WI0700308_GEO THERMAL_20130212

NA 5A1
MCDEMR
North Carolina Department of Environmentand Natural Resources
Division of Water Quality
~
Pat McCrory
Governor
Timothy & Laural Washburn
518 Hollywood Boulevard .
Havelock, North Carolina 28532
Charles Wakild, P.E.
Director
Aquifer Protection Section
February 11, 2013
SUBJECT: Groundwater Sampling Results 5 A --::/
5A7 UIC Permit No. WI0700308
Issued to Timothy 8c Laural Washburn
Havelock, Craven County, North Carolina
Dear Mr. and Mrs . Washburn:
John E. Skvarla 111
Secretary
RECEIVEDIDENR/DWQ
FEB 12 2013
Aquifer Protection Section
On January 8, 2013, staff from the Washington Regional Office (WaRO) of the Aquifer Protection Section collected
samples of the influent (supply well) and effluent (injection well) from your geothermal heat pump system. The samples
were analyzed for metals, nutrients, and other inorganic constituents by the Division of Water Quality 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 two constituents were detected above state
groundwater standards in the samples from your system:
Parameter Units NC Groundwater Standard Results
Iron ug/L 300 2600 (supply well)
2700 (injection well)
Manganese ug/L 50 87 (supply well)
88 (injection well)
The exact source of these exceedances is unknown; however, iron and manganese exceedances in groundwater
are often due to naturally occurring conditions. While these exceedances should not affect the operation of your
geothermal heat pump system, it is recommended before using the water from this well for personal consumption that you
consult with the Craven County Environmental Health Department. If you have any questions regarding the sampling
results or your permit, please feel free to contact me at [phone] .
:8:'1<11~ ,;~
Dwight Randy Sipe ':f}
Hydrogeologist
Aquifer Protection Section
Attach me~
cc: v{r.ic Smith -APS Central Office
Mina Shehee -(Medical Evaluation & Risk Assessment, Occupational & Environmental Epidemiology, Dept. of Health and
Human Services, 1912 Mail Service Center, Raleigh, NC 27699-1912)
Craven County Environmental Health Department
WaRO
North Carolina Division of Water Quality
943 Washington Square Mall
Washington, NC 27889
Internet: www.ncwaterguality.org
Phone: [phone]
FAX [phone]
An Equal Opportunity/Affirmative Action Employer -50% Recycled/10% Post Consumer Paper
No~l,,.c 1· · 01 u1 aro 1na
Jvnturall!f
Parameter Fecal Coliform
units CFU/100ml
NC MCL and/or EPA Standard NCMCL=< 1
Influent Sample Results < 1
Effluent Sample Results < 1
Parameter Nitrate+ Nitrite
units mgflas N
NC MCL and/or EPA Standard NC MCL= 11
EPA PDWS = 11
Influent Sample Results <0.2
Effluent Sample Results <0 .2
Parameter Chromium, Cr
units µgfl
NC MCL and/or EPA Standard NC MCL= 10
EPA PDWS = 100
Influent Sample Results < 10
Effluent Sample Results <10
Parameter Sodium, Na
units mg/L
NC MCL and/or EPA Standard NS
Influent Sample Results 7 .5
Effluent Sample Results 7 .5
NC DIVISION OF WATER QUALITY
LABORATORY ANALYTICAL RESULTS
5A7 GEOTHERMAL UNDERGROUND INJECTION CONTROL (UIC) WELL
PERMIT NO .: WI0700308
PERMITTEE(S): Timothy & Laural Washburn
SAMPLE COLLECTION DATE : 01/08/2013
Total Coliform Total Dissolved Solids Chloride, Cl
CFU/100ml mg/L mg/L
NC MCL= 1 NC MCL= 500 NC MCL= 250
EPA SOWS = 500 EPA SOWS= 250
< 1 273 7.8
< 1 268 7.8
Hardness as CaCO3
Nitrite (by Calculation) • Aluminum, Al
mgflas N mg/L as CaCO3 µg/L
NC MCL= 1 NS NS
EPAPDWS= 1 EPA SOWS= 50 to 200
< 0.01 219 < 50
< 0.01 229 < 50
Copper, Cu Iron, Fe Potassium, K
µgfL µg/L mgfL
NC MCL= 1000 NC MCL= 300 NS
EPA SOWS = 1000; PDWS = 1300 EPA SOWS = 300
<2.0 2600 0 .92
2 .3 2700 0 .9
Nickel, Ni Lead, Pb Zinc, Zn
µg/L µg/L µg/L
NC MCL= 100 NC MCL= 15 NC MCL= 1000
EPAPDWS = 15 EPA SOWS= 5000
<2 .0 <2 .0 <10
<2 .0 <2 .0 <10
Fluoride, FL
mg/L
NC MCL= 2
EPA PDWS = 4.0
<0.2
<0.2
Arsenic, As
µg/L
NC MCL= 10
EPA PDWS = 10
< 2 .0
< 2.0
Magnesium, Mg
mg/L
NS
1.6
1.7
pH (field)
units
NC MCL = 6.5-8.5
EPA SOWS= 6.5 to 8.5
7
6 .5
NC MCL = North Carolina Maximum Contamination Limits per 15A NCAC 2L . 0200
EPA PDWS = Environmental Protection Agency Primary Drinking Water Standards
EPA SOWS = Environmental Protection Agency Secondary Drinking Water Standards
NS = No Standard
* Calculation performed by WaRO
Sulfate, SO4
mg/L
NC MCL= 250
EPA SOWS= 250
<1 .0
<1.0
Calcium, Ca
mgll
NS
.85
89
Manganese, Mn
µg/L
NC MCL= 50
EPASDWS=50
87
88
'N(' (LY144) 1:hnr ry Sec__ rn_n (Reslifts
Cbunty: BEAUFORT
River Basin
Report To WAROAP
Collector: A SCARBRAUGH
Region: WARD
Sample Matrix: GROUNDWATER
Loc. Type: WATER SUPPLY
Emergency Yes/No
COC Yes/No
it WA7 Sample ID: AB91343
O�.TQ PO Number # 13G0012
C.
+ >< r Date Received: 01108/2013
Final Report
Visits❑
Time Received: 08:00
Labwarics Login1D HMORGAN
Final Report Date 2/6/13
Report Print Date: 02/07/2013
Loc. Descr.: TIMOTHY AND LAUREL WASHBURN 518 HOLLYWOOD BLVD- INFLUENT
Location ID: NIWWCRAVE 700308 Collect Date: 01/08/2013 Collect Time: 10:25 Sample Depth
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes_
CAS # Analyte Name
_AB
PQI_
Result/
Qualifier
Sample temperature at receipt by lab 2.3
Units
a�+
Reference Date
Method Analysis Validated by
119113 HMORGAN
VI IC
Colifarm, MF Fecal in liquid 1 1 62 Q1 CFU1100m1 APHA9222D-20th 1/9/13 ESTAFFORD1
Coliforrn, MF Total in liquid 1
B201 CFU11oom1 API-IA9222B-20th 1/9/13 ESTAFFORD1
NET
Ion Chromatography
TITLE mg/L EPA 300.0 1/23/13 CGREEN
Chloride
0.5 7.8 mg/L EPA 300.0 1/23113 CGREEN
Fluoride 0.2 0.2 U mg/L EPA300.0 1123113 CGREEN
Sulfate 1.0 1.0 U mg/L EPA 300.0 1/23/13 CGREEN
Total Dissolved Solids in liquid 12 273 mg/L APHA2540C-18TH 1/11/13 CGREEN
NUT
NO2+NO3 as N in liquid
0.02 0.02 U mg/L as N Lac10-107-04-1-c 1/9/13 CGREEN
mg1L as N Lachat107-04-1-c 1/11/13 CGREEN
Nitrate as N in liquid
0.02 0.02 U
Nitrite as N in liquid
0.01 0.01 U mg/L as N Lachatl07-04-1-c 1/9/13 CGREEN
MET
7429-90-5 Al by ICP 50 50 U ug/L EPA200.7 1/24/13 ESTAFFORD1
7440-38-2 As by ICPMS
2.0 2.0 U ug/L EPA200.8 1/28/13 ESTAFFORD1
7440-70-2 Ca by ICP
0.10 85 mg/L EPA 200.7 1124113 ESTAFFORD1
7440.47-3 Cr by ICPMS
10 10 U ug/L EPA 200.8 1/28/13 ESTAFFORD1
7440-50-8. Cu by ICPMS
2,0 2.0 U ug/L EPA 200.8 1/28/13 ESTAFFORD1
7439-89-6 Fe by ICP
50 2500 ug/L EPA 200.7 1/24/13 ESTAFFORD1
7440.09-7 K by ICP
0,10 0.92 mg/L EPA 200.7 1/24/13 ESTAFFORD1
7439-95-4 Mg by ICP
0.10 1.6 mg/L EPA 200.7 1/24/13 ESTAFFORD1
7439-96-5 Mn by ICP 10 87 ug/L EPA 200.7 1/24/13 ESTAFFORD1
7440-23-5 Na by ICP
0.10 7.5 mg/L EPA 200.7 1/24/13 ESTAFFORD1
7440-02-0 Ni by ICPMS 2.0
2.0 U ug/L EPA 200,8 1/28/13 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0
2.0 U uglL EPA 200.8 1/28/13 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 10 U ug/L EPA 200.8 1/28/13 ESTAFt=ORDI
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699.1623 [phone]
For a eetaifed description of the crJaNfle! 006s feler l7 15fxa:Lgstcaizsdgquagwebl !8 jgafhrifoettu sssrsi Orr: f a �alifin Cudns ehrr 1lr�fSal.ncdenr.oryJwelwglfal isFifAnfp�reC .
Page 1 of 1

