WI0700323_GEO THERMAL_20160202

■ Complete items 1, 2, and 3. Also complete
item 4 If Restricted Delivery Is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Atte,ch this card to the back of the mailplece,
or on the front if space permits.
1. Article Addressed to:
Bernard & Ella Dougherty
1409 Potomac Drive
Chocowinity, NC 27817
lfYES,
FEB -2 2018
3. Service Type ~ I □ Certified Mai l □ ~ I
□ Registered m Receipt for Merchandise
□ Insured Mail O C.O.D.
4. Restricted Delivery? (Extra Fee) □ Yes
2. Article Number
(Transfer from service label) ~b40 ODDO 9792 3209
PS Form 3811, February 2QO.+ Domestic Return Receipt 102595-02-M-1540·
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vV. Oi-0° 323
WELL CONSTRUCTION RECORD
Otis form oan be used for sin& or multiple wells RECEIVED/DENR.ID,VR
I, Well Contractor Information:
BILL MAGETTE
well Contractor Name
2299
NC Well Contractor Certification Number
Water Quality Region??
O'r3ttanc Section
MAGETTE WELL & PUMP COMPANY
Company Nano
2. Well Construction Permit il: W10700323
Lis' all applicable well perm tr fr.e. County, Sarre. Yariawre, Injeetton. ere.)
3. Well Use (checkweil use):
Water Supply Well:
t7Agriculturdl
❑Geothermal (Heating/Cooling supply)
O industrial/Commercial
°Irrigation
❑MunicipalfPubl is
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
?1Geothemial (Heating/Cooling Realm)
°Groundwater Remedtation
❑ Salinity Barrier
❑ Stormwatcr Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under #21 Remarks)
4. Dale Well(s) Completed: 10.15.1
5a. Well Location:
BERNIE DOUGHERTY
Facility/Owner Name
Well ID#
Facility IN/ (ifappiicabk)
1409 POTOMOC DRIVE CHOCOWINITY NC 27817
Physical Address, City. and Gp
BEAUFORT
County Parcel Identification No. ('EN)
5b. Latitude and Longitude in degreeslminuteslseconds or decimal degrees:
Orwell field, one lat/long is sufficient)
35.492250 -77.047165
6. Is (are) the well(s): ZIPermanent or ❑Temporary
W
7.15 this a repair to an existing well: Ole es or MNo
Ijobis tx a repair, fill out known well ramsiructian infarmallah and explain the nahme of the
repair under 421 remarks section or an the hock of (his farm.
B. Number of wells constructed: 1
For multiple injection or Hann -wrier supply wells ONLY with the saute conrrrunsIon• you ran
subs it one forni-
9. Total well depth below land surface: 1 6V (ft.)
For multiple wells fist all depths if dlffrrenl (example- 30200' and 2@100')
10. Static water level below top of casing: 26 (ft.)
If waar kid Is above casing, use "
11. Borehole dianteter: 8.75 (in.)
12. Well construction method: ROTARY
tr
(Leauger, rotary. cable. dirccr push, cit.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type: HTH
1
Method of test:
Amount- 1.5 POUNDS
FROM TO
For internal Use ONLY.
14. WATEB ZONES
FROM 1
60
if -
ft.
TO
160 it.
Ft.
DESCRIPTION
SAND & LIMESTONE
OVTF, CABDVG Ifor nniT -ea aed Wahl OR LINER I}rap heal e)
THICKNESS MATERIAL
S.
DIAMETER
in.
IC MIT CA N[:1 R TUBING Iekulheruial clmrd-lnow
DIAMETER
FROM
TO
+2
ft.
140 rt•
4
FI,
in,
THICKNESS
S
SCH 40
MATERUL
PVC
17. SCRTTN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
140 n
R.
160 ft-
lit. GROUT
PROM TO
ft.
4
is
in.
MATERIAL
.032
SCH 40
PVC
ItMPt•ACEMENT METHOD & AMOUNT
0 F• 120 f'- BENTONITE TREMIE
fL
fL
FI.
ft.
