pages
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
4. Drilling Contractor: Name: Carlton Lynn Morris
Address; 165 Happy Indian Lane
Southern Shores_ NC 27949
NC Certification number: 2205-A
7. Complete and attach NEW Injection Facility Inspection Report, if applicable
w EVALUATIONAND RECOMMENDATIONS
1. Provide any additional narrative regarding your review oftho Application: No issues observed with new in,.
well. Recommend that permit. be renewed and modified to include 6" hiLivell.
2. Attach new Injection Facility Inspection Farm, if applicable
3. Do you foresee any problems with issuance/renewal of this permit? ❑ 'Yes ® No. if yes, please explain
briefly.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item;
Item Reason
'WV lttr 4tinllly
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 f 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 L Reason
APS-GPU Reg iana] Staff Report (Sept 09) Page 3 of 4 Pages

AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
7 Recommendation: ❑ Hold, pending receipt and review ofadditional information by regional office; ❑ Mold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
$. Signature of report Preparers): _
Signature of APS regional supervisor:
Bate: �~ S
UL ADDITIONAL INFORMATION AND SITE MAP {Sketch of site shgwin,, house and waste irr!kation
st'stem, sl;raj, or drlL) IIeld, location oI rvell(s), and/or other relevant inlurmatian- SIIOY!'NOR 7HAR {Ott
APS-GPU Regional Staff Report (Sept 09) rage 4 of 4 Pages

I
New
Pecks, Re!

North Carolina Department of Environment and Natural Resources
Division of Water Quality -Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700013
DA TE OF INSPECTION: 4/28/15
INSPECTOR: R. Sipe w/WQROS WaRO
NAME OF PERMITTEE(S) William and Amber Tice
MAILING ADDRESS OF PERMITTEE 180 New Beach Rd., Point Harbor, NC 27964
PHYSICAL ADDRESS OF SITE (if different than above) ________________ _
PERSON MET WITH ON-SITE William Tice; TELE NO.[phone]
WELL(S) STATUS:
X Existing and operating Class V Well
__ Existing well proposed to be converted to Class V well
__ Proposed/not constructed
LAT/LONG OF WELL(S) 36.094960N, 76.802141W
Appx. distance of well to property boundaries: approx. 25 feet
Appx. distance of well from foundation of house/structure: approx .. 37 feet
Appx. distance of well from septic tank/field (if present): approx .. 50 feet
Appx. distance of well to other well(s) (if present): approx .. 75 feet to supply well.
Appx. distance to other sources of pollution: ________________ _
Flooding Potential of Site: _high __ moderate __K_low
Comments: The injection well was replaced in Dec. 2013. A new 6 inch PVC inj. well was constructed in the
same location as the previous 2" inj. well because ofrecurring fouling issues with the 2" well. The current inj.
well is constructed to approx. the same depth as the previous well. A construction diagram provided by the
driller is attached. The current well is in good condition with the proper stick up and well tag and has been
operating adequately.
Inj ectio n Facility lnsp. Report (Rev . Sept 2009) Page I of 3 Pages
See attached map
DRAW SKETCH OF SITE ABOVE (Show property boundaries, buildings, other wells, septic tanks/drain fields, other
potential pollution sources, roads, approximate scale, and NORTH arrow)
See attached diagram and GW-1 for the injection well injection well installed in Dec 2013 at the same location
as the previous well. The diagram contains the correct construction information as verified by the driller.
Draw Schematic of well above showing TD, casing depth, grout, etc.
Injection Facility Insp. Report (Rev. Sept 2009) Page 2 of3 Pages
Well Construction Information
Date Constructed: 12/18/13
Well Contracting Company: Coastal Drilling
Well Driller Name: Carlton Lynn Morris
NC Well Cert. No.: 2205-A
(New Injection Well)
Address: 165 Happy Indian Ln., Southern Shores, NC 27949
Telephone No.:[phone]; Cell No.: ________ _
Email Address: -----------
Proposed Depth of Well(s): 40 feet
Total Depth: 36 feet BLS Total Depth of Source Well, if present: 89 feet (from previous insp. report)
Casing:
Depth: 0 to 21 feet; Diameter: 6 inches; Type (gav. steel, PVC, etc.): Sch. 40 PVC; Stick Up: 12 in .
Grout:
Depth: 0 to 20 feet; Type (cement, bentonite, etc.):cement; Placement (pumping, press. etc.):pumped
Well ID Plate Present (Y or N): _Y.__; Heat Pump ID plate present (Y or N): Y
Influent spigot (Y or N): -~Y __ Effluent spigot (Y or N): __ Y __ _
Well Sampled? (Y or N): Y ; If Yes, Lab Sample ID numbers: Influent -Inf, Effluent -Eff
Static Water Level: 6 feet
Injection Information (if applicable):
Injection Rate: GPM -------
Injection Pressure: PSI
Injection Volume: GPD
Temperature-Summer: p 0
Temperature-Winter: P0
Comments/Notes: The 6" PVC inj. well appeared to be in good condition and operating adequately at time of
inspection. Mr. Tice stated that the well was constructed by Lynn Morris in Dec. 2013 because the previous 2"
inj. well had recurring issues with fouling. The 6" inj. well was constructed in the same location as the
previous 2" inj. well and to approx. the same depth. The construction details for the new well were verified
with the driller via telephone on 5/1/15. __________ _
Inj ecti on F ac ility In sp. Report (Rev . Sept 2009) Page 3 of3 P ages
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01/04/2007 02:59 2522617102
COASTAL DRILLING
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Com pliance Ins pection Re port
Expiration: 06/30/15 Owner: Andres Del Toro Perm it: WI0700013
SOC:
County: Currituck
Region: Washington
Effective: 07/19/10
Effective: Expiration: Facility: Andres and Hope Del Toro -5A7 SFR
180 New Beach Rd
Point Harbor NC 27964
Contact Person: Andres Del Toro Title: Phone: [phone]
Directions to Facility:
From WaRO take US 17N to Elizabeth City, take exit 255 and follow US 17N Bus -4.6mi stay L, follow S Hughes Blvd -1.6mi turn R,
follow US 158E-40.1mi turn L, follow New Beach Rd -0.4mi, the property is on the Rt
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 04/28/2015 Entry Time: 10:00AM Exit Time: 10:45AM
Primary Inspector: Dwight R Sipe Phone:
Secondary lnspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well
Facility Status: ■ Compliant D Not Compliant
Question Areas:
■ Other
(See attachment summary)
Page: 1
Permit: WI0700013
Inspection Date: 04/28/2015
Inspection Summary:
Owner. Facility: Andres Del Toro
Inspection Type : Compliance Evaluation Reason for Visit: Routine
On 4/28/15 a site visit was conducted by R. Sipe and A. Clark w/ WaRO WQROS as part of the permit renewal application
review process for the existing 5A7 injection well. At the time of the inspection, a 6" PVC injection well was observed at the
site. This well appeared to be in adequate condition and operating in compliance with permit# WI0700175. Also, there were
no potential pollution sources observed. The new owner, Mr. William Tice, stated that the previous 2" inj. well had recurring
fouling issues and in Dec. 2013 He had the well replaced with current 6" inj. well by Lynn Morris w/ Coastal Drilling. The
current inj. well was installed at the same location as the previous inj. well. The new well was installed to approx. the same
depth as the previous well. Well construction details for the new inj. well confirmed with Mr. Morris during a telephone
conversation on 5/2/15. Influent and effluent samples were collected for lab analyses upstream and downstream of the
heaVAC units.
Page: 2
Permit: VVI0700013
Inspection Date: 04 /28/2015
Other
Comment:
Owner -Facility : Andres Del Toro
Inspection Type : Compliance Evaluation Reason for Visit: Routine
Yes No NA NE
Page: 3
Ro gers, Michael
From:
Sent:
To:.
Sipe, Randy
Monday, May 18, 2015 4:44 PM
Rogers, Michael
Subject: FW: Wl0700013 Permit Renewal Staff Report & attachments
Also, the current owner, Mr. Tice, stated that since he has owned the property in 2012, he has only used 1 injection well.
Randy Sipe, P.G.
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Washington Regional Office
[phone]
Note: All e-mail sent to and from this account are subject to the North Carolina Public Records Law and may be disclosed
to third parties
From: Sipe, Randy
Sent: Monday, May 18, 2015 4:33 PM
To: Rogers, Michael
Subject: RE: WI0700013 Permit Renewal Staff Report & attachments
It is my understanding that it has been abandoned. Both Alan Clark, who did the previous inspection, and I were there
and we did not see any evidence of it during our visit.
Randy Sipe, P.G.
Hydrogeofogist
Division of Water Resources
Water Quality Regional Operations Section
Washington Regional Office
[phone]
Note : All e-mail sent to and from this account are subject to the North Carolina Public Records Law and may be disclosed
to third parties
From: Rogers, Michael
Sent: Monday, May 18, 2015 12:48 PM
To: Sipe, Randy
Subject: RE: WI0700013 Permit Renewal Staff Report & attachments
Randy-
The previous inspection in 2010 showed 2 wells being used for injection (plus info for 2 IWs in BIMS). I know per your
report that one of the wells was replaced w/ 6" casing: Do you know the status of the other IW, i.e., still active, P&A,
etc. Thanks .
From: Sipe, Randy
Sent: Tuesday, May 05, 2015 5:13 PM
To: Rogers, Michael
Subject: WI0700013 Permit Renewal Staff Report & attachments
1
Michael,
A signed, scanned copy of the staff report and attachments is attached to this message. Hard copies are being sent to
you via courier. Let us know if you need anything else.
Randy Sipe, P.G.
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Washington Regional Office
[phone]
Note: All e-mail sent to and from this account are subject to the North Carolina Public Records Law and may be disclosed
to third parties
2
Rogers, Michael
From: Andy DelToro [[e-mail]]
Sent: Tuesday, March 17, 2015 12:04 PM
To: Rogers, Michael
Subject: RE: W10700013 Del Toro Geothermal Well Permit Renewal
From: Rogers, Michael [mailto:[e-mail]]
Sent: Tuesday, March 17, 2015 12:03 PM
To: Andy DelToro
Subject: RE: W10700013 Del Toro Geothermal Well Permit Renewal
❑K, thanks. Were you still using the welt as a geothermal water return welt?
From: Andy DelToro [mailto:andyCabac;,-ardliquids.com]
Sent: Tuesday, March 17, 2015 11:27 AM
To: Rogers, Michael
Subject: RE: WI0700013 Del Toro Geothermal Well Permit Renewal
I sold the home in 2011, please check tax record for new owner.
From: Rogers, Michael [mailto:[e-mail]]
Sena: Tuesday, March 17, 2015 9:52 AM
To: and < back ardli uids.com
Subject: W10700013 Del Toro Geothermal Well Permit Renewal
Mr. and Mrs. Del Toro:
Your geothermal permit is clue to expire June 30, 2015. Do you wish to renew your geothermal permit? If so, I will email
you a renewal application. We attempted to mail you a renewal application, but is was returned undeliverable.
Thank you.
Michael Rogers, P.G. [NC & FL]
Hydrogeologist
NCDENR - DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://Portal.ncdenr.org/web/wg/aps/gwpro/reportifig-forms
NOTE.: 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.

kTI.9;Vj
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
April 1, 2015
William and Amber Tice
180 New Beach Road
Point Harbor. NC 27964
RE: Acknowledgement of Application No. W 10700013
Geothermal Heating/Cooling Water Return Well
Currituck County
Dear Mr. and Mrs. Tice:
Donald R. van der Vaart
Secretary
The Water Quality Regional [operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on March 31. 2015. Your application
package has been assigned the number listed above, and the primary reviewer is Michael Rogers.
Central and Washington Regional Office staff will perform a detailed review of the
provided application, and may contact you with a request for additional information. To ensure
maximum efficiency in processing permit applications, the Water Quality Regional Operations
Section (WQROS) requests your assistance in providing a timely and complete response to any
additional information requests.
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. Tf you have any questions, please contact
Michael Rogers at [phone] or michael.rogers@7a ncdenr,gov.
Sincerely,
[zebra J. Watts. Supervisor
y Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
cc: Washington Regional Office, WQROS
Permit File WI0700013
1636 Mall Service Center, Raleigh, North Carfllina 27699-1636
Phone' 919-807-6464 � Internet http;llwww.ncwater.org
Asl Epval ❑pKtinity 1 Afirnative Action Employer — Made in pari by recycW paper

Selected Parcels Feature
Parcel ID Number
Global PIN
Number
A pt/Number
Street Direction
Street Name
Street Typ e
Street Suffix Direction
City
Subdivision
Lee;al Descri ption
Townshi p
Owner Name 1
OwnerName2
OwnerName3
Billing Address
Billing Address Continued
Billing City
Billing State
Billine ZIP Code
Acreage (Legal)
Acreage (GIS)
Tax Value: Land
Tax Value: Buildine s
Tax Value: Deferred
Tax Value: Total
Last Sale Date
Last Sale Price
Qualified Sale?
Deed Book
Deed Page
Plat Cabinet
Plat Slide
Data Date
OwnerName4
OwnerName5
OwnerName6
OwnerName7
OwnerName8
OwnerName9
Owner Name 10
132
~84
180
A00300300000
6-48-5752
INE WBEACH
lRD
IPO INT HARBOR
PO INT HARBOR BEACH
BL
PO
K 3 LOT 30 POINT HARBOR BEACH
PLAR BRANCH ML
TI CE, WILLIAM CLIFFORD
180 NEWBEACHRD
INT HARBOR PO
NC
279 64
0
0.0 9
113 00
135 500
0
146 800
201 2-09-06
170 000
NO
121 5
398
l
83
201 5-03-17
http://currituckncgov.com/Freeance/Client/PublicAccessl/printFrame.html
Page 1 of 1
3/17/2015
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE QUEST FORM
Date: April 1, 2015
To: WaRO-WQROS: David May/ Robert Tankard
From: Michael Rogers, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
A.
B.
c.
D.
Permit Number: WI0700013
Applicant: William and Am her Tice
Facili ty Name:-
Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal with Major Modification ~.AIM(!: GJJ~.,A) c::.:~)
E. Comments/Other Information:
D I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a com pleted W OROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact
person listed above .
RO-W OROS Reviewer: Date: ------------------------
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 092614 Page 1 of 1
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 02C .0224
GEOTHERMAL HEATINGICOOLING WATER RETURIN 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 Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 1 L l DJ(-VV Q'S ,20 1 �; PERMIT lti OM )1'000t3 (leave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave blank if New Application)
l . Current Use of Well
a. Con tinue to use as
Supply
)C Geothermal Well Dririlcing Water Supply Other Water
b, 'Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below_ If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
❑ Yes, I wish to rescind the permit
Cnrrent ownership Status
Has there been a change of ownership since permit fast issued? YES ❑ NO
If yes, indicate new owner's contact information: TT"
Name(s) W 1 III Ck 'V) �- [ j �,-Q— �(Yl% S —Tl C.---P"—
Mailing Address: r ti iJ tl-L )2(-xA--
City: f ' State: Zip Code:��� Caunty_� u
Day Tele No.: LSS- � q � 1` 1 ~U�3`f- E-mail Address._AtShACCUk
R, STATUS OF APPLICANT (choose one) RECEiVEMENRlQil N
Non-Govemment- Individual Residence Business/Organization
-.r . .
Government' State Municipal County _ _ Federal
C_ WELL OWNER(S)IPERMIT APPLICANT -- For individual residences, fist owner(s) on property deed_ For
all others, list name of entity and name of perso+ delegated authoriV. to sign:.
Ll
Mail ing A dd ress:
City: plaLni _-- State: -Zip Code.-OaNa, County
Day Tele No.: ��4 rt. - ra' Ceil No.:
EMAIL Address:- �' GL-i��` • P_CIF.Nn_= NIA -_-
Gcothrrmal Wafer Retum Wei Permit Application (Rcvi-sed fan 2015) Paer I

D. WELL OPERATOR (if different from well owner) -For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the
business or agency: ______________________________ _
Mailing Address: _______________________________ _
City: State: __ Zip Code: _______ County: _____ _
Day Tele No.: _______________ ___,,E,,,,m=ru=·"'---1 A"----"--"'d=dr"-'e=s=s._,_: ___________ _
E. LOCATION OF WELL SITE-Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: __________ County: _____ _
(2) Physical Address (if different than mailing address): ________________ _
City: ________________ State: NC Zip Code: _________ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: __________________________ _
NC Well Drilling Contractor Certification No.: ______________________ _
Company Name: _________________________________ _
Contact Person~: _______________ EMAIL Address: ___________ _
Address: ___________________________________ _
City: __________ Zip Code: _____ State: __ County: _________ _
Office Tele No.: Cell No .: _________ Fax No.: ________ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
H.
HVAC Contractor's Name: ____________________________ _
NC HVAC Contractor License No.: _________________________ _
Company Name: _________________________________ _
Contact Person.~: ________________ EMAIL Address : ___________ _
Address:------------------------------------
City: Zip Code: _____ State: __ County: _________ _
Office Tele No.: _________ Cell No.: __________ Fa:x No.: _______ _
WELL USE Will the injection well(s) also be used as the supply well(s) for th e following?
(])
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS-As specified in 15A NCAC 02C .0224 (d):
--
(1) The water supply well shall be constructed in accordance with the water supply well requireme nts of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effltient, then the injection well shall be construct ed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Pem1it Application (Revised Jan 2015) Page 2
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
____ *EXISTING WELLS ____ PROPOSED WELLS
* For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
(c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(D"(8 )
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATINGDATA
(1) Injection Rate: Average ( daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons pe~ day (gpd).
(3) Injection Pressure: Average ( daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, A ve:rage (July) __ ° F.
L. SITE MAP -As specified in 15A NCAC 02C .0224(b )( 4 ), attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2} Any other potential sources of contamination listed in 15A NCAC 02C .0 l 07 ( a 1(2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, soutb, west or east)
Geothermal Water Return Well Permit Application (Rcvi~cd .Ian ~() 15) Page 3
NOTE. In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS websife. Typically, the property can be searched by
owner name or address. The location of Me wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can Then he drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .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(s) Iisted on the roropgM 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 applications on their behalf.
"1 hereby certify, under penally 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 relaters appurtenances in accordance with the approved specifications and conditions of
the Permit."
Jr m
Signature of Prope OwnerlApplicant
na
M OJ ka -IC e
d—'-_
Print or Type Dull Name
Signature of Property OwnerlApplic_AN�Xv -Tic
ant
Prins or Type Ful] Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
'1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Retum Well Permit Application (Revised Jan 2015) Page 4

North -C~arolina Department of Environment and Natural Resources
Division of Water Resources
PERMIT NAME/OWNERSHIP CHANGE APPLICATION FORM
l INSTRUCTIONS
1. Complete this form in its entirety as follows:
(a) Change of Ownership -Provide the information in Parts II and m and submit legal documentation of
the transfer of ownership such as a contract, deed, article of incorporation, etc . The certifications in part
IV must be signed by both the current permit holder and the new applicant(s).
(b) Name Change Onl -Provide the information in Parts II and ill. Sign the certification for the new
applicant in pa.rt IV.2.
2. Submit the properly completed form to the address on bottom of Page 2.
n CURRENT PERMIT F RMATI N
I. Permit number. -~=~_.!.C"""--""""-"-''-'-1 _3 ___ --c-----,---------------
2. Permit holder's name(s): ___._ ...... a-'d;"""-=(-'-.f__,_S..L.-W'°-=-.::....:---=._,__ ...... \:b....o=...Jx=rt,.-,<>-o<'-----77'_,__,o""'-v___,_Q '----____ _
3. Permit signing official's name and title: __________________ _
(Person legally responsible for permit)
(Title)
4. Mailingaddress: \ll\Q,CT)LJ.,)Q \ OC,Q;th)'{) l CD~ ,Oto
City: ___________ State: -----Zip: ---------
Telephone number: L....:.._) ______ _ Facsimile number: L_J _____ _
fil NEW OWNER/NAME INFORMATION
1. This request for a permit change is a result of:
)(_ a. Change in ownership of property/company
_ b . Name change only
_ c . Other (please explain): _____________________ _
FORM: GPU-PNOC 2/21/2014 Page 1 of2
tlil:IVEDIDENRIDWR
MAR 3 I 2015
Water O\•ality Regional
Oper~11ans Sf:¾ct:on
2. New owner's name(s) as listed on the property deed (Please Print/or Type):
,S• 1
3. New owner's or signing official's name and rifle: G L{,�,,
(Person legally risponsible for permit)
C7WiA--�( -
- (-Title)
r� -►
4. Mailing Address: 1D N='�_ � -�_- D-aot
city: W�C(>' State: PVC- Zip: rn-!2
Day/Cell Phone No.
(3%) Y [� - V 2-3 � Fax number: () � A
EMAIL Address:h, Z�lay-] r 1,+,
IV. CERTIFICATION L
1. Current Permiuee's Certification- �`{� lr"DL�n �yz��r l �LJr1Cti�
1, attest that this application for name/ownership change has been
27
revewed and is accurate and complete to the best of my knowledge. i understand that if all required pans of
this application arc not completed and that if all required supporting information and attachments are not
included, this application package will be returned as incomplete. l understand l will continue to be
responsible for compliance with the current permit until a new permit is issued.
New Appticantfs)'s Certification:
llwe. C attest that this application
for name/ownership change has been reviewed and is accurate and complete to the best of my knowledge- I
understand that if all required parts of this application are not completed and that if ail required supporting
information and attachments are not included, this application package be returned as incomplete. I
further certify that I will operate and maintain the pennitted facility in accordance with the permit and
related regulatory
y ree uirements.
Signature: Lf-�Z 7' s< � L � Date:__
Signature: '-- Date:
S[IBMIT THE COMPLETE APPLICATION PACKAGE VIA ONE OF THE FOLLOWING METHODS:
U.S, Postal Service: Courier 1 Special Deiiyery 1 In Person:
WQROS-Groundwater Protection Branch WQROS-Groundwater Protection Branch
NC Division Of Water Resources NC Division Of Water Resources
1636 Mail Service Center 512 North Salisbury Street
Raleigh, NC 27699-1636 Raleigh, NC 27604
TELEPHONE NUMBER.: [phone]
FORM: CPU-PNQC 2/21/2014 Page 2 of 2

F.',ar�•Y�.y
OMB Approval No. 2502-0265
y a �• i
A. Settlement Statement (HUD-1)
�y^N okr�CY
B, Typo of Liman
1.0 FHA ZO RHS 3XIConrr. Unios. 6- File Number 7. Loan Humber 8. Mortgage insurance Case Number
4.121 VA 5.0 Canv. ins. R14607ILR 80200SD731 18-18-&0952358
C. Nate: This form is !furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items
marked "(p.o c.)a were paid outside the closing, they are shown here for information purposes and are not included in the totals.
D. Name and Add n_ss of Borrower E. Name and Address of Seiler F. Name and Address of tender
William Clifford Tice Andres R. DeITDro Navy Federal Credit Union
773 Bells Island Road Hope C. DelTaro 5550 Heritage Oaks Drive
Currftuck, NC 27929 180 New Beach Read Pensacola, FL 32526
Point Harbor, NC 27964
G. Property Location H. Settlement Agent (PH: (252)-261-2125)
180 New Beach Road SHARP MICHAEL & GRAHAM, LLP
Point Harbor, NC 27964
Lots 28, 29, 30, 31, 32, 34, 36 & 38. Black 3 Place of Settlement I. Settlement Date
Section 1, Paint Harbor Beach 4417 NORTH CROATAN HIGHWAY 09M&12
P.O. DRAWER 1027
KITTY HAWK, NC 27949
J. SUMMARY OF BORROWERS TRANSACTION:
K SUMMARY OF SELLER'S TRANSACTION:
IDD. GROSS AMOUNT DUE FROM BORROWER
400. GROSS AMOUNT DUE TO SELLER
Contract sales price
170 0D0.00
401. Contract sales rice
402. Psrsonaljrqpe
170 0X00
_101-
102. Personal property y -� W
103. Settlement charges to borrower Mine 14001
10,89B.20
403,
104.
404.
105.
T
405.
A jhastrnents far Owns paidseller in advance
Acquahnevits for Items pald by setMor in advamor
108. City Taxes to
400. City Taxes to
107. County Taxes 09f04 to 12131
333.14
407. County Taxes to
108. Homeowners Dues to
408. Homewmers Dues to
109.
409.
i 10.
410.
Ill.
411.
412.
112.
120. GROSS AMOUNT DUE FROM BORROWER
181,229.34
420. GROSS AMOUNT DUE TO SELLER
170.900.00
200. AMOUNTS PAID BY OR IN WHALF OF BORROWER
5W. REDUCTIONS IN AMOUNT TO SELLER
201. Deposit or earnest money
1 000.OD
501 • Excess Deposit inetnuons
202. Principal amount of new loan(s)
173 W,00
502. Settlement charges to seller Qkie 1400)
13,265.00
203. Existing foen(s) taken subject to
503. Existing loans taken subject to --
204.
504. Payoff of first mortgage loan
15O 585.58
PNC Mortgage
205. Lender Promo Credit
Z,5D0.00
505. Payoff of second mortgage loan
5.000.00.
Hampton Roads Bankshares
206.
5W.
207.
507. Deposit being disbursed as proceeds 1,OW.00
.20tt:
508.
299.
W9.
Ilyeelitnhmler Tar tthhh�hs htid b1►aeinr
ri-unp2ld by seller
1
_
_
PA - % t1i1Ii1 to 09M 700.17
zli 51& Past due Tam Tat 34
137.59
214
514. Past due Taxes Lot 36
233.06
215.
515- Past due Taxes Lot 38
137.59
2t6.
516.
if7.
517.