' Cf)r{,tt_._L_a1 ioralO v '_J eL• L ton (_esuLt
County: BEAUFORT
River Basin
Report To WAROAP
Collector A SCARBRAl1GH
Region: WARO
Sample Matrix' GROUNDWATER
Lac. Type: WATER SUPPLY
Emergency Yes/No
COC Yes/No
Final Report
VisitID
WAre Sample ID: AB91344
+�Q,: PO Number# 13G0013
Date Received: 01109/2013
`f Time Received: 08:00
Labworks Login ID HMORGAN
Final Report Date' 2/6/13
Report Print Date: 02/07/2013
Loc. Descr.: TIMOTHY AND LAUREL WASHBURN 518 HOLLYWOOD BLVD- EFFLUENT
Location 1D: NIWWCRAVE 700308
Collect Date: 01/08/2013
Collect Time: 10:45
Sample Depth
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
CAS # Analyte Name
PQL
Result)
Qualifier
Units
Reference Date
Method Analysis Validated I,y
Sample temperature at receipt by lab 2.3 °c 1/9/13 HMORGAN
WIC
Coliform, MF Fecal in liquid 1 113201 CFU1100m1 APHA9222D-20th 1/9113 ESTAFFORD1
Coliform, MF Total in liquid
1 1 B2Q1 CFU1100m1 APHA92228-20th 1/9/13 ESTAFFORD1
NET
Ion Chromatography
TITLE mg/L EPA 300.0 1/23113 CGREEN
Chloride
0.5 7.8 mg/L EPA 300.0 1/23/13 CGREEN
Fluoride 0.2 0.2 U mg/L EPA 300.0 1/23/13 CGREEN
Sulfate 1.0 1.0 U mg/L EPA 300.0 lam 3 CGREEN
Total Dissolved Solids in liquid 12 268 mg/L APHA2540C-18T1-I 1/11/13 CGREEN
VUT
NQ2+NO3 as N in liquid
0.02 0.02 ii mg/L as N Lac10-107-04-1-c 1/9/13 CGREEN
Nitrate as N in liquid
0.02 0.02 U
mg/L as N Lachat107-04-1-' 1/11/13 CGREEN
Nitrite as N in liquid
0.01 0.01 U mg/L as N Lachat107-04-1-c 1/9/13 CGREEN
VI ET
'429-90-5 Al by ICP 50 50 U ug/L EPA 200.7 1/24/13 ESTAFFORD1
'440-38-2 As by ICPMS
2.0 2.0 U ug/L EPA 200.8 1128/13 ESTAFFORDI
'440-70-2 Ca by ICP
0.10 89 mg/L EPA 200.7 1/24/13 ESTAFFORD1
'440-47-3 Cr by ICPMS 10 10 u ug/L EPA 200.8 1/28/13 ESTAFFORD1
'440-50-8 Cu by ICPMS
2.0 2.3 ug/L EPA 200.8 1/28(13 ESTAFFORD1
'439-89-6 Fe by I C P
50 2700 ug/L EPA 200.7 1/24/13 ESTAFFORD1
'440-09-7 K by ICP 0.10 0.90 mg/L EPA 200.7 1/24/13 ESTAFFORDI
'439-95-4 Mg by ICP
0.10 1.7 mg/L EPA 200.7 1/24/13 ESTAFFORDI
'439-96-5 Mn by ICP
10 88 ug/L EPA 200.7 1/24/13 ESTAFFORDI
'440-23-5 Na by ICP
0,10 7.5 mg/L EPA 200.7 1/24/13 ESTAFFORD1
'440-02-0 Ni by ICPMS 2.0 2.0 U ug/L EPA 200.8 1/28113 ESTAFFORD1
'439-92-1 Pb by ICPMS 2.0
2.0 U ug/L EPA 200.8 1/28/13 ESTAFFORD1
'440-66-6 Zn by ICPMS
10 10 U ug/L EPA 200.8 1/28/13 ESTAFFORD1
Laboratory Section» 1623 Mall Service Center, Raleigh, NC 27699-1823 [phone]
For a detailed descripioan of the uualifer cpdes refer 10 Anv l/avncdrnr,arylwrtIwulGvlsnninlnlcecna.VqaPAca qualifier Coder shrin llpon?.i.nmrRi.ortjwtbr,wg pfs[ajfinronechasn,
Page 1 of 1