19. ! %ItkvEL PACK i1f aatlilicablct
FROM
TO
MATERIAL
tMFLAC ML T airrlEDn
120 ft.
162 fr.
ft.
SP 3
le. DRILLING I 1- ch additional sheets if nete-SSan'
FROM
0 fL
30 't
40
ft.
56 Tr-
40
ft
56
fL
fl. ft.
11- REM_IRKS
TREMIE
DrSCIuPT IttN i ce3vi, hardness, salhael, is1Pr, traii erc.i
CLAY
SAND
CLAY
SAND AND LIMESTONE
INJECTION CAPACITY 10 GPM PER FOOT OF RISE
22. Ce
11.4.15
sig,rirure of Certified well Cant&#or Dale
By eigning ibis form. I hereby terrify Char the well(s) Ivor (were) constructed in accordance
with ISA bICAC 02C .OJOIJ or ISA NCAC BAC ,0200 Well Corralruc•iron Standards acid shot a
copy of this rdcard has been provided la the wen owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well sire details or well
construction details. You may also attach additional pages if necessary,
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this farm within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. Fur Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this faun within 30 days of completion of well
construction to the following'
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supph & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-t
North Carolina Deparnouri of Environnicnt and Natural Resources — Division of Water Resources Revised August 2013

Rogers, Michael
From: Rogers, Michael
Sent: Thursday, October 01, 2015 4:27 PM
To: May, David
Cc: Hart, William; Watts, Debra
Subject: RE: Injection Well Replacement - Bernard Dougherty Open Loop Geothermal System -
Beaufort County - WI0700323
i concur with the proposed approach except I would suggest (1) you request the owner/driller give you 2-3 business days
advance notice on well construction/abandonment activities, (2) the existing well be P&A prior to drilling the
replacement well, and (3) the CO needs to get a copy of the GW-1 and GW-30 when completed.
Regards,
From: May, David
Sent: Thursday, October 01, 2015 4:08 PM
To: Rogers, Michael <[e-mail]>
Cc: Hart, William <[e-mail]>; Watts, Debra <[e-mail]>
Subject: injection Well Replacement - Bernard Dougherty Open Loop Geothermal System - Beaufort County -
W 10700323
Michael,
The referenced site has been having problems with the injection well. It keeps getting plugged. The well has been
extended once (last year - see attachment).
Another well driller called earlier today and said he's been hired to abandon the existing plugged well and construct a
new one. He wanted to verify what form of approval was needed prior to replacing the well.
My thoughts are:
• Submit: a)construction details for planned well; and b) updated site map indicating where the replacement well
would be located
• Regional office verifies that new location is acceptable
• Regional office views replacement of well as "maintenance" and grants approval to construct new well (with no
permit action needed). Such action would be consistent with that taken with the Fast well extension (as
described in attachment).
• Submit new GW-1 Well Construction record after well completion.
Could you let us know whether the process described above is acceptable or if a formal permitting action would be
needed.
Please let us know if there are any questions.
Thanks
David May
Regional Supervisor
Division of Water Resources
Water Quality Regional Operations Section
1

943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
E-mail: david.ma v@ ncdenr.gov
htt p://www.ncwater.org/
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
2
cveiMt0
Fear iuueroal Use ONLY:
WELL CONSTRUCTION REC�
This form can be used far single or multiple wells
1. Well Contractor Information:
John Taylor
Well COmhactur Name
2435A
• L
i
•
NC Wall Coal -actor
Taylor Well Systems
t'ompany Name
2, Well Construction Permit #: 41 2 0' 7 410 3 23
List all applicable wail permits (i.e. Carve. State, Variance, Injection etc..)
