WI0700087_GEO THERMAL_20160208

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
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 X 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: October 15 .20 20 PERMIT NO. _ WI0700087 (leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as ® Geothermal 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).
RECEIVED
❑ Yes, I wish to rescind the permit
NOV 4 6 2020
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES ® NO NC DEGWWE
If yes, indicate New Owner's contact information: Central Office
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 X
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, list name of business/agency and name of person and title with delegated authority
to sign: Ashton — Lewis Lumber Company. Inc. Michael Lancaster. Vice President of Sawmill Operations
Mailing Address: P.O. Box 25
City: Gatesville State:_ NC_ Zip Code: 27938 County: Gates
Day Tele No.: [phone] Cell No.: [phone]
EMAIL Address: mlancasterO,ashton-lewis.com Fax No.: [phone]
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 1

NOTE. Inmost cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a `layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021 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 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 of the
Permit."
Nom A 6 2020
i
I
NC. v.__•....ID
Ccr tral Office j
Signature of Property Owner/Applicant
_Michael Lancaster Vice President of Sawmill Operations
Print or Type Full Name and Title
Signature of Property Owner/Applicant
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 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 4

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
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 X 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: October 15 . 20 20 PERMIT NO. W10700087 (leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as ® Geothermal 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 RECEWD
2. Current Ownership Status NOV 0 S 2020
Has there been a change of ownership since permit last issued? ❑ YES ® NO
If yes, indicate New Owner's contact information: NC DEQ/DWR
Name(s) _.. Central ()M!*
Mailing Address:
City:
Zip Code: County:
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence Business/Organization X
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, list name of business/agency and name of person and title with delegated authority
to sign: Ashton — Lewis Lumber Compare Inc. Michael Lancaster, Vice President of Sawmill Operations
Mailing Address: P.O. Box 25
City: Gatesville State: NC Zip Code: 27938 County: Gates
Day Tele No.:. [phone] Cell No.: [phone]
EMAIL Address: mlancasteraashton-lewis.com Fax No.: [phone]
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 1

NOTE. Inmost 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(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 erson 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 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."
FtEGEW®
Gov 06 TO
� a% Ce
Signature of Property Owner/Applicant
Michael Lancaster. Vice President of Sawmill Operations
Print or Type Full Name and Title
Signature of Property Owner/Applicant
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 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 4

PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Water Resources
E\JVIRO,'lM~NTAL GUAL!TY
February 3, 2016
Michael Lancaster, General Manager
Ashton Lewis Lumber Company, Inc.
P.O. Box 25
Gatesville, North Carolina 28562
SUBJECT:
Dear Mr. Lancaster:
Groundwater Sampling Results
UIC Permit No. WI0700087
Issued to Ashton Lewis Lumber Company, Inc.
Gatesville, Gates County, North Carolina
Secreta,y
S. JAY ZIMMERMAN
RECEIVED/NCDEQJOWR
FEB 08 201S
Water Quality
ReslonaJ Operations Section
Director
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 December 29, 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 the
samples from your system:
Parameter Units NC Groundwater Results
Standard
Fluoride Milligrams per Liter 2 2.4 (supply well-influent)
(ma/L) 2.4 (i n jection well-effluent)
Total Dissolved Solids Milligrams per Liter 500 830 (supply well-influent)
(m g/L ) 824 (i njection well-effluent)
pH Standard Units 6.5 to 8.5 6.0 (supply well-influent)
6.0 (in jection well-effluent)
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.
In addition, the following constituent exhibited an increase in concentration between the influent
(supply well) and effluent (injection well):
Parameter Units NC Groundwater Results
Standard
Zinc Micrograms per 1000 85 (supply well-influent)
Liter (ua/L) 320 (in jection well-effluent)
While the concentrations of this constituent are below state groundwater standards, these results
may indicate that your geothermal heat pump system is having an effect on the groundwater flowing through
the system. This information is being provided to help you operate the system in the future.
State of North Carolina I Environmental Quality I Water Resources -Water Quality Regional Operations-Washington Regional Office
943 Washington Square Mail, Washingtoo, NC 27889
252-946-6481
Michael Lancaster
February 3, 2016
Page 2 of 2
If you have any questions regarding the sampling results or your permit, please feel free to contact
me at [phone].
Attachmr,ts
;J
Sincerely, -/} ?L f' ,
v~# /~J /~
Dwight Randy Sipe, P.G., Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ
cc: /Michael 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 MCL=< 1
Influent Sample Results < 1
Effluent Sample Results < 1
Parameter Nitrate+ Nitrite
units mg/Las N
NC MCL and/or EPA Standard NC MCL= 11
EPA PDWS= 11
Influent Sample Results <0.02
Effluent Sample Results <0.02
Parameter Chromium, Cr
units µg/L
NC MCL andfor EPA Standard NCMCL=10
EPA POWS = 100
Influent Sample Results <5 .0
Effluent Sample Results <5.0
Parameter Sodium, Na
units mg/L
NC MCL and/or EPA Standard NS
NC DIVISION OF WATER RESOURCES
LABORATORY ANALYTICAL RESULTS
5A7 GEOTHERMAL UNDERGROUND INJECTION CONTROL (UIC) WELL
PERMIT NO.: Wl0700087
PERMITTEE(S): Ashton Lewis Lumber
SAMPLE COLLECTION DATE: 12/29/2015
Total Coliform Total Dissolved Solids Chloride, Cl
CFU/100ml mg/L mg/L
NCMCL=1 NC MCL=500 NC MCL=250
EPA SOWS = 500 EPA SOWS = 250
<1 830 170
<1 824 170
Hardness as CaC03
Nitrite (by Calculation) * Aluminum, Al
mg/Las N mg/L as CaC03 µg/L
NC MCL= 1 NS NS
EPAPDWS=1 EPA SOWS = 50 to 200
<0 .01 10 <50
<0 .01 10 <50
Copper, Cu Iron, Fe Potassium, K
µg/L µg/L mg/L
NC MCL= 1000 NCMCL=300 NS
EPA SOWS= 1000; PDWS = 1300 EPA SOWS = 300
39 <50 13
22 <50 13
Nickel, Ni Lead,Pb Zinc, Zn
µg/L µg/L µg/L
NCMCL= 100 NC MCL= 15 NC MCL = 1000
Fluoride, FL
mg/L
NCMCL=2
EPA PDWS = 4.0
2.4
2.4
Arsenic, As
µg!L
NC MCL= 10
EPAPDWS=10
<2 .0
<2 .0
Magnesium, Mg
mg/L
NS
1.7
1.7
pH (field)
units
NC MCL = 6.5-8.5
EPAPDWS= 15 EPA SDWS = 5000 EPA SOWS= 6.5 to 8.5
Influent Sample Results 320 <2.0
Effluent Sample Results 350 <2.0
NC MCL = North Carolina Maximum Contamination Limits per 15A NCAC 2L .0200
EPA PDWS = Environmental Protection Agency Primary Drinking Water Standards
EPA SOWS = Environmental Protection Agency Secondary Drinking Water Standards
NS = No Standard
5.0 85 6
3 .3 350 6
• Calculation performed by WaRO
Sulfate, S04
mg/L
NC MCL= 250
EPA SOWS= 250
56
56
Calcium, Ca
mg/L
NS
1 .3
1,3
Manganese, Mn
µg/L
NCMCL=50
EPASDWS=50
<10
<10
North Carolina Division of Water Resources
Central
Central Laboratory [Water Sciences Section]
Water Sample Collection & Submittal Farm
visit Ip'
(optional]
Tay Irtfiuen
ID
_Lab Use Only.
T ----------- ----
-----
laboratory �
Sample Nurnher.
Lacotion Description: ASt3fnn-Lewis Lumber,
Lewis
_
Mil! Rd, Galesville, NC
[oration cede:
WI0700087
Date Received: '1'r
County: Gates
Coffector.• R. Sipe
priority:
❑ Ambient
El❑ Routine
OCompliance
❑ COC
❑Emergency
❑4A
Water Matrix-
❑ surface
2 Ground
❑ Waste
❑ Blank
❑ Solution
Lecatlan Type:
❑River/Stream ❑Lake
[Estuary ❑Canal
stormwater
❑Monitoring Well ❑Water Supply
[]Effluent ❑ influent
❑Field Blank
❑Trip Blank
❑Filter Blank
❑Other: Geotherm Supply Well
12-39d J�
nmeReceived: e
DWRRegion: WaRCI
ffiMedmmunty)
QWROffrre: WaRO
Inravermrrmmej
Received By:
-
River Basin: Chowan
paw; �F
State Caurier
Delivery method. ❑Hand Delivery
❑other:
Nptes:
��
rime.1
❑ Chlorinated ❑De Chlnrirraled in Field
Sampling 2Gra6 LJcomposite
method.. El Other
temperature /'CJ
on arrival
Dissolved analysis: Enter"Ole
❑ Filtered in Field in check_troxes for parameters
Sample Depth: 11}IA
Collector's Comments:
Microbiology Parameters:
TOBAS (surfactanlsj
mg/L
Metals Parameters:
tin (Sn) pVL
Acidity, as CaCO3, to pH 4.518.3
mg/1
Oil and Grease. HEM, Total Recoverable
mK/L
X
AlUminum (Al)
lrg/L
Titanium (Ti) PEA
Alkalinity, as CaCo3,to pH 4.518.3
mg1L
Phenols, Total Recoverable
pg/L
Antimony (Sb)
pelt I
Vanadlurn (V) "A
BOD: eiochernrcal Oxygen Nmand,S-dav
mg/L
Residue: Total (Total5olids)
ffWL
X
Arsenic (As)
Pz/L
R
Zinc (2nj gg/L
CBOD: Carbonaceous SOD, S-day
mg/L
Residue: Volatile/Fixed, Total
mg/L
Barium (Ba)
VC/L
X
Cokform: Fecal MF
/1OOMI
Resid u e. 5 uspend e d (SuspendedSollds)
mg/L
Beryllium (Bel
lig/L
Boron (a). Total pg/L
X
Cokform: Total Iv1F
/looml
Residue: Volatite/Fixed, Suspended
mg/L
Cadmium (Cd)
ug/L
Mercury 1631, low-fevel ng/L
Coltfarm:TubeFecar
/100ml
X
TOS-Total Dissolved Solids
mg/L
X
Calcium(Ca)
rnglL
Cokform: Tube Total
/10Om1
Silica
nWL
X
Chromium (Cr),Total
lig/L
Organics Parameters:
Specific Conductance, at 25 °C
umhoslem
Sulfide
mg/L
Cobalt (Co)
lig/L
Arid Herbicides
TOC- Total Organic Carbon
mg/L
Tannin & Lignin
mg/L
X
Capper (Cu)
pg/L
orgsnochlvrine pesticides
Turbidity
NTti
X
iron (Fe)
ligJL
Organonitrogen Pesticides
Other Parameters:
X
Lead (Pb?
Pg/t
Organophosphorus Pesticides
Wet Chemistry Parameters:
pH
s_u-
lithium (Li)
Ng/L
PCBs (polychlorinated hiphenyls)
Bromide
mg/L
Hardness. Total as CaCO3- by titration
mg1L
X
Magnesium (Mg)
mg/L
X
Chloride
rngll
X
Manganese (Mn)
Ng/t
Semi -Volatile Organics (aNAs)
Fluorine
mg/L
d
Mercury (Hg)
Vg/L
TPH Diesel Range
Sulfate
mg/L
Nutrients Parameters:
Molybdenum (Mal
p9A
Chlorophyll a
llg/L
Ammonia as N (NH3-N)
mg/L
X
Nickel (Ni)
llg/L
Volatile Organics (VOA)
Color: ADIVIS
C.U.
X
Narate•N(trite as N (NO3+NO2-N)
mg/L
X
Potassium (K)
rnglL
Color_ Platinum Cobalt
C.U.
Total KleldahI Nirxagen as N (TKN)
m&A
Selenium (Se)
llg/L
T'PH Gasoline Range
COI]: Chemical Oxygen Demand
mg/L
Total Phosphorus as P (TP)
mg/L
Silver (Ag)
hell
Btotagfcal:
Cyanide, Total mglL
X
Nitrite as N (NO2-N) rn L
X
Sodium (Na) mg/L
Formaldehyde
mg/L
Nitrate as N (tY03-N calculated)
mg/L
Strontium (5r)
llg/L
PhytapFankton / Algae
HexavaleM Chromium ((:r6+)
mg/L if
I orthophosphate as P (PO4)
mg/L
Thailium (TI)
►rg/!
LAB COMMENTS',
Field Parameters(aptJanoij: WaterTemp (°Cl: pH (s-u,): Dissolved Oxygen (ppm]: ConductivityIpmhos/cm): Salinity (ppt):
- On -
flevision: 2/06/2015 - - - -

AC25377 :NC '-DW".R. Water Sciences Section-Cfiemistry La6oratorv ".R?su(ts
County:
River Basin
Report To
Collector:
Region:
Gates
CHO01
WARO
R_SIPE
WARO
Sample Matrix: GROUNDWATER
Loe. Type: Monitoring Well
Emergency Yes/No
COC Yes/No
J Location ID: WI0700087
DWR
Division of Water Resources
Final Re p ort
VisitlD
Loe. Descr.: ASHTON LEWIS LUMBER
I Collect Date: 12/29/2015
Sample ID: AC25377
PO Number# 15G0320
Date Received: 12/30/2015
Time Received: 08:30
Labworks Login ID TASCENZO1
Final Report Date: 2/1116
Report Print Date: 02101/2016
J Collect Time: 10:15 l Sample Depth
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
CAS# Anal yte Name POL Result/ Units Method Analysis Validated by
Qualifier Reference Date
LAB
Sample temperature at receipt by lab 2.5 Coe 12/30/1! MSWIFT
MIC
Coliform, MF Fecal in liquid 1 1 B2Q1 CFU/10Dml APHA9222D-20th 12/30/1! ESTAFFORD1
Coliform, MF Total in liquid 1 1 B2Q1 CFU/100ml APHA9222B-20th 12/30/1! ESTAFFORD1
WET
Ion Chromatography TITLE mg/L EPA 300.0 rev2.1 1/15116 CGREEN --
Fluoride 0.4 2.4 mg/L EPA 300.0 rev2.1 1/15/16 CGREEN
Chloride 1.0 170 mg/L EPA 300.0 rev2.1 1/15/16 CGREEN
Bromide 0.4 0.79 mg/L EPA 300.0 rev2.1 1/15116 CGREEN
Sulfate 2.0 56 mg/L EPA 300.0 rev2.1 1115116 CGREEN
Total Dissolved Solids in liquid 12 830 mg/L SM 2540 C-1997 1/4/16 CGREEN
NUT
NO2+NO3 as N in liquid 0.02 0.02 U mg/Las N EPA 353.2 REV 2 12131/1! CGREEN
Nitrate .as N in liquid 0.02 0.02U mg/Las N EPA 353.2 REV 2 1/5/16 CGREEN
Nitrite as N in liquid 0.01 0.01 U mg/Las N EPA 353.2 REV 2 12/30/1! CGREEN
MET
7429-90-5 Al by ICP 50 50 U ug/L EPA 200.7 1/13/16 ESTAFFORD1
7440-38-2 As by ICPMS 2.0 2.0 U ug/L EPA200.8 1/13/16 ESTAFFORD1
7440-70-2 Ca by ICP 0.10 1.3 mg/L EPA200.7 1/13/16 ESTAFFORD1
7440-47-3 Cr by ICPMS 5.0 5.0 U ug/L EPA200.8 1/13116 ESTAFFORD1
7440-50-8 Cu by ICPMS 2.0 39 ug/L EPA200.8 1/13116 ESTAFFORD1
7439-89-6 Fe by ICP 50 50 U ug/L EPA200.7 1/13116 ESTAFFORD1
7440-09-7 K by ICP 0.10 13 mg/L EPA200.7 1/13116 ESTAFFORD1
7439-95-4 Mg by ICP 0.10 1.7 mg/L EPA200.7 1/13116 ESTAFFORD1
7439-96-5 Mn by ICP 10 10 U ug/L EPA 200.7 1/13116 ESTAFFORD1
7440-23-5 Na by ICP 0.10 320 mg/L EPA200.7 1/,13/16 ESTAFFORD1
7440-02-0 Ni by ICPMS 2.0 2.0 U ug/L EPA200.8 1/13116 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0 5.0 ug/L EPA200.8 1/13116 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 85 ug/L EPA200.8 1/13116 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
For a detailed descriotion of !he aualifier codes refer to <htto ://oortal.ncdenr. orn:/web/wq/oos/methods-and-oq ls>
Page 1 of 1
------·----··•··
1166�, z/
North Carolina Division of Water Resources
Central Lahorato (water sciences sect3an
r]' ]
Water Sample Collection & Submittal
Fnrtrr
Visit ID:
(optiarral]
Tag
Effluen
ID
Lab Use Only:
----------------------_
Laboratory
sample Number.
Location Description: Ashton -Lewis Lumber,
Lewis
Mill Fed, Galesville, NC
Location Code:
W10700087
note ReCrived:
af�1Tj
County; Gates
Collector: R. Sipe
Priority:
❑ Ambient
❑ Routine
0 Compliance
❑ CDC
Emergency
❑ g
❑4A
Water Matrix-
❑ surface
D Ground
❑ Waste
❑Blank
❑Solution
location Type:
❑River/Strearn ❑lake
[❑Estuary ❑Canal
❑Stormwater
❑Monitoring well ❑Water Supply
❑Effluent ❑Influent
❑Field Blank
❑Trip Blank
❑Filter Stank
❑Dther: Geatherm IN. Wei;
Time Received:
Received By.
DWRRegion: WaRD
?based on counryJ
DWROffce. WaFiO
{oragencyaame)
RiuerBusin: Chnwan
Duce: �����°/��`"
[G.tL
_ 51ate Courier
Uefivery iNerhod: ❑ hand delivery
❑other;
—
Tem erature
p (',Cl
ore Arrival:
Notes:
/�irY l/�]
Time: L l" Y it
❑Chlorinated De -chlorinated in Field
Sampling Q Grab L I Composite
Method: ❑Other_
Dissolved analysis: Enter "DIS'
❑ Filtered in Field in neck -boxes for parameters
Sample Depth., N/A
Collector's Comments:
Microbiology Parameters:
MBAS (surfactants)
mg/L
Metals Parameters:
Tin {5n) µg/L
Acidity, asCaCO3,in pH 4.518.3
mg/L
Oil and Grease, KEM, Total Recoverable
mg/L
%
Aluminum (All
lig/L
Titanium (Til µglL
Vanadium (V) µg/L
AfkaSnity, asCaCO3, to pit 4.5183 mg/L
Phenols, Total Recoverable lig/L
Antimony (Sod IJRA
Boo: ttiochemical Oxygen Demand, 5-day
mg/L
Residue. Total (TotalSolids )
mg/L
X
Arsenic (As)
jrg/L
x
Zinc [2n) µg/L
eROD: Carbonaceous BOD, 5-day
mg1L
Residue: ValatilelFixed, Total
rng/L
Barium (Ba)
pa/L
X
Coliform: Fecal MF
/]0t1m1
Residue: Suspended (Suspended Solids)
mg/L
t3erytfium (Be)
lig/L
Boron ft Total µg/L
X
Coliform: Total MF
/100m1
Residue: Va(atlle/Fixed, Suspended
mg/L
Cadmium (Cd)
µg/L
Mercury 1631, low-level ng/L
Coldorm: Tube Fecal
1100m1
x
TDS- Total Dissolved Wids
rrmVt.
x
Calcium (Cal
tngll_
Caliform:Tube Total
1100m1
Silica
mg/L
X
Chromium (Cr), Total
µg/L
Organics Parameters:
Specific Conductance, at 25 C
umhoslao
Sulfde
mglL
Cobalt (CO)
lig/L
Acid Herbicides
TOO -Total Organic Carborn
mg/L
Tannin & Lignirt
mg/L
x
Capper (Cu)
µg/L
Organachlorine Pesticides
Tirrhidlty
NTu
%
Iron;Fe}
µg/L
Orpanonitragen Pesticides
Other Parameter:
x
Lead (Pb)
µgA
Drganophosphorus Pesticides
WetChemis" Parameters:
pit
s.u.
Lithium (U)
ylglt
PCBs {polychlorinated biphenyls)
Bromide
mgll
Hardness, Total as CaCO3 - by titration
mg1L
x
Mag"sium (Mgj
mg1L
X
Chloride
mg/L
x
Manganese (Mn)
lig/L
Semi-Vo)atile Organics (BNAs)
Fluoride
mg/L
NlercurytHgl
µGil
TPH Diesel Range
sulfate
mg/L
Nutrients Parameters:
-Molybdenum (Mal
µ91L
Chlorophyll
µKA
Ammonia as N (1`41,13-N)
mg/L
X
Nickel (Ni)
µgA
Volatile Organics(VOA)
Color. ADlvll
c.u.
X
Nitrate -Nitrite as N (NO3+NO2-N)
mg1L
X
Potassium (Kl
mgll.
Color. Platinum Cobalt
c.u.
Total KjAdaht Nitrogen as N (TKfdj
mg/L
Selenium J$e)
}ig/L
TPH Gasoline Range
COD. Chernical Oxygen Demand
mg/L
Total Phosphorusas P (TP)
mg/L
Silver Ad
j!g/L
Cyanide. Total
mg/L
X
Nitrite as N (NO2-N)
mg/L
x
Sodium (Naj
mg/L
Biological:
Formaldehyde
mg1L
Nitrate as N (NO3�1 calctriated)
mg/L
Strontium (Srl
)jg/L
Phytaplankton IAlgae
tlexavalent Chromium (CrG+)
mg/L
orthophosphate as P (PO4)
mg/L
Thallium [TI)
lJ$1L
tAB COMMENTS
new Parametersroprranaq:I Water Temp ('Q- I pH;s.u.): 6 j Dissolved oxygen (ppm): 1 Conductivity (pm hos/cm): I Salinity (Opt):
Revision:

