WI0700195_GEO THERMAL_20160208

Water Resources
iaNVIRO M ;NT AL OUA~ITY
February 3, 2016
Thomas and Melinda Kay Amsler
4510 Moncks Court
New Bern, North Carolina 28562
SUBJECT: Groundwater Sampling Results
UIC Permit No. WI0700195
Issued to Thomas and Melinda Kay Amsler
New Bern, Craven County, North Carolina
Dear Mr. and Mrs. Amsler:
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secrelary
S. JAY ZIMMERMAN
RECEIVEDINCDEQ/OWR
FEB 0·8 2016
Water Quality
ReQlonaJ OP8fations Secalon
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 28, 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
Iron Micrograms per Liter 300 5100 (supply well-influent)
(ug/L) 5100 (in jection well-effluent)
Total Coliform Colony Forming Units 1 120 (injection well-effluent)
per 100 milliliters
(CFU/100ml )
pH Standard Units 6.5 to 8.5 6.0 (supply well-influent)
6.0 (injection well-effluent)
The exact source of these exceedances is unknown; however, Iron and pH exceedances in
groundwater are often due to naturally occurring conditions. Total Coliform bacteria results may be affected
by sampling methods. 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 the Craven County Health Department.
In addition, the following two constituents exhibited an increase in concentration between the influent
(supply well) and effluent (injection well):
Parameter Units NC Groundwater Results.
Copper
Nickel
Standard
Micrograms per 1000 8.8 (supply well-influent)
Liter (ug/L) 23 (in jection well-effluent)
Micrograms per 100 <2.0 (supply well-influent)
Liter (ug/L ) 3.1 (in jection well-effluent}
State of North Carolina I Environmental Quality I Water Resources -Water Quality Regional Operations-Washington Regional Office
943 Washington Square Mail, Washington, NC 27889
252-946-648 l
Thomas and Melinda Kay Amsler
February 3, 2016
Page 2 of 2
While the concentrations of these constituents are still well below state groundwater standards, these
results may indicate that your geothermal heat pump system is have an effect on the groundwater flowing
through the system. This information is being provided to help you operate the system in the future.
If you have any questions regarding the sampling results or your permit, please feel free to contact
me at [phone].
Attachments
Dwight Randy Sipe, P.G ., Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources , NCDEQ
cc: /4ichael Rogers -DWR Groundwater Protection Unit, Central Office
Craven County Health Department
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
EPAPDWS=11
Influent Sample Results <0.02
Effluent Sample Results <0.02
Parameter Chromium, Cr
units µg/L
NC MCL and/or EPA Standard NC MCL= 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 .: WI0700195
PERMITTEE(S): Thomas and Melinda Amsler
SAMPLE COLLECTION DATE: 12/28/2015
Total Coliform Total Dissolved Solids Chloride, Cl
CFU/100ml mg/L mg/L
NCMCL= 1 NCMCL=500 NC MCL = 250
EPA SDWS = 500 EPA SOWS= 250
<1 347 7.3
120 338 7.2
Hardness as CaC03
Nitrite (by Calculation) * Aluminum, Al
mg/Las N mg/Las CaC03 µg/L
NC MCL=1 NS NS
EPAPDWS= 1 EPA SOWS = 50 to 200
<0.01 337 <50
<0.01 312 <50
Copper, Cu Iron, Fe Potassium, K
µg/L µg/L mg/L
NC MCL= 1000 NC MCL= 300 NS
EPA SDWS = 1000; PDWS = 1300 EPA SOWS= 300
8.8 5100 0.93
23 5100 0.92
Nickel, Ni Lead, Pb Zinc, Zn
µg/L µg/L µg/L
NC MCL = 100 NC MCL=15 NC MCL = 1000
Fluoride, FL
mg/L
NC MCL=2
EPA PDWS = 4.0
<0.4
<0.4
Arsenic,As
µg/L
NCMCL=10
EPAPDWS=10
<2.0
<2.0
Magnesium, Mg
mg/L
NS
3.1
3.0
pH (field)
units
NC MCL = 6.5-8.5
EPAPDWS= 15 EPA SOWS = 5000 EPA SOWS = 6.5 to 8.5
Influent Sample Results 8.3 <2 .0
Effluent Sample Results 8 3.1
NC MCL = North Carolina Maximum Contamination Limits per 15A NCAC 2L .0200
EPA PDWS = Environmental Protection Agency Primary Drinking Water Standards
EPA SDWS = Environmental Protection Agency Secondary Drinking Water Standards
NS = No Standard
<2.0 13 6
<2 .0 14 6
• Calculation performed by WaRO
Sulfate, S04
mg/L
NC MCL= 250
EPA SOWS = 250
13
13
Calcium, Ca
mg/L
NS ·
130
120
Manganese, Mn
µg/L
NCMCL=50
EPASOWS=50
25
26
North Carolina Division of Water Resources
Central Labarata Water Sciences Section
r}' ( }
Water Sample Collection &Submittal Form
visit ID:
o tiorral
� p �
rag
1D Iniluen
_ Lab Use Only:
--------___
toharatary
Sample Number.
Location aescripilvn: Amster, 4510 Monoks Court, New Bern, NC
Location Cade: WI0700195
Dote Received: rrr
County: Craven
collector. R. Sipe
'Priority:
❑ Ambient
ElRoutine
❑J Compliance
❑CAC
❑Emergency
UOFl
Water Matrix.
❑S
i.-:Jl Ground
❑Waste
❑ Blank
Solution
Location Type:
River/Stream ❑ take
❑urface ❑Estualy ❑Canal
❑Stormwater
❑monitoring Well ❑Water Supply
❑Effluent ❑ Influent
❑Field Blank
❑Trip Blank
[]Filter Blank
GOtrier: Geotherm Supply Wel!
Time Received:
D WR Region: WaRO
ft5edancaunryj
DWR Off, WaRCf ce:
eurdgency-mrj
RecelvedBy.
River Basin: Neuse
Date:
State Courier
DelivreryMedwd. []Hand Delivery
❑ 0ther.
Naves:
Time: I23 Q �]j/I/J
L r JJ
❑ Chlorinated ❑De-etrlar+nated in Field
Sampflag Grab Campasiile
0
Method: ❑ Other_
remperurum ('CJ
onArriwal: 0 •�
Dissolved analysis_ Enter "DIS•
El F313ered in Field In Check_baxes for parameters
Sample Depth. NIA
CoIlector's Comments.
Microbiology Parameters:
MBA5 (suriaaam)
mg/L
Metals Parameters:
Tin (Sn) µg/L
Acidity, as CaCO3, to pH 4,5/8.3
mg/t
Oil and Grease, HEM, Total Recoverable
mg/L
X
Aluminum (Al)
pg/L
Titanium (Tij fsgiL
Alkalinity, as CaCO3, to pH 4.5/8.3
mg/1
Phenols, Total Recoverable
pg/L
Antimony (5b)
pgA
Vanadn:m (V) µg/t,
BOQ: Siochemiral Oxygen armand, 5-day
mg/L
Residue: Total (TaCut SolidS)
mg/L
X
Arsenic [As)
pg/L
X
Zinc (Zn) flg/1
cli= Carbonaceous BUD, 5-day
mg/t
Residue: Valatile/Fixed, Total
mg/t
Barium (Ba)
pgA
X
Cori Farm: Fecat OAF
/100ml
Residue- Suspended (Suspended5ohds)
mg/t
Beryllium (Be)
pg/L
Boron (a), Total I.g/L
X
Celiform: Total MF
/100ml
Residue: Volatile/Fixed, Suspended
mg/L
Cadmium [Cd)
pg/L
Mercury 163% low-level ttg/L
Coliform- Tube Fecal
/looml
x
TDS - Total Dissolved Solids
mg/L
X
Calcium (Ca)
mg[L
Coiiform: TubeTotat
/100ml
Silica
mg/1
X
Chromium (Cr), Total
pg/L
Organics Parameters:
Specific Conductance, at 25 °C umhos/cm
sulfide
mg/L
Cobalt (Co)
pg/L
Acid Herbicides
TOC -Total Organic Carbon
mg/L
Tannin & Lignin
rrg/L
X
Capper (Cu)
pgjL
Organochloine Pesticides
Turbidity
NTU
X
Iron [Fe)
fig/L
Organonitrogen Pesticdes
Other Parameters:
X
Lead (Ph)
pg/L
Organophusphorus Pesticides
Wet0mmistry Parameters:
pH
s.u.
Lithium iti)
pg/L
Kos (polychlorinated biphenyls)
Bromide
mg/L
Hardness, Total as CAC03 - by titration
mg/L
x
Magnesium (Mg)
mg/L
X
Chloride
mg/L
X
Manganese Wn)
pg/L
Semi•Volahle Organics (8NAsj
Fluoride
mg/L
Mercury (Hg)
VRA
TPH Diesel Range
Sulfate
mg/1
Nutrients Parameters:
Molybdenum (Mo)
lsg/L
Chlorophyl I a
}Ig/L
Ammonia as N (NH3-N)
mg/L
X
Nickel (M)
pg/L
Volatile Organics (VOA)
Color: ADMI
c.u,
X
N ltrate- N it rite as N (NO3+NO2-N)
mg/L
X
Potassium (K)
mg/L
Coicir. Platinum Cobalt
e.u.
Total Kjeldahl Nitrogen as N (rKN]
mg/L
Selenium (Se)
pg/L
TPH Gasoline Range
COD: Chemicat Oxygen oema :d
mg/L
Total Phosphorus as P (TP)
mg/L
Silver (Ag]
pg/L
Cyanide. Total
mg/t
X
Nitrete as N (NO2-N)
mg/L
X
Sodium (Na)
mg1L
Biolagral:
Formaldehyde
mg/L IrNit
rate as N (NO3-N calculated)
mg/L
Strontium (Sr]
pg/L
Phytopiankton /Algae
Hexavalent Chromium (Cr6+)
mg/t
fl
I orthaphosPhale as P (Y04)
mglL
Thallium M)
pg/L
LAB COMMEti1T$ -
Field Para meterslapt;anoy:l WaterTemp(°C): I PH (S-u.): 6 I flissolved Oxygen (ppml-. I Conductivity (limbos/cm): I Salinity Ippt): I
Revision:

AC25371 ¾C <DWCJ{ Water Sciences Section-Chemistry La6oratory CJ{esults
County: ~ Sample ID : AC25371
River Basin NEU01 DWR PO Number# 150318
Report To WARO Date Received : 12/29/2015
Collector: R.SIPE Time Received : 09:00
Region : ~ Division of Water Resources
Labworks LoginlD MSWIFT
Sample Matrix: GROUNDWATER
Final Report Date: 1126116
Loe. Type : QIB§R Final Re port Report Pr int Date: 01/26/2016
Emergency Yes/No VisitlD
COC Yes/No
Loe. Descr.: AMSLER ,4510 MONCKS COURT, NEW BERN , NC
I Location ID : WI0700195 I Collect Date: 12/28/2015 I Collect nme: 12:38 l Sample Depth I
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
CAS# Analyte Name POL Result/ Units Method Analysis Validated by Qualifier Reference Date
LAB
Sample temperature at receipt by lab 0.5 ·c 12/29/1 ! MSWIF T
MIC
Coliform , MF Fecal in liquid 1 1 B2O1 CFU/100ml APHA9222D-20th 12/29/1! ESTAFFORD1
Coliform , MF Total in liquid 1 1 8201 CFU/100ml APHA92228-20th 12/29/1! ESTAFFORD1
WET
Ion Chromatography _TITLE mg/L EPA 300 .0 rev2.1 1 /15/16 CGREEN -
Fluoride 0.4 0.4 U mg/L EPA 300 .0 rev2 .1 1 /15/16 CGREEN
Chloride 1.0 7.3 mg/L EPA 300 .0 rev2.1 1/15/16 CGREEN
Bromide 0.4 0.4 U mg/L EPA 300 .0 rev2 .1 1 /15/16 CGREEN
Sulfate 2.0 13 mg/L EPA 300 .0 rev2 .1 1/15/16 CGREEN
Total Dissolved Solids in liquid 12 347 mg/L SM 2540 C-1997 12129/1 ! CGREEN
NUT
NO2+NO3 as N in liquid 0 .02 0.02 U mg/Las N EPA 353 .2 REV 2 12/31/1 ! CGREEN
Nitrate as N in liquid 0.02 0.02 U mg/Las N EPA 353 .2 REV 2 1 /5/16 CGREEN
Nitrite as N in liquid 0.01 o.otu mg/Las N EPA 353 .2 REV 2 12/30/1! CGREEN
MET
7429-90-5 Al by ICP 50 sou ug/L EPA200 .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 0.10 130 mg /L EPA200 .7 1/13/16 ESTAFFORD1
7440-47-3 Crby ICPMS 5.0 5.0 U ug/L EPA200 .8 1/13/16 ESTAFFORD1
7440-50-8 Cu by ICPMS 2.0 8.8 ug/L EPA200 .8 1/13/16 ESTAFFORD1
7439-89-6 Fe by ICP 50 5100 ug/L EPA 200.7 1/13/16 ESTAFFORD1
7440-09-7 K by ICP 0.10 0.93 mg/L EPA200.7 1/13/16 ESTAFFORD1
7439.95.4 Mg by ICP 0.10 3.1 mg/L EPA200 .7 1/13/16 ESTAFFORD1
7439-96-5 Mn by ICP 10 25 ug/L EPA200 .7 1/13/16 ESTAFFORD1
7440-23-5 Na by ICP 0.10 8.3 mg/L EPA 200 .7 1/13/16 ESTAFFORD1
7440-02-0 Ni by furnace 2.0 2.0 U ug/L EPA200 .9 1/15/16 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0 2.0 U ug/L EPA200 .8 1/13/16 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 13 ug/L EPA200 .8 1/13/16 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
Fora detailed description of th e a ualifi ercodes refer to <htto://oortal.ncdenr.org/web/wa/oos/methods-and-oals>
Page 1 of 1
----------·-··-· ····-------------·---···-··•--·---·-----··-·-·--
sC,3 a
Borth Carolina Division of Water Resources
Central Laboratory (Ware rSciencesSection)
Water Sample Collection & 5ubmitml Farm
visitif]:
(optianalJ
Tqg
>=ffluen
ID
_Lob_sornpie Numbe,
taborutory
LowtionDescripiian: Amster, 4570 Mantles
Court,
New 8em, NC
Location Code:
WIG70fl'i95
Duce Recr3wed: �I,c�
County: Craven
-
Wiector: R. Sipe
Priority.
❑Ambient
Routine
OComp€lance
❑CDC
❑Emergency
❑OA
Water Matrix.
❑ Surface
[]Ground
❑Waste
❑ Blank❑Trip
❑Solution
Location Type:
❑River/Stream ]Lake
❑Estuary ❑Canal
❑Stormwater
❑Monitoring Well ❑Water5upply
❑Effluent ❑Influent
❑Field Blank
Blank
❑Filter Blank
Pother: Geotherm Ini- Well
,
1 "7'-' .'(
Time Received: q , Q d
OWItRegion: WaRC)
ibasedunrountVI
OWROfce: WaRO
(oragerKyr+nr 1
Rece7ved8y, a
River Basin: Neuse
r
Dare: (2, /29 !
State Courier
Delivery method. El Hand Delivery
❑01her_
Notes:
nme 1
1
❑ Chlorinated ❑De -chlorinated in Field
Sampong Grab CompcsRe
Methad. Other'
Temperalure{•C) rr
on Arrival: (7 • 7
Dissolved analysis: Enter'f]IS"
❑ Filtered in Field in check boxes for parameters
Sample Depth: NIA
Collector's Comments:
Microbiology Parameters:
I
MBAS (surfacta(its)
mg/L
Metals Parameters:
Tin [Sn] pg/L
Asidety, as CaCO3, to pH d.5/8.3
mgjL
0i1 and Grease, HEM, Total Recoverable
mgiL
x
aluminum {AI]
}:gIL
Titanium [TL] y�gli
Alkalinity, asCaCO3. to pH 4.5/83
mg/L
Phenols, Total Recoverable
pg/L
Anrim any [Sb}
p9/1
Vanadium (V) WL
800: StachemicaI Oxygen 9emand, 5-pay
mg/L
Residue; Tout (Torol5Qlids)
mg/L
X
Arsenic [As)
µgo%
x
zinc {fin] pg/L
cDOD: Carbonaceous SOD, 5-day
mg/L
Residue: Volatile/Fixed, Total
mg/L
Barium tBa]
pg/L
X
Coliform: Fecal MF
/10ansl
Residue 5uspended (Suspended Solids j
mg/L
Beryllium (Be)
pg/L
Baron (e), Total yWL
X
Ccliform:TotaI MF
/100ml
Residue: Volatile/ Fixed, S uspended
mg/L
Cadmium (Cd]
WJL
Mercury 1631, low-level ng/L
Coiiform:Tube Fecal
IlWrnl
x
TDS - Total Dissolved Solids
mg/L
X
Calcium (Ca)
mg/L
Colifor=Tube Total
/loom!
Silica
mg/L
)(
Chromium (Cr), Total
lig/L
Organics Paraareteis:
Specific Conductance, at 25 °C
uinhoslCm
sumde
mg/L
Cobah (t'ol
PBIF
Acid Herbicides
TOC- Total OrgenicCarbon
mg/L
Tannin &Lignin
mg/L
X
Copper(Cu)
)jg/L
OrganochlorinePesticides
Orgarionitrogen Pesticides
Turbidity NTU
x
Iron (Fe) pg/L
OtherParameters:
x
(Ptl)
}rgA
Organophosphorus Pesticides
Wet Chemistry Parameters:
pH
S.U.
_Lead
Lithium (U)
pg/L
PCBs [polychlorinated biphenyls]
Bromide
mg/L
Hardness, Total as CaCO3 - bytftra[ion
mgJL
X
Magnesium (Mg]
rtlg/L
X
Chloride
mg/L
x
Manganese (Mn1
pg/L
Semi -Volatile Organics (BNAs)
Fluoride T
mg/L
Mercury (Hg)
pg/L
TPH Diesel Range
Sulfate
mg/L
Nutrients Parameters:
Molybdenum (Ma)
pg/L
Chlorophyll a
}lg/L
Ammonia as N (NH3-N)
mg/L
x
Nickel (Nil
pg/L
Volatile 0rganics{VDA]
Color_ ADM
C.U.
x
Nitrate -Nitrite as N (NO3+NO2-N]
mg/L
X
Potassium (K)
mgiL
Color. Platinum Cobalt
C.u.
Total Qeldahi Nitrogen as N (TItN)
mg/L
Selenium (Se)
pg/L
TPH Gasoline Range
COD: ChemicalDxvgen Demand
mg/L
Total Phosphorus as P (TP]
mg/L
5ilver (AS)
pg/L
Cyanide, Total
mg/L
X
Nitrite as N (NO2-N)
mg/L
X
Sodium (Na}
mg/L
Biological:
Formaldehyde
mg/L
Nitrate as N (NO3-N calculated}
mgJl
strontium (Sr)
pgil
Phytapfanktan /Algae_
Hexavaient Chromium (Cr6+1
mg/L
Orthophosphate as P (PO4)
mgJL
Thallium (-rl)
pg/L
f�
LAB COMMENTS
Field Para meters(opfianca) Water Temp {°C)• pH [s,u.1: Dissolved Oxygen (ppm): Conductivity (pmhoQcm): Salinity (ppt):
Revision: Z/a6/�g15