3_ Well Use (check well use):
Water Supply Welt
❑Agricultural
°Geothermal (HeatinpfCoohng Supply)
° Ind ustrial/Commercial
°Irrigation
Non -Water Supply Well:
°Monitoring
°Municipal/Public
°Residental Water Supply (single)
❑Residential Water Supply (shared)
°Recovery
injection Well:
°Aquifer Recharge
❑ Aquifer Sttuage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
IDGeothermal (Heating/Cooling Return)
°Groundwater Remcdiatian
°Salinity Barrier
[7Stormwater Drainage
❑Subsidence Control
°Tracer
❑Other (explain under #21 Remarks)
4. Date Well(a) Completed: / ' 30'r f Well IDJI
5a. WeLl Location:
? remliz i5 lJA 6LG hiPr ly
Facility/OwnerNams I
Facility ID # (ifapplicablo)
Mat Pa4,f, 4_ bt. C1 ncaca.`�t .,sac a ll
Physical Address, City, and Zip
16 -
Comity Pa reel Idena5cation Na. (PIN )
5b. Latitude and Longitude in degrees/minutes/seconds ar decimal degrees:
(if well field. one latlloag is sufficient)
N W
6. la (are) the well(a)_ t;aPermanent or ❑Temporary
7_ Is this a repair to an existing welt El Yes or ONo
If this is a repair, fill out buow n wall construction information and sr plain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: 1
I•br multiple injection or non -water supply wells ONLY' with the same cow ruc ion, you can
submit one form
9. Total well depth below land surface: 160 (ff )
For multiple wails List all depths errbfercnt (example- 3@200' and 2[se)l0U')
10. Static water level below top of casing: (ft.)
y warerlevel is above casing, use "+"
11_ Borehole diameter:
(in.)
12. Well construction method:
Fmger, rotary, cable, direct push, etc.]
FOR WATER. SUPPLY WELLS ONLY:
13a. Yield (gpm) 60 Method of test: air
13b. Disinfection type: chlorine talcs Atonnnfr 50
. WATER ZONES
rROM
TO
10D tt•
160 it
11.
rt
pLtclurnow
soft rock
1S OUTER CASING jfor multi -cased wells} OR LINER Of appra abtel
ERODE TOD1AM(s DIAMETER Ttuc1 Nt s MATERIAL
ft. i
16.10inER CA3tr4G OR TUBING txao'rhermat dersed-sap)
EOM
TO
DIAMETER
THICENESS
MATERIAL
Ft.
f.
,e.
11.
in.
17. SCREEN -
Mom
ft.
-I1
S.
DIAMETER
is
sun siZ6
TRIMNESS
MATENAL
t.
ia-
1& GROUT
PROM
ft.
-ro
rt.
MATERIAL
R
R.
ft.
19. SANAIGRAVEL PACK {if appIknbley
FROM TO MATERIAL
fr.
ft
EMPLACEMENT MEIROD & ❑MOUrcr
ft_
EMPLACEMENT ME HOD
211. UR1LUNG LOC (attach addnfionel sheets if aeensarvl
DRUM TO DESCRIPTION tcaFar, hardaasq xtalfreektrpe, kniin cis.,
100 R 160 e- soft rock
5.
ft.
RELEIVFD'r 'PIRiOINP,
21. REMARKS
W
8ter [1tlAlti t�rrrn
fporatLnfl on
extended existing open bore to 160'
Nt+) e 1-r Art1.71s
22. Certification:
8y .rignirtg this form I hereby certify mat the walls) was (ware) constructed et accordance
with ISA NCAC 02C -0100 or ISANCAC 02C ,0200 WStJ Construction Standards and chat a
copy of this record has been provided m the well owner.
23. Site diagram or additional well details:
You may use the hack of this page to provide additional well site details ar well
coostraction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTUONS
24a. For All Wells: Submit this form within 30 days of caompletion of well
construction to the following:
Division of Water Resources, Information Processing Bait,
1617 Mail Service Center, Raleigh, NC 27699-1617
24h. For Infection Wells ONLY; lo addition to sending the form to the address in
24a above, also submit a copy of this farm within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Welts:
Also subunit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed
Form GW-I
North Carolina Department of Environment and Natural Resources - Division of Water Reaaurec5 Revised August 20l3

Ro g ers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Michael,
May, David
Thursday, November 13, 2014 10:35 AM
Rogers, Michael
Hart, William
GW-1 for WI0700323 -Beaufort County
DOC111314.pdf
FYI. Well driller dropped off the attached GW-1 for the above referenced site. Hard copy on the way via courier.