AC25378 XC 0r WaterSciences Section -Chemistry Laboratory &suits
County: Gates
River Basin C"001
Report To WARO
Collector:
R SIPE
Region:
VVARO
Sample Matrix:
GROUNDWATER
Loc. Type:
Monitorino Well
Emergency Yes/No
CDC YeslNo
DWR
Division of Water Reso+trrces
Final Report
visiliD
Loc. ❑escr.: ASHTON LMIS LUMBER
Sample ID:
AC25378
PO Number #
15G0321
Date Received:
12130/2016
Time Received:
08:30
Lebworks Loginl❑
TASCENZ01
Final Report Date.
211116
Report Print Date,
02/0112016
Location ID: WI07000117 Collect Date: 1212912016 Collect Time: 10:30 Sample Depth
If this report is labeled preliminary report, the results have not been validated Do not use for Regulatory purposes.
CAS #
LAB
Analvte Name
Sample temperature at receipt by lab
POL
--
Result!
Qualifier
2.5
Units
T
Method
Reference
Anal sis
Date
12130111.
validated b,
MSWIFT
MIC
Collform, MP fecal in liquid
1
1 B2Q1
CFL111D0ml
APHA9222D-20th
12130/1!
ESTAFFORDI
Coliform, MF Total in liquid
1
1 B2Q1
cru/100ml
APHA9222B-20th
1213QMI
ESTAFFORDI
WET
Ian Chromatography
_TITLE_
mg1L
EPA 300.0 rev2.1
1115116
CGREEN
Fluoride
0.4
2,4
rng1L
EPA 300.0 rev2.1
111511E
CGREEN
Chloride
1.0
170
mg1L
EPA 300.0 rev2.1
1115116
CGREEN
Bromide
0.4
0.81
mg1L
EPA 300.0 rev2.1
1115116
CGREEN
Sulfate
2.0
56
mg1L
EPA 300.0 rev2.1
1M5116
CGREEN
Total Dissolved Solids in liquid
12
824
mg1L
SM 2540 C-1997
114116
CGREEN
NUT
NO2+NO3 as N in liquid
0.02
0.02 U
mg/L as N
EPA 353.2 REV 2
1213111!
CGREEN
Nitrate as N in liquid
0.02
0,02 U
mg1L as N
EPA 353.2 REV 2
115116
CGREEN
Nitrite as N in liquid
0.01
0.01 U
mg/Las N
EPA 353.2 REV 2
1213011!
CGREEN
MET
742-9-90-5
Al by ICP
50
50 U
uglL
EPA 200.7
1113116
ESTAFFORDI
7440-38-2
As by ICPMS
2.0
2.0 U
ug[L
EPA 2018
1/13116
ESTAFFORDI
7440-70-2
Ca by ICP
0.10
1.3
m911_
EPA 200.7
1i13116
ESTAFFORD1
7440.47-3
Cr by [CPMS
5.0
5.0 U
ugIL
EPA 200.8
1113116
ESTAFFORDI
7440-50.8
Cu by ICPMS
2.0
22
ug/L
EPA200.8
1/13116
ESTAFFORDI
7439-89-6
Fe by ICP
50
50 U
ugJL
EPA200,7
111311E
ESTAFFORDI
7440-09-7
K by ICP
0.10
13
mg1L
EPA 200.7
111311E
ESTAFFORDI
7439-95-4
Mg by ICP
0.10
1,7
mglL
EPA 200.7
1113/16
ESTAFFORDI
7439-9"
Mn by ICP
10
10 U
ug1L
EPA 200.7
1113116
ESTAFFORDI
7440-23-5
Na by ICP
0.10
350
mg1L
EPA 2003
1113/16
ESTAFFORDI
7440.02-0
Ni by ICPMS
2.0
2.0 U
ug/L
EPA 200.8
1113116
ESTAFFORDI
7439-92-1
Pb by ICPMS
2,0
3.3
ug1L
EPA 200.8
1113116
ESTAFFORDI
7440-65-6
Zn by ICPMS
10
350
ugIL
EPA 200.8
1113116
ESTAFFORDI
WSS Chemistry laboratory>> 1623 Mail Service Center, Raleigh, NC 27699.1623 [phone]
For a data -led dascr!alion of she nua!ifiei codes rarer to <httD://llorta1.ncdenr. or0web/W Q I0175/methods-and-vals>
Page 1 of 1

Sy mbol
A
B
BB
C
G
J
Definition
Value reported is the mean (average) of two or more detenninations . This code is to be used if the results of two or more
dis crete and separate samples are averaged. The se 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, colifonn or acute/chronic metals
reporting since averaging multiple results for these parameters is fundamental to those methods or manner of reporting .
1. The reported value is an average, where at least one result is qualified with a "U". The PQL is used for the qualified
resul t(s) to calculate the average.
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 tilter (MF) colony counts. It is to be used if less 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 colon ies. Reported value is estimated or is a total of the counts on all filters
reported per 1 00 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 I 00 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
enterococcus and 80 for total), multiplied by JOO 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 reported 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., Bl, B2, etc.).
Note: A "J2" should be used for spiking failures .
This code applies to most probable number (MPN) microbiological tests.
I. 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 reported as a greater than ">" value .
Note: A "BB" value shall be accompanied 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 organics.
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 1.0 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 mglL.
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 accomoanied bv justification for its use denoted by the numbers listed above (e .e.., 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 an v accurate determination.
4. The data is questionable because of improper laboratory or field protocol s (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 compliance monitoring.
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 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 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, 12, etc.). A "J"
value shall not be used if another code aoo lies (e.g., N, V, M).
M Sample and duplicate results are "out of control". The sample is non-homogenous (e.g., VOA soil), The reported value is the
lower value of du plicate anal yses of a samole.
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 of analyte 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/or 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 in strument noise level. This code is used
when an MDL has not been established/or 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 .
l. 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 ported with the "U" Qualifier is equal to the laborato ry 's practical quantitation limit*.
V Indicates the analyte was detected in both the sample and the associated blank. Note : The value in the blank shall not be
subtracted from the associated samples ..
l. The analyte was detected in both the sample and the method blank.
2. The anal vt.e was detected in both the sam ple and the field blank
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 accom panied by j ustification for its use by the numbers listed .
y Elevated 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 .
Supporting Definitions listed below
MDL A Method Detection Limit (MDL) is defined as the minimum concentration of a substance that can be measured and reported
with 99 percen! confidence that the true value is greater than zero and is determined in accordance with 40 CFR Part 136,
Appendix B.
ML Minimum Levels are used in some EPA methods. A Minimum Level (ML) is the lowest level at which the entire analytical
system must give a recognizable signal and acceptable calibration point for the analyte. It is equivalent to the concentration of
the lowest calibration standard, assuming that all method • specified sample weights, volumes, and cleanup procedures have
been employed.-The ML is calculated by multiplying the MDL by 3 .18 and rounding the result to the nearest factor of I 0
multiple (i.e., 1, 2, or 5). For example, MDL= 1.4 mg/L; ML= 1.4 mg/L x 3.18 = 4.45 rounded to the nearest factor of 10
multiple (i.e., 5) = 5.0 mg/L
*PQL The Practical Quantitation Limit (PQL) is defined as the lowest concentration that can be reliably achieved within specified
limits of precision and accuracy during routine laboratory operating conditions. PQLs are subjectively set at some multiple of
typical MDLs for reagent water (generally 3 to 10 times the MDL depending upon the parameter or analyte and based on the
analyst's best professional judgement, the quality and age of the instrument and the nature 'of the samples) rather than explicitly
determined. PQLs may be nominally chosen within these guidelines to simplify data reporting and, where applicable, are
generally equal to the concentration of the lowest non-zero standard in the calibration curve. PQLs are adjusted for sample
size, dilution and% moisture. For parameters that are not amenable to MDL studies, the PQL may be defined by the sample
volume and buret graduations for titrations or by minimum measurement values set by the method for method-defined
parameters (e.g., BOD requires a minimum DO depletion of2.0 mg/L, fecal coliform requires a minimum plate count of20
cfu, total suspended residue requires a minimum weight gain of2.5 mg, etc.). Additionally, some EPA methods prescribe
Minimum Levels (MLs) and the lab may set the PQL equal to this method-stated ML. Determination of PQL is fully described
in the laboratory's analytical Standard Operating Procedure·(SOP) document.
06/25/2015
Permit Number WI0700087
Program Category
Ground Water
Permit Type
Injection Healing/Cooling Water Return Well
Primary Reviewer
rnichael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Ashton Lewis Lumber Company
Location Address
96 Lewis Mill Rd
Gatesville NC
Owner
Owner Name
Ashton Lewis Lumber Company
Dates/Events
Orig Issue
11/17/2005
App Received
11/23/2015
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27938
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
1/11/2016
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Gates
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Thomas Coxe
PO Box25
Gatesville
Issue
NC
Effective
27938
Expiration
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
12/2/15
1 /7 /16
Subbasin
PAT MCCRORY
·Governor
DONALD R. VAN DER V AART
Water Resources
ENVIRONMENTAL QUALITY
Michael Lancaster, General Manager
Ashton-Lewis Lumber Company, Inc.
P.O. Box25
Gatesville, NC 27938
Re: Issuance of Injection Well Permit
Permit No. WI0700087
January 13, 2016
Geothermal Heating/Cooling Water Return Well
Gates County
Dear Mr. Lancaster:
Secretary
S . JAY ZIMMERMAN
D irector
In accordance with your permit renewal application received November 23, 2015 , I am forwarding
Permit No. WI0700087 for the continued operation of geothermal heating/cooling water return
well(s} located at 96 Lewis Mill Road, Gatesville, Gates County, NC 27938 . This permit shall be
effective from date of issuance until December 31, 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 .December 29, 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 transferable 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 me at [phone] .
State ofN011l1 Ca rolin a I En vironm e111al Quality I Water Resources
1611 Mai! service Center j Raleigh, Nort h Caroli na 27699-161 I
9 19 707 9000
Best Regards,
}faM ~✓
Michael Rogers, P.G. (NC & FL)
Underground Injection Control (UIC) Manager -Hydrogeologist
Division of Water Resources, NCDEQ
Water Quality Regional Operations Section
cc: David May & Robert Tankard, Washington Regional Office
Central Office File, WI0700087
Gates County Environmental Health Department
Page J of2
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE 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 HERESY GRANTED TO
Ashton -Lewis Lumber Company, Inc.
FOR THE CONTINUED OPERATION OF TWO (2) GEOTHERMAL HEATING/COOLING WATER
RETURN WELLS), defined in Title 15A North Carolina Administrative Code 02C .0224(a), which will be used
for the injection of heat pump effluent. The injectionwell(s) located at 96 Lewis Mill Road, Gatesville, Gates
County, NC 27938 will be operated in accordance with the application submitted November 237 2015, and
conformity with the specifications and supporting data, all of which are filed with the Department of
Envirolunental Quality and are considered a part of this permit.
This permit is for continued operation of an injection well shall be m compliance with Title 15A Noah Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Mules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until December 31, 2020, and shalt be
subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 13th day of January 2016.
akc—],
S. Jay Zimmerman, P.G.
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Permit # W W700087 U105A7 Page 1 of 5
ver. 31/15/20 f 5

PART I -PERMIT GENERAL CONDITIONS ,.
1. The Permittee shall comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (ISA 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 ,vater 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 .0107(i)(2)].
Permit #Wl07000S7 UIC/5A7
ver. 11/15/2015
Page 2 of 5
7. • A completed Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 of this
permit.
PART III -OPERATION AND USE CONDITIONS
1. 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 [ISA 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[ISA NCAC 02C .021l(k)]
1. 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(£)(1 )].
3. The Permittee shall report any monitoring or other information 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) OraJ notification shall be given within 24 hours of the occurrence, or first knowledge of the
occurrence, to the Washington Regional Office, telephone number 252-946-6481.
(B) Written notification shall be made within five days of the occurrence and submitted to the addresses
in Item #5 below.
Pennit #WT0700087 UIC/5A7
ver. l 1/15/2015
Page 3 of 5
(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
94 3 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.
Pcnnit #Wl0700087 UIC/5A7
ver. l 1/15/2015
Page 4 of5
PART VII-CHANGE OF WELL STATUS [15t\ 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
Perrnittee shall permanently abandon that injection well in accordance with the procedures specified in 15A
NCAC 02C .0l 13(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.
(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) shal.l be submitted to the addresses specified in Part
V.5 above.
Permit #Wl0 700087 UfC/5A7
ver. J 1/15/2015
Page 5 of5
AQUIFER PROTECTION SECTION'•*- GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: 1./5/16 Permittee(s): Ashton Lewis Lumber
Permit No.: WI0700087
To: APS Central Office County: Gates
Central Office Reviewer: Michael Roper Project Name: Ini. Heatinyjcoolint, Return Well
Regional Login No:
I. GENERAL INFORMATION
1. This application is (check all that apply): ❑ SFR Waste Irrigation System M UIC Wells)
❑ New M Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporationllnfiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 -regulated ❑ 50; exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation M Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? M Yes or ❑ No,
oen�nacr«
a. Date of site visit: 12/29/15
b. Person contacted and contact information: Michael Lancaster
JAN 4 7 2018
c. Site visit conducted by: R. Sipe
wew ctuaim►
d. Inspection Report Attached. ® Yes or ❑ No, ftwnwopeffloonsSaCom
2. Is the following information entered into the BIMS record forth is application correct?
® Yes or ❑ No, If no, please complete the following or indicate that it is correct on the current application.
For SFR Treatment Facilities:
a. Location: NA
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude: Method Used (GPS, GoogleTM, etc.);
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For UIC Injection Sites:
ff aultilAe sites either indicate which sites the, information applies to. com and paste a new section_ into the
document for each site. or attach additional -pages for each site
a. Location(s): no change since permit was issued.
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude: Method Used (GPS, Goo,gle'", etc.);
APS-GPO Rcgional StafTReport (Sept 09) Page 1 of 4 Pages

AQUIFER PROTECTION SECTION'-r_ 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:
[8J Heating/cooling water return flow (SA 7)
D Closed-loop heat pump system (5QM/5QW)
0 In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (SL/"Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? [8J Yes O No
Note: The system is constructed so that the two wells may be used for su pp ly and in jection interchan geabl y.
Durin g this ins pection Well #1 was bein g used for su pp ly and Well #2 for injection , as was the case durin g the last
ins pection.
3. Are there any potential pollution sources that may affect injection? D Yes [8J No
What is/are the pollution source(s)? . What is the distance of the injection well(s ) from the pollution
source{s )? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? NIA,
5. Quality of drainage at site: D Good [8J Adequate D Poor
6. Flooding potential of site: [8J 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)? [8J 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. See attached ma p
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 [8J No. If yes , ex plain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes. ex plain:'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 ofgroundwater remediation permits (of an y typ e ), will
continued/additional/modified in jections have an adverse im pact on mi gr ation of the plume or manag ement of
the contaminationincident? D Yes D No. If yes , exp lain: NA
4. Drilling Contractor: Name: Bobby Harrell -Magette Well and Pump Co., Inc.
Address: 2341 US 13 South
Ahoskie, NC 27910
NC Certification number: 2936-A
5. Complete and attach NEW Injection Facility Inspection Report, if applicable
V. EVALUATION AND RECOMMENDATIONS
1. 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? D Yes t8] No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5 . List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
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; ❑ ttold,
pending review of draft permit by regional office. ❑ Issue upon receipt of needed additional information,
Issue; ❑ Deny. if deny, please state reasons:
8. Signature of report Preparers);
Signature of APS regional sit perv'tsor:
Date: _ �l
V1._ ADDITIONAL INFORMATIONAND SITE MAP (Sketch of site shoyLmg house and waste irritation
system s ra or dri tell ' location o wells and/or outer relevant in ormation- SHOW NORTH ARRO I i'
Both ini., and supply wells appear to be in good condition consistent with findings of prior inspections
and operating adequately. There was a leak at a valve on the line going into Well #2, but the
operation of the well itself did not appear to be affected. The Ashton Lewis emnlo`ee onsite stated that
it was scheduled to be repaired.
APS-GPU Regional Staff deport (Sept 09) Page 4 of 4 Pages

.I
j IFER PROTECTION SECTION = GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
YI. ADDITIONAL INFOAMATIONAND SITE MAP (Sketch of site showing house and waste irrigation
system. spray or drip- field, location of wellW,-and/or other relevant information- SHO WNORTHARRO H)
Lmm, kr Compp. ntj
APS-OPU Regional Staff Report (Sept 09) Page 4 of 4 Pages

North Carolina Department of Environment and Natural Resources
Division of Water Quality -Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700087
DATE OF INSPECTION: 12/29/15
INSPECTOR: __ R_. S_1 ..... ·p_e ______ _
NAME OF PERMIITEE(S) Ashton Lewis Lumber
MAILING ADDRESS OF PERMI'ITEE PO Box 252 Gatesville, NC 27938
PHYSICAL ADDRESS OF SITE (if different than above) Lewis Mill Rd., Gatesville, NC 27938
PERSON MET WITH ON-SITE LT. Downs; 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)
Well #1 (Supply Well): 36.397778N; 76.767222W
Well #2 (Inj. Well):36.398056N; 76.7675W
Appx. distance of well to property boundaries: _200 feet (Well #1-Supply); 60 feet (Well #2-Inj .)_
Appx. distance of well from foundation of house/structure : _15 feet (both wells) _______ _
Appx. distance of well from septic tank/field (if present):_ 400 feet (Well #1- Supply): 450 feet (Well #2-Inj.)
Appx. distance of well to other well(s) (if present): _150 feet between Well #1 and Well #2 ____ _
Appx. distance to other sources of pollution: _ None ________________ _
Flooding Potential of Site: _high __ moderate _X_low
Comments: Both inj., and supply wells appear to be in good condition consistent with findings of prior inspection
and operating adequately. There was a leak at a valve on the line going into Well #2, but the operation of the well
itself did not appear to be
affected. -----------------------------------
Injection Fac ility Insp . 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 GW-1 well records
Draw Schematic of well above showing TD, casing depth, grout, etc.
Injection Facility lnsp. Report (Rev. Sept 2009) Page 2 of 3 Pages
Well Constr..uction Information
Date Constructed:_ Well #1 (9/19/05); Well #2 (9/16/05)_
Well Contracting Company: _Magette Well and Pump Co., Inc. ____________ _
Well Driller Name: _Bobby Harrell _______________ _
NC Well Cert. No.: 2936-A ----
Address:_2342 US Hwy 13 South, Ahoskie, NC 27910 --------
Te I e phone No.: _(252)332-2265 _____ ; Cell No.: ________ _
Email Address: -----------
Proposed Depth of Well(s): _NIA _______ _
Total Depth: _331 feet (Well #2-Inj.) __ Total Depth of Source Well, if present: 346 Feet (Well #1-Supply)_
Casing:
Depth: 315 feet (Well #2-Inj.); 321 (Well #1-Supply); Diameter: 4 inches Type: PVC; Stick Up: 3 feet.
Grout:
Depth: 0 -20 feet (both wells); Type Cement; Placement: Pumping.
Depth: 20 -285 feet (Well #2-Inj.); 20-300 feet (Well #1-Supply); Type Bentonite; Placement: Pumping
Well ID Plate Present (Y or N): _Y_; Heat Pump ID plate present (Y or N): _N __
Influent spigot (Y or N): _Y __ ; Effluent spigot (Y or N): __ Y __
Well Sampled? (Y or N): __ Y_; If Yes, Lab Sample ID numbers: Well #I-Supply (Influent) & Well #2 Inj .
(Effluent)_
Static Water Level: not measured ---
Injection Information (if applicable):
Injection Rate: _______ GPM
Injection Pressure: PSI
Injection Volume: GPD
Temperature-Summer: P0
Temperature-Winter: p 0
Comments/Notes: Both inj., and supply wells appear to be in good condition consistent with findings of prior
inspection and operating adequately. There was a leak at a valve on the line going into Well #2, but the operation
of the well itself did not appear to be affected.
Injection Facility Insp. Report (Rev. Sept 2009) Page 3 of 3 Pages
.�itIFER PROTECTION SECTION.- GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
YI ADDTl'aNAL I1VFnRH4TlONA1VD SITE MAC Sketch of site showing house and waste irrigation
system. spray or drip fielit location ol' we21(s), and/or other relevant information- SHOWNORTHAAR0ff i
LvAmbtr Gompmj
APS-GPU Regional Staff Report (Sept 09) Page 4 of 4 Pages

�ss' STA7f
�F ..may- •.i' l;f
1. WELL CONTRACTOR:
NONRESIDENTIAL VVELL CONSTRUCT[oN REcoxn
North Carolina Department of Environment and Natural Resources- Divtsion of Water Quality
WELL CONTRACTOR CERTIFICATION # 2300
S,a-mue.l._J L. Wiggins
Well Contractor (Individual) Name
ette Well & PtsmprO_.--r_;,Tllc-- --
W Contractor Company Name
STREETADDRESS 2342 US 13 S
Ahoskie NC 27910
City or Town State Zip Code
(252
AFea coda- Phone number
2, WELL INFORMATION; well #1
SITE WELL ID #(II appltcabte)
STATE WELL PERMIT#(If applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring 0 MunicipatIPublic ❑
IndustriallCommerclai ❑ Agricultural ❑ Recovery ❑ lnjecllon [X
Irrigation❑ OtherC3 (list use)9e0therma1 heat ijum
DATE DRILLED 9 /19 0 5
TIME COMPLETED 3 = d 0 AM ❑ PM]
3. WELL LOCATION:
CITY:GatesVille CouN-I-y Cates
Lewis Mill Road �
(Street Name, Numbers, Community, Subdiftion, Lot No., Parcel, itp Code)
TOPOGRAPH?C I LAND SETTING:
(DSlope []Valley [fFlat ❑Ridge Q Other
(check appropriate box)
LATITUDE -,L 6d 23 • 868n May bcindegrees,
minutes, seconds or
LONGITUDE ! 6d 46.018w in a decimal format
Latitude/longitude source: ❑ GPS uTopographic map
(facaBon of wag must he shown an a USGS topo map and
attached to this loan # not usft GPS)
4, FACILITY -is the name or the ausinesa Whwe the Wall Ir IecaWL
FACILITY iD #(If applicable)
NAME OF FACILITY Ashton Lewis Lumber Co.
STREET ADDRESS Lewis Mill Road
Gatesville NC 27938
City or Town State Zip Code
CONTACT PERSON TOM Cox
8AltING ACI�RESS PO Sox 5 "1
ttaea esv� e INc I 22 si3:j1
City or Town ;_ _. ----State Zip Code
252 I- 357DD5
Area code - Phone nurnbeF � Q i
5. WELL DETAILS:
I•.
a. TOTAL DEPTH: 3
b. DOES WELL REPLACE? EXISTINCIl liFj40, A"j❑ No
t{�
c. WATER LEVEL 9elgwTgp of Casino : � FT.
(Use'+^ if Abov6jpp•ohCssIng)
d. TOP OF CASING IS 3 FT. Above Land Surface`
'Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .C1 i B.
e. YIELD (gpm): 8 0 METHOC OF TEST_ air lift
f. DISINFECTION: Type HTH Arnaunt 2 1bs -
g. WATER ZONES (deplh):
From3 21 To 3 41 From To
From To From To
From To From To
S. CASING: p Thiiiccgknn}essf
From+1 npt�❑ Ft. �i Fe' IL}I� 21 met
IV
Fran+3 To 321 Ft 4 , " SDR 17PPV�C
Frorn341 To 346 Ft, 41j SCH 80 PVC
7. GROUT: depth Matedal Method
From 0 Te 20 Ftneat cement pump
From —To �Ft!•entonit grout pum
From Ta Ft.
B. SCREEN. Depth Diameter Slat Site Material
From_3 21 To 3 41 Ft. 4 1n. .03q, stain le
From To— Ft in. in.
From Tc Ft, in, In.
8. SANDIGRAVEL PACK:
Depth - - . ..'Sae Material
From 300 To 346 FL 3 Southern Prod
From To Ft.
From To Ft.
1e. DRILLING LUG
From To Formation Description
c.t ay
12 - 1$ sand
18 - 110 clay with sand
110 - 225 sand fine to med.
C ax
3 sac i ne to met-
II.REMARKS:
Wells are designed to inject water
from heat pumps hhen cycle and
produce water fur heat pumps.
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRIJC'nON STANDARDS, ANO THAT COPY OF TH]S
RECOR 5 ESEEN PROVIDED . THE WELLOWNER,
�o ilo
si NATURE OF CERTIFIE LL CONTRACTOR DATE
Samuel L. Wi gins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
;s
FCts
Submit the original to the Division of Water Quality within 30 clays. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. 019) 733 7015 axt 568.
Form GW-1b
Rev. 7/05