S y mbol
A
B
BB
C
G
J
Definition
Value reported is the mean (average) of two or more determinations. This code is to be used if the results of two or more discrete
and separate samples are averaged. These samples shall have been processed and analyzed independently (e.g., field duplicates,
different dilutions of the same sample). This code is not required for BOD or coliform reporting since averaging multiple
dilutions for these parameters is fundamental to those methods.
Results based upon colony counts outside the acceptable range and should be used with caµtion . 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 100 ml.
2. Counts from all filters were zero. The value reported is based on the number of colonies per 100 ml that would have
been reported if there had been one colony on the filter representing the largest filtration volume (reported as a less
than"<" value).
3. Countable membranes with more than 60 or 80 colonies . The value reported is calculated using the count from the
smallest volume filtered and reported as a greater than">" value .
4. Filters have counts of both >60 or 80 and <20. Reported value is estimated or is a total of the counts on all filters
reported per 100 ml.
5. Too many colonies were present; too numerous to count (TNTC). TNTC is generally defined as > 150 colonies. Toe
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 100 and then divided by the smallest filtration volume analyzed. This
number is reported as a greater than value.
6. Estimated Value. Blank contamination evident.
7. Many non-coliform or non-enterococcus colonies or interfering non-coliform or non-enterococcus growth present. In
this competitive situation, the reported value may under-represent actual density .
Note : A "B" value shall be accompanied by justification for its use denoted by the numbers listed above (e .g., Bl, B2, etc.).
Note: A "J2 " should be used for spikin 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 accom panied by iustification for its use denoted bv the numbers listed above (e.l!., BBl, BB2, etc.).
Total residual chlorine was present in sample upon receipt in the laboratory; value is estimat.ed. Generally applies to cyanide,
ohenol, NH3, TKN, coliform, and or ganics.
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/Land/or a DO residual of
at least 1.0 mg/L.
3. No sample dilution met the requirement of a DO depletion of at least 2.0 mg/L and/or a DO residual of at least 1.0
mg/L.
4. Evidence of toxicity was present. This is generally characterized by a significant increase in the BOD value as the
sample concentration decreases. The reported value is calculated from the highest dilution representing the maximum
loading potential and should be considered an estimated value.
5. Toe glucose/ glutamic acid standard exceeded the range of 198 ± 30.5 mg/L.
6. Toe 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 accomoanied by justification for its use denoted b ~ the numbers listed above (e .g., GI, G2, etc .).
Estimated value; value may not be accurate. This code is to be used in the following instances:
1. Surrogate recovery limits have been exceeded.
2. Toe reported value failed to meet the established quality control criteria for either precision or accuracy.
3. Toe sample matrix interfered with the ability to make any accurate determination.
4. The data is questionable because of improper laboratory or field protocols (e.g., composite sample was collected
instead of grab, plastic instead of glass container, etc.).
5. Temperature limits exceeded (samples frozen or >6°C) during transport or not verifiable (e.g., no temperature blank
provided ): non-re portable for NPDES com oliance 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
instrument/method . The reported value should be considered estimated.
of the analytical
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 ana/yte in question.
12. The calibration verification did not meet the calibration acceptance criterion for field parame·ters.
Note: A "J" value shall be accompanied by justification for its use denoted by the numbers listed above (e .g., Jl, J2, etc.). A "J"
value shall not be used if another code applies (e .g., N, V , M).
M Sample and duplicate results are "out of control". The sample is non-homogenous (e .g ., VOA soil). The reported -value is the
lower value of duplicate anal vses of a sample.
N Presumptive evidence of presence of material; estimated value . This code is to be used if:
1. 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
thl!D the laboratory practical quantitation limit and greater than the laboratory method detection limit. This code is not
routinely used for most analyses.
4 . This code shall be used if the level is too low to permit accurate quantification, but the estimated concentration is less
than the laboratory practical quantitation limit and greater than the instrument noise level. This code is used when an
MDL has not been established for the analyte in question.
5. The component has been tentatively identified based on a retention time standard .
Q Holding time exceeded . These codes shall be used if the value is derived from a sample that was received, prepared and/or
analyzed after the approved holding time restrictions for sample preparation and analysis. The value does not meet NPDES
requirements.
1. 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" c1 ualifier is eq ual to the laborator-'s practical quantitation limit*.
X Sample not analyzed for this constituent. This code is to be used if:
1. Sample not screened for this compound.
2. Sampled, but analysis lost"or not performed-field error.
3. Sampled, but analysis lost or not perfonned-lab error .
Note: an "X" value shall be accompanied by justification for its use by the numbers listed .
V Indicates the analyte was detected in both the sample and the associated method blank. Note : The value in the blank shall not be
subtracted from the associated sarnoles .
y Elevated PQL * due to insufficient sample size.
z The sample analysis/results are not reported due to:
1. Inability to analyze the sample.
2. Questions concerning data reliability.
The oresence or absence of the analvt e cannot be verified .
*PQL The Practical Quantitation Limit (PQL) is defined and proposed as "the lowest level achievable among laboratories within
specified limits during routine laboratory operation". The PQL is about three to five times the calculated Method Detection Limit
(MDL) and represents a practical and routinely achievable detection limit with a relatively good certainty that any reported value
is reliable".
3/10/2011
GROUNDWATER FIELD/LAB FORM
Location code Kl-Z XI) n1 GRP i6 at" 30b
County 13tRtii°'t ,I
Quad No Serial No.
Lat. Long.
Report To. ARO, FRO, MRO, RRO,0, WiRO,
WSRO, Kinston FO, Fed. Trust, Central Off., Other:
Shipped by: Bus, + !atii Hand Del., Other: Purpose: r.
Collecton(s): AVincikiy C/Ai 4' Date t i 3 Time 'CI :11" ij aseline Complaint, Compliance, LUST, Pesticide Study, Federal Trust, Other:
FIELD ANALYSES Owner 10 r14.1 Ar.'A L t,1 vLIfti‘, .i'ne}
pH 400 7 Spec. Cond.94 at 25°C Location or Site rl3 ItGl..L f IAIVo j j EaUL1-ij ri$1 v6e-ct:14,J W -
Temp.t0 °C Odor Description of sampling point S rii4p. f• F' 30.:F_y It/4 u.�.
Appearance Sampling Method C M,4/3 Sample Interval ./ 4-
Remarks F11r?°. bale , sec i
North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
SAMPLk TYPE SAMPLE PRIORITY
3 Water 0 Routine
i] Soil D Emergency
❑ Other
D Chain of Custody
Lab Number
Date Received, Time:
Rac d By: From -Bus, Courier. Hand Del.,
Other.
Field Analysis By: AtiTfjteva
f_:i ikr3 ;11, ki it
LABORATORY ANALYSES
BOO 310
rng/L
COO High 340
mg/L
COO Low 335
mgIL
Calirorm: MF Fecal 31616
110omt
Cosifarm' MF Total 31504
_ 1100m1
TOC 660
mg/L J
Turbidity 76
NTU
Residue, Tc4ai Suspended 530
mg/L
pH 403
units
AlkaTtnily to pH 4.5 410
mg/L
Alkalinity to pH 8.3 415
mgIL
Carbonate 445
mg&
Bicarbonate 440
mg/L
Carbon dioxide 405
mg/L
Chloride 940
mg/L
-Chromium: Hex 1032
uglL
Color: True 80
CU
Cyanide 72D
rr19/L
Data Entry By: Ck:
Date Reported:
jc
[Ass. Solids 70300
mg/L
Fluoride 951
mg/L
x
Hardness: Total 900
mg/L
Hardness (non -carp) 902
mglL
Phenols 32730
ug1
S eciftc Cond. 95
OAhos/cm
Sulfate 945
mg/L
Sulfide 745
mg!L
Oil and Grease
mg/L
NH3asN610
mgri
TKN as N 625
mgIL
X
NOr+ NOa as N 630
mg/L
P. Total as P 665
mg/L
Nitrate (NOyas N) 620
mgIL
X
nitrite INO2 as N} 615
mg/L
a
Lab Comments
(Pumping me, air temp.. etc.)
Ag-Silver46566
ug/L
Al -Aluminum 45557
ug/L
X
As -Arsenic 46551
ugh
8a-Barium 46558
ug/L
Ca -Calcium 46552
mg/L
Cd-Cadmium 46559
ugh.
X
Cr-Chromium 46559
uitfL
-
Cu-Copper 46562
uglL
X
Fe-lfon 46563
uglL
Hg-Mercury 71900
ug/L
K-Potassium 45555
mg'L
Mg -Magnesium 46554
mg1L
Mn-Manganese 46565
u
Ne-Sodium 46556
m9/L
y
Ni-Nickel
ug&L
Pb-Lead 46584
ug/L
Se -Selenium
„glL
Zn-Zinc 46567
L
IX
Orgenochlarine Pesticides
Oroanophosphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCBS
Semirvdaiile Organics
TPf-1-Diesel RaNie
Volatile Organics (VOA bottles
TPH-Gasoline Rare
TPH-BTEX Gasoline Range
LAB LISE ONLY
Temperature on arrival (°G).
GW-54 REV 4106
For Dissolved Analysis-submik filtered sample and write 'DU in block.