David May
Regional Supervisor
Division of Water Resources
Water Quality Regional Operations Section
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
E-mail: david.ma v@ ncdenr.q ov
htt p://www.ncwater.org/
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
1
Rogers, Michael
From: May, David
Sent: Friday, July 25, 2014 2:02 PM
To: [e-mail]; [e-mail] ,
Cc:
Subject:
Slusser, Thomas; Watts, Debra; Rogers, Michael; Hart, William; [e-mail]
Geothermal Injection \/\@II -Permit No . WI0TQ0323 -O'Ougherty Residence -1409 Potomac
Drive
Attachments: DOC041111.pdf
Mr. Taylor,
The geothermal heating/cooling water return well serving the above referenced property was originally permitted on
April 30, 2013 (permit attached).
Thank you for contacting our office regarding the potential need to modify the geothermal injection well at the above
referenced property. Based on available information, the well may be extended approximately 50 feet as discussed.
Please note that the well should not be extended to a depth that would result in interconnection of different aquifers or
an aquifer system that is different from that supplying the source water supply well.
As a condition of this approval, an updated GW-1 Well Construction Record shall be submitted to the Washington
Regional Office within 30 days of completion of any well modifications. For reference, our address can be found
below.
Please let me know if you have any questions.
Thanks
David May
Regional Supervisor
Division of Water Resources
Water Quality Regional Operations Section
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
E-mail: [e-mail]
http://www.ncwater.org/
E-:mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
1
ATA
FbENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Water Quality Programs
Pat McCrory Thomas A. Reeder John E. Skvarla, Ill
Governor Director Secretary
October 4, 2013
Bernard and Ella Dougherty
1409 Potomac Drive
Chocowinity, North Carolina 27817
RE: Groundwater Sampling Results
•r 5IL7 t;11C Pennit Vie10700323
Bernard and Ella Dougherty
Chocowinity, Beaufort County, NC
Dear Mr. and Mrs. Dougherty:
R-12 4
RECEIVEDIDENR!DWQ
OC f 0 9
AguiferPirotectian Section
On September 10, 2013, staff from the Washington Regional Office Division of Water Resources
collected samples from the influent (supply well) and effluent (injection or return well) from your
geothermal heat pump system. The samples were analyzed for metals, nutrients, and other inorganic
constituents by the Division of Water Resources laboratory_ A summary of the analytical results and the
laboratory reports are attached to this letter, Iron was detected at concentrations of 4200 ug/L and 4300
ug/L in the supply and injection wells, respectively; the Groundwater Standard for iron is 300 ug/L.
Manganese was detected at a concentration of 120 ug/L in both wells; the Groundwater Standard for
manganese is 50 ug/L,
The exact source of the exceedances is unknown; however, iron and manganese exceedances are often
due to naturally occurring conditions. While these exceedances should not affect the operation of your
geothermal heat pump system, it is recommended that you consult with the Beaufort County
Environmental Health Department before using the water from this well for personal consumption. If you