NONRESIDENTIAL WFLL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quelity
WELL CONTRACTOR CERTIFICATION # 2936
1. WELL CONTRACTOR:
Bobby L. Harrell
Well Contractor (Individual) Name
Ma�_aette Well & Pump co., Inc.
Well Contractor Company Name - -- -
STREETADDRESS 2342 OS 13 S
Ahoslcie NC 27910
City or Town State Zip Cade
2{ 52 ]- 332-2265
Area code- Phone number
2, WELL INFORMATION:
SITE WELL ID #(ir applicabla). Well # 2 _
STATE WELL PERMIT#(if applicable)
DWO or OTHER PERMIT.#(if applicable)
WELL USE (Cheek Applicable Sax) Monitoring ❑ MunicipallPublic ❑
IndustriailCammarclal C] Agricultural[] Recovery C] Injection! tf
Inigaticno Other❑ [listus6) Cjeothe>rma1 heat pum
DATE DRILLER 9 16105
TIME COMPLETED = 00 AM ❑ PM M
3. WELL LOCATION:
CITY: Gatesville OOUwry Gates
Lewis Mill Road
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
[]Slope p valley EWIat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE _,L, d 23.879n
may ;"degrees
7 5 d 4 6 .018 w minutes, seconds ar
LONGITUDE � in a decimal format
Latitude/longitude source: ?; GPS CiTopographic Wrap
{Iocatk n of well must be shown on a USGS tops map and
attached to this fart if not using GPS}
4. FACILITY- is the name at the businsu whore Ina wall Ta located.
FACILITY ID #(if applicable)
NAME OF FACILITY Ashton Lewis'Lumber Co.
STREETADDRESS Lewis Mill Road
_^^
Gatesville NC 27938
City or Town State Zip Code
CONTACT PERSONTom Cox
V(LINGAQ SS PO Box 5
Ga esva I I e �� �_ _ , _ 5�!
City or Town S{a{e; i "'D +zip '
L252 )_ 357-0050��_..
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3,31
b, DOES WELL REPLACE Ex15TING+1[EEYu �i'pClle] NO
c, WATER LEVEL Below Top of Cos' FT.
(Use "+" if Above Top ii Casing)
d. TOP OF CASING Is 3 FT. Above Land Surface
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
a. YIELD (gptrt): 1 ()+ -METHOD OF TE51a i t lift
1. DISINFECTION: Type HTH Amount ,2 dun d
g. WATER ZONES (depth);
From 31 a Tc 325 From To
From To From To
From To Fram To
G. CASING: Thickness!
Depth Diameter Weight Material
From +1 To 20 Ft. 19" SDR 21 PVC
Frcm +3 To�Ft. 4.5" SDR 17 PVC
Pram Ta Ft.- -_—
7. GROUT: Depth Material Method
From 0 To 20 Ft, meat cement pump
From 20 To 315 Ft Benton i to pump
From To Ft.
8. SCREEN: Depth Diameter Slat Size Material
From 315 To 325 Ft. 4 in. .03Qn. 9tainle.-
From To FL in. in.
From To Ft, in. in.
9. SANDIGRAVEL PACK:
Depth Size Material
From 285 To 331 Ft- 3 Souther' Pro,
From To Ft.
From To R.
10. DRILLING LOG
From To Formations Description
- 12 cla�;.
12 - 18 sand
18 - 110 clay with sand
_11C_-225
AAna fine to mpri-
2 295� i
27� 34% —s an_� _f +yte t a --me d
11. REMARKS -
Wells are designed to inject water
heat pumps then cycle and orcduce w
for _heat our s
I bn HEREBY CERTIFY THAT THIS WELL. W AS CONSTRUCTED IN ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRt1CTI0N STANDARDS, AND THAT A COPY OF THIS
Ain7z7W�
� ok2_a
SIGNATURE OF CERTIFEDWELL CONTRACTOR DATE
Bobby L . _Harrell
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ucts
rom
ter
Submit the origlnal to the Division of Water Quality within 30 days, Attn: Information Mgt., Form GW-1b
1617 Mail Service Center- Raleigh, NC 276994617 Phone No. (919) 733-705 ext 56& Rev. 7105

Com pliance Ins pection Re port
Permit: WI0700087
SOC :
Effective : 01/28/11
Effective:
Expiration: 12/31/15 Owner: Ashton Lewis Lumber Company
Expiration: Facility: Ashton Lewis Lumber Company
Route 137 Lewis Mill Rd County: Gates
Region: Washington
Contact Person: Thomas Coxe
Directions to Facility:
Gatesville NC 27938
Title: Phone: [phone]
from Washington, take 13 N to Ahoskie. Cross Chowan Bridge. Go approx 2 miles, take right onto 137 E towards Gatesville.
Cross Ballards Crossroads. Next paved road on right is Lewis Mill Road. Lumber Company located .5 mile at the end of the road.
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 12/29/2015 Entry Time: 10:00AM Exit Time: 11 :OOAM
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:
Question Areas:
■ Other
■ Compliant
(See attachment summary)
D Not Compliant
Page: 1
Permit: W10700087
Inspection Date: 12/29/2015
Inspection Summary:
Owner. Faclllty: Ashton Lewis Lumber Company
Inspection Type : Compl iance Evaluation Reason for Visit: Routine
As part of the renewal process for Penni!# WI0700087 R. Sipe w/ WQROS WaRO inspected and sampled two (2) wells
(Well #1 and Well #2) whic_h are associated with the UIC geothermal heat pump system under Permit# WI0700087 . Also
present during the inspection was Ashton Lewis employee Mr. L.T. Downs . The system is plumbed in such a way that
allows the wells to be used interchangeably for supply and injection . At the time of this inspection Well #1 was being used
for supply and Well #2 was being used for injection , as was the case during the last inspection . Both inj .and supply wells
appear to be in good condition consistent with findings of prior inspections and operating adequately . There was a leak at a
valve on the line going into Well #2 , but the operation of the well itself did not appear to be affected . Mr. Downs stated that
repair of the leak is planned in the near future .
Page: 2
Rogers, Michael
From:
Sent:
To:
Subject:
Michael,
Good Morning,
Michael Lancaster <[e-mail]>
Tuesday, January 12, 2016 10:48 AM
Rogers, Michael
RE: Permit Renewal for Permit# Wl0700087
My Title is General Manager. I am the one that has been designated to sign all our Environmental Permits.
Sincerely,
Michael Lancaster
From: Rogers, Michael [mailto:[e-mail]]
Sent: Monday, January 11, 2016 11:32 AM
To: Michael Lancaster <[e-mail]>
Subject: RE: Permit Renewal for Permit# Wl0700087
Michael-I am working on your renewal permit. What is your title? A company officer needs to sign the renewal app.
From: Michael Lancaster [mailto:[e-mail]]
Sent: Thursday, November 19, 2015 4:14 PM
To: Rogers, Michael <michael.rogers @ncdenr.gov>
Subject: Permit Renewal for Permit# WI0700087
Michael,
Good Afternoon,
I received you phone message on renewing our Geothermal well permit. Please email me the application and I will
immediately complete it and send it back.
The address for the well is: 96 Lewis Mill Road, Gatesville, NC 27938.
My Contact information is :
Michael Lancaster
Ashton Lewis Lumber
PO Box 25
Gatesville, NC 27938
Ph# [phone]
Cell# [phone]
Appreciate your phone call.
Sincerely,
Michael Lancaster
2
Well Gravel Packs -Southern Products & Silica Co. Page 1 of 1
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Well Gravel Packs
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Gravel Pack Fine Sand 16-40 #1
Gravel Pack Medium Fine 12-40 #lA Sand
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Gravel Pack Coarse Sand 5-16 #3
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Page 1 of 1
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Copyright Ashton Lewis Lumber Company 2001, All Rights Reserved
http:llwww,ashton.-lewis.com/Distrihutor.hiiii 1/11/2016

PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretar)'
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
Michael Lancaster
Ashton Lewis Lumber Co., Inc.
P.O. Box 25
Gatesville, NC 27938
December 2, 2015
RE: Acknowledgement of Application No. WI0700087
Geothermal Heating/Cooling Water Return Well
Gates County
Dear Mr. Lancaster:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
pennit application and supporting documentation received on November 23, 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 pemiit 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
Michael Rogers at [phone] or [e-mail] .
cc: Washington Regional Office, WQROS
Permit File WI0700087
Sincere I~ ~~---
Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
State of North Carolina I Environmental Quality I Water Resources
1611 Mail service Center I R.sleigh, North Carolina 27699-161 I ·
919 707 9000
Director
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE QUEST FORM
Date: December 2, 2015
To: David May & Robert Tankard
From: Michael Rogers, WQROS -Animal Feeding Operations and Groundwater Protection Branch
A.
B.
C.
D.
Telep/zone: 919-807-6406 Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0700087
Applicant: Ashton Lewis Lumber Co.
Facilitv Name:
Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
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 fonn, 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-WOROS Reviewer: ___________________ Date: _____ _
COMMENTS:
NOTES:
~(p ~ )17 Jot J17
:~ ·11p:=r
FORM: WQROS-ARR ver. 092614 Pagel of 1
Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Friday, November 20, 2015 9:17 AM
'm [e-mail]'
Subject:
Attachments:
FW: WI0700087 Geothermal App
20151119162929534 .pdf
Per your request, please find attached the renewal application for the geothermal return well. Please complete page 1
and page 4 (the signature page) and send back at address indicated on page 4. Thanks.
-----Original Message-----
From: Michael Rogers [mailto:[e-mail]]
Sent: Thursday, November 19, 2015 4:29 PM
To: Rogers, Michael <[e-mail]>
Subject:
This E-mail was sent from "RNPAC7DDO" (Aficio 2075).
Scan Date: 11.19 .2015 16:29:29 (-0500)
Queries to: [e-mail]
1
Ro gers , Michael
From:
Sent:
To:
Subject:
Michael,
Good Afternoon,
Michael Lancaster <[e-mail]>
Thursday, November 19, 2015 4:14 PM
Rogers , Michael
Permit Renewal for Permit# WI0700087
I received you phone message on renewing our Geothermal well permit. Please email me the application and I will
immediately complete it and send it back.
The address for the well is : 96 Lewis Mill Road, Gatesville, NC 27938 .
My Contact information is:
Michael Lancaster
Ashton Lewis Lumber
PO Box 25
Gatesville, NC 27938
Ph# [phone]
Cell# [phone]
Appreciate your phone call.
Sincerely,
Michael Lancaster
■ ASHTON· LEWIS
Premium Pine
November 20, 2015
Division of Water Resources
Attn. Mike Rogers
1636 Mail Service Center
Raleigh, NC 27699-1636
Dear Mr. Rogers,
RECEfVEO/OENR/OWR
NOV 2 3 2015
w=::at=~a•
Enclosed with this letter is two copies of a request to renew our well permit -JtWI0700087. If you have
any questions, please contact me at 252-357-0050 or email me at mlancaster(@ashton-lewis.com.
Sincerely, D
~ c1~
Michael Lancaster
Ashton Lewis Lumber Company
The best-dressed rooms wear Ashton Lewis pine.
96 Lewis Mill Road/ PO Box 25 • Gatesville, NC 27938 • TEL [phone] • FAX [phone]
www.ashton-lewis.com
RECEIVED/Dwim
WSW Quailly Region9l
NORTH CAR0LiI4 F EM'MONMENT AND N.ATUFAL RESOURCES
APPLICATION FOR A PERMff TO CONSTRU ClI' OR OPERATE iNJEC:TION WEMLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTMRMAL HEATING/COOLING WATER RETURN WEL��
These wells) inject groundwater directly into the gubsurA, cc as pan ❑f a geothermal hinting and cooling system
CHECK ONE OF T E, FOLLOWING:
New Application Renewal's Modilf esition Permit Rescissiioa RequeA*
*For Permit Ren als or Rescission Request, complete faggg 1 d <z (signature page) o*
Print or Type Information and Mail to theAddrsss on the Last Pats. Illegible Applications lVill Be ReturnedAs Incomplete.
DATE. 0oJ,.,nb•-, 90 ,24 1 ]PERM YT NO.Ug-"D19W SY7 (leave bla* if New Application)
A- CURRENT WELL USE AND € WNERSIFI_F STATUS (leave blarillc if New Application)
1. Current Use of Well
a. Continue to use as Geothermal Well Drinking Nisi}ter Supply Other Water
Supply
b. Terminate Use: If the well is no longer being used as a geothermal injection wetl and you wish to
rescind the permit, check the box below. If aba.ndarted, 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? XYES ❑ NO
If yes, indicate n"-ew owner's contact information:
Name (
s) - � �' �rL U ' L U m6 z-, M �!�
Mailing Addre
`s
-s: 1P b �A a ��V�LQ-T�.- >, C f'n- L
City. ��[a e 5 %I-. L" State: Zip Cod,:Q J!J 39
Day l ele No.: IS ]t3 7 — 00 S _ _ Email Address ilr+_ _&4 -T �h - S
R_ STATUS OF APPLICANT (choose one)
Non -Government- individual residence: Businessfftvn.liza:tion
Government- State Municipal County __ Federal
C. WELL OWNER(S)IPERMIT APPLICANT- for individual .esidences. Ilst ownerrtSl on pro 7 -!y deed. F•3t
all others, Iist name of entity and name of person delegated authority so sitrn-_aj!�n T > ^ ® '. f
"A3GO r.:+o� s Once l Lcrn c.4 sA-tr -L-7e-r-ter-1
Mailing Address`: l�oe• s�_�Z _ _ ti..Z? �rriLJ RD.)
City_ 1. lV'L State: J4-- 7_ip Code: as-M3 county: Lie
Day Tele No.: a, - _fA_S - �'�._ _ Cell No-- -A-
EMAIL Address: Ml1 l NG, 1,.�[� i- a Fax No.:
f�� tp ram,
GeathcrrnaI Wat<r Roam WWII Per n,ii Application t ised Jan 21l `:) Page i

D. WELL OPERATOR (ff differeat from weg owaar) — For individual a nidences, list owner(s) on property
deed. For all others, list name of entity grad name of person delegated authority to sign on behalf of the
business or agency:
Mailing Address: _
City: Slate: Zip Code: County:
Day Tale No-: Email Address.: _
E. LOCATION OF WELL BITE — 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: Stye: NC .Gip Code:
F
WELT, DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
Contact Person:
Address:
City: Zip Code:
Office Tele No.: Cell No-:
FlVVJL
State: County: ____
Fax No.:
G. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name:
NC HVAC Contractor License No-:
Company Name:
Contact Person: EN LUL Address:
Address:
City: _ Z'sp Code: State: County:
Office Tele Nm: Cell No_:
III. WELL USE Will the injection wells) also be used as the supply well(s) for the following?
(1) The injection operation? YE-S NO
(2) Personal consumption? YES NO
n L , WELL CONSTRUCTION REQTJ)C NXNTS — As specified in 5� A ;AC{]2C 0-2. 24(d):
.r, (1) The water supply well skralI be constructed in accordance with the water supply well requirements of
SAA NCAC 42C _0107.
If a separafe 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 42C .0107, except that:
Geothermal Water Return Well Permit Application (Revised Ian 2025) 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, th1~ 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 s~urce 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 SPECIJFICATIONS
(1) Specify the number and type of wells to be used for the geothem1al heating/cooling system:
____ *.EXISTWG WELLS ____ PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Reco,·d (Fann GW-1) if available .
(2) Attach a schematic diagram of each water supply and injection well serving the geothennal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distingu1shes each well from one another.
Each diagram shall demonstrate compliance with the well construcrion requirements specified in Part
H above and shall include, at a minimum, the following well construction specifo;:ations:
(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) sunounding 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(0(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 DA TA
(I)
(2)
(3)
(4)
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
Average (daily) __ -=gallons per minute (gpm).
Average (daily) ____ gal\om: per day (gpd).
Average (daily) ___ pounds/square inch (psi).
Average (January) ___ ° F, Average (July) __ ° F.
L. SITE MAP-As specified in 15A NCAC 02C .0224(b'l(4 L 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 li sted in l '>A NCAC 02C .0 I 07 1 a}Q) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet ofthe parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal di rections (north, south, west or east)
Gc,1thcrn1ol WLJfcr Return Well Permit Appli~.i1inn (l{c,·i ",:c..l Jan :!O 15) Pag.e 3
NOTE Inmost cases an aerial photograph of the property parcel showing, property limey and strractures con be
obtained and downloaded from the applicable count, GI.S' *ebsite. Zvpicalty, ih,? prone>.roi can be searched by
owner name or address. Tlie location of the wells in relation to properdy boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand Also, 4 `layer' can,be selected showing topographie contours or
elevation data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
l5A NCAC Q2C .D2I1(requires that all permit applications sbali 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 a.Il-the persnz>{s} listed on the I _rn_per deed.
If an authorized agent is signing on behalf of the applicant, thca supplyr .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 personalJy examined am familiar with the information
submitted in this document and all attachutents thereto and 'drat, bayed on my biquky of those individuals
immediately responsible for obtaining said information, I believe that th.e information is true, accivate 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
i u l Lo!1tcis-6x,
Print or Type Full Naine
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent; if any
Print or Type Full Name
Submit twa copies of the completed application package to:
Division of Water Resources
Water- Quality Regional Operatioims Section (WQROS)
1636 Mail Service Center
Raleigh, NC 2769946-36
_Telephone [phone] ,
Geothermal Water Return Well Permit Application (Revised Ian 2015) Page 4

Permit Number W10700087
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
}ohn.mccray
Coastal SW Rule
Permitted Flow
3ciiit,
Facility Name
Ashton Lewis dumber Company
Location Address
Route 137 Lewis Mill Rd
Galesville NC 27938
Owner _
Owner Name
Ashton Lewis Lumber Company
Dates/Events
Scheduled
Orig issue App Received Draft Initiated Issuance
11/17/05 07/28/10 01/25/11
Re-lulateal Activities
Heat Pump Injection
Central Files: APS 5WP
01 /31111
Permit Tracking Slip
Status
Project Type
Active
Renewal
Version
Permit Classification
2.00
Individual
Permit Contact Affiliation
MajorWinor Region
Minor Washington
County
Gates
Facility Contact Affiliation
Owner Type
Non -Government
Owner Affiliation
Thomas Coxe
PO Box 5
NC 27938
Public Notice Issue Effective
01 /28/ 11 01 /28/ 11
Re-mested;Recelved Events
Additional information requested
RO staff report received
Additional information received
Expiration
12/31 / 15
08/31/10
10/01/10
12/02/ 10
Outfall NULI
Waterbody Name Stream Index Number Current Class 5ubbasin