AC25372 ¾C VW<R.. Water Sciences Section-Cfiemistry La6oratory <R.~su{ts
County: ~ Sample ID : AC25372
River Bas in NEU01 DWR PO Number# 15G319
Report To WARO Date Received : 12/29/2015
Collector: RSIPE
Time Received : 09:00
Region : ~ Division of Water Resources
Labworks LoginlD MSWIFT
Sample Matrix: GROUNDWATER
Final Report Date: 1/26/16
Loe . Type : QlliER Final Re port Report Print Date: 01/26/2016
Emergency Yes/No VisitlD
COC Yes/No
Loe. Descr.: AMSLER,4510 MONCKS COURT, NEW BERN . NC
I Location ID : WI0700195 I Collect Date: 12/28/2015 I Collect Time : 13:00 l Sample Depth I
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
CAS# Ana lyte Name PQL Result/ Units Method Analysis Validated by
Qualifier Reference Date
LAB
Sample temperature at receipt by lab 0 .5 ·c 12/29/1! MSWIFT
MIC
Coliform , MF Fecal in liqu id 1 1 B2Q1 CFU/100ml APHA9222D-20th. 12/29/1! ESTAFFORD1
Coliform , MF Total in liquid 1 120Q1 CFU/100ml APHA9222B-20th 12/29/1 ! ESTAFFORD 1
WET
Ion Chromatography TITLE_ mg/L EPA 300 .0 rev2 .1 1 /15/16 CGREEN -
Fluoride 0.4 0.4U mg/L EPA 300.0 rev2.1 1/15/16 CGREEN
Chloride 1.0 7.2 mg/L EPA 300 .0 rev2.1 1/15/16 CGREEN
Bromide 0.4 0.4U mg/L EPA 300 .0 rev2 .1 1/15/16 CGREEN
Sulfate 2.0 13 mg/L EPA 300 .0 rev2 .1 1/15/16 CGREEN
Total Dissolved Solids in liquid 12 338 mg/L SM 2540 C-1997 12/29/1! CGREEN
NUT
NO2+NO3 as N in liquid 0.02 0.02 U mg/Las N EPA 353 .2 REV 2 12/31/1! CGREEN
Nitrate as N in liquid 0.02 0.02 U 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 EPA200.7 1/13/16 ESTAFFORD1
7440-38-2 As by ICPMS 2.0 2.0 U ug/L EPA200.B 1/13/16 ESTAFFORD1
7440-70-2 Ca by ICP 0 .10 120 mg/L EPA200.7 1/13/16 ESTAFFORD1
7440-47-3 Crby ICPMS 5.0 5.0 U ug/L EPA200.B 1/13/16 ESTAFFORD1
7440 -50-8 Cu by IC PMS 2 .0 23 ug/L EPA200.B 1/13/16 ES TAF FORD 1
7439-89-6 Fe by ICP 50 5100 ug/L EPA200.7 1/13/16 ESTAFFORD1
7440-09-7 K by ICP 0.10 0.92 mg/L EPA 200 .7 1/13/16 ESTAFFORD1
7439-95-4 Mg by ICP 0.10 3.0 mg/L EPA200.7 1/13/16 ESTAFFORD1
7439-96-5 Mn by ICP 10 26 ug/L EPA200.7 1/13/16 ESTAFFORD1
7440-23-5 Na by ICP 0.10 8.0 mg/L EPA200.7 1/13/16 ESTAFFORD1
7440-02-0 Ni by furnace 2.0 3 .1 ug/L EPA200.9 1/15/16 ESTAFFORD1
7439-92-1 Pb by ICPMS 2 .0 2.0 U ug/L EPA200.B 1113/16 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 14 ug/L EPA200.8 1113/16 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
For a detailed description of the aualifier codes refer to <htto :/ /oortal .ncdenr. org/we b/wq / oos/methods-and-oa ls>
Page 1 of 1
-·-·--· -· --~ ----·--·-·-· -----··-
Symbol
A
B
BB
C
G
J
Definition
Value reported is the mean (average) of two or more determinations. This code is to be used if the results of two or more
discrete and separate samples are averaged. These samples shall have been processed and analyzed independently (e.g. field
duplicates, different dilutions of the same sample). This code is not required for BOD, coliform or acute/chronic metals
reporting since averaging multiple results for these parameters is fundamental to those methods or manner of reporting.
I. The reported value is an average, where at least one result is qualified with a "U". The PQL is used for the qualified
result(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 filter (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 colonies. Reported value is estimated or is a total of the counts on all filters
reported per I 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 > I 50 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 I 00 and then divided by the smallest filtration volume analyzed. This
number is reported as a greater than value.
6. Estimated Value. Blank contamination evident.
7. Many non-coliform or non-enterococcus colonies or interfering non-coliform or non-enterococcus growth present. In
this competitive situation, the 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., BI, B2, etc.).
Note: A "J2" should be used for s pikin g 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 org,anics.
A single quality control failure occurred during biochemical oxygen demand (BOD) analysis. The sample results should be
used with caution.
I. The dissolved oxygen (DO) depletion of the dilution water blank exceeded 0.2 mg/L.
2. The bacterial seed controls did not meet the requirement of a DO depletion of at least 2.0 mg/L and/or a DO residual
ofat 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 mg/L.
7. Less than I mg/L DO remained for all dilutions set. The reported value is an estimated greater than value and is
calculated for the dilution using the least amount of sample.
8. Oxygen usage is less than 2 mg/L for all dilutions set. The reported value is an estimated less than value and is
calculated for the dilution using the most amount of sample.
9. The DO depletion of the dilution water blank produced a negative value.
Note: A "G" value shall be accompanied bv justification for"its use denoted by the numbers listed above (e.~., GI, G2, 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 sam ple matrix interfered with the abili ty to make an y accurate determination.
4. The data is questionable because of improper laboratory or field protocols (e .g., composite sample was collected
instead of grab, plastic instead of glass container, etc.).
5 . Temperature limits exceeded (samples frozen or >6°C) during transport or not verifiable (e.g., no temperature blank
provided): non-reportable for NPDES 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, J2, etc.). A "J"
value shall not be used if another code app lies (e.R., 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 sam ple.
N Presumptive evidence of presence of material; estimated value. This code is to be used if:
I. The component has been tentatively identified based on mass spectral library search.
2. There is an indication that the analyte is present, but quality control requirements for confirmation were not met (i.e.,
presence 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 instrument 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 .
I. Holding time exceeded prior to receipt by lab.
2. Holding time exceeded following receipt by lab.
p Elevated PQL* due to matrix interference and/or sample dilution.
s Not enough sample provided to prepare and/or analyze a method-required matrix spike (MS) and/or matrix spike duplicate
(MSD).
u Indicates that the analyte was analyzed for but not detected above the reported practical quantitation limit*. The number value
re 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.
I. The analyte was detected in both the sample and the method blank.
2. The anal yte 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 justification 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 percent confidence that the true value is greater than zero and is detennined 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 10
multiple (i.e., I, 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 I 0
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 san1ples) rather than explicitly
detennined. 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 colifonn 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
Program Category
Ground Water
Permit Type
WI0700195
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Thomas F. and Melinda K. Amsler SFR
Location Address
4510 Moncks Ct
New Bern NC
Owner
Owner Name
Thomas F
.Dates/Events
Orig Issue
12/8/2010
App Received
11/23/2015
Regulated Activities
Heat Pump Injection
Well Construction
Outfall
Waterbody Name
28562
Amsler
Draft Initi ated
Scheduled
Issuance Public Notice
Central Files : APS SWP
1/14/2016
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Thomas F. Amsler
Owner
4510 Moncks Ct
New Bern
Region
Washington
County
Craven
NC
Issue Effective
28562
Expiration
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
12/2/1 5
1nt16
Subbasin
PAT MCCRORY
Go vernor
DONALD R. VAN DER VAART
Water Resources
ENVIRONMENTAL QUALITY
Thomas K. and Melinda K. Amsler
4510 Moncks Court
New Bern, NC 28562
Re: Issuance of Injection Well Permit
Permit No. WI0700195
January 18, 2016
Geothermal Heating/Cooling Water Return Well
Craven County
Dear Mr. and Mrs. Amsler:
Secretary
S. JAY ZIMMERMAN
Director
In accordance with your permit renewal application received November 23, 2015, I am forwarding
Permit No . WI0700195 for the continued operation of geothermal heating/cooling water return
well(s) located at the above referenced address. 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 28, 2015. Laboratory analytical results will be forwarded to
you when it becomes available.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this
permit is not 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].
Best Regards,
~R;__-
Michael Rogers, P.G. (NC & FL)
Underground Injection Control (UIC) Manager -Hydrogeologist
Division of Water Resources, NCDEQ ·
Water Quality Regional Operations Section
Sta te ofNortlt Carolina I Environmental Q ua lil)' I Water Resources
r6 1 J Ma il service Celll.cr I Raleigh , N orth Carol in a 27699-16 l l
919 707 9000
cc: David May & Robert Tankard, Washington Regional Office
Central Office File, WI0700195
Craven County Environmental Health Department
Page 2 of2
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COIVI USSION
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 HEREBY GRANTED TO
Thomas K. and Melinda K. Amsler
FOR THE CONTINUED OPERATION OF I 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 injection wells) located at 4510 Moncks Court, New Bern, Craven County,
NC 28562 will be operated in accordance with the application submitted November 23, 2015, and conformity
with the specifications and supporting data received December 14, 2015, all of which are filed with the
Department of Environmental Quality and are considered a part of this permit.
This permit is for continued operation of an injection well shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any ether Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall he effective, unless revoked, from the date of its issuance until December 31, 2020, and shall be
subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 18th day of January 2016.
S. Jay Zimmerman, P-G.
Director, Division of Water Resources
By Authority of the Environmental Management Commission,
Permit##WI0700195 U1C15A7 Page 1 of
ver. 11/15/2015

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 (15A NCAC 2C .0200). Noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is grounds
for enforcement action as provided for in N.C.G.S. 87-94
2. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data [15A NCAC 02C .021 l(a)].
3. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data [15A NCAC 02C .0211(1)].
4. This permit is not transferable without prior notice and approval. In the event there is a desire for the facility
to change ownership, or there is a name change of the Permittee, a formal permit amendment request must
be submitted, including any supporting materials as may be appropriate, at least 30 days prior to the date of
the change [ISA NCAC 02C .021 l(q)].
5. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met [15A NCAC 02C .0203].
PART II -WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed in accordance
with the requirements of rule 15A NCAC 02C .0107 except as required in Item #2 below.
2. Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC 02C .0107
except that the entire length of the casing shall be grouted in such a way that there is no interconnection of
aquifers or zones having differences in water quality that would result in degradation of any aquifer or zone.
For screened wells, grout shall be emplaced from the top of the gravel pack to the land surface. For open-
end wells, the casing shall be grouted from the bottom of the casing to the land surface [15A NCAC 02C
.0224(d)(2),(3)).
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing conditions.
[15A NCAC .0225(g)(8)].
4 . The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [15A NCAC 02C .0224(d)(4)].
5 . Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal as defined in G .S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .0107G)(2)].
Penn it #Wl0700 l 95 UJC/5A7
ver. 11/15/2015
Page 2 of5
7. A CO]Jlpleted Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 ofthis
~ 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 [15A NCAC 02C .021 lG)].
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface water
or groundwater resulting from the operation of this facility. In the event that the facility fails to perform
satisfactorily, including the creation of nuisance conditions or failure of the injection zone to adequately
assimilate the injected fluid, the Permittee shall take immediate corrective actions that may be required,
such as the repair, modification, or abandonment of the injection facility [15A NCAC 02C .0206].
PART IV-INSPECTIONS [15A NCAC 02C .021 l(k)]
I. Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation of credentials, enter and inspect any property, premises, or place on or related to the
injection facility at any reasonable time for the purpose of determining compliance with this permit, may
inspect or copy any records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwater, surface water, or injection fluids.
2. DWR representatives shall have reasonable access for purposes of inspection, observation, and sampling
associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary samples of the injection facility's activities.
PART V -MONITORING AND REPORTING REQUIREMENTS
1. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on-site and available for inspection [15A NCAC
02C .0224(±)(2), (4)].
2.-Monitoring of any well may be required to ensure protection of the groundwater resources of the State and
compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
.0224(±)(1)].
3 . The Permittee shall report any monitoring or other information that indicates noncompliance with a specific
permit 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 .0211(r), noncompliance notification shall be
as follows:
(A) Oral 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.
Permit #WJ0700195 UlC/5A7
ver. 11/15/2015
Page 3 of5
(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(±)(3)].
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
UIC Program Staff
Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Water Quality Regional Operations Section
DWR Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
PART VI-PERMIT RENEWAL (15A NCAC 02C .0224(c)]
As required by rule an application for permit renewal shall be made at least 120 days prior to the expiration
date of the permit. This permit condition does not apply if the Permittee chooses to discontinue operation
of the well for injection of effluent from the geothermal heating and cooling system associated with this
permit.
Permii #Wl0700 195 UIC/5A7
ver. l 1/15 /2015
Page 4 of 5
PART VII-CHANGE OF WELL STATUS [15A NCAC 02C .0240]
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complying with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to rule
15A NCAC 02C .0113(b) in order to prevent the well from deteriorating and acting as a source or conduit
of contamination, which is prohibited by General Statute 87-88(c).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well
seal that cannot be removed without the use of hand or power tools.
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall permanently abandon that injection well in accordance with the procedures specified in 15A
NCAC 02C .0113(b), which include, but are not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Ea~h 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 Pem1ittee shall submit a Well Abandonment Record (Fonn GW-30) as specified in
15A NCAC 2C .0224(£)(4) within 30 days of completion of abandonment.
5. The written documentation required in Part VII ( 4 )(F) shall be submitted to the addresses specified in Part
V.5 above.
Pennit #Wl0700195 UIC/5A7
ver. 11/15/2015
Page 5 of5
AQUIFER PROTECTION SECTION.:... GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: 1/4/16 Permittee(s): Thomas & Melinda Ka y Amsler
Permit No.: WI0700195
To: APS Central Office County: Craven
Central Office Reviewer: Michael Ro gersProject Name: In j. Heatin g/Coolin g Return Well
Regional Login No: __ _
I. GENERAL INFORMATION
1. This application is (check all that apply): D SFR Waste Irrigation System r8] UIC Well(s)
D New r8] 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 r8] Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? r8] Yes or D No.
a. Date of site visit: 12/28/15
RECEIVED/NCDEQ/DWFC
b. Person contacted and contact information: Melinda Kay Amsler JAN O 7 2016
c. Site visit conducted by: R. Si pe & A. Clark
d. Inspection Report Attached: r8] Yes or D No.
Water Quality
Regional Operations Section
2. Is the following information entered into the BIMS record for this application correct?
r8] Yes or D N9. 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, Google™, etc.); __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For UIC Injection Sites:
(I f multi ple sites either indicate which sites the information a pp lies to , co p y and paste a new section into the
document for each site. or attach additional pa ges for each site)
a. Location(s): no chan ge since permit was issued.
b. Driving Directions: __
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude: __ Method Used (GPS, Google™, etc.); __
APS-GPU Regional Staff Report (Sept 09) Page I of 4 Pages
AQUIFER PROTECTION SECTION.:... GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description of Well(s) and Facilities -New, Renewal, and Modification
I. Type of injection system:
C8J Heating/cooling water return flow (SA 7)
D Closed-loop heat pump system (SQM/SQW)
D In situ remediation (SJ)
D Closed-loop groundwater remediation effluent injection (SL/"Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes C8] No
3. Are there any potential pollution sources that may affect injection? D Yes C8] 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 C8] Adequate D Poor
6. Flooding potential of site: C8] 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)? C8] 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 map
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 C8] No. If yes. exp lain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes , explain: NA
3. For renewal or modification of groundwater remediation permits (of an y tvp e ). will
continued/additional/modified injections have an adverse im pact on mi gration of the p lume or management of
the contamination incident? D Yes D No. If yes , explain: NA
APS-GPU Regional Staff Report (Sept 09) Page 2 of 4 Pages
AQUIFER PROTECTION SECTION~ GROUNDWATER PROTECTION UNIT
. REGIONAL STAFF REPORT
4. Drilling Contractor: Name: Jamie Canter w/ A pp lied Resource Management. P.C .
Address: 257 Transfer Station Rd.
Ham pstead . NC 28443
NC Certification number: 3253-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 [8J No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5 . List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
APS-GPU Regional Staff Report (Sept 09) Page 3 of 4 Pages
AQUIFER PROTECTION SECTION = GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
7. Recommendation- ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
8, Signature of report Preparers):
Signature of APS regional supervi
Date:�'o
V1. _ADDITIONAL INFORMATIONAND SITE MAP (Sketch of site showing house and waste kcr udon
system s ra , or dri) field, location oL wells and/or other relevant in nrmation- SHOW NORTHARR010
APS-GPO regional Staff Report (Sept 09) Page 4 of 4 Pages

V,
Approximate Property Lines
Approximate Sewer Lines
Approx#mate g-Tii3, Well Location
Approximate &L Well Location i
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services,
Adapted from Google Earth and Craven County GIS Map, October 2010.
TITLE: CIS MAP FIGURE:
lied Resource Marna emerit FIG 4510 MONCKS COURT
D. Box 562, Hampstead, NC 2 443 JOB; SCALE: DATE' DRAWN BY:
[phone] FAX 2ZO-2988 � Amsler i I" = 60' 10/27/10 DNH