have any questions regarding the sampling results or your permit, please feel free to contact me at 252-
948-3911,
Will Hart, Hydrogeologist
Division of Water Resources
Water Quality Section
cc: Mr. Michael Rogers, PG Groundwater Protection Unit
Beaufort County Environmental Health Department
WaRO
Water Quality Section
943 Washington Square Mall, Washington, North Carolina 27899
Phone: [phone] FAX: [phone]
Internet: www,ncwaler,arn
An Equal opportunely 1 Aifirmalhre Action Employer

? C' tom (V 1O Laboratory .S•ection Results
County: BEAUFORT
River Basin
Report To WAROAP
Collector: W HART
Region WARD
Sample Matrix: GROUNDWATER
Loc. Type: WATER SUPPLY
Emergency Yes/No
COC Yes/No
OF wA��R�G
r"
Final Report
VisitlD
Sample lD: AC00112
PO Number # 13G0762
Date Received: 09111/2013
Time Received: 08:15
Labworks LoginID MSWIFT
Final Report Date: 9/30113
Report Print Date: 10/04/2013
Loc. Descr.t BERNARD AND ELLA DOUGHERTY 1409 POTOMAC CHOCAWINITY. NC
Location ID: WI323
Collect Date: 09110/2013
Collect Time: 09:10
Sample Depth
if this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
CAS # Analyte Name
LAB
PQL
Result)
Qualifier
Sample temperature at receipt by lab 1.3
Units
oC
Method Analysis Validated by
Reference Date
9111/13 RBYRD
MIC
Coliform, MF Fecal in liquid 1 1 B2Q1 CFU110Om1 APHA9222D-20th 9/11/13 ESTAFFORDI
Coliform, MF Total in liquid 1 1 B2Q1 CFU1100m1 APHA9222B-20th 9/11/13 ESTAFFORD1
WET
Ion Chromatography
TITLE mg/L EPA 300.0 9/19/13 MOVERMAN
Chloride
1.0 6.7 mgfL EPA 300.0 9/19/13 MOVERMAN
Fluoride 0.4 0.4 U mg/L EPA 300.0 9/19/13 MOVERMAN
Sulfate
2.0 3.8 mg/L EPA 300.0 9/19/13 MOVERMAN
Total Dissolved Solids in liquid 12 283 mglL APHA2540C-18TH 9/17/13 CGREEN
NUT
NO2+NO3 as N in liquid
0.02 0.02 U
mg/L as N Lac10-107-04-1-c 9/11/13 CGREEN
MET
7429-90-5 Al by ICP
50 50 U ug/L EPA 200.7 9119/13 ESTAFFORDI
7440-70-2 Ca by ICP
0.10 $7 mg/L EPA 200.7 9/19/13 ESTAFFORD1
7440-47-3 Cr by ICPMS 10 10 U ug/L EPA 200.8 9/17/13 ESTAFFORD1
7440-50-8 Cu by 1CPMS 2.0
2.0 U ug/L EPA 200.8 9/17/13 ESTAFFORD1
7439-89-6 Fe by ICP
50 4200 ug/L EPA 200.7 9/19113 ESTAFFORD1
7440-09-7 K by 1CP
0.10 1.5 mg/L EPA 200.7 9/19/13 ESTAFFORDI
7439-95-4 Mg by ICP
0.10 2.5 mg/L EPA 200.7 9/19/13 ESTAFFORD1
7439-96-5 Mn by 1CP
10 120 ug/L EPA 200.7 9/19/13 ESTAFFORD1
7440-23-5 Na by ICP
0.10 7.3 mg1L EPA 200.7 9/19/13 ESTAFFORD1
7440-02-0 Ni by ICPMS 2.0
2.7 ug/L EPA 200.8 9/17/13 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0
2,0 U ug/L EPA 200.8 9/17/13 ESTAFFORD1
7440-68-6 Zn by ICPMS 10 120 ug/L EPA 200.8 9117/13 ESTAFFORD1
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
For a detailed deer ipfiarl of the que i Ier Codes refer Iv hgelimal.nrxVenr.oralwcaiwallahJsta[flnfo teci•assiszMData Qualifier Codas .htiMmr5 ncden r_u rthva6twq/I 0j no f nfokechassisr>
Page 1 of 1

WC DUD La bora torn . Vection Resufts
County: BEAUFORT
River Basin
Report To WAROAP
Collector: W HART
Region: WARO
Sample Matrix: GROUNDWATER
Loc. Type: WATER SUPPLY
Emergency Yes/No
COC Yes/No
Sample ID: AC00113
PO Number# 13G0763
Date Received: 09/11/2013
Time Received: 08 15
Labworks Loginla MSWIFT
Final Report Date: 9130113
Report Print Date: 10/04/2013
VisiteD
Loc. Descr.: BERNARD AND ELLA DOUGHERTY 1409 POTOMAC CHOCAWINITY, NC
Location ID: W1323
Collect Date: 09/1012013
Collect Time: 09:31
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
LAB
Result!