.A.TA
CDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
January 28, 2011
Thomas Coxe
Ashton Lewis Lumber Co.
P.O. Box5
Gatesville, NC 27938
Re: Issuance oflnjection Well Permit
Permit No. WI0700087
Issued to Ashton Lewis Lumber Company
Gates County
Dear Mr. Coxe:
Dee Freeman
Secretary
In accordance with your application received July 28, 2010, I am forwarding Permit No. WI0700087 for the operation of a
5A7 geothermal underground injection control (UIC) well heat pump system located at Route 137, Lewis Mill Road,
Gatesville, Gates County. This permit shall be effective from the date of issuance until December 31, 2015, and shall be
subject to the conditions and limitations stated therein.
Also attached is a summary of the laboratory sampling results from water samples collected from your geothermal well on
September 8 and October 21, 2010. Laboratory analyticaf results of both the influent and effluent samples collected on
October 21 indicate exceedances in the maximum contamination level (MCL) or elevated levels for the following
parameter( s): ·
Parameter Units I MCL I Results
Sodium mg/L Background level 320 (effluent)
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 Crates County Environmental Health Department.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application to renew
the permit 120 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,
./
7 / # 4£/,; ---;,..(, Y'-/?·1, ~ h/ -~ /, .
John McCray
Environmental Specialist
AQUIFER PROTECTION SECTION
1636 Mail Service Cenier, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterauali ty .o ro
An Equal Opportunity \ Affirmative Action Employer
Ni¥t:11 Carolina
JVaturall!f
cc: David May -Washington Regional Office
Central Office File -WI0700087
Gates County Environmental Health Dept.
Attachment( s):
Permit
Sample Results
l
MEMORANDUM 18-0ct-10
To: Thomas Coxe -Ashton Lewis Lumber Company
From: John McCray [phone]
Re: Groundwater Sampling Results from September 8 and October 21, 20 I 0
Influent Water Saml!le Effluent Water Sam11 le
Parameter Standards Results Standards Results
Groundwater Drinking Groundwater Drinking
Coliform, total 1 per 100ml zero <1 Coliform, total 1 per 100ml zero <l
Coliform, fecal 1 per 100ml zero <1 Coliform, fecal 1 per 100ml zero <1
pH 6.5-8.5 7.0-8.5 8 pH 6.5 -8.5 7.0-8.5 7.9
Hardness no standard no standard 10.2 mg/L Hardness no standard no standard 10.2 mg/l
Chloride, Cl 250 mg/L no standard 200 mg/L Chloride, Cl 250 mg/L no standard 190 mg/L
Flouride, F 2 mg/l 4mg/L 2 .3 mg/L Floride, F 2 mg/L 4 mg/L 2.3 mg/L
Sulfate, SO4 250 mg/l no standard 57 mg/L Sulfate, SO4 250 mg/L no standard 38 mg/l
Dissolved Solids 500 mg/l no standard 804 mg/L Dissolved Solids 500 mg/l no standard 766 mg/L
NH3 as N in liquid 1,500 ug/L no standard 0.4 mg/L NH3 as N in liquid 1,500 ug/L no standard 0.32 mg/L
Total Kjeldahl N 0.2 mg/L no standard 0.66 mg/L Total Kjeldahl N 0.2 mg/L no standard 1 mg/L
as Nin liquid as N in liquid
No2• + NoJ· asN 10 mg/L 10 mg/L <0.02 mg/L NO2· + NOi-as N 10 mg/L 10 mg/L <0.2 mg/L
Phosphorus total_ .02 mg/L no standard 0.2 mg/L Phosphorus total .02 mg/L no standard 0 .53 mg/L
as Pin liquid as P in liquid
Nitrate as N in liquid 10 mg/L 10 mg/L mg/L Nitrate as N in liquid 10 mg/L 10 mg/L mg/l
Nitrite as N in liquid 1 mg/L 1 mg/L mg/L Nitrite 1is N in liquid 1 mg/L 1 mg/L mg/L
Aluminum, Al 50 ug/L no standard <50 ug/L Aluminum, Al 50 ug/L no standard <50 ug/L
Arsenic, As 50 ug/L 10 ug/L <2.0 ug/L Arsenic, As 50 ug/L 10 ug/L <2.0 ug/L
Barium, Ba 2.0 mg/L 2.0 mg/L 28 ug/L Barium,Ba 2.0 mg/L 2.0 mg/L 28 ug/L
Cadmium,Cd 1.75 ug/L 5.0 ug/L <1.0 ug/L Cadmium.Cd 1.75 ug/L S.O ug/L <1.0 ug/L
Calcium, Ca 0.1 mg/L no standard 1.3 mg/L Calcium,Ca 0.1 mg/L no standard 1.3 mg/L
Chromium, Cr 10 ug/l 100 mg/L <10.0 ug/L Chromium, Cr 10 ug/L 100 mg/L <10.0 ug/L
Copper, Cu l mg/l 1.3 mg/L 0 mg/L Copper, Cu 1 mg/L 1.3 mg/l 0 mg/L
Iron, Fe 300 ug/l no standard <50 ug/L Iron,Fe 300 ug/L no standard <50 ug/L
Lead, Pb 15 ug/L 15 ug/L <10.0 ug/l Lead.Pb 15 ug/L 15 ug/l <10.0 ug/L
Magnesium, Mg 0.1 mg/L no standard 1.7 mg/L Magnesium, Mg 0.1 mg/L no standard 1.7 mg/L
Manganese, Mn SO ug/L no standard <10 ug/L Manganese, Mn 50 ug/L no standard <10 .0 ug/L
Mercury, Hg 1.05 ug/L 2.0 ug/L <0.2 ug/L Mercury,Hg 1.05 ug/L 2.0 ug/l <0.2 ug/L
Nicke~ Ni 100 ug/L no standard <10.0 ug/L Nickel.Ni 100 ug/L no standard <10.0 ug/L
Potassium, K 0.1 mg/L no standard 14 mg/L Potassium, K 0.1 mg/L no standard 14 mg/L
Selenium, Se
Silver, Ag
Sodium, Na
Zinc,Zn
50 ug/L
17.5 ug/L
0 .1 mg/L
1 mg/L
50 ug/L
100 ug/L•
no standard
no standard
<5.0 ug/L
<5.0 ug/L
310 mg/L
<10.0 ug/L
Selenium, Se
Silver, Ag
Sodium, Na
Zinc, Zn
50 ug/L
17.5 ug/L
0 .1 mg/L
1 mg/L
50 ug/L
100 ug/L •
no standard
no standard
<5.0 ug/L
<5.0 ug/L
320 mg/L
23 ug/L
l .t
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Ashton Lewis Lumber Company
FOR THE OPERATION OF 2 TYPE SA 7 INJECTION WELLS, defined in Title 1 SA 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 Route 137, Lewis Mill Rd, Gatesville, Gates County, NC 27938, and will be
constructed and operated in accordance with the application July 28, 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 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 15.A 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 December 31, 2015, and shall
be subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
Permit issued this the 28th day of January, 2011.
M\.Coleen H. Sullins, Director
~ Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0700087 UIC/5A7
ver. 03/2010
Page 1 of 5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
PART II-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effectjve 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, 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.
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.
Permit #WI0700087 UIC/SA7 Page 2 of 5
ver. 03/2010
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 Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART IV -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times .
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
PART V -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the .Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any 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 VI -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
Permit #WI0700087 UIC/SA7 Page 3 of 5
ver. 03/2010
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Washington Re,brional 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 perfohn satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VII -PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
PART VIII-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is ,taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 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.
Permit #WI0700087 UIC/5A7 Page 4 of 5
ver. 03/2010
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of.the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
Permit #WI0700087
Aquifer Protection Section-DIC Program
DENR-Division of Water Qu_ality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/SA7
ver. 03/2010
Page 5 of 5
Permit Number Wl0700087
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Ashton Lewis Lumber Company
Location Address
Route 137 Lewis Mill Rd
Gatesville NC
Owner
Owner Name
Ashton Lewis Lumber Company
Date s/E vents
27938
Scheduled
Orig Issue
11/17/05
App Received Draft Initiated ·Issuance
07/28/10 01/25/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
01/26/11
Permit Tracking Slip
Status
In draft
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Was~ington
County
Gates
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Thomas Coxe
PO Box 5
Gatesville NC
Public Notice Issue Effective
eauestedJReceived Events
Additional information requested
RO staff report received
Additional information received
27938
Expiration
08/31/10
10/01/10
12/02/10
Waterbody Name Stream Index Number Current Class Subbasin
1
V" 01 O La6oratorv.Section Resuft s
County: GATES Sample ID; A864859
RiverSaslr. 0� �RrEig4 ! PO Number it 19G0736
Report To WAROAP � jJ e. ❑ate Received: 1012Y1201D
1 1a Time Received: 08:40
Collector. A CLARK O
Region: WARO , Labworks LoginlD SMATHIS
Sample Matrix: GROUNDWATER Report Generated 11/18/10
11 Date Reported; 11116/2010
Lac. Type: MONITORING WELL
Emergency Yes/No VtsitlD
COC Yes1No
Loc. nesm: ASHTON LEWIS LUMBER COMPANY
Localiurl ID: APS-N-SWW-GATES-9087 Golfed Dale;-1012112010 Coiled Urna, 11:40 Sample Depth -
CAS #
LAB
Anaivte Name
Sample temperature at receipt by lab
PQL
Result/
Qualifier
1.5
nits
C
Method
Reference
Analysis
[]ate
10/22/10
Validated
SMATHIS
MET
7440-22-4
Ag by ICPMS
5
5.0 U
u9IL
EPA 200.8
1012611a
ESTAFFORDI
7429-90-5
Al by ICP
so
50 U
uglL
EPA 200.7
10/26/10
ESTAFFORDI
7440-58-2
As by ICPMS
2
2.0 U
ug&
EPA 200.8
1012W10
ESTAFFORDI
7440-38-3
Ba by ICP
10
28
u9n-
EPA 200.7
1W25H0
£STAFFORD1
7440-70-2
Ca by ICP
0.1
1.3
mgIL
EPA 200.7
10/25/10
ESTAFFORDI
7440-43-9
Cd by ICPMS
1
1.0 U
ug1L
EPA 200.8
10/26110
ESTAFFOR01
7440-47-3
Cr by ICPMS
10
IOU
ugn-
EPA 200.8
10/26/10
ESTAFFORDI
7440-50-8
Cu by ICPMS
2
2.9
ug&
EPA 200.8
IM6110
ESTAFFORDS
7439-09-6
Fe by'iCP
50
sou
uglL
EPA 200.7
10/26110
ESTAFFORDI
7439-97-6
Hg 245.1
0.2
0.20 U
ug1L
EPA 245.1
10127110
ESTAFFORDI
7440-09-7
K by ICP
0.1
14
mg/L
EPA 200.7
10125/10
ESTAFFORDI
7439-95-4
Mg by ICP
0.1
1.7
mglL
EPA 230.7
10/25110
ESTAFFORDI
7439-96-5
Mn by ICP
10
IOU
ug1L
EPA200.7
10/26110
ESTAFFORDI
7440-23-5
Na by ICP
0.1
310
mg1L
EPA 200.7
10/25/10
ESTAFFORDI
7440-02-0
Ni by ICPMS
10
IOU
u911-
EPA 200.8
10126/10
ESTAFFORDI
7439-92-1
Pb by ICPMS
10
IOU
ug1L
EPA200.8
10/26/10
ESTAFFOR01
7782-49-2
Se by ICPMS
5
5.0 U
ug1L
EPA 2008.
10M76110
ESTAFFORD I
7440- "
Zn by ICPMS
10
IOU
ug(L
EPA 200.5
10/26/10
ESTAFFORGI
RECSVOIDMof M
Aquifer Pr0#echou Section
__ :. _0OW
Laboratory Sectlrnv> 1623 Mah Service Center, Raleigh, NC 276994623 1919) T33-3908
For adera'led doso-okon v(-gaalir- cwes m%rrd st-Il[U�i' ..�i�Shr O.•y/WAI�w bar,+s+mn�al4r ass an!!�a_4yntlfrpr congf eryllSY r{ainWQrLS40 � � .9iE[19. ,51�
Page 1 of 1

North Carolina
GROUNDWATER FIELD/LAB FORM Departmenl of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Location code ti -i `; ` SW W SAMP E TW-F- SAMPLE PRIORITY
County Ga r-ZS. 4'� Wafer tA Routine Lab Number RV
Vs
Quad No Serial No. 0 Soil ❑ Emergency . r pate Recein im D �
LaL Long_ ❑ Other Reed By_ From: Bus, CDurie , i land Del..
❑ Chain or Custody Other:_
Report To: ARC, FRO, MRO, RR ' WaR W RO, Data Entry By: Ck'
WSRO, Kinston FO Fed. Trust, Central Off., Other. pate Reported:_
Shipped by: Bus, t n Hand Del„ Other. _ Purpose-.
CoNectar{s}: ,� i f r Gt Datey o Time L!' 4+h Raseaine, Complai t, CornpUance, Lu , Pestici¢ Study. Federal Trust, other ,
FIELD ANALYSES Owner -Un LQVw 1SeO"g}
pH eon '� Spec. Cond. ,. at 25°C Location or Site _q, 'S j'V N- o:; r, V, "-VL IN 5 Lk
Ternp.l❑ 2.0, (s>,6_ °C Odor )Ao _ _ Description of sampling point _ W
Appearance C.1ettr Sampling Method OD S mple interval
Fuld Analysis By:A.-Q,_t Remarks P.O.r e'y `.� flC�_ c ems .c��o•na fir. �I. [m __
LABORATORY ANALYSES %1j,(v„npng �me, ai<iernv., elr.7
ODD 310 mgA_
Diys. Solids 70306 � T m91t
_
COD High 340 mgfL
Fluoride 951 mglL
COD Low 335 mg1L
Hardness' Trawl goo M91
Col Norm: MF Feral 31616 1100m1
Hardness [norrearb3 902 mg1L
'Conform: WTotal 31S❑4 11Bond
Phenols 32730 USIA
TUC Sato mg1L
Specific Cond, 95 uMhoslcm
Turbidity75 N'ru
Sulfate 945 m91L
Residue. Suspended 530 mg1L
Sulfide 74S mg1L
Oil and Grease mg1L
��—
PH 403 units
Alkalinity lei pH 4.5 410 mg1L,
Akalinity la pH 0.3 415 rnglL
r
Carbonate 445 mg/L
NHS as N 610 mg/L
E iaftmate 440 mgA-
TKN as N 625 mgR
Carbon dioidde 4 05 mg/L
NOz + N04 as N 630 m91L
Chloride 940 mg1L
P. Total as P 665 rng1L
Chromiurn: Hex 1032 uglL
Nitrate (NO3 as N) 620 mglL
Color. True 80 Cu
Nitrite (NO, as NI 6IS mgR,
Cyanide 720 mgA_
Lab Comm erns w
GW-54 REV- 7163 For {Tsselved Anal ysis-subrtrtfrllered sample and wrile'AIS- in Wnd-
A¢Sliver 46566 u (L
AI -Aluminum 45557 u rL
Or• wwChlarine Pesuddes _
Or ono has arcs Pesucides ��
Njbx en Pesliddes
Acid I-Imt cides
As -Arsenic 46551 u !L
$a -Barium 46558 u !L
Ca -Calcium 46552 1141 2agy� m !L
Cd•Cadmlum46559�rl-r[j�>C�[rjrttl
PCt3s
�r
Cr-Chromium 4u IL
Cu-Coppar 49592 (it - C
Fe -Iron 46563 A
f
Semiwlatiln Organics
T_PH-Diesel Range
Hg-Mercury 71900 vWL
K-Potassium 46555 rng1L
Mg -&Magnesium 46SS4 mg1L
Mr�lUanganese 465G5 u 1L
-R.
Volatile prgani[s (VOA kiottle)
TPH-Gasoline Range
TPH-137E_7C Gasoline Ranter
ilia -Sodium 46555 m 1L
m6mickei uglL_
Pb-Lead 46564 uU91L
xn-Zinc 46567 µ uq
t.P6_L]SE ONLY
Temperature on arrival [°Gj:
T

! r
County: GATES Sample ID: AB64858
River Bastin NNA PO Numbar# 10G0735
Report To WAROAP O� 5� Date Received: 10/2212010
Collector. A CLARK � Time-Reratvad: 08:40
Lobworks LoglnlD SMATN(S
Reglon: WAR Q
SReport Generated: 1?I12I70
Sample Matrix; GROUNDWATER
Date Reported: 1111212010
Loc. Type: MONITORING WELL
Emergency YeslNo V19RID
COC Yes/No
Loc. Deser„ ASHTON LEWIS LUMBER COMPANY
Location ID: APS-N-IWW-GATES-0087 Collect Date: 1012112010 Collect Time: 12,10 Sample Depth
CAS # Analyte Name POL ResulV Units Method Analysis Validated by
1
Qualifier Reference Date
LAB
Sample temperature at receipt by lab j,$ `C 10/22/10 SMATl1I'S
MET
7440-22-4 Ag by ICPMS 5 5.0 U ug8- EPA200.6 10126M0 ESTAFFORDI
7429-90-5 Al by ICP 50 50 u ug/L EPA 200.7 10/25/10 ESTAFFORDI
7440-38-2 As by ICPMS 2 2.0 U uA EPA 200.8 10128/10 ESTAFFORDI
7440-38-3 Be by ICP 10 28 ug1L EPA 200.7 10125A0 ESTAFFOR01'
7440-70-2 Ca by ICP 0.1 1.3 mg1L EPA 200.7 10125/10 ESTAFFORDI
7440-43-9 Cd by ICPMS 1 1.0 u uglL EPA 200.8 10/26/10 ESTAFFORDI
1440-47-3 Cr by ICPMS 10 10 U ug1L EPA 200.8 10/25/10 ESTAFFORDI
7440-50-8 Cu by ICPMS 2 3.8 uglL EPA 200.8 Imam ESTAFFORDI
7439-89-6 Fe by ICP 50 50 U Ug1L EPA 2001 10/28/10 ESTAFFORDI
7439-97-6 Hg 245.1 0.2 0.20 U ugll. EPA 245A 10127/10 ESTAFFORDI
7440.09-7 K by ICP 0.1 14 mglL EPA20G_7 10/25/10 ESTAFFORDI
7439-95-4 Mg by lCP 0.1 1.7 mWL EPA 200.7 10/25/10 ESTAFFORDI
74394M Mn by ICP 10 10U ug& EPA 200.7 10/26/10 ESTAFFORD1
7440`23-5 Na by ICP 0.1 320 mg/L EPA 200.7 10t25110 ESTAFFORDI
7440-02-0 Ni by ICPMS 10 IOU uglL EPA 200.8 10/26/10 ESTAFFORDI
7439-92-1 Pb by ICPMS 10 IOU uglL EPA200.8 10/26/10 ESTAFFORDI
7782-49-2 Se by ICPMS 5 5.0 u ugIL EPA 200.8 10/26/10 ESTAFFORDI
744M6.6 Z_n by ICPMS 10 23 u9lL EPA 200.8 101a5110 ESTAFFORDI
07
Laboratory Section-1623 Mail Sarylce Center, RaleigR, NC 27609-1523 1919) 733-3908,
nr � dela@ed 0as cripdon of [he quek3 fer codas referw lril 1!110.1 e11 M11 nr, mr: as%iFIVCIA la ❑ rw rim C 1 eI s . I of !
Page 1 of 1

NMh Carolina
GROUNDWATER FIELD/LAB-FORM Department. or Environment. and Natural Resources
_ _ DIVISION OF WATER QUALITY-GiRbU DWATER SECTION
Location c-ode + � `ZYJ111� '� q QS— �� SAMPLE TYPE Sg )aLE PRI�RIFY_ I �� - '3 5- 1
County � a� _ it W4ler Ftoutine La1b Dumber
Quad No 5eslal No- - Emergency i��2 �-
❑ Soil ❑ �'�"� }� Date Receiv _ Ti
LaL Lang. — ❑ Other ReCd By. r From.13- .., Gouri , Hand Del-
0 Chain or Custody Other_
Report To: ARO. FRO. MRO, RR WaR W1RO, - - - - Data Entry By, — Ck: _
WSRO, ffinston FO Fed. Trust, Central Off-, Other Date deported' _
Shipped by- Bus, oun Hand Del., Other. _ Purpose:
Collector(s): _�D. 5, �Vt � Date �d Zcl Time :40 `Baseline, Complaint. C-ornpit ance. LUST, Peshci¢e 5turiy, Fe-d�eral Trust, Other. _
FIELD ANALYSES Owner - TW � �.��rd �`7 �xi]i [;[ [rrrr• SnrUe anal �Cirnl� s �/�l i � L� �]Q� T
PH 4- Spec. Cond.94 —at ZSoC Location or Site�i.avJ�'� t�1� 0- & rQy
Ternp_1a D, °C Odor Na Description of sampling mint
Appearance p • Sampling Method z 00 Sample Int I _
r, �T.r
Field Ali ysis By._ Remarks ❑ = O , �_ z 5 11 _BAH r _ra? �{ k�_4 m� "3`
LABORATORY Ali ALYSES� �
BOO 310 mg1L Diss _Solids 70300 -- mg7L Ag-Silver 46566 ug(L O_r �anxhlorine pes50des
-- CDf3 Fhglr 340 -- - mglL Fluoride 951 --� - mglL Al PJuminum iGS57 u..&L Osgano�hosphwus Pesticides
GODtuw 335 - - mgrL Hardness:ToW 900 - mgA. As -Arsenic 46551
'Col iFornl: MF Fecal 31616 7100m1 Piaidnesa (non-�carh)9112 mglL 8a-Banum 4655e uglL Acid Herbicides
Colftm: MF Total 31504 MUM Phends 327313 ugA Ca-Caldum 46552 _ m PCBs It.
TOC 660 - - mg/L SpedfiicCond. 95 ui1 hosrcm Cd-Cadmium 46559 tAA-- V3 ug7L-
Turbidity76 NTU Sulrate945 �mg1L CNChrcrAw +46559 — 5'�ii'tLti ug1L
Residue. Suspended 530 mg/L Sulfide 745 mgR cu-copper46562 "r \
Fu-Irorl46563 � � - semivolable_Organics_ -
Oil and Grease mgrt lig Mercury 71900 TPH-Diesel Range
PH403 - - l -- units -- K-Potassium 46555
Alkalinity to pH 4.5 410 rng1L- Mg -Magnesium 46554 - mgIL - - -
Alknliraty to PH a.3A15 - mgR _ -- - - Mn-Manganese 46565 u�iL Volatile qr ag nirs (VOA Wtlle)-
Carbonale 445 mglL NH' as N 6 1 a - niq& Ma- Sodium 46556 mQ�1 TPH-Gasriine Range
8+rarbvnate 440 - w mg& TKN as N 625 rngrL N-Nicks - _ u91L TPH-BTEX Gasoline Range
Carbon diardde 405 - mgA- NDi +NO3 as N 67d mgR Pb-Lead 45564 vgR
Chimide940 mgr+,. e; Total as P 665 mgA_ Se -selenium ugR
Chmmnrrm: Hex 1032 - ug1L Mtrale (NO, as N) 620 mgA Zn-Zinc 4 656 7 u R - -�-Y
Color. True 80 cu - Nitrite (KOz as 14) 615 mg1L LAB U5 DAl LY
— — Cyanide 720 mg1L Temperature on arrival ("C): 1
_- - - ---� - -- - -
Lab Comments
GW511 REV. 7163 Fur Dissolved Arnalysis-submit rille-red sample and write -DIS- in bto&-
s

Caunly:
GATES
Sample 101
AB63259
River Basin
g V+1ATF,Qv
PO Number 9
W100683
Report To
WAROAP
�D
pale Received:
09108120113
i'
:4
Time Received:
15:30
Collector:
A CLARK
Labworks LoginlD
MSTARR
Region'
WARD
Report Generated:
9115110
Sample Matrix:
GROUNDWATER
Date Reported,.
09115/2010
Loc. Type:
MONITORING WELL
Emergency Yes/No
Vlsltlt7
C� Yes/No
� �� � • r� 1�7
Loc. Descr.: THOMAS CORE- ASHTON LEWIS LUM13ER COMPANY
Location 9
APS-N-IWW-GATES-0087
Cflllect Date: OUW2014
Collect Tlme: 11:10
Sample Depth
Result/
Method
Analysis
CAS # AnalO fame PQL
L nits
Yalid> ev
—
Qualifier
Reference
Date
WARD
Sample temperature at receipt by lab
1.8
°c
918110
SMATHIS
Coliform, MF Far -al in liquid 1
1 131
CFU1100ml APHA92221320th
91B110
1-STAFFOR01
Collform, MF Total in liquid
1
UUf100m1 APHA9222B-2oth
916110
ESTAFFORD1
GJ
W '
Laboratory SectinM1» 1623 Mal Service Center, Raleigh, NC 27699.1623 [phone]
for a detailed de3".rip1,.P of the quuliiier cud" War le inyt-r/�rift511••x7en• err ^S! '-'1�!?!', .Af!"�°64 DR"'k1�nJ�'a.-SlY.9i ,k�Q.!'; ,'�,t�P-H� +,n;r(eJ),r n]-j�r��r �[{�.1• R'nlc h x;�..5j=
Page 9 of I