lr-'1'A
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
March 17, 2015
CERTIFIED MAIL #7014 1200 0001 3432 8411
RETURN RECEIPT REQUESTED
William Clifford Tice
180 New Beach Road
Point Harbor, NC 27964
Subject:
Dear Mr. Tice:
Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0700013
Currituck County
Donald R. van der Vaart
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above-referenced operating permit"for the
geothermal injection well system located on your property at the above referenced ad~ress was
issued to Andres and Hope Toro on July 19, 2010, and expires on June 30, 2015. Per permit
conditions and requirements per I SA NCAC 2C .0224( c ), the renewal application must be
submitted at least 120 calendar days prior to expiration of the permit if you wish to continue
operating the injection well on your property. According to our records, the permit renewal
application is now past due. Please submit your renewal application (attached) as soon as possible
if you wish to continue using the well for injection.
If Your Geothermal Water Return Well is Still Currently Being Used for In iection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title I SA, Subchapter 2C, Section . 0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells -Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http://portal.ncdem.org/web/wq/aps/gwpro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Being Used for Iniection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title I SA, Subchapter 2C, Section
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Phone: [phone] Internet: http://www.ncwater.org
An Equal Opportunity\ Affirmative Action Emp loyer-Made in part by recycled paper
William Clifford Tice
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
If There has been a Change of Ownership of the Property:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for your
cooperation and timely response. If you have any questions, please contact me by phone at (919)
807-6406 or by email at [e-mail].
Regards,
A~L~
Michael Rogers , P ~-~-~FL)
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington Regional Office -WQROS w/o enclosures
Central Files -Permit No . WI0700013 w/o enclosures
■ Complete items 1, 2, and 3. Also complete
Item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
WILLIAM C. TICE
180 NEW BEACH ROAD
POINT HARBOR, NC 2794
7014 1200 G001 3432 8411
A. Signature. 'Z.-,j L 2
0 Agent
x C Ti 1-C ❑ Addressee
B. Received bjLPgiqted Name} C. QW9of Delive3Y
L�. C. 1►� I L� I
D. Is delivery address different from item 17 Yes
If YES, enter delivery address below: ❑ No
3. Servks type
❑ Certified Mail ❑ Express Mai
❑ Regwered ❑ Return Receipt for Merchandise
❑ tnstued Mail ❑ O.O.A.
4. Reshlcted Delivery? (Extm Feel ❑ Yes
P5 Form 3811, February 2004 Domestic Mitum Rewlpt r oz5s-5-M-Fn-,5aa

4,.;,VA.
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrary Donald R. van der Vaart
Govemor Secretary
March 2, 2015
CERTIFIED MAIL # 7014 1200 0001 3432 8381
RETURN RECEIPT REQUESTED
Andres and Hope Del Toro
or Current Resident
180 New Beach Road
Point Harbor, NC 27964
Subject: Notice of Expiration (NOE)
Geothermal Water Retzn/Open-Loop Injection Well
Permit No. W10700013
Cum -tuck County
Dear Mr. and Mrs. Del Toro (or current resident):
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Dar records indicate that the above -referenced operating permit for the
geothermal injection, well system located on your property located at the above referenced address
was issued to you on. July 19, 2010, and expires on June 30, 2015. Per permit conditions and
requirements per I 5A NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior to expiration of your permit if you wish to continue operating the injection well.
According to our records, your permit renewal application is now past due. Please submit your
application (attached) as soon as possible if you wish to continue using the well for injection.
If Your Geothermal Water R Wra Well is Still Currently Beine Used for Iniection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A. Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells.)_ The form is also available on-line at our website
littp:l/portal _ncdenr. orglweblwglapslgwprolpermit-appl ications.
If Your Geothermal Water Return Well is NO LONGER Beine Used for Iniection:
If the well is no longer being used for injection, you do not have tc] xru w#wvr permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and 'vindicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.).. If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listedVr`der NCAC Title I SA, Subchapter 2C, Section
1636 Mail Service Center, Raleigh, North Carolina 27599-163G
Phone:,919807-C4gI1nternet: www.ncdew.gov
An Equal ❑pporlunily I Affirmative Aden Emoayer - Made in part by recycled paper

~;--'
.~ '
~ '
_., ·.;
~~:; .. -
Andres and Hope Del Toro (or cun-ent resident)
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
If There has been a Change of Ownership of the Pro pe rtv :
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Forni must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for your
cooperation and timely response. If you have any questions, please contact me by phone at (919)
807-6406 or by email at Michael.Ro!!ers(a),n cdenr .gov .
Regards,
~ ~/h_.
Michael Rogers, P.~. ~ & FL)
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington Regional Office -WQROS w/o enclosures
Central Files -Permit No . WI0700013 w/o enclosures
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application ___ Renewal* __ Modification __ Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages I and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: _________ ,20 __ _ PERMIT NO. ______ (leave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave blank if New Application)
1. Current Use of Well
a. Continue to use as
Supply .
Geothennal Well __ Drinking Water Supply Other Water
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).
D Yes, I wish to rescind the permit
2. Current Ownership Stat1;1s
Has there been a change of ownership since permit last issued? D YES D 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 Business/Organization __
Government: State Municipal __ County __ Federal
C. WELL OWNER(S)/PERMIT APPLICANT-For individual residences, list owner(s) on property deed. For
all others, list name of entity and name of person delegated authority to sign: ___________ _
Mailing Address :---------------------------------
City: State:_·_ Zip Code:. _______ County· ___ _
Day Tele No_: _______ ----------=C=e=ll--'-N~o=-~: ________ _
EMATL Address : _______________ ~F=ax~N~o~-=~---------------
Gcmhcrmaf Water Return Well Permit ;\ppfication (Revised Jan 20 l 5) Page I
D. WELL OPERATOR (if different from well owner) -For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the
business or agency: ______________________________ _
Mailing Address:---------------------------------
City: ____________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: ---------------~E=m=a=i~l A~d~dr~e~ss~-~= ___________ _
E. LOCATION OF WELL SITE-Where the injection wells are physically located:
Parcel Identification Number (PIN) of well site: __________ County: _____ _
(2) Physical Address (if different than mailing address): ________________ _
City: _____________ _ State: NC Zip Code: ________ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: __________________________ _
NC Well Drilling Contractor Certification No.: _____________________ _
Company Name: _________________________________ _
Contact Person"-: ---------------~EMAIL Address: ___________ _
Address:------------------------------------
City: __________ Zip Code: _____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ________ _
G. HV AC CONTRACTOR INFO~TION (if different than driller)
H.
HVAC Contractor's Name: ____________________________ _
NC HVAC Contractor License No.: _________________________ _
Company Name: _________________________________ _
Contact Person: EMAIL Address: ----------------------------
Address: ___________________________________ _
City: __________ Zip Code: ____ _ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ------------------
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
.YES
----NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS-As specified in 15A NCAC 02C .0224(d ):
..
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page2
(.3)
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface. _ _ _ _ _ _ ___ _ _ _ _ _
A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior-to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
____ *EXISTING WELLS ---~PROPO~ED WELLS
*For existing wells, please attach a copy of the _Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal ·
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
(c) Casing depth below land surface
(d) Casing h~igbt "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(f)(8 )
(f) Length of well screen or open borehole and depth below land surface
(g) · Length of sand or gravel packing around well screen and ·depth below land surface
K. OPERA TING DATA
(1) Injection Rate: Average (daily) crallons per minute (gpm).
(2) Injection Volurne: Average (daily) gallons pe~ day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP -As specified in 15A NCAC 07C .0224(b)( 4 ), attach a site-specific map that is scaled or other>Nise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s). ·
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0 I 07 ( a )(?) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Wei I Permit Application (R c vi~cd .Ian :!() 15) Page3
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data
M. _ CERTIFICATION (to be signed as required below orby that person's authorized agent)
15A NCAC 02C .021 l(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by all -the person(s) listed on the pro perty 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
injectio.n well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Propert)' Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Section (WQROS)
·1636 Mail Service Center
;Raleigh, NC 27699-1636
·Telephone [phone] ·
Geothennal Water Return Well Permit Application (Revised Jan 2015) Page4
MDERP,
North Carolina Department of Environment and Natural Resources
Pat McCrory Donald R. van der Vaart
Governor Secretary
March 2, 2015
CERTIFIED MAIL # 7014 1200 0001 3432 8381
RETURN RECEIPT REQUESTED
Andres and Hope Del Toro
or Current Resident
180 New Beach Road
Point Harbor, NC 27964
Subject; Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No- W10700013
Currituck County
Dear Mr. and Mrs. Del Toro (or current resident):
The Underground Injection Control (U1C) Program of the North Carolina Division of Water
Resources (DVWR.) is Entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property located at the above referenced address
was issued to you on July 19, 2010, and expires on June 30, 2015. Per permit conditions and
requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior to expiration of your permit if you wish to continue operating the injection well_
According to our records, your permit renewal application is now past due. Please submit your
application (attached) as soon as possible if you wish to continue using the well For injection.
If Your Geothermal Water Return Well is Still. Currently Beim Used for In iection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section -0211, you must submit the enclosed renewal
application. (Application for a Pemiit to Construct or Operate Injection Wells— Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http:l/portal.ncdcor.org/web/wqlaps/gwpro/petmil-applications.
If Your Geothermal Water Return Well is NO LONGER Bein_, Used for Injection:
I=fthe well is no longer being used for injection, you do not have to Xcaew*oVr permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (Le., used as water supply well, irrigation. well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the re�@_alatory requirements Listed -under NCAC Title 15A- Subchapter 2C, Section
1636 Mail Service Center, Raleigh; North Carolina 27699-1636
Phone, 919-807-6466 Internal: wAnro.ncdenr.pv _
Am Goal ❑optdimily ti Kfffirmalive Anion Employer - Made in pars by mcyc►ed paper

Andres and Hope Del Toro (or current resident)
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
If There has been a Change of Ownership of the Proper-M.
if there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94_ Thank you in advance for your
cooperation and timely response. If you have any questions, please contact me by phone at (919)
807-6446 or by email at Michael_Ro,�ersl,i.�ncdenr_-fov_
Regards,
Michael & FL Roger P.G. 1�f C
g � t )
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington Regional Office — WQROS w/o enclosures
Central Files - Permit No. W10700013 w/o enclosures

Page 1 of 1
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Global PIN 9 846-48-5752 .. . --·-· .
Number 180
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Street Name NEWBEACH
Street Typ e RD ····· Street Suffix Direction
City POINT HARBOR
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Townshi p POPLAR BRANCH ML
Owner Name 1 n c;e-wILLIAM CLIFFORD
OwnerName2
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180-1IBW BEACH RD
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Billing Ci ty POINT HARBOR IN C ······· ..... . ........
Billing State
Billin g ZIP Code 2 7964
Acreage (Legal) 0
Acreage (GIS) 0 .09
Tax Value: Land 11300 ............ , ........... .................
Tax Value: Buildines 135500
Tax Vaine: Deferred 0
Tax Value: Total 14 6800
Last Sale Date 2012-09-06 •·········•······ ...
Last Sale Price 170000
!N O --... ·-·--... --·· ····-... ••·•··--............ .• ... ~
Qualified Sale?
Deed Book 1215
Deed Page 398
Plat Cabinet 1
Plat Slide 83
Data Date 12 015-03-02
OwnerName4 ..
OwnerNameS
OwnerName6
OwoerName7
OwnerName8 ............. , ......
OwnerName9
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Owner Name 10
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CERTIFIED MAIL™ RECEIPT
(Domestic Mail Only; No Insurance Coverage Provided)
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(Endorsement Required)
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Sent O Current Resident ::r
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"" citii.siaie.-:z,p.;Point Harbor, NC 27964
PS Form 3800, Aug ust 2006 See Reverse for Instruction
I
Permit Number WI0700013
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Andres and Hope Del Toro -5A7 SFR
Location Address
180 New Beach Rd
Point Harbor.
Owner
Owner Name
"Andres
Dates/Events
NC 27964
Del Toro
Orig Issue
05/11/92
App Rece ived Draft Initiated
03/12/10
Scheduled
Issuance
Central Files: APS_ SWP_
08/06/10
Permit Tracking Slip
Status
Active
Version
2.00
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Currituck
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Andres Del Toro
180 New Beach Rd
Point Harbor NC 27964
Public Notice Issue
07/19/10
Effective
07/19/10
Expiration
06/30/15
_R_e_..9._u_la_t_e_d_A_c""'t"'-iv-'-'i-'-ti-'-e_s ________________ ~R=e=a=u=e=s=te,,_,d=/_,_R=e=c=e"'iv=-=e=d=-=E=v=e -=-=-nt=s=-------------
Heat Pump Injection Add it ional information re ceived
Outfall NULL
Waterbody Name
Additional information requested
RO staff report rece ived
Stream Index Number Current Class
04/05/10
05/19/10
Subbasin
Perm it Number WI0700013
Program Category
Ground Water
Permit Type
Central Files: APS_ SWP_
03/26/10
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Injection Heating/Cooling Water Return Well (5A7)
Permit Classification
Individual
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Cody, Ernest -SFR
Location Address
180 New Beach Rd
Point Harbor
Owner
Owner Name
Megan
Dates/Events
NC 27964
Oaksmith
Orig Issue
05/11/92
App Received Draft Initiated
03/12/10
Re g ulated Activities
Heat Pump Inj ection
Outfall NdLL
Waterbody Name
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Currituck
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Megan Oaksmith
Home Owner
180 New Beach Rd
Point Harbor NC 27964
Scheduled
Issuance Public Notice Issue Effective Expiration
Stream Index Number Current Class Subbasin
NA
·NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Andres Del Toro
180 New Beach Road
Point Harbor, NC 27964
Re: Issuance of Injection Well Permit
Permit No. WI0700013
Issued to Andres Del Toro
Cunituck County
Dear Mr. Del Toro:
Coleen H. Sullins
Director
July 19, 2010
Dee Freeman
Secretary
In accordance with your application received April 9, 2010, I am forwarding Permit No. WI070001 3 for the operation of a
5A7 geothermal underground injection control (UIC) well heat pump system located at the above referenced address.
This permit shall be effective from the date of issuance until June 30 , 2015, and shall be subject to the conditions and
limitations stated therein. · 1
Also attached is a summary of the laboratory sampling results from water samples collected from your geothermal well on
May 11, 2010. Laboratory analytical results of both the influent and effluent samples indicate exceedances in the
maximum contamination level (MCL) or elevated levels for the following parameter(s):
Parameter Units MCL Results
Aluminum µg/L No standard 1900 (influent)
790 (effluent)
Calcium mg/L No standard 120 (influent)
Iron µg/L 300 1900 (influent)
790 (effluent)
Potassium mg/L .No standard 63 (influent)
57 (effluent)
Magnesium mg/L No standard 16 (influent)
Sodium mg/L No standard 18 (influent)
(detect) 19 (effluent)
Lead µQ /l 1000 1300 (influent)
The source or cause of these exceedances is unknown. It is recommended before using water from this well for personal
consumption that you consult with the Currituck County Environmental Health Department.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Locatio n: 2728 Capital Boulevard , Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
A1 Equa 1 Opportun::1 I Afflrmative Action Employer
One C 1. North aro 1na
)Vaturally
Please note Condition IV (1) in the permit requiring you to bring the well heads to proper construction standards
within ninety (90) days of the issuance of this permit. In order to continue uninterrupted legal use of this system for the
stated purpose, you should submit documentation of the repair work to:
Aquifer Protection Section -UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
And
Aquifer Protection Section -Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
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,
~£,,,/ty/
~R.McCray
Environmental Specialist
cc: David May -Washin 1-->1on Regional Office
Central Office File -Wl0700013
C unitu ck County Environmental Health Dept.
Attachment(s):
Permit
Sample Results
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLIiti A
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
Andres Del Toro
FOR THE OPERATION OF 2 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 150 New Beach Road, Point Harbor, Currituok County, NC 27964, and will be
constructed and operated in accordance with the application March 12, 2010, and in conformity with the
specifications and supporting data submitted, all of which are filed with the Department of Environment and
Natural Resources and are considered a part of this permit.
This permit is for operation of an injection well shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use_
This permit shall be effective, unless revoked, from the date of its issuance until .t une 30. 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through Vlll hereof.
Permit issued this the _� day of } , 2010.
Coleen H, Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
W10700013

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 pennanently 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 RecQrd (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 -Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
(
,-.,--,,. "'A' •4g1 .:..:)..'..' '''+v-':• <:
GW-ls 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 -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 Pennittee, 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.
WI0700013 2
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordin~ces, ~hich may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
PART III-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Pennittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART IV -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection well heads shall be repaired and brought to the proper height of at least ·twelve inches above
land surface or a request to rescind the permit should be submitted if the system is converted to a surface
discharge system and the wells are no longer needed within 90 days of the issuance date of this permit.
2. The injection facility shall be properly maintained and operated at all times.
3. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
PART V -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain.
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
WI0700013 3
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Raleigh Regional Office, telephone number [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 VII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART VIII-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily. the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that w ,:::, ,;1ust be pem1anently abandoned according to ISA NCAC 2C .0213(h)(l), Well
Construction Standard5:
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 irt accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A)
(B)
(C)
WI0700013
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.
The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
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.
4
(D) Each well shall be compl,etely 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 VIII (1) and (2) (G) shall be submitted to:
WI0700013
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
MEMORANDUM 16-Jul-J0
To: Andres Del Toro
From: John McCray [phone]
Re: Groundwater Sampling Res ults from May 12,2010
Influent Water Sam l!le Effluent Water Sam11 le
Parameter Standards Results Standards Resu lts
Groundwater Drinking Groundwater Drinking
Coliform, total l per 100ml zero ND Colifonn, total l per 100ml zero ND
Coliform, fecal l per 100ml zero ND C oliform, fecal l per 100ml zero ND
pH 6.5 -8.5 7.0-8.5 7 pH 6.5-8.5 7.0-8.5 7
Hardness no standard no standard 45.17 mg/L Hardness no standard no standard 46.00 mg/L
Chloride, Cl 250 mg/L no standard 29 mg/L Chloride, CJ 250 mg/L no standard 31 mg/L
Flouride, F 2 mg/L 4mg/L ND Floride, F 2 mg/L 4 mg/L ND
Sulfate, SO4 250 mg/L no standard 18 mg/L Sulfate, SO4 250 mg/L no standard 19 mg/L
Dissolved Solids 500 mg/L no standard 122 mg/L Dissolved Solids 500 mg/L no standard 129 mg/L
NH3 as N in liquid 1,500 ug/L no standard ND NH3 as N in liquid 1,500 ug/L no standard ND
Total Kjeldahl N detect no standard 0.33 mg/L Total Kjeldahl N detect no standard ND
as N in liquid as N in liquid
NO2-+ NO,-as N detect 10 mg/L 1.8 mg/L NO2-+ NO,-as N ' detect 10 mg/L 4 .9 mg/L
Phosphorus total detect no standard 0.41 mg/L Phosphorus total detect no standard ND
as P in liquid as P in liquid
Nitrate as N in liquid 10 mg/L 10 mg/L 1.8 mg/L Nitrate as N in liquid 10 mg/L 10 mg/L 4.9 mg/L
Nitrite as N in liquid 1 mg/L lmg/L ND Nitrite as N in liquid 1 mg/L l mg/L ND
Aluminum, Al detect no standard 690 ug/L Aluminum, Al detect no standard 360 ug/L
Calcium, Ca detect no standard 11 mg/L Calcium,Ca detect no standard 11 mg/L
Chromium, Cr 10 ug/L 100 mg/L ND Chromium, Cr 10 ug/L 100 mg/L ND
Copper, Cu lmg/L 1.3 mg/L .066 mg/L Copper, Cu 1 mg/L 1.3 mg/L 43 ug/L
Iron, Fe 300 ug/L no standard 4600 u9/L Iron, Fe 300 ug/L no standard 120 ug/L
Potassium, K detect no standard 3.4 mg/L Potassium, K detect no standard 3 .7 mg/L
Magnesium, Mg detect no standard 4,3 mg/L Magnesium, Mg detect no standard 4.5 mg/L
Manganese, Mn 50 ug/L no standard 29 ug/L Manganese, Mn 50ug/L no standard 32 ug/L
Sodium,Na detect no standard 18 mg/L Sodium,Na detect no standard 19 mg/L
Nickel, Ni 100 ug/L no standard ND Nickel, Ni 100 ug/L no standard ND
Lead,Pb 15 ug/L 15 ug/L 44 ug/L Lead .Pb 15 ug/L 15 ug/L ND
Zinc , Zn 1 mg/L no standard .42 mg/L Zinc,Zn l mg/L no standard 31 ug/L
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: Ma+! 17.2010 Permittee(s): Andres Del Toro
Permit No.: W10700013 M
To: APS Central Office County: Currituck ►r
In
Central Office Reviewer: Project Name: Del Toro
Regional Login No:
L GENERAL INFORMATION
1. This application is (check all that uppiy): ❑ SFR Waste Irrigation System ® UIC Well(s)
❑ New ❑ Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment 3 included ❑ 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation ® Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No,
a. Date of site visit: Mar 1 Z 2010
b_ Person contacted and contact information: Andres Del Toro. 180 New Beach Road. Point Harbor. NC
27964: phone [phone]. - -- —
c. Site visit conducted by: Allen Clark and Don Burke. DWt 11APS WaRO
d. Inspection Report Attached: ® Yes or ❑ No.
2. Is the following information entered into the BIMS record for this application correct?
® Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application.
For UIC Injection Sites:
(if multiple sites either indicate which sites the information applies_to . copy—g d_paste a new section into the
document for each site. or attach additional cages for each site}
a. Locations): 180 New Beach Road, one ( 1) infection well -in front � ardT and_one ( 1.) injection well is
located in the hac1_•ard,
b. Driving Directions: New Beach Road is located approximately 1.5 miles north of the Currituck/Dare
Couno, bride_ alon the Caratoke H%+,% .. in Currituck Count►.. House located on New Beach Rd._ 0.4 miles
from Caratoke H�%%.
c. USGS Quadrangle Map name and number;
d, Inj. Well in Front %ard: latitude: 36 Deg.. 05 Min._ 43 Sec: Longitude: 75 De&.. 48 Min., 09_Sec.
Inj. Well in BacLN ard: Latitude: 36_Dea,. 05 Min,_ 42_Sec: Longitude: 75 Dee.. 48 Mini_08 Sec.
Method Used (GPS, Google m, etc.); Google Earth.
11. NEWAND MAJOR MODIFICATIONAPPLICATIONS this section not needed Lop renewals or mirror
modifications, skip to next section j NA
111. RENEWAL AND MODIFICATIONAPPLICATIONS fuse previous section {far new er maior modification
s stems NA
APS-GPU Regional Staff Report (Sept 0 ) Page 1 of h Pages

AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
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 of Well(s) and Facilities -New, Renewal, and Modification
1. Type of injection system:
~ Heating/cooling water return flow (5A 7)
D Closed-loop heat pump system (SQM/SQW)
D In situ remediation (SI)
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 source(s)? . What is the distance of the in jection well(s ) from the pollution
source(s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? ___ ft~._N_A
5. Quality of drainage at site: D Good ~ 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: NA
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? D Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal and Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
~Yes D No. If v es e~ lain: The owner stated that the two 2 in'ection wells occasionall Q.et "clo ed
u p ." When this happ ens, the owner uses an air hose, sometimes as often as four (4 ) times a year, to "blow" the
wells clear. Owner stated that he is considerin g abandonin g the two (2 ) in jection wells and pi pin g the effluent
water onto the ground.
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 ves . exp lain: NA
APS-GPU Regional Staff Report (Sept 09) Page 2 of 4 Pages
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
3. For renewal or modification of groundwater remediation permits (of an y typ e), will
continued/additional/modified in jections have an adverse im pact on mi Q.ration of the plume or management of
the contamination incident? 0 Yes D No. If ves . ex plain: NA
4. Drilling Contractor: Name: __
Address:
NC Certification number:
5. Complete and attach NEW Injection Facility Inspection Report, if applicable
V. EVALUATION AND RECOMMENDATIONS
I. Provide any additional narrative regarding your review of the Application:
2. Attach new Injection Facility Inspection Form, if applicable
3. Do you foresee any problems with issuance/renewal of this permit?~ Yes O No. If yes, please explain
briefly. System is presentl y not workin g. In jection wells become "clo gged" often. Owner is considerin g
abandonin g the wells and pi pin g effluent onto the land surface.
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
Within 90 days of permit issuance, the injection Wells completed below grade. Owner indicated
wells shall be repaired to bring the well heads at he may abandon wells and discharge water onto
least 12 inches above land surface, or a request ground.
to rescind the permit should be submitted if the
system is converted to surface discharge of the
water and the injection wells are no longer
needed.
APS-GPU Regional Staff Report (Sept 09) Page 3 of 4 Pages
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
7, Recommendation: ® Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft: permit by regional office; ❑ Issue upon receipt of needed additional information; ❑
Uume- n TI-mv Tf [ env. nleme ctatP reatznns:
8. Signature of report Preparer(s):
Signature of APS regional supery
Date:_
VI. ADDITIONAL INFORMATIONAN_D SITE MAP fSketch aLsite shofui►rg hoarse and waste irrigation
$1 spray or drip field, location of tm lfs . and1or other relevant information- SHOW NOR THARR0117
As listed above, the owner stated that the two (2) infection wells oemionally get "clogged up." When this
happens, the owner uses an air hose_ sometimes as often as four (4) times a year, to "blurt?' the wells clear.
Owner stated that he is considering abandoning the two 2 injection wells and piping the effluent water onto
theground, Influent and effluent samples collected. Sample results to be forwarded to Central Office once
submitted. Wells are currently completed below grade level. However, the desiy—n has not been changed since
previous renewal and -was not identified as an issue in previous inspections.
1-
too GFF.
i
act
5eWc,
I � �. , �0 � � n., M-.
A.PS-GPU Regional Staff Report (Sept 09) Page 4 of Pages

WASHINGTON REGIONAL OFFICE - APS SECTION - PHOTOGRAPHIC RECORD
Site Name: Del Toro residence Permit Numbe WI0700013
Site Location 180 New Beach Road Site Town[Cit►
Point Harbor, NC
Photographer:
Photographer:
A. Clark
A. Clark
} +� u ��•
�'• �:. �� r x ' `.
. +.�:.'
Date:
i
Date:
w
5/12/2010
f`
5/1212010
Photo Location:
. �, .►'P ;' +
Photo Location:
Influent
Front Yard
r x C1' l i
Sampling Polnt
1
Injection Well
:,s a�4•
_w}•�:,� ++-�
Photo Direction:
Photo Direction:
. �" '�'.r
Utility Room
_ . fir~►'';:
Comments:
-�
Comments:
Influent Water
sampled from
Injection Well that
is located in the
�• , •S
++>,•,+Y r .
white pipe.
front yard.
Photographer:
Photographer:
A. Clark
A. Clark
Date:
Date:��
511212010
Photo Location:
•
511212010
Photo Location:
• °' ►
Effluent
+
�'
Backyard-
ti ' : "
Sampling Point
j
Injection Well
Photo Direction
Photo Direction:
'� 'r _' = �� :.
�fj °">�
"3, J'. +�+�+':ti
Utility Room
_�
.;. - .'.,• _
Comments:
Comments:
-
Effluent Sample
injection Well that
`•��,: �. r, s; • i ;.' T.�' , x:r r
= �':,�
from spigot,
is located in the
4 �a►`t ,�
yellow hose was
hack yard.
removed.