North Carolina Department of Environment and Natural Resources
Division of Water Quality -Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700195
DATE OF INSPECTION: 12/28/15
INSPECTOR: __ R_. _S _.i p_e_&_A_. _C_la_r_k ______ _
NAME OF PERMITTEE(S) Thomas & Melinda Ka y Amsler
MAILING ADDRESS OF PERMITTEE 4510 Moncks Court, New Bern, NC 28562
PHYSICAL ADDRESS OF SITE (if different than above) Same as above
PERSON MET WfI1I ON-SITE Melinda Kay Amsler; 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) 35.0861N, 77.09W (Inj. Well)
Appx. distance of well to property boundaries: _10 feet (lnj. Well) ____________ _
Appx. distance of well from foundation of house/structure: _32 feet (lnj. Well) _______ _
Appx. distance of well from septic tank/field (if present): _NIA ________ _
Appx. distance of well to other well(s) (if present): _125 feet to supply well ______ _
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. -----------------------------------
Injection Facility 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 Construction-Information
Date Constructed: 12/22/2010 --------
Well Contracting Company: _Applied Resource Management, P.C. ____________ _
Well Driller Name: Jamie Canter ----------------
NC Well Cert. No.: 3253-A ----
Address:_257 Transfer Station Rd., Hampstead, NC 28443 _______ _
Telephone No.: _(910)270-2919 _____ ; Cell No.: ________ _
Email Address: -----------
Proposed Depth of Well(s): _NIA _______ _
Total Depth: _80 feet ___ _ Total Depth of Source Well, if present:_68 feet __
Casing:
Depth: 60 feet; Diameter: _4 inches_; Type (gav. steel, PVC, etc.): _PVC_; Stick Up: _1.5 feet __ ft
Grout:
Depth: 25 feet; Type (cement, bentonite, etc.):_Bentonite; Placement (pumping, press. etc.): _Tremmie ..
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: Supply well (Influent) & Inj. well
(Effluent)_
Static Water Level: _3 feet (at installation) __ _
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. ____________________________________ _
Injection Facility Insp. Report (Rev. Sept 2009) Page 3 of 3 Pages
11
Approximate Property trines
Approximate Sewer Lines
Approximate t N3d Well Location
Approkmate5at r f y Well Location
r
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
kdapted from Google Earth and Craven County GIS Map, October 2010.
m'LE: GI5 MAP FIGURE;
lied K600urce Mama emerit f G 4510 MQNCKS. COURT
s ❑m ❑ JOB: ! SCALE: � 1 DATE: DRAWN BY:
At910j 27�2919 FAX 27C3 29$8 Amster 1 = G0 10127/10 i ❑NH

� SrAig4 4.
1' A j��
� Ic N.[ ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
3253A
1, WELL CONTRACTOR:
,Jamie L. Canter
Well Contractor (individual) Name
Applied Resource Manaciement_. P.C. _
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Hampstead _ NC 28443
City or Town State Zip Code
sc� 270-2919
Area code Phone number
2, WELL INFORMATION:
WE1L CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicaeie)W 10700195
SITE WELL ID #(it appi!cable) I n l ection W el d `
d. TOP OF CASING IS �. 5 FT_ Above Land Surface'
'Top of casing terminated atlor below land surface may require
a valiance in accordance with i SA NCAC 2C .0118.
e. YIELD (gpm): 60+ METHOD of TrzSTAirlift_
f. DISINFECTION: Type HIH ' Amount 3aa l ayL
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top_
Top Bottom _ Top_ _
7, CASING: depth Diameter
Top +1.5 Bottom 60 R 4"
Top Bolton Ft.
Top Bottom Ft
Bottom
Bottorn
Bottom
Thlcknessl
Weight Material
sch4O PVC
3. WELL USE (Check One Box) Monitoring ❑ MuniapallPuhiic ❑ $• GROUT: Depth Material Method
Industria)[Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑ : Top 4 8attom 25 Ft. Bentanite Tremmie
Irrigation❑ Other [(list use} Geothermal = Top Bottarrm Ft.
DATE DRILLED 12/2211 D ; Top Bottom Ft.
4. WELL LOCATION:
4510 Moncks Court
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, zip Code)
CITY. New Bern COUNTY Craven
TOPOGRAPHIC f LAND SETTING: (check appropriate box)
[]Slope ovalley g(Rat ❑Ridge ❑Other
LA-nTUDE 35 -5 1 r.000a " DM5 OR DD
LONGITUDE 77 a 5 230000 " DMS OR DD
LatitudeAongitude source: MPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form ff not using GPS)
5. FACILITY (Name of the business where the welI is located.}
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Contact Name
Mailing Address
City or Town Slate zip Coda
Area code Phone number
9. SCREEN: Depth Diameter Stot Size Material
Top.O Bpttom__g___ Ft. 4 in. .010 in. PVC
Top Bottom Ft in. in.
Top Bottom Ft. in. in.
10. SANDIGRAVEL PACK:
Depth Size Material
Top 55 Bottom 8a FL Cgarse Sand_ _
= Tag Bottom Ft.
Top Bottom Ft.
11. DRILLiNG LOG
Top Bottom
01 10,
10, 13C'
30' 155'
55' 1 80'
1
1
Formation Description
Tan sand
Medium rat ed Sand
-Qr@_.-Clay
Limestone
rl 5 n t�
12. REMARKS:
G. WELL DETAILS: I Do HEREeY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C Y� CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO +1 _ N PROVVDE6 7O TFjE WELL OWNER.
a. TOTAL DEPTH: °{l' �r
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 9/ �4
-` Sl N. UP OF Cr . IFlED WELL CONTRACTOR DATE
e. WATER LEVEL Below Top of Casing: _ FT. Jamie L. Conte[ _
(Ilse "•+^ if Above Top of Casing) : PR(NTEO NAME OF PERSON CONSTRUCTING THE WELL
Submit: within 34 days of completion to: Division of Water Quality Information Processing, Farm GW-ih
Y P rtY ' 9 Rev. 2149
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: (919) $D7-6300

NoNREs.rDENim r. WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3253A
I. WELL CONTRACTOR:
Jamie L. Canter
Well Contractor (Individual) Name
Apolied Resource Manaciement. P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Hampstead _NC 28443
City or Town State Zip Code
9; 10 ) 270-2919_
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(i€ appllcable)v l 070Q1 95
SITE WELL ID#(irappricable) Pumping Well
3. WELL USE (Check One Box) Monitoring C1 Municipal/Public
Industrial/Commercial EI Agricultural ❑ Recovery Li tnjection ❑
Irr1galionL7 Other d(list use) _Geothermal
DATE DRILLED-1 2/21 / 10
4. WELL LOCATION:
4510 Moncks Court
(Street Name,, Numbers, Community. SubdivAinn, tot No., Parcel, Zip Code)
CITY. New Bern cauNTYCraven
TOPOGRAPHIC 1 LAND SETTING_ (check appropriate box)
❑Slope OVailey piFlat DPidge ❑Other
LATITUDE 35 .5 9.0000 DMS OR _ DO
LONGITUDE 77 ^ s • 23.DWO DMS OR DD
Latitudeflongitude source: WGPS Qropographie map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5, FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
LL? ) 635-5857 Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 6�,'
b. DOES WELL REPLACE EXISTING WELL? YES p NO U/
da 0377------
d. TOP OF CASING t5. 1-5 _ FT. Above Land Surface
'Top of casing terminated aVor below tend surface may require
a variance in accordance with 15A NCAC 2C .Oi1B.
e. YIELD (gpm): �s� --- - METHOD OF TEST Alriift _
f. DISINFECTION: TypG HTH Amount 30alt
g. WATER ZONES (depth):
: Top - —_
Bottom
Top
Bottom
Tap
Bottom
Top
Bottom
Top
Bottom_
Top
Bottom
Thickness!
: 7. CASING:
Depth
Diameter
Weight Material
Tap +1.5
Bottom 48
Ft. 4"
sch40 PVC
Top
Bottom
Ft.
Tap
Bottom
Ft.-
B. GROUT:
Depth
Material
Method
Top 0
Bottom 25
Ft.
Bentonite
Trernmie
Top
Bottom
Ft,
Top
Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top 48
Bottom 68
Ft.
4 in.
.010 in_ PVC J
Top
@attom
Ft.
in.
In_ _
Top
Bottom
FI.
in.
in.
10. SANDIGRAVEL PACK -
Depth Size Material
Top 43 Bottom 68 Ft.—qoarsend.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0' ! 10' Tan sand
10' 1 48' Medium Gralr,ed $arid
48' 1 73' _! ime_stonq
1
1
1
1
1
grill
1
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
i3A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF T4S
RECORD
PRDYIDEDTOTHE OWNED
�
�
tG VA RE _ r CERTI I a WELL CONTRACTOR DATE
c. WATER LEVEL Befow Top of Casing: _a FT. Jamie L. Canter
(Use "+" if Above Top of Casing) PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Information Processing, Form 109
Y p Y - g Rev_ zras
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]

Com pliance Ins pection Re port
Permit: Wl0700195
SOC:
Effective: 12/08/1 O
Effective:
Expiration: 11 /30/15 Owner : Thomas F Amsler
County : Craven
Region: Washington
Contact Person: Melinda K Amsler
Directions to Facility:
Expiration:
Title:
Facility: Thomas F Amsler SFR 5A7
4510 Moncks Ct
New Bern NC 28562
Phone : [phone]
From WaRO take US 17S to US 70W in New Bern , take exit 416 turn L, take Country Club Rd ~2.7mi turn R, take Country Club Dr.
~0 .9mi turn L , the property is the second driveway on the left on Moncks Ct.
System Classifications:
Primary ORC: Certification: Phone :
Secondary ORC(s):
On-S ite Representative(s):
Related Permits:
Inspection Date: 12/28/2015 Entry Time: 12:15PM Exit Time: 01 :30PM
Primary Inspector: Dwight R Sipe Phone:
Secondary lnspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well
Facility Status: ■ Compliant D Not Compliant
Question Areas:
■ Other
(See attachment summary)
Page: 1
Pennit: WI0700195
Inspection Date: 12/28/2015
Inspection Summary:
Owner -Facility: Thomas F Amsler
Inspection Type : Compliance Evaluation Reason for Visit: Routine
As part of the renewal process for Permit# WI0700195 R. Sipe and A. Clark w/ WQROS WaRO inspected and sampled
two (2) wells (1 supply well and 1 injection well) which are associated with the UIC geothermal heat pump system under
Permit# WI0700195. The wells were found to be in good condition and operating adequately. The location and construction
of the wells are consistent with the findings of the previous inspection on 2/23/11 They are considered in compliance with
Permit# WI0700195.
Page: 2
i. -
WATER QUALITY REGION.AL OPERATIONS SECTION
APPLICATION REVIEW REQ UEST FORM
Date: December 2, 2015
To: David May & Robert Tankard
From: Michael Rogers, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
A. Permit Number: WI0700195
B. Applicant: Amsler
C. Facility Name:
D. 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 infonnation submitted in support of the above-referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a com pleted W OROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WQROS Reviewer: ___________________ Date: _____ _
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 092614 Page 1 of l
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
December 2, 2015
Thomas and Melinda Amsler
4510 Moncks Court
New Bern, NC 28562
RE: Acknowledgement of Application No. WI0700195
Geothennal Heating/Cooling Water Return Well
Craven County
Dear Mr. and Mrs. Amsler:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit 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 permit applications, the Water Quality Regional Operations
Section (WQROS) requests your assistance in providing a timely and complete response to any
additional infonnation 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 WI0700195
Sincerely,
.~~~
(J uv Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
Slate ofNor1h Carolina I Environmental Qualily I Water Resources
1611 Mail service Cen ler I Raleigh, North Carolina 2 7699-I 611
919707 9000
Direcror
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
1n Accordance With the Provisions of 15A NCAC 02C_.t}24
GEOTHERMAL HEATING/COOLING WATER RETURN WELLS
These wells inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
(check one) New Application Renewal* Modification
* For renewals complete Paris A-D and 1, the signature page.
Print or Type Information and Mail to the Address on the ,fast Page. Illegible Applications Will Be Returned As Incomplete.
DATE_ - I 1 �-�' I In - 2ff� 1 'Ol� I �Y
PERMIT NO. w 10 rl p Q !�5 -(leave blank if New Application) /0 0�rr
A. STATUS OF APPLICANT (choose one)
Nan -Government: Individual Residence X Business/Organization
Government: State Municipal County Federal
91
C.
WELL OWNERIPERMTf APPLICANT - For individual residences_ list owner(s) on property deed. For all
others, list name of entity and name of person delegated authority to sign on behalf of the business or agency.
rr\elirzla.KeeV -a a d mmi' a'- - --!R-A M v-
Mailing Address: 1 a M on Cr-s _ toLL L+
City: N eu.I �•�-!U State: NC- Zip Code: ;.$ S 4? 2-' County: C�y ex -
Day Tele No.: _ _ _ Cell No.: 7 5_ 2 - -�.S&" 1 Z9S
EMAIL Address: ks) c�ltR� h Fax : -
pr- - -
WELL OPERATOR (if different From well oi'vner) - For individual residences, list owner(s) on properly
deed. For all others, list name of entity and name of person delegated authority] two sign on behalf of the
business or agency:u-
Mailing Address: 451LJ Cog Or
City: I) e W S e— ZA .} State: PJ Ui p Code: —wLS5 fo 2-County: Q
Day Tele No.: _ _. _. . _ _ Cell No.: a,S 2 - D. lb b - 1 ZrTS
EMAIL Address:U; 1 +s
LOCATION OF WELL SITE - Where the injection wells are physically located:
(1)
p
Pamel Identification Number (PIN) of well site:
Physical Address (if different than mailing address?:
City: ?J,11 Sr
State: NC Zits Code:
County-. Qxn'VP n

E. WELL DRil.,LER INFORMATION
Well Drilling Contractor's Name: __________________________ _
NC Well Drilling Contractor Certification No.: _____________________ _
Company Name:. _________________________________ _
Contact Person"'"": _______________ EMAIL Address: ___________ _
Address: ___________________________________ _
City: __________ Zip Code: _____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ________ _
F. HV AC CONTRACTOR INFORMATION (if different than driller)
G.
HVAC Contractor's Name: ____________________________ _
NC HVAC Contractor License No.: _________________________ _
Company Name: ________________________________ _
Contact Person_,_: _______________ EMAIL Address: ___________ _
Address:------------------------------------
City: __________ Zip Code: _____ State: __ County:
Office Tele No.: Cell No.: Fax No.: ------------------
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(])
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES ___ _ NO ___ _
H. WELL CONSTRUCTION REQUffiEMENTS -As specified in 15A NCAC 02C .0224 (d J:
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
I. WELL CONSTRUCTION SPECIFICATIONS
J.
( 1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
______ *EXISTING WELLS _____ .PROPOSED WELLS
* For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the 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 distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b)
(c)
(d)
Well casing and screen type, thickness, and diameter
Casing depth below land surface
Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(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
OPERATING DATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day {gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
K. SITE MAP-As specified in 15A NCAC 02C .0224 (b )(4 l, attach a site-specific map that is scaled or othenvise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield. waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in I SA NCAC 02C .OJ 07 (a l(2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
NOTE: /11 most cases a11 aerial photograph of the property parcel s/rowil1g property lilles a11d structures co11 be
obtained and dow11/ooded from the applicable county GIS website. Typicol(J', the property ca11 be searched by
owner name or address. The location of the wells il1 relatio11 to property boundaries, houses, septic tanks, other
wells, etc. con then be drown in by hand. Also, a 'layer' co11 be selected !,;howing topographic contours or
elevation data.
L. CERTIFICATION (to be signed as required below or by that person"s authorized agent)
I SA NCAC 02C _0211 { el requires that all pen -nit 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 (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. 1 am aware that there are sip
tificant penalties. including the passibility 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 Gwner/Applicant
--AMS LEI
Print or Type Full Name
Signature of Property 5wner/Ap 4ant
nr1r-1; A.) d Ar 1:�Y pkrn� 1 l=- 9—
Print or Type Full Name
Signature of Authorized Agent if any - --
Print or Type Full Name
Submit two copies of the completed application package to:
Underground Injection Control Program
NC Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (9I9) 807-6496

• - GEOTHERMAL HEATINGICQOLING WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxes. Fill in depths and details of well construction on
the blank lines provided. Use additional sheets as needed
Q en -Bole Well Desi la Screened Well Resign
• Proposed Existing D Proposed El Existing
❑ Injection, ❑ Supply; ❑ Injection; ❑ Supply;
❑ Dual Purpose ❑ Dual Purpose
Record Depths Below
Land Surface on Lines
Provided
(FL.)
Return or Supply Line
Casin
Grout
WELL DETAILS
Casing Material:
Casing Diameter (in.):
Casing Thickness (in.):
Grout Type. _4_
(cement bentonite. or mix)
Screen Material:
Screen Slot Size (in.):
Sand/Gravel Pack
Material:
Bentgnite Seat
(if present)
Bedrock
SandlGravel Pack
Open Hole
Screen
(Ftl
Record Depths Below
Land Surface on Lines
Provided
(FL)
(Ft.)
(FL)
NC Certified Well Driller Name _Certificalion � _