Qualifier
Units
Method Analysis Validated by
Reference Date
Sample temperature at receipt by lab 1.3 'C 9/11/13 RBYRD
MIC
Coliform, MF Fecal in liquid
1 1 B2Q1 CFU1100ml APHA9222D-20th 9/11/13 ESTAFFORD1
Coliform, MF Total in liquid 1 1 B2QI CFU1100m1 APHA9222B-20th 9111113 ESTAFFORDI
WET
Ion Chromatography
TITLE mg/L EPA 300.0 9/19/13 MOVERMAN
Chloride
1.0 6.6 mgfL EPA 300.0 9/19/13 MOVERMAN
Fluoride 0.4 0.4 U mg/L EPA 300.0 9/19/13 MOVERMAN
Sulfate
2.0 3.9 mg/L EPA 300.0 9/19/13 MOVERMAN
Total Dissolved Solids in liquid 12 274 mg/L APHA2540C-18TH 9117/13 CGREEN
NUT
NQ2+NC3 as N in liquid
0.02 0.02 U
mgfL as N Lac10-107-04-1-c 9/11/13 CGREEN
MET
7429-90-5 Al by 1CP 50 50 U ug/L EPA 200.7 9/19/13 ESTAFFORD1
7440-70-2 Ca by 1CP
0.10 87 mg/L EPA 200.7 9/19/13 ESTAFFORD1
7440-47-3 Cr by ICPMS 10 10 U ug/L EPA200.13 9/17/13 ESTAFFORDI
7440-50-8 Cu by ICPMS 2.0
2.01j ug/L EPA 200.8 9/17/13 ESTAFFORDI
7439-89-6 Fe by 1CP
50 4300 uglL EPA 200.7 9/19/13 ESTAFFORDI
7440-09-7 K by I C P
0.10 1.5 mg/L EPA 200.7 9/19/13 ESTAFFORDI
7439-95-4 Mg by 1CP
0.10 2.5 mg/L EPA 200.7 9/19113 ESTAFFORDI
7439-96-5 Mn by ICP
10 120 uglt_ EPA 200.7 9/19/13 ESTAFFORDI
7440-23-5 Na by ICP
0.10 7.2 mg/L EPA 200.7 9119/13 ESTAFFORDI
7440-02-0 Ni by ICPMS
2.0 2.2 ugfL EPA 200,8 9/17/13 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0
2.0 U ug/L EPA 200.8 9/17/13 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 10 U ug/L EPA 200.8 9/17/13 ESTAFFORD1
Laboratory Sectiorv> 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
Fora detailed description of the qualifier cods refer to nue:Ilpartnl.ncdenr.anlwn6lwollab staffinkoliedeassatt61M 4ualifief Codes ehtliti/portal.ncdaor.oreheall eofiakikgfiknioitedissgist
Page 1 of 1

Permit Number WI0700323
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Bernard & Ella Dougherty SFR
Location Address
1409 Potomac Dr
Chocowinity
Owner
Owner Name
Bernard
Dates/Events
NC 27817
Dougherty
Scheduled
Orig Issue
04/30/13
App Received Draft Initiated Issuance
03/28/13
Regulated Activities
Heat Pump Injection
Outfall NULL
~-5A7_ -
Central Files: APS_ SWP_
05/07/13
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Beaufort
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Bernard Dougherty
Owner
1409 Potomac Dr
Chocowinity NC
Public Notice Issue
04/30/13
Effective
04/30/13
Requested/Received Events
Additional information requested
RO staff report requested
Additional information received
RO staff report received
27817
Expiration
04/30/18
04/10/13
04/11/13
04/11/13
04/23/13
Waterbody Name Stream Index Number Current Class Subbasin
Permit Number WI0700323
Central Files' APS SWP
04/25/13
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael.rog ers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Bernard & Ella Dougherty SFR
Location Address
1409 Potomac Dr
Chocowinity NC 27817
Owner
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
MajorlMinor
Minor
Region
Washington
County
Beaufort
Facility Contact Affiliation
Owner Name
Bernard
Dates/Events
Orig Issue
App Received
03/28/13
Regulated Activities
lieal Pump Injection
❑utfall NULL
Dougherty
Draft Initiated
Scheduled
Issuance
Owner Type
Individual
Owner Affiliation
Bernard Dougherty
Owner
1409 Potomac Dr
Chocowinity
Public Notice
ift1611
NC 27817
Effective
Re nested/Received Events
Additional information requested
RO staff report requested
Additional information received
RO staff report received
04/10/13
04/11/13
04/11/13
04/23/13
Waterbody Name Stream Index Number Current Class Subbasin