North Carolina Department of Environment and Natural Resources
Division of Wate.r Quality -Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700013
DATE OF INSPECTION: May 12, 2010
INSPECTOR: Allen Clark, Don Burke; WaRO
NAME OF PERMITTEE(S) Andres Del Toro
MAILING ADDRESS OF PERMITIEE: 180 New Beach Road, Point Harbor, NC 27964
PHYSICAL ADDRESS OF SITE (if different than above) _______________ _
PERSON MET WITH ON-SITE: Andres Del Toro; TELE NO. [phone]
WELL(S) STATUS:
__ Existing and operating Class V Well
__ Existing well proposed to be converted to Class V well
__ Proposed/not constructed
Injection Well in Front Yard: Latitude: 36 De g .. 05 Min., 43 Sec : Longitude: 75 De g., 48 Min .. 09 Sec.
Injection Well in Backyard: Latitude: 36 De g ., 05 Min .. 42 Sec ; Longitude: 75 De g .. 48 Min .. 08 Sec.
Appx. distance of well to property boundaries: 20 feet (both wells )
Appx. distance of well from foundation of house/structure: 50 feet (both wells )
Appx. distance of well from septic tank/field (if present): 50 feet (both wells )
Appx. distance of well to other well(s) (if present): The Injection Well that is located in the backyard is
approximately 50 feet from the supply well.
Appx. distance to other sources of pollution: ___________________ _
Flooding Potential of Site: _high __ moderate X low
Comments:
Injection Facility Insp. Report (Rev. Sept 2009) Page I of3 Pages
VA -io-4-000\3
i
GFF.
�7'
Approx.
64-4.____
m
DRAW SKETCH OF SITE ABOVE (Show properly boundaries, buildings, other wells, septic tanksldrain fields, ocher
potential pollution sources, roads, approximate scale, and NORTH arrow)
5 i n;,lz
z-�' -= ��— s �c ati-, 5 tr bv�, �1eC��nC11s .
t
��)
�4� G� -� � � �� � �� `�s � �t , S tr fi � ��n �� r �VJ�I �►� 'des � ��
}
yo�\ Acs �A�X-�tvr' co -A 11� '4
bx w i�,�•�, �Yvj'} � �c� �w �� cA�s . i; e4r� o nC�
Draw Schematic of well above showing TD, casing depth, grout, etc.
In;ectiori Facility Insp. Report (Rev. Sept 2009) page 2 of 3 Pages

Well Construction Information
Date Constructed: 1986-1987?
Well Contracting Company: Mr. Lori Stillman. III (deceased 1988 )
Well Driller Name: Mr. Lori Stillman. III {deceased 1988 )
NC Well Cert. No.: -----
Address: ---------------------
Telephone No.: ___________ ; Cell No.: _________ _
Email Address: -----------
Proposed Depth of Well(s): _______ _
Total Depth: 40 feet (both injection wells) Total Depth of Source Well, if present: 89 feet
Casing: (Both Injection Wells the Same)
Depth: 40' (p er past records ); Diameter: 2 inch; Type (gav. steel, PVC, etc.): PVC; Terminated 3 inches BLS.
Grout:
Depth: 2-2.5 feet per prior ins pection; Type (cement, bentonite, etc.): Cement; Placement (pump, press. etc.):.'.?.
Well ID Plate Present (Y or N): No; Heat Pump ID plate present (Y or N): No
Influent spigot (Y orN): No (sample taken from pipe leading into heating unit); Effluent spigot (Y orN): Yes
Well Sampled? (Y or N): Yes [sample taken from pipe leading into heating unit (between jet pump and heating
unit)];
If Yes, Lab Sample ID numbers: _______________ _
Static Water Level: 1.
Injection Information (if applicable):
Injection Rate:? _____ GPM
Injection Pressure:? ______ PSI
Injection Volume: ? _____ GPD
Temperature-Summer: ? ____ F0
Temperature-Winter: ? ____ F0
Comments/Notes: Owner stated that the system is not workin g at this time. He stated that the two (2) in jection wells
occasionally get "clogg ed u p." When this happ ens . the owner uses an air hose . sometimes as often as four ( 4 ) times a vear.
to "blow" the wells clear. Owner stated that he is considering abandonin g the two (2 ) in jection wells and pi pin g the effluent
water onto the ground.
Injection Facility Insp. Report (Rev. Sept 2009) Page 3 of 3 Pages
County:
Cumituck
Sample Id:
AUSE225
River Basin
[�_ CIARK
rc YW ATE
p ,Q
PO Number #
GW1OM7
Report To
¢�
WAROAP
`0
pate Received:
Rived:
0WIM1110
15:30
Collector:
p C►ARii
o
LaLworks Loginl❑
L@ll1CK
Region
WARD
Report Generated:
W20110
Sample Matrix:
SURFACEWATER
Gate Repo
Reported:
U5I2012010
Lot. Type:
EFFLUENT
Emergency Yes/No
Visitl❑
COC YeslNo
Loc. Cesct.- ANDRESDO—TORO
Location ID-
APS-N-IWW-CURRI-0013
Collect Dale: 05MV2010
Collect Time: 11:00
Sample Depth
Result/!!nits
Method
Analysis
CAS # Analvte_Name PEE_
Validated by
Qualifier
Reference
Date
WARD
Sample temperature at receipt by lab
2.0
'C
5112/10
SIUATHIS
Coliform, MF Fecal in liquid 1
1 B2
CIKU1100ml APHA92220-201h
SH2110
ESTAFFORDI
Colgorm, MF Total in liquid 1
1 B2
CFW100ml APHA92226-20th
5112110
ESTAFFORD1
Latmmtory 9Pcdan» 1623 Mall Service Center, Raleigh, NC 27699.1623 [phone]
For a detailed description of the qualifier codes refer to www-dwglab.org under Staff Access
Page 1 of 1

I
GROUNDWATER FIELD/LAB FORM
r.
t_oGarion code _,s . N - v, cl:: (T-51- f?'�
County �� t ''A� I ,tiVater
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Report To, ARO HZO MR01 RRO%''_WaRQj VARO•
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Slipped by: 13 CaL�rier�- Hand De
004ectoifM): r1C %; t� - s LL.r�: _ Gate
FIELD ANALYSE 3 t
pH 1. — --_ Spec G0rtd.N4_. _ » _ ..-..at 25*c
Temp.,r -°C Oder -
Appearariee
Field Analysis By.—
LABORATORY ANALYSIES
rng 1, �DDim- a"-;ys 70300
t _ * Coo H.3h :Acl f rng1L ] F ,1.k; Cv _
-ieOf) LcwSIS� wQOL 1F+•dne�s 1At8i sGtl T
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i _ joc ZW1 T _ nvk 5{5A+a0c C1304d 55—�pl�!'saslG-� I cd-cadnirwn 40555-
iwrG+ctr 5 KTL tia5 q*L Li "550 ursrL I
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i7}I % tSCt+15 i
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.rt
C"I bow a A 4 S rrsy+L
fiasha.•s �irxic�s d"•: �• :rgPL
Color. P aE 80 Cif -
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t Cki :;w Zrr'vm
1 KH;; 2S N fi i 0
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NOko3� �N 63C
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DI'4510N CAP WATER 00Ai.11rY-G..R0[.U)VVXrr R SECTION
2km_R rF�iCJ)1m!,
T 14 tfi f)a',§ Reeeived�VW
l Ro. 'd By: �� FrarrrBtte, Ct,utiir r, fi d ` I..
Oa$a Entry By Ck:
Date Reported:
Purpnse- r�
easeliria CpfrtpLaIre. caTpikmnr.:B IJST, Past.c4a 5twiy, mod* ral Trust, Oavv-
—
�..00#LlOri C}! .�a'iLr; a .. �.�` 1:- riSS?:..�1
� w♦
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Descriprion Of S tng AUljit
��� ..-
'?j 1 ' 1:.
Samp ng Method i t
Sample lnlarr4
Remarks a - t r ti! •
�: -
_ _
----.... _ — . - -
i•'i.�•,-d.:3
i -•+s ur :aro;. at_ �
---.__-'',�'
j
A 6
i 4`$:vN"• ISs@G �._...�_..._._.---__
_-. y-•. � ;L
if
mgN,
ti Rh rrv! .r. 9655T�R-L1ra�ttr
e as arcPr_� jee J
IL
it Nil e s pextL..!. is j
W-. E18r!',.r:: 4"th —
..-._...._..�(I& Y�
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r�-IrwAfdSB3_ ul
. 5�! siYt �ti12- _CF7U7if 6
- --
iuyL - I Hq•AiatGr y 7.4G3 ul- TF'i�- t� #i^n
Fi N,-!!--sm .46N4 mSFL
anp-FAa6r.esuurr &ds!i _ mWL
ppgw"-4M5 _ Mary. VIAN0. ]rry M. '-IV NM "tf[-}FrIgA.�_-
_ _ rn � j 1i'M•3d645rIG H3f1�P. _ .. �^....-.. .,,,,_......,_,,....._
mg+L' 4a400
- _ mglL ~ .� ref Lu''�; :' .
L AR USA C!NL Y
rurrparaaiire or nrriyal {'C.)

r
n
County: Currituck
Sample to-.
A858224
River Basin A CLARK
WA rSR
QG
PO Number 0
GW100427
Report To WAROAP
0
Date Received:
05ri2120i0
�
Time Received:
15:14
Collector A CLARK
Labworks Loginl❑
LBi1CK
Region: WAR
Report Generated:
5120110
Sample Matrix: SURFACENlATER
Dale Reported:
0512012010
Loc. Type: INFLLIEHT
Emergency Ye"o
VisItID
COG Yes1No
Lac- Dascr.: ANDRES DEL TORO
Location ID: APS-N-SWW-r-URRt-N13
Collect Da4e_ 0511s12010
CollectTiime: 11:10
Sample Depth
Resultl
Method
Analysis
CAS # Analvte Name
PQL
Units
Validated by
Qualifier
Reference
[late
NWARO
Sample temperature at receipt by lab
2.0
'C
5112110 SUATHIS
Coliform, MF Fecal in liquid
1 B2
CFW700m1 APHA92221)-20th
511217o ESTAFFORDI
Coliform, MF Total in liquid 1 1'62 CFUll0oml APHA9222B-2ft 6112110 ESTAFFORD7
R C GC ltr C U I WA I DWO
�����Q ���H�cr�wT ►�s��a ���►�r�rl�+v �zc�lV
JUN 21 ZUW.,
Laborwary SectiOn77 1623 Mall Sarvice Canter, Raleigh, NC 27699-1623 [phone]
For a detailed description of the qualifier codes refer to www-dwglab.org under Staff Access
Page 1 of 1

GROUNDWATER FIELD/LAB FORM
Location cact&•
Quad No
Lai
r " Dak41"r7eil3 Ot EOV+FE'iROIC-I'll grid NOIUal
VIV- il(}' OFWATC'i=AGrFy-Lsr><(jiJNlYkrdATJ' i tE.COON
sAnrpu -ryf?F Mt4PRIOR17Y
[ ►eftarur Rot,'.s,a 1 I_ah 14umber��l��� � d
Crate Recejved •:':ft d/Ap
❑ QIIt r Rae; d By.
4-� T,,�� >-ratrl;�;rs. Gaufler. I r1d �
�•ss.. G (;he -I 0C:rr.�r,ar•1 other
PD- ARC]; FRO. MF?O. l�ROV, -0 wiw, �_ . _ (iota FnUY Sy..
:6RO, Kil7mr1 FO, Fed. Trkrat, CCrrtr7l ., r tcr; - --- l�tite Re�pomfad "_ __
Si:Oed by: Bus. coij*ie cN,46n [)�d) Olt-w- Pu-pose _—
couector(s): A C:. r `..� i� i c F .�� Tir�ae_I = r9 ^.: iy Bay ;re Carrlpf nilC pliMn .l1 T, f'esti^irja Study. t ad r ! : r. i. lthr r
FIELD ANAt_Y ES
PH '�. E Pec, cond.,, at 251C Location w Site I` �2I �` C:.-,ti
Tr�r�tla. ;;, _=L Odor . T_ _ Y •_ � Dosexlpt:on cat ,�irn��n�
FgaranGeSmpling IWehad era 5;srpl@t[v i
FieldAnal t3Y f2�rn sis a:k.s �t
_.C}ire i�+Eg rcr�lr-a G s+:ti... > �•.;�1.. 4" !'..�•.�L
_ _ . _ _---- .................. m ..
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......
COhroirfl ?AF Vecr l ICX Pi dites%902 s.� 1 Ld•:idr. on 405 ,. ur rt i At4w 114rtrr '•s @
t+Tcxtn 4if i� dSrx;+ rIf mll f�Cf3s
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— 1
'TomdI
roll 14,gm e:� =_ mqk ! 511'ide745 11rV L arm 4l 5C� L
Fe-1!�1s
IRM h�'1 ! rr�N-G• eScl ii 1.'
011 40a L`V ; iY&. 4b*5i
A!Fka:'ndy ..v pH k: 410 n •T ! bP�• gr. x m an: s ag f f ? - r — . Y . _„
f k-K4;'�o "i B-3.4# 0 ,. r i L ! V:;�r v ih aro4s ,.,...,..
CxrbC.e=A6 rw z; ask S1 —__ �� ....., ... 9' _ R "
_ ��.! _ _—NcT�i.+��.•_—__� ._...._.............—...�—raw 7ret G.ssaC Rarme .......W.........._w_.. ,
V j rty3n8tr as0 nq� 7rgh ss # B m: _ ? ~.3 N-IVoCr,iil
_ _ L.._.__ _._ __. _... —--- - -
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s caZ rs c: :�e a 3v mla , . sn, c = tz r � Z. ,_ F t .,rk• � a 4�ee � �
�- --_.._..W....._ ......... _. _ ..�.._—.... 4 il_---
__... _._
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Chrc- man la x hoer; :t t!i� E. Fd, a2r it i+L f.. F 7
'm A - �7"ems l r
- -
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_,_ _ -- —� , -_ .. -- ---._. �.._.._ _ — t mpzra: 1rs nn yrrivaa i"G3 a: K-
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Long _
4,�i-,,I Rej '"k _�h.r.. i rorra garrpK-. and wrne- is - tr`r•_r

County:
CURRITUCIC
Sample ID:
A$58191
River Basin
�CF W RTE
PO Number #
10G0259
Report To
INAROAP
�D
Hale Received:
051t712010
�i
1
rime Received:
09:20
Collector
A CLARK
LabMft LoginlD
SMATHIS
Region:
WARD
Sample Matrix: GROUNDWATER
Date Rert ported:
Date Reported:
05107J
Ofi10712010
Lac. Type;
WATER SUPPLY
Emergency
Yes/No
Vis-PHD
GOC Yes/No
Lac. Descr.: ANDRES
DEL TORO
Location ID: APS-N-1WW-CURRI-0013
Collect aster
05117J2010
Collect Time: 11:00
Sample Depth
Result/
Method
Method
Analysis
CAS #
Analrie Name
P[ L
Units
Validated by
ualiFier
Date
LAB
Sample temperature at receipt by lab
1.2 'G
5113110 SAMATHIS
WET
Ian Chromatography
_TITLE_ mg1L
EPA 300.0
VI 41111 MOVERMAN
Chloride
1
31 mg1L
EPA 300.0
5124110 MOVERMAN
Fluoride
0A
0.4 U mg1L
EPA 300-0
5124110 MOVERMAN
Sulfate
2
19 mg1L
EPA 300-0
5124110 MOVERMAN
Total Dissolved Solids in liquid
12
129 mg1L
APHA254OC-15TH
51201111 MOVERMAN
NUT
NH3 as N in liquid
0.02
0,02 U mgfL as N
Lac10-107-06-1-J
5119110 CGREEN
Total lgeldahl N as N in liquid
0.2
0.2 U mglL as N
Lachat107-Afi-2-H
51WO CGREEN
NO2+NO3 as N in liquid
0.02
4.9 mgfL as N
Lac10-107-04-1-c
5119110 CGREEN
Phosphorus —total as P in liquid
0.02
0-02 U mg1L as P
LaG10-115-01-if<F
5117110 CGREEN
Nitrate as N in liquid
0.02
4.9 mgfL as N
Lachat107-04-1-r
&24110 CGREEN
Nitrite as N in liquid
0-01
0,01 U mg)Las N
LachaI107-04.1.c
W13110 CAREEN
MET
7429.90.5
Al by ICP
50
360 ug1L
EPA 20D.7
W27110 ESTAFFORDI
7440.70-2
Ca by ICP
0.1
11
mglL
EPA200.7
&27110
ESTAFFORDI
7440-47-3
Cr by ICPMS
10
IOU
ug/L
EPA200.8
5117110
ESTAFFORDI
744MO-8
Cu by ICPMS
2
43
ugIL
EPA20D.8
5117110
ESTAFFORDI
743MM
Fe by ICP
50
120
ugIL
EPA2U0.7
5127110
ESTAFFORDI
7440-09-7
K by ICP
41
3.7
mp/L
EPA 2DD.7
5127110
ESTAFFORDI
7439-"
Mg by ICP
0.1
4.5
mgk
EPA 200.7
5127110
ESTAFFORDI
7439-96-5
Mn by tCP
10
32
uWL
EPA200.7
5127110
ESTAFFORD1
7440-23-5
Na by ICP
❑,f
19
mg1L
EPA 200,7
5127110
ESTAFFORD1
7440-02-0
Ni by ICPMS
10
IOU
uglL
EPA 200.E
5117110
ESTAFFORD1
7439-92.1
Pb by ICPMS
10
IOU
ug&
EPA ZDD.B
6117110
ESTAFFORDI
7440.66,6
Zn by ICPMS
14
31
ug&
EPA 200.8
5117110
ESTAFFORD1.
IN 10
Laboratory Section» 1623 Mal Service Center, Raleigh, NC 27699-1623 [phone]
FWA Oetated 66"fjojOn 9t Jill qu Mfibr=ttl rrrlr in iltlp'NNL�fL;J4Ur�] nn h L,mynhiwgi;Yl'!atetrJf!h�Il4Fh-+.:$iI D S75liL Uo-°A9k ..:-i-�{I7:111S7firs✓.�rdL�.�Y.-Lh>h!Y-i!i�'9:`: !SIaItPfui-_.@C_EChnes4.p
Page 1 of 1

GROUNDWATER FIELD/LAB FORM
Location code -:rwW-'Z,44t- 0013 SAMPLE TYPE SAMPLE LEQRiTY
county—.- C► (- r ary� a Wafer ID Routine
Quad No Serial No. ❑ Sal ❑ Emergency
Lat. Long. ❑ Other
0 Chain of Custody
Report To: ARO, FRO, MRO, RRO, aR WlRO, — -
WSRO, Kinston FO E d. Trust; Central Off.. Other
Shipped by: B Courier d Der., ❑ er Purpose:
Cgneclor[s]: f L� cy , d'+ & Date_51MZaVU-Time t] a 6aseiine, o Im
FIELDANALYSES Owner
pH 4ou r to Spec. Cond.,< at 256C Location or Site i
Temp.io °C Odor description of sam Gngg poirl
Appearance Sampling Methot cc._
Field Analysis By: Remarks P)60.'.5 t 04r
SOD 310 mg&
Diss. sdids 7W 00 HNSL
COD High 340 mglL
Fiuodde 951 mWL
COD Low 336 mg&
Hardness' Total 900 mg1L
Califorrn: MF Fecal 31616 1100ml
Hardness (w esrb) 902 mg -
Celiti m . MF Total wim 1100161
Phenols 32730 ugq
TOC 68o mglL
spedfic Cad. 95 uwoslcm
Turbidity 76 NTU
Sulfate 945 mg1L
Residue. Suspended 530 rng1L
Ll
SutFde 745 mgfL
ON and Grease mglL
pH 403 Units
- —
Allvlink !o pH 4.5 410 mgfL
�4
Alkalinity ko pH 5-3 41S mg[L
Cadxmate 445 ntg1L
NH3 as N Sit) t ' t� rrngA-
Bkarbvnate 440 mg1L
TKN as N 825 ` mglL
Carbon dtoAde 405 m9k
NOr+ NO2 as N 630
•; ntglL
Chlortde'940 mglL
P Toia1 as P 865
y m91L
Chromkm Hex 1032 UD&
Nitrate (N%as N) 626 mg1L
Coker. True 80 Cu
NMI@ (Nq as N) 615 mg1L
'Cyanide 7211 mgrL
Lab
GiN-54 REVM Fer Dissolved Analysis-suba t filtered sample and write •DIS' in bkxk
North Carolina
Departmeni of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Lab Number
❑ate Received Time: ao
Rec'd By: From:Bus, au er Hand Del„
Other:
Data Entry By; Ck:
Rate Reported:
n tCompliianc LUST, Pesticide Study, Federal Trust, Other_
;ordaonej Q, . 1 i� 'T 2 \-I (N-v% —\-3
E
(P. h,pft lime. alr temp., etc)
Ay-Silver48566
u IL
F t-Aluminum 46557
ug&—
As-Arsenic 46551
u
BA-aadum 46558
u IL
Ca -Calcium 45552
m
Cd-Cadmium 46559
1.10
Cr-Chromiurn 48559
u ✓L
Cu-Capper46562
S, ugfL
Fe-Irm 46583
Hg-Mercary 71900
4 h
ug1L
uglL
K Potassium 46555 -
m IL
Mg-Magnealurn 48554 t
��
mglL
lNn 144anganese 46565
—
ug&
Na-Sodium 46556
. IL
NFNickelLLBA-
INS
Pb-Lead 46564
u
So -Selenium
u 2
Zn-Zinc 45567
u k
4
p anochlorine Pestiridcs
-Orc]0nopiwspmrys Pcs4¢dcr.
Hi n Pesticides
_ Arid Herbirldes
PCas
Semiwlawe or poles
TPH-Diesel flan e
Vol abla Organics E9A bottle)
_
TPH-Gasoline Rarge^
TPH-BTEX Gandine Range
LW USE ONLY
Temperature on arrival (IC).-

r J
County:
CURRITUCK
-
Sample ID,
A858192
River Basin
0� W
PO Number #
1000260
Report To
WAROAP
0 q
Date Received
0Sl1312010
Time Received:
09:20
Collector-.
A CLARK
Labwc*s LoginlO
Sh1ATHiS
Region'
WARD
Report Generated'
61711(l
Sample Matrix'
GROUNDWATER
Date Reparied;
0510712010
Lac. Type:
WATER SUPPLY
Ernargancy YesN40
VISitID
CDC YeslNo
Lce. Descr.: AHORES DELTORO
Location ID:
APS-N-SWIM1I-CURRI-0013
Collect Data: 05112=10
Called Time: 11:10
Sample Depth
CAS #
LAB
Analyte Name
Sample temperature at receipt by lab
PQL
Resulbt
Qualifier
1.2
Units
C
Method
Reference
Analysis
Date
5113110
Vaiisiasad h�
SMATHiS
WET
Ion Chromatography
_TffLE_
mWL
EPA 300.0
5124110
MOVERMAN
Chloride
1
29
mg1L
EPA 300.0
5124110
MOVERMAN
Fluoride
0.4
OA U
mgfL
EPA300.0
5124110
MOVERMAN
Sulfate
2
18
fnglL
EPA300.0
W4110
MOVERMAN
Total dissolved Solids in liquid
12
122
mg1L
APHA254OC-19TH
W20110
MOVERMAN
NUT
NH3 as N in liquid
O} 02
0.02 U
mgfL as N
Lac10-107-09-1-J
5119/10
CGREEN
Total Kjeldahl N as N in liquid
0.2
0.33
mg1L as N
Lachatl07-06-2-H
5119110
CGREEN
NO2+ND3 as N in liquid
0.02
1.8
mgfL as N
Laa10-107-04-1-c
5115110
CGREEN
Phosphorus -total as P in liquid
0.02
0.41
mgfL. as P
LarIO-116-01-1EF
511711D
CGREEN
Nitrate as N in liquid
0.02
1.8
rng1L as N
Lachatl(17-04-1-c
5124110
CGREEN
Nitrite as N in liquid
0.01
0.01 U
mgfL as N
Lechat107-04-1-c
Ell 3/10
CGREEN
MET
7429-90-5
Al by ICP
50
690
ug/L
EPA200.7
5127110
ESTAFFORDI
7440-70-2
Ca by ICP
0.1
11
mgfL
EPA 200.1
5127110
ESTAFFORDI
744047-3
Cr by ICPIVIIS
1 D
IOU
ugh
EPA 200.0
511711D
ESTAFFORDI
7440-50-0
Cu by ICPMS
2
56
u9fL
EPA 200.E
5/17110
ESTAFFDROI
7498.5"
Fe by ICP
5D
4600
ugfL
EPA 200.7
5127110
ESTAFFORDI
7440-09-7
K by ICP
0.1
3.4
mgfL
EPA 200.7
6127110
ESTAFFORDI
7439.95-4
Mg by ICP
0A
4.3
mgfL
EPA200.7
5127110
ESTAFFOROI
7439.96-5
Ma by ICP
10
29
ug/i
EPA200.7
5127110
ESTAFFORDI
7440-23-5
Na by ICP
0A
18
+ng1L
EPA200.7
5127110
ESTAFFORDI
7440-02-0
Ni by ICPMS
10
10 U
ug1L
EPA 200.B
5f17110
ESTAFFORDI
7439-92-1
Pb by ICPMS
10
44
ug1L
EPA 200.9
511711G
ESTAFFORDI
7440-8-�5
Zn by ICPMS
10
420
ug1L
EPA 200.B
5117110
ESTAFFORDI
jL11!
Laboratory Section-1623 Mail Service Center, Raleigh, NC 27699-1023 1919) 733.3900
rm a dotsiiad dasaipoan of the gwiioar codas infer lu ! ftL7iPDr A1. r, it xfltrhi gwa_'4N_I:JTat siarc :hu[ecnastsl�Elalg C y�er_cndex :nll�'uy_ns� nmrg r.py�yLplVylL7sllslil�in f_'{n ciyafsi95
Page 1 of 1