. .
--!•·i,~.a
HCDENR
North Carolina Department of Environmental Quality
Pat McCrory
Governor
November 3, 2015
CERTIFIED MAIL# 7014 1200 0001 3432 8541
RETURN RECEIPT REQUESTED
Thomas and Melinda Amsler
4510 Moncks Court
New Bern, NC 28562
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0700195
Craven County
Dear Mr. and Mrs. Amsler:
Donald R. van der Vaart
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above-referenced operating permit for the
geothermal injection well system located on your property at the above referenced address was
issued on December 8, 2010, and expires on November 30, 2015. Per permit conditions and
requirements per ISA NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior to expiration of the permit if you wish to continue operating the injection well
on your property. According to our records, the permit renewal application is now past due.
Please submit your renewal application (attached) as soon as possible if you wish to continue using
the well for injection.
If Your Geothermal Water Return \Vell is Still Currentlv Being Used for Injection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells -Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http ://portal .ncdenr. org/web/wq/aps/ g,vpro/pem1i t-applicati ons.
If Your Geothermal Water Return Well is NO LONGER Being Used for Injection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you v,1ish to rescind the permit and indicate
the current status of the well (i.e., used as ,,vater supply weJJ, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
1636 Mai! Service Center, Raleigh, North Carolin& 27€-99-1636
Phone: 9i9-807-6464 '. internet: hitp://www.ncwaler.org
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
If There has been a Chan g e of Ownershi p of the Pro perty:
If there has been a change of ownership of the property, an "Injection Wel1 Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for your
cooperation and timely response. If you have any questions , please contact me by phone at (919)
807-6406 or by email at Michael.Ro [e-mail].
Regards,
fa/~~----
Michael Rogers, P.G. (NC & FL)
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Washington-Regional Office -\VQROS w/o enclosures
Central Files -Permit No. WI0700195 v,.'/o enclosures
1 r ONRESIDENTML WELL CONSTRUCTION RECORD
North Carolina Dcpartment of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3253A
1. WELL CONTRACTOR. -
Jamie L. Canter
Well Contractor (Individual) Name
Applied Resource Management. P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Hampstead NC 28443
City or Town State Zip Code
sr 10 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMITt111(ifapplicable) WI 0700195
SITE WELL to tt(irapplicam q. Pumping Well
3. WELL USE (Check One Box) Monitoring ❑ MunlcipaUPubtic ❑
IndustriallComnlercial ❑ Agricultural o Recovery ❑ Injection ❑
Irrigation[] Other [j(nist use) Geothermal
DATE oxii-LED 12121 /1 D
4. WELL LOCATION:
451 ❑ Moncks Court
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Curie)
CITY. New Bern coutm Craven
TOPOGRAPHIC I LAND SET RNG: (check appropriate box)
[]Slope ❑Vatley Flat []Ridge ❑Other
LATfTuDE 35 e 5 ' 9-00W " DMS OR DD
LONGITUDE 77 " 5 ' 23.OWO " DMS OR DD
Latitudeliongitude source: WPS DropograpNe map
(location of well must he shown on a USGS tape map andattached to
this norm of not using GPS)
S. FACILITY (Name of the business where the well is tocated.)
Facirdy Name Facility iD# (if applicable)
Street Address.
City or Town State Zip Code
ThIImq & Kav_Amsler
Contact Name
451 ❑ Mancks Court
Mailing Address
New Ram NC 28569
GRy or Town State Zip Code
2252 636-5857
Area code Phone number
e
d. TOP OF CASING IS -1 .5 FT. Above Land Surface'
`Top of casing terminated atJnr below land surface may require
a variance in accordance with 15A NCAC 2C .011 B.
e. YIELD igpmj: 60+ MMOD OF TEST-A![lo�
f. DISINFEGWN F. Type HTH_ _ _ Amount _ 3q
g. WATER
ZONES (depth):
Top
Bottom
Top Bottom
Top
Bottom
Top Bottom
Top
Bottum
Top Bottom
Thickness;
7. CASING:
Depth
✓Olarneter Weight Material
Top +1.5
Bottom 4�
Ft.' sch40 PVC
Top
BDttom
Ft,
Top
Bottom
Ft.
8. GROUT:
Depth
Material Method
Top 0
Bottom 25
Ft. _Bentonite Tremmle
Top
Bottom
Ft.
'Fop
Bottom
Ft.
= S. SCREEN: Depth
Diameter Slot Slze Material
Top 48
Bottom S$
Ft. 4 in. .010 In. PVC
Top
Boa m
Ft. in. in.
Top
BDatom
Ft. in. in.
: 10. SANDIGRAVEL PACK:
Depth Size Material
Top 43 Bottom 68 Ft. coarse sand
Top Bottom Ft.
Top Bottom Ft,
11. DRILLING LOG
Top Bottom Formation Description
0' 1 10,
48' 1 _
1
1
1
r�
12. REMARKS:
,on wad
Medium Grainer_! Sand
Limestone
gn
6. WELL DETAILS: : I DO HEREBY CERTIFY THAT THIS WELL WAS coNSTRur-TED IN ACCORDANCE WITH
M NCAC 2C, WELL CONSTRUMON STANDARDS, AND THAT A DOPY OF THIS
a. TOTAL DEPTH:-68' _ RE PROWIM To THE _e O1IVNER,
b. DOES WELL REPLACE EXISTING WELL? YES +❑ NO i� 1212911 D
G A R CERTI D WELL CONTRACTOR DATE
C. WATER LEVEL Below Top of Casing: 3 _ FT. Jamie L Canter
(Use "+' if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Subrirkit Within 34 days of Completion to: Division'of Water Quasi Information Processing, Form Gw-1 b
Y p - Quality 9� Rev.2109
1617 Mail Service Center, Raleigh, VC 27699461, Phone : (919) B07-B300

NIaNRESIDENTUL WELL CONSTRUCTION RECORD V' 0 .9 7 8
.. i. North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3253A
1, WELL CONTRACTOR:
Jarnie L. Canter
Well Contractor (Individual) Name
Applied Resource Mananement, P.C.
Well Contractor Company Flame
257 Transfer Station Rd,
Street Address
Hampstead NC 28443
CityorTown State Zip Code
[10 1 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable) Wl 0700195
SITE WELL ID #(if applicable] I niection Well
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Publlc ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation[] Other d"(tist use) Geothermal
DATE DRILLED 12/22/10
4. WELL LOCATION:
4510 Moncks Court
(Street Name, Numbers, Community, SubdiviAlon, Lot No., Parsed, Zip Cede)
ctrr: New Bern comirY Craven
TOPOGRAPHIC 1 LAND SETTING: (check appropriate tax)
0slope ovaltey VFIaj ❑Ridge ❑Other
LATITUDE 35 .5 111.0000 " DMS OR DD
LONGITUDE 77 ° 5 ' 23.00N " DMS OR OD
LatitudeAongitude source: V3PS ❑Topographic map
(location of well most be shown on a USG5 ropo map andattached to
this fwm if not using GPS)
S. FACILITY (Blame of the business where the well is located.)
Facility Name Facility;D# (If applicable)
Street Address
City or Town State Zip Code
_lhomas & Kay Arrts#er
Contact Name
451EIl MCincks Court
Mailing Address
—New Bern _ NC 28562
City or Town State Zip Code
2f 52 a 5_ 6-5857
Area code Phone number
C WELL DETAILS:
a. TOTAL DEPTH: 80'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOW
d, TOP OF CASING IS 1 5 FT. Above Land Surface
'Top of casing terminated atlor bellow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): �— METHOD OF TEST -Airlift-_
f. DISINFECTION: Type HTH Amount 3,Qa Q
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Tap Bottom
Top Bottom Top Bottom
Thickness)
7. CASING: Depth diameter Weight Material
:Top +1.5 Bottom 60 Ft. 4" sch40 PVC
Top Bottom Ft. _
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 25 Ft. Bentonite. Tremmie
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 60 Bottom 80 Ft. 4 in. 010 in. PVC
Top Bottom FL in. in.
Tap Bottom Ft. in. In.
% SAND)GRAVEL PACK:
Depth Size Material
Top 55 Bottorn 0� Ft, coarse sand
Top Bottamn Ft.
Top Bottom Ft.
11. DRILUNG LOG
Top Bottom Formapon Description
0_1_7 0' _Tansand —
10, 130, -Madiurn Grained Sand
30' 1 55' rAy Qlay
55' 180` Limestone —_
1
1
1
1
I
. 1
12. REMARKS:
100 HEREBY CERTIFY THATT"S WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2�CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
cN PROVIDED TO TF WELL OWNER.
�� 12/22/10
- SIGNATURE OF CEFTTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing. _3 FT. .ramie L. Canter
(Use "+" if Above Top of Casing) PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 36 days of completion to: bivisiofl of -Water Qudifty d Information ProceForm GW-1b
ssing, Rev. GW
1617 Mail Service Center, Raleigh, NC. 27699-461, Phone : [phone]

Permit Number WI0700195
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facmtv
Facility Name
Thomas F Amsler SFR 5A7
Location Address
4510 Moncks Ct
New Bern
Owner
Owner Name
Thomas
Dates/Events
NC
F
28562
Amsler
Central Files: APS_ SWP_
12/20/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Thomas F. Amsler
Owner
4510 Moncks Ct
New Bern NC
Major/Minor
Minor
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual .
Owner Affiliation
Thomas F. Amsler
Owner
4510 Moncks Ct
New Bern NC
28562
28562
Orig Issue
12/08/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
12/08/10
Effective
12/08/10
Expiration
11/30/15 11/08/10
Re crn lated Activities Re q uested/Rece ive d Events -~----------------------
Heat Pump Injection RO staff report requested
Private residence, single family RO staff report received
Outfall l\!UL.L
Waterbody Name Stream Index Number Current Class
11/22/10
12/02/10
Su.bbasin
NCDENR
North Carolina Department of Environment and Natural Resources
Division of water Quality
Baveriy Eaves Perdue Coleen H. Sullins
Goverrior DlrecV
December S. 2010
Thomas and Melinda Ammsler
4510 Moncks Court
New Bern, NC. '2856"
Re: Issuance of Injection Well Permit
Permit No. W10700195
Issued to Thomas and Melinda Amster
Craven County
Dear Mr. and Ms. Ams]e:-:
Dee FreenlEP
Secretary
In accordance with your application received JJovember S. 2010.1 am forwarding Permit No. WI0700I95 for
the construction and operation of a 5A7 geothermal underground injection control (UIC) well heat pump system
located at the above referenced address. This permit shall be effective from the date of issuance until
November 30, 210 15, and shall be subject to the conditions and limitations stated therein.
Please pay special attention to the permit conditions Part E l and 2 which require you to notify the Washington
Regional Office at 252-946-6481 so that site visits can be arranged during construction and to collect groundwater
samples from the influent and effluent sampling spigots prior to start up.
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 Quality.
If you have any questions regarding your permit or the Underground injection Control Program please call me
at [phone]
Best Regards,
John MCC -ray
Environmental Specialist
cc: David Mai, — %Vasbington Regional Office
Central Office File — W10700195
Craven County Environmental Health Dept.
Attachment: Permit WI0700195
AOUIF-R PR07EUION SECTION
1636 Mail Service Cenrer, Race h. North CaroNna 27R9-163C
Lnc wn' 2728 CapiraI Boulevard. RalergF, North Carolina 276(4
ph"-: 919.733-3221 ', FAX [phone]; FAX [phone] i Ck--tamer .++epme: 1-377-623�674&
Intema,; www.nmaten-galirv.o—,
AnEgWlOppaw'y' AMnnaWaft oa=rnplayar
On- * r
Noah Carolina
�A/ai ul`17141/

EMIT.7i It K: t r7 RIM,
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTM ENT 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; Articie 21, Chapter- 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Thomas and Mefinda hmsler
FOR THE CON STR11CTION AND OPERATION OF 2 TYPE 5A7 INJECTION WELLS, defined in Title 15A
North Carolina Administrative Code 2C .0209(e)(3)(A), which will he used for the injection ofheat pump
effluent. This injection well is located at 451() Moncks Court., New Berri. Craven ioursy, NC 2956^, and will be
constructed and operated in accordance with the application received INoveznb �-r IS. 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 perni t is for Con struction and Opera ion of an injection well shall be in compliance with Title 15A North
Carolina Administrative Code ?C .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 Novcmher 30. 2015, and shall
be subject to the specified conditions and limitations set forth in Parts 1 through IX hereof.
Permit issued this the day ofy t� , i.? } ( !.
0� C-- L� u JA
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0700195 UIC/5A7 Page 1 of 5
ver. 03/2010

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 i~iection well shall be secured to reasonably insure against unauthorized access and use. Each
well shall be permanently labeled with a warning that it is for injection purposes and the entrance to each
well must be secured with a locking cap.
6 . Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section -UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636·
Ph# 919-715-3221
Aquifer Protection Section
y,:asi1ington Regional Office
9-B \':' ashington Seman:· Jv'lall
Washing.to.a. N:·· 2788L
.Phf 252-946-6481
GW-ls must be submitted within 30 days of completion of well construction. Copies of the GW-1 form(s)
shall be retained on-site and available for inspection.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall notify the
Aquifer Protection Section-Underground Injection Control (UIC), Central Office staff, telephone number
[phone] and the \Vashington Regional Office Aquifer Protection Section (APS) Staff, telephone
number [phone].
2. Within 30 days of injection well completion, Permittee must contact the \\'asi1infJon Regional Office APS
Staff in order to have samples collected at the source well and injection well.
3. 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.
4. The injection well system must be constructed with sampling ports so that system influent and effluent
may be sampled.
Permit #WI0700195 UIC/5A7 Page 2 of 5
ver. 03/2010
5. The injection well must be constructerl to a depth such that it is injecting ,vater into the same aquifer that
the source well is drawi11g from.
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership , or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including an y supporting materials as may be appropriate, at least 30 days prior to the date of the
change .
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances , which may be imposed by other local, state, and federal
agencies , which have jurisdiction. Furthermore , the issuance of this permit does not imply that all
regulatory requirements have been met.
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater which will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the injection
zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective actions
including those actions that may be required by 'the Division of Water Quality such as the , repair,
modification, or abandonment of the injection facility .
2 . The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3 . The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2 . The Permittee must notify the Division and receive prior written approval from the Director of any planned
physical alterations or additions in the permitted facility or activity not specifically authorized by the
permit.
3 . At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section-Underground Injection Control (UIC),
Central Office staff, telephone number (919) 715-E 16 8 . Notification is required so that Division staff can
inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
Permit #WI0700195 UIC/5A7 Page 2 of 5
ve r. 03/2010
PART VI -INSPECTIONS ·O
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 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 \.Vashington Regional Office, telephone number (252) 94(,-64g), any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of
· any incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection well.
Such a change would include the discontinued use of a well for injection. If a well is taken completely out
of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used for any
purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well
Construction Standards.
Permit #WI0700195 UIC/5A7 Page 3 of 5
ver. 03/2010
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) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Parr IX (1) and (2) (G) shall be submitted to:
Permit #WI0700195
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/5A7
ver . 03/2010
Page 4 of 5
Permit Number WI0700195
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
Thomas F Amsler SFR 5A7
Location Address
4510 Moncks Ct
New Bern
Owner
Owner Name
Thomas
Dates/Events
NC
F
28562
Amsler
Central Files : APS_ SWP_
12/08/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Thomas F . Amsler
Owner
4510 Moncks Ct
New Bern NC
Major/Minor
Minor
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Thomas F. Amsler
Owner
4510 Moncks Ct
New Bern NC
28562
28562
Orig Issue App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective Expiration
11/08/10
_R_e_..g ..... u_la_t_e_d_A_c_t_iv_i_ti_e_s ________________ Re o uested/Received Events
Heat Pump Injection RO staff report requested
Private residence , single family RO staff report receiv ed
Outfall l\'ULL
Waterbody Name Stream Index Numper Current Class
11/22/10
12/02/10
Subbasin
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: 11/29/2010
To: APS Central Office
Central Office Reviewer:
Regional Login No:
L GENERAL INFORMATION
1. This application is (check all that apply)
Permittee(s):Thomas and Melinda Amsler
_ : m
Permit No.: W10700196
= 0 m
County: Craven
3 v
Project Name: Amsler
V, m
=' t _
� v
&
❑ SFR Waste Irrigation System ® UIC Wells)
0
® New ❑ Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation ® Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No
a. Date of site visit: 11/24/2010
b. Person contacted and contact information: Thomas and Melinda Amster. 4510 Moncks Court New Berri,
INC 28562
c. Site visit conducted by; Alien Clark and Randy Sipe, DWQJAPS Washington Regional Office
d. Inspection Report Attached: Z Yes or ❑ No.
2. Is the following information entered into the BIMS record for this application correct'
® Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application.
For UIC Injection Sites:
of multiple sites either indicate which sites the information aonlies to coon and paste a new section into the
document for each site, or attach additional oaoes for each sitel
a. Location(s); 4510 Moncks Court New Bern. Craven County_ NC
b. Driving Directions:
c. LISGS Quadrangle Map name and number:
d. Latitude: 35 05 11 N Longitude: -77 05 23 W Method Used; Goggle Earth
H. NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section l Description of Waste System and Facilities: NA
Ill. RENEWAL AND MODIFICATION APPLICATIONS fuse previous se_ ctron for new or major modification
systemsa: NA
IV. INJECTION WELL PERMITAPPLICATIONS (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(sy and Facilities — New, Renewal, and Modification
1. Type of injection system:
® Heatinglcooling water return flow (5A7)
APS-OPU Regional Staff Report (Sept 09) Page 1 of 3 Pages

. '
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
D Closed-loop heat pump system (5QM/5QW)
□ In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5L/"Non-Discharge")
D Other (Specify: ___)_
2. Does system use same well for water source and injection? D Yes ~ No
3 . Are there any potential pollution sources that may affect injection? D Yes ~ No
What is/are the pollution source(s)? . What is the distance of the in jection well (s ) from the pollution
source (s )? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 10 ft.
5. Quality of drainage at site : ~ Good D Adequate D Poor
6. Flooding potential of site: ~ Low D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach map
of existing monitoring well network if applicable . If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? ~ Yes or O No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal and Modification Only: NA
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes D No. If 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:
3. For renewal or modification of groundwater remediation permits (of an y typ e ), will
continued/additional/modified injections have an adverse im pact on mi g ration of the p lume or mana gement of
the contamination incident? 0 Yes D No. If yes 1 expla in:
4. Drilling Contractor: Name: H. Michael Sage , Applied Resource Management
Address: PO Box 882 , Hamstead , NC 28443
NC Certification number: 2531-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 ~ No. If yes, please explain
briefly. __ .
APS-GPU Regional Staff Report (Sept 09) Page 2 of3 Pages
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
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:
I Condition I Reason I
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.
7
t:3
Condition
Reason
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 reas +ns:
Signature of report Preparers): �,
P.
Signature of APS regional supervisor: _ 1-'ttC C r If r-
Date:
VI. ADDITIONAL INFORMATION AND SITE MAP (Sketch of site showing house and waste irrigation system,
spray or drip field. location of well(sl, andlor other relevant information- SHOW NORTH ARROWf
Met on -site with home owner, Mrs. Melinda Amster, on November 24, 2010. to conduct a site visit as part of th_e_
application review process to install Type 5A7 iniection well. No problems were observed. Purposed location
measured 55 feet from home. The residence is on public water and sewer. There were no potential pollution
sources observed.
*See Attached Site Map.
APS-GPU Regional Staff Report (Sept 09) Page 3 of 3 Pages

r
r'
Am-s4f PTO Pk6-y , p o TEA*�N' -7-0-f ti
Approximate Property Lines
�---- Approximate Sewer Lines
N Approximate Supply Well Location
* Approximate Injection Well Location
Notes:
1. Subject property and surraund�ng area are serviced by public sewer and water services.
Adapted from Googie Earth and Craven County G!S Map, October 2010.
TITLE: GIS MAP FIGURE:
iied ResourcIhan�1 ement t'C--__.-._...�. 451 MQNCKS CGURT
7 e _
Box Hamps'oaa n 7844 , JOB: Ti SCALE: ji7Alti; DRAWN BY; I
(9101270 2919 FAX 27D-2988 Amsler I" = 60' 1 10/27/10 DNH 1
I