North Carolina I GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
Location code f':/.l \:V\,1/C:$'1 Ve:.1 D0·Jo</
County 1'¼:,1\-vFt.:S,(
SAMPLE TYPE SAMPLE PRIORITY
nq· Routine Lab Number _______________ _
Quad No _____ _ Serial No . _______ _
[81' Water
0 Soil
D Other
D Emergency 8~fl"'L.~';..I\. "' Date Received _______ Time : ______ _
Rec'd By : From:Bus, Courier, Hand Del. D Chain of Custody Other: __________________ _
Report To : ARO , FRO, MRO, RRO, @o;, WiRO, Data Entry By: _______ _
Lat. _______ _ Long. ________ _
Ck : _____ _
WSRO, Kinston FO, Fed. Trust, Central Off., Other: Date Reported :. _____________ _
Shipped by : Bus, ~Hand Del., Other: _____ """="...,....,,~----Purpose: ~-
Collector(s): f\,rnteC::'1 SutAli:'!.:!IYk·"i Date 1,/'i/t }, Time {0~·•1TtiA~ ~ Complaint , Compliance, LUST, Pesticide Study, FederalTrust, Other: ____ _
FIELD ANALYSES Owner 'TI'Mt•TlN ANC i...l)\J¼L--E:v6 ';ittf;'t~,oneJ
pH 400 t;,. s· Spec. Cond.94 _______ at 25°C Location or Site <) ,j H OW...;{ 1<1,1<;,t) ,., CU USy 4{'3 'i,id vf;l,..1!;4 l ,-1Iik
Temp .10 ________ 0 c Odor _____________ Description of sampling point 5e,M f li[ por..S c 1V i;-t•JJr,--c.rr.-;,v WlLl-
Appearance Sampling Method GA{'{-~ Sample lnterval----'i"'-'v/""'11,.____ ___ _
• v Remarks iP umo. bailer. eic.) Field Analysis By : {Jwtl\}'v•/ ,.5 f,•3!'V~&?::!G v,
LABORATORY ANALYSES (Pump ing time , air temp .• etc .)
BOO 310 mg/L )< Diss. Solids 70300 mg/L Ag-Sliver 46566 uo/L · Oro anochlorine Pesticides
C00High340 mg/L Fluoride 951 mg/L ;,<,.. Ai -Aluminum 46557 ua/L Oro an"""osohorus Pesticides
COD Low335 mg/L ·x Hardness: Total 900 _mg/L x' As-Arsenic 46551 uo/L Nitrooe n Pesticides
IX Colifom,: MF Fecal 31616 1100ml Hardness (non-carb) 902 mg/L
, ..
Ba-Barium 46558 ua /L Acid Herbicides
X Colifom,: MF Total 31504 1100ml Phenols 32730 ug/1 IX Ca-Calcium 46552 mo/L PCBs
TOC 680 mg/L Specific Cond . 95 µMhoslcm Cd-Cadmium 46559 U<i /L
Turbidity 76 NTU Sulfate 945 mg/L X. Cr-Chromium 46559 uo/L
Residue , Total Suspended 530 mgll Sulfide 745 mg/L IX Cl.l-Copper 46562 uc/L
h( Fe-Iron 46563 uc/L Semivolatile Oroanics
Oil and Grease mg/L Hg-Mercury 71900 ua /L TPH-Oiesel Rance
pH403 units X. K-Potassium-.46555 moll
Alkalinity to pH 4 .5 410 mg/L x' Mg-Magnesium 46554 mc /L
Alkalinity to pH 8 .-3 415 mg/L Ix' Mn-Manganese 46565 ua/L Volatile Oro anics !VOA bottle)
Carbonate 445 mg/L NH, as N610 mg/L. ·,(. Na-Sodium 46556 mn/L TPH-Gasoline Ran c e
Bicarbonate 440 mg/L TKN as N 625 mg/L 1x· Ni-Nickel uo/L TPH-BTEX Gasoline Ran □e
; Carbon dioxide 405 mg/L )( N02 + N03 as N 630 mg/L IX Pb-Lead 46564 uc/L
ix. Chloride 940 mg/L P : Total as P 665 mg/L Se-Selenium uc/L
Chiomium: Hex 1032 ug/L Nitrate (NO, as N) 620 mg/L K Zn-Zinc 46567 uc /L
Color: True 80 cu
Cyanide 720 mg/L
X Nitrite (N02 as N) 615 mg/L LAB USE ONLY
Temperature or\ arrival (°C):
Lab Comments; _______________ ~---------------------------'---------------------
GW-54 REV. 4/06 For Dissolved Analysis-submit fiHered sample and write ·01s• in block.
AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: November 16. 2012 County: Craven
To: Aquifer Protection Central Office Permittee: Timothy J. And Laurel A. Washburn
Central Office Reviewer: Project Name: Washburn SFR Geothermal Onen Loan
Regional Login No: Application No.:
L GENERAL INFORMATION lJ 063o9
1. This application is (check an that apply): ® 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 l<I1 Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? E Yes or ❑ No.
a. Date of site. visit: November 16. 2012
b. Person contacted and contact information: Timothy J. Washburn 252-626-4939
c. Site visit conducted by: W. Hart and A. Scarbraugh w/APS-WaRO
d. Inspection Report Attached: ® Yes or ❑ No.
2. Is the following informations entered into the BIMS record for this application correct?
❑ Yes or ❑ No. Tim, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
e, Regulated Activities / Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For Disposal and Iniection Sites:
Cif multiple sites either indicate which sites the information applies to, copy and paste a new section into the
documentfor each site, or attach additional pages for each site)
a. Location(s): 518 Hollywood Boulevard. Havelock., Craven County
b. Driving Directions: Take US Highway 70 East to Hollywood Blvd. and continue to follow to 518
c. USGS Quadrangle Map name and number: _
d. -Latitude: 34.86 N Longitude: 76.9056 W
IY. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed -loop groundwater reinediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of WelliS) And Facilities — New, Renewal, And Modification
1. Type of injection system:
Heatinglcooling water return flow (5A7)
FORM: APS permit staff report

AQUIFER PROTECTION REGIONAL STAFF REPORT
0 Closed-loop heat pump system (5QM/5QW)
0 In situ remediation (51)
0 Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge")
0 Other (Specify:)
2. Does system use same well for water source and injection? D Yes IZJ No
3. Are there any potential pollution sources that may affect injection? IZJ Yes D No
What is/are the pollution source(s)? Inactive septic drain field. What is the distance of the in jection well(s)
from the pollution source(s)? 5 ft .
4. What is the minimum distance of proposed injection wells from the property boundary? 25 ft.
5. Quality of drainage at site: IZJ Good O Adequate D Poor
6. Flooding potential of site: IZJ 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? IZJ Yes O 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)? IZJ Yes or D No. If
no or no map, please attach a sketch of the site . Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow .
In jection Well Permit Renewal And Modification Only:
I. 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 O No. If yes , explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? 0 Yes D No. If yes. ex plain :
3. For renewal or modification of groundwater remediation permits (of any typ e). will
continued/additional/modified in jections have an adverse im pact on mi gration of the plum e or mana gement of
the contamination incident? D Yes D No. If yes, ex plain:
4. Drilling contractor: Name: __
Address:
Certification number: __
5 . Complete and attach Well Construction Data Sheet.
FORM: APS permit staff report 2
AQUIFER PROTECTION REGIONAL STAFF REPORT
V, EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.: See staff report
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, please explain
briefly.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item
Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition
Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition
Reason
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ HoId,
pending review of draft permit by regional office; Issue upon receipt of needed additional information; PC
issue; ❑ Deny, If deny, please state reasons:
8. Signature of report preparer(s):
FORM: APS permit staff report

AQUIFER PROTECTION REGIONAL STAFF REPORT
Signature of APS regional supervisor
Date: t t — 'ICJ
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: APS permit staff report 4