GROUNDWATER FIELD/LAB FORM
Laration code
ovad No seqa, Nu.
�^•-� ri+,r:f! f:'Sri,-,r1,3
J1, f)[partmem of Eru4gr•-r:r'•t• »s ?� 4,r.:.,l+1 Fle-,!urca,
rr1 istoN Of WATER Ol•IA[, Y-(iH'J.11';AVA rER ai=CT(ON
VYPF SAlsSP, E PRIORI I Y
4hr.: r Routine
J rru*
k
Rep,h7 To AR-1 FRQ{ f`R0.
Ft,r'SRO. ft vmint) FQ, Fec !_ C_ei ni T]kr- Offief
,�hril:,�,r:t4 r,y r� s, �;n;,r>r,r. i:s'st:• f rc-�i"ru�r. ..----- �- .-_ j p�trp;�se.
0r) Tir11f?, arse iainL, fiUn
y
+ f _ ,i .. •V r"7.TdFc. L�iY id.,p. Sr. • T..cu-Woo o'::I{i•'
�_..
Ur:n-';nOwyn of nam I�plq pvt]I' .. .�i
Apprwwiu _, � Y - - - h=srr� :iris3 A�w l r _ ': t•.a t _T r1 1 _ :!rivet . _
�._.._..-...... ..... _.,.... _.......... .-..... _.. .
L AE30R I Of t' ANAI `i51=. ---- ---- -- rn; r . .. ,. ,
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u:
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; � _ � _ _ • - 'mot i s- � � r,� � z I s. �r� 1 r _
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Lab ihirrnrir•r L/-,J � n � —�
Rr,o'd Sy k for'I rhj,�, Cousio:.9-1--and CFI.,
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rwe. LUST 1::il;.Fsy rdt fat rum Oihiv

WCUM0 LaboratonNection&sults
County; GATES I Sample 10'. ABfi3262
River basin Of W A7c� %� PO Number # 1flG0632
Report To WAROAP �O� aG \0 Date Revolved: 0910912010
Coileetur A CLARIC y 4 Q � Time Received: 09:20
Region' WAR ❑ ! abworks LoginlD SMATRIS
f2cpcirt Generated: 1017110
Sample Matrix' GROUNDWATER
Loc. Type: MONITORING WELL Date Reporlrad: 1010717910
Emergency YeslNo VlsilID
CDC YeslNp
Loc, Oescr.: THOMAS CORE-ASHTON LEWfS t.UtMBER COMPANY
Lovation i0: AP3•N4wW-GATES-0087 Calleet Data: 0910812010 Collect Time: 11:10 Sample Depth
CAS #
LAB
Arlalyte Name
Sample temperature at receipt by Jab
p-0-L
Result/
Quaiifier
1.0
Units
c
Method
Reference
Anal sis
Date
919nv
Validated b
SMATHIS
WET
ion Chromatography
TITLE
m91L
EPA300-0
912711D
CGREEN
Chloride
1
190
m9n-
EPA 300.D
9127110
CGREEN
Fluoride
0.4
2.3
mglL
EPA 3DD.0
9127110
CGREEN
sulfate
2
38
englL
EPA 300.0
9127110
CGREEN
Total dissolved Solids in liquid
12
765
me&
ikPHA254OC-18TH
9110tio
MOVERMAN
NUT
NH3 as N in liquid
0.02
0.32
rrt91L as N
Lac1D-107-W1-J
919110
CGREEN
Total Kf eldahl N as N in liquid
0.2
1.0
m4iL as N
Lachatla7-06-2-H.
9121110
CGREEN
NO2-�NO3 as N in liquid
0.02
0.02 U
mglL as N
Lac10-107-04-1-c
919110
CGREEN
Phosphorus total as P in liquid
0.02
0.53
mglL as P
Lac10-115-01-lEF
9110110
CGREEN
MET
7429.90-5
Al by tCP
50
50 U
ugfL
EPA 200.7
9113110
ESTAFFORDI
740-70-2
Ca by ICP
0.1
1-0
mg&
EPA 200.7
9113110
ESTAFFORDI
7440-47-3
Cr-by ICPMS
10
10 u
uglL
EPA 200.8
9115110
ESTAFFORD1
7440-50.8
Cu by ICPMS
2
450
vglL
EPA 200.9
9115110
ESTAFFORDI
743m9$
Fe by ICP
s0
1300
ugA-
EPA20D.7
9113110
ESTAFFORDI
744M9-7
K by ICP
0.1
14
nVtL
EPA 200.7
9/13110
ESTAFFORDI
7439-95-4
Mg by ICP
0.1
1.2
mglL
EPA 200.7
9113110
ESTAFFORDI
7439-9&5
Mn by ICP
10
18
uglL
EPA 200.7
Sit V10
ESTAFFORDI
7440-23-5
Na by ICP
0.1
330
rng11
EPA 200.7
9113110
ESTAFFORDI
7440-W-D
Ni by ICPMS
14
1 o t1
u91L
EPA 260.E
9115110
ESTAFFORD1
7439-s2.1
Pb by ICPMS
10
130
uglL
EPA200.8
9115110
ESTAFFOROI
7440-65-6
Zn by ICP
10
48000
ug/L
EPA 200.7
9113f10
ESTAFFORDI
Laboratory Sectlonas 1623 Mail Service Center, Raleigh, NC 27699.1623 (919) 733-39o8
For a deiaPM d�y„hplip a the q,.dTer cWe$ refar to IS �i+w1ASr1Pf8�1�-5>�I�l� _ l ;er [`�. srTkL;e prta��lgjp�r.pry .�yyrlgt�(q�.Ss(y(lerh�rGl@I�
Page i of i

GROUNDWATER FIELD/LAB FORM
Location code_&ti
County G
Quad No
Lat
NoRh Carolina
Deparlment of Environment and Natural Resources
_ DIVISION OF WATER QUALITY-GROUNOWATFR SECTION
SAMPLE ��' ��a��--
lu .Routine Lab Number
ElEmergeney Date Received Time' �;Zb
Rec'd By: `� From -Bus, ourie , Hand Del„
r_ + Other
Report Ta ARO, FRO, MRO, RRO WaR WtRO, �--- - - Data Entry By., Ck:
WSRO, Kinston FO Trust Central Off., Other- Date Reported
Shipped by_ �us, 'aUri hand Del.; Other_ Purpose:
b%TimeBaseline, Complain Cornplianc. LUST Pesticide Study, Federal Trust, Other:
F-1 ELO ANPyLYSES Owners ��s� �.� -
PH 400_ Spec- Corld.94 at 250C Location or Sitel,;�,,,;
Tip-,n QC Odor Description of sam lin pointer ti
Appearance Sampling Meta❑ ta� S mple Interval
Field Analysis By: Refnar 5 i�i L}��5 c OR -(-I egY- ,q i•
LABORATORY ANALYSES _ j!' pr+ssme-aria„p..'W" _
BOD310 mglL Diss.Solids70300 mglL A¢5il�er4fiS66
_ _ _ u !L �r anochlarine Pesticides
COD High 340 mglL Fluoride 951 m IL N-AlumVam 46557 pr�� h - -
g u IL arw hoc erus P-Jcidrs
a as irraw ra cis
Serial No.
Long.
SAMPLE TYPE
19 Water
❑ Soil
0 Other
❑ Chain of Custody
-
Col] Low 335 mgrL
Hardness' Totat son ruglL
Hardness !non -cart}) 902 mglL
_ -
CoRorm:-MF FM4 3161S /loom$
'Colilorrn: MF Tod 31504 I10ornt
roc 660 mg&
Phenols 32730 u9A
Specific Card- 95 uMhoslcm
Turtidity7B NTU
Sulfate945 mglL
Residue. Suspended 530 mg1L
Sulfide 745 mglL
-
064 and Grease mglL
_
pH 403 units
Alkalinq to pH 4-5 410 mglL'
Alkalinity to pH 8.3 415 mglL
Carbnmate 445 mgn_
N%.as N 510
Ncarbonale 440 mglL
TKN as N 625 '� fnglL
Carbon dioid4e 405 mglL
NOz+N%as N 630�rp r7 mgA_
Chloride 940 mg&
P_ Total as P 653 g� -�Y 4v z �f�glL
Ctrnmium: Hex 1032 ug&
Nitrate (NOD as N) 620 mglL
Color True ao CU
Nitrite (NO= as NJ 515 mgA-
'Cyraoide 720 mglL
—
Lab Commerds
Gv1L54 REV_ 7103 For ❑iwwd Analysis submit 5itered sampre and wrlie - 0 1S' 1n block
AS -Arsenic 46551
_ ugly
Ba-Sadum 4655E
ugll
Ca -Calcium 46
mg2
m552
Cd-Cadium 46559
u li
Cr-Chromium 4e5S
u 2
Cu-Copper46562tY`
Fo-lror+155fi3
it.ug1L
Hg-Mercury 71900
!-Potassium 46555
mg1L
Mg -Magnesium 46554
� ;) Z. mglL
r,.,y��
Mn-Manganese 45W [ ,�
No -Sodium 46556
mglL
Ni-N}ckrJ ug&
Pb-Lead 46564
ugR
se -selenium
- _ ugn-
Zn-Zinc 46557 ,�'
_
uqA_
Ni"en Pesti ides
Acid HarbWdes
PCBs
SemiWathe Organics
TPH-Diesel Ranee
Volable Orgar4cs (VOA battle)
_TP_H-Gasoline Rangk
TPH-EfTEX Gasoline Range
LAB 11SE flNL.Y
Temperature on arrival (°C): }

9W011,10 Labuwlary-Yca�w
County:
GATES
Sample ID:
AB63261
River Basln
OF WArF
PO Number k
10G0631
Report To
WAROAP
;�
Dale Received:
0910912010
}
r1
Time
me Received:
08:20
Colleeror:
Region:
A CLARK
WARD
1p •
Labworks LoginlD
SMATHI5
Report Gencraled'
10[7110
Sample Matrix:
GROUNDWATER
Date Reported-
10/0712010
Loc•_Type'
MDNITORING WELL
Emergency YeslNo
Vi511ID
COC Yes1Na
Lac. Descr_: THOMAS COXE-ASFtTON LJFVAS LUMBER COMPANY
Location ID;
APS-N-SVYW-GATES4087
Collect Bute: 0910812010
CGllect Tim a: 10:55
Sample Depth
Result/ Method Analysis Validated by
CAS # Anaiyte Name PQ4 Units
Qualifier Reference date
LAS
Sample temperature at receipt by lab . 1.0 `r 919110 SMATHIS
tan Chromatography
TITLE
rngA-
EPA 300.0
9127110
CGREEN
Chloride
1
200
mglL
EPA 300.0
9127110
CGREEN
Fluoride
0A
2.3
mgR.
EPA 300A
9127110
CGREEN
Sulfate
2
57
mg1L
EPA 300.0
9127110
CGREEN
Total dissolved Solids in liquid
12
804
mglL
APHA2540C-i81'H
91101i0
MOVERMAN
NUT
NH3 as N in liquid
0.02
0.40
mg1L as N
Lac10-107-06-i-J
919110
CGREEN
Total Kjeldahl N as N in liquid
0.2
0.66
mglL as N
Lachat107-06-2-H
9121110
CGREEN
NO2+NC3 as N in liquid
0.02
0.02 U
mg4-asN
L.aciD-10744-1-c
919110
CGREEN
Phosphorus total as P in liquid
0.02
0-20
mglLas F
LacID-115-01-1EF
9110110
CGREEN
MET
7429-90-5
AJ by ICP
so
50 U
ug/L
EPA 200.7
9113110
ESTAFFORDI
7440-70-2
Ca by ICP
0.1
1.3
m91L
EPA 200.7
9/13110
ESTAFFORD1
7440-17.3
Cr by ICPMS
10
10 U
uglL
EPA 200.8
9115110
ESTAFFOR07
74411-50-9
Cu by ICPMS
2
28
u911-
EPA 200.8
9115(10
ESTAFFOR01
7439-89-6
Fe by ICP
so
680
ag/L
EPA 200.7
9113110
ESTAFFORDI
7440-09-7
K by ICP
0.1
15
mglL
EPA 200.7
g/13110
ESTAFFOR01
7439-95-4
Mg by ICP
0.1
1.7
mg1L
EPA 200.7
9113110
ESTAFFORDI
7439-96-5
Mn by ICP
10
IOU
uglL
EPA 200.7
W13110
ESTAFFORDI
7440-23-5
Na by ICP
0.1
330
mg1L
EPA 200.7
W13110
ESTAFFORDI
7440-D2-0
Ni by ICPMS
10
IOU
ug/l_
EPA 200.8
9115110
ESTAFFORDI
7439-92-1
Pb by ICPMS
10
'l o U
ug&
EPA 200.8
911511 o
ESTAFFORDI
7440-06-5
zn by lCP
10
140D
ug1L
EPA 200.7
9113110
ESTAFFORDI
Laboratory Suctivn�> 1623 Mail Service Center, RalelgK NC 27699-1623 t919j 733-3908
Fa a uatallsd tla 7"tbl of Ihu gp6ilfnr cadea infer Ju kk •'Y 1 r. r ! k !WVW,i1r'-yROr C:cdrs rl�M �,YJ�'� n�l�t2.1L�R'1+'d�t W1'�Vid:NH fi9/ISrili.�sm+
Page 1 of 1

GROUNDWATER FIELD/LAB FORM
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Location code_ f��?�-N- 5�r►nf 4 q'�_S .` -�
vM 5
E
- - ---- ---
SAMPLE PRIORITY
W
Count Y •G _
Routine��_
Lab Number
Quad No Serial No.
Long.
rOther
❑ Emergency
�G Fe❑ate
q
ReceivedI'�lO Time•Lat.
Rec'd By, From:Bus, aurifir, land ❑el„
of Custody
Other:`
Report To: ARO, FRO, MRO, RRO art INIRO,
----- - - - -
-
_
Data Entry By: Ck__
WSRO, f(inston FO. Fed. Trust, Central Off.', Other.
Date Reported,. — —
Shipped by: Sus, <varier and gel., Other.
collector(s)A. G r iJate�G `r 0)6 Mime�r+Saseline,
Par ose:
Complaint Compliant _ LU57,
peLsGr�derStudlyx, Federal Trust, Other
>=1EL0 ANALYSES
pR 40o Spec.Cvnd.�.,
at 259C
Owner �it see ❑ -
Location or Site La ('rS iTemp.jo Avtvce
l TrOw W
y+
aC Odor
Description of.sampling point S = ❑
Appearance
Sampling Method Gc Sample l tefylI
'-§0. `
Field Analysis Sy.
Rem ar#t's Ptak [ of Oruc pad _ ;°
s D t &CI w+ t
Boo 310
COD High 340
COD Low 335
CoMO= Aw FerA 31516
'Coliform: MF Total 31504
TOC 68o
Turbi ft 76
Residue, •Suspended 530
pH 403
Wtmlinity to pH 4.5 410
Wkaliruty fo pH S_3 415
Cerborrale 445
Bicarbonate 440
Carbon dioAcle 4D5 4
Chloride 940
Chromium: Hex ID32
Color Tnm 80
Cyanide 720
Lab Comments
mg&
mg1L
mg7L
Il00rrd
ISe0fhl
mglL
NTU
mg1L
Diss. Solids 70300
f - —
f mpvL
Fluoride 951
mglL
T
Hardness: Total 900
m9&
Hardness {non -cart} 902
mglL
Phenols 32730
uglAf
Speofic Cond_ 95
upmaslrm
sulfate 945
mgA-
Sulfide 74'5
mgk
Oil and Grease mglL
units
mrdvL'
mglL
mgA-
_
NH, asN8i0 t
mg1L
T as N SZ5
mg(L
NO, + NOS as N 630 I
mwt
UP&
P; Total as A 665
Nitrate (NO, as N) 620
CLI
Nrtrile (N%as NI 915
mg/L
-
&ti ! �fr mglL
l r' (3 Lpgot
C}mg(L
mg/L
GW-54 REV- 7103 Fof1 issolved Anal ysisrs+i#vvtfiltered sample and write -015- in b1ocYC
.� • (Pumping lime. air temp., et&j
Ag-$i1vrr46566~ T — Or3anochlori tie Pes66das
AI -Aluminum 46557 uglL _ -Urr]—jigs —s PesU des -
As -Arsenic 46551 u• Ni en PesGrides
Ba-sanum 4655a ugX -Acid Herbicides
Ca-Caleiurn 46552 - mglL_ PCBs
Cd-Cadmium 46559 ug& —
Cr-Chrornium 48559u
Gu Copper46562ftt] ugfL
Fe-kan 46563 rYv�Ys uglt
Semivotatile Organics
TPH-Diesel Range
VolaSle O ardcs(VOA bottle)
TPH-Gasoline Range —
TPH-87EX Gasoline Range
Hg-Mercury71900 1 r rr• uDIL
K-Potassium 165�5 —� m IL
Mg -Magnesium 46554-
Mn-Manganese 46SGS , "vz <2u&-
Na-Sodium 46556 mg1L
Nf-Nickd l 4jpfL
Pb-Lead 46564
5e-Selenrum �
Zn-Zinc 4fi5677
upfL
u
LAB U5k-QNLY
Temperature on arrive] ('C)., l r�

ftwm
County, GATES
sampse lu:
AB63258
River Basin
pF '4TE,�
PQ Number is
Wi00692
Report To Afl+1 RDAP
�� r '�Q
data Received:
0910S12010
ai
�
'r
Time Received-
15:30
t,^,vpesloC. A CLA RK
`�
Labworks LoginlR
MSTARR
Region: WARD
`��y;
Re pwt Generated:
9115110
Sample Matrix GROUrdOYVATER
pate Reported:
0911512010
Lac, Type: MGNITORING WELL
Emergency Yes1No
UShIn
COG Yes1No
-fin
' '
�,� C} , r � �' �]
Loc. Desw.: THOMAS
CORE - ASH1014 LEWIS
LUM6ER COMPANY
�"
L.-:7h. tD: APS N-V"-GATES-0087
Collect Date-
09108170Tfl
Collect Time: 10:55
Sample Depth
Result/
Method
Analysis
CAS # Analvte Name
POL
Units
Validated by
Qualifier
Reference
Vats
WARO
Sample temperature at receipt by lab
1.8
°C
98110 SMATHIS
Coliform, MF Fecal in liquid 1 1 131 CFU1100ml APHA9222D-20th 918110 ESTAFFORD1
Coliform, MF Total in liquid 1 1 61 CFU1100ml APHAS222B-20th 916110 F-STAFFOR01
Laboratory Section-1623 Mail Service Center, Raleigh, NC 27699.15Z3 [phone]
Fb+Ydelailed dess=iµl rn+6f 1118 gyHMrier Codes feFnT to injki. Ypvnal r. g.nr.nro:Wn reu9&r kt�•{v;een�s•_¢Wf]nt-CQ A!kj_qi dtenr a :s.;7Fri ariplTJd�l� p• ��
Page 1 of 1

Ctrpxtrrterl of rnv�:: rin se-tr : t d N. : -•• RE-+sreoz�
CIVISION DiF YVATER WAf_r} "-ORO-*%-- ''iA rE R SECTION.
c% lab N tmbu r \�j
> lv�+� I 1 Date- R-3cvwd r
Reed E . �;' rrcm '.31;s. Col. [m,r, i,g[;r� i-at t
Othor: _
[ ,cUt}+�,�r
Cagrr�iur(s:. �7[-`1�ari=cw14 s`. C3as I�nr , Cc a!pint,t c+rnr++ar, e U :T, PqG#-r ;s S{:, y,=�dfI'Tr �sl, �ihi� 1. _
1F(ELD F[NAt SF Ll l 7 4 , 1 YL • t /r
!r, Lf}ni. �a r�1r-c i.ot_'.ai�
0-+y.E,; Y'l'i.SLR'} �_.�S�l �S -7 �— '�
1cr _ f�f'SCF.f]tionof . «siurnp!'nq [JC?'rFt +y •"t .�r t t.._ ..... ..'»... T _
plvid Anvly^ is f3Y _ _ f-�emarK&_._.
i�.3''L�:+i: ti�:F I � e1b'; •5e . �., -�+rll triy;f_ � A'F• �i'te.r rr._ ,, ... l � �� f~t•;�az: ;..:�yr::A 1-t� •hY Lf........... ........ .... ....................... .....................
_..._.-...,_.................. _......._........ ........ ....._....._............._._.._.._.........._
P; ^ �:: _ n�rL I ir:r,...
,s_R: -- ; .........................._ _ ....
ry nr::[:... ,a:5 l uy�i N fr: _, t._.,y
_ ....
sJ�
C,:If't rr,-: M�' F'ec..i +:','}. �;Fr�rl _ € ralrsn�s rr.[s .c• rr� + _. r- g�L R:: F',3rtt`� � - � .. ;,++
Crti�'!t r-...hiF Ica i'S}'. jr, [ �,:fi i �- pr>er �h 3
Ihh
` GCs7 c eew ai
'lr : Z� !d.rtl I y r�4-I; It D4,- fr , --.i .-f•C:Y,+I'•t �.ur3+ C;:' ; _ _ i
.. - • :: i�.�a•t�� s,t �: . ;.?. f r �asf•`.t:i r45 .T, r, y.f:[".N: t'• _ '
----] E
ff r r? .win
I -i�t .f _ 'sl�^ yam" ....«. _.. ..
��II rT,�,y +• � ^ 1
fv ;= L_r ,p
7­2;7t� ,Fnld., of
f t.rr r.•xe S;c
......
_
GROUNDWATER FIELD/LAB FORM
LocationG[7{9 ! i`1
Ouad
1-1 Coa-it 0 CI.i-Audyr
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·•
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: Se ptember 27 , 2010 Permittee(s): Ashton Lewis Lumber Com pan y
Permit No.: WI0700087
To: APS Central Office County: Gates
Central Office Reviewer: _ Project Name: Ashton Lewis Lumber Com pan y
Regional Login No: __ _
L GENERAL INFORMATION
1. This application is (check all that apply): D SFR Waste Irrigation System IZJ UIC Well(s)
D New D Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation IZl 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: Se ptember 8. 2010
b. Person contacted and contact information: Thomas Coxe . Route 13 7 . Lewis Mill Road. Gatesville. NC
27938: phone [phone].
c. Site visit conducted by: Allen Clark. DWQ/APS WaRO ; Carrie Stone. DWM WaRO
d. Inspection Report Attached: IZI Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
IZl Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For UIC Injection Sites:
(If multi p le sites either indicate which sites the information a pp lies to . co py and paste a new section into the
document for each site . or attach additional pa ges for each site )
a. Location(s): Route 137 , Lewis Mill Road , Gatesville. NC 27938, one (1) well located on the east side of
the buildin g and the other well is located on the west side of the building .
SPECIAL NOTE: The wells can be switched manually, changing the supply well to an injection
well, and visa versa.
b. Driving Directions: From Gatesville . go west on H w 137 (SR 1343 , Court Street) for a pproximatel y 0.5 miles. Tum
left on Lewis Mill Road . (SR 1134). go to the end of the road. The wells are located on either side of the bi g blue
metal buildin g at the end of the road.
c. USGS Quadrangle Map name and number: __ .
d. Supply Well (also referred to as Well #1, located on the east side of the building): Lat: 36 Deg., 23 Min .. 52
Sec; Long: 76 De g .• 46 Min .• 02 Sec.
e. Injection Well (also referred to as Well #2, located on the west side of the building): Lat: 36 De g,. 23 Min.,
53 Sec; Long: 76 De g .. 46 Min., 03 Sec. Method Used (GPS, Google™, etc .); Goog le Earth.
APS-GPU Regional Staff Report (Sept 09)
~ +i =OHJ~ I -lJO O 1
: • ' 1 ,... .. . .
','
Page I of 4 Pages
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section) NA
/IL RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or maior modification
s11stems) NA
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description ofWell(s) and Facilities -New, Renewal, and Modification
1. Type of injection system:
IZI Heating/cooling water return flow (5A 7)
0 Closed-loop heat pump system (5QM/5QW)
0 In situ remediation (51)
0 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 t8J No
3 . Are there any potential pollution sources that may affect injection? D Yes IZI No
What is/are the pollution source(s)? . What is the distance of the injection 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: t8J Good D Adequate D Poor
6 . Flooding potential of site: t8J 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 O No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: ------"N""'A'-"'
8 . Does the map presented represent the actual site (property lines, wells, surface drainage)? t8J 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)?
OYes iZ!No.
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. ffye ,, explain!:, r · ! • ·NA
., ~~., ~\r~~ :;; !;·-.,,_.: ....
1.!) · I '.1 .. ' . .
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 remedintion permits (of any type), will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? ❑ Yes ❑ No. If yes, explain: NA
4. Drilling Contractor: Name: Mauette Well and Pu_CampanRy. Inc.
Address: 2341 US 13 South. Ahoskie. NC 27910
NC Certification number: 2340
& Complete and attach NEW Injection Facility Inspection Report, if applicable
1. 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 ® 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 = _j
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 r Reason
5. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition;
Condition _ Reason
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
® Issue; ❑ Deny. if deny, please state rea ons:
8. : Signature of report Pre arer s
g F P �)
Signature of APS regional supervisor:
Date: -
APS-GPU Regional Staff Report tScpt 09) Page 3 of 4 Pages

AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
VI. ADDITIONAL INFORMATIONAND SITE MAP .Sketch o site showin = house and waste irrigation
sf stem Mray or drinfeld, location o _ well(s), and/or other relevant information- SHOW NORTH ARRDii )
�.e.Y►i �S Lmm� tr Compull
A.PS-GPU Regional Staff Report (Sept 09) Page 4 of 4 Pages

North Carolina Departmen:t of Environment and Natural Resources
Division of Water Quality -Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700087
DATE OF INSPECTION: September 8, 2010
INSPECTORS: Allen Clark, DWQ/APS WaRO; Carrie Stone, DWM WaRO
NAME OF PERMITTEE(S) Ashton Lewis Lumber Company
MAILING ADDRESS OF PERMITTEE: Route 137, Lewis Mill Road, Gatesville, NC 27938
PHYSICAL ADDRESS OF SITE (if different than above) ________________ _
PERSON MET WITH ON-SITE: Thomas Coxe; TELE NO. [phone]
WELL(S) STATUS:
J__Existing and operating Class V Well
__ Existing well proposed to be converted to Class V well
__ Proposed/not constructed
Supply Well (Well #1, east side of building): Lat: 36 Deg .. 23 Min .. 52 Sec : Long: 76 Deg .. 46 Min .• 02 Sec.
Injection Well (Well #2, west side of the building): Lat: 36 Deg .. 23 Min., 53 Sec: Long: 76 De 11 .. 46 Min .. 03 Sec.
NOTE: The wells can be switched manuall v, chan gin g the su pp lv well to an injection well , and visa versa.
Appx. distance of well to property boundaries: 60 feet (Well #2. In jection We ll); 200 feet (Well #1, Supp ly Well)
Appx. distance of well from foundation of building/structure: 15 feet (In iection We ll): 15 feet (Su pp l y wel l)
Appx. distance of well from septic tank/field (if present): 450 feet (I n jection Well): 400 feet (Supp ly Well )
Appx. distance of well to other well(s) (if present):
Appx. distance to other sources of pollution: --------------------
Flooding Potential of Site: _high __ moderate X low
Comments: No problems were observed during the ins pection/ permit renewal site visit.
Injection Facility Insp . Report (Rev. Sept 2009) Page l of 3 Pages
"S bAn)bLf Co np i%pj
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)
Injection Facility Insp. Report (Rev. Sept 2009) Page 2 of 3 Pages

Well Construction Information
Date Constructed: Supph (East) Well: Se ptember 19 . 2005 : Injection (West) Well: Se ptember 16 . 2005.
Well Contracting Company: Magette Well & Pump Co .. Inc.
Well Driller Name: Bobby L Harrell
NC Well Cert. No.: 2936
Address: 2342 US 13 South. Ahoskie. NC 27910
Telephone No.: ~<2_5_2~} ~3~32_-~2_26~5'--_______ ; Cell No.: ________ _
Email Address: -----------
Proposed Depth of Well(s): _______ _
Total Depth of Injection (West) Well: 331 feet Total Depth of Source (East) Well: 346 feet
Casing:
Depth: Injection Well 315'; Supply Well 321 '. Diameter: 4 inch; Type (gav. steel, PVC, etc.): PVC;
Grout:
Depth: Depth not checked durin .!. this permit renewal ins pection; Type (cement, bentonite, etc.): Cement; Placement
(pump, press. etc.): pumped.
Influent spigot (Y or N): Yes (spigot at well); Effluent spigot (Y or N): Yes (spigot at well)
Well Sampled? (Y or N): Yes (both supply and injection well sampled);
If Yes, Lab Sample ID numbers: _______________ _
Static Water Level: ?
Injection Information (if applicable):
Injection Rate:? ______ GPM
Injection Pressure:? ______ PSI
Injection Volume: ? ______ GPD
Temperature-Summer: ? ____ F 0
Temperature-Winter: ? ____ F 0
Comments/Notes: No problems were observed durin R. the ins pection/ permit renewal site visit. As stated earlier. the wells
can be switched manuall y. chan 1:t ing the supp l v well to an in jection well. and visa versa.
lnjection Facility Insp. Report (Rev . Sept 2009) Page 3 of 3 Pages
WASHINGT0N REGIONAL OFFICE - APS SECTION - PHOTOGRAPHIC RECORD
Site Name: Ashton Lewis Lumber Company Permit Numbe Wl0700087
Site Location Lewis Mill Road Site Town/Coi Gatesville1Gates Count
Photographer:
Photographer:
A. Clark
A. Clark
Date:
r
Date:
9181201 D
9/8/2010
Photo Location:
Photo Location:
Well #1 East
Well #1 East Side
Side of Building
of Building
r
Photo Direction:
Photo Direction:
}
West
r...
West
Comments:
Comments:
Photographer:
Photographer.
A. Clark
A. Clark
Date:
Rate:
.
91812 01 D
} 9/81201D
Photo Location:
�` w
Photo Location:
Well #2 West
Well #2 West
Side of Building
Side of Building
Photo Direction:
I
i
-
Photo Direction:
East
u'. East
s r
?
Comments:
Comments:
-

' ' SA
HCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
August 5, 2010
Thomas Coxe
Ashton Lewis Lumber Company
Route 13 7 Lewis Mill Road
Gatesville , NC 27938
Subject: Acknowledgement of Application No. WI0700087
Ashton Lewis Lumber Company
Injection Heating/Cooling Water Return (5A7)
Gates
Dear Mr. Coxe:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on July 28, 2010. This application package has been assigned the number listed above and will be reviewed by
Thomas Slusser.
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 pennit applications, the Division requests your assistance in providing a timely and complete
· response to any additional information requests.
Please be aware that the Division 's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 -90 days after receipt of a complete
application.
If you have any questions, please contact Thomas Slusser at 919-715-6629, or via e-mail at [e-mail]. If the
reviewer is unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To
review our new organizational chart, go to http ://h2o.enr.state.nc.us/documents/dwo orn chart.p df.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
o~~
for Debra J. Watts
Supervisor
cc : Washington Regional Office, Aquifer Protection Section
Permit Application File WI0700087
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone : [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opponunily \ Affirmative Action Employer
Ni~hCarolina Jvaturally
1'1'A· ~~----NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Thomas Coxe
Ashton Lewis Lumber Company
Route 13 7 Lewis Mill Road
Post Office Box 5
Gatesville, NC 27938
Coleen H. Sullins
Director
July 2, 2010
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. WI0700087
Gates County
Dear Mr. Coxe:
Dee Freeman
Secretary
RECEIVED / DENR I LJvVQ
AQUIFl=RPROTFr.TION S/;CTION
1JUL 2 8 2010
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, which was issued to you on November 17, 2005, and
expires on November 30, 2010, has not been .renewed. 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 ln.jection with
Geothermal Heat Pump System for Type 5A7 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.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard. Raleigh. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality .org
An Equal Opportunity \ Affirmalive Action Employer
One • ...
NorthCarohna
Jvatural/11
If there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form must also be submitted.
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 days of the receipt of this letter to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Centex
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
hLtp:/Ai2o,enr.state.ne.us/aps/gpElforTns.htm.
Thank you in advance for your cooperation and timely response. if you have any questions,
please call me at [phone].
Sincerely,
R,EC>=NEfl l OENR! flWQ
AQu��aP��+7Fi''rinN ��.
Eric G. Smith, P.G.
JUL
Hydrogeologist
Attachments
cc: Washington Regional Office - APS w/o enclosures
APS Central Files - Permit No. W10700087 w/o. enclosures

< I •
NORTH CAROLINA
RECEIVED/ DENR / owa
AQU\Ff:R•PRnTFr.TION S!-:CTION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES JUL 2 8 2010
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A GEOTHERMAL HEAT PUMP SYSTEM
TYPE SA7 "OPEN LOOP" INJECTION WELL(S)
(check one) __ New Permit Application · ~Renewal
DATE: 3 u. \ i J}] 20 ;i_o ID
PERMITNO.: WI 070DO 87 (leave blank if NEW permit application)
A. PROPERTY OWNER/PERMIT APPLICANT .
Modification
Name of each owner li.sted on property deed. For a business or government agency, state name of entity and
name of person delegated authority to si~ application on behalf of ~usiness/agency: ______ _
i\s ~-to n Lev..>~ S. l-u.,v\ \:>d C.c • \ home""> G,,ce,__ -c.ovq---~
(1) Mailing Address: f'.. 0 . \So~ 5 ·
City: &oJte sv':\\e_ State: Ne Zip Code: .;l. ~938 County:---~
Home/Office Tele No.: g_S;i.-3 s 7 -00 So Cell No.:. rz S J -l o$ 0 -~ 54\
Fax No. ;;LS .2..-3 S 7 -(Xs:i '7 S Email Address: -\-co'ke.@ o..s'\\-\-o~-\eJ,~ . Gow)
(2) Physical Address of Well Site (if different than above): le.w; '::. '('f\ ~ \ \ \\-o ct.~ ~ R. ¾ \3 7
City: G-°'--\-~s v~ \\E... State:~ Zip Code: ot"79 3 R County: G a,,-\-e.,s
Home/Office Tele No.: ___________ _,C=e=ll:...:N"'-'o=•.:....: _________ _
Fax No. Email Address: --------------------------
B. PROPERTY OWNERSHIP DOCUMENTATION
Provide legal documentation of property ownership, such as a contract, deed, article of incorporation, etc. and
a PLAT map showing the property. This information may be obtained from county Register of Deeds or GIS
website.
C. AUTHORIZED AGENT, IF ANY
If the property owner/perm.it applicant wants to authorize someone else to sign the permit on their behalf, then
attach a signed letter from the property owner/permit applicant specifying and authorizing the4" agent ( well
driller, heat pump contractor, or other type of contractor/agent) to sign this application on their behalf.
Company Name: ____________________________ _
Contact Person.c_: ---------------=Em=a1=·1=A=d=dr=e=ss==-----------
Address: --------------------------------
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Fax No. Cell No.:
Website Address of Company, if any: ______________________ _
Type SA 7 Injection Well Permit Application (Rev. August 2009) Page I of4
D. WELL DRILLER INFORMATION
Company Name:- _ �(` ] ' �2 xxi'5— L� 11 �' u w��' D
Well Drilling Contractor's Name: Qok�bi ter' T-,eN
NC Contractor Certification No.: v2 q ZQ Contact Person:
Company Website: WWW. Email Address:
Address:
City.
Office Tele No.:
State: Zip Code:
Fax No..
County:
Cell No.:
E. HEAT PUMP CONTRACTOR INFORMATION (if erect than Driller)
Company Name: ut a 1 Cantact Person: A 0.,Q"
CompanyWebsite: WWW. Email Address:
Address:
X-o•-t-
City: 5 !tA(Ak- Startle: a► Zip Code: vP,3 43 `f County:
Office Tele No.: 7�']_ 5I39 - %4 Fax No. Cell No.
l G►n5•e r>� a —A
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
-Awe- oxre' Mwro t LH0 ; Vk "} 5;7MC-t`r<. , r'4'0]r loll ia, a� a': k L' �A�l
G. WELL USE Will the injection well(s) also be used as the supply weIl(s) for the followme.
(1) The injection operation? YES V- NO
(2) PersonaI consumption? YES NO 13L,
H. WELL CONSTRUCTION DATA
PROPOSED Weil(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.
DL , EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (7)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
GW-1) if available.
(1) Well Construction Date: v?0{} j Number of borings:
Depth of each boring (feet):{
(2) Well casing. Is the well(s) cased?
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel Black steel Plastic Other (specify)
Casing thickness: diameter (inches): Z.
depth: from n to LD feet (relative to land surface)
Casing extends above ground inches
(b) NO
(3) Grout material surrounding well casing:
(a) Grout type: Cement-;! Bentonite* Other (specify)
*By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(1)(A), which requires a cement type groat.
(b) Depth of grout around well casing (relative to land surface): from C5 to '2D feet
�
0
Type 5A7 Injection Well Permit Application (Rev. August 2009) Page 2 oF4

(4) Well Screen or Open Borehole depth (relative to land surface): from lf;._o to Lf~D feet
(5) N.C. State Regulations (Title 15A NCAC 2C .0200). require the Permittee to make provisions for
monitoring wellhead processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Will there be a faucet on:
(a) Influentline? Yes~No__ (b) Effluentline? Y~s~No
(6) Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Form GW-1). If Form GW-1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment units will the groundwater be withdrawn? (e.g.
granite, limestone, sand, etc.) ·
Depth: _______ Formation: ______ Rock/sediment unit: _______ _
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHERWISE UNAVAILABLE.
I. OPERATINGDATA
(1)
(2)
(3)
(4)
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
J. INJECTION-RELATED EQUIPMENT
Average ( daily) 'a0 gallons per minute (gpm).
Average (daily) llS, Zo"gallons per day (gpd).
Average (daily) l O pounds/square inch (psi).
Average (January) jo ° F, Average (July) gl) ° F.
Attach a schematic diagram or cross-section of the well construction that shows the total depth, length of casing,
extent of grout, stickup, location of influent/effluent sampling_ ports, etc. If this is · a modification, show the
engineering layout or proposed modification of the injection equipment and exterior piping/tubing associated with
the injection operation. The manufacturer's brochure may provide supplementary information if needed.
K. LOCATION OF WELL(S)
(1) Attach a site map (can be drawn) showing: houses and other structures, property lines, surface water bodies,
potential sources of groundwater contamination, and the orientation of and distances between the proposed
injection well(s) and any other existing well(s) or waste disposal facilities such as septic tanks or drain fields
located within 1000 feet of the geothermal heat pump well system. Label all features clearly and include a
north arrow.
(2) Attach a scaled topographic map of the area extending 1/4 mile from the property boundary that indicates
the facility's location, a north arrow, and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by owner
name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other wells, etc.
can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or elevation data.
Type 5A7 Injection Well Permit Application (Rev. August 2009) Page 3 of4
As�+zrO4,ewis
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REGOVa+ i DENR 1 UWb
AQlll��'pRI��F�".TI�1AI ;FC�'4i�N
JUL
L. CERTIFICATION (to be signed as required below or by that person°s authorized agent)
NCAC 15A 2C .d211 (b) requires that all permit applications shall be signed as follows:
1, for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner.
If an authorized agent is signing on behalf of the applicant, then submit a letter signed by the
applicant that names and authorizes their agent as specified in Part C of this permit application.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted in
this document and all attachments thereto and tha# based on my inquiry of those individuals immediately responsible for
obtaining said infomnation, 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 w 11 and all related appurtenances in accordance with the approved
specifications and conditions of the Permit."
Signature of Property Owner/Applicant
i h� was G. cr� y.&,
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 signed copies of the completed application package and ail attachments to:
TAC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail. Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Type 5A7 Injection Well Permit Application (Rev. August 2009) Page 4 of 4

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: W f O 7D002 7
Permittee Name: b\.aon l.ew'\s llAW'.._\-e..( Q o,
Address: ~-0 , \Dof_ 5 , G:oJ\esJ,\\e 'N C.. a)93~
RECEIVED / DENR / DWQ
AQUIFJ:R·PR()TFr.TtON ~FCTION
JUL 28 2010
Please check the selection which most closely describes the current status of your injection well system:
I) ✓well(s) still used for injection ~ctivities, or may be in the future.
2) 0 Well(s) not used for injection but is/are used for water supply or other purposes.
3) □ Injection discontinued and: a)□ Well(s) temporarily abandoned
b) □ Well(s) permanently abandoned
c) □ Well(s) not abandoned
4) □ 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 of how the well
was sealed and the type of material used to fill the well if permanently abandoned):
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? · □ Yes □ No
Certification:
"I hereby certify, under pen ~flaw, that I have personally examined and am familiar with the information submitted
in this document, and that to the best f my knowledge the information is true, accurate, and. complete."
=<;i~~~/~,. Date
Revised 5/05 GW/UIC-68
STA:7r4 .
NONRESIDENTIAL WELL CONSTRUCTIONRECORD
North Catalina DepaflmcnI of Environmcnt and Nxtund Resources- Division of Water Qualily
WELL CONTRACTOR CERTIFICATION # 2300
1. WELL CONTRACTOR:
SaM el L. Wiggins
Well Contractor (indMduai) Name
MaQette Well ge Piirnp (n-, Tnc--
Weil Contractor Company Name
STREETAL3DRESS 2342 US 13 S
Ahoskie NC 27910
City or Town State Zip Code
(252_
Area code- Phone number
2, WELL INFORMATION, Well # 1
SITE WELL I #tit appItablej
STATE W ELL P E R M I T#(If applicable)
❑WQ or OTHER PERMIT #(it applicable) Cy 'T 6) t�
WELL USE (Check Applicable Box) Monitoring ❑ Municipal/Public❑
Industrial/Commercial ❑ Agricultural12 Recovery a Injection of
IrrigationO other ❑ oist cseageothermal heat 'um
DATE DRILLED 9 i 19 / 0 5
TIME COMPLETED—5 '- 0 C AM ❑ PMY9
3. WELL LOCATION:
CITY:Gatesyille COUNTY Cates
Lewis Mill Road
(Street Narne. Numbers, Community, Subdhislon, Lot No„ Parcel, Tip Cade)
TOPOGRAPHIC 1 LAND SETTING:
MSlope ❑Valley CNFiat pRidge ❑ Other
[cbeck appropriate box)
LATITUDE 6d 23.868n May be indegrees,
minutes, %wands or
LONGITUDE 7 6 d 46.018W in a decimal formal
Latitude/longitude source: ❑ GPS ❑Topographic mats
(locsibn of we#musf be shown on a USGS topo map and
attached to this form ffnal usk7g GPS)
4. FACILITY- le are roma of the ewslneee where Ora wan is located.
FACILITY ID "f appllcable)_
NAMEOFFACILITY Ashton LewiS Lumber Co.
STREETADDRESS LeWiS kill Road
Gatesville- NC 27938
City or Town State Zip Coda
CONTACT PERSON Torn Cox
MAILING AQD,RESS PO 'BOX 5
Gatesya e
City or Town State Zlp Code
( 252_ )- 3570050
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 4 6 r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO6
c. WATER LEVEL Below Top of Casing: 29 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS 3 FT, Above Land Surface
'Top of casing terminated alloy below land surface may require
a variance in accordance with 15A NCAC 2C .011B.
e, YIELD {gpm): 8 0 _ METHOD OF TEST air. lift
f. DISINFECTION: Type HTH Amount, 2 b
g. WATER ZONES (depth):
From321 To 341 From To
From Tn From To
From Tc From Tc
6. CASING: ThIcgk�ntessi �q
From} 1 pTotlo Ft. �I gter S EM 21 MP V
From+3 To 3� Ft.� S DR 1! P V C
Fra7341 To348 Ft, 4" SCH 80 PVC
7, GROUT: Depth Material Method
From 0 To 20 F""at cement pump
From^ To--TUO FtO eft e � r O 11 t pLZRi
From To R.
E. SCREEN: Depth Diarrneter $m Size Material
Rorrl 321 To. 341 Ft. 4 in. .03gn. stainle
From To Ft, in. in.
From TO Ft. tn. in.
8. SANDIGRAVeL PACK:
De th - -Size Material
From 300 To 346 Ft.3 Southern Prod
From Tc Ft
From Ta Ft.
10, DRILLING LOG
From To Formation Description
c ay
12 - 18 sand
18 - ll9 clay with sand
sand tine to mad.
-2 C1a
295 - sand fine to med.
11. REMARKS:
Wells are designed to inject water
from heal~ pumps bhen cycle and
roduce water for heat pumps.
DO HEREBY CERTIFY THAT THIS WELL WAS CON STRUL.I r0 IN ACCORDANCE W TH
ILA NCAC 2C, W ELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOR BEAN PROVIDED T THE WELL OWNER
ko) o,
SI NATURE OF CERTITi
L L CONTRACTOR DATE
Samuel. L, Wis
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
3s
I-C t s
.__0
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center-- Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev- 7105