North Carolina Department of Environment and Natural Resources
Division of Water Quality -Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700195
DATE OF INSPECTION: November 24, 2010
INSPECTOR: Allen Clark; WaRO
NAME OF PERMITTEE(S): Thomas and Melinda Amsler
MAILING ADDRESS OF PERMITTEE: 4510 Moncks Court, New Bern, NC 28562
PHYSICAL ADDRESS OF SITE (if different than above) ________________ _
PERSON MET WITH ON-SITE: Mrs. Melinda Amsler; Tele no. [phone]
WELL(S) STATUS:
__ Existing and operating Class V Well
__ Existing well proposed to be converted to Class V well
____K___ Proposed/not constructed
Purposed Injection Well Location: Latitude: 35 De g .. 05 Min .. 11 Sec N : Longitude: -77 De g ., 05 Min .. 23 Sec. W
Appx. distance of well to property boundaries: 10 feet
Appx. distance of well from foundation of house/structure: 55 feet
Appx. distance of well from septic tank/field (if present): NA
Appx. distance of well to other well(s) (if present): The purposed Injection Well will be approximately one-
hundred twenty-five (125) feet from the proposed Supply Well. ·
Appx. distance to other sources of pollution: ___________________ _
Flooding Potential of Site: _high __ moderate X low
Comments: There were no potential problems observed during the site visit.
Injection Facility Insp. Report (Rev. Sept 2009) Page I of 3 Pages
MI
m54T P-io PO�)
Approximate Properly Lines
Approximate Sewer Lines
Approximate Supply Well Location
* Approximate injection Well Location
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
Adapted from Goggle Earth and Craven County GIS Map, October 2010.
DRAW SKETCH OF SITE ABOVE (Show property boundaries, buildings, other wells, septic tanks/drain fields, other
potential pollulion sources, roads, approximate scale, and NORTH arrow
Injection Facility Insp. Report (Rev. Sept 2009) Page 2 of 3 Pages

Well Construction Information
Date Constructed: Not yet constructed
Well Contracting Company: A pp lied Resource Management, P.C.
Well Driller Name: H. Michael Sage
NC Well Cert. No.: 2531-A
Address: PO Box 882 , Ham pstead. NC 28443
Telephone No.: ""(9""""'1....c.0 .... ) 2~7~0~-2=9~1~9 _____ ; Cell No.:
Email Address: -----------
Proposed Depth of Well(s): 120 feet
Total Depth: TBD Total Depth of Source Well, if present: Not v et constructed
Casing:
Depth: TBD Diameter: 4 inch; Type (gav. steel, PVC, etc.): PVC;
Grout:
Depth: Type (cement, bentonite, etc.): Placement (pump, press. etc.):
Well ID Plate Present (Y or N): ; Heat Pump ID plate present (Y or N):
Influent spigot (Y or N): (sample taken from pipe leading into heating unit); Effluent spigot (Y or N):
Well Sampled? (Y or N):
If Yes, Lab Sample ID numbers: _______________ _
Static Water Level: 1.
Injection Information (if applicable):
Injection Rate:? _____ GPM
Injection Pressure:? _____ PSI
Injection Volume: ? _____ GPD
Temperature-Summer: ? ____ P 0
Temperature-Winter: ? ____ P0
Comments/Notes: Met on-site with permit/ pro perty owner Mrs. Melinda Amsler on November 24 . 2010 . to
conduct a site visit as part of the a pp lication review process to install T ype SA 7 in jection well. No problems were
observed. Purposed in jection well location is fift y-five (55 ) feet from the house. Pro posed supp l y well location is
a pproximatel y one-hundred twent y-five (1 25 ) feet from pro posed in jection well. Other than the house . no other
potential pollution sources were observed.
Injection Facility lnsp. Report (Rev. Sept 2009) Page 3 of 3 Pages
_ X ^ i al
ICE r1�5CR '-, _� = r •_-- r�. GR4F�SK S -- a a
iL
E
a y� hi
N H _ ; Flew
Ip
L4 1 iii i I 4" Lti•'
FC?RO, --j
QY
37
71.
1p�
_ r r: �• p
R� CK RE
kA
-7 0.5 2,5 �� y� 1 inch = 2199 feet
Craven CaLnty does NOT we -ram the ]rforrn8iion shown on IN -%map wd sheutd be used ONLY Tor Fax as se ssmen I pugmses. �. � '

•~A e_.1_;~31.
NC DE MR
North Carolina Department of Environment and Natural Resources
Divis ion of Water Quality
Bever ly Ea ves Perdue
Governor
Cole en H. Su lli ns
Directo r
November 18 , 2010
Thomas F. Amsler
Melinda K. Amsler
4510 Moncks Court
New Bern, NC 28562
Subject: Acknowledgement of Application No. WI0700195
Thomas F Amsler SFR
Injection Heating/Cooling Water Return Well ( 5A 7)
Craven
Dear Mr. and Mrs. Amsler:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on November 8, 2010. This application package has been assigned the number listed above and will be reviewed
by John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary . To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional infonnati~n 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 John McCray at 919-715-6168, 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 htt p://h2o .enr.state.nc .us /documents/dwg or~cbart.n df.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT .
JM ~W10
for Debra ~ts
Supervisor
cc: Washington Regional Office, Aquifer Protection Section
Diana Helias (Applied Resource Management, P.C., P.O. Box 882, Hampstead, NC 28443)
Patrick McKee (Airtech Mechanical Services, 153 Two Lakes Dr., New Bern, NC 28560)
Permit Application File WI0700195
AQUiFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Caro lina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Serv ice: 1-877-623-6748
Intern et: www.ncwaterguality .org
An Equal Opportun':y I Affirmaiive Action Employer
Ni~hCarolina
;JVat11rallg
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT` TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A GEOTHERMAL HEAT PUMP SYSTEM
TYPE 5A7 "OPEN LOOP" INJECTION WELLS)
(check one) 2j_ New Permit Application Renewal Modification
DATE. October 27. 2010
PERMIT NO.: WI .S (leave blank if NEW permit application)
A. PROPERTY OWNERMERMIT APPLICANT
Name of each owner listed on property deed. For a business or government agency, state name of entity and
name of person delegated authority to sign application on behalf of the business/agency-
Melinda Kai, Amsler & Thomas F. Amsler
(1) Mailing Address: 4510 Moucks Court
City: New Bem State: NC Zip Code: 28562 County: Craven
Home/Office Tele No.: 252-636-5857 Cell No.:252-288-1275
Fax No,
Email Address: kayquiltsi.%isuddenlink.net
(2) Physical Address of Well Site (if different than above):
City:
Home/Office Tele No.:
Fax No.
State: Zip Code:
Email
B. PROPERTY OWNERSHIP DOCUMENTATION
County:
Provide legal documentation of property ownership, such as a contract, deed, article of incorporation, etc. and
a PLAT snap showing the property. This information may be obtained from county Register of Deeds or G1S
website.
AUTHORIZER AGENT, IF ANY
If the property owner/permit applicant wants to authorise someone else to sign the permit on their behalf, then
attach a si ned letter from the property owner/permit applicant specifying and authorizing their agent (well
driller, heat pump contractor, or other type of contractor/agent) to sign this application on their behalf.
Company Name:
Contact Pcrson: Email Address:
Address:
City:
Office Tele No,.
State:
Zip Code:
County:
Website Address of Company, if any:
Type 5A7 Injection Well Permit Application (Rev. August 2009) Page l of 4

C. WELL DRILLER INFORMATION
Company Name:. ___ =-cAc.i=p=p=lie"-'d~R~es=o=u=rc=e---=M==an=a=g=e=m=e=nt=·=P-'--'.C=--------------------
Well Drilling Contractor's Name: --------"'-H=.---"-M=1=· c=h=ae=l---"S=a""g""---e ________________ _
NC Contractor Certification No.: __ ______,2=5=3---=l=A"-------------=C"---'o=n=ta=c--=--t =-Pe=r=so=n=: ___ ---=D=i=a=na==H=e=li=as"------
Company Website: WWW.arm-pc.com Email Address: Diana ARM@ bellsouth.net
Address: ----=-P=.O=·---=B=o=x=---8=8=2"--------------------------------
City: Ham pstead State: NC Zip Code: 28443 County: --~P.,:een,..,d:oe:e:!..r __ _
Office Tele No.: 910-270-2919 Fax No.: 910-270-2988 Cell No.:. ________ _
HEAT PUMP CONTRACTOR INFORMATION (if different than Driller)
Company Name: ___ A~irt=e=c=h__.c.M=e=c=h=an=i=c=al'-'S=e=rv-'-'i=c=es"---=C=o=nt=a=ct,_,P'-'e=rs::<,o=n"'-: ....:aP-"a""tr""ic""'k"-'M=cK=e.,,_e _____ _
Company Website: WWW.airtechnc.com Email Address:
Address: --------"'-1=53::......:.T"""'w""'o---=L=a=k=e=-s =D-"'ri:...:..v-=-e _______________________ _
City: New Bern State: NC Zip Code: --=2=85~6~0 ____ County: -----"'C'-"-'ra:::..:vc:::e=n __ _
Office Tele No.: 252-636-5841 Fax No. 252-636-5842 Cell No. 252-725-7100
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Passive infiltration of well water used for geothermal heat exchan ge
D. G.
(1)
(2)
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
The injection operation?
Personal consumption?
YES ___ _
YES ___ _
NO --"-X-"----
NO --"-X;c__ __
H. WELL CONSTRUCTION DATA
(1)
X ____ PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(7) below as PROPOSED construction specifications. Submit Form GW-1 after construction.
____ EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (7)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
GW-1) if available.
Well Construction Date: __ l~l~/1=5~/~10=--_____ Number of borings: ---"2'-----
Depth of each boring (feet): ________ _
(2) Well casing. Is the well(s) cased?
(a) YES _X ___ Ifyes, then provide the casing information below.
Type: Galvanized steel __ Black steel __ Plastic X Other (specify) ______ _
Casing thickness: SCH40 diameter (inches): 4" depth: from _O"--' ___ to 120' feet (relative
to land surface)
Casing extends above ground > 12 inches
(b) NO
Type 5A7 Injection Well Permit Application (Rev. August 2009) Page 2 of 4
(3) Grout material surrounding well casing:
(a) Grout type: Cement____x_ Bentonite* Other (specify) ______ _
*By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .02l3(d)(l)(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from _O ___ to 20 feet
(4) Well Screen or Open Borehole depth (relative to land surface): from ____ to ____ feet
(5) N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provts1ons 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) Influent line? Yes X No (b) Effluent line? Yes X 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: Approx 120' Formation: Castle Hayne Rock/sediment unit: Limestone
NOTE: THE WELLDRILLINGORHEATPUMP CONTRACTOR CAN HELP SUPPLYTHEDATAIFTIIlS
INFORMATION IS OTHERWISE UNAVAILABLE.
I. OPERATING DATA
(1) Injection Rate: Average (daily) <15 gallons per minute (gpm).
(2) Injection Volume: Average (daily) <21 ,600 gallons per day (gpd).
(3) Injection Pressure: Average (daily) <15 pounds/square inch (psi).
(4) Injection Temperature: Average (January) 60 ° F, Average (July) 65 op,
J. INJECTION-RELATED EQUIPMENT
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 5A 7 Injection Well Permit Application (Rev. August 2009) Page 3 of 4
L CERTMCAT14N
Note: This Permit Appliratian must he signed by 1%ach person appearing on the
recorded legal property dee&
"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 tbereto and tbA based on mY inquiry of ti osa individuals
immBdiately responsible for obtaining said information, I balieve that the information is true, accurate and complete.
I am aware that there am signiftmu penalties, ineiuding the passibility of fines god imprisonment, for suing
false information. I agree to construct, operate, maintains, repair, and if applicable, abandon the injection well and
all rclatcd appartcnancc6 in accordance with the approved specifications and conditions of the Permit.,"
! r
5ignar<ue ofProparty 0"er/Applicant T` --
_ ] 1!Dman E AMS kg'
Print or Type Full Name
S%113MM of Property /ACp�pli_cant
InIE I S7 vA \I Ep—
Printer I`ype Lull Name
of Authorized Agent, if any
Print or Type Fall Name
Please return two copies ofthe completed Application package to:
North Carolina DENS DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPtNUZC $A7 Wel! Pam&Appiicaiion gtev. Avert 2009)
PVC a of 4-
90/90 39dd OAS HD3W H03INIV Zb899E:969Z Stb:SI 01OZ/8I/e1

Craven County Geographic Information System
Craven Counly does NOT warrant the information shown on this page and should be used ONLY For tax assessment purposes.
This report was created by Craven County GIS reporting services on 11l112010 12:46:41 PM
Parcel ID :
8-203-A -056
Owner:
AMSLER, THOMAS F & MELINDA K t. "''
Mailing Address :
4510 MONCKS CT NEW BERN NC 28562
Property Address :
4510 MONCKS CT
Description :
9 BELLEFERN SEC 5 1712
Lot Description :
Assessed Acreage :
0.000 Calculated Acreage: 0.520
Deed Reference :
1781-0735 Recorded Date : 10 20 2000
Recorded Survey
Estate Number :
Land Value:
$84,500 Tax Exempt: No
Improvement Value :
$317,060 # of Improvements : 1
Total Value :
$401,560
City Name:
TRENT WOODS Fire tax District
Drainage District:
Special District:
Land use :
RESIDENTIAL - ONE FAMILY UNIT
Recent Sales Information
SALE DATE Sellers Name Buyers Name Sale Type Sale Price
10/20/2000 HOLLYSILLT INC AMSLER, THOMAS F & STRAIGHT $310,0()0
MELINDA K TRANSFER
415/2000 MEADOWS
HOLLYBILLT INC STRAIGHT $45,000
PROPERTIES LLC TRANSFER
5/10/1998 MEADOWS,
SARA ET AL MEADOWS PROPERTIES MULTI -PARCEL- $0
LLC SALE
List of Improvements to Site
Type of Structure
Year Built Base Area Value
RESIDENTIAL CONSTRUCTION 2000 2446 $317,060

P
b
Approximate Property Lines
Approximate Sewer Lines
Approximate Supply Well Location
Approximate Injection Well Location
� � r
Notes:
I - Subject property and surrounding area are serviced by public sewer and water services.
Adapted from Google Earth and Craven County GIS Map, October 2010.
TITLE: GIS MAP FIGURE:
7 PC). lied �e5ource Mana ernent PC 4510 MONCKS COURT
Box M2, HcirnpsteW, N(,; 26443 JOB: SCALE: DATE: DRAWN BY:
[phone]FAX [phone] Amster 1" = 60' 10/27/10 DNH

r
'I
Subject Property
N
Irrigation Well
Notes:
1. Subject property and surrounding area are serviced by public sewer and wafer services.
Adapted from Google Earth and Craven County GIS Map, October 2010.
TITLE: SITE MAP FIGURE:
7 �,rlied Keeoume Mariagment f G _ 4510 MONCKS COURT
P Qx Hamps ea , a JOB: SCALE: DATE: DRAWN BY:
[phone] FAX [phone] Amster NTS ' 10/27/10 DNH 2

;VSU
6
In
Adopted from USGS Topographic Map N
"New Bern, NC," 1950, Photo Revised 1983
Contour Interval = 5 Feet
TITLE: SITE VICINITY MAP FIGURE:
4510 MONCKS COURT
;.lied Reoouroe Mana-�ement f C
Box ampsread, NC 28443JOB: SCALE; DATE: DRAWN By.
3
At410J 27p-2419 FAX 27� 2988 Ams12r 1 " 2,000` 1 1 /3/2010 KLC

......ram
RCDEN R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
August 31, 2011
Thomas and Melinda Arnsler
4510 Moncks Court
New Bern, NC 28562
Re: Issuance of Injection Well Permit
Permit No. W10700195
Issued to Thomas and Melinda Amster
Craven County
Dear Mr. and Mrs. Amslen
Dee Freeman
Secretary
Attached is a summary of the laboratory analytical results from water samples collected from your geothermal
well system on February 14, 2011, by the Washington Regional Office. Laboratory analytical results indicate
exceedances in the maximum contamination level (MCL) or elevated levels for the following parameters):
Parameter units MCL l Results
-7
pH (field) Units 6.5 - 8.5 6 (influent)
5 "5 (effluent y
Iron uglL 300 ` 3000 (influent)
2900 (effluent)
The exact source or cause of these exceedances is unknown; however iron exceedances in groundwater are
typically due to naturally occurring conditions. It is recommended before using water from this well for
personal consumption that you consult with the Craven County Environmental Health Departnrzent. If you have
any questions regarding your permit or the Underground Injection Control Program please contact David May
with the Washington Regional Office at 252-946-6481 or me at [phone].
Best Regards,
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
cc, David May, Washington Regional Office
Craven County Environmental Health Dept.
Attachment(s)
AQUIFER. PROTECTION SECTION
1636 Mail Semite Center, Rakeigh, North Carolina 27699-1636
Locafion. 2723 Capital Boulevard. Raleigh. North Carolina 27604 11L
Phone: 91B 733-3:21 t FAX 1: 919C715-05ft, FAX 2; 915-115.9481 Customer 5ervm- 1.877-623.6746 N (-w fll C.WT.01-111L
Internet: www. mwateroualiL• .tiro
'r"
ark Equal 0gort;:m, l Afiirma;iva Action Employer