North Carolina Department of Environment and Natural Resources
Division of Water Quality-Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. =--P -=en=d=i=n ,_,,g ____ _
DATE OF INSPECTION: 11/16/12
INSPECTOR: W. Hart & A. Scarbraugh w/ APS-WaRO
NAME OF PERMITTEE(S) Timothy J. & Laurel A. Washburn
MAILING ADDRESS OF PERMITTEE 518 Holl ywood Blvd., Havelock , NC 28532
PHYSICAL ADDRESS OF SITE (if different than above) same as above
PERSON MET WITH ON-SITE Laurel A. Washburn ; TELE NO. (252 )626-4939
WELL(S) STATUS:
__ Existing and operating Class V Well
__ Existing well proposed to be converted to Class V well
X Proposed/not constructed
LAT/LONG OF WELL(S) 34.86N , 76.9056W
Appx. distance of well to property boundaries: Su pp l y Well -25 feet In j. Well -25 feet
Appx. distance of well from foundation of house/structure: Su pp l y Well -35 feet In j. Well -95 feet from
house and 25 feet from detached gara ge
Appx. distance of well from septic tank/field (if present): Su pp l y. Well. -120 from an inactive se ptic tank In i.
Well~ 5 from an inactive se ptic tank/field. Residence in connected to sewer.
Appx. distance of well to other well(s) (if present): _NIA_
Appx. distance to other sources of pollution: No other source of pollution were identified.
Flooding Potential of Site: _high __ moderate X low
Comments: Durin g the site visit an inactive se ptic tank and drainage field were observed within 5 feet of the
proposed in jection well location. The pro perty owner confirmed the residence was connected to sewer system
and the se ptic system was inactive.
Injection Facility lnsp. Report (Rev. Sept 2009) Page I of 4 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 Application
Draw Schematic of well above showing TD, casing depth, grout, etc.
Injection Facility lnsp. Report (Rev. Sept 2009) Page 2 of 4 Pages
Well Construction Information
Date Constructed: TBD (wells not yet constructed)
Well Contracting Company: A pplied Resource Management
Well Driller Name: H. Michael Sage
NC Well Cert. No.: 2531 -A
Address: PO Box 882 . Hampstead , NC 28443
Telephone No.: [phone] ; CeHNo.: [phone]
Email Address: _tanµ[e-mail]_
Proposed Depth of Well(s}: 150 feet
Total Depth: NA Total Depth of Source Well, if present: 150 feet ( pro posed )
Casing:
Depth: NA ; Diameter: _NA_; Type (gav. steel, PVC, etc.): _ _.;..N=A..a;.,_ ___ ; Stick Up: NA ft
Grout:
Depth: NA ; Type (cement, bentonite, etc.): __ N_A ___ ; Placement (pumping, press. etc.): ------'N-"A'"'-----
Well ID Plate Present (Y or N): NA ; Heat Pump ID plate present (Y or N): NA
Effluent spigot (Y or N): ---"N_A __ Influent spigot (Y or N): --'-N~A __
Well Sampled? (Y or N): NA
Static Water Level: NA
; If Yes, Lab Sample ID numbers: ______________ _
Injection Information (if applicable):
Injection Rate: NA GPM
Injection Pressure: _....;:.Nc...:..:A=-=-__ PSI
Injection Volume: NA GPD
Temperature-Summer: NA F°
Temperature-Winter: NA F0
Comments/Notes_ This office sugg ested that the permit contain a condition req uiring an y well used for in jection to
be grouted all the way down to the to p of the gravel pack to hel p ensure that there will be no cross connection
between the Castle Hayne aquifer were the wells will be screened and the overlying Yorktown and Surficial
a uifers.
Injection Facility lnsp. Report (Rev. Sept 2009) Page 3 of 4 Pages
Proposed I nj well
7UM-i—, Septic Drain
Ffeid
j -
Ale
.. '+may _ = r
� tie• � ��[,
.fir/ ' •
-
t
10
- -. 44
L �Z ter! _ s � i_ • . _ �r_.
�'!�: -•�. =� �>� _ �,. 'ti�1+t� _"' iF 'i

Permit Number WI0700308
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Timothy & Laural Washburn SFR
Location Address
518 Hollywood Blvd
Havelock
Owner
Owner Name
Timothy
Dates/Events
NC 28532
J Washburn
Scheduled
Orig Issue
11/16/12
App Received Draft Initiated Issuance
11/15/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
11/16/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
H Michael Sage
Driller Well
PO Box 882
Hampstead NC
Major/Minor
Minor
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Timothy J. Washburn
518 Hollywood Blvd
Havelock NC
Public Notice Issue
11/16/12
Effective
11/16/12
Requested/Received Events
RO staff report received
RO staff report requested
28443
28532
Expiration
10/31/17
11/16/12
Waterbody Name Stream Index Number Current Class Subbasin
Permit Number W10700308
Central Files: APS SWP
11/16/12
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Status Project Type
In review New Project
Version Permit Classification
Injection Heating/Cooling Water Return Well individual
Primary Reviewer
erio.g.smith
Coastal SW Rule
Permitted Flow
Facility
Permit Contact Affiliation
H Michael Sage
Driller Weil
PO Box 882
Hampstead NC 28443
Facility Name
Timothy & Laura] Washburn SFR
Location Address
518 Hollywood Blvd
Havelock NC 28532
Owner
Major/Minor Region
Minor Washington
County
Craven
Facility Contact Affiliation
Owner Name
Timothy
Dates/Events
Owner Type
Individual
J Washburn Owner Affiliation
Timothy J. Washburn
518 Hollywood 8ivd
Havelock
NC 28532
Orig Issue App Received Graff Initiated
11/15/12
Scheduled
Issuance
Public Notice rsu�+ Effective 714323g1(
�VA/IJ
Regulated Activities Reguestcd!Received Events
RO staff report received
RO staff report requested 11/16/12
❑utfall NULL
Waterbody Name Stream fndex Number Current Class Subbasin

NA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Timothy & Laural Washburn
518 Hollywood Boulevard
Havelock, NC 28532
Re: Issuance of Injection Well Permit
Permit No. WI0700308
Issued to Timothy & Laural Washburn
Craven County
Dear Mr. and Mrs. Washburn:
Charles Wakild, P.E.
Director
November 16, 2012
Dee Freeman
Secretary
In accordance with your application received November 15, 2012, I am forwarding Permit No. WI0700308 for the construction
and operation of geothennal heating/cooling water return well located at the above referenced address. This pennit shall be
effective from the date of issuance until October 31, 2017, and shall be subject to the conditions and limitations stated therein.
Please Note the Following:
• Per Permit Condition Part 1.9, a copy of the Well Construction Forms (GW-1), which is completed and signed
by the well contractor, must be submitted to this office and the Wasltington Regional Office within 30 days of
completion ofthe injection well. Copies of the GW-1 shall be retained on-site and available for inspection.
• Per Permit Condition Part 11.3, within 30 days of injection well completion, Permittee must provide an 'as-built'
diagram of the injection system to the Washington Regional Office APS Staff, and to have influent and effluent
samples collected.
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 pemiit 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 pennit
or the Underground Injection Control Program please call me at [phone].
Best Regards,
!Jrd~-
Eric G. Smith, P.G.
Hydrogeologist
cc: David May, Washington Regional Office
Central Office File, WI0700308
Craven County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: [phone] \ FAX : [phone]
Internet www . ncwatemuality.orq
· An Equ al Opportunity I Afftrmative Action Employer
Ni~carolina
~tit11ral4J
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTEE) TO
Timothy & Laural Washburn
FOR THE CONS'I RUCTION AND OPERATION OF A GEOTHERMAL HEATING/COOLING WATER
RETURN WELL, defined in Title 15A North Carolina Administrative Code 2C .0224, which will be used for
the injection of heat pump effluent. This injection well is located at 518 Hollywood Boulevard, Havelock,
Craven County, North Carolina 28532, and will be constructed and operated in accordance with the application
received November 15, 2012, and conformity with the specifications, all of which are filed with the Department
of Environment and Natural Resources and are considered a part of this permit.
This permit is for construction and operation of an injection well shall be in compliance with Title 15A North
Carolina Administrative Code 2C .0100 and _0200, and any other Laws, Rules, and Regulations pertaining to
well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until October 31, 2017, and shall be
subject to the specified conditions and limitations set forth in Parts 1 through IX hereof.
Permit issued this the 16 day of November , 2012
)'''t•Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #W10700308
LAC/Return Well - New Construction Page 1 of 5
per. 07/2012