AVA,
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory John E. Skvarla, III
Governor Secretary
April 30, 2013
Bernard and Elia Dougherty
1409 Potomac Dr.
Chocowinity, NC 278I7
Re: Issuance of Injection Well Permit
Permit No. WI0700323
Issued to Bernard and Ella Dougherty
Beaufort County
Dear Mr. and Mrs. Dougherty:
In accordance with your application received March 28, 2013, 1 am forwarding Permit No. WI0700323
for the construction and operation of geothermal heating/cooling water return well located at the address
referenced above. This permit shall be effective from the date of issuance until April 30, 2018, and shall
be subject to the conditions and limitations stated therein.
Please Note the Following:
• Per Permit Condition Part L9, 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
Washington Regional Office within 30 days of completion of the injection well. Copies of
the GW-1 shall be retained on -site and available for inspection.
• Per Permit Condition Part II.1, each injection well, shall, be grouted the entire length of the
casing.
• PerPermit Condition Part II.4, within 30 days of injection WRIT completion and operation,
Permittee roust contact the Washington Regional Office APS; Staff to have influent and
effluent samples collected.
• During the site inspection by the Washington Regional Office on April 17, 2013, it was
observed that the supply well for the geothermal system was missing a well tag. The
regional office staff will be following up with you to have the tag installed.
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].
1601 Mail Service Center, Raleigh, North Carolina 27699-1601
Phone: 919-707-B6001 Internet: www,ncdenr.gav
Ars Equal Oppnrtunq t Affirmative Action Ernptoyer - 50% Recycled 110% post Consumer Paper
One
NorthCarohhna
Naturally

~ IL~--
· Michael Rogers, P.G: (NC f FL)
Hydrogeologist
cc: David May, Washington Regional Office
Central Office File, WI0700323
Beaufort County Environmental Health Department
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Bernard and Ella Dougherty
FOR THE CONSTRUCTION AND OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING
WATER RETURN WELL(S), 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 1409 Potomac Dr.
Chocowinity, Beaufort County, NC 27817, and will be constructed and operated in accordance with the
application received March 28, 2013, and additional information received April 11, 2013, and in conformity
with the specifications and supporting data, all of which are filed with the Department of Environment and
Natural Resources and are considered a part of this permit.
This permit is for 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 April 31, 2018, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the day oft-: , 2013
,310
riviCharles Wakild, P.E., Director
sion of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0700323
UIC/Retum Well - New Construction Page I of 5
ver. 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 Well Construction Record (Form GW-1) completed and signed by the well contractor, 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 Sq. 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
I. 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 #WI0700323 UIC/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.
4. Within 30 days of injection well completion and operation, Permittee must contact the Washington
Regional Office APS Staff to have influent and effluent samples collected.
5. 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.
6. The injection well system must be constructed with sampling ports so that system influent and effluent
may be sampled.
7. Each injection well must be constructed to a depth such that it is not injecting groundwater of~ lower
quality from a supply aquifer (if present).
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the 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.
Permit #WI0700323 DIC/Return Well -New Construction
ver. 07/2012
Page 3 ofS
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.
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this 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 rui
acceptable sampling reporting schedule shall be followed. 1
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 #WI0700323 DIC/Return 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 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 .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 pwpose, the
Permittee shall abandon that i.Itjection well in accordance with the procedures specified in ISA NCAC 2C
.0240, including but not limited to the following:
(A)
(B)
(C)
(D)
(E)
(F)
(G)
All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
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.
In the case of gravel-packed wells i~ 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.
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.