FAS
·1
Co ll
\
c ...... rf--
Iv
NONRESIDENTIAL WELL CONSTRUCTION RECORD _
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2936
I. WELL CONTRACTOR:
Babb•, L . Harrell
Well Contractor (Individual) Name
Ma�ette Well & Pum} eo., Inc.
Well Contractor Company Name
STREETADDRESS 2342 US 13 S
Aho_skie NC 27910
City or Town state Zip Code
2i 52 )- 332-2265
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 11pl applicable) Well # _2
STATE WELL PERMIT#(ff applicable)
DWO or OTHER PERMIT.#(if applicable) WTQ9 x,041
WELL USE (Check Applicable Sox) Monitoring ❑ MunicipallPublic ❑
1ndusWallComrnercial ❑ Agricutturat ❑ Recovery 0 Injection ff
Wgationo Other ❑ (list use) geothermal heat pum t
DATE DRILLED 9� 05
TIME COMPLETED 6 = 00 AM ❑ PM IN
3. WELL LOCATION:
CITY: Gatesyi11e COUNTY Gates
Lewis Mall Road
{Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Cede)
TOPOGRAPHIC I LAND SETTING:
❑ Slope ❑ Vaiiey ❑flat ❑ Ridge ❑ Other__
(check appropriate box)
LATrrLjDE 3 6 d 23.879n May be in degrm,
minutes, seconds or
LONGITUDE 7 5 d 46.018W in a deeirml format
Iatitudeflangitude source: 6GPS ❑Topographic trap
(location or we# must be shown on a USGS topo map and
attached to Phis form if not using GPS)
4. FACILITY- Is are name of The &Wnew where the wall Is lovaled.
FACILITY 113 #(if applicable)`
NAME OF FACILITY Ashton Lewis Lumber Co.
STREET ADDRESS Lewis Mill Road
Catesville NC 27938
City or Town state Zip Code
CONTACT PERSON Tam CoX
MAILING Af7 PESS PO Box 5
Gatesville NC
City or Town state Zip Code
{ 252 i_ 357-0050
Area code • Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:_3 31 t - -
h. DOES WELL REPLACE EXISTING WELL? YES O NO [�
c. WATER LEVEL Below Top of Casing: 29 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 3 FT. Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance In accordance with 1SA NCAC 2C ,0118.
e. YIELD (gpm): 1 Q 0+ METHOD OF TESlai t lift
f. DISINFECTION: Type HTH Amount _2 _p,oun
g. WATER ZONES (depth):
From 315 To 3 2 5 Frown To
From To From To
From To From TO
8, CASING: Thicknessl
Depth Diameter 'rdeight Material
From +1 To 20 Ft. 19 " S D I 21 P V C
From +3 To315FL 4.5" SDR 17 PVC
From To, Ft.
7. GROUT: Depth Material Method
From 0 To 20 Ft. neat cement pump
Frarrl 20 To315 Ft. bentonite pump
From TO FL
S. SCREEN: Depth Diameter Slot Size Material
From 315 To 325 Ft. 4 in. . 0 3 0n. stain 1 e
From To Ft. In. in.
From To FL In. In.
9. SANDIGRAVEL PACK:
Depth Size Material
Frorni 285 Ta 331 FL 3 Southern Pro;
From To Ft.
From To Ft.
10. DRILLING LOG
From TO Formation Description
0 - 12 clay
12 - 18 sand
18 - 110 clay with sand
110 —225 sand fine to mnr7
215 — 92I�
11. REMARKS:
Bells are designed to inject water- I
teat pumps 'then cycle_ and_-roduce we
for heat um 1s
100 HERESY CERTIFY THAT TH:S WELL WAS CONSTRUCTER tN ACCORDANCE WITH
ISA NCAC ZG, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
2RECAi;�
R9VIR R TD THE W LL DW NER.
/ 19 0,S7-
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
lobby L. Harrell
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
)/41]1 z
s5
lucts
rom
ter
Submit the original to the division of Water Quality within 30 days. Attu: information Mgt.,
1617 Mail Service Center— Raleigh, NC 276994617 Phone No. [phone] ext 568.
Form GW-16
Rev. 7105

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7-A
MCDEHR
North Carolina Department of Environment and
Division of Water Quality
Beverly Laves Perdue Colean H. Sullins
Governor Director
July 2, 2010
Thomas Coxe
Ashton Lewis Lumber Company
Route 137 Lewis Null Road
Post Office Box 5
Gatesville, NC 27938
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. W10700087
Gates County
Dear Mr. Coxe:
Natural Resources
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, which was issued to you on November 17, 2005, and
expires on November 30, 2010, has not been renewed. 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 andlor Use a Wells) far Injection with
Geothermal heat Pump System for Type 5A7 Well(s) if the injection well system on your
property is still active.
-OR-
B- Status of Injection Well Svstern if the injection well system is inactive or has been
temporarily or permanently abandoned.
AQUIFER PROTECTION SECTION
1636 "1 Service Center, Raleigh, North Carolina 27699-1636
i-omOon: 2728 Capital Boulevard, Rst*h. North Carolina 27604
Phone' 9IW33-322 i I FAX 1: 919-715.0588; FAX 2: 919-715-54461 Customer Service: 1-877-623-6748
Intamet; www.ncwatemuaotv.org
An Equal 4porrur-1,y l Af rmarrvE �kaan Ernplw-
One.
NortbCarafina

If there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form must also be submitted.
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 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 forces are also available on-line at the DWQ website at
http://h2o.en-r.state.ne.us/aps/DIL/forms.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call me at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
Attachments
cc: Washington Regional Office - APS w/o enclosures
APS Central Files - Permit No. WI0700087 w/o enclosures

Of W A �E,� Michael F. Easley, Governor
William Q Ross Sr., Secretary
U3 r North Carolina Department of Environment and Natural 12esourcm
Alan W. Klimek, P.E. Director
Division of Water Quality
DIVISION OF WATER QUALITY
Aquifer Protection Section
December 5, 2005
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7003 3110 0002 0578 4739 T`
Magette Well & Pump Company, Inc.
Post Office Box 451
Ahoslcie, North Carolina 27910
and
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7003 3110 0002 0608 6450
Ashton Lewis Lumber Company
Post Office Box 5
Gatesville, North Carolina 27938
DN
AW1FFR R41 CT1 �5 {'►110N
DEC 49zoo
Reference. NOTICE OF VIOLATION of the NORTH
CAROLINA WELL CONSTRUCTION STANDARDS
Ashton Lewis Lumber Company — Injection Wells I and 2
Gates County, North Carolina
Dear Magette Well & Pump Co., Inc. and Ashton Lewis Lumber Company:
The Aquifer Protection Section of the Division of Water Quality (DWQ) is responsible for
the regulation of well construction activities within the State of North Carolina. Injection well
Permit # WI0700087, dated November 17, 2005, was issued by the Underground Injection Control
Program to the Ashton Lewis Lumber Company located off of Hwy 137 on Lewis Mill Road in
Gatesville, in Gates County, North Carolina- A preconstruction inspection associated with permit
issuance was conducted on September 26, 2005. The site visit and review ofDWQ records revealed
that the 2 wells associated with injection well permit W10700087 were constructed prior to obtaining
the proper permit as required by I5A NCAC 2C .0211 Permits of the NC Well Construction
Standards.
North Carolina Division of Water Quality Internet h2o.em-slate.nmus
443 Washington Square MIL11 Phone. [phone]
Washington, NC 27889 FAX [phone]
NorthCarolina
Natumllb'
An Equal OpportunitylAifirmative Action Employer— 50% Recycledll0% Post Consumer Paper

Magette Pump & Well Co., Inc./Ashton Lewis Lumber Co.
December 5, 2005
Page 2
Pursuant to North Carolina General Statute 87-91(a) you are hereby notified that Magette
Pump & Well Company Inc. and Ashton Lewis Lumber Company are in violation of the Well
Construction Standards indicated in Subchapter 2C, Title 15A, of the North Carolina Administrative
Code. These Standards were adopted by the Environmental Management Commission under
authority granted by the North Carolina Well Construction Act. This notice is given in accordance
with North Carolina General Statutes 87-83 et seq.
No corrective action is required at this time. Please ensure that pennits are obtained from the
Director prior to constructing, operating, or using any well for injection purposes in accordance with
2C .0211 Permits. Future violations may result in the initiation of enforcement actions available to
the Division.
Ifyou have any questions or require any additional information, please contact Carrie Stone at (252)
948-3847.
DATE
cc- Gates County Health Department
APS Central Office --- L IC Program,
Washington Regional Office
IN) u&W
hu4co"&'
David May l
Aquifer Protection Supervisor
Washington Regional Office

W R
Michael r. Easley. Govemvr
November 17, 2005
Tom Coxe
Asliton Lewis Lumber Company
P.D. Box 5
Gatesville, NC 27938
Ref: Issuance of Injection Permit.
Permit Number W10700087
Ashton Lewis Lumber Company
Dear Mr. Coxe:
William G. Ross Jr., Secretary
North Catalina Dcpanment of Envimnment and Natural Resonrccs
Alan W. Klimek, P.E. Director
Divisino of Water Quality
In accordance with your application submitted August 26, 2005, the Division of Water Quality's Underground
Injection Control (UIC) Program is forwarding Permit No. W10700087 for the construction and operation of a
geothermal heat pulnp injection system at Ashton Lewis Lumber Company on Lewis Mill Road in Gatesville,
Gates County, North Carolina, This permit shall be effective from the date of issuance until November 30,
2010, and shall be subject to the conditions and limitations stated therein. Please read your permit carefully to
make sure you thoroughly understand its requirements your and responsibilities.
Post -construction inspection and sampling of this geothermal heat pump system is necessary to complete the
pennitting process. You must contact the Division of Water Quality's Washington Regional Office at (252)
946-6481 to schedule the post -construction inspection once the injection well system becomes operational.
Please note, if the sample results exceed groundwater quality standards, it is the well owner's responsibility to
take corrective action as stated in Title 15A Subchapter 2C, Section .0206.
Thank you for submitting this notification- Please contact me at 919-715-6166 or Evan Kane at 919-715-6182
if you have any questions regarding this transmittal or the UIC Program.
Best Regards,
Thomas Slusser
Hydrogeological Technician II
UIC Program
cc: David May, Washington Regional Office
CO-UIC Fifes
Na E Carolina
l7114r17111, j
Aquifer Protection Section T636 M a i I service Center Raleigh, NC 27699-1636 Phone (9I9) 733-3221 CUi DnxT Service
Intcmet http:IRi2o.enr.state. nc.us 2728 Capital Boulevard Raleigh, NC 27604 Fax (9] 9) 715 0588 1477-623-6748
Fax [phone]
An Equal OpportunitylAfflrmaSe Acton Empbyer- 50% Recydedl10% Post Consumer Paper

DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
November 9, 2005
MEMORANDUM
TO: Debra Watts J0~ ...
THROUGH: Evan Kane 4i__ \t/\~
FROM:
RE:
Thomas Slusser I$
Issuance of Injection Permit WI0700087
Type 5A7 Injection Wells
Ashton Lewis Lumber Company
I am recommending that injection permit WI0700087 be issued to Ashton Lewis Lumber Company for
the injection of heat pump effluent. On September 26, 2005 Carrie Stone of the Washington Regional
Office conducted a pre-construction inspection and observed that the injection wells do not comply
with the required 25-foot separation distance between wells and building foundations. On October 31,
2005 the Washington Regional Office issued a variance for this well construction standard based on
construction details of the building and the wells, and recommends issuance of this permit. The permit
application and well construction details are sufficiently sound and merit issuance of this permit. The
related but technologically-separate issue of injection well construction without a permit ~ be
addressed via a Notice of Violation to the well contractor. ~-
Attachment
-p~-;_,,.~ v-;{ ~ ~~-•~--;; -t>.-
~tJo./. k
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR TIDE 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
ASHTON LEWIS LUMBER COMPANY
FOR THE CONSTRUCTION AND 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. The injection wells will be located on Lewis Mill Road in Gatesville,
Gates County, North Carolina, and will be operated in accordance with the application submitted
August 26, 2005 and in conformity with the specifications and supporting data submitted, all of
which are filed with the Department of Enviromnent and Natural Resources and are considered apart
of this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the Water
Use Actor any other applicable Laws, Rules, or Regulations. Operation and use of an injection well
shall be in compliance with Title 1 SA North Carolina Administrative Code 2C Al 00 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 November 30, 2010
and shall be subject to the specified conditions and limitations set forth in Parts I through X hereof.
4-
Permit issued this the 1- day of , 2005.
*1 Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. W10700087 PAGE t OF 4
GWlUIG5 per. 7105

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface
cannot migrate into the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use. -
7. Each 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, DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1636
Mail Service Center, Raleigh, NC 27699-1636, 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 Aquifer Protection Section-Underground Injection Control (UIC), Central Office
staff, telephone number [phone] and the Washington Regional Office Aquifer
Protection Section 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.
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
PermitNo. WI0700087
GW/UIC-5 ver. 7/05
PAGE20F6
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. Furthennore,
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.
i. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section-Underground
Injection Control (VIC), Central Office staff, telephone number [phone]. Notification
is required so that Division staff can inspect or otherwise review the injection facility and
determine if it is in compliance with permit conditions.
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
Permit No. WI0700087
GW/UIC-5 ver. 7/05
PAGE30F6
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 m:ust be maintained
under the terms and conditions of this permit, and m:ay 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 in any unusual
operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report to
the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an
extension.
Permit No. WI0700087
GW/UIC-5 ver. 7/05
PAGE40F6
PART IX-CHANGE OF WELL STATUS
1. The Perrnittee shall 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 Perrnittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to ISA NCAC 2C .0213(h)(l), Well Construction
Standards.
2. When operations have .ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(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)
PermitNo. WI0700087
GW/UIC-5
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion of
abandonment.
PAGE50F6
ver. 7/05
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X-OPERATION AND USE SPECIAL CONDITIONS
None
PermitNo. WI0700087
GW/UIC-5 ver. 7/05
PAGE60F6
Memorandum
TO: Thomas Slusser -UIC Control -Central Office
RECEIVED/ DENR / DWQ
AQUIFER PROTECTION SECTION
NOV O 8 2005
THROUGH: David May-Aquifer Protection Section Regional Supervisor -Washington OL /VJ
FROM: Carrie Stone -Hydro geological Technician -Aquifer Protection Section {fJz!)
WaRO
SUBJECT: Ashton Lewis Lumber Company -UIC PreConstruction Inspection
DATE: October 31, 2005
On September 26, 2005, the Washington Regional Office conducted a site visit to the Ashton Lewis
Lumber Company located off of 137, on Lewis Mill Road in Gatesville, in Gates County, North Carolina
to perform a PreConstruction inspection for the location of the proposed injection well system. Both of
the injection wells have been installed but are not in service yet. The wells are located approximately 10
to 15 feet from the building foundation of the new saw mill, currently under construction. One well is
located approximately 8 to 10 feet from a possible storm water drainage line. The separation distances
from the wells to the building foundation is less than the 25 feet required by the NC Well Construction
Standards. A request for a variance from the Well Construction Standards has been submitted.
According to information supplied, the building foundation is concrete and steel and will not have any
pesticide treatment. The Well Construction Records indicate that the wells have been grouted to depth of
at least 300 feet. Based on this supplemental construction, in this case, this office finds that technically,
the separation distance requirement violation may not pose an increased risk of contamination. A
variance for well location only has been granted.
If you have any questions, please call me call me at [phone].
y 6s{. 3 V2 s
North Carolina Department of Environment and Natural Resources
Division of Water Quality -Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTION
REPORT -FORM A
INJECTION WELL PERNHT NO. WI01COOV DATE 4-6-G-0'S
NAME OF OWNER As►4-roA LEwr.>)-UYneo GnY$PATgV - Tarn (2)?(E
ADDRESS OF OWNER ` WT dFFr
(Screed road or loc and suddivision, county, Sowni
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable
- F -r K z T �► a .T nsa 5 o rnirs. w lN5 Cu,a-Y-rL,l , r „sr�j►,�, ,a.
(Streell road or lot and suddivision , county, town, ii(dierent than owner's address, plus description of location on side)
Potential pollution source Distance from well 4zf6-rAflr1 �77' sbezuD�
Potential pollution source •5Toa1`DeAirA Distance from well LEtbTiiAA 15'
Potential pollution source
Distance from well
Minimum distance of proposed well from property boundary > `ju
Qualiry of drainage at site GOOD Flooding potential of site fyt:feATYs
(good,ad equate.poor), (12iQ ir,moderate, law)
DRAW SKETCH OF SITE
(Show property boundaries, buildings, xvells, poceniial pollution sources, roads, approximate scale, and north arrow)
OPFIC�
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March 98

Page 2 of i
PRECQNSTRUCTION NINJECTION FACILITY
INSPECTION REPORT,- FORM A (cant)
COA MEN S
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INSPECTOR L!ACar-
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WITNESS
Address
WITNESS
Address
March 98

Ashton Lewis Lumber Company PreConstruction Injection Faciltiy Inspection
Gatesville, Wayne County Site Visit Date: 09/26/2005 Well#'I

Well#2
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: Se ptember 26 , 2005
To: A quifer Protection Section Central Office
Central Office Reviewer: Thomas Slusser
Regional Login No: __ _
L GENERAL INFORMATION
County: Gates
Permittee: Ashton lewis Lumber Com panv
Project Name: T pe 5A7 In jection Well System
Application No.: WI0700087
1. This application is (check all that apply): IZ! New D Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation IZ! Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IZ! Yes or D No.
a. Date of site visit: Se ptember 26. 2005
b. Person contacted and contact information: Tom Coxe [phone]
c. Site visit conducted by: Carrie Stone
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 Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude: __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Dis posal and Injection Sites:
(If multip le sites either indicate which sites the information a pplies to . copv and paste a new section into the
document for each site. or attach additional p a ges for each site)
a. Location(s): New Saw Mill at the Ashton Lewis Lumber Company Facility located on Lewis Mill Road off
of H wy 137 in Gatesville in Gates County .
b. Driving Directions: From Washington. take 13 North to Ahoskie. Cross Chowan Bridge. Go approx. 2
miles , take a ri ght onto Hwy 137 towards Gatesville. Go strai ght through Ballards Crossroads. Lewis Mill
Road is the first p aved road on the right. The saw mill is approx .. 5 mile at the end.
c. USGS Quadrangle Map name and number: Gatesville (Dl 7b)
d. Well#l Well# 2
Latitude: 36 23 52.08 Longitude: 76 46 01.08 Latitude: 36 23 52.08 Longitude: 76 46 01.08
FORM: APS StaffReport 1
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed fo r renewals or minor
modifi cations , skip to next section )
Description Of Waste (S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No D N/A. Ifno, please explain: __
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No D N/A. Ifno, please explain: __
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes D No D N/A. Ifno, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No D
NI A. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D N/ A. If no, please explain: __
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No D N/A. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit: __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well
network if applicable. fudicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
IIL RENEW AL AND MODIFICATION APPLICATIONS (use previous section fo r new or maior modification
systems)
Description Of Waste (S) And Facilities
1. Are there appropriately certified ORCs for the facilities? D Yes or D No.
Operator in Charge: __ Certificate #: __
Backup-Operator in Charge: Certificate #:
FORM: APS Staff Report 2
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
2. Is the design, maintenance and operation ( e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D No.
If no, please explain: __
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? D Yes or D No. If no, please explain: __
4. Has the site changed in any way that may affect permit (drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain: __
5. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
D Yes or D No. If no, please explain: __
6. Are the existing application rates (hydraulic or nutrient) still acceptable? D Yes or D No. If no, please
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes D No D N/ A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Will seasonal or other restrictions be required for added sites? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, please attach a
map showing conflict areas or attach any new maps you have received from the applicant to be incorporated
into the permit: __
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? D
Yes or D No. Ifno, please explain: ____ _
11. Were monitoring wells properly constructed and located? D Yes or D No D N/A. If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? D Yes or
D No D N/A. Please summarize any findings resulting from this review:
13. Check all that apply: D No compliance issues; D Notice(s) of violation within the last permit cycle; D
Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc):
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? D Yes
D No D Not Determined D N/A.. Ifno, please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? D
Yes or D No D N/A. If yes, please explain: __
FORM: APS StaffReport 3
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PEllMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description OfWell(S) And Facilities -New, Renewal , And Modification
1. Type of injection system:
[Z] Heating/cooling water return flow (5A7)
D Closed-loop heat pump system (5QM/5QW)
□ In situ remediation (5n
D Closed-loop groundwater remediation effluent injection (5L/"Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? [Z] Yes D No
3. Are there any potential pollution sources that may affect injection? [Z] Yes D No
What is/are the pollution source(s)? Building foundation and poss ible stormwater pi ping. What is the distance
of the injection well(s) from the pollution source(s)? There are 2 wells . both are a pprox. 10 to 15 feet from both
potential pollution sources.
4. What is the minimum distance of proposed injection wells from the property boundary? > 50 ft.
5. Quality of drainage at site: IZI Good D Adequate D Poor
6. Flooding potential of site: D Low [Z] Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? IZI Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
In jection Well Permit Renewal And Modification Onlv :
1. For heat pump systems, are there any abnormalitie·s in heat pump or injection well operation ( e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes D No. If yes, explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes . explain:
3. For renewal or modification of groundwater remediation permits (of an y typ e), will
continued/additional/modified injections have an adverse impact on mi gration of the plume or management of
the contamination incident? D Yes D No. If ves . explain:
FORM: APS StaffReport 4
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
4. Drilling contractor: Magette Well and Pump Co .. Inc.
Name: Samuel L Wi gg ins
Address: 2341 US 13 South , Ahoskie , North Carolina 27910
Certification number: 2300
5. Complete and attach Well Construction Data Sheet.
FORM: APS StaffReport 5
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
Both of the injection wells have been installed but are not in service yet. The wells are located approximately 10 to
15 feet from the building foundation of the new saw mill, currently under construction. One well is located
approximately 8 to 10 feet from a possible stormwater line. The separation distances from the wells to the building
foundation is less than the 25 feet required by the NC Well Construction Standards. A request for a variance from
the Well Construction Standards has been submitted. According to information supplied, the building foundation is
concrete and steel and will not have any pesticide treatment. The Well Construction Records indicate that the wells
have been grouted to depth of at least 300 feet. Based on this supplemental construction, in this case, this office
finds that technically, the separation distance requirement violation may not pose an increased risk of
contamination. A variance for well location only has been granted, with conditions added to further minimize the
potential for the wells to function as a contaminant migration source.
2. Attach Well Construction Data Sheet -if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? D Yes ~ No. If yes, please explain
briefly. Based on the de gree of ITToutin g. this office does not foresee problems with issuance of permit..
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5 . List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information~-
Issue; D Deny. If deny, please state reasons: __
FORM: APS Staff Report 6
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
l ? 1 ,,---,
8.-Signature ofreport preparer(s): -~'.,._1]4.~,~~-'"""-',_Q_i)-'.'_L~-/ ____________ _
Signature of APS regional supervisor: _Q,...· ............. £10~• ~L~)_fv\~-~-------------
Date: l \ ~ ~ ,-0 /
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: APS Staff Report 7
(ItlC
Michael F. Easley, Governer
William G. Ross Jr., Secretary
North Carolina Deparnrrc of Envnrntmertt and Natural Resources
Alan W. Klimck, P.& Director
Division of Water Quality
DIVISION OF WATER QUALITY
Aquifer Protection Section
October 31, 2005
Mr, Tom Coxe
Ashton Lewis Lumber Company
Post Office Sox 5
Gatesville, North Carolina 27938
RE: Variance Request to Rule 15A NCAC 2C.0107(a)(2)(M)
Ashton Lewis Lumber Company — New wells 1 and 2
Lewis Mill Road
Gatesville, Gates County, North Carolina
Dear Mr. Coxe:
On October 28, 2005, the Washington Regional Office received your request for a variance to rule 15A
NCAC 2C.0107(a)(2)(M) of the Well Construction Standards for new wells l and 2, The locations of the wells,
located as referenced in the attached map at the Ashton Lewis Lumber Company located off of 137, on Lewis
Mill Road in Gatesville, in Gates County, North Carolina, do not meet the horizontal separation distance of 25
feet between a well and building foundations as required by the referenced rule. The wells were constructed for
the purpose of water injection associated with a geothermal heat pump system. According to information
supplied by you, the building foundation is concrete and steel and will not have any pesticide treatment. The
Well Construction Records indicate that the wells have been grouted to depth of at least 300 feet. Based on this
supplemental construction and a site visit conducted by staff from this office on September 26, 2005, a variance
to the above cited rule is granted, with the following conditions:
1. The well head and areas surrounding the well head shall be constructed and finished in a manner
to prevent stormwater and runoff from migrating vertically along the well below the concrete
pad.
2. Safety retention devices shall be constricted around the wells to prevent damage from traffic.
The granting of the variance is for location of the wells only, and in no way relieves the owner or agent
from other requirements of the North Carolina Well Construction Standards, or any other applicable law, rule or
regulation that may be regulated by other agencies. Additionally, please note that issuance of this variance does
not imply approval of these wells to be used as injection wells. If you are dissatisfied with this decision, you
may commence a contested case by filing a petition under G.S. 105-23 within sixty (60) days after receipt of the
decision.
Plortir Carolina Division of Water Quality Internet: QD.enr.state. nc.us
943 Washing -tan Square Mall Phone: [phone]
Washington, NC 27889 FAX [phone]
One
NorthCarolina
Naturally
An Equal opportunity/Afirmative Aden Employer-50%Recycled1lD%Post Consumer Paper