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be sealed with a watertight cap or well seal, as defined in G.S. 87-85(16).
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
.01070).
8. The Permittee shall record the number and location of the well(s) with the register of deeds in the county
in which the facility is located.
9. A copy of the completed Well Construction Record (Form GW-1) must be submitted for each injection
well to:
Aquifer Protection Section -UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Copies of the GW-1 form(s) shall be retained on-site and available for inspection.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. Each injection well shall be grouted from land surface to bottom of casing to reduce risk of commingling
of separate aquifers, and effluent being injected up the annulus of the well ('daylighting').
Permit #WI0700308 DIC/Return Well -New Construction
ver. 07/2012
Page 2 of5
2. At least forty-eight ( 48) hours prior to constructing each injection well, the Permittee shall notify the
Aquifer Protection Section-Underground Injection Control (UIC), Central Office staff, telephone number
[phone] and the Washington Regional Office Aquifer Protection Section (APS) Staff, telephone
number 252-946-6481.
3. Within 30 days of injection well completion, Permittee must provide an 'as-built' diagram of the injection
system to the Washington Regional Office APS Staff, and to have influent and effluent.samples collected.
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
5. The injection well system must be constructed with sampling ports so that system influent and effluent
may be sampled.
6. Each injection well must be constructed to a depth such that it is injecting water into the same aquifer _that
a source well, if present, is drawing from.
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance ofthis permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
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.
Penp.it #WI0700308 UIC/Retum Well -New Construction
ver. 07/2012
Page 3 of5
3. The issuance of this permit shall not relieve the Perrilittee 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.
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place ori 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 Washington Regional Office, telephone number 252-946-6481, any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
Permit #WI0700308 UIC/Retum Well -New Construction
ver. 07/2012
Page 4 of5
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 Pennittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the 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 .0240,
Abandonment and Change-of-Status of Wells.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Pennittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0240, 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 .0224(f)( 4) within 30 days of completion of abandonment.
3 . The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Pennit #Wl0700308
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
163 6 Mail Service Center
Raleigh, NC 27699-1636
VIC/Return Well -New Construction
ver. 07/2012
Page 5 of5
Application Reviewer: C+t'
Pre -Review: Conducted? s ❑ No
O.K. to Process? Yes ❑ No
If No, What Action Is Needed? ❑ Pre -Review Return
J
❑ Hold, Pending Receipt of Addinfo.:
Name/Affiliation of Person Contacted:
Crwrici : L] Existing
'known Owner Type
Facility/Operation: I ' oposed ❑ Existing
Non -Gov't ( Ind, or ❑ Org)
El Gov. -County El Gov. -State
❑ Facility ❑
El Gov. -Municipal
❑ Gov. -Federal
Operation
Regulated Activities:
Anplicat ion/Permit:
Permit Type:
❑ Injection Water Only GSHP Well System (SQW)
❑ Injection Mixed Fluid GSHP Well System (SQM)
E Injection Tracer Well (5T)
Project Type: [ New ❑ Major Mod.
Notes: .. f
❑ Injection In situ Groundwater Remediation Well (5I)
Injection Heating/Coaling Water Return Well (5A7)
❑ Injection Other Wells (5Z)
1 J Injecnon A gUiler Recharge (51i2I )
❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
FORM: BIMS 10/04/2007

A7A
::._ .saw.
rtrt
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
November 15, 2012
Timothy Washburn
Laurel A Washburn
518 Hollywood Blvd
Havelock, NC 28532
Dear Mr. and Mrs. Washburn:
Subject; Acknowledgement of
Application No. W10700308
Timothy & Laurel Washburn
SFR
Injection Heating/Cooling
Water Return Well System
Craven County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on November 15, 2012. Your application package has been assigned the number
listed above, and the primary reviewer is Eric Smith.
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 Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Eric Smith at [phone] or [e-mail].
Sincerely,
Aito
for DebraJ. Wail
Groundwater Protection Unit Supervisor
fl.
cc: Washington Regional Office, Aquifer Protection Section
Tammy Schilling— Applied Resource Management, P.C.
Patrick McKee - Airtech Mechanical
Permit File WI0700308
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raleigh, North Carnllna 27699•1636
Location: 512 N. Salisbury St., Raleigh, North Caralirra 27604
Phone: [phone]FAX: [phone]
Internet. mmt.nowateraualltv.are
Al Equal Opportunity I Affirmative Action Employer
One
Northearol a
Naiad

RECEIVEDIDER04
r
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOiftger Protection Section
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
OPEN -LOOP GEOTHERMAL INJECTION WELLS
These wells discharge groundwater directly into the subsurface as part of a geothermal heating and cooling system
(check One) x New Application Renewal* Modification
* Pnrrpna.rrvle onrnnlata Parte A_!` Unr1 rha cirrnafirra nano
Pr ni or Type trnformahon ana mart ro me 1aaress on me Last rage. rnegenre -Ipp/rcattons rrr1Je t(etamed Js rncomprete.
DATE: 10/10 . 20 12
PERMIT NO.
(leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence X, Business/Organization
Government:
State Municipal County Federal
B. PERMIT APPLICANT — For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
Timothy J. & Laura' A. Washburn
Mailing Address: 518 Hollywood Blvd.
City: Havelock State: NC Zip Code: 28532 County: Craven
Day Tele No.: 252-626-4939 Cell No.:
EMAIL Address: lwashburnlJu'ec.rr.com Fax No.:
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel identification Number (PIN) of well site: 6-059-039 County; Craven
(2) Physical Address (if different than mailing address):
City: State: NC Zip Code:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: H. Michael Safe
NC Well Drilling Contractor Certification No.: 2531-A
Company Name: Applied Resource Manaeement. P.C.
Contact Person: Tammy Schillinz
Address: P.O. Box 882
EMAIL Address: tammv armrcbellsouth.net
City: Hampstead _ Zip Code: 28443 State: NC County: Pender
Office Tele No.: 910-270-2919 Cell No.: Fax No.: 910-270-2988 4
GPUIUIC 5A7 Permit Application (Revised 3/ 18/2011) Page 1

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Airtech Mechanical
F.
Contact Person: Patrick McKee
Address: 153 Two Lakes Trail
EMAIL Address: [e-mail]
City: New Bern Zip Code: 28560 State: NC County: _C==ra"""v""'"en=-------
Office Tele No .: 252-636-5841 Cell No.: 252-725-7100 Fax No.: 252-636-5842
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES X
YES ___ _
NO ----
NO --=X-=-----
G. WELL CONSTRUCTION DATA
(1)
X PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(6) 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 (6)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
GW-1) ifavailable.
Well Construction Date: ________ Number of borings: 2
Depth of each boring (feet):_---=1=5=0_' ______ _
(2) Well casing type: Galvanized steel __ Black steel __ Plastic __ Other (specify) _ _;P~V'-C"'-----
Casing thickness (in.): sch40 Diameter (in.): _4_" __
Casing depth: from: _+_,l'-" __ to: 95' feet below land surface
Casing extends above ground ----=1=2_" __ inches
(3) Grout material surrounding well casing:
(a) Grout type: Cement__ Bentonite* _x__ Other (specify) --------
*By selecting bentonite grout, a variance is hereby requested to lSA NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from _O_' __ to 95 ' feet
(4) Well Screen or Open Borehole depth (relative to land surface): from __ 9~5_' ___ to __ 1_5_0_' __ feet
(5) N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Is there 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: __ ...c-9~5--1=5~0'---Formation: Castle Hayne Rock/sediment unit: Limestone
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHERWISE UNAVAILABLE.
GPU/UIC SA 7 Permit Application (Revised 3/18/2011) Page 2
H. OPERATING DATA
(1) Injection Rate: Average (daily) 4 gallons per minute (gpm).
(2) Injection Volume: Average (daily) 5760 gallons per day (gpd).
(3) Injection Pressure: Average (daily) 30 pounds/square inch (psi).
(4) Injection Temperature: Average (January) 55 ° F, Average (July) 75 o F.
L WELL LOCATIONS-Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
2524649379 1:18:30:52 a.m. 11-13-2012 2 /2
r. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate offitcer,
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a stato, federal, ar other public agency: by either a principal executive
officer or ranking publicly elected official;
4, for all others: by the well owner (which means all persons listed an 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 authors their agent to sign this application on Weir 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, F believe that the information is true, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. 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."
RECEIVE !OEt RAa
,- 'Ifi11
IY l 6-
Aquifer Protection Section
OwnertAppliccant
MIA I-J4 5 G, us A-4
Print or hill Name
r•
of Prpperty Owner/Applicant
raft-- I Awn Lk -10
Print or Type Full Name
Signaature of Authorized Agent, if any
Print ar Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]