Parameter
units
NC 2L and/or EPA Standards
lnHuent Sample Results
Effluent Sample Results
Parameter
units
NC 2L and/or EPA Standards
Influent Sample Results
Effluent Sample Results
Parameter
units
NC 2L and/or EPA Standards
NC DIVISION OF WATER QUALITY
LABORATORY ANALYTICAL RESULTS
5A7 GEOTHERMAL UNDERGROUND INJECTION CONTROL (UIC) WELL
PERMIT NO .: WI0700195
PERMITTEE(S): Thomas and Melinda Amsler
SAMPLE COLLECTION DATE: Februa ry '14 , 2011
Fecal Coliform Total Coliform Total Dissolved Solids Chloride, Cl
CFU/100ml CFU/100ml mg/L mg/L
NC 2L = < 1 NC2L= 1 NC 2L = 500 NC2L=250
EPA SOWS = 500 EPA SOWS= 250
<1 <1 290 5.3
< 1 <1 298 5.3
Nitrate Nitrite Nitrate + Nitrite Silver,Ag
mg/Las N mg/Las N mg/LasN 119/L
NC2L=10 NC2L= 1 NC 2L = 10 NC 2L= 20
EPAPDWS=10 EPAPDWS= 1 EPA PDWS = 10 EPA SOWS= 100
NA NA <.02 NA
NA NA <.02 NA
Barium, Ba Calclum, Ca Cadmlum,Cd Chromium, Cr
119/L mg/L 119/L 11g/L
NC 2L = 700 NS NC2L= 2 NC 2L = 10
Fluoride, FL
mg/L
NC2L=2
EPA PDWS = 4.0
<0.4
<0.4
Aluminum, Al
119/L
NS
EPA SOWS= 50 to 200
< 50
< 50
Copper, Cu
119/L
NC 2L = 1000
EPA POWS = 2000 EPAPOWS=5 EPA PD WS = 100 EPA SOWS= 1000; PDWS = 1300
Influent Sample Results NA 95
Effluent Sample Results NA 94
Parameter Potassium, K Magnesium, Mg
units mg/L mg/L
NC 2L and/or EPA Standards NS NS
Influent Sample Results 0.52 1.9
Effluent Sample Results 0.49 1.8
Parameter Selenium, Se Zinc, Zn
units 119/L 119/L
NC 2L and/or EPA Slandards NC 2L = 20 NC 2L = 1000
EPAPDWS =50 EPA SDWS = 5000
Influent Sample Results NA 29
Effluent Sample Results NA <10
GA G 2l .0200
Water Standards
NC 2L = North Carolina Maximum Contamination Limits per 15A N
EPA PDWS = Environmental Protection Agency Primary Drinking
EPA SOWS= Environmental Protection Agency Secondary Drink ing Water Standards
NS = No standard
NA = Not analyzed
< 1.0 < 10 19
< 1.0 < 10 4.4
Manganese, Mn Sodium, Na Nickel, Ni
119/L mg/L 119/L
NC 2L= 50 NS NC2L = 100
EPASDWS=50
19 4.5 < 10
18 4.3 <10
pH(field) Ammonia Phosphorus
units mg/L mg/L
NC 2L = 6.5-8.5 NC IMAC= 1.5 NS
EPA SOWS = 6.5 to 8.5
6 0.08 0.62
. 5.5 0.08 0.62
Parameter Total Kjeldahl N as N
units mg/L
NC 2L and/or EPA Standards NS
Influent Sample Results <.2
Effluent Sample Results 0.23
Sulfate, S04
mg/L
NC2L=250
EPA SOWS= 250
13
13
Arsenic, As
11g/L
NC 2L = 10
EPAPDWS=10
NA
NA
Iron, Fe
11g/L
NC 2L = 300
EPA SOWS = 300
3000 ·
woo ·
Lead, Pb
119/L
NC2L= 15
EPAPDWS=15
< 10
< 10
Hardness
mg/L
NS
240
240
Routing Slip for 5A7 Well
Laboratory Review
Date; I- z11
Permit No. .0270 1
Permittee(s): -/M-ra<
l have reviewed the attached laboratory analytical
results and have made any comments below.
qhlzml Date
5:1UIMPU flouring Slip for 3A7 Wells).doc

Date: March 28, 2011
To: John McCray, DWQ/APS/UIC Program
From: Allen Clark, DWQ/APS Washington Regional Office
Subject: Lab results
Permit# WI0700195, Thomas and Melinda K. Amsler
RECENED / DENR I DWQ ..
AQUIFFR·PRnTFr.TION St;CT{(M
MAR 2 9 20111
Enclosed are the lab results for the above mentioned (Type SA7) facility's injection well and supply well.
� r f '
7Y ) I r' )
County:
CRAVEN
Sample ID:
A868424
River Basin
p �f�+
\�G
PO Number #
11GO133
Report To
WAROAP
�0
Date Received:
0211512011
Collector
A Ci ARK
Y
Time Received:
08:30
Region!
Reg
WARa
~�
Labworks Loglnl❑
HMQRGAN
Report Generated:
3121111Date
Sample Matrix:
GROUNDWATER
�
Reported:
03/21/2011
Loc. Type:
WATER SUPPLY
(�
Emergency Yes/No
VESEtfD
1Q
COC Yes/No
4"S C
,
Luc. Descr.: THOMAS AND MELINDA ANI ER
r
Location lD:
APS-N-SWW-CRAVE-0195
Collect Date: 02/14/2011
Collect Time: 11:40
SampleJ Depth
CAS
LAB
Analvte Name
Sample temperature at receipt by lab
PQL
Result!
Qualifier
0.4
Units
°C
Method
Reference
Analysis
Date
2115111
Validated by
HMORGAN
WET
Ion Chromatography
TITLE_
mglL
EPA 300.0
Z17111
MOVERMAN
Chloride
1
5,3
mglL
EPA 300.0
2/17111
MOVERMAN
Fluoride
0.4
0,4 U
mglL
EPA 300.0
7/17?11
MOVERMAN
Sulfate
2
13
mglL
EPA 300.0
2-117111
MOVERMAN
Total Dissolved Solids in liquid
12
290
mg1L
APHA254OC- 18TH
2117111
CGREEN
NUT
NH3 as N in liquid
0.02
0.08
mg1L as N
LaC10-107-06-1-J
2/16111
CGREEN
Total Kieldahl N as N in liquid
0.2
D.2 U
mglL as N
Lachat107-06-2-H
2122/11
CGREEN
NO2+NO3 as N in liquid
0.02
0.02 U
niglL as N
LacID-107-04-1-c
2/16111
CGREEN
Phosphorus total as P in liquid
0.02
0.62
n1gIL as P
Lacl0-115-01-1EF
2/18/11
CGREEN
MET
7429-90-5
Al by ICP
50
50 U
uglL
EPA 200.7
311111
ESTAFFQRDI
7440-70-2
Ca by ICP
0.1
95
mg1L
EPA 200,7
311111
ESTAFFQRDI
7440-43-9
Cd by ICPMS
1
1.0 U
ug1L
EPA 200.8
2JI8111
ESTAFFQRDI
7440-47-3
Cr by ICPM5
10
IOU
uglL
EPA 200.8
21I8111
ESTAFFQRDI
7440.50.8
Cu by ICPMS
2
19
uglL
EPA 200.8
2/18111
ESTAFFQRDI
7439-89-5
Fe by ICP
50
3000
ug1L
EPA 200,7
311111
ESTAFFQRDI
Hardness by Calculation
1
240
mg1L
SM2340BEPA 200.7
311111
ESTAFFQRDI
7440-09-7
K by ICP
0.1
0,52
mglL
EPA 2003
311111
ESTAFFQRDI
7439-95-4
Mg by ICP
0.1
1.9
rnglL
EPA 2017
311111
ESTAFFQRDI
7439-06-5
Mn by ICP
10
19
ug/L
EPA 200.7
311111
ESTAFFQRDI
7440-23-5
Na by ICP
0.1
4.5
rng1L
EPA 200.7
311111
ESTAFFQRDI
7440-02-0
NI by ICPMS
10
10 U
uglL
EPA 200.8
2118/11
ESTAFFQRDI
7439-92-1
Pb by ICPMS
10
10 U
ug1L
EPA 206-.8
2/18/11
ESTAFFQRDI
7440-66-6
zn by ICPMS
10
29
ugfL
EPA 200.8
2118h 1
ESTAFFQRDI
Laboratory Sectionaa 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
For a detailad doneption of rho qualifier codas refer:o hl1;;N: ortal.rcoa�r.or. ,�Neh+w Ilah�slaHnlollEchassisE9ltJaia ,ualifier Codes <htk..:11, ori8l• 1 nr. r itwat!tt l- lelsfri jjachassisl!
Page 1 of 1

;A-95- N - - C C y,� �, --a\� s
GROUNDWATER FIELDILAB FORM
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUMIDWATER SECTION
SAMPLE - -_- SAMPLE P fR ORITY l { c Q 3-3
Location Code ISS w W - C
County C co LX)
alp Ratline
Lab Number
Quad nl0 5eriai No.
LaL Long.
❑'Soil ❑ Emerl7ency
Other
kp pate Received �'�J' l _rime: Tf_-
Reer'd By •11 From: Bus, CrSGrie ,Hand l7e!„
Report Ta ARO, FRO. MRO, RRO,7�Z��_R�.?> MO,
Cl Chan of Custody
Other: _
WSRO, Kinston FO-Eed. Trust. Centra-f i, Other
-
— -- - - Data Entry By: _ Ck: - _
Date Reported:
Shipped by B sf Coiner, . and,Dek., Dther_
Cgilectur(s): ►
P asp -- -
�-[7 '• `
, Date
Time E tx-Baseline, Complaint, ompiiance, LUST, Pesticide Study, Federal gust. Other:.
FIELD AN_ LYSES
pH .eo Spec. Cond �,
Temp.ro OG Odor
�drde one)
Owner i 1� c t�z � [�1;� L� as � r
at 25°G Location or Site t 0 t , , n �5 N( (a. c- - — - -
Description of.sampl n tirt ��T
point Y' � --
Appearance
Sampling Method `•- : c' ; Sample Interval -
Field Analysis By-
Remal-ks
LABORATORY ANALYSES
SPwpiriq We, air tffnp., etr-I
_
Bon 310 - mg1L
CUD High 340 my1L
}s
Diss. Solids 70340 Y - - mglL
Fluwlde 9514 mglL
!
Ag-Silver 46566 uge
AM AlumifNrn 46657u4'j
QrganochForins Pesticdes _
BA arw A►arus Pes@cadet--- _ _ _
COD taw 335 tdglL
Hardness: TOW @Op mgJL
Hardness jnwr-umb! 302 mgA.
Phenols 32730 - - ugA
Gotham' W Feca131616 1100rri
-Golifamr LIF Tutal 31504 1tOt w
TOC 650 mglL
Specific Cond. 95 u@Ihas!!Ccn
Turbidtty76 Ni11
Sulfate 945 mglL
Residue, Suspended 530 rnglL
Sulfide 745 mg1L
09 and Grease — - - mg&
- -
-
PH 403 w[[ls
AlkaFffft In PH 4-5 410 mglL
Alital wdy 10 pH E,3 415 m91L
- -- -
Cmbminte 445 -J&
NH' as N O D { V? 4.5 i y L -C IL
Ncarbanahe 440 mglL
_
M as N 625
Carbon dio]ade 405 mglL
C hlo►ider94e mglL
NQz+ NOs as N 630 Fy Y7. Y (� mwL
P: Tdtal as P 665
Chramiun: Hex 1032 ug&
I4ilrale [NO, as N] GA mg/L
Odor. True 80 CU
Nitrite (NGi as N) 61 S mg/L
Cyame 720 mg1L
Lab
GW-54 REV 7103 For t lirs0lued Analysi%,subrnit filtered sample and seine'=" In bladL
As -Arsenic 46551 uA
Ba Barium 46556 UcpIL
Ca-Caiavm 46552 --myn
Cd Cadrnkim 46559 U211.
Ct-Chmmiurn 45559 'u,�•* l ugR
Cu-Capper 46562tL4My uglL
Fe -limn 46%3 ryy. }s UgIL
Hg 8llarwry71800 � u L
i' ?-
K Aalnssnarn 46555
Mg -Magnesium 46554-
a--
>< n-Manganese 4656 U C�82
Na-Swift 46556 mgll
Ph -Lead 46564
Pn•Z[nc 45557 x
Mhogen Pesticides -
Acid Her6icrdes v
PCBs
Semivolatile Qrgnmcs
TPH-❑iesel Range
Volatile Orga�U 5 bolire
TPH-Gasoline Rangy
TPH-STEX Gasoline Range
— ---='9N I I- - -L- -
-uv- _.
F�Ep".jUSE ONLY
ure on arrival ['C]:

(D If,
County.
CRAVEN
Sample ID:
AB68423
River Basin
pF NNA+�
PO Number #
11GO132
Report To
WAROAP
Date Received:
D211512011
r11
a
Time Received:
08:30
Collector:
A CLAR}C
p Is
Labworks LoginlD
HMORGAN
Region:
WARD
Report Generated;
2118111
Sample Matrix:
GROUNDWATER
Date Reported:
0211812011
Loc, Type:
WATER SUPPLY
Emergency Yes1No
COG- Yes/No
Visid!)
A,,)
Loc. Descr.: TF40MAS AND MELINDA AMSTMr—
Location ID:
APS-NSWW-GRAVE-0195
I Collect Date: 02/14124111
1 Collect Time: 11:40
Sample Depth
CAS # Analyte Name pQL
Result/ [hits
Method
Analysis
Validated by
-
Qualifier
Reference
Date
LAB
Sample temperature at receipt by lab
0.4 "C
2/15111
HMORGAN
M IC
Coliform, MF Fecal in liquid 1
1 02,Q1 CFLII100ml
APHA9222D-20th
2115111
MOVERMAN
Coliform, MF Total in liquid 1
1 B2,Q1 CF111100ml
APHA9222B-20th
2J15111
MOVERMAN
Laboratory SectiarFwa 1623 Mail Ser►Fice Center, Raleigh, NC 27690-1623 [phone]
Fora data➢ad deseriplian of the gualffiw oodus rigor to ih 1^Jlnortal _-- gnu or. _ ±.vyi � RFW�@¢Y,�essi@I#D�ta fin{ ier Codes SI3i ..oriul.�cdmr. Fwebfw���iabls�a
Page 1 of. 1,

GROUNDWATER FIELDILAB.FORM
Location Code C` �(— S 4--c Pr e
County I Gl� 0 tr)
Quad No Serial No.
Lat_ Long.
Report Tm ARO, FRO, MRO, RR , WaR IRO,
WSBO, lgnston F ed, Trust Can Other
Shipped by: Bus, Coln, and Del., Other•
FIELD ANALYSES
pH 4o�_ 6.cj _ Spec, Cond-9
Temp.la -°C Odor
Appearance
Field Analysis By:
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
SAMPLE TYPE SAMPLE I'MOR1TY I(( () 'i � Az J � � , [
0 Water ��Roittine Lab Number ►U `7�
❑ soil ❑ Emergency 6'�'4'N pate Received ?-I I Time: ' `-3
❑ ggle( Redd By: y l't . From: Bus, rourierHand Del.,
❑ Chain or Custody Other:
Data Entry By: Ck:
Date Reported:
Purpose:
o Time ems, Baseline, Compl int Complia LUST, Pesticide Study, Federal Trust, Othei
Owner i (� �;� {srrua anej - -
at 25eC Location or ite, S; IQ Mn cn L
Description of samqjluig p -
Sampling Method Y] ample Interval
Rem arks _ Lk(► t �S
(Nm#ng Urn@. ar lamp . etc)
Boo 310 mg1L
Diss. Solids 70300 — - mg/L
COD High 34o mg1L
Fluoride 951 mqR
COD Low 335 mg/L
Hardness: TOW 900 mg&
Coliform: MF Fecal 31616 110om1
Hardness [non-carh) 902 mull
`
'CoWorm: MF TOW 315N liDftl
I
Phenols 3273U U94
70C Sao rng]i_
' e '5c Cand. 95 uMhWcm
Turbidity 76 NTu
Sulfate 945 mg1L
Residue. Suspended 530 mgA-
Sulfide 745 m91L
pH 4G3
Alkalinity In pH 4-541(1
Alkalinity to pH 8.3415
Carbonate 445
Bicaibonate 440
Cerban diodde 405
r,hlorkW940
Chromiin: Hex 1032
Colar. True an
cyanide 720
Lab Comments
Oil and Grease
units
mgrL
mg&
mg1L
NHJ as N Stu
rngA-
TKN as N 625
mg1L
NO=+ Nei m N ban
mW1L
R Total as P 665
ug1L
Nitrate (NO3 as Nl 620
CI7
Nibile [NO2 as NI 615
Mq&
GM-54 REV. 7/03 For Di"ved Anal ysissu"IfiriterW sarnpie and wr1te'D15' in biP*L
m¢1L
mglL
mutt
mg1L
mglL
mglL
Ag-Silver 46566 ug2
N-Aluminum 45657 �u r!
As Arsenic4fi55T uyL
13a-Barium 45558 u rL
Ca -Calcium 45552 m 1L
Cd-Cadmium 45559 u8A_
Cr-Chromium 48559 u ll.
Cu-Gopper M 62 ug1L
Fe-taon 46563 u _
Hg`Mercury 71900, ug1L
K Potassium 46555 m L
Mg -Magnesium 465S4 mg1l.
hl"anganess 46565 uqL_
NarSodiurrm 46555 m 1L
All -Niches y
PW.ead 46564 ugAL
Se -Selenium ug2
Zn•1inc46567 y k
Ur aaocirlodne Pesticides
Or ana hosfborus Pesticides
Mon1cn Peslcides
Acid Fterbiddes
PCBs
Se_m1 adle Or anus
-TP> -Diesel Ran
Vol able Or anics (VOA battle)
TPWCasoime Rangy`
TPH-6TEX Gasoline Range
LAB USEONLY
Temperature on arrival MY

Rive: Basin
I report To
CRAVEN
WARCAP
Collector:
ACLARK
Region:
WARD
Sample Matrix:
GROUNDWATER
Loc, Type:
WATER SUPPLY
Emergency Yes/No
COC Yes/No
t f
L)
VisitlD
Loc. Deser.: THOMAS AND MELINDA AIGISTER--
Sample ID:
A1368426
PO Number #
11 GO135
Date Received:
0211512011
Time Received:
08:30
Labworks LoginlD
HMORGAN
Report Generated:
3/21/11
Date Reported:
03/21/2011
Location ID: APS-N4WW-CRAVE-0195 I Collect Date: 02/14/2011 1 Collect Time: 12:05 1 Sample Depth I
CAS # Analyte Name POL Result/ Units Method Analysis Validated by
Qualifier Reference_ Date
LAB
Sample temperature at receipt by lab 0.4 °O 2115111 HMORGAN
JA 41
Ion Chromatography
_TITLE_
mg/L
EPA 300.0
2117111
MDVERMAN
Chloride
1 5.3
mg1L
EPA 300.0
2117111
MDVERMAN
Fluoride
0A 0.4 U
mg1L
EPA 300.0
2117111
MDVERMAN
Sulfate
2 13
rnWL
EPA 300.0
2JI7111
MDVERMAN
Total Dissolved Solids in liquid
12 298
mg1L
APHA2540C-18TH
2117111
CGREEN
NUT
NH3 as N in liquid
0,02
0.08
mg1L as N
LaC10-107-06-1-J
2116111
CGREEN
Total Kjeldahi N as N in liquid
0.2
0.23
mg/L as N
Lachat107-06-2-H
2122111
CGREEN
NO2+NO3 as N in liquid
0.02
0.02 U
mg/L as N
LaC10-107-04-1-c
2116111
CGREEN
Phosphorus total as P in liquid
0.02
0.62
mg1L as P
Lac10-115-01-1EF
2118111
CGREEN
MET
7429-90-5
AI by ICP
50
50 U
ug/L
EPA 200.7
311111
ESTAFFOR01
7440-70-2
Ca by ICP
0.1
94
mg1L
EPA 200.7
312111
ESTAFFORDI
7440-43-9
Cd by ICPMS
1
1.0 U
ug/L
EPA 200.8
2118111
ESTAFFORD1
7440-47-3
Cr by ICPMS
10
IOU
ug/L
EPA 200.8
2118111
ESTAFFORDI
7440-50-8
Cu by ICPMS
2
4.4
ug/L
EPA 200.8
2118111
ESTAFFORD1
7439-B9-6
Fe by ICP
50
2900
ug/L
EPA 200.7
312111
ESTAFFOR01
Hardness by Calcuiation
1
240
mg/L
SM2340BEPA 200.7
312111
ESTAFFORDI
7440-09-7
K by ICP
0.1
0.49
mg1L
EPA 200.7
312111
ESTAFFORDI
7439-95-4
Mg by ICP
0,1
1.8
mg1L
EPA200.7
312111
ESTAFFORD1
7439-96-5
Mn by ICP
10
18
ug1L
EPA 200.7
312111
ESTAFFORD1
7440-23-5
Na by ICP
0.1
4.3
mg1L
EPA 200.7
312111
ESTAFFORDI
7440-02-0
Ni by ICPMS
10
IOU
ug1L
EPA 200.8
2118111
ESTAFFORD1
7439-92-1
Pb by, ICPMS
10
IOU
ug/L
EPA 200.8
2J18/11
ESTAF50RD1
7440-66-6
Zn by ICPMS
10
10 U
ug1L
EPA 240.8
2/18/11
ESTAFFORDI
A 4 � RECEI
1 iiVVO
MAR 29 UJ I,
MAR 2 A 2011
Laboratory Section=> 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone]
For a detailed d9sCllgilon of the qua9tlar aode5 *afar to T1L:�J_!-_Qrts:,nGd�rv_..W1Avehlw• IfuWsleffinf0llgc]+a� isU9 a La _ualijier Codas shi�ri, rta�nr�enr.o[r,lweprw. Ileblsiag{�1r�flaFhasslsl�
Page 1 of 1