Mr.Coxe ·
October 31, 2005
Page2
(
If you.have any questions regarding this variance, please contact Carrie Stone at [phone]. Any
questions or concerns regarding use of the wells for injection purposes should be directed to Thomas Slusser
with the Underground Injection Control Program at [phone].
Sincerely,
(J rw-cl <fb
David May
Aquifer Protection Regional Supervisor
Washington Regional Office
cc: Magette Well & Pump Co., Inc. 2342 US 13 S., Ahoskie, NC 27910
UIC
WaRO
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NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Eavirommal and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION t# 2 9 3 6
1, WELL CONTRACTOR:
Bobby L. Harrell
Well Contractor (Individual) Name
Maget_te Well & Pump cc., Inc.
Well Contractor Compeny Name
STRIrETADDRESS 2342 US 13 S
Ahoskie NC 27910
City or Town state zip Code
2i 52 1- 332-2265
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #{lr applfcttble) Well 02
STATE WELL PERMIT#(Inapplicable)
DWG! or OTHER PERMIT.#(if applicable) -
WELL USE (Check Applicable Box) Monitoring ❑ Municipal/Public p
IndustriallCommereial ❑ Agricultural ❑ Recovery ❑ Injection t9
IrrigatlonU Other ❑ (rlst use) geothermal heat puml
DATEDRIL.LED 9/16/05
TIME COMPLETED 6 - 00 AM ❑ PM it
3. WELL LOCATION:
CITY: Gatesville COUNTY Gates
Lewis Mill Road
{Street Name, Numbers, t o nmunity, SubdM5ion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0slope ❑Valley plat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE 3 6 d 23.879n May he in degrees,
7 d.0 l 8w minutes, seconds or
LONGITUDE 7 _ in a decimal fornisL
Latitude/longitude source: 6 GPS oTopographic map
{location of well must be shown on a USGS topo map and
alrached to this Iarrn If not Gsfag GPSy
4, FACILITY- is his name & the busIrwisa where the well is located.
FACILITY ID #(if applicable)
NAMEOFFACILITY Ashton Lewis Lumber
STREETADDRESS Lewis Mill Road
Gatesville NC 27938
City or Town State Zip Code
CONTACT PERSON Tom Cox
'gip
MAILING AD SS PID Sox 5 - :r
Gatesvia .\;�- _- �il 1 -
City or Town , 5taiql � L7iP.00dR•J".
Area code • Phone number
or
5. WELL DETAILS;
a. TOTAL DEPTH: 3 3 1 r -- •�-�.•��Fick
' „ i,wE�I.uYAL
b. DOES WELL REPLACE EWTING } tL'7°} Sy jlC NO
c. WATER LEVEL Below Top of Cam FT.
(Use ";` if Above Top a` Casing)
d. TOP OF CASING 19 3 FT. Above Land Surface'
'Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C ,0118.
a. YIELD (gpm): 1 00+ METHOD OF TES -Id i I: lift
f. DISINFECTION. Type H TH Amount -2-pound
g. WATER ZONES (depth):
From 315 To 325 From To
From To from To
Fran To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From +1 To 20 Ft. 19" SDR 21 PVC
From +3 To-3-15 Ft. 4, 5" S D R 17 P V C
From To— Ft
7. GROUT; Depth Material Method
From O To 20 Ft. neat cement pump.]
From 20 Ta 315 Ft, bentonite _ pump
From To Ft�
S. SCREEN: Depth Diameter Slot Size Material
Fran 315 To 325 FL 4 in. .03DIn. stainle
From To Ft. In. in.
From To Ft in. tn,
9. SANAIGRAVEL PACK:
Depth Size Materlal
From 285 To 331 Ft.3 �2!o�atherm- Pro,
From To Ft,
From To Ft,
10. DRILLING LOG
From To Formation Description
0 - 12 clay
12 - 18 sand
18 - 110 clay with sand
Ila —225 sAnri f i np t-n Mer3
11. REMARKS:
N]ells are designed to inject water
i_eat pumps then cycle and produce w
fors heat Ruin_is -- -
IbO HEREBY CERTIFY T14AT THIS W ELL WAS CONSTRUCTS] IN ACCORDANCE WITH
1§A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REC HAS PROVI 0 Tl] T}1 yy LL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Hobby L. Harrell
PRINTED NAME OF PERSON CONSTRUCTING THEW ELL
acts
rom
ter
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-lb
1617 Mall Service Center— Raleigh, MC 27699-1617 Phone No. [phone] ext 568. Rev. 7/05

+f STATE o-
NON RESIDENTUL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division ❑f Water Quality
WELL CONTRACTOR CERTIFICATION # 2300
1. WELL CONTRACTOR:
.amiia7_
Well Contractor (Individual) Name
We I Contractor Gompany Name
STREETADDRESS 2342 US 13 S
Ahoskie NC 27910
City or Town State Zip Code
(252 )- 39 2P6�
Area code- Phone number
2. WELL INFORMATION:: well # 1
SITE W ELL ID#(If appkat)le)
STATE WELL PERMIT*01 applicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Appllcabie Sax) Monitoring ❑ MunicipallPublic❑
IndustriallCommerclal ❑ Agricultural ❑ Recovery ❑ Injection IX
Irrigation❑ (them (Iistuse).eothermal heat um
!SATE; DRILLED 9119
TIME COMPLETED a = 00 AM ❑ PMYj
3. WELL LOCATION:
CITY:0ate5yille COUNTY Ga yes
Lewis Mill Road
(Street Name, Numbers, Communlly, Subdivislon, Lot No., Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
❑Slope ❑Valley ENFlat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE —I— 6 d 23.668n May be in degrees,
minutes, seconds or
LONGITUDE 7 6 d 46 • 018w in a decimal Format
L.atitudellangitude source: ❑GPS oTopographic map
(bcaftn of weill must be shown on a USGS fopa map and
ettached to this form H not using GPS}
4. FACILITY- in the nams or the bUIVARLe where the well is Iraceted.
FACILITY to #(if applicable)
NAMEOF FACILITY Ashton Lewis Lumber Co.
STREET ADIDREss Lewis Mill Road
Gat:esville NC 27938
City or Town State Zip Cads
CONTACT PERSON Tom Cox
G1AIPNSAAD fJSS PC) Box 5
7
City or Town c-, SWe
t 252_� 357❑0
Area code • Phone number. 5 i .. 1 T
5. WELL DETAILS: ar'1 : , ., � ; �
a. TOTALDEPTH:
t }
b, DOES WELL REPLACE EAST
uik
c. WATER LEVEL Below Tip of Cesin
(Use'+" 1f Abeve\Tgp vi waslag;
d. TOP OF CASING IS 3
FT. Above Land Surface"
'Top of casing terminated atlor below land surface may require
a variance in accordance
with 15A NCAC 2C .0118,
a. YIELD (gprn): 80
METHOD OF TEST a 1 r l i f t
f. DISINFECTION: Type
,
HT H Amount 2 AS,
g. WATER ZONES (depth):
From3aaf21 Tfl341
From T❑
From To
From To
From To
From To
a. CASING:
DTgtll0
p VT�hlcc�kness)
Dien}ptar 5I3R 21 Matgri
L UU. Pvt
From+1
From+3 Ta 332�
F[.
Ft. 4 .�'f' S D R 17 PVC
Frorn341 To 346
Ft. 4" 5CH 80 PVC
7. GROUT: Depth
Material Method
From 0 Ta 20
Ftnea�t cement pump
Fr,,=To=Ft
a17L] tOi71'LE C-r0�-7um
From To
FL
B. SCREEN. Depth Diameter Slot size Material
From 321 To341 Ft, 4 in. 103gn stainle Is
From To Ft. In. ln.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
De th Size Matedal
From 300 To 346 Ft. 3 Southern Prod �cts
From To Ft.
From Tc Ft.
10. DRILLING LOG
From To Formation Dessriptbn
c ri y
12 - 18 sand
18 - 110 clan with sand
sand fine to med.
-2757 c a
295 5 �sand fine to med-
1
l� 11. REMARK$:
Wells are designed to inject water
>� ~. from heat pumps hhen cycle and
produce water for heat_ pumps.
1130HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wm1
1 ISA HCAC 2c, wELL c0NSTRUCTIDN STANDARDS. AND THAT A COPY OF THIS
1 RECOR S BEEN PROVIDED? THE WELL OWNER.
}� ❑� 51 NATURE DF OERTIFI LL CONTRACTOR DATE
FT, Samuel L. Wi gins _
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the origins] to the Division of Water Quallty within 30 days. Attn, Information Mgt., Form GW-1b
1617 Mall Service Center— Raleigh, NC 276994617 Phone No. [phone] ext 558, Rev. 7105

RECENED I DENR I DWO
AMIFR PROTECTION SECTION
SEP 0 $ -2005
AM FER PRI)TECTIUN SECTION
APPLICATION REVIEW REQUEST FORM
Date: August _31.2005
To: ❑
Landon Davidson, ARO-APS
❑
Art Barnhardt, FRO-APS
❑
Andrew Pitner, MR0-APS
❑
Jay Zimmerman, RRO-APS
From: Thomas Slusser, , Groundwater Protection Unit
Telephone: [phone] t -
E-Mail: thomas.slusserCeincmail.net
0 David lvfay, WaRO-ANS
❑ Charlie Stehman, WiRO-APS
❑ Sherri Knight, W SRO-APS
Fax: [phone]
A. Permit Number: W10700087
B. Owner: ASHTON LEWIS LUMBER COMPANY
C. Facilitv/O_peration:
❑ Proposed ® Existing ❑ Facility
D. Application:
NMI
WASHtNGTO D EGED iAL OFFiCf
Operation
1. Permit Type. ❑ Animal ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Remediation (ND)
® UIC - (SA7) 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 Certifieation 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 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: Ir ; Date: l ^
FORM: APSARR 09/04 Page 1 of I

pF W A 7-p Michael F, Easley, Governor
,O� �G William G. Ross Jr., Secretary
North Carolina Department of Environment anti Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Qua)ity
August 31, 2005
Tom Coxe
Ashton Lewis Lumber Company
P,O. Box 5
Gatesville, NC 27938
RE: Pemilt Application Receipt
Type 5A7 Injection Well
Dear Mr. Coxe:
Ashton Lewis Lumber Company's application for a permit to construct and use a well for the injection of
geothermal heat pump effluent has been received and is under review. A member of the Aquifer Protection
Section's Washington Regional Office staff will be contacting you to arrange an. inspection of the injection
well site as part of the review.
Please contact me at 919-715-6166 or Evan lane at 919-715-6182 if you have any questions regarding this
transmittal or the Underground Injection Control Program,
Best Regards,
Thomas Slusser
Hydrogeological Technician II
Underground Injection Control Program
Enclosure
cc: David May, Washington Regional Office
CO-I,11C Files
I4�on�` Caroliria
Atwirally
Aquifer Proicetion Section 1636 Mail Smice Center Raleigh, NC 27699-1636
Intemev hltpWhlo.enr,statemc.us 2728 Capital Boulevard Raleigh, NC 27604
An Equal Qpporfunity)ATiirmative Action Employer— 50% RecyeledllD%Post Cit}MUMer Paper
Phone [phone] Customer Service
Fax [phone]
Fax [phone]

A QUIFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: August 31 . 2005
To: D Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS .
0 Andrew Pitner, MRO-APS
D Jay Zimmerman, RRO-APS
From: Thomas Slusser , Groundwater Protection Unit
Teleplio1te: [phone] /~
E-Mail: [e-mail]
A. Permit Number: WI0700087
B. Owner: ASHTON LEWIS LUMBER COMPANY
C. Facilitv/O peration: __
D Proposed [8] Existing
D. Application:
[8] David May, WaRO-APS
0 Charlie Stehman, WiRO-APS
□ Sherri Knight, WSRO-APS
Fax: {919) 715-0588
D Facility D Operation ·
I. Permit Type: D Animal D Surface Irrigation D Reuse D H-R Infiltration
D Recycle D 1/E Lagoon D GW Remediation (ND)
[8] UIC-(5A7) open loop geothermal __
For Residuals: D Land App. D D&M
D 503 D 503 Exempt
D Surface Disposal
D Animal
2. Project Type: [8] New D Major Mod. D Minor Mod. D Renewal D Renewal w/ Mod.
E. Comments/Other Information: D I would like to accompany you on a site visit.
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:
[8J 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 09/04 Page 1 of 1
�htab► i��
BILLM
TELEPHONE [phone]
FAX [phone]
MAGETTE WELL AND PUMP CO., INC.
DEEP WELL DRILLING ■ WATER GUARANTEED
2342 US 13 S
AHOSKIE, NORTH CAROLINA 27910
RECEIVED J DEINR I DWQ
,,,,,,SRPR0TEGM0R 5EC'CO
mG % 6 200S
August 23, 2005
Tom Coxe
Ashton Lewis Lumber Company
PO Box 5
Ciatesville NC 27938
Dear Tom,
Please find enclosed application permit for injection wells. Please fill in line F. Page two (2) and
sign on page four (4) and send two copies to the state.
Thank you,
Kathy Sumner

NORTH CAROLINA
RECEIVED I DENR/ DWQ
AQU\FfiR PROTECTION SECTION
AUG 2 6 2005
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type 5A7 and SQM 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 DNISION OF WATER QUALITY
DATE: August 23 20 05 --
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1)
(2)
(3)
X Type 5A 7 wells inject water used to provide heating or cooling for structures.
Type 5QM wells contain a subsurface system of continuous piping, that is
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes and/or corrosion
inhibitors.
Type 5QW wells contain a subsurface system of continuous piping, that is
isolated from the environment and only circulates potable water. If you selected
this well type, then complete form GW-57 CL, Notification Of Intent To
Construct A Closed-Loop Geothermal-Water Only Injection Well System.
B. PERMIT APPLICANT
Name:Ashton Lewis Lumber Company
Address: Rt. 137 Lewis Mill Road PO Box 5
City: Gatesville State~ Zip Code: 27938 County: Gates
Telephone: [phone]
C. PROPERTY OWNER (if different from applicant)
Name: __________________________ _
Address: _________________________ _
City: _________ Sate: __ Zip Code: ___ County: ____ _
Telephone:
D. STATUS OF APPLICANT
Private: Federal: Commercial: X
State: Municipal: __ Native American Lands:
GW-57 HP (Jan, 2000) Page 1 of 4
E. FACILITY (SITE) DATA
F .
(Fill out ONLY if the Status of Owner is Federal, State , Municipal or Commercial).
Name of Business or Facility: Ashton Lewis Lumber Company
Address: Rt 137 Lewis Mill Road
City: Gatesville Zip Code: 27938 County: _G_a_t_e_s ____ _
Telephone: __________ Contact Person: __________ _
HEATPUMPcoNTRA9'f?R D AT~~ A.. r1
Name: :_S ~ S~ ~CC>l
Address: ~le_~ G ('O..~ '° y s-ty-~e =r
City: s lA. f ¼\Ii J \{fl Zip Code: 2-Sc./ > 'f County: ~--~-----
Telephone: 751-SS4-7t/8 t/ Contact Person: Ca \0.. C.P 'a\;
G. INJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.)
There will be 2 wells approximately 440' deep spaced approximately
100' apart, each with a pump installed well 1 will produce water
and inject into well 2 for a set period of time then well 2 will
nJ::.Onufie waLefi and irtiect into well 1. . H. -w .bI:r..; :sE W1 rn:e mJecuon welf(s) also oe useo as the supply well(s) for the following?
(1) The injection operation? YES X NO ___ _
(2) Personal consumption? YES ____ NO _X __ _
I. CONSTRUCTION DATA (check one)
X
EXISTING WELL 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.
PROPOSED WELL 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) Well Drilling Contractor's Name: _B_o_b_b_.y..__H_a_r _r _e_l_l ____________ _
NC Contractor Certification number: 2 9 3 6 ------------
(2) Date to be constructed: August 2005 Number ofborings: 2 ___ _
Approximate depth of each boring (feet): __ 4_4_0_' ____ _
(3) Well casing: Is the well(s) cased?
(a) YES X If yes, then provide the casing information below.
Type: Galvanized steel __ Black steel __ Plastic_X_ Other (specify) ______ _
Casing depth: From O to 4 2 0 ft. (reference to land surface)
Casing extends above ground 2 4 inches
(b) NO __
GW-57 HP (Jan, 2000) Page 2 of4
( 4) Grout (material surrounding well casing and/or piping):
(a)
(b)
Grout type: Cement~ Bentonite X Other (specify) _______ _
Grouted surface and grout depth (reference to land surface):
--around closed loop piping; from to (feet). --- ---
3" around well casing; from O to 20 (feet).
~ ~ 400
(5) Screens (for Type 5A7 wells)
(a) Depth: From 420 to440 feet below ground surface.
(6) N .C. State Regulations (Title 15A NCAC 2C .0200) require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent (fluid being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? yes_X __ no__ (b) the effluent line? yes_X_ no __
(7) SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well).
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available,
provide the data in part K (1) of this application form to the best of your knowledge .
NOTE : THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS .
J. PROPOSED OPERATING DATA (for Type 5A7 wells)
(1) Injection rate: Average (daily) 80 gallons per minute (gpm).
(2) Injection Volume: Average (daily)115 ' 2 <tQJ.1ons per day (gpd).
(3) Injection Pressure: Average (daily) 10 pounds/square inch (psi).
(4) Injection Temperature: Average (January) 50 ° F, Average (July)~° F .
K. INJECTION FLUID DATA
(1) Fluid source (for Type 5A7 wells) If underground, from what depth, formation and type of
rock/sediment unit will the fluid be drawn ( e .g., granite, limestone, sand, etc.).
Depth : 420-440 Formation: not sure Rock/sedimentunit:_s _a_n_d __ _
(2) Chemical Analysis of Source Fluid (for Type SQM wells)
Provide a complete listing of all chemicals added to the circulating heat transfer fluid :
Not available however with both wells bein g the same de p th the water
quality to be injected will be identical to water at injection point.
L. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
GW-57 HP (Jan, 2000) Page 3 of4
M. LOCATION OF WELLS) Attach two maps.
(I) 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 snap of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(I) Hazardous Waste Management grogram permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
O 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 construct, operate, maintain,
repair; and if applicable, abandon the injection wall and all related appurtenances in accordance with
the approved specifications and conditions of the Permit."
(Signature of well Own Authorized Agent)
If aulborized agent is acting on behalf of the well owner,
please supply a letter signed by the owner authorizing the above agent
P CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is awned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the injection well(s) conforins to the Well
Construction Standards (Title I SA NCAC 2C .0200)
(signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
OW-57 HF (lan, 2000) Pace 4 of 4

P/I 0sP4
ualC

,trrr�c_4 �: ";S;:a'i';t UialiU�li�f■1 � j' � f�
r rJ �
T. 'gMe WC11 & Pump compL,y
f ,Clip i]F' WELL For
re t Wit., C��l�
Cnnnty, State _ __ -
0aLe Drl11ing Started— Ifi Date Starter{—_
finished UrMin$
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�f. etiF Lh Ur R1ze OF
F'nlnl 1]gpt}t 17rplh ClF _.._._ inl.nt 1 E•n::lh F.ns:lr Sec. 4f SlxrIFy Screen C nnl!e
Saeh FnrmaMn Found At E--wh Slralwn Of All Srrernc rcen Or `
Of All S!}.a{p Srtren Or Or of St rrrn
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- - - teol
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19 SLuLic Lavet
�4197
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prodordorl
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r"
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lA 5latie Isc�rl
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Sbop No.
Type I'IenlL • f-.._
PUMP DATA:
Type Lumber
Sire Suction
(BP to Rillj
__---_
Sire Column
Type F3rtw1
No. Stages
LrngLll Suclinrr
Lmsth Air Line,
.
I)fscharge
C'np'v. nllrl Y're" i
PrnRedrn