GROUNDWATER FIELD/LAB FORM
Location code �kPs-N_SWV+�- C�,r "`�-- �_ v 3^ sAfMLgTv(�E
CIbunny - 'ZtA% C t~tL MWater
Quad No SeriBi No. 0 soil
Lat: Long. 0 Other
❑ Ghairt of Custody
Report To: ARO, FRO, MRO, RRO, WaR WiRO,
WSRO, ir(inston FO. Fed_ Trust, Central Off., Other:
Shipped by: BusQL4Hand Del., Other. Purpose:
Ccftdor(s): fate541-?_Z8 Dunne '
IFIELP ANALYSES Owner
PH , -Q Spec. Cond.s�A at 2S'C Location or Si
Temp.," °C Odgqrr Description of.
Appewance - &> 4 t"' a Sampling Metl
Field Analysis BY: Remarks TW
LABORATORY ANALYSES
North Carolina
Department of En%4ronrnent and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
SAMPLE ?RJORITY j o � DZ� O �� r
I� Routine Lab Ntmlber 1+
I.�
ti
Emergency u Qa pate Received Sj -13- P Tim UW) D
Re�'d By: From:BLls Courier Hand Del..
Other:
- Data Entry By; Ck:
Date Reported
Baseline, Complaint Compliant- LUST, Pesticide Study Federal Trust. Other.,
____-___-'� �� ❑�� �Dj ,� lnrGrane) { �CRi��- ■V =❑ T'L�da�
to r9'n K 0 -1
BGp 310 mg&
Kiss. Solids 70300 mg1L
Ag-Silver 46566
AI Hturrlhm+m 46557
COD High 340 mglL
Fluoride 951 mg1L
COD Low 335 mglL
Hardness: Tntsl 900 m91L
As -Arsenic 46551
Ba-Badum 46558
CdKotm: MF Fecal31618 11100ml
Hardness (g"n-r.") 902 mglL
CvGiorm: W ToW 31SO4 1100W
Phends 32730 u94
Ca -Calcium 46552
TOC 680 mg1L
Specific Cond. 95 0100slan
Cd-Cadmium 46559
Turbrdty 76 N Tit
Sulfale 945 rng1L
CrrvChronium 46559
Residue, Suspended 530 mg&
Sulfide 746 mg1L
Cu-Copper 46562
Fe4ron 46563
Cal and Grease mgR
Hg-Menwry 71900
pH 403 units
Y( ?ntassiurm 46555
Alkalinity to pH 4.5 410 mglt
Mg -Magnesium 46554
Mn-Manganese 45565
Alkalinity to pH 8.3 415 mgll_
Carbonate 445 mglL
NH, as N 610 �t j 4 L mgR
Na-Sodium.46556
Blcardonate 4411 mg1L
TKN as N 62S mg1L
Ni-Nic"
Carbon Conde 405 m91L
f9h + NO, as H 630 Lu �.'mgll_
Total as P 865 5V mg/L
Pb�Lead 46564Gdoride940
mg1LR
Ise
-selenium J
Chromium- Hex 1032 ugfL
Nitrate (NO3 as N) 620 m91L
In -Zinc 48567
Color. True ap cu
bkd
Nitrite (NO, as Nl 615 mg►L
Cyanide 720 mg&
Lab Comments
GW-54 REV, 7103 For pissolved Analysis-sub"t Filtered sample and write -ply' In WddL
[Pumping fte, air Wnp_
Sample I�njjte"rrr !
rlorine Pesticides _
los 5 Pesticirles
Acid Herbicides
Semiwlatile_Organics
TPH-Diesel Ranna
Vol Blue Organics OAhi
rri ►L TPH-GaWine Range
ue1L I TPH-8TEX G$sdine Ran
LA USSE O L
Temperature on arrival ("C)- ,

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: Anri15, 201
To: ❑ Landon Davidson, ARO-APS ® David May, WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Charlie Stehman, WiRO-APS
❑ Andrew Pitner, MRO-APS ❑ Sherri Knight, WSRO-APS
❑ Fay Zimmerman, RRO-APS
From: John McCray, , Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E-Mail: John-mccravfa-,ncdenr.t-,ov
A. Permit Number: WI0704013
B. Owner: Andres and Hope Del Toro
C. Farilit►•/Operation: Andres and Ho )e Del Toro 5A7 SFR
❑ Proposed ® Existing ❑ Facility ❑ Operation
D. Application:
L Permit Type: ❑ Annual ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Remediation (ND)
® UIC - (5A7) open loop geothermal
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type. ❑ New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ® Renewal w/ Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
® Return a Completed Form APSSRR.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU,
❑ Issue an Attachment B Certification from the RO*.
* Remember that you will be responsible for coordinating site visits, 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 RPF 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: q -9-go to
FORM: APSARR 02/06 Page 1 of 1

A QUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: A pril 5 . 2010
To: 0 Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS
0 Andrew Pitner, MRO-APS
D Jay Zimmerman, RRO-APS
[XI David May, WaRO-APS
0 Charlie Stehman, WiRO-APS
0 Sherri Knight, WSRO-APS
From: John McCrav , Groundwater Protection Unit
Telephone:. (919 ) 715-6168 Fax: [phone]
E-Mail: [e-mail]
A. Permit Number: WI0700013
B. Owner: Andres and Hope Del Toro
C. Facility/Op eration: Andres and Hope Del Toro 5A7 SFR
D Proposed [XI · Existing D Facility D Operation
D. Application:
1. Permit Type: D Animal D Surface Irrigation D Reuse D H-R Infiltration
D Recycle D I/E Lagoon D GW Remediation (ND)
[XI UIC-(5A7) open loop geothermal __
For Residuals: □ Land App. 0 D&M
D 503 D 503 Exempt
D Surface Disposal
□ Animal
2. Project Type: D New D Major Mod. D Minor Mod. D Renewal [XI Renewal w/ Mod.
E. Comments/Other Information: D I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review , comment, and/or action. Within 30 calendar days, please take the following actions:
[XI Return a Completed Form APSSRR.
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 , 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 02/06 Page 1 of 1
~A ;;-;;;-. ,,. .
~CDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Andres Del Toro
180 New Beach Road
Point Harbor, NC 27964
Coleen H. Sullins
Director
March 26, 2010
Subject: Acknowledgement of Application No. WI0700013
Cody, Ernest -SFR
Injection Heating/Cooling Water Return Well (5A 7) System -SFR
Currituck
Dear Mr. Del Toro:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on March 12, 2010. This application package has been assigned the number listed above and will be reviewed by
John McCray.
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 permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requ~sts.
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 John McCray at 919-715-6168, or via e-mail [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/dwo orn chart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
lOlttt{ ~
for Debra J. Watts
Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Permit Application File WI0700013
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588: FAX 2: 919-715-6048 \ Customer Service: 1-877-623-5748
Internet: www.ncwaterguality.org
An Equal Opportunity \ Affirmative Action Employer
None, C 1. ortn aro 1na
,lvaturall!f
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
Any changes made to this form will result in the application being returned.
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
For more information, visit our web site at: http ://h2o.enr.state.nc.us/laulmain.html
I. RE QUIRED ITEMS
1. Submit one original of the completed and appropriately executed Permit Name/Ownership Change Form.
For a change of ownership, the certification must be signed by both the current permit holder and the new
applicant. For a name change only, the certification must be signed by the applicant.
2. Provide legal documentation of the transfer of ownership (such as a contract, d.::ed, article of incorporation,
etc.) for ownership cha..,ges.
3. Change of Ownership. Applications for Homeowners Associations (HOAs) shall include the HOAs bylaws,
covenants, etc. [15A 2T .0115(c)] ·
4 . Submit a properly executed Operation and Maintenance Agreement for all Single Family Residence Surface
Irrigation permits requesting a change of ownership.
II. CURRENT PERMIT INFORMATION
1. Penni.t number: w:r O 1 0 0 D I ~
2. Permit holder's name: _i_ A I Gee OU ( 0 J 7
3. Permit's signing official's name and title: ____________________ _
(Person legally responsible for permit)
(title)
4. Mai.ling address: \A N '(..Nov-' rJ ..
City:
I \
___ State: ·_ __ Zip: ____ .,_/ ___ _
Telephone number:
IlL NEW OWNER/NAME INFORMATION
1. ~uest for a permit change is a result of:
_ a. Change in ownership of property/company
_ b. Name change· only
_ c. Other (please explain):
..
Facsimile numbe;
2 . New owner's name (name to be used in pe~t): _ _..,:_4__,l.,...!..V\.~d::i...:..r....:e::...,..1..[_...1b.....L-e=--J....I _L_._o_r?...co=------
FORM: PNOCF 09-06 Page 1 of 2
RECEIVED / DENR I D'[VQ
Aquifer Protection Section
MAR 12 20\0
I
i
f
I
I
3 . New owner's or signing official's·name and title:--~---------~----------
(Person legally responsible for permit)
£)1..,J~
(title)
4. Mailing address: --,-..,_/ 'o_O____.__f V....:....v.,v...;..__--..1Jj=-=--e_-tt_C ,:__~------'f._~..¥,...;....;..(A J"'--------
City: Po iA ± th:-.rloo~ State: tv C..,, Zip: '2 7 j f.p 1/
Telephone number: (151_) '2, 0 2. -/ 9 {! Facsimile number: ( 2 p_) 2-D / ~ 0 7 0 1j
IV. CERTIFICATION
1. Current Permittee's Certification:
2.
I, __________ , attest that this application for name/ownership change has been
reviewed a.'1<l i5 ... ccurate and cc,mple::te to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting information and attachments are not
included, this application package will be returned as incomplete. I understand I will continue to be
responsible for compliance with the current permit until a new permit is issued.
Signature: _____________________ .Date: _________ _
Appli~t's Certificatio~: _
I, cp,.. ek-e.r l).e f lo~ attest that this application for name/ownership change has been
reviewed and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting infonnation and attachments are not
included, this application package will be returned as incomplete .. I further c.::rtify that the applicant or any
affiliate has not been convicted of an environmental crime, has not abandoned a wastewater facility without
proper closure, does not have an outstanding civil penalty where all appeals. have been exhausted or
abandoned, are compliant with any active compliance schedule, and do not have any overdue annual fees
under Rule 2T .010=. ~.J ~ ---::::,
Signature: ~ L · c.__ Date: ~ // D / I O
I
THE COMPLETED APPLICATION PACK.AGE, INCLUDING ALL SUPPORTING INI<'ORMATION AND
MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
LAND APPLICATION UNIT
Via U.S. Postal Service
1636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
Via Courier / S pecial Deliven •:
2728 CAPITAL BOULEVARD
RALEIGH, NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone]
FORM: PNOCF 09-06 Page 2 of 2 RECEIVED/ DENR .
Aquifer Protection Sf'!r.tlOn
MAR 12 2010
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
IiNJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
DATE: 3
TYPE 5-A7 WELL(S)
New Permit Application OR � Renewal (check one)
20J
PERMIT NO. Wx ° Z D00 1 3 (leave blank if NEW permit application)
A. PROPERTY OWNER(S)IAPPLICAINT(S)
List each Property Owner listed on property deed (if owned by1a business or government agency, state name of
entity and a representative w/authority for signature): AK4re.t e- De- C TO ro
(1) Mailing Address!! 190 r V 0.4�"`�`^' ` 1 p�/
City: QUY4 t-tr or State: 01 Zip Code: 2 7 9b 7 County:
Home/Office Tele No.: 2 727 r
2-o Z — r ? 11 Cell No.:
EMAIL Address: r� 64Ck x aw- W li d r • rap—,
(2) Physical Address of Site (if different than above): SAvv-%�
City: State: Zip Code: County:
Home/Office Tele No.: Cell No.:
EMAIL Address:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate LTIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State: Zip Code: County.
Office Tele No.: Cell No..
Website Address of Company, if any:
RECEIVED I DENR 10VVQ
Aquifer Profe tion Secfivrl
GPLARC 5A7 Well Permit Application (Revised 9/2007)
Pagel

C. WELL DRil,LER INFORMATION
CompanyNam, C,041 \,Ji \\ b,,-;\\i '1)
Well Drilling Contractor's Name: __________________________ _
NC Contractor Certification No.: __________________________ _
Contact Person.,_: _______________ _,E=M=AI=L~A=d=d=r=e=ss==------------
Address: ------------------------------------
City: __________ Zip Code: _____ County: ______________ _
Office Tele No.: Cell No.: __________ _
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: ________________________________ _
Contact Person~: ---------------~E=M=AIL=~A~d=d=r~e=ss==------------
Address: ------------------------------------
City: __________ Zip Code: _____ County: ______________ _
Office Tele No.: Cell No.: __________ _
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: __ Native American Lands:
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)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
H. WELL CONSTRUCTION DATA (Skip to Section I if this is a Permit RENEWAL)
(1)
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 Form GW-1 (Well Construction
Record) if available.
Date to be constructed: ________ Number of borings: ___ _
Approximate depth of each boring (feet): ________ _
(2) Well casing. Is the well(s) cased? (check either (a .) YES!!!. (b.) NO below)
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel __ Black steel __ Plastic __ Other (specify) _______ _
Casing thickness: __ diameter (inches): ___ depth: from ___ to ___ ft. (reference to land surface)
Casing extends above ground ____ inches
GPU/UIC SA 7 Well Permit Application (Revised 9/2007) Page2
(b) NO
(3) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite Other (specify) _______ _
(b) Grouted surface and grout depth (reference to land surface):
___ Around closed-loop piping; from ____ to ___ (feet).
___ Around well casing; from ___ to (feet).
(4) Well(s) Screen Information
Depth of Screen: From ____ to ____ feet below land surface
(5) N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make prov1s1ons for
monitoring wellhead water quality and 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) Influent line? 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 Form GW-1 (Well Construction Record). If Form GW-1 is not available, provide the
following data:
Groundwater Source. From what depth, formation, and type of rock/sediment units will the groundwater
be withdrawn? (e.g. granite, limestone, sand, etc.)
Depth: _______ Formation: ______ Rock/sediment unit: _______ _
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR PROPOSED WELLS IF
THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
I. OPERATING DATA
(1) Injection rate:
(2)
(3)
(4)
Injection.Volume:
Injection Pressure:
Injection Temperature:
J. INJECTION-RELATED EQUIPMENT
Average (daily) (~ gallons per minute (gpm).
Average (daily) __ gallons per day (gpd).
Average (daily) -2:b___ pounds/square inch (psi).
Average (January) ___ ° F, Average (July) __ ° F.
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
K. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
GPU/UIC SA 7 Well Permit Application (Revised 9/2007) Page3
L. CERTIFICATION
Nate: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"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. -
Signature of Property Owner/Applicant
&JoreS D?
Print or Type Full Name
162�� lod
T-
Signature of Property Owner/Applicant
Imo? _De lr"�ro
Print ❑r'fype Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
TIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED r DENR r MNO
Aquifer Protection Section
GPU/L,IC 5A7 Well Permit Application (Revised W2007) WAR 12 2010 Page 4

State of North Carolina
Department of Environnrent and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: yy� D -7 D oD 13
Permittee Name: r DL
Address: l Poo bt t, iv" - ��r�++ rkse NC- 2--7 1 4
Please check the selection which most closely describes the current status of your injection well system:
1) & Wells) still used for injection activities, or may be in the future
2) ❑ Wells) not used for injection but is/are used for water supply or other purposes.
3) ❑ Injection discontinued and: a) Ll Well(s) temporarily abandoned
b) ❑` Well(s) permanently abandoned
c) ❑ Well(s) not abandoned
4) ❑ Injection weli(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
Ifyou checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description ofhow the well
was sealed and the type ofmaterial used to fiill the well ifpermanently abandoned)
Permit Rescission:
Ifyou checked (2), (3), or (4) and will not use a well for injection on this site in the future, you should request rescission of the
permit. Do you wish to rescind the hermit?
❑ Yes ❑ No
Certification -
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
Signature
Revised 5105
q lld
Date
RECFJVED r DENR 1 OWO
GWIUIC-68 AgWforftba ion won
MAR 12 2810

·MA NCDEM R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7006 2150 0003 5467 4354
Andres and Hope Del Toro
180 New Beach Road
Point Harbor, NC 27964
Coleen H. Sullins
Director
November 17, 2009
Subject: Notice of Violation with Intent to Enforce (NOV-2009-PC-0919)
5A7 Geothermal Injection Well
Permit No. WI0700013
Currituck County
Dear Mr. and Mrs. Del Toro:
Dee Freeman
Secretary
As we indicated in our August 28, 2009, letter, the above-referenced permit, which was
originally issued to Megan Oaksmith on September 24, 2004, and expired on October 8, 2009,
has not been renewed. This permit was issued for the operation of a SA 7 geothermal injection
system on your property located at 180 New Beach Road, Point Harbor, North Carolina. If you
wish to keep this permit and operate the injection well system, the permit must be renewed and
issued in your name. To do this, we have enclosed a Change of Ownership form for you to
complete.
A permit renewal application package with instructions to submit the--necessary paperwork
within 30 days of its receipt was also sent to you on August 28, 2009. To date, the Groundwater
Protection Unit has not received your completed renewal appiication package. In ·addition, our
records do not indicate that the well system has been plugged and abandoned.
Therefore, the following violation(s) exists:
VIOLATION 1:
Operating an injection well without a permit is a violation of rule 15A NCAC 2C .021 l(a).
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] i FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
A1 Equal Opport~nity I Affinnatlve Action Employer
REC_EIVED I D~NR I D~~hCarolina
Aquifer Protection Sectio'1Vaturnllll
MAR 12 2010
REQUIRED CORRECTIVE ACTION FOR THIS VIOLATION
Please take one of the following corrective actions within 30 da s of receipt of this letter:
1. APPLY FOR PERMIT RENEWAL. When you apply for and receive a
renewal, operation of your well system will be permitted to continue. As such, all
sampling requirements and any operation and maintenance procedures specified
in your previous permit will be required. To renew, you must submit the
following information to the address below:
a) A completed Application for Permit (Renewal) to Construct and/or Use a
Well(s) for Injection with Geothermal Heat Pump System for Type SA 7
Well(s) (Enclosure 1). This form must be signed by each
property/permit owner.
b) A completed Change of Ownership Form (Enclosure 2). If available,
please have the previous owner sign this form where indicated.
-OR-
2· APPLY FOR PERMIT RESCISSION. If the geothermal well system has not
been constructed or is no longer being used for injection purposes, the permit may
be rescinded. Indicate on the attached Status of Injection Well System (Enclosure
3) your desire to rescind your permit and one on the following:
a. Current use of UIC well if it is still being used for other purposes
(i.e.irrigation, drinking, etc.).
b. Well abandonment information if the well is inactive and no longer in use.
NOTE: For a well system that is no longer active and is no longer being used
for any purpose, it must be permanently abandoned according to the
regulatory requirements listed under NCAC Title 15A, Subchapter 2C,
Section .0214. When each well is plugged and abandoned; the well
abandonment record (Form GW-30) must be submitted to the address below
to certify that the abandonment was properly conducted.
All forms must be submitted to the following address within 30 calendar days of the receipt of
this letter to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
http ://h2o.enr.state.nc.us/aos/gp u/forms.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call Eric G. Smith at 919-715-6196, or email him at eric.l!.smith(a)ncdenr.,rov.
Enclosures:
1. Change of Ownership form
2. GPU/UIC SA 7 (revised 9/2007)
3. GW/UIC-68 (revised 5/2005)
Sincerely,
J]}x, J , wJJs-
Debra J. Watts, Supervisor
Groundwater Protection Unit
cc: Washington Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0700013 w/o enclosures
RECEIVED I DENR / DWQ
Aquifer Protection Section
MAR 12 2010
AN
�
MCDEN R
North Carolina Depar rnent of Environment and Natural Resources
Pat McCrory Donald R. van der Vaart
Governor Secretary
March 2, 2015
CERTIFIED MAIL # 7014 1200 0001 3432 8381
RETURN RECEIPT REQUESTED
Andres and Hope Del Toro
or Current Resident
180 New Beach Road
Point Harbor, NC 27964
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. 'A 10700013
Currituck County
Dear Mr. and Mrs_ Del Toro (or current resident):
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located on your property located at the above referenced address
was issued to you on July 19, 2010, and expires on June 30, 2015. Per permit conditions and
requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior to expiration of your permit if you wish to continue operating the injection well.
According to our records, your permit renewal application is now past due. Please submit your
application (attached) as soon as possible if you wish to continue using the well for injection.
If Your Geothermal Water Return Well is Still Currently Being Used for Iniection.
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http://portal _nc denr. org/weblwglaps/gwproYpernii t-appl ications.
If Your Geothermal Water Return Well is NO LONGER Being Used for lniection:
If the well is no longer being used for injection, you do not have tv, _rw W permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e_, used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
acftrdi*to the regulatory requirements listedirftderN'CAC Title 15A, Subchapter 2C, Section
1636 Mail Service Center, Raleigh„North Carolina 27699-1636
Phone: 919-%7 1 Internet: www.mcdPVAJav , ,
An Equal Oppodaaity � Affirmative Adoe Employer — Made in part by recycled paper

Andres and .Hope Del Toro for current resident)
_0240_ When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
H There has been a Change of Ownership of the Propem:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for your
cooperation and timely response. If you have any questions, please contact me by phone at (919)
847-6406 or by email at Michael.Rogers(hincdenr.gov.
Regards,
�F.
Michael Rogers, P.G. t C &: FL)
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington Regional Office — WQROS w/o enclosures
Central. Files - Permit No. W10700013 w/o enclosures

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL{S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application ------'Renewal* __ Modification _· _Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages I and 4 (signature page) only
Print or Type Information andMail to the Address on the Last Page. _Illegible Applications Will Be Returned As Incomplete.
DATE: ________ ~20 __ _ PERMIT NO. ______ (leave blank if New Application)
A. CURRENT WELL USE AND OWNERSHIP STATUS (leave blank if New Application)
1. Current Use of Well
a. Continue to use as
Supply
Geothermal Wel1 __ Drinking Water Supply Other Water
b. Tenninate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the pennit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
D Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since pennit last issued? D YES D NO
If yes , indicate new owner's contact information:
Name(s) _
Mailing Address: ______________________________ _
_________ State: __ Zip Code: _____ _ City:_
Day Tele No.:
County : _____ _
Email Address·.:
B. STATUS OF APPLICANT (choose one)
Non-Government: Individual Res ide nc e Bus iness /Organization __
Government: State Municipal __ County __ Federal
C. WELL OWNER(S)/PERMIT APPLICANT -For individual re s idences, list owner(s) on property deed. For
all others, list name of entity and name of person delegated authority to sign: ___ _
Mailing Address :---------------------------------
City : _____________ State: __ Zip Code: _______ County:
Day Tele No.: Cell No.:
EMAIL Address: _______________ -'-F=ax'-'---'-N"""'o""".:'----------------
Geotherma l Wa ter Return Well Pe rmit 1\pplica tion (Revi s ed Ja n 20 I 5) Pag.e I
D. WELL OPERATOR (if different f.rom well owner) -For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the
business or agency: ______________________________ _
Mailing Address:--------------------------------
City: ____________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: ----------------=E=m=ai=·=-1 A=-=d=dr ... e=s=s . ..,_: ___________ _
E. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1)
(2)
Parcel Identification Number (PIN) of well site: __________ County: _____ _
Physical Address (if different than mailing address): ________________ _
City: ________________ State: NC Zip Code: _________ _
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: __________________________ _
NC Well Drilling Contractor Certification No.: ______________________ _
Company Name: _________________________________ _
Contact Person~: ________________ EMAIL Address: ___________ _
Address:------------------------------------
City: __________ Zip Code: _____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ________ _
G. RV AC CONTRACTOR INFORMATION (if different than driller)
H.
HVAC Contractor's Name: ____________________________ _
NC HVAC Contractor License No.: __________________________ _
Company Name: _________________________________ _
Contact Person.,_: ---------------~EMAIL Address: ___________ _
Address: ___________________________________ _
City: __________ Zip Code: _____ State: __ County: _________ _
Office Tele No.: _________ Cell No.: __________ Fax No.: _______ _
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(I)
(2)
The injection operation?
Personal consumption?
YES ----YES ___ _
NO ___ _
NO ----
I. WELL CONSTRUCTION REQUIREMENTS -As specified in 15A NCAC 02C .0224(d):
..
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) -. If a separate well is used to inject the heat pump e:ffl.ttent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107 except that:
Geothermal Water Return Well Permit Application (Revised Jan 2015) Page 2
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampl1ng tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the .number and type of wells to be used for the geothermal heating/cooling system:
____ *EXISTING WELLS ____ PROPO~ED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system . A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifi9ations:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
(c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(/)(8 )
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATING DATA
(l) Injection Rate : Average (daily) gallons per rninute (gpm).
(2) Injection Volu111e: Average ( daily) gailons pe~ day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Inj ection Temperature: Average (January) ° F, Average (July) __ ° F .
L. SITE MAP -As specified in 15A NCAC O?C .0224 b 4 , attach a site-specific map that is scaled or otherwise
accurately indicates d istances .and orientations of the specified features from the injection well(s). The site map
shall includ e the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield , waste
application area, and repair area located within 250 feet of the injection well(s). ·
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0 I 07( a )(?) located within 250
feet of the proposed injection we ll(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection we ll(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Gcothennal Water Return Well Permit Application (Re vi,c·d Jan~() 15) Page3
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand.. Also, a 'layer' can be selected showing topographic contours or
elevation data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
l SA NCAC 02C .021 l(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 pe rson(s) listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty oflaw, 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."
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Property Owner/ Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
Division of Water Resources
Water Quality Regional Operations Sedion (WQROS)
·16~6 Mail Service Center
Raleigh, NC 27699-1636
-__ !.elephone [phone]
Geothermal Water Return Well Pennit Application (Revised Jan 2015) Page4
RECEIVEL
NOTICE OF SERVICE FEB 01 241Q
0 i311Ga
I certify that this NOTICE OF SERVICE was received on Q 1 day of 2010
and together with the document(s) was served as follows:
Date Served:
z496li o
Designated Recipient(s): Andres and Hope Del Torn
Place of Service: K61t j
(fill in address)
a
Served By: '-�k P. �Lv�
rving Officer (Print)
Check one of the following:
By personally delivering copies to the named individual(s);
By leaving copies of the Notice and original letter at the named individual's dwelling, house
or place of buginess with a person of suitable age and discretion then residing therein. Name of the
person with whoin the copies were left:
If not served to the named individual(s) above, please state reason why:
Serving Officer's Signature
Service Fee: — _ Waived (State Agency)
Please return this form to: Eric G. Smith
E'J"
County
Division of Water Quality
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Paid
-Z -15r-10
Date
RECEM) DENR I NO
p WPRnT;r.0 l SEM
FEB 112010

FgCDENR
North Caro#ina Department of Environment and Natui al Resources
Division of Water Quality
Beverly Eaves Perdue Coleell H. Sullins
Governor Director
February 1, 2010
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7006 2150 0003 5467 3418
Attn: Leslie Rupp
Currituck County Sheriff Department
407 Maple Road
Maple, North Carolina 27956-9714
Subject: Check for Sheriff's Service of Documents
Ms. Rupp:
Dee Freeman:
Secretary
Please find the enclosed check for $15 to have documents served to Andres Del Toro by the
Sheriff. Also, please remind the sheriff to fill out the Notice of Service document I had sent with
the original documents and return it to our office after the service.
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
Enclosure: Check
AQUIFER PROTECTION SECTION
1636 h^ari Service Center, Raleigh !North Carolina 27699-1636 One
Location: «28 Capital Bauleva(d. Raleigh, North Carolina 27W4 No Carolina
Phone: [phone] FAX [phone]; FAY:2: 919-715•60M 1 CUstomer Service: I-B77-623.6748 �p try ��
Internet: vnvw.nmammuaiiri1.orn L y
An Ettual Opportunity %A&M81K Adrian Employer