•
f
151
'1
:• •
•
'
H=74.
�-_-
t
41.
k
SUBJECT PROPERTY r
-r wr.. err 4E741-
-�r ek swr j� err Jr: -r
x.- �c.�raYy� �`„ r. 'y" - -. ! sr- -•r 4x.
, 4 -y -ate 21•-
}
• -
v+
-'.-., -.'.t �`.y. Y'-`. - '!--b- --.-
---.-,A.. x -ill. _--4- -�-9---�' a�=- = 1
=u` -s �- -4. -"-"-.r -er -ld. '3i' -Pt = 4- ,.-.- --
-4- .+� 0.^ _ -------a.- = tiy. .y= ... -i_•-l_ y°'--_- A......_‘..
- .Y► ... JW= y. c.,.= .. - lt= . w - ,ab- ab= y. ri - r , 4 , _ ...
r S'-- 4--4• J`_ 0r J} oN,y ' -- ._.--• ;--.a ^.--&- -+� Ail = \ .
2--
Note: Adapted from USGS Masontown, NC Topographic Quadrangle (1994),
76c-
plied Resource Mariaiement PC
17.0. Box 882, Hampstead, NC 28443
[phone] FAX [phone]
TITLE:
JOB:
Hollywood
Blvd
SITE VICINITY MAP
SCALE: DATE: 1DRAWN BY:
1 "=2,000' 10/16/12 i KLC
FIGURE:
1

Applied Resource
Management, P. C.
Hamptead, NC 28445
hfITLE:
Proposed Well Locations
JOB: SCALE: DATE: DRAWN BY:
Washburn 1" = 150' 10/24/12 TAS
Legend
Proposed Injection Well Location
* Proposed Supply Well Location
Note: Adapted from Brunswick County on-line GIS
FIGURE:
2

SECEIVEOIDENR(DWO
Icy ] 1 -
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOIReieTUtectIon &lion
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
OPEN -LOOP GEOTHERMAL INJECTION WELLS
These wells discharge groundwater directly into the subsurface as part of a geothermal heating and cooling system
(check one) x New Application Renewal* Modification
* Pnr ranw..,olo rnrnr.Ia+n ➢arty A J' and th . cinr+atnro nue..
Print or type trrtormation ana Rau to ale 1 Caress on the Last rage. trregarnre Applications t't arr [seitenignit�
DATE: 10/10 . 20 12
PERMIT NO.
(leave blank if New Application)
NOV is 2f112
Aquifer Protection Selman
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence _XBusiness/Organization
Government: State Municipal County Federal
B. PERMIT APPLICANT — For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
Timothy I. & Laural A. Washburn
Mailing Address: 518 Hollywood Blvd.
City: Havelock State: NC Zip Code: 28532 County; Craven
Day Tele No.: 252-626-4939 Cell No.:
EMAIL Address; lwashburnl iatc.rr.com Fax No.:
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 6-059-039 County: Craven
(2) Physical Address (if different than mailing address):
City: State: NC Zip Code:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: H. Michael Sage
NC Well Drilling Contractor Certification No.: 2531-A
Company Name: Applied Resource Management. P.C.
Contact Person: Tammy Schillirn EMAIL Address: tammv arrnrrt}beilsouth.net
Address: P.O. Box 882
City: Hampstead Zip Code: 28443 State: NC County: Fender
Office Tele No,: 910-270-2919 Cell No.: Fax No.: 910-270-2988
GPLJIUIC 5A7 Permit Application (Revised 3/1812011) Page 1

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name : Airtech Mechanical
F.
Contact Person: Patrick McKee
Address: 153 Two Lakes Trail
City: New Bern
Office Tele No.: 252-636-5841
Zip Code:
EMAIL Address: [e-mail]
28560 State: NC County: _C~r~a~ve=n~-----
Cell No.: 252-725-7100 Fax No.: 252-636-5842
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES _X=--=-----NO ___ _
YES ___ _ NO _~X~--
G. WELL CONSTRUCTION DATA
(1)
__ X~ __ PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(6) 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 (6)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
GW-1) if available.
Well Construction Date: Number of borings: ----------~--2
Depth of each boring (feet):._---'1=5~0_' ______ _
(2) Well casing type: Galvanized steel __ Black steel __ Plastic __ Other (specify) __ P~V~C _____ _
Casing thickness (in.): sch40 Diameter (in.): _4'-"--
Casing depth: from : _+-=l'-"--to: 95' feet below land surface
Casing extends above ground ----"1=2_" __ inches
(3) Grout material surrounding well casing:
(a) Grout type: Cement__ Bentonite* _X __ Other (specify) _______ _
*By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from _0_' __ to 95' feet
(4) Well Screen or Open Borehole depth (relative to land surface): from -~9_5_' ___ to ---'l=-=5'""0_' __ feet
(5) N.C. State Regulations (Title ISA NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Is there 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: _____ 9~5~-1=-=5~0 __ Formation: Castle Hayne Rock/sediment unit: Limestone
NOTE : THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHERWISE UNAVAILABLE.
GPU/UIC SA 7 Permit Application (Revised 3/18/2011) Page 2
H. OPERATING DATA
(1) Injection Rate: Average (daily) 4 gallons per minute (gpm).
(2) Injection Volume: Average (daily) 5760 gallons per day (gpd).
(3) Injection Pressure: Average (daily) 30 pounds/square inch (psi).
(4) Injection Temperature: Average (January) 55 ° F, Average (July) 75 o F.
L WELL LOCATIONS-Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn In by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
2524649379 08:30:52 a.m. 11.13 20'f2 212
L CERTIFICATION (to be signed as required below or by that person's authored agent)
I5A NCAC 02C .0211(b) requires that ail permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listedon_tltt property dead)_
If au 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.
"l hereby certify, under penalty of law, that 1 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 fir obtaining said information, I believe that the information is tole, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well arid all related appurtenances in accordance with the approved specifications and conditions of
the Pennit."
C ECEIVEDIDENDDL
!Tv 15 t,
Aqaar Protett O 1 SeCtiasl
erty Owner/Applicant
,,nfr AIJO5 4 I _��
Print or Tye Full Name
r.
Si�r►aiure ofPtoperty Owner/Applicant
Lau \r k inn ti hcA-\i>in
Print or Type lull Name
Signature of Authorized Agent, deny
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]

Note: Adapted from LJSG5 Masontown, NC Topographic Quadrangle (1994),
TITLE:
A(
ppfied Resource Manaecl�ement PC
PO. Box 862. Hampstead, NC 28443 JOB:
9101270-2919 FAX [phone] Hollywood
K fivri
SITE VICINITY MAP
SCALE: 'DATE: DRAWN BY:
1"=2,000' 10/16/12 KLC
FIGURE:
1