GROUNDWATER FIELDILAB FORM
Location code P5' IN Gwkp'.=-q
County C % ¢,'[fir c�
quad No Serial No. _
Lak Long.
Report To: ARO, FRO, MRO, RRO WaR ,WiRO,
WSRO, Kristen FO. Fed. Trust, Central Off., Other:
5AMPLE YPE
M, Water
❑ Soil
❑ other
❑ Chain of Custody
PRIORITY
. Rc-line
❑ Emergency
Slipped by: Bus, vuRer and Del.. Other. PLT ose:
Cnlle5dor(s): . C i �' :sue Date2 i �10 "time _1" - Qlg srZaseline, Comply
FIELD ANALYSES Owner -i, 6 r�As * rf
PH 40n 51 ". Spec- Cond.•.,_ _ _— at 25°C Location or Site W610 n1
Temp.io UC Odor Description of sampling point
Appearances Sampling Method fc17
Field Analysis By: _ Remarks --
LABORATORY ANALYSES
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALFTY-GROUNDWATER SECTION
0�A
Lab Number
Date Received Z' 151 k Time- g
Rec d By: Nf Frorrl:E3us, uri , Hand Del..
Other:
Data Entry By: _ . Ck:
Date Reported
gmpliaQce, LL►§T,.Pesticlde Study, Federal Trust, Other:
Sample Interval
-
(PYrt nq Ime, air temp_ rtcj
SOD 310 mglL Hiss. Sotids7030b -D& A9-Slwr 465s6 -
- — _ _ - - -- - _ - u�lL Or_Uapochtwine Pcs4cidcs-
COp High 340 mgfL 'Fluoride mgR Rl-Numinurn 46557 u IL -Dr ano hos s PesG ndes
- - - -- -- - -.4 8_-�.��. - -
COO Low 335 mgrL Hardness: Toldsoo - mglL AsArserpc 46551 uylL NiLngen Pesr}cides —
CdiFarm: tar Fecal 31slo 1100ml Hardness (rwn-car>zl 902 - - - —
Cordnrrrr_ MF TOW 31504 nflo ri! Phenols 32730
TOC 5B0 mglL SpedCnt Cond- gs
Tur3idity76 NTU sulfate945
Residue. Suspended 530 mg1L Suicide 745
Oil and Grease
uAlhosl[m
mplL
--mg1L
mglL
p11403
Alkalinity to pH4.5410
-
— mgll.-
-
—
-- --
- --
AliralinilytopH8.3415
mg&
Carbonate 445
+ng7L
NH,, as N 6ii,-
Birarbonate 440
mglL
TM as H 625
Carbon doxide 405
mglL
15:-a
Nok , Noj m, N 630
9' eb
Z'—
CNO& 540
mgll
— -
P. Total as P rAs 7� fl ' r {2+gIL
Ctrcmiurn: Hex 1032
ug1L
Nil.ate (NO, as N) 620 mglL
Color: True 80
Cll
Nitrite (Ng as N) 6IS mglL
Cyanide 720
Lab Comments
-- —
- - -- - —
GW-54 REV, 7703 Fttr aissnlLed Anaiysis su6rriitfiltered sampiearld wrve'DlS- m Wow
Ba-Banurn 46558 uglL -Acid Herbicides - - -
Semiw1a41e Organics
TPH-Diesel Range
Ydahla t7r�anics OA bolt3e} -
TPH-Gasoline Range _
TPH-BTEX Gasoline RaugS­
LAB
USE ONLY
Temperature on arrival (°C):

County: CRAVEN Sample ID: AES68425
River Basin WATPO Number # 11GO134
Re; ort To WAROAP ¢GDate Received: 07JI512011
E v' e Time Received: 08.30
Collector: A CLARK a
Labworks LogInID IiMORGAN
Region: WARD Report Generated: 2/18/11
Sample Matrix: GROUNDWATER Date Repwted: 0211812011
Loc. Type: WATER SUPPLY
E nergency Yes/No VSWD m5
COO Yes/No �]
Loc. Descr.: THOMAS AHED MELINDA AMSZER—
Location ID: APS-N4ww-CRAVE-0185 Collect Date: 0211412011 Collect Time: 12:05 Sample Depth
Result/
Method
Analysis
CAS # Analyte Name RQL
-
Units
qualifier
Reference
Date
11alldeted�by
LAB
Sample temperature at receipt by lab
0.4 C
2115111
HMORGAN
M lC
Colifbrm, MF Fecal in liquid 1
I B2,01 CFU1100ml
APHA9222D-20th
2115M1
MOVERMAN
Coliform, MF Total in liquid 1
1 B2,41 CFU1100ml
APHA922213-20th
2115/11
MOVERMAN
Laboratory Section>> 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
Fora delaiied deg7a Vion of The qualifiacwdes refer la hit.) Ik rta0cdenr.of�j•,ahF.�A ab/ataffinfohechassisi7Dats Dualli ier. Codes <Nii -fiuwsl.ncdenr.orLYw- _ ,,iabl�nraAtechessish
Page 1 of 1

GROUNDWATER FIELD/LAB FORM
Location code l\£S -N-·.L"fv'N -Ct"'c,\I'~" 0\Cj S
County · C: \' ~ X t c'\
Quad No ____ _ Serial No .. ______ _
Lat _______ _ Long . _______ _
Report To: ARO FRO MRO RR~ WiRO
SAMPLE TYPE
tg Wi!ler
0 Soil
D Other
0 Chain of Custody
SAMPLE PRIORITY
m .R_ouline
D Emergency
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY0 GROUNDWATER SECTION
8 V\G/0(34 ~
Lab Number ______ ......,..:6-=--0-=---...ci_y_,_i'---S"-------
Date Recei~~ 2,i 16-· I Time: 'i: 3'L)
Rec'd By: ~ Frorn:Bus. ~-Hand Del..
Other: _________________ _
Data Entry By : ______ _ Ck : ____ _
WSRO, Kinston FO, Fed. Trus~ Central Off., Other._________ Date Reported .· _____________ _
Shipped by: Bus, ~Han9,_Del., Other: ____ --,---1-.-------,=-Purpose:
Collector(s): A, C.\°'~\\ 1 \\, S1p.q Date -;2..\,11\20\\ Time\~~ tl°S"'Q-. Baseline, Comiilcl,irt. Comp~anceiJt-UST, Pesticide Study, Federal Trust, Other : _____ _
FIELDANALYSES r . ~ \ Owner 1homti~..,;. nH)11)t\1, ~Le~one)
. pH ◄00 s .... 5 . Spec. Cond."'-_____ at 25°C Locati_o_-. n-_ o-r-'-S.:..:it~e =g-'-.-_-s~--, o~_ .........:.ro:..:,.--r')=-=-.~~:;.-5~_. '-'-cf,:::~:e..\,:::,:£-i-~-:-.... N,-,--~--8,........t-,-n-,-N~c,--.,---------
T emp. 1o °C Odor_____________ Descnption of.samRhng po111t.._.___,$;....,._· '-'r:,-=->--+P.uli..c•:<>~~,.1,_a..""~¼---'-r,'--f.___~~ .... tl. ....... '\ ___ :--_-:--:---:---------
Appearance ______________________ Sampling Method G'('c..X) Sample Interval. _______ _
Field Analysis By: __ --:---------------Remarks S c.~~·vs te,'J,ij D '0 19~~-~{i~'tUcH''h bi\-\\(!::, l.ABORA TORY ANALYSES (Pumping time , air temp .. elc.J
BOO 310 mg/L Diss. Solids 70300 mgll. Ag-Silver 46566 UQ/L Oroanochlotine Pesticides
COD High 340 mg/L Fluoride 951 mg/l. Al-Alumim.m 46557 UQ/L -0 ,:llanoehosehorus Pesticides
CODLow335 mg/L Hardness: Total 900 mg/\_ As,,Arsenic 46551 uo/l Nitrooen Pesticides
"X_ Colif01JT1 : MF Fecal 31616 /100ml Hardness (noll-Cllrb) 902 mg/l Ba-Barium 46558 ug/L Ac.id Herbicides
'x ·Coliform: MF Total 3150-4 1100ml Phenols 32730 ug~ Ca-Calcium 46552 mg/L PCBs
TOC 680 mg/l Specific Cond. 95 uMhos/cm Cd-Cadm ium 46559 uo/l.
Turbidity 76 NTU Sulfate 945 mgll. Cr-Chromium 46559 UQ/L
Residue. Suspended 530 mg/l Sulfide 745 mgll Cu-Copper 46562 ug/L
Fe-Iron 46563 ug/L Semivolatile Organics
m and Grease mg/L Hg-Mercury 71900 ugll TPH-Oiesel Ranoe
pH 403 units K-Polassium 46555 m Q/L
Nkalinity lo pH 4.5 410 mgll · Mg-Magnesium 46554 mg/L
~kalinity lo pH 8.3 415 mg/L Mn-Manganese 46565 ug/L Volatile Oraanics f',/OA bottle)
Carbonate 445 mg/l NH, as N 610 mgll Na-Sodium 46556 mall TPH-Gasoline Range
Bicarbonate 440 mg/L TKN as N '625 mg/L Ni-Nickel ua/L TPH-BTEX Gasoline Range
Carbon dioJdde -40S mg/l N02 + NO, as N 630 mg/L Pt>-Lead 46564 ua/L
Chloride· 940 mg/l P: Total as P 665 mgll Se-Selenium ug/L
Chromiim: Hex 1032 Ug/l Nitrate (No, as N) 620 mg/l Zn-Zinc 46567 ugll
Color: True BO cu
Cyanide720
..
mg/l
Nitrite (NC½ as N) 61 S mg/l LAB USE ONLY ({), 4 Temperature on arrival (°C):
I labC~ments.~-----------------------------------------------------
GW-5-4 REV. 7103 For DissOlved Analysis-submitfiltere<I sample and write ·01s· in block.
Date: March 1, 2011
To: John McCray, DWQ/APS/UIC Program
From: Allen Clark, DWQ/APS Washington Regional Office
Subject: Injection F·acility Inspection Report and Compliance Inspection Reports
Permit# WI0700195, Thomas and Melinda K. Amsler
Enclosed is an Injection Facility Inspection Report (updated) and Compliance Inspection Reports for this
permitted facility's (Type 5A7) newly constructed injection well and supply well. The lab results of the
water samples taken on February 14, 2011 will be forwarded to you as soon as they are received.
I have updated this permit in BIMS (as much as possible) in regards to the actual location and
construction specifics of both the injection well and the supply well.
Q'
North Carolina Department oiEnvironment and Natural Resources
Division of Water Quality -Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700195
DATE OF INSPECTION: February 14, 2011 and February 23, 2011
INSPECTOR: Allen Clark; WaRO
NAME OF PERl\ffTTEE(S): Thomas and Melinda K. Amsler
MAILING ADDRESS OF PERMITTEE: 4510 Moncks Court, New Bern, NC 28562
PHYSICAL ADDRESS OF SITE (if different than above) ________________ _
PERSON MET WITH ON-SITE: Mrs. Melinda K. Amsler; Tele no. [phone]
WELL(S) STATUS:
__ Existing and operating Class V Well
~E-c.:1v:.1.,; , u~ , ~ : Jv;..,) __ Existing well proposed to be converted to Class V well
~Newly constructed (Type 5A7)
AC w ---~-10~.
MAR O 2 2011
Injection Well Location: Latitude: 35.0861 N : Longitude: -77.09 W
Supply Well Location: Latitude: 35.0865 N : Longitude: -77.0899 W
Distance of well to property boundaries: 10 feet In jection well : 15 feet Supp ly well
Distance of well from foundation of house/structure: 32 feet In jection well : 48 feet Supply well
Distance of well from septic tank/field (if present): NA
Distance of well to other well(s) (if present): The Injection Well is approximately one-hundred twenty-five (125)
feet from the Supply Well.
Distance to other sources of pollution: ___________________ _
Flooding Potential of Site: _ high _moderate X low
Comments: The proposed location of the injection well and the supply well were changed, or switched, with
each other when the wells were constructed (but the locations are not a problem). See Comments/Notes on page
3 for additional well inspection/ site information.
Injection Facility Insp. Report (Rev. Sept 2009) Page I of 3 Pages
AL'
Approximate Property Lines
--- Approximate Sewer Lines
_'�j Qt� !❑ YY zlk Lc r;.G-�1L, (3�.' Ylam �}B y� � N
Notes,
1, Subject properly and surrounding area are serviced by public sewer and wafer services.
Adapted from Goegle Earth and Craven County G I S Map, October 201 Q-
DTLE. GIS MAP
r-kc4 Keeiource Mana:�emcnt PC 4510 MONCKS COURT
7kL(FU. 130X 682. Homos eccl DA4a_ J05: SCALE: TE: DFA,WIi i B910) 270-2919 FAX 270-298a I AMSler 1 " = b0' 1 1 C1'e-' 71i 0 ❑NH
DRAW SKETCH OF SITE ABOVE (Show property boundaries, buildings, other wells, septic tanksldrain 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
Dat~ Constructed: Iniection Well 12/22/2010: Supp lv Well 12/21/2010
Well Contracting Company: A pp lied Resource Management, P .C.
Well Driller Name: Jamie L. Canter
NC Well Cert. No.: 3253-A
Address: 257 Transfer Station Road. Ham pstead . NC 28443
Telephone No.: =(9---=l ..ca.O.,_) 2=-7~0~-2=9'----'1=9 _____ ; Cell No.:
Email Address: -----------
Tot a I Depth: In jection well 80'; Supply well 68'
Casing:
Depth: In jection well 60': Supply well 48' Diameter: 4 inch; Type (PVC)
Grout:
Depth: In jection well 25 ': Supply well 25' Type: Bentonite Placement method: Pumped
Well ID Plate Present (Y): Heat Pump ID plate present (Y or N): Not evaluated
Influent spigot (Y): Effluent spigot (Y):
Well Sampled? (Y):
If Yes, Lab Sample ID numbers: _______________ _
Static Water Level: 1
Injection Information (if applicable):
Injection Rate:? ______ GPM
Injection Pressure:? ______ PSI
Injection Volume: ? _____ GPD
Temperature-Summer: ? ____ F 0
Temperature-Winter: ? ____ F 0
Comments/Notes: Met on-site with p ermit/ pro perty owner Mrs. Melinda K. Amsler on February 14 , 2011. to
sam · ect the newl constructed in' ection well and su · rocess of this T I e
5A7 geothermal s vstem. No problems were observed with the ins pection of the in jection well. The ins pection of
the su pply well revealed a threaded s pi got with no backflow p reventer. The su ppl y well also did not have a
threadless sam pling tap. The well contractor was notified b y phone of the problems with the supp l well. A
February 23 . 2011 re-ins pection revealed that a threadless sampling tap had been installed on the supp ly well. as
well as a backflow preventer on the threaded s pi got. Other than the house. no other p otential pollution sources
were observed.
Injection Fac ili ty ln sp. Report (Rev . Sept 2009 ) Page 3 of 3 Pag es
1. WELL CONTRACTOR:
Mamie L. Canter
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Camlwa Department ofEnvironmeut and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3253A
Well Contractor {Individual} Name
Applied Resource Management. P.C.
Weil Contractor Company Name
257 Transfer Station Rd.
Street Address
Hamy-stead NC _ 28443
City or Town State Zip Code
9{ 1 o , 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(it applicable) W 10700195
SITE WELL ID #(if applicable) Injection Weil
V k
d. TOP OF CASING IS -1,5 FT. Above Land Surface'
'Top of casing terminated allor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e, YIELD (gpm): fiO+ - METHOD OF TEST AirI t
f. DISINFECTION: Type HTH ` Amount
g. WATER ZONES (depth):
Top Bottom
Top
Top Bottom
Top
Top Bottom
Top
7. CASING: Depth Diametor
Top +1.5 Bottom_60Ft. 4"
Top Bottom Ft.
Top Boiiom Ft,
3. WELL USE (Check One Box) Monitoring ❑ MunicipallPubfic Q ; B. GROUT'. Depth Material
IndusiriallCommerclal 0 Agricultural ❑ Recovery ID Injection ❑ : Top 0 Bottom 25 Ft._ Bentonite
Irrigation❑ CJther {(list use) Geothermal Top Bottom Ft.
DATE DRILLED 12/22/10 Top Bottom Ft.
4. WELL LOCATION:
4510 Moncks Court
(Street Name, Ndrnoers, Community, Subdivision, Lot No., Parcel, ZlpCode)
cITY: New Bern COUNTY Craven
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
OSiope pvailay OFlat ]Ridge ❑other__
LATITUDE 35 e 5 • 11.000 " OM$ OR D❑
LONGITUDE 77 = s ' 23.OWO n OMS OR DD
LalitudeAongitude source- v3ps ❑Topographic map
flocafron of we11 must be shown on a USGS tops map andaffached to
this form rf not using GPSj
S. FACILITY {Name of the business where the well is located-}
FaciRy Name Facillty ID# {if applicable}
Street Address
City or Town State Zip Code
Thomas & Kay Amsler
Contact Name
_45JO Moncks Court
Mailing Address
NeW Bern NC 28562
City or Town State Zip Code
(52 6afi-5U7
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH:30'
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO EV
c. WATER LEVEL Below Top of Casing. ' FT
tUse "+° If Above Top of Casing)
Bottom
Bottom
Bottom
Thickness/
Weight Material
sch40 PVC
Method
Tremm ie
9. SCREEN' Depth Diameter Slot Size Material
Top 60 Bottom 80 Ft_ 4 in- .010 in. PVC
Top Bottom Fl. in. in.
Top Bottom Ft. in. in.
10, SANDlGRAVEL PACK:
Depth Size Material
Top 55 Bottoms Ft. coarse sand
Top Bottom Ft.
Top Botloln Ft.
11. DRILLING LOG
Top Bottom
0' 1 1 ❑'
'k ' 1 30'
30' 155'
1
f
1
1
1
1
r
12. REMARKS:
Formation Description
Tan sand
_Mg�ju n Grained Sand
Grgy clay
t.i estop
1 DD HEREBY CERTrFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C. CONS' RUCTION STANDARDS, AND THAT A COPY OF THIS
RPROVIDECTOT WELLOWNER.
51GP-r-`TLF OF Ctr. IFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Information Processing, Rev 109
Y p Y ' 9� Rev 2109
1817 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]