Postal
OCERTIFIED MAIL,,, RECEIPT
m(Domestic
ri
? Postage
s
Ln
Certified Fee
rn Pcstmar$t
d Return fiacelpt Fee Here
It (endorsement Required)
C] Rest rcted ❑e6Wery Fee
SEredonsemant Required}
Q
t13
,-q Total
ru Attu:- Leslie Rupp
- Currituck County Sheriff Dept.
'Poe . 407 Maple Rd. .......
, $R Maple, NC 27956-97.14
■ Complete items 1, 2, and S. Also complete
item 4 if Restricted Delivery Is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece.
or on the front If space permits.
1. Article Addressed to:
Attu: Leslie Rupp
Currituck County Sheriff Dept.
407 Nlaple Rd.
Alaple, NC 27956-9714
A. SlgnpM
x ❑Agent
❑ Addressee
B. Receiv y (Prinf e) C. Date of Delivery
LSG4LC'Y /a^A -21Aho
D. Is delivery address different from item 1? U Yps
if YES, enter delivery address below: ❑ No
s. Service Type
❑ Certified Mail
❑ Express Mall
❑ Registered
❑ Retum Receipt for Merchandise
❑ Insured Mall
❑ C.O.D.
4. Restricted Delivery4 (Extra Fee) p Yes
2. (Transcle Number
rfroms 7006 2150 0003 5g67 3418
� (Transfer from service labefj �I
PS Form 3811, August 2001 Domestic Return Receipt 2AGPRl-G&Z-09W :I

STATE OF NORTM U
CAROLINA �a3�ff
DEFT. OF ENV3# NIVrRNT & iIATURAL RESOURCES ND. 2320012 MAIL SEFtVICE CENTER
RALEIGH, RQRTH GAROLINA:27t 3 1606 0Payat�laai Par• filrw+eh PQdNral Re9�Ive SySlem
'TAX ID# 56-60 72. State i rk;i - er. Ra :04 rlt� -l�itl Afle� Orm yunr
P y ENTITY BATE' I AMOUNT
4
�x.x�,rxxx.
PAY 'Fifteen and 001.1`00 Dollars
TO THE ORDER OF
CURRITUCK COUNTY SHERIFF ❑EPT
407 MAPLE RD
MAPLE NC 27956-9714
V0 2 3 2D0 L III' I:❑ 5 3 1 10 S 9 49, L*1100D1,104DuR
10FT STATE OF NORTH CAROLINA
DEPT OF ENVIRONMENT S NATURAL RESOURCES
1606 MAIL $ERVICE CENTER RALEIGH. NC 27W9.1606
AUTHOWE7 SIGNATURE 1 J
NO. 2320012
DATE
INVOICEICREDFT MEMO
TYPE
DESCRIPTION
INVOICE AMOUNT
REDUCTIONS OR
DISCOUNT
NET AMOUNT
01/14/10
DWQ-AP FEES 0110
012110-3146
$15.00
$15.00
CALL
ANGELENA 8076316 TO
PICK UP
HECK",
TOTALS
$15MI
$15.0

Smith, Eric
From: King, Angelena
Sent:
To:
Friday, January 22, 2010 10:14 AM
Smith, Eric
Subject: RE: Check for $15 for Currituck County Sheriff
Eric,
I have processed the memo for payment. Once the check is cut someone ofthe controller's office will call me to pick up
the check and I will then inter-office the check to you. I will email or call you to inform you that the check is on the way.
The controller's office only cut checks once a week.
Have a great weekend.
Angelena King
Accounting Clerk
919-807-6316 office
919-807-6490 fax
NC DENR-DWQ Budget Office
517 N. Salisbury Street
Raleigh, NC 27604
E-mail correspondence to and from this address may be subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Smith, Eric
Sent: Friday, January 22, 2010 10:09 AM
To: King, Angelena
Subject: Check for $15 for Currituck County Sheriff
Angelena:
Did you receive my request for a check for $15 for the Currituck County Sheriff's Office? I had sent the memo on
January 14th and requested that the check be sent to me and then I would forward it on to the Sheriff with a memo.
-Eric G. Smith
Eric G. Smith, P.G.
Hydrogeologist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-6196
919-715-0588 Fax
http://h2o.enr.state.nc.us /aps/gp u.htm
1
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.
2
NCDENR
North Carolina aepariment of Environment and Natural Resources
Division o` Waier Quality
Severfy Paves PesauE- Coleen H- Sullins
Governor Director
J anuary 14, 2010
To: Angelena King — DWQ Budget Office
From: Eric G. Smith — DWQ Aquifer Protection (Central Office)
Re: Request for check for Sheriff Delivery of Documents
Dee Freeman
Secretary
Please issue a $15.00 check payable to the Cutrituck County Sheriffs Office for personal
delivery of documents to be served via sheriff,
Please send the check to me at:
NCDENR
DWQ APS
Attn: Eric G. Smith
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
If you have any questions, please contact me at [phone] or at erica -=. Smith 0bncdenr.gro4 .
Thank you,
Eric G. Smith
Hydrogeologist
DWQ — Aquifer Protection Section
A OU'R PROTECTION SECTION
1626 Maj! Sevkce Center, Raleigh, Nn00 Uatuhm 2 635-]636 One
trcaron:2728 Cav,ai Bo0evsrd. Raleigh,1,ord, Cam;ha 27604 North Carol Lima
phone: 91V33-322i } FAX i' §19-71"586; FAX 12:519-715-CCa81 Customer veNiC£: 1-877•$23.674^■11�.�ry�}`
Inremel, Ww .nx lerguahtv.�t11 N' F�i�GbLC Lta �
N, Fou .l ilpwm f^ tY + rAlrm me �L1kr z—TDJ. ?

rkv�:)'!!����**,A
NCDENR
North :�arofirtr D,�Pa-tment of Envi cnment and Naiura! Fie&aurces
bvi-ior o-'Vatc- Qoa1.ty
t3ty- -I,v EaveS C-Aee- H- ZAIl-5 Duo! F�eewi
:;0veT,C- D'rec10F
10:
Frorn.
Re�
January 13, 2010
AnatAcna King - DWQ Bodget Office
Robbie Bultock WaRO DWQ Surface Water Protection
Request for checr, for Sheriff DcAivafy of Documents
Nease issu[.' a $15.00 check rjayabtE to the Beaufort County Sheriff for persona de,ivery of the fc:low019
dec u-nent *:a he sorved v=a she-i$f_
Notice of Viaiatior for Rohe i Cutler
Kcasc: ca.l or ern; i. Katie Iv:erritt to retrieve i` persona3y, as ofIrcial documentation :s reouired to accorroany
-he ci+eC' .. before ii is sort. tv the she ff 7 s off'icc,. Below is thr- contact riformation for Katic 1+P1'crritt.
Ka`_ie Merrit`
Wedanc!s anti Stormvvater B�atic h, I]WQ Central Office (Archcale BUiLding)
f919] SC7-6371
tia.ie.rnerrktcor cdenr tavv.
li y'Ou h�-.ve any quesdom, ptease tail Robbie PLAtock at (Z52) 948-f924 or X Hodge a: (252) 948-384.1.
1 f!arw you.
ltobtmc Fiulloci.
IA72M)
fl,WQ. Sul.acc Water l'rotectiLIrt
�112 rrC.f' W ii J7��L ]11I111011(y '•W-
:K:. -r y.
01,
Nc)
alul vl ll

Smith, Eric
From:
Sent:
To:
Hardee, Ed
Wednesday, January 13, 2010 9:58 AM
Smith, Eric
Subject: FW: Civil Penalty
Eric,
Below is message from Jay about new policy for fee payment. It looks as if you will go through Wendy.
--H • ------
Wend y S posto
Accounting Clerk
Ed Hardee
Aquifer Protection Section
Land Application Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
Phone [phone]
Fax [phone]
BDA's
Travel Advances
Expense Accounts
Registration Fees
1219N
DISCLAIMER: Per Executive Order No . 150, all e-mails sent to and from
this account are subjec t to the North Carolina Public Records Law and
may be disclosed to third parties.
From: Zimmerman, Jay
Sent: Tuesday, September 29, 2009 12:40 PM
To: Bowden, Kevin; Hardee, Ed
Cc: Bush, Ted
Subject: FW: Civil Penalty
Guys,
807-6318
I am forwarding to you an email I received concerning the fee assoc. with using a County Sheriff to deliver a civil
penalty (I'm sending to both of you since you are likely the most knowledgeable). We have also used the
Sheriff's Office to deliver NOV's . We had paid a fee to the Durham Co . Sheriff to serve a penalty and had
requested reimbursement like we would for mileage, parking costs, etc. Apparently we were supposed to be
routing these through the Controller. It is my understanding, based upon an email I received from Wendy
Sposto, that when the CO has need for this service, they have a check cut by the Controller to the Sheriff. I'm
not sure what is done in the APS CO. Can either of you look into this and make sure it is necessary? It sounds
like an unwritten policy that will now be in writing, which will become an extra burden for the regions ,
particularly those outside of Raleigh.
In the past 20 years that I have been doing this, it is news to me. In the past we had produced a receipt from
the Sheriff and were reimbursed through Petty Cash. We had also received reimbursement for parking fees
through Petty Cash, until Tammy Ward told me to stop (apparently there is a policy against this as well that we
didn't know about). I'm surprised some of these "long-standing" policies weren't known by us and we are just
now being advised about them . Any help you can muster is appreciated.
Thanks
Jay
1
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Zimmerman, Jay
Sent: Tuesday, September 29, 2009 12:25 PM
To: Hollins, Maureen
Subject: RE: Civil Penalty
Thanks ....... Just to clarify it was a delivery fee to send a civil penalty, and not a civil penalty of $15.00. It's good
to have a policy as up to this point the regional offices (at least ours) was not aware of the need for these to go
through the Controller's Office. I'll advise management and thanks.
Jay
E-mail co1Tespondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third ))arties.
From: Hollins, Maureen
Sent: Monday, September 28, 2009 1:50 PM
To: Sposto, Wendy; Dodd, Tammy; Zimmerman, Jay
Cc: Jennings, Bud; Hartman, Cindy
Subject: Civil Penalty
I paid the travel reimbursement $15.00 for the civil penalty for Jay Zimmerman. In the future,
all civil penalties must be submitted to Cindy Hartman in the Controller's Office and be paid
with a paper check. The Controller's Office is in the process of writing up a policy to address
the procedures of all civil penalties. The purpose of this policy is not to duplicate any
payments being sent to a County Sheriff's Department.
Thank you for your cooperation in this matter.
Mo
Maureen Hollins
NCDENR Controller's Office
Accounts Payable Manager
Ph: 919-733-1695
Fax: [phone]
Please note my email address has changed to maureen.hollins @ncdenr.oov
2
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PROPERTY INFORMATION
General
Information
Parcel ID: 132AC0300300000
Property Address: 180 NEW BEACH RD
POINT HARBOR, NC
27964
Acres: 0.00
Lot *: 30 Block #: 3
Map *: 132A 3urisdiction: 10
k
(Move Pointer Here far All
owners)
Owner: DEL TORO, ANDRES R
180 NEW BEACH RD
POINT HARBOR, NC 27964
Section *:
POINT
Subdivision: HARBOR
BEACH
Legal Desc: 8LK 3 LOT 30 POINT HARBOR BEACH
SALE INFORMATION
Book: 868 Page: 289 Price: 266,000 Gate: 5/25/2005 Valid: N
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Land: 11,200 Building: 190,238 Total: 201,438
Deferred. 0 Taxable: 201,43E
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Parcel ID: 132AO0300300000 Owner: DEL TARO, ANDRES R
Building Information
PREV
Building 1 of 3 NEXT
Type: Single-family Residence
Value: 189,524
Pleated Area: 2,300
Year guilt: 1989
Effective Year Built: 1999
Quality: Average
Manufactured Home?:
# Bedrrn: 5
# Bath; 2
# Partial Bath: 1
# Fireplaces: 1
Fireplace Type: Single I -Story fireplace {#)
Foundation: Raised Subfloor (% or SF) Frame Type: Stud Frame
Style: Two Story
Style 2: 1 1/2 Story Finished
Ext Wall I: Frame, Siding, Vinyl
Ext Wall 2:
Heat/Air 1: Heat Pump
Heat/Air 2:
Roof Cover: Composition Shingle
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12/22/2009

HA
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7006 2150 0003 5467 4354
Andres and Hope Del Toro
180 New Beach Road
Point Harbor, NC 27964
Coleen H. Sullins
Director
November 17, 2009
Subject: Notice of Violation with Intent to Enforce (NOV-2009-PC-0919)
5A7 Geothermal Injection Well
Permit No. WI0700013
Currituck County
Dear Mr. and Mrs. Del Toro:
Dee Freeman
Secretary
As we indicated in our August 28, 2009, letter, the above-referenced permit, which was
originally issued to Megan Oaksmith on September 24, 2004, and expired on October 8, 2009,
has not been renewed. This permit was issued for the operation of a 5A 7 geothermal injection
system on your property located at 180 New Beach Read, Point Harbor, North Carolina. If you
wish to keep this permit and operate the injection well system, the permit must be renewed and
issued in your name. To do this, we have enclosed a Change of Ownership form for you to
complete.
A permit renewal application package with instructions to submit the necessary paperwork
within 30 days of its receipt was also sent to you on August 28, 2009. To date, the Groundwater
Protection Unit has not received your completed renewal application package. In addition, our
records do not indicate that the well system has been plugged and abandoned.
Therefore, the following violation(s) exists:
VIOLATION 1:
Operating an injection well without a permit is a violation of rule 15_A NCAC 2C .021 l(a).
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Locaiion: 2728 Capital Boulevard. Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Eoual Opportuniiy I Affirmative Action Employer
NirthCarolina
,Natura/tu
REQUIRED CORRECTIVE ACTION FOR THIS VIOLATION
Please take one of the following corrective actions within 30 days of receipt of this letter:
1. APPLY FOR PERMIT RENEW AL. When you apply for and receive a
renewal, operation of your well system will be permitted to continue. As such, all
sampling requirements and any operation and maintenance procedures specified
in your previous permit will be required. To renew, you must submit the
following information to the address below:
a) A completed Application for Permit (Renewal) to Construct and/or Use a
Well(s) for Injection with Geothermal Heat Pump System for Type SA 7
Well(s) (Enclosure 1). This form must be signed by each
property/permit owner.
b) A completed Change of Ownership Form (Enclosure 2). If available,
please have the previous owner sign this form where indicated.
-OR-
2. APPLY FOR PERMIT RESCISSION. If the geothermal well system has not
been constructed or is no longer being used for injection purposes, the permit may
be rescinded. Indicate on the attached Status of Injection Well System (Enclosure
3) your desire to rescind your permit and one on the following:
a. Current use of UIC well if it is still being used for other purposes
(i.e.irrigation, drinking, etc.).
b. Well abandonment information if the well is inactive and no longer in use.
NOTE: For a well system that is no longer active and is no longer being used
for any purpose, it must be pennanently abandoned according to the
regulatory requirements listed under NCAC Title 15A, Subchapter 2C,
Section .0214. When each well is plugged and abandoned, the well
abandonment record (Form GW-30) must be submitted to the address below
to certify that the abandonment was properly conducted.
All forms must be submitted to the following address within 30 calendar davs of the receipt of
this letter to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
httn://h20.enr.state.nc.us/aps/gp u/fi1m1s.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call Eric G. Smith at 919-715-6196, or email him at eric.2.smith@.ncdenr.2ov .
Enclosures:
1. Change of Ownership form
2. GPU/UIC SA 7 (revised 9/2007)
3. GW/UIC-68 (revised 5/2005)
Sincerely,
~J ~wJJs-
Debra J. Watts, Supervisor
Groundwater Protection Unit
cc: Washington Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI07000 13 w/o enclosures
U.S. Postal Service n,
CERTIFIED MAll,M RECEIPT
.:r-
U"J rn .:r-
(Domestic Mail Only; No Insurance Coverage Provided)
1"-
...a .:r-
U"J
I
•I••· .
Postage
Certified Fee
Return Receipt Fee
(Endorsement Requlrad)
rn
□
□ □ Restncted r
□ (Endorsama
U1
.-'I Total Pos1
ru
...a ,..,s""enc-:-t ""o-
g Street, Apt
I"-or PO Box 1'
City, State, ZIP+4
·"" ... ...• ~, . '
$
= ~ "u •= ·-· ·-·
Postmark
Hen,
Andres & Hope Del Toro
180 North Beach Road
Point Harbor, NC 27964
------------------------------------------·-·······
PS Form 3800, Augu~t 2006 See Reverse for Instructions
I
NA
-, ENR
North Carolina Department of Environment and Natural Resources
Division of Water Qualiiy
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
August 28, 2009
Andres and Hope Del Toro
180 New Beach Road
Point Harbor, NC 27964
Subject: Notice of Expiration (NOE)
5A 7 Geothermal Injection Well
Permit No. WI0700013
Currituck County
Dear Mr. and Mrs. Del Toro
Dee Freeman
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water Quality (DWQ) is
entrusted to protect the groundwater quality and resources of the State of North Carolina, and is responsible for
the regulation of injection well construction and operation activities within the state. Our records indicate that
the above-referenced operating permit for the underground injection well system located at above referenced
address, which was issued to Ms. Megan Oaksmith (previous owner) on September 24, 2004, and expires on
October 8, 2009, has not been renewed. As the current property owner, if you wish to keep this permit and
operate the injection well system, the permit must be renewed and issued in your name. Our records do not
indicate that the well system has been plugged and abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative Code (NCAC)
Title 15A, Subchapter 2C, Section .0211 , you must submit one of the following forms:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for Injection with Geothermal Heat
Pump System.for Type 5A 7 Well(s) if the injection well system on your property is still active.
-OR-
B. Status of Injection Well System if the injection well system is inactive or has been temporarily or
permanently abandoned.
If there has been a change of ownership of the property, an Injection Well Permit Name/Ownership Change
Form must also be submitted.
AQ UIFER PROTECTION SECTION
1636 Mail Ser11ice Center, Raleigh, North Carolina 27699-1636
Location : 2728 Capital Bou~vard. Raleigh. North Caroiina 27604
Phone : [phone] \ FAX 1: 919-715-0588: FAX 2: 919-715-6048 i Customer Serv ice 1-877-623-6748
Internet www.ncwatero~
An :qual OppoNun ity \ Affirmative Action Employer
NOnehC ,. ort arollna
JVaturatlu
,.; ... 1,·1-,
If the injection well system is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section .0214. When
each well is plugged and abandoned, the well abandonment record (Form GW-30) must be submitted to our
office to certify that the abandonment was properly conducted. If the injection well system is still active and
you wish to renew your permit, the renewal application must be submitted within 30 calendar davs of the
receipt of this letter to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties in accordance
with North Carolina General Statute 87-94. For your convenience, a renewal application and a UIC well system
status form are attached along with a self-addressed envelope. The above referenced forms are also available
on-line at the DWQ website at http://h2o.enr.state.nc.us/ans/gou/forms.htm.
Thank you in advance for your cooperation and timely response. If you have any questions, please call me at
[phone].
Attachments
Sincerely,
/4~/4:_pe~~
Michael Rogers /
Environmental Specialist
cc: Washingtion Regional Office -APS w /o enclosures
APS Central Files -Permit ~o. \VI0700_~l i-3 w 'o enclosures
2
A~i.~A Jl!i,,'f.;~J.
NCOENR
North Carolina Department of Environment and Natural Resources
Division ofWater Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
December 31, 2009
Currituck County Sheriff's Office
Sheriff Susan Johnson
407 Maple Road
Maple, North Carolina 27956
Subject: Notice of Service
Andres and Hope Del Toro
Permit No. WI0700013
Currituck County
Dear Sheriff Johnson:
Dee Freeman
Secretary
Please serve the enclosed Notice of Violation letter to the persons listed above at the following address:
180 New Beach Road
Point Harbor, North Carolina 27964
Please return the completed Notice of Service form in the enclosed return envelope. The Division of
W~ter Quality greatly appr!;':ciates this assistance from your office. Please contact me at [phone]
or email Die at eric.2:.smith@ncdenr.!l ov if you have any questions or need additional information.
Sincerely,
~. 0 /rruit.
Eric G. Smith
Aquifer Protection Section
Groundwater Protection Unit
Enclosures
cc: Wasliington Regional Office-APS
APS Central Files -Permit No. WI0700013
AQUIFER PROTECTION SECTION
1636 Mail Service Center:Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone : [phone] I FAX 1: 919 -715-0588 ; FAX 2: 919-715~048 i Customer Seivice : 1-877-623~748
Internet: www.ncwaterguality.org
An Equal Opportunity I Affirmati~e Action Employer
None , C 1. ortn aro 1na
. .Naturally
NOTICE OF SERVICE
I certify that this NOTICE OF SERVICE was received on ____ day of ____ 2010
and together with the document(s) was served as follows:
Date Served:
Designated Recipient(s):
Place of Service:
(fill in address)
Served By:
Check one of the following:
Andres and Hope Del Toro
Serving Officer (Print)
By personally delivering copies to the named individual(s);
By leaving copies of the Notice and original letter at the named individual's dwelling, house
or place of business with a person of suitable age and discretion then residing therein. Name of the
person with whom the copies were left: ___________ _
If not served to the named individual(s) above, please state reason why:
Serving Officer's Signature County
Service Fee: X Waived (State Agency) ------
Please return this form to: Eric G. Smith
Division of Water Quality
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Date
Paid
ATA
NCDENR
Nort h Carolina Department of Environmen t and Natu ral Resources
Div ision of Water Quality
Beverly Eaves Perdue
Governor
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
1006 2150 0003 ·5467 4354
Andres and Hope Del Toro
180 New Beach Road
Point Harbor, NC 27964
Coleen H. Sullin s
Director
November 17, 2009
Subject: Notice of Violation with Intent to Enforce (NOV-2009-PC-0919)
SA7 Geothermal Injection Well
Permit No. WI0700013
Currituck County
Dear Mr. and Mrs. Del Toro:
Dee Freeman
Sec retary
As we indicated in our August 28, 2009, letter, the above-referenced permit, which was
originally issued to Megan Oaksmith on September 24, 2004, and expired on October 8, 2009 ,
ha:s not been renewed . This permit was issued for the operation of a SA 7 geothermal injection
system on your property located at 180 New Beach Road, Point Harbor, North Carolina. If you
wish to keep this permit and operate the injection well system, the permit must be renewed and
issued in your name. To do this, we have enclosed a Change of Ownership form for you to
complete.
A permit renewal application package with instructions to submit the necessary paperwork
within 30 days ofits receipt was also sent to you on August 28, 2009. · To date, the Groundwater
Protection Unit has not received your completed renewal application package. In addition, our
records do not indicate that the well system has been plugged and abandoned.
Therefore, the following violation(s) exists:
VIOLATION 1:
Operating an injection well without a permit is a violation of rule 15A NCAC 2C .021 l(a).
AQUIFER PROTECTION SECTION
1636 Mail Service Ce nte r, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Bo ul evard, Raleigh. No rt h Carolina 27604
Phone: [phone] \ FAX 1: 919-715.0588; FAX 2: 919-715-6048 \ Customer Service 1-877-623-6748
Internet: www .ncwaterguality.org
An Equal Opportunity I Affirmative Action Employer
N°orth Carolina
lvaturallg
RE QUIRED CORRECTIVE ACTION FOR THIS VIOLATION
Please take one of the following corrective actions within 30 da vs of receipt of this letter:
1. APPLY FOR PERMIT RENEWAL. When you apply for and receive a
renewal, operation of your well system will be permitted to continue. As such, all
sampling requirements and any operation and maintenance procedures specified
in your previous permit will be required. To renew, you must submit the
following information to the address below:
a) A completed Application for Permit (Renewal) to Construct and/or Use a
Well(s) for Injection with Geothermal Heat Pump System for Type SA 7
Well(s) (Enclosure 1). This form must be signed by each
property/permit owner.
b) A completed Change of Ownership Form (Enclosure 2). If available,
please have the previous owner sign this form where indicated.
-OR-
2. APPLY FOR PERMIT RESCISSION. If the geothermal well system has not
been constructed or is no longer being used for injection purposes, the permit may
be rescinded. Indicate on the attached Status of Injection Well System (Enclosure
3) your desire to rescind your permit and one on the following:
a. Current use of UIC well if it is still being used for other purposes
(i.e.irrigation, drinking, etc.).
b. Well abandonment information if the well is inactive and no longer in use.
NOTE: For a well system that is no longer active and is no longer being used
for any purpose, it must be permanently abandoned according to the
regulatory requirements listed under NCAC Title 15A, Subchapter 2C,
Section .0214. When each well is plugged and abandoned; the well
abandonment record (Form GW-30) must be submitted to the address below
to certify that the abandonment was properly conducted.
All forms must be submitted to the following address within 30 calendar davs of the receipt of
this letter to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
httn://h20.enr.state.nc.us/ans/!!Pu/fom1s.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call Eric G. Smith at 919-715-6196, or email him at [e-mail].
Enclosures:
1. Change of Ownership form
2. GPU/UIC SA 7 (revised 9/2007)
3. GW/UIC-68 (revised 5/2005)
Sincerely,
~J~wJJs-
Debra J. Watts, Supervisor
Groundwater Protection Unit
cc: Washington Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0700013 w/o enclosures
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 5-A 7 WELL(S)
____ New Permit Application OR -----Renewal (check one)
DATE:-------~ 20
PERMIT NO. _________ (leave blank if NEW permit application)
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): __________________ _
(1) Mailing Address: _________________________ _
City: _________ State: __ Zip Code: ______ County: _____ _
Home/Office Tele No.: -----------~C~el=l ~N~o~.: __________ _
EMAIL Address: ________________ _
(2) Physical Address of Site (if different than above): ________________ _
City: _________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: -----------~C~e=ll~N~o~.:'-------------
EMAIL Address: ________________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: _____________________________ _
Contact Person.~: --------------=E=MAI==L"""A""'dd==-re=s=s:'-------------
Address: ________________________________ _
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: _______________ _
GPU/UIC SA 7 Well Permit Application (Revised 9/2007) Page I
C. WELL DRILLER INFORMATION
Company Name: ________________________________ _
Well Drilling Contractor's Name: __________________________ _
NC Contractor Certification No.: __________________________ _
Contact Person . .:..: _______________ ....,E""M"""-AI=L'---'A'---'='dd=r=e=ss"'": ___________ _
Address:------------------------------------
City: __________ Zip Code: _____ County: ______________ _
Office Tele No.: Cell No.: __________ _
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: ________________________________ _
Contact Person . .:..: _______________ ....,E""M"-""-AI=L,....,A'--"-d=d=r=e=ss"'": ___________ _
Address:------------------------------------
City: __________ Zip Code: _____ County: _____________ _
Office Tele No.: Cell No.: __________ _
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: __ Native American Lands:
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)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES __ _ NO ___ _
H. WELL CONSTRUCTION DATA (Ski p to Section I if this is a Permit RENEW AL )
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.
(1)
(2)
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 Form GW-1 (Well Construction
Record) if available.
Date to be constructed: ________ Number of borings: ___ _
Approximate depth of each boring (feet): ________ _
Well casing. Is the well(s) cased? (check either (a.) YES.!!!: (b .) NO below)
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel __ Black steel __ Plastic __ Other (specify) _______ _
Casing thickness : __ diameter (inches): ___ depth: from ___ to ___ ft . (reference to land surface)
Casing extends above ground ____ inches
GPU/UIC SA 7 Well Permit Application (Revised 9/2007) Page 2
(b) NO
(3) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite Other (specify) _______ _
(b) Grouted surface and grout depth (reference to land surface):
___ Around closed-loop piping; from ___ to ___ (feet).
___ Around well casing; from ___ to (feet).
(4) Well(s) Screen Information
Depth of Screen: From _____ to ____ feetbelow land surface
(5) N.C. State Regulations (Title 15A NCAC 2C :0200) require' the Permittee to make provts1ons for
monitoring wellhead water quality and 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) Influent line? 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 Form GW-1 (Well Construction Record). If Form GW-1 is not available, provide the
following data:
Groundwater Source. From what depth, formation, and type of rock/sediment units will the groundwater
be withdrawn? (e.g. granite, limestone, sand, etc.)
Depth: _______ Formation: ______ Rock/sediment unit: _______ _
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DAT A FOR EITHER EXISTING OR PROPOSED WELLS IF
THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
I. OPERATING DATA
(1) Injection rate:
(2)
(3)
(4)
Injection-Volume:
Injection Pressure:
Injection Temperature:
J. INJECTION-RELATED EQUIPMENT
Average ( daily) __ _..,gallons per minute (gpm). ·
Average (daily) __ gallons per day (gpd).
Average (daily) ___ pounds/square inch (psi).
Average (January)_. __ ° F, Average (July) __ ° F.
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
K. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
GPU/UJC 5A7 Well Permit Application (Revised 9/2007) Page 3
L. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"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 appurtenanc~s in accordance with the approved specifications and conditions of the Permit."
Signature of Property Owner/ Applicant
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
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC SA 7 Well Permit Application (Revised 9/2007) Page4
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: ___________ _
Permittee Name: ___________________ _
Address: _________________________________ _
Please check the selection which most closely describes the current status of your injection well system:
1) D Well(s) still used for injection activities, or may be in the future.
2) D Well(s) not used for injection but is/are used for water supply or other purposes.
3) D Injection discontinued and: a) D Well(s) temporarily abandoned
b) D Well(s) permanently abandoned
c) D Well(s) not abandoned
4) D Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description ofhow the well
was sealed and the type of material used to fill the well if permanently abandonedj :
Permit Rescission:
If you checked (2), (3), or (4) and will not use a well for injection on this site in the future, you should request rescission of the
permit. Do you wish to rescind the permit?
D Yes □ No
Certification:
"I hereby certify, under penalty oflaw, that I have personally examined and am familiar with the information submitted
in this document, and that to the best ofmy knowledge the information is true, accurate, and complete."
Signature Date
Revised 5/05 GW/UIC-68
..
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
Any changes made to this form will result in the application being returned.
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
For more infonnation, visit our web site at: http://h2o.enr.state.nc.usllaulmain.html
I. RE QUIRED ITEMS
1. Submit one original of the completed and appropriately executed Permit Name/Ownership Change Fonn.
For a change of ownership, the certification must be signed by both the current permit holder and the new
applicant. For a name change only, the certification must be signed by the applicant.
2. Provide legal documentation of the transfer of ownership (such as a contract, d.:::ed. article of incorporation,
etc.) for ownership changes.
3. Change of Ownership. Applications for Homeowners Associations (HOAs) shall include the HOAs bylaws,
covenants, etc. [15A 2T .0115(c)]
4. . Submit a properly executed Operation and Maintenance Agreement for all Single Family Residence Surface
Irrigation permits requesting a change of ownership.
II. CURRENT PERMIT INFORMATION
1. Permit number : _____________________________ _
2. Permit holder's name: ___________________________ _
3. Permit's signing official's name and title: _____________________ _
(Person legally responsible for permit)
(title)
4. Mailing address: ____________________________ _
City: _____________ State: ______ Zip: _________ _
Telephone number: ( __ ) _______ _ Facsimile number: ( __ ) ______ _
ill. NEW OWNER/NAME INFORMATION
1. This request for a permit change is ·a result of:
__ a. Change in ownership of property/company
__ b. Name change· only
c. Other (please explain):
..
· 2. New owner's name (name to be used in permit): ___________________ _
FORM:·PNOCF 09-06 Page 1 of 2
3 . New owner's or signing official's ·name and title : ___________________ _
(Person legally responsible for permit)
(title)
4. Mailing address: -------------------------------
City: _____________ State: ______ Zip: _________ _
Telephone number: ( __ ) ________ _ Facsimile number: ( __ ) ______ _
IV. CERTIFICATION
1. Current Permittee's Certification:
I, ___________ , attest that this application for name/ownership change has been
reviewed and is accurate and complete to the best of my knowledge . I understand that if all required parts of
this application are not completed and that if all required supporting infonnation and attachments are not
included, this application package will be returned as incomplete. I understand I will continue to be
responsible for compliance with the current permit until a new permit is issued.
Signature: _____________________ Date: _________ _
2. Applicant's Certification:
I, ___________ _, attest that this application for name/ownership change has been
reviewed and is accurate and complete to the best of my knowledge . I understand that if all required parts of
this application are not completed and that if all required supporting infonnation and attachments are not
included , this application package will be returned as incomplete. . I further c:~rtify that the applicant or any
affiliate has not been convicted of an environmental crime, has not abandoned a wastewater facility without
proper closure, does not have an outstanding civil penalty where all appeals . have been exhausted or
abandoned, are compliant with any active compliance schedule, and do not have any overdue annual foes
under Rule 2T .0105.
Signature: _____________________ Date: _________ _
THE COMPLETED APPLICATION PACK.AGE, INCLUDING ALL SUPPORTING INl<'ORMATI0N AND
MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRON1',-1ENT AND NATURAL RESOURCES
DIVISION 01:<' WATER QUALITY
AQUIFER PROTECTION SECTION
LAND APPLICATION UNIT
Via U.S. Postal Service
1636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
Via Courier/ S pecial Deliven •:
2728 CAPITAL BOULEVARD
RALEIGH, N0RTII CAROLINA 27604
TELEPHONE NUMBER: [phone]
FORM: PNOCF 09-06 Page 2 of 2
MEMORANDUM
To: David May
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
September 24, 2004
Washington Regional Office
From: Thomas Slusser-zrs
Central Office
Re: Issuance of a Water-source Heat Pump Injection Well Permit (Type SA 7):
Permit Number WI0700013 to operate 2 wells for the operation of a water-source heat pump
injection well system has been issued to Ernest Cody in Point Harbor, North Carolina. A copy of
this permit is enclosed for your files. This permit is due to expire on October 8, 2009.
Thank you and your staff for helping to get this permit issued. If you have any questions
regarding this memorandum or the UIC program, please contact me at [phone] or Evan
Kane at [phone].
cc: CO-UIC Files
Enclosures
Michael F. Easley, Governor
WiIIiarn G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. director
Division of Water Quality
September 27, 2004
Mr. Ernest Cody
180 New Beach Road
Point Harbor, NC 27964
Ref: Issuance of UIC Permit # W10700013
Dear Mr. Cody:
In accordance with your application dated May 1, 2004, 1 am forwarding Permit No. W10700013 for the
operation oft injection wells associated with your geothermal heat pump system at 180 New Beach Road, Point
Harbor, in Currituck County. This permit shall be effective from the date of issuance until October 8, 2009, and
shall be subject to the conditions and limitations stated therein, Pay special attention to the special use
conditions on Page 5 of your permit.
Water samples were taken at the influent and effluent sampling ports during inspection of this geothermal heat
Pump system and are included for your information. Please note that sample results for the injection well in
your front yard exceeds the groundwater quality standard for Iron of 300 µglL, as stated in the North Carolina
Administrative Code, Title 15A, Subchapter 2L, Section .0202. Dr. Luanne Williams, an Epidemiologist in the
Division of Public Health, stated that this exceedence is not a health risk and will not adversely affect your
ability to operate your injection well system.
If you have any questions regarding these results, your permit, or injection well rules and regulations, please
contact me at (919) 715--61.66 or Evan Kane at (919) 715-61 f 5.
Sincerely, pp
Thomas Slusser
Hydrogeologica] Technician 11
Underground Injection Control Program
f+ ` i am sna
Naturally
Acluiter Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Phone [phone] Customer Service
Inlenict: ht1p:llh2menr.s1ate.ne.us 2728 Capital Boulevard Raleigh, NC 27604 Fax [phone]
Fax [phone]
An Equal ❑pportunilylAffirmalive Action Employer- 50%Reeyaled1101% Post Consumer Paper

ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION OF A WELL FOR INFECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, acid
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
ERNEST CODY
FOR THE OPERATION OF 2 TYPE 5A7 INJECTION WELLS, 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 wells are located at 180 New Beach Road, Paint Harbor, in Currituck County.
The injection well system will be operated in accordance with the application submitted May 1,
2004 and in conformity with the specifications filed with the Department of Environment and
Natural Resources, which are considered a part of this permit.
This permit is for Operation only, and does not waive any provisions of the Water Use Act or any
other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be in
compliance with Title 15A North Carolina Administrative Code 2C .0100 and ,0200, and any other
Laws, Rules, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of issuance until October 8, 2009, and
shall be subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
-kr—
Permit issued this the 2A day of 2004.
Ted L. Bush, Sr., Chief
Aquifer Protection Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. W10700013 PAGE 1 OF 5
GWUC-5 ver. 3/01

PART I -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of_Water Quality (Director). In the event there is a desire for the facility to
change ownership,_ or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances that may be imposed
by other local, state, and federal agencies that have jurisdiction. Furthermore, the issuance
of this permit does not imply that all regulatory requirements have been met.
PART II-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater that will render it unsatisfactory for normal use. In the
event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART III -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.
PermitNo. WI0700013
GW/UIC-5 ver. 3/01
PAGE20F 5
PART IV -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, · ···-, ·
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART V -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 Permitee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Washington 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.
Permit No. WI0700013
GW/UIC-5 ver. 3/01
PAGE3 OF S
PART VI -PERMIT RENEWAL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
PART VII -CHANGE OF WELL STATUS
I. The Permittee shafl provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinuation of use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
,;_\
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe 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.
PennitNo. WI0700013
GW/UIC-5 ver. 3/01
PAGE4 OF 5
(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 VII (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-me Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART VIII-OPERATION AND USE SPECIAL CONDITIONS
Both injection wells must have identification tags placed on them according to North Carolina
Administrative Code Title 15A 2C .0213 (g) • that includes, but is not limited to, the following:
• date of construction
• name of well driller
• type of well casing
• depth and width
• screened interval
Written notification of completion of this requirement must be submitted to the address in Part
VII, Item 3 above within 30 days ofreceipt of this permit.
• Inclusion of a well contractor certification number is not applicable in this case since the well
driller, Mr. Lori Stillman III (deceased), operated prior to the Well Contractor Certification
Program.
Permit No. WI0700013
GW/UIC-5 ver . 3/01
PAGES OF 5
Ni results for 401143-1145
1 of 1
Subject: Ni results for 4Gl 143-1145
From: Roy Byrd <[e-mail]>
Date: Thu, 23 Sep 2004 12:21 :25 -0400
To: Thomas Slusser <[e-mail]>
CC: Cindy Green <[e-mail]>
Thomas,
Nickel was analyzed and here are the results.
4G1143 is IOU
4G1144 is IOU
4G1144 is lOU
U Indicates that the analyte was analyzed for but not detected above the reported practical quantitation limit*. The number value reported with the
"U" qualifier is equal to the laboratory's practical quantitation limit*.
Roy Byrd
9/23/2004 1: 17 PM
COUNTY; CURRITUCK
QUAD NO:
REPORT TO : WARO
COLLECTIONS) : A HARMS
DATA 711 m
TIME-,
PURPOSE:
Regional Office
LABORATORY
ANALYSIS
BOD 310
COD I h 340 Wit
COD Low 335 agElL
Coliform: MF Fa l 31616 ! I Wait
Coliform: MF Told 31 YW 11oom1
TOC m !I
Turbnity NTU
Residue_, Susleaded 530
ToW $uspended wlids tnpA
H units
Alkgirdt to rH 43 m k
Alkalinity io i3 S.3 rn
Carbanatz rngA
Bicarbonate nqvL
Carbon dioxide
X
Chlotidc 43
Chromium 14cx 1032 u
Color. T1vc 80 c u.
Cyanide 720 mg/L
COMMENTS
DIVISION OF WATER QUALITY
Chemistry Lnbontory Rep nri IGround Water Quality
SAM FI F. PP I OR ITY
X]ROU-ME ❑EMERGENCY
CHAIN OF CUSTODY
W 5-1
W� SAMPLE TYPE
Owner: E R-C(ILY
Location or Site:
Description of sampling point_
Sampling Method- _
Remarks;
X
Diss. Solids 70360
180
m R,
Fluoride 951
nr
Hardness toml900
r
Hardness: fnon-carb) 902
WtI,
Pheoals 32730
u IL
S � ifcCond.95
umlleskm2
StdZim
myl
Sulfide 745
MBAS
AL
Oil and Grease
fL
Silica
23tL
Sown
Fotmaldeh de
ai
NH3 as N 610
NIL
TKN as N 625
m rL
X
NO2+NO3 as Ti 630
3.7
tit -
P: T•oW as P 665
IL
PO4
m
x
I ff torte (NO, as M)620
3.7
mgfL
Nitrite (NO2 as N) 615
0.01 u
mglL
A -Silver 46566
uglL
x
At -Aluminum 46557
140 uglL,
As -Arsenic 46551
uglL
Ba-Barium 46558
u
x
Ce-Calcium 46552
73
Cd-Cadum 4,6559
uglL
X
Cr-Chrom.1=66560
25U uglL
A
Co- Copper 1042
11 u
X
Fo- h-on 1045
64 u
H - Mercury 719M
uglL
X
K-Parassitin 46555
GA m
X
- Magncsitim 927
4A mWt
x
Mrt-MLugxncse 1055
36 VL
X
Na- Sodium 929
27 mg(L
X
Ni-Nickel
1Q V11
X
1'b-Lead 46564
10U ug/L
Se-5elenirim
U dL
X
Zn_Zanc46i56'1
25 ugIL
lab Number 4GI143
Dale Recairr4 : 7129nO4
T.roc Rcccired 9r15 AM
Received By DS
�L41
lCslrascd By '. AR
Date repanled : 911412M
OrgonmMonne Pesticides
0rgau2Lhosl,bmsPcsdc1dcs
Nilm en Pesticides
Acid Hctloid ea
Scruivoladles
TPH-Diasel Runge
Vvlatilc Orgauics (VOA bonlc)
TTH-Gasoline Rapize
TPH-STEX Gasoline R.
4
Q
fY1
h3
CZ)
C.7
f\]
co
SEP ] 6 2004
I
del1.0

COUNTY CURRITUCK
QUAD NO:
REMRT TO ►►'APO RCgloual OfrF=
COLLECrOR(S) : A HARMS
DATE: MUM
TIME:
DIMION OF WATER QUALITY
Chrmistry Laboralary RgmrtI Gronad Water Quality
SAMP! F PRIORIT'Y
%]ROUTINE EMERGENCY
[] CHAIN OF CUSTODY
EFF-2
Wl SAMPLE TYPE
PURPOSE: _ Owner. M&b=T a copy
Locetion or Sire: - - S I GE t
Description of sampling paint
Sampling Method:
Remarks:
LABORATORY ANALYSIS
BOD 314
COD High 340 m L
COD Low 335
Colifotm: MF Feeal31616 1100m1
Colirt:rm: MFToW 31504 Afflad
TOC
Turbi6iv NTU
Residue.. Suspended 530 m
Tyner Sustrnded solids m
H units
AikRhnity to +H 4S
Aikaliniity is P H S.3
Carbonate
SicArbonalC mWL
Carbon dioxide MVL
K
Chloride 60 m
Chromium: Hex t 03 2
Color True 80 c.u.
Cyerdde 720 mgA-
COMM£Nn:
X
Disa. Solids 70300
160
Fluoride 951
liatdnCss: [eta[ 9110
m
Hardness: (noa-aut) 902
m
Phertols 32730
u -
S .ific Conti 95
umhoslcm2
Sulwe
WA
Sulfide 745
A.
MBAS
UX
041 and Crease
Swa
R
Baron
Farmeldeh do
NH3 n N 610
TXNuN625
m
X
NOi+NO3 as n &30
3.6
P: ToWtl as P 665
m
POa
n314.
X
N-orate (ND3 as N) U0
3.6
ERB&
Nitrite [NDt as N) 615
0.01 U
n&
Ag-Si1Ver46566
]C
AI -Aluminum 46557
140 uglL
As-Arrgric 46551
uVL
Ba-Barium 46559
uglL
•
Ca-Celdttm 46552
14 mglL
Cd-Cadium 46559
u
IL
Cr-Chum ium46560
25U ug/L
%
C-tt- CoMr 1042
2-Olt
X
Fc- Iron 1045
60 ug/L
a-Matury 71900
uglL
X
X-Parassidro 46555
6.2 mgfL
?
h!-M n�kno 927
4.5 rn
X
Ivlu Manganese 1055
37 ug1L
7i
I Na- Sodium 929
30 m
7C
Nt-Nickel
f D 0 ug/L
X
P&Izad4G554
IOU u
Sr.Srtenium
up/L
K
7p_= 46567
14 ugil-
I-Ab Number
4GI145
Datc Received
7/29/2004
Time Received :
9:45 AM
Received By
'/—y
DS
11A�,Jti
�Y)
Date rcponed :
9114rMO4
Orpnochlorina Pesticides
Drgano hos horus Pesticides
Nitro en Pcstici lm
Acid Hrrbicidrs
Semivolatiira
TPH•Diesel Range
Volatllc Organics {VOA battle)
TPH-Gasoline Raage
TPH•BTFX Gasoline Ranee
I
i
S EP 16 2004
11i rr . ' i

t`I
COUNTY :
QUAD NO:
CUFRRITUCH
REPORT TO : WARO Regional 0fficc
COLLECTOR(S) : A HARRIS
DATE =Ram
TIME:
D"ION OF WATER QUALIFY
CLemlatry Laboratory Report 1 Ground Water duality
SAMPi F PRIORYTY
QROUTINE EMERGENCY
CHAIN) OFCUSMDY
EFF-7
® SAMPLE TYPE
PURPOSE: Owner. E81= rm CODY
LABORATORY
ANALYSIS
SOD 3 rn /1_
COD High 340 m .
COD Low 335 m IL
Colirorm: MF Feral 31616 11 ochn1
Colifotm: MF Taud 31Y A 1100m1
TOC
Twblti NTU
Residue.. SuspeRded 530 MBIL
Total Su .nded solids m
H tU44
Alkidinily to pH 4.5 to IL
Alkdrdt w tH 8.3 m&11-
Carbonitle m
Bicarbonate m 1L
Curbon dioxide m
X
Chloride 60 TIL
Chromikum H" 1032 u
Color. True 80 c.u.
Cyanide 720 mg1L
COMMENTS:
Location or Site: ro I >r� 4 7 rt'e I i YTO7] ! O_
Description of aampling Will
Sampling Muhod:
Remarks:
X
Dias, Solids 703W
140
ruKR
Fluoride 951
MBIL
Hardness: tolai 900
TE
Hardne (non-esrb)9pR
Phenols 32730
u
Spe6fic CcrKL 95
umhoslcm2
Sulfate
2
Sulfide 745
1L
MBAS
m 1L
Oil and Grosse
fntJL
Silica
m IL.
Boron
FI.Wdeh de
m IL
NH3 as N 610
IL
TKN as N 625
mg1L
x
NO2 +NO3 as n 630
3.6
P: To W ea P 665
aqtL
PO4
X
fYiomte [NO3 as N) 620
3.6
mr/L
Wiitrite(NO=asN)6)5
wmu
mg/L
-Silver 4066
u
X
Al-Alunikum 46557
210 uglL
As-Arseslic 46551
u !L
Bn-Barium 4058
ug1L
X
Ca- Calcium 46552
15
Cd-Cadium 46559
u
*
Cx-ChmE ium 45560
25U uVL
X
Cu- Copp= 1042
2.0 u
X
Fe- Iron 1045
620 up1L
If hSerr ury 7 ! 9e0
uWL
X
K-Poussium 46555
5.1 m 1L
X
Mg- Magnesium 927
4.4 m 1i.
X
mu -manganese 1055
38 uglL
X
Na. S.M.929
31 rnp/L
X
Ns•Niekd
U WSIL
X
Pb•Lcad 46564
IOU u -
Se-Sdenium
u
X
Zn 4rkc46567
1ou ngR
Lab Ntirnt— -
4G1344
Dale Received
7/29120D4
Time Received =
9-45 AM
Received By
Ds
ay :
AR
Date reported :
9114120[I4
Organochiorine Pesticides
oronuphosphams Pesticides
Nitmsen Pesticides
I I Acid Herbicides I
I I Volatile Organics ( VOA bottle) I
Gasoline
'. 1 "J 5 EP 16 2004
L L'..'I{a. 4cn
■

ALT -K WA
Til'a
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Aquifer Protection Section
Michael F. Easley, Governor
MEMORANDUM
DATE: duly 29, 2004
William G. Ross, Jr., Secretary
Alan W. Klimek, R.E., Director
TO: Thomas Slusser — Hydrogeological Technician H
Aquifer Protection Section — Central Office
t
THROUGH: Willie — Regional Aquifer Protection Section Supervisor — WaRO
FROM: An' M Harris — Hydrogeologist — Aquifer Protection Section — WaRO
RE: Permit Renewal # W10700013: Inspection and sampling of Ernest G. Cody's geothermal
injection well system located at his residence, 180 PointHarbor.Road, Point Harbor, Currituck
County, North Carolina.
+ A site inspection was conducted on July 28, 2004.
■ The supply well is located beneath a storage shed. The homeowner indicated the wellhead was
completed in the early 1960s below grade by Mr. Cody by Mr. White of Camden County. This
well is 89 feet deep, constructed of 1- 1/4 inch galvanized steel. The sampling port for the supply
(influent) well is located at the house by the pump_
There are two injection wells onsite. One is located in the front yard, 47 feet in front of the house
(labeled EFF-1 on field/lab form)- The second injection well is located in the back yard, 37 feet
behind the house (labeled EFF-2 on field/lab form). The homeowner indicated both of these
wells were completed by Lori StiltTnan, III (deceased) of Currituck County in 1986 or 1987.
They are both 2" PVC wells, 40 feet deep, and screened from 30-40 feet. Wells appear to be
grouted: Grout present at 2.0-2.5 feet. The ID tags were not present during the inspection, and
the homeowner installed spigots on top of the individual injection wells during the inspection.
The spigots were flushed with 70% alcohol prior to installation,
• The influent and effluent sampling ports were opened and purged for 10 to 15 minutes prior to
sampling. Analytical results will be forwarded to you once they are received by the WaRO.
+ Photographs were taken during the site inspection. Files containing the photographs will be
emailed to you.
Please contact me at [phone] ext. 354 should you have any questions or require additional
information.
cc: WaRO
943 Washington Square Mali, Washington, North Carolina 27889
Phone: 252946-$4M1 1 FAX: [phone] Internet: h2o.enr.state.naus
An Equal OpportunitylAffirmative Action Employer - 50% Recyciecft 0% Past Consumer Paper
NorthCarolina
Naturally

INJECTION FACILI fY INSPECTION REPORT -FORM B (CONT11VUE
'" ELL CONSTRUCTION
Date constructed 1R2&-1987 er t� nwne�
Drilling contractor: Name Lori 6d e.eeasm
Address Cur•r43jctC,a.
Registration number
Total depth of well{xT+kx;tc 4p'
Total depth of source well ' gr curre
+ —
per ow r 4f^
(if applicable)
r Nth,
Inspection point
easurement Meets rninimum standards
Comments
yard11,�a
Yes No
Casing
,
J
Depth
40
'f o
►�`
per i r Q owner
Diameter
2-"
2.
urL-A --
Height (A.L.S,)
! W
+��
►�
�,
Grout
cke4k,cd
to
Depth
2.5$
2.,0t
1 owa,-
Screens
Depth(s)
!
t wne�
Len;th(s)
,f
I.D. Plate
iNQZ[[r�na q 7
Static Hater level
no_
r%
rz�Gi
Well yield
n a
r
Enclosure
V�
Enclosure floor
(concrete)
—
i
Sarnpling Port
✓
r1 1 d
(labeled)
spy+5 �br rwG �nS�an
Water tight }pipe entry
V
it 0L rS WA.*ONl
fi
Well enclosure entry
�.
Vent
Functioning of heat Bump system (Determine from the owner if heat purnp functions praperlu)
grti r Wei 1 ►r*s e k r, whi±t as C g ro on LD
l r S r tiuQ l2 _lae!0 W5Ut And } 5 _01 l/q r, a� I Va nl V_ {are l Lie td � W n er,
INSPECTOR L office
WITNESS Address
❑N'TTNESS ArtrlrPcr

North Carolina Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WIO76M 13 DATE( 2F 0 L�
NAME OF OWNERg tJ ST
ADDRESS OF OWNT-R t -W hJe j °Road
(5creetl road or for and subdivision, counry, toivn)
LOCATION OF INJECTION WELL (and source wells), if applicable) cA ve
(Screed road or lot and subdivision, counry, town, rf d�erenr than owner's address, plus description of location on sire)
+�e l
Potenctia oii; 'on source 61j)�5 r�, jA= Distance from well 2,7�
l�oI'nja o LL10i1 SoLi3Ce h���, CC51��P1Y6 Distance
iTDm well Z'F'
Po enfi `
tiial � lutionrelln source FWriev-S- I-fq,[(j,gnCe Distance from well .�._
Minim' urn distance of well from property boundary 16 fr ca d waq Ca-or%t 61� P�W�4Y
Quality of drainage at site 00 Flooding potential of site 1QW
(good, adequate, poor) (high, moderate, low)
DRAW SKETCH OF SITE (show property boundaries, buildings, wells, eoten:ral polWion sources, roads, approximate scole
arrow) !swrM well' 3fi, 5'+41.y�iSil"N��S°cF8'(a.�i7�W�"W
ls'. pe Pvw7 ; 3(.' S' 4 9, 3-7344" ,N, -7 s°+F$ S . +o`i 54 FR-r',"%I 6hCr-,.
I
�N-rrt hkar's
{ yrt�
41,
4 AG1rt� �
—,-> -to M'Y d Y9
NEw Qe� R-el
DESCRIBE INJECTION SYSTEM (vertical closed loop, uncased borehole or cased water fuel[; separate source well and inj
combination source and injecrion well; or other description as applicable)
CG _ 5OL r Ctt i lit' 3PL` 1n WeLs _