•Applied Resource
Managemerit, P. C.
Hampeteasi. NC 2044
TITLE:
Proposed Well Locations
JOB: SCALE: 1DATE: ❑RAWN BY:
Washburn 1" = 150' 10/24/12 TAS
Legend
Proposed Injection Well Location
* Proposed Supply Well Location
Note: Adapted from Brunswick County On-line GIS
FIGURE:
2

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERkIIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
OPEN -LOOP GEOTHERMAL INJECTION WELLS
These wells discharge groundwater directly into the subsurface as part of a geothermal heating and cooling system
(check one) x New Application Renewal* Modification
* Pnr r»noiai01C .+nnlnrotP Rona A -r vnrl t).n Dlhn.31 u,a na rim
Pr to or r vpe rnJorinatlor one' Aialr ro rffe : iaa ess on the i.asi rage_ ulig1f51c :,fpp wwallans +i III ,1e KOH) rrea its incomplete.
DATE: I41 I t) 20_12___,
PERMIT NO. (leave blank if New Application)
RECEIVEDICENRJCWQ
1
A. STATUS OF APPLICANT (choose one) Aquifer Protection Section
Non -Government: Individual Residence _X Business/Organization
Government: State Municipal County Federal
B. PERMIT APPLICANT — For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
Timothy 3. & Laura' A. Washburn
Mailing Address: 518 Hollywood 131,41,
City: Havelock State: NC Zip Code: 28532
Day Tele No.: 252-626-4939 Cell No..
EMAIL Address: [e-mail] Fax No.:
County: Craven
C, LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 6-059-039 County: Craven
(2) Physical Address (if different than mailing address):
City: State: vC Zip Code:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: H. Michael Sage
NC Well Drilling Contractor Certification No.: 2531-A
Company Name: Applied Resource Mana2�ement. P.C.
Contact Person: Tammy Schilling EMAIL Address: tammv arrn�`rlbellsouth.net
Address: P.O. Box 882
City: Hampstead Zip Code: 28443 State: NC County: Pender
Office Tele No.: 910-270-2919 Cell No.: Fax No.: 9I0-2702988 II g7
GPU/IIIC 5A7 Permit Application (Revised 3/18/2O I I) Page 1

E. HEAT VUMP CONTRACTOR INFORMATION (if different than dri I ier)
Company Name: Airtech Mechanical
Contact Person: Patrick McKee EMAEL Address: Patrickeairtcchnc.com
Address: 153 Two Lakes Trail
City: New Bern
Zip Code: 28560 State: NC County: Craven _
Office Tele No.: Z52-636-5841 Cell No.: 252-725-7100 Fax No.: 252-636-5842
F. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(I) The injection operation?
(2) PersonaI consumption?
YES X
YES
NO
NO X
G. WELL CONSTRUCTION DATA
X PROPOSED Weil(s) to be constructed for use as an injection well. Provide the data in (I) through
(6) below as PROPOSED construction specifications, Submit Form GIN -I after construction.
EXISTING WelI(s) being proposed for use as an injection well. Provide the data in (1) through (6)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
GW-1) if available.
(I) Well Construction Date: Number of borings, 2
Depth of each boring (feet): 154i'
(2) Well casing type: Galvanized steel Black steel Plastic Other (specify) PVC
Casing thickness (in): sch40 Diameter (in.): 4"
Casing depth: from: +1" to:. 95' feet below land surface
Casing extends above ground 12" inches
(3) Grout material surrounding well casing:
(a) Grout type: Cement Bentonite* X Other (specify)
'By selecting bentanite grout, a vurianee is hereby requested to 15A NCAC 2C .0213(d)(1)(A), which requires a cement type groat,
(b) Depth of grout around well casing (relative to land surface): from 0' to 95' feet
(4) We11 Screen or Open Borehole depth (relative to land surface): from 95' to 150' feet
(5) N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead processes. A faucet on both influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Is there 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 Forth GW-i 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, Iimestone, sand, etc.)
Depth: 95-150 Formation: Castle Mayne Rock/sediment unit; Limestone
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHERWISE UNAVAILABLE.
G'UR7iC 5A7 Permit Application (Revised 3/ 181201 I )
Page 2

FI. OPERATING DATA
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
Average (daily) 4 _gallons per minute (gpm).
Average (daily) 5760 gallons per day (gpd).
Average (daily) 30 pounds/square inch (psi),
Average (January) 55 ° F, Average (July) 75 ° F.
I. WILL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection weli(s). Label all features clearly and include a north arrow.
[1)
Attach asite-specific reap showing the locations of the following:
* Proposed injection wells
* Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map narne.
NOTE: in most cases, an aerial photograph of Me property parcel showing property lines and sfruclures can be
obtained and downloaded from the applicable county GIS webske. x]ylcaUy, the property can be searched by
owner name or address. The location of the wells In relation to properly boundaries, Mouser, septic tanks, other
wells, etc. can then be drawn in by hand Also, a layer' can be selected slowing topographic contours or
elevation data.

2624649379
08:30:52 a.m. 11-19-2012 2 /2
x.
CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021I(b) requires that all permit applications shall be signed es 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, ar other public agency: by either a principal executive
officer or ranldng publicly cleated official;
4. for all others: by the well owner (which means all persons listed on the moony Arty deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter slgned by the
applicant that names and authorizes Weir agent to sign this nppfcafigtt on their behalf
"I hereby certify, under penalty of law, that I have personally exmnined and am familiar with the Information
submitted in this document and all attachments tha eto and that, based on my inquiry of those individuals
ianxuediately responsible for obtaining said information, I believe that the intimation is true, accuratr end
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair; and if applicable, abandon the
injection well and all related appurtenances in accordenee with the approved specifications and conditions of
the Permit."
petty Owner/Applicant
.177 Lk? S Is 4,, F/]
Full Nance
))
sf_ aturc of ' • perty Owner]Applicant
Print or Type Full Name
Signature of Authorized Agent, If any
Print or Type Full Nerne
Submit two copies of the completed application package to:
»WQ - Aquifer Protection Section
1636 Mali Service Center
Raleigh, NC 27699-1636
Telephone (919) 81I7-6464
RFCFIVEOIOENPJDWQ
NOV 15 {4l f
Aquifer Protion Section

1
SUBJECT PROPERTY
- - - �..0- —
„
=` x B`ea.
w
sue — 7w_ —
�.�. - _ a►. tee+ r A
Note: Adapted from USGS Masontown, NC Topographic Quadrangle (1994),
rs
?k.•..15:6(.612,..1-tornp§feoaliC.i8443
lied geoource lviana a errient PC.
1.0) 2la2919:FA'i[ 270-2988
TtTLE:
SITE VICINITY MAP
LiOS: SCALE:
�. Hti wood l "=zoo
L.
DATE: D ?AV i .BY;
100 6/12 liLC
. FIGURE:

N
Applied ReaOyu!. . .
Managerfient P
. tiorP60141, K2040
mTLE:,Itend
Proposed Well LocatiOns.1* Proposed Injection Weil Location
;de -SCALE ciAit:.--1544*Tity71* Proposed Supply We Location
Wasnbumi = 150' 10/24/12 TAS Note:Adapted from Brunswick County On-line GIS
FIGURE:

_414
518 Hollywpod Blvd, 'g;roat an National

s
Note: Adapted from Google Earth
Proposed Geothermal Well Locations
ex
Irrigation Well Locations
❑ Pump Station
TITLE:
FIGURE:
Proposed Well Locations
DRAWN BY: , ti;.
TAS

Note: Adapted from Google Earth
Proposed Geothermal Well Locations
Pumi*Station:
Irrigation Well Locations
❑ Pump Station
FIGURE:
JOB: SCALE: DATE: DRAWN BY:
Washburn 1" _ 200' 10/15/12 TAS