3 1 !' oNRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Departmeut of Environment and Natural Resources- Division of Water Quality S';
• ":•' : - WELL CONTRACTOR CERTIFICATION # 3253A
1. WELL CONTRACTOR:
Jamie L. Canter
Well Contractor (Individual) Name
Apolied Resource Manaciement-P.C.
Well Contractor Company Name
257 Transfer Station Rd -
Street Address
Hampstead NC 28443
City or Town State Zip Code
r 9191 0 13 27 0-2919
Area code Prone number
2, WELL INFORMATION.
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMITIi if applicable) WI 0700195
SITE WELL iD *(ir applicable) Pumping- elI
3. WELL USE (Check One Box) Monitoring 0 MunicipallPL"ic ❑
Industrial/Cornmefcial Gl Agricultural ❑ Recovery [7 Injection n
irrigationp Other N((list use) Geothermal
DATE DRILLED 12/21/10
4. WELL LOCATION:
4510 Moncks Court •
(Sveet Name, Numbers, Communily, SUtidivislon, Lot No., Parcel, Zip Cade)
CITY' New Bern COUNTY Craven
TOPOGRAPHIC 1 LAND SETTING: (check appropriate box)
pSlope 1[3Valtey I/Flal ❑Ridge ❑Other -
LATITUDE 35 " 5 9,0000 " DIMS OR DO
LONGITUDE 77 = 5 4 23,0000 " pMS OR DD
LaNudellongilude source W3PS Ofopographic map
(10caflon of well most be shower on a USGS topo map andaftached to
this form if not using GPS)
S. FACILITY (Name of the business where the well is located.)
Facility Name Faculty lD# {f applicable)
Street Address
City or Town Stale Zip Code
Shames & Kay Amster
Contact fame
4510 MnnCks Cotlri __-
Mailing Address
New._rn Nc 28562
City or Town State Zip Code
{52 } 636-5857
Area erode Phone number
6. WELL DETAILS:
a. TOTAL DEF'TH:,68, TT
b. DOES WELL REPLACE EXISTING WELL? YES D NO p/
d. TOP OF CASING IS �� FT Above Ladd Surface'
'Top of casing terminated allor below land surface may require
a variance in accordance with 15A NCAC 2C .0f 18.
e. YIELD (gpri): 60+ METHOD OF TEST Alflift
f, DISINFECTION: Type HTH Amount lQa j 0 fl
g. WATER ZONES (depth),-
Top- Bottom Top Bottom
Top Bollom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth D-rameter Weight Material
Top +1.5 Sottom 4FL 4" srh40 PVC
Top Bottom Ft.
Top Bottom FI.
; 8. GROUT- Depth Material Method
Top 0 Bottom 25 Ft. Bentonite Tremmie
Top Bottom Ft
Top Bottom Fl.
9. SCREEN: Depth Diameter Slot Size Material
Top 48 Bottom 88 Ft- 4 in, .010 In. PVQ _--
Top Bottom Ft. in in_
Top sottom Ft in- In.
10. SANDIGRAVEL PACK:
Depth
Sire Material
Top 43 Bottom fib
Ft- Coarse sand
Top Bottom
R.
Top Bottom
Ft.
11. DRILLINC LOG
Top Bottom
Formation Description
0, 1 10,
Tan sand
0! 48'
Medium Grained Sand
48' i 73'
LiMestone
1
1
1
1
. 1
-
r
; -
i'
12- REMARKS.
I DO HEREBY CERTIFY `*HAT'iHIS WELL WAS CON STRUC7ED IN ACCORDANCE WITH
1M NCAC 2C, WELL CONSTRLlCTiON STANDXROS, AHD ThAT A COPY OF THIS
RECORD Ho'" PRnVIM070TH OWNER.
12121/1�
. IG R Rt _,r CERTI 1E0 WELL CONTRACUDATE
c. WATER LEVEL Below Top of Casing FT Mamie L. Canter
(Use "+" if Above Top of Casing) PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Information Processing. Form 109
Y P Y - �� Rev �los
1617 Mail Service Center, Raleigh, NO 27699-161, Phone : [phone]

WASHINGTON REGIONAL, OFFICE -APS SECTION - PHOTOGRAPHIC RECORD
Site Name:
Amsler
Permit Numbe WI0700195
Site Location 4510 Moricks Court
City/County: New Bern/Craven
Photographer:
Photographer:
A" Clark
-J 1
!
A" Clark
Date:
Date:
,
2/14/2011
s•
2/14/2011
Photo Location.
.,
Photo Location: -• �-
3-
Front Yard
—
MW
Front Yard
Photo Direction:
Photo Direction:
North
East
Comments:
Comments:
Injection well+
MSupply well in
e • , �:i:
Injection well w
a
background
Photographer:
Photographer:
�t
A" Clark
A. Clark
Date:
Date:
2/23/2011
2/23/2011
v r,•r-
Photo Location;
Photo Location:
r-
Backyard
Backyard
-
A r.
Photo Direction:
Photo Direction:
North
North
Comments:
r .•�
+�
Comments:
r.
Supply wells:
�c
.� .i "� '
Supply well

Compliance Inspection Report
Permit: WI0700195
SOC:
County: Craven
Region: Washington
Effective: 12/08/10 Expiration: 11/30/15
Effective: Expiration:
Contact Person: Melinda K Amsler Title:
Directions to Facility:
Owner: Thomas F Amsler
Facility: Thomas F Amsler SFR SA?
4510 Moncks Ct
New Bern NC 28562
Phone: [phone]
From WaRO take US 17S to US ?OW in New Bern, take exit 416 turn L, take Country Club Rd ~2 .?mi turn R, take Country Club Dr
~0 .9mi turn L, the p~operty is the second driveway on the left on Moncks Ct.
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Penn its:
Inspection Date: 02/23/2011
Primary Inspector: Allen Clark
Secondary lnspector(s):
Entry Time: 11 :30 AM
Certification: Phone:
Exit Time: 11 :55 AM
Phone:
Reason for Inspection: Follow-up Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well (SA?)
Facility Status: ■ Compliant D Not Compliant
Question Areas:
■Wells
(See attachment summary)
Page : 1
�"e I
Approximate Property Lines
Approximate Sewer Lines
"FP1'ti well l.� c��c� n (49' -fr-r"
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
Adapted from Google Earth and Craven County OIS Map, October 2010.
TITLE. GIS MAP FIGURE:
-Fled Resource Mana ernent E�e __ 4510 MONCKS COURT
x 2. Hampsead, 94 JOB: SCALE: ]DATE: DRAWN BY;
(9101 270-29 9 Fax 27❑ 2�aa Amsler 1 1" = 60' 1 10/27/10 ❑NH

WASHINGTON REGIONAL OFFICE - APS SECTION - PHOTOGRAPHIC RECORD
Site Name:
Amsler
Permit Numbe WI0700195
Site Location 4510 Moncks Court
City/County: New Bern/Craven
Photographer:
Photographer ■ •
A. Clark
A- Clark
r R�r
II
Date:
Rate:
211412011
' ,
2/14/2011
Photo Location:
Photo Location:
Front Yard
y
-
Front Yard=' 411100111r 1
_ 'e. t r
Photo Direction:
_
Photo Direction:
North
Fast_
,4�r.- :_.
Comments
Comments:
Injection well
y
wlSupply well in
�-
��, S' lti-tr.: t '';r
Injection well is
background
• _. `� - . ..
'�c =,,. • ��err`.�.
-
Photographer:
Photographer:
A. Clark
ri - -'
xr
A. Clark
Date:
Date.
2/23/2011
l
2/23/2011
o
Photo LocaVon-.
Photo Location:
Backyard
A
Backyard
�'�
Photo Direction:
._
Photo Direction:
North
North
�^
Comments:
y
Comments:
Supply well i
•f F
Supply well
v
, L V

Permit: WI0700195
Inspection Date: 02/23/2011
Inspection Summary:
Owner. Facility: Thomas F Amsler
Inspection Type: Compliance Evaluation Reason for Visit: Follow-up
On February 23, 2011, WaRO DWQ staff Allen Clark and Robbie Bullock conducted a follow-up site inspection of the
supply well for the geothermal heating (Type 5A7) system . The follow-up inspection was to ensure that problems found
on the supply well from a Feb 14 , 2011 inspection had been corrected .
On February 14, 2011, WaRO DWQ/APS staff Allen Clark and Randy Sipe conducted well inspections and sampled the
newly constructed injection well and supply well. No problems were observed with the inspection of the injection well.
However, the inspection of the supply well revealed a threaded spigot with no backflow preventer. It also revealed that
the supply well did not have a threadless sampling tap . The well contractor was notified by phone of the problems with
the supply well .
This February 23, 2011 re-inspection revealed that a threadless sampling tap had been installed on the supply well and
that a backflow preventer had been added (installed) onto the threaded spigot.
No other problems were observed on the day of this re-inspection .
Allen Clark
DWQ/APS
WaRO
Page : 2
Permit. VVID700195 Owner - Facility; Thomas F Amsler
inspection Date: 02/23/2011 Inspection Type. Compliance Evaluation Reason for Visit. Follow-up
BIMS015027 S �+ , �s, wQ1\
Location 1
Yes No NA NE
Distance from septic tank & drainfield (feet)
Distance from other waste disposallcoltection (feet)
Comment
Property is on public water and sewer.
Distance from other pollution source (feet)
Comment
Supply well is located 48 feet from house.
Is well location subject to flooding?
❑ ■ ❑ ❑
Minimum distance to property boundary (it)
Comment: Supply (irrigation) well locatation is not subject to flooding, or is at a very
low risk of flooding,
Casing
Yes No NA NE
Type
PVC
Depth (ft b.l.$) (Decimal range, e.g 15.5 to 25.5 ft)
0
48
Weight/thickness
Height (A1.S) 1
Comment:
Grout Yes No NA NE
Type
13entonite Grout
Thickness
0
Depth (Decimal range, e.g. 15.5 to 25.5 ft) 25
Comment:
Screens Yes No NA NE
Screened or Open Borehole Completion?
Screenedlopen borehole interval (ft b.1.$) 48
60
Comment:
ID Plate Yes No NA NE
Page: 3

perinnit: W107001 °s Jwnef - Facility: Thwnas F Arrm!er
Inspection Date: 0212312411 Inspection Type: Compliance Evaluation
Reason for Visit: Folk+ -up
11) PWe present & properly completed?
■
1100
Well Contractor indicated on ID Plate?
■
n
n
❑
Comment:
Wellhead Completion
Yes
Na
NA
NE
Access port present?
■
n
n
❑
Spigot present?
■
❑
❑
❑
Suction Line meets standards?
■
❑
❑
❑
Comment:
Tee filet} meets standards?
❑
❑
■
❑
if naturally Bowing well, is flow valved?
❑
❑
■
❑
Vent meets standards?
■
❑
❑
❑
Watertight pipe entry meets standards?
■
❑
❑
❑
Well Entry meets standards?
■
❑
❑
❑
Pitless adaptor (if used) meets standard,-,?
❑
❑
■
❑
We!i enclosure meets standards?
■
rl
❑
Q
1nfuent (water source) sampling port present and labeled?
■
❑
n
n
Effluent (injected fluid) sampling port present and labeled?
❑
❑
■
❑
Disinfection
Yes
No
NA
NE
Disinfection m compliance with standards?
■
n
❑
n
Describe disinfection if observed
Comment: According to GVV-1 Well Construction Record for this Supply (irrigation)
Well, disinfection was accomptished by using HT with 3 grams @10%.
GW-1130 Construction Record Yes No MA NE
Well constructionlabandonment record submitted? ■ 0 D Q
Comment:
BIMS012359
Location Yes Ns NA NE
Distance from septic tank & drainfield (feet)
Distance from other waste disposal/collection (feet)
Comment
Property is on public water and sewer.
Page: 4

Permit: \11!!0700195 Owner. Fac!!ity: Thomas F Amsler
Inspection Date: 02/23/2011 Inspection Type: Compliance Evaluation
Distance from other pollution source (feet)
Comment
Injection well is located 32 feet from house.
Is well location subject to flooding?
Minimum distance to property boundary (ft)
Comment:
flooding.
Injection well location is not subject to flooding, or is at very low risk of
Casing
Type
Depth (ft b.l.s)
WeighUthickness
Height (A.L.S)
Comment:
Grout
Type
Thickness
(Decimal range, e.g. 15.5 to 25.5 ft)
Depth
Comment:
(Decimal range, e.g. 15.5 to 25.5 ft)
Screens
Screened or Open Borehole Completion?
Screened/open borehole interval (ft b.l.s)
Comment:
ID Plate
ID Plate present & properly completed?
Well Contractor indicated on ID Plate?
Comment:
Wellhead Com pletion
Access port present?
Spigot present?
Reason for Visit: Follow-up
0 ■00
10
Yes No NA NE
PVC
0
60
Yes No NA NE
Bentonite Grout
0
25
Yes No NA NE
PVC
60
80
Yes No NA NE
■ODO
■ODO
Yes No NA NE
■000
■ODO
Page: 5
Permit: WI0700195
Inspection Date: 02/23/2011
Suction Line meets standards?
Comment:
Tee Oet) meets standards?
Owner -Facility: Thomas F Amsler
Inspection Type: Compliance Evaluation
If naturally flowing well, is flow valved?
Vent meets standards?
Watertight pipe entry meets standards?
Well Entry meets standards?
Pitless adaptor (if used) meets standards?
Well enclosure meets standards?
lnfuent (water source) sampling port present and labeled?
Effluent (injected fluid) sampling port present and labeled?
Disinfection
Disinfection in compliance with standards?
Describe disinfection if observed
Comment: According to GW-1 Well Construction Record for this Injection Well,
disinfection was accomplished by using HTH with 3 grams @10%.
GW-1/30 Construction Record
Well construction/abandonment record submitted?
Comment:
Reason for Visit: Follow-up
DO ■□
DO ■ D
DO ■ D
■ ODO
■ DOD
■ 000
D 0 ■ 0
■ ODO
DD ■ D
•□□□
Yes No NA NE
•□□□
Yes No NA NE
•□□□
Page : 6
Compliance Inspection Report
Permit: WI0700195
SOC:
County: Craven
Region: Washington
Effective: 12/08/10 Expiration: 11/30/15
Effective: Expiration:
Contact Person: Melinda K Amsler Title:
Directions to Facility:
Owner: Thomas F Amsler
Facility: Thomas F Amsler SFR 5A7
4510 Moncks Ct
New Bern NC 28562
Phone: [phone]
From WaRO take US 17S to US ?OW in New Bern, take exit 416 turn L, take Country Club Rd ~2.7mi turn R, take Country Club Dr
-0.9mi turn L, the property is the second driveway on the left on Moncks Ct.
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 02/14/2011
Primary Inspector: Allen Clark
Secondary lnspector(s):
Dwight R Sipe
Entry Time: 11 :00 AM
Certification: Phone:
Exit Time: 12:15 PM
Phone:
Phone:
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Injection Heating/Cooling Water Return Well (5A7)
Facility Status: 0 Compliant D Not Compliant
Question Areas:
■Wells
(See attachment summary)
Page: 1
Permit: WI0700195
Inspection Date: 02/14/2011
Inspection Summary:
Owner• Facility: Thomas F Amsler
Inspection Type: Compliance Evaluation Reason for Visit: Routine
On February 14, 2011, as part of the permit process for this Type 5A7 geothermal system, WaRO DWQ/APS staff Allen
Clark and Randy Sipe met on-site with permit/property owner Mrs. Melinda K. Amsler, to conduct an inspection and to
sample the newly constructed injection well and supply well. No problems were observed with the inspection of the
injection well. The inspection of the supply well revealed a threaded spigot with no backflow preventer. The supply well
also did not have a threadless sampling tap. The well contractor was notified by phone of the problems with the supply
well. A February 23, 2011 re-inspection revealed that a threadless sampling tap had been installed on the supply well. A
backflow preventer had also been installed on the threaded spigot. Other than the house, no other potential pollution
sources were observed.
Allen Clark
DWQ/APS
WaRO
Page: 2
Compliance Inspection Report
Permit: WI0700195
SOC:
County: Craven
Region: Washington
Effective: 12/08/10 Expiration: 11 /30/15
Effective: Expiration:
Contact Person: Melinda K Amsler Title:
Directions to Facility:
Owner: Thomas F Amsler
Facility: Thomas F Amsler SFR 5A7
4510 Moncks Ct
New Bern NC 28562
Phone: [phone]
From WaRO take US 17S to US 70W in New Bern, take exit 416 turn L, take Country Club Rd ~2 .7mi turn R , take Country Club Dr .
~0 .9mi turn L , the pr_operty is the second driveway on the left on Moncks Ct.
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 11 /24/201 O
Primary Inspector: Allen Clark
Secondary lnspector(s):
Dwight R Sipe
Entry Time: 10:15 AM
Certification: Phone:
Exit Time: 11 :00 AM
Phone:
Phone:
Reason for Inspection: Routine Inspection Type: Reconnaissance
Permit Inspection Type: Injection Heating/Cooling Water Return Well (5A7)
Facility Status: ■ Compliant O Not Compliant
Question Areas:
■Other
(See attachment summary)
Page: 1
Permit: VV!0700195 Ov,ner -Facmtt;: Themas F .~,ms!er
Inspection Date: 11 /24/201 O Inspection Type: Reconnaissance Reason for Visit: Routine
Inspection Summary:
On Wednesday, November 24, 2010, WaRO DWQ/APS staff Allen Clark and Randy Sipe met on-site with permit and
property owner, Mrs. Melinda Amsler, to conduct a site vist of this permitted facility. There were no problems observed at
·this site in regards to the approval to proceed with the construction of an injection well for the permitted Type 5A7
geothermal heating system.
Allen Clark
WaRO
Other
Comment:
Yes No NA NE
Page: 2