WASHINGTON REGIONAL OFFICE - GROUNDWATER SECTION - PHOTOGRAPHIC RECORD
Site Name: Ernest Cody Residence IncidentlPerm W 10700013
Site Location 180 New Beach Road Site Town/Cit► Point Harbor, Currituck County
Photographer:
Photographer:
AMH
AMH
r:�.,•,
+
Date:
Date:
7/28104
7128/04
Photo Location:
Photo Location:
Front Injection
Well
�-
Back Injection
Well
� . .r� �'.�f'�1,; - . :• •_
,r
1' ► _
Comments.
r :
Comments:
'0
(EFF-1 )
(EFF-2)
.l,
Photographer:
Photographer:
`
AMH
AMH
�• .'�e�r �f'" 4
Date:
Date:
_
r•
7128104
7128104
Photo Location:
Photo Location:
Back yard
45
Infulent spigot
Comments:
Comments:
Supply well
----
beneath shed in
back, injection
�� ��'_ '•?':f ,, • ' �, , : �;. Timm
'� • . "
_ "t. •.: - �x
=�
Pump is inside
door.
S
well in forground.
_ "e
.r
i
�4 a r� r4I.�•}�;

z
F. �
t�r�
Wiliam G. Ross Jr.. Secretary
--1 Departrnerrt of EnvironrneW and Natural Resources
%low Alan W. t4imek, P.E. otrector
r l7nrision of water Quarrty
DIVISION OF WATER QUALITY
Groundwater Section
June 9, 2004
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
70033110000205784692
Ernest G. Cody
180 New Beach Road
Point Harbor, North Carolina 27964
Dear Mr. Cody:
Your permit to use a well for the injection of geothermal heat pump effluent has been up
for renewal. Your renewal application was received May 13, 2004. The Groundwater
Section of the Washington Regional Office has attempted to contact you by phone on
numerous occasions to set up an appointment. Please contact the Washington Regional
Office to arrange for an inspection of the injection system.
If you have any questions please feel free to call at [phone].
Sincerely
f �•{� j-�
Allison Gresham
Hydrogeological Technician
Groundwater Section
cc: WaRO
Evan Kane — CO UIC '-
raw
l45�
Customer Service Division of Water Quality 1 Groundwater Section
1 840 623-7748 943 Washington Square Map Washington, NC 27889
Phone: [phone] Fax [phone] Internet_ httpJlwww.gw.ehnr_state.nr-us

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
May 14, 2004
To: Willie Hardison, Groundwater Supervisor
Groundwater Section
Washington Regional Office
From: Thomas Slusser~
Central Office
Re: Renewal of Permit #WI0700013, Ernest G. Cody; Request for inspection and routine
sampling of Mr. Cody's geothermal injection well in Point Harbor, North Carolina.
1. Please review the application and submit any comments to CO-UIC group. Retain the
application for your UIC file.
2. Please inspect the injection well site to verify that the location and construction plans
submitted in the application are accurate and that the NCAC Title 15A 2C.0200 standards
are being complied with, using the enclosed Injection Facility Inspection Report (Form
B) as appropriate.
3. Collect samples from the influent and effluent sampling ports and submit the results
to the CO-UIC.
You are requested to return the completed Injection Facility Inspection Report (Form BJ to the
CO-UIC by June 7, 2004. Ms. Dorsch has informed me that she is regularly out ofto\\'ll on
business Monday through Friday, so scheduling may be a problem. She also informed me that
she will be home the week of May 31 to June 4, which may be her best time for the inspection.
Please make the best arrangements possible to get the permit reissued in a timely manner.
The UIC group appreciates your assistance with this review. If you have any questions regarding
this review or the UIC program, please contact me at [phone].
cc: CO-UIC Files
Enclosures
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
❑ lqii� `c
May 14, 2004
Ernest G. Cody
180 New Beach Road
Point Harbor, NC 27964
Dear Mr. Cody:
Alan W. Klimek P. E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of rater Qi4ity
Your renewal application for a permit to use a well for the injection of geothermal heat pump
effluent has been received and is under review. A member of the Groundwater Section's
Washington Regional Office staff will be contacting you to arrange an inspection of the injection
well and collect water samples as part of the review.
Ifyou have any questions about permit or injection well rules please contact me at [phone] or
Evan Kane at [phone].
CC: CO-UIC filcs
WaROAHC files
Sincerely,
Thomas Slusser
Hydrogeological Technician H
Underground Injection Control Program
N. C. Division of Water Quality 1 Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27699-1636 Customer smix
Phone: (919)M-3221 Far: [phone] Internet: http://gw.ohnrstate.ne.us 1-877-623-6748

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM
Type 5A7 and 5QM Wells
In accordance with the provisions ofNCAC Title ISA: 02C.0200
complete application and mail to address on the back page.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE:- 20
A. PERMIT APPLICANT
Permit Number: _ W��mm�
Name: �e..f/e es 6'K o
Address: `k Q
City: �►i - �� �Getw
ce C-e+�f 0
�It-4�' P Qy
the bottom of each page of you permit)
Stater Zip code: z
County: Telephone:
PROPERTY OWNER (if different from applicant)
Name:
Address:
City:
State: Zip code:
County: Telephone:
C. STATUS OF APPLICANT
Private: _f,_/f Federal: Commercial:
Native American Lands:
State: Public:
FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Public or Commercial).
Name of Business or Facility:
Address:
City: State: Zip code:
County: Telephone:
Contact Person:
Standard Industrial Code(s) which describe commercial facility:
ver. 10/03 GW/UIC-57 HPR Page 1 of 3

E. INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
/{_/( \ 7
.I
F. WELL USE Is(are) the injection well(s) also used as the supply well(s) for either of the following?
(1) The injection operation? YES_ NO~
(2) Your personal consumption? YES__ NO-f'"="
G. CONSTRUCTION DATA
H.
(1)
(2)
Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection permit. ~
d /
NC. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes. A faucet on both influent (groundwater entering heat pump) and
effluent (water being injected into the well) lines is required. Is there a faucet on:
(a) the influent line? YES_ NO ,~,,.
(b) on the effluent line? YES_ NO_¼.
CURRENT OPERATING DATA
(1) Injection rate: Average (daily) /I:> gallons per minute (gpm)
(2) Injection volume: Average (daily) gallons per day (gpd)
(3) Injection pressure: Average ( daily) /'] pounds per square inch (psi)
(4) Injection temperature: Annual Average {d_ 75 degrees Fahrenheit (°F)
I. INJECTION-RELATED EQUIPMENT
Attach a diagram showing any modifications to injection equipment since the issuance of the previous injection
permit including the engineering layout of the ( 1) injection equipment, and (2) exterior piping/tubing associated
with the injection operation. The manufacturer's brochure, if detailed, should satisfy ( 1 ).
J. LOCATION OF WELL(S) Attach a map
Include a site map (can be drawn) showing: the orientation of and distances between the injection well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
ground-source heat pump well system; include buildings, property lines, surface water bodies, any other potential
sources of groundwater contamination. Label all features clearly and include a north arrow to indicate
orientation.
K. PERMIT LIST: Attach a list of all permits or construction approvals, received or applied for by the applicant
that are related to the site. Examples include:
( 1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
L. OTHER MODIFICATIONS: Indicate any other modifications to the injection well system (equipment, fluid,
operation, etc.) that have occurred since the issuance of the previous injection permit and have not been noted
elsewhere on this application.
ver. 10/03 GW/UIC-57 HPR Page 2 of 3
M. CERTIFTCATION
"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 operate, maintain, repair, and if applicable, abandon the injection well
and all related appurtenances in accordance with the approved specifications and coplitions of the Pernut,"
7-
(Signature of Well Ow r or Authorized Agent)
ff authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
N. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property rights in the
well(s). A well is real property and its construction on land rests ownership in the land owner in the absence of
contrary agreement in writing,)
If die property is owned by someone other than the applicant, the property owner hereby consents to allow the
applicant to operate an injection, well(s) as outlined in this application and that it shall be the responsibility of the
applicant to ensure that the injection well(s) conform to the Well Construction Standards (Title 15A NCAC
Subchapter ZC MOO) _
Z!-,
(Signature of Property Owner if Different From Applicant)
Please return the completed Application package to:

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY, GROUNDWATER SECTION
STATUS OF INJECTION WELL SYSTEM
Permit Ni imhor-
Permitte(
Address:
Please check the selection which most closely describes the current status of your injection well.
In addition, please provide the requested information.
1) �� Well is still used for injection activities.
2) _ Well is not used for injection but is used for water supply or other purposes.
3) Injection discontinued and: a} Well temporarily abandoned
b) Well permanently abandoned
c} Well not abandoned
4) Injection well never constructed
fA
If you checked (2), describe the well use (potable water supply, irrigation, etc), including pumping rate and other
relevant information.
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well, (Include a description of
how the well was sealed and the type of material used to fill the well if permanently abandoned):
Certification- (For well abandonment)
"I hereby certify, under penalty of law, that I am personally responsible for the proper abandonment of any
injection well as required in Title 15A NCAC 2C .0214 Criteria and Standards Applicable to Injection Wells."
Signature
Date
Certification: (For information verification)
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document, and that to the best of my knowledge the information is true, accurate, and complete."
Signature
Date
ver.9103 GWIUIC-fib

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
April 19, 2004
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
Ernest G. Cody
180 New Beach Road
Part Harbor, NC 27964
Ref.: Expired UIC Permit # W10700013
Dear Mr. Cody:
The Underground Injection Control (UIC) Program of the North Carolina Division of Water Quality
is responsible for the regulation of injection well construction and operation activities in the state.
Our records show that a geothermal heat pump system with an associated injection well was
constructed and permitted on your property under the name of Ernest G. Cody. The permit for this
injection well expired on March 31, 2004; therefore, your well may be in violation of North
Carolina General Statute Section 88-870) and other state regulations.
The UIC Program would like to help you resolve this situation by completing one of the following
procedures:
1.} If a geothermal heat pump system is operating on yourproperty and you have an injection
well as part of this system, please complete and sign the enclosed form "APPLICATION
FOR PERMIT RENEWAL To USE A WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM."
2.) If an injection well is not operating on your property, please complete and sign the
enclosed form "STATUS OF INJECTION WELL SYSTEM" indicating that an injection
well is not in operation on your property.
3.) If you are unsure whether you have an injection well, please contact us at the phone
number below so that we can help you make that determination.
N, C. Division of Water Quality 1 Groundwater Section
1636Mail Service Center Raleigh, N.C. 27699-I636 F11170
mer Service
Phone: (919] 733-3221 Fax: [phone] Internet: httpV/gw.ehnr.state.nc.us 7-623-6748

Mr. Ernest Cody
Expired UIC Permit # WI0700013
April 19, 2004
Page 2 of 2.
The UIC Pro gram is sendin g this letter in ex pectation that you res pond regardless of whether or not
you currently have an injection well as part of your heating and cooling system. Please note that if
you do not respond to this letter within 30 days an inspection of your property may be forthcoming
to determine if an injection well is operating on your property.
If you would like assistance completing any of the forms, or if you have any questions regarding the
UIC Program or injection well rules, please contact me at [phone] or Evan Kane at (919)
715-6165.
cc: CO-UIC Files
Enclosures
Best regards,
CJ/~~-
Thomas Slusser
Hydrogeological Technician II
UIC Program
GROUNDWATER SECTION
~ ....
March 23, 1999
MEMORANDUM
To :
From:
Re:
Willie Hardison
Groundwater Section
Washington Regional Office
AmyAxo~
UIC Group
Groundwater Section
Issuance of injection well permits
Permit No. WI0700013 to use a well for the injection geothermal heat pump effluent has been issued
to Mr. Ernest Cody of 30 New Beach Road, Port Harbor, Currituck County, North Carolina. A copy
of this permit is enclosed for your files. The Underground Injection Control Group appreciates your
staffs assistance with injection well inspection and sampling tasks. If you have any questions
regarding this permit or the UIC program, please contact me at [phone].
Enclosures
cc: UIC Files
JAMES 8 . HUNT JR.
GoVERNOR
....
WAYNE MCDEVITT •-'tL:\
SECRl!TARY •1f. '/_.
'""'{,-,.--/ ,· 'if~ ,f ·j
~--37,5
A. PRESTON HowAii;;_1.,:'<'
'·~.!:,~,:~ JR., P.E. ,,,. .t:,. ·"".
',M _DIRECTOR
Mr. Ernest Cody
30 New Beach Road
Point Harbor, NC 27964
Dear Mr. Cody:
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
GROUNDWATER SECTION
March 23, 1999
DIVISION OF WATER QUALITY
In accordance with your application submitted October 2, 1997 and
subsequently submitted information, we are forwarding Permit No. WI0700013
for the operation of a geothermal heat pump injection well at 30 New Beach
Road, Point Harbor, North Carolina, Chatham County.
This permit shall be effective from the date of issuance until March 31, 2004,
and shall be subject to the conditions and limitations stated therein. In order to
continue uninterrupted legal use of this well for the stated purpose, you should
submit an application to renew the permit three months prior to its expiration
date.
If you have any questions regarding your permit please feel free to contact me
_ at(919)715-6165.
W.a--
A melia A. Axon, Program Manager
Underground Injection Control
Enclosures
cc: UIC Files
RRO Files
C:\MyFiles\Documents\permits\ 1999\transmittals\ TRAN5A7 .pie. wpd
GROUNDWATER SECTION
P,O Box 29!578, RALEIGH, NC 27626-0578 -2728 CAPITAL BLVD., RALEIGH, NC, 27604
PHONE [phone] FAX 919-71 S-0S88
AN EQUAL OPPORTUNITY/ AFFIRMATIVE ACTION EMPLOYER -50% RECYCLED/I 0% POST-CONSUMER PAPER
MEMORANDUM
To: Ernest Cody
30 New Beach Road
Point Harbor, NC 27964
From: Amy Axon
March 23, 1999
Underground Injection Control Group
NC -DENR, Division of Water Quality
Groundwater Section
Re: Groundwater Sampling Results from February 10, 1998
Effluent Water Sample
Coliform, total <1/lO0ml
Chloride 14 mg/L
Hardness 44 mg/L
NO2 +NO3 asN 5.5 mg/L
Chromium, Cr <25 ug/L
Copper, Cu 53 ug/L
Iron, Fe 180 µg/L
Magnesium, Mg 4.6mg/L
Manganese, Mn 32 ug/L
Nickel, Ni <10 ug/L
Lead, Pb <10 ug/L
Zinc, Zn 60 ug/L
State Groundwater Quality Standards:
Classifications and Water Quality Standards Applicable To The Groundwaters of North Carolina
(North Carolina Administrative Code Title 15A: 02L.200)
Coliform, total 1/100 ml ~,._
Chloride 250 mg/L
NO2 +NO3 asN 1 mg/L
Chromium, Cr 50 ug/L
Copper, Cu 1000 ug/L
Iron,Fe 300 ug/L
Manganese,Mn 50 ug/L
Nickel, Ni 100 ug/L
Lead, Pb 15 ug/L
Zinc, Zn 2100 ug/L
mg/L = milligrams per liter = parts per million
ug/L = micrograms per liter= parts per billion
1000 ug/L = 1 mg/L
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, N6RTH 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
Ernest G. Cody
FOR THE CONSTRUCTION AND OPERATION OF AN INJECTION WELL for the purpose of
operating a geothermal heat pump system. This well will be is located at 34 New Beach Road, Port
Harbor, North Carolina, in Currituck County, and will be constructed and operated in accordance
with the application dated October 2, 1997, 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.
Tl�s permit is for Construction and Operation only, and does not waive any provisions of the Water
Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an injection well
shall be in compliance with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and
any other Laws, Rules, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until March 31, 2004,
and shall be subject to the specified conditions and limitations set forth in Parts I through X hereof.
Permit issued this the -' "day of March, 1999.
--may
Ted L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Perniit No. W10700013 PAGE 1 OF 6
_�i

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 conditi~s 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 injection well shall have permanently affixed an identification plate.
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection
well, to the Division of Water Quality (Division), within 30 days of completion of well
construction.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight ( 48) hours prior to constructing each injection well, the Permittee shall
notify the Groundwater Section -Underground Injection Control (UIC), Central Office staff,
telephone number [phone] .
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.
Permit No . WI0700013 PAGE2 OF 6
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to change
ownership, or there is a name change of the Permittee, a formal permit amendment request
must be submitted to the Director, including any supporting materials as may be appropriate,
at least 30 days prior to the date of the change.
~
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying
with any and all statutes, rules , regulations, or ordinances which may be imposed by other
local, state, and federal agencies which have jurisdiction. Furthermore, the issuance of this
permit does not imply that all regulatory requirements have been met.
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, 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 Permittee 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.
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 Groundwater 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.
Permit No. WI0700013 PAGE 3 OF 6
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 aty reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained under
the terms and conditions of this permit, and may obtain samples of groundwater, surface water,
or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided for
in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with
the injection facility activities.
PART 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 Washington Regional Office, telephone number [phone], any
of the following:
(A) Any occurrence at the injection facility, which results m 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 Permittee shall promptly submit the relevant and correct facts or information
to the Director.
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.
Permit No. WI0700013 PAGE4 OF 6
PART VIII -PERMIT RENEW AL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
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, that well must be permanently abandoned
according to 15A NCAC 2C .0213(h)(l), Well Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose,
the Permittee shall abandon that injection well in accordance with the procedures specified in
15A NCAC 2C .0214, including but not limited to the following:
{A) All casing and materials may be removed prior to initiation of abandonment
procedures if the Director finds such removal will not be responsible for, or
contribute to, the contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(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.
Permit No. WI0700013 PAGE 5 OF 6
(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 ~rt IX (1) and (2) (G) shall be submitted to:
Groundwater Section -UIC Staff
DENR-Division of Water Quality
P.O. Box 29578
Raleigh, NC 27626-0578
PART X-OPERATION AND USE SPECIAL CONDITIONS
NONE
Permit No. WI0700013 PAGE 60F 6
.r
99 FF0 23
COUNTY
CARRITDCK
QUAD 140-.
REPORTTO -
►!'ARO
COLLECTOR(S)
SAItOOP
DATE:
VIN98
TIME:
PURPOSE:
LABORATORY ANALYSIS
COWLIENTS:
Regional Office
DIVISION OF WATER QUALITY
Cheasistry Lnboralory Iteporl I Ground Nnler Ounlity
SAMPLE PRIORITY
El ROUTINE EMERGENCY
❑ CHAIN OF CUSTODY
EFF.
W❑ SA61PI_F.TYPE
Owmcr ERNEST CODV
L.mcmian or Site:
De5criplion of smrprmg paint
Sampling Nlethod:
Rtmarks:
Di%,. Solids 70300 mWL
Fluoride 951 mg]L
x
Ilardness: total 900 44 mWL
I rmdness: (aorr cart) 902 mglL
Pbmis 32730 uWL
Specific Caul. 95 umhoshm2
Sulfate mWL
Sulfide 145 mgR.
N19AS malL
Oil and Rrem 911g
Silica MWIL
Doran
Formaldehyde mvL
NH3 as N 610 0.09 mjlL
TKN as N 625 mWL
%
NO2 +NO3 as n 630 5.5 mWL
P7 Tutal as P 665 Ing1I.
Poi mgIL
Lab Number 8C6354
Daie Received
2 laM
Tim firceived ;
2:50AM
Received By
DS
ILelomd III Its
Pmc relxntcd 343II9g
Organoehlwine Pesticides
Oigmwphosphorus Pesticides
Nitrogen Pesikidcs
Arid Herbicides
Semlvolatiles
TPH•Diesel Range
Volatile Organics (VOA botRe)
TPH•Oasoliae Range
T?II-BTEX Gmaline Range
11'ASillNGTsN�p rjc�
APR D 2 1998
D. F M.
4G;W.A.FEO

- 1-
GF7bUNDWATER FIELD/LAB FORM
NorIIt CaroIIita
Department of EI►vlroriment, Health, and Natural Resources
DIVISION OF WATER QUALITY - GROUNDWATER SECTION
SAMPLE TYPE SAMPLE PRIORITY
Quad No H ?' r? Serial No. Water Routine
Lai. ` r3'� Long. S 'f�,� Soil Emergency w
❑ oilier
Lab Number
Date Received
Rec'd by:_z
Other:
_Time
Bus, Courier Qand el.,
Report To: A110, 1-110, MRO, RRO aT , wino, 11 AP11dy Data Entry By: CEO:
WSRO, Kinston FO, Fed. Trust, Central 011., Oilier: ' - Date Reported:
Shipped by: Him. Courier, and ., Diller- __
l7 Date _!0g � � 1'ui pass:
Colleclor(sj�, L.�- - e,, q l ime ,,:. �_ E31501ille. Congllair 11L}QLUSi', Pesticide Stdrsly, Federal Tnlst, Ott Pei:
Ln ANAUSE3 Owner ! 1..-�z G,,_i d,
pHro _ Spec. Cond,94 at 250 C Location or site �
Temp.l� ��? oC Odor rug+ u Description of sampling point
Appearance_._._-!- 4A_ Sampling Methods �G`;L.t>�_- _ Simple Interval
Field Analysis By: _ S r �-fi t. .�. Rental ks rrw„q� �,, ��. ale-)
LABORATORY ANALYSES
i30D, 310
n1g11
CUD I liglr 340
rng/l
COD Low 335
ingll
Coliilorllr: MF Fecal 31615
11001711
Coliiorm: Mr loial 31504
11001111
TOC 680
mr n
Turbidity 76
NTU
nesidue., Suspended 530
nlgll
' 1403
U1145
Alkalinlly Io pl 1 4.5 410
nlg/l
Alkalinity to pl 1 8.3 415
1ng11
Carbonale 4,15
rng11
Bicarbonale 440
mrlll
Calborl dioxide_ •105
n1g11
C111011de 940
nigh
Chromium: Hex 1032
ugll
Color: True 80
CU
Cyanide 720
111911
Lau Coninteols,
Setnivolatile Organics
TPH - Diesel Range
Volatile Organics (VOA bottle)
TPH - Gasollne Han e
TPH - BTEX Gasoilre Range
OW-51 nEV. 7190 For Dissolved Analysis - sulm tilt littered sample and wlito VIS" In block.

North carolina Department of Environment, Health, and Natural Resources
❑ivision of Environmental Management - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WI
- J 0c:� U e DATE
HAKE OF OWNER�r-
ADDRESS OF OWNER � 0
(Streetl road or lot and suddi0sion, county, tarn)
LOCATION OF INJECTION WELL (and source well(s), if applicable)
(Street/ road or lot and suddiyision , county, tarn, if different than owner's address, plus description of location on site)
Potential pollution source 1;xy-nc -rK,j Distance from well
Potential pollution source
Potential pollution source
Distance from well
Distance from well
Minimum distance of well from property boundary -' C)
Quality of drainage at site
4111-0u�--
(good, adequate, poor)
Flooding potential of site
(hfgh,moderate,7ow)
DRAW SKETCH OF SITE (Show property boundaries, buildings, we77s. potential pollution sources, roads, approximate
scale, and north arrow.) @ — Nc- +s &'
0 Wt 41
W%
tp w1'4t
n►z-rJ 3r-$cftlz.�
DESCRIBE INJECTION SYSTEM (vartica l closed loop, encased borehole or cased water well; separate source well and
injection well; combination source and injection well; or other description as applicable)

INJECTION FACILITY INSPECTION REPORT -FORM B (CONTINUED)
WELL CONSTRUCTION
Date constructed Ar, j f qy 2
� F
Drilling contractor: Name ' '�: � � ; c . �� �i
Address � � , _-- --� j -: r
Registration number
Total depth of well '" `' Total depth of source well
(if app7icah7e)
Inspection point
Casing
Depth
Diameter
Height (A.L.S.)
Grout
Depth
Screens
Depth(s)
Length(s)
I.D. Plate
Static water level
Well yield
Enclosure
Enclosure floor
(concreted)
Sampling port
(labelled)
Water tight pipe entry
Well enclosure entry
Vent
Measurement
2 -2
A r :i "I -
Meets minimum standards Comments
Yes No
Functioning ❑f heat pump system (Oetem M from tre owner if heat pump fu»ctio,-s properly.)
INSPECTOR Office
WITNESS Address
WITNESS
Address
JULY, 1994

i
� q 7 '7 l O ` 3f5-3777
7-96
Od
17
Aa

GROUNDWATER SECTION
October 3, 1997
MEMORANDUM
To: Scott Wood
Groundwater Section
Washington Regional Office
From: Marcus Geist
UIC Group
Groundwater Section
Raleigh Central Office
Re: Request for routine sampling/inspection of facility with
Injection well Permit No. WI0700013 issued to Mr. Ernest G. Cody.
1. Please review the application and submit any comments to RCO-UIC . Retain the
application for your UIC file.
2. Please inspect.the injection well facility to visually determine the integrity of wellhead
construction, the presence and accessibility of eftluent and influent taps, and other requirements
for compliance with the NCAC T15A:02C.0200 standards, using the enclosed Injection Facility
Inspection Report (form B) as a guide.
3. Please sample the influent and eftluent using the Sampling/Inspection Procedure for
Injection Wells as a guide. Complete the enclosed Groundwater Field/Lab Report (form GW-54).
Please return any application review comments and sample and inspect the injection well
facility by October 24, 1997 (within 3 weeks). (If sampling and inspection cannot be
accomplished by this date, please inform RCO-UIC .) Send a copy of the completed Injection
Facility Inspection Report (form B) to RCO-UIC and request the DWQ lab to send a copy of the
Groundwater Field/ Lab Report (form GW-54) to RCO-UIC.
Note: Although Mr. Cody has indicated that his heat pump system is closed-loop, review of his
previous permit applications indicates that he does have an open-loop system which uses separate
supply and injection wells . While inspecting the injection well, please inform Mr. Cody
immediately of any construction violations such as wellhead completion below land surface.
cc: UIC Files
WAR.OFiles
Enclosures
C:\ WPDOCS\PERMIT\ASKRWSAM .WPD
NORTH CAROLINA
ENVIRG1,,4E.WTAL MANAGEMENT COMM-I S S TL .
DEPARTMENT OF ENVIRONMENT, h7—XLTH, ' AND NATURAL RESOURCES
GROUNDWATER SECTION
STATUS OF INJECTION WELL SYSTEM
Date: Permit Number: WI C�
Name:
Address:
Please check the selection which most closely describes the current status
of your injection well. in addition_, please provide the requested
information..
Well is still used for injection activities.
2} Injection discontinued;
a} Well temporarily abandoned bj well permanently abandoned
Describe the method used to properly abandon the injection well. Include a
-description of how the well was sealed and the type of material used to
ill the well if permanently abandoned:
Certification: (For well abandonment)
"I hereby certify, under penalty of law, that I am personally:,
responsible for the proper abandonm.E t of any injection well as requires in
Title 15A NCAC 2C .0214 Criteria and Standards Applicable to Injection
Wells. 11
(Signature)
Certi f icaticn: (For information verification)
"I hereby certify, under penalty of law, that I have personally
examined and am familiar with the information submitted in this document,
and that to the hest of my knowledge the information is true, accurate, and
complete.
(Signature)
GW - 6 8

�/-ro-7 0001-3
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
APPLICATION FOR PERNIIT RENEWAL TD USE A WELL(S) FOR
INJECTION WITH A HEAT PUMP SYSTEM
In accordance with the provisions of NCAC Title 15A: 02C.0200
complete application and mail to address on the hack page.
Type 5A7i5QM Wells
TQ DIRECTOR, NORTH CAROLINA DIVMSION OF WATER QUAI=
DATE: � r , 19-0-17
Please type or print clearly.
A. SYSTEM CLASSIFICATION Does the system re -circulate only potable water without
any additives such as corrosion inhibitors or antifreezes in continuous piping which
isolates the fluid from the environment?
YES �If
yes, do not complete this form. A form OW-57 CL, (Notification
Of Intent To Construct A Closed -Loop Geothermal -Water -Only
Injection Well System), should be completed.
Q
NO _ If no, then continue completing this form.
PERNIlT APPLICANT
Name:
Address:
City:
County:
Zip code_
Telephone:
C. PROPERTY OWNER (if different from applicant)
Name:
Address:
City: Zip code. -
County; Telephone:
D. STA-'US OF APPLICANT
Private: Federal: Commercial:
State: Public: Native American Lands:
GW-57 HPR (April 1997) Page 1 of 4

0. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other
property rights in the well(s). A well is real property and its construction on land
rests ownership in the land owner in the absence of contrary agreement in
writing.)
If the property is owned by someone other than the applicant, the property owner
hereby consents to allow the applicant to operate an injection well(s) as outlined
in this application and that it shall be the responsibility of the applicant to
ensure that the injection well(s) confonn to the Well Construction Standards
(Title 15A NCAC Subchapter 2C .0200)
GW-57 HPR (April 1997)
f .VU,~ (',"~
(Signature of Property O~er if Different From Ap pi?cant)
Please return the completed Application package to:
Underground Injection Control Program
Groundwater Section
North Carolina DEHNR-DWQ
. PO. Box 29578
Raleigh, NC 27626-0578
( telephone: [phone])
Page 4of 4
Q

State of North Carolina 1
Department of Environment,
Health and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Wayne McDevitt, Secretary
A. Preston Howard, Jr., P.E., Director
GROUNDWATER SECTION
September 22, 1997
Mr. Ernest G. Cody
30 New Beach Road
Point Harbor, NC
Dear Mr. Cody :
On May 14, 1997, this office notified you in writing that the operating permit for the heat pump
injection well on your property expired on May 11, 1997, and requested that you submit either the
enclosed Application for Permit Renewal to Use a Well for Injection With a Heat Pump System
(form GW-57 HPR) or the enclosed Status of Injection Well System (form GW-68) certifying that
the injection facility was no longer in use. You were advised that if the well were no longer used
for any purpose, the well was to be abandoned according to the regulatory requirements (15A
NCAC 2C .0213) and the enclosed Well Abandonment Record (form GW-30) was to be
submitted. However, our office has not received any of these forms from you.
Please note that if you use the injection facility without a permit, you are it1 violation of the
regulatory requirements for permitted injection facilities (15 NCAC 2C .0211). Operating an
injection facility without a permit is illegal. I again enclose forms and a copy of the current
Injection Well Standards to facilitate your application for permit renewal; the completed form(s)
must be submitted to this office by October 6, 1997 . If you have any questions regarding your
permit please contact me at [phone] or Amy Axon at [phone].
Sincerely,
~,(/,,,:,<_~\
Marcus Geist
Underground Injection Control Program
cc : UIC Files
WAR.OFiles
Enclosures
Groundwater Section
P.O. Box 29578, Raleigh, North Carolina 27626-0578
2728 Capital Blvd., Raleigh, North Carolina 27604
C:\WPDOCS\NOV\RENWCODY.WPD
Voice 919/733-3221 FAX [phone]
An Equal Opportunity/Affirmative Action Employer
50% recycled/ 10% post-consumer paper
GROUNDWATER SECTION
September 15, 1997
I !R1761741MUM
To: Scott Wood
Groundwater Section
Washington Regional Office
From: Marcus Geist (919) 715-6IG6 ��L;7
Li1C Group
Groundwater Section
Raleigh Central Office
Re: Injection Well Construction Standards Violations.
As per our telephone conversation today, I am sending draft copies of the NOVs to be sent to
Cody Well Drilling and Cyclone Well Drilling. Additionally, I have included copies of the letters
which I will send to the well owners, notifying them that they will need to have their injection
wells modified before a pen -nit renewal can be issued. Please review this material. I will
telephone you later today to discuss the matter.
By calling both well owners, Mr. Vick and Mr. Preston, you could inform them that they will be
receiving a copy of the NOV and they will need to comply with current injection well rules to
receive a permit renewal. I appreciate your help in resolving these problems.
Enclosures

r
R042516A. STS bd 4,1
PFSTAT Ver 3.3
Copyright tcj Trimble Navigation, Ltd, 1991, 1994. All rights reserved
"47525R:COR
Statistics Version 3
.3
Recs
Mean Std Lev Minimum
Maximum
Latitude 184 36o05'42.75333"N 3.41092 36o05'42.34980"N
36o05'43.07291
" N
Longitude 184 75o48108.3060911W 4.56389 75o48'08.79594"W
75o48107.74521
"W
Altitude 184
-28.42139 4.62230-47.48580
-13.007
23
No velocity records in
file.
N❑ DOP records in file.
Start CPS Week #798 on
04/25/95 at 16:25:31
End CPS Week #798 on
04/25/95 at 16:34:05
Datum
: WGS-84
Coordinate System
: Latitude/Longitude
Altitude Mode
: Height Above Ellipsoid
Altitude/Distance Units
: Meters
Velocity Units
: Meters/Second
LL30
Page 1

State of North Carolina
Department of Environment, Health and Natural Resources
Northeastern Region
1424 Carolina Avenue, Washington, North Carolina 27889-1424
James G. Martin, Governor
William W Cobey, Jr., Secretary Lorraine G. Shinn
Regional Manager
DIVISION OF ENVIRONMENTAL MANAGEMENT
Groundwater Section
Mr. Ernest G. Cody
30 New Beach Road
Point Harbor, NC 27964
Dear Mr. Cody:
May 11, 1992
~©~_Xii)
MAV1 18111
GROUNDWATER SECTION
RALEIGH, NC
In accordance with your application dated February 25, 1992, we are
forwarding Permit No. 26-0001-W0-0001 for the Operation and Use of a well,
for the purpose of injecting heat pump effluent, in Currituck County.
This permit shall be effective from the date of issuance until
May 11, 1997 and shall be subject to the conditions and limitations stated
therein.
In order to continue uninterrupted legal use of this well for the
stated purpose, you should make application for permit renewal at least 30
days prior to its expiration date.
Attachment
cc: /uic Files
WaRO Files
Sincerely,
lj,fJ-tl,l
Jim Mulligan
Washington Regional Supervisor
P.O. Box 2188, Washington, North Carolina 27889-2188 Telephone [phone] FAX: [phone]
An Equal Opportunity Affirmative Action Employer
NORTH CAROLI)U
ENMON WI!AL MANAGEMENT COM ISSION
DEPARTHIENT OF ENVIRONMENT, HEALTH AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATIONNSE OF A WELL OR WELL SYSTEM 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
Ernest. G. Cady
FOR THE OPERATION AND USE OF AN INJECTION WELL/WELL SYSTEM located at 30
view Beach Road, Point Harbor, North Carolina, Currituck County, in
accordance with the application dated February 25, 1992, and in conformity
with the specifications and supporting data submitted, all of which are
fled with the Department of Environment, Health, and Natural Resources and
are considered a part of this Permit.
This Permit is for Operation and Use only, and does not waive any
provisions of the Water Use Act or any other applicable Laws, Rules or
Regulations. Operation and use of a well or well system shall be in
-compliance with Title 15 Forth Carolina Administrative Code 2C, and any
other Laws, Rules and Regulations pertaining to well construction and use.
This Permit small be effective, unless revoked, from the date of its
issuance until May 11, 1997 and shall be subject to the specified
conditions and limitations set forth in Parts I and II hereof.
Permit issued this the 11th day of May, 1992.
'0a L)
Jim Mulligan
Washington Regional Supervisor
By Authority of the Environmental Management Commission.
PERMIT NO. 25-0001-WO-0001

PERMIT NO. 26-0001-W0-0001
PART I
A. GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this
Permit and with the standards and criteria specified in
15A NCAC 2C .0200. Any Permit noncompliance constitutes a
violation of the appropriate Act and is grounds for
enforcement action; for Permit termination, revocation and
reissuance or modification; or for denial of a Permit
renewal application.
2. It shall not be a defense for a Permittee in an
enforcement action that it would have been necessary to
halt or reduce the permitted activity in order to maintain
compliance with the conditions of this Permit.
3. The Permittee shall take all reasonable steps to minimize
or correet any adverse impact on the environment resulting
from noncompliance with this Permit.
4. The Permittee shall give advance notice to the Director of
any planned changes in the permitted facility or activity
which may result in noncompliance with the Permit.
5. The Permittee shall report all instances of noncompliance,
not reported under condition 1. of this Part, at the time
monitoring reports are submitted.
6. Where the Permittee becomes aware of a failure to submit
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 by the
Permit tee.
7. The Permittee shall give notice to the Director as soon as
possible of any planned physical alterations or additions
to the permitted facility.
8. In the event that the permitted facilities fail to perform
satisfactorily, the Permittee shall take such immediate
action as may be required by the Director.
9. The injection system shall be effectively maintained and
operated at all times so that there is no contamination of
groundwaters, or other actions or occurrences which .
renders them unsatisfactory for normal use. In the event
the facilities fail to perform satisfactorily, including
the c·reation of nuisance conditions, the Permi ttee shall
take such immediate corrective action as may be required
by the Director.
I
PERMIT N'-'. ·26-0001-W0-0001
PART I (continued)
10. Department representatives shall have reasonable access
for purposes of inspection, observation and sampling
associated with injection and related facility.
11. This Permit is not transferable without prior notice to,
and approval by, the Director.
12. An application for modification, renewal or transfer of
this Permit shall be filed with the Department at least 30
days prior to the expiration date of this Permit.
13. Provisions shall be made for collecting samples of
facility effluent, both prior to its entrance to treatment
devices and subsequent to leaving the treatment devices
but before entering the injection well.
PART II
A. SPECIFIC CONDITIONS
1. The fluid used in the heat pump system shall be comprised
of clean water or a mixture of clean water and prophylene
glycol. The use of ethylene glycol, alcohols or other
chemicals not specifically approved by the Director,
Division of Environmental Management, are expressly
prohibited.
2. The Permittee shall install, in a readily accessible
location, a faucet or other device suitable for collecting
a sample on the effluent (water into well) line of the
injection system.
North Carolina
GROUNDWATER FIELD/LAB FORMDepartment of Environment, Health, and Heturai Resources
DIVISION OF ENVIRONMENTAL MANAGEMENT - GROUNDWATER SECTION
County-V��' ►�' �- _ Lab Number 8
Quad No N ' S `� Serial No. SAMPLE PRIORITY Dale Received CIA Time
Lat Long. RO UT I NE EMERGENCY 1 Reed by: From: Bus ourie
Report To; ARO, FRO, MRO, RRO, WaR , WiRO, S Date Entry By; `h Ck. f
WSRO, Kinston FO, Other Date Reported: SII i #1
Shipped by: Bus, ourie Other
Collector[sY?-E�� CAo.sk- Date Time i 3 - LA 5 Purpose: Baseline, Complainta Compliance, UST, Other
FIELD ANALYSES Owner _ E c-n_ts'�_ God �-) . . _
pH 4v Spec. �Can,,T.94 o C Location or site -3 0 %@W Q C c1 YO,n' - H t YJat' AI '�Temp., p °C Description of sampling point1uAppearance aste Sampling Method �a Sample Interval
Field An-aJ yV 8ii y: Remarks .�7S,�r-, ca r ���c�a�, r' 81�1 r; , n_.__ 5 r, _fir•
L-A13ORATORY ANALYSES I `pu `ft Sune.as lamp. ow.)
BOD5 310 m A
Diss, Solids 70300 m !1
A - Silver 1077 u A
COD High 340 mgll
Flouride 951 m A
Al - Aluminum 1105 u 11
COD Low 335 m A
Hardness: 7atal 900 m A
Ba - Barium 1007 u A
Coliform: MF Fecal 3161 tt 1100ml
Hardness non -cart 902 ' m A
Ca - Calcium 916 m A
Coliform: MF Total 31504 1100m1
Phenols 32730 uq_
Cd - Cadmium 1027 ugll_
TOC 680 mgA
5 ecific Cond. 95 uMhoslcm2
Chromium: Total 1034 C"dS u 11
Turbidity 76 NTU
Sulfate 945 mclA
Cu - Copped D42 i ugn
Sulfide 745 m A
Fe - Iran 1045 220 u9A
H - Mercury 71900 u A
T
pH 4035,Le units
K- Potassium 937 Mg/1
Alkalinity to pH 4.5 410 it mgA
M - Magnesium 927 m A
Alkalinity to pH 8.3 415 41 mgA
Mn - Manganese 1055 u AA
Carbonate 445 < mgA
Na - Sodium 929 rrl A
Bicarbonate 440 mgA
NH3 as N 610 6.07 m 11
Ni - Nickel 1067 E 10 uqA
Arsenic: Total 1002 c u A
TKN as N 625 m /1
Pb - Led 1051 UgLI
Carbon dioxide 405 m JI
NO 2 + NO3 as N 630 4. m II
Se - Selenium 1147 u gA
Chloride 940 mgA
P: Total as P 665 Q, 61 m II
zn - Zinc 1092 c IO YsA—
Chromium: Hex 1032 u A
Color: True 80 Pt -Co
Cyanide 720 mgA
Lab Comments:
Pesticides
Herbicides
Base/Neutral Extractable
Acid Extractable Oraanic
1.2 -
GW-54 REV. 3192 For Dissolved Analysis - submit filtered sample and write 'DIS" In block
While Copy - Groundwater Central Office Yellow Copy - Regie- -1 Office Pink Copy - Central Files Goldenrod Copy - lab

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF NATURAL . RESOURCES AND COMMUNITY DEVELOPMENT
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR
INJECTION �� ►" ; - -� „-, ' -
CLASS 5 WELLS !'-I
TO: DIRECTOR, NORTH CAROLINA DIVISION OF ENVIRONMENTAL MANAGBMENT�+RR 20 19
DATE: ,1} p�l10,
�
In accordance with the provisions of Article 7, Chapter, 87; Article 21, Chapter 143, and regulation--4
pursuant thereto, APPLICATION is hereby made for a PERMIT to construct and/or use a well or well system as
described below and in any accompanying data submitted as a part of this APPLICATION.
A. OWNER DATA: Name:
Address -,a
City: /Qrtr •� 111 h o i+ _ Zipcode: ;2 7 5'' a; `7'
County: �_ r rn . � Telephone: Y P'/ _ g! �4 4-1—
Ownership: Federal
Public
Other (Specify)
state Privateer
Commercial
B. FACILITY DATA (Fill out ONLY if the injection well(s) is (are) for the purpose of serving a business or
industry): _r �—
Busine,WCorporate Name:
Address:
County:
Zipcode:
Telephone:
C. HEATING CONTRACTOR DATA (For heat pump systems only. Please give information for the contractor
that installed or will install your system):
Name: _1 _ �'� t:Wf'll5 ; areI S Pf �.
Address: �r_ 'l�' II 6.el v
City: _ Zipcode: Q3 2j.P Telephone: L'
D. INJECTION PRCKrDUAE: B iefly de� �haw the injection wells will be used-
E. WELL USE: Will the injection weil(s) also be used as the supply well(s) for either of the following?:
(a) The injection operation? YES NO _,n--
(b) Your personal consumption? YES NO
F. _ CONSTRUCTION DATA: (check one)
1
EXISTING WELL being proposed for use as an injection well. Attach a copy of Form GW-1 (Weil
T_ Construction Record) and famish (7 & 8) below. If Form GW-1 is not available, furnish the data in (1)
through (8) below to the best of your knowledge.
GW-57B amy,1989. Replaces OW-57A.. and OW-SM (2I84)

PROPOSED WELL to be constructed for use as an injection well. Furnish the data in (1) through (8)
below as PROPOSED construction specifications.
NOTE:
(1)
(2)
(3)
(4)
THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING
OR PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
WellDrillingContractor'sName: {!<!Jell/ u./4_// a:t .~ ~
Date (to be) Constructed ________ _,· Approximate Depth 1 ~ ft.
Well Casing:
(a) Type: Galvanized Steel __ Black Steel__ Plastic / Other (Specify) ___ _
(b) Inside Diameter:~ inches; Wall thickness (inches) __ or schedule# t.ft:J
(c) Casing Depth: From O to 20 ft. (referenced to land surface)
Cement Grout:
(a) Around inner or "primary" casing: From __Q_ to _'2..0 ft
(b) Around outer (pit) casing, if present: From __ to __ ft.
(5) Screen(s): (if applicable)
(a) Type: / f/V ; Inner Diameter: --~ ____ inches
(b) Depth: From 2 e, to 1 CJ feet below land surface
(6) Gravel: (if applicable) From: -;2.0 to '3 0 feet below land surface
(7) N.C. State Regulations (15, 2, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes. A faucet on both the influent (water from well) .. and effluent (water
into well) lines is required/Is there a faucet on (a) the influent line YES_/ __ NO __ , or (b)
the effluent line YES_,_,.. __ NO __ ?
(8) Attach a diagram showing the details of construction of the existing and/or proposed well(s).
G. PROPOSED OPERATING DATA: (The manufacturer's brochure should include this information.)
(a) Injection Rate: Average (Daily) / $-gallons per minute (gpm)
(b) Injection Volume:
(c) Injection Pressure:
Average (Daily) ___ gallons per day (gpd)
Average (Daily) -2 2-pounds/square inch (psi)
(d) Injection Temperature: Winter Average (Daily) ___ degrees F
Summer Average (Daily) ___ degrees F
H. INJECTED FLUID DATA:
(1)
(2)
Fluid Source (From what depth and what type of rock/sediment unit does the fluid to be injected
derive, i.e. granite, limestone, sand, etc.) /J
Depth: 30 Rock/sediment unit: -~2,c________,,o=-----c./f.../ __ U---'=------------
Chemical Analysis of Source Water: The following chemical characteristics MUST accompany
this application;
pH 4:7 ; Total Hardness __ ppm (parts per million or mg/1); Iron ppm; c> • 3
Chloride ~-.i:> ppm; Nitrate ___ ppm; Coliform bacteria ____ counts/100 ml
GW-57B May, 1989, Replaces GW-57A, and GW-57B (2/84)
NOTE: Assistance in obtaining these values may be facilitated by contacting (a) your local or county health
official, (b) a commercial water-testing laboratory, (c) yom well drilling contractor, or (d) the Regional
Hydrogeologist, North Carolina Dept. of Natural Resources & Community Development
NOTE: If injection system is not for a heat pump, then a detailed analysis of both the source water and the
injection fluid may be required.
I. INJECTION-RELATED EQUIPMENT:
Attach a diagram showing the engineering layout of the (1) injection equipment, and (2) exterior
piping/tubing associated with the injection operation.
NOTE: The manufacturer's brochure, if detailed, should satisfy (1) above if the system is a heat pump.
J . LOCATIONOFWELL(S):
Attach a detailed map showing the orientation of and distances between the proposed well(s), any existing
well(s) that will in any way be involved in the injection opera-tion, and at least two (2) nearby reference
points such as roads, wad intersections, streams, etc. The roads should be identified by U.S., N.C. or SR
(county secondary road) numbers, and streams should be named. In addition, the diagram should show the
direction and approximate distance to any existing water-supply and/or injection wells within 1,000 feet of
the proposed injection well.
K. CERTIFICATION:
"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 operate and use the injection well and all related
appmrenancesin accordance with the approved specificati~~
(Signature of Owner or uthorized Agent)
FOR OFFICE USE ONLY:
1. Initial Application: Complete__ Incomplete __
If INCOMPLETE, Date of Notification _____ and Resubmittal ____ _
2. Standard Industrial Code(s) which best reflect the principal products or services provided by this
facility -if applicable.
(a) ___ (b) ___ (c) ____ (d) ___ _
3. APPLICATION NO. ______ _
GW-578 May, 1989, Replaces GW-57A, and GW-578 (2/84)
DIVISION OF ENVIRONMENTAL MANAGEMENT
GROUNDWATER SECTION
April 30, 1992
MEMORANDUM
TO:
FROM:
Mark Purser
Henry Kwiecinski
SUBJECT: UIC Permit Program Issuance -Ernest G. Cody
The central office has completed its review of the UIC
permit application for the injection facility to be operated
by Ernest G. Cody of Currituck County. Attached you will
find a copy of this application along with the draft permit
and transmittal letter for this facility.
Please make arrangements to sample the heat pump
effluent at this facility at your earliest convenience.
Subsequent to your review and approval of this application,
please complete the permit and transmittal letter and
forward them to the applicant. This will require that you
obtain the Regional Supervisor's signature, date the
transmittal letter and fill in the expiration date of the
permit. Please remember to make copies of the completed
documents and send them to me.
If you have and questions concerning the permit
process, please give me a call.
Attachments
F
State of North Carolina
Department of Environment, Health, and Natural Resources
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27604
James C. Martin, Governor
William W. Cobey, Jr, Secretary April 20, 1992
George T Everett, Ph.D.
Director
Regional Offices
Asheville
704/251-6208
Fayetteville
919/486-1541
Mooresville
704/663-1699
Raleigh
9191733-2314
Washington
919/946-6481
Wilmington
919/395-3900
Winston-Salem
Mr. Richard K. Rowe
Public Water Supply Section
Division of Environmental Health
P.O. Box 29536
Raleigh, NC 27626-0536
Dear Mr. Rowe:
This office has received the applications for Permit to
Construct and/or Use a well or well system for injection, as
listed below. In accordance with Article 7, Chapter
87-88(j), General Statutes of North Carolina, we submit the
following application(s), in addition to a draft copy of
each proposed Permit, to DHR for review and recommendation:
9191896?007 APPLICANT
Oper.
Permit
Renewal
Permit Injection Source
Heat Pump Cody, Ernest X
Please note that the application complies with the
specified requirements as prescribed by 15 NCAC 2C .0200.
If we have not received any comments or recommendations
within ten ( 1 0) working days of the above date, we will
assume that DHR has no objection to the project as proposed.
Please do not hesitate to contact me at 733-3221 if you have
any questions.
Enclosures
Sincerely yours,
Henry M. Kwiecinski
Permits and Compliance Unit
Groundwater Section
(
~
~~it.t~ ~.,Jll}Jj
~:::.:.--···
State of North Carolina
Department of Environment, Health, and Natural Resources
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27604
James C. Martin, Coverno r
William W. Cobey, Jr., Secretary
George T Everett, Ph.D.
Din:c tor
Rc ~'i orial Olliu:,
A,hev illc
70-1/2 ; 1-6 208
Fayetteville
9l9'486 -15-11
l\·loo resville
7().1166 3-1699
Ral ei iih
919733 -231-1
\'i--:i..hin~rtc,n
<lt<l </4(,./,481
\X'ilminj.'ton
Yl'l'3 '1 5-39<Xl
\X 'in-.ton-S.1ltm
'11'1 xw,:;1x,,
Mr. Greg Cody &
Mrs. Donna Cody
Cody Well Drilling·
30 New Beach Road
January 21, 1992
Point Harbor, NC 27964
Dear Mr. & Mrs. Cody:
This is in response to our conversation early last
week, which was prompted by your submittal of a tear-out
card from the Groundwater Section's "Injection Wells"
pamphlet. During our conversation, you indicated that Cody
Well Drilling had completed a number of wells that were to
be used for the disposal of water from heat pumps. Although
I realize it is a hassle, this is a formal request that you
go through your files and forward to me a list (names and
addresses) of your clients that may be using their wells to
dispose of heat pump discharge water. Please keep in mind
that your clients will not be penalized in any way. We will
merely initiate the permit process as described in your
"Injection Wells" pamphlet. As the pamphlet explains, there
is no fee associated with the permit process and your
affected clients will also get their injected water sampled
every five years at no cost.
Enclosed please find a copy of the injection well
regulations and several applications for permit to construct
and/or use a well for injection. As you have indicated that
you own a well that is used for the disposal of heat pump
effluent, please complete one of the enclosed applications
and return it to my attention at the address indicated
above. Upon receipt of your complete and approvable
application, a representative of our Washington Regional
Office will make arrangements to sample your injected fluid.
As for your request that a representative of the
Division of Environmental Management (DEM) speak at a
meeting of the Outer Banks Homebuilders Association, we
think it is an excellent idea. However, it is not
particularly practical for one .of us in Raleigh to give a
brief presentation on the Outer Banks. Accordingly, we have
passed your request along to Mr. Willie ·Hardison,
Groundwater Section Regional Supervisor of DEM's office in
Washington,-NC. Please contact Mr. Hardison at (919)
946-6481 to discuss the possibility of having one of his
staff attend your meeting.
Please do not hesitate to contact me at [phone]
if you have any questions or require further assistance. I
look forward to ~eceiving .your permit application and your
li~t of clients with injection wells. We greatly appreciate
your continued cooperation in protecting our underground
drinking water supplies.
cc: Bob Cheek
Willie Hardison
RT/Cody
Sincerely,
/·.-=--, ~),.)~
Robert J . Turner, Manager
Underground Injection Control Program
Groundwater Section
.TES. STATE OF NORTH CAROLINA POINT HARBOR QUADRANGLE�-
IE INTERTOR • DEPARTMENT OF NATURAL RESOURCES
NORTH CAROLINA
t]RVEY
AND COMMUNITY DEVELOPMENT 7.5 MINUTE SERIES ORTHOPHOTOMAP (TOPOGRAPHIC)
RALEIGH, NORTH CAROLINA SEI4 POWELLS POINT 15' QUADRANGLE
—_ 123 424 P7
W:tts P07Yr 4T +[7A 426 r5856 W NE
(JARVISBURG) 428 47`30" 429 2 950 000 FEET 431 °32 75.45
• :'f. •= i.:. v.- r y_�'�y .�, .' t>, ,y�• 1 t` v�, :� .�y% _ _
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