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:
Permit #Wl0700323
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/Return Well -New Construction
ver. 07/2012
Page 5 of5
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: A pril 19 , 2013
To: APS Central Office
Central Office Reviewer: Michael Ro gers
Permittee(s): Bernard & Ella Dou gherty
Permit No.: WI0700323
County: Beaufort
Project Name: Dou ghe rtv Geothermal
Regional Login No: __ _
L GENERAL INFORMATION
1. This application is (check all that apply): D SFR Waste Irrigation System IZI UIC Well(s)
IZI New D Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation IZI Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IZI Yes or D No.
a. Date of site visit: A pril 17 . 2013
b. Person contacted and contact information: Mr. David Bernier. HY AC Contractor
c. Site visit conducted by: Will Hart
d. Inspection Report Attached: D Yes or IZI No.
2. Is the following information entered into the BIMS record for this application correct?
IZI Yes or D No. Ifno, please complete the following or indicate that it is correct on the current application.
For UIC Injection Sites:
(If multi ple sites either indicate which sites the information a pp lies to, co py and paste a new section into the
document for each site , or attach additional pa ges for each site )
a. Location(s): __
b. Driving Directions: __
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __ Method Used (GPS, Google™, etc.); __
IL INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description of Well(s) and Facilities -New, Renewal, and Modification
1. Type of injection system:
IZI Heating/cooling water return flow (5A 7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (5L/"Non-Discharge")
D Other (Specify: )
APS-GPU Regional Staff Report (Sept 09)
RECEIVED/DENR/DWQ
APR 2 3 2013
Aquifer Protection Section
Page I of 2 Pages
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
2. Does system use same well for water source and injection? ❑ Yes ® No
3. Are there any potential pollution sources that may affect injection? ❑ Yes ® No
What is/are the pollution source(s)? . What is the distance of the injection well( s) from the pollution
source(sJ? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? 50 ft.
5. Quality of drainage at site: ❑ Good ® Adequate ❑ Poor
b. Flooding potential of site: ❑ Low ® Moderate ❑ 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? ❑ Yes ❑ No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: NIA
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? ® Yes or ❑ 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,
III. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the Application: The distance between the proposed
return well and the residence is probably closer to 50 feet than the reported 35 feet. The return well will be
located approximateh 25 feet from the suppir well.
2. Attach new Injection Facility Inspection Form, if applicable
3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes F451 No. If yes, please explain
briefly.
4. 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:
5. Signature of report Preparer(s):
Signature of APS regional supervisor:
-I
Date: '._L
L
r�%
.ru f
APS-GPU Regional Staff Report (Sept 09) Page 2 of 2 Pages

Rogers, Michael
From: Rogers, Michael
Sent:
To:
Thursday, April 25, 2013 12:36 PM
Hart, William
Subject: RE: WI0700323 -Dougherty
Also, I forgot to mention in the previous e-mail, during your follow-up inspection w/sampling please obtain the estimated
injection rate and total gallons injected per day. The application had a 35 GPM rate and a. daily total average of 35 gallons.
Finally, after the site inspection please provide the as built well construction info for both the supply and return well.
Thanks
From: Hart, William
Sent: Monday, April 22, 2013 2:57 PM
To: Rogers, Michael
Subject: WI0700323 -Dougherty
My completed staff report is on its way to you. The well ID tag was missing from the existing supply well; I told the
contractor to make sure one is there when I ~eturn to sample.
Will Hart, Hydrogeologist
Division of Water Quality/ Aquifer Protection Section
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
william.hart @ncdenr.gov
Telephone: [phone]
Fax: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties.
1
Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Thursday, April 25, 2013 12:32 PM
Hart, William
Subject: RE: WI0700323 -Dougherty
Can you confirm that the supply well is that the same general depth as the proposed return well?
From: Hart, William
Sent: Monday, April 22, 2013 2:57 PM
To: Rogers, Michael
Subject: WI0700323 -Dougherty
My completed staff report is on its way to you. The well ID tag was missing from the existing supply well; I told the
contractor to make sure one is there when I return to sample.
Will Hart, Hydrogeologist
Division of Water Quality/Aquifer Protection Section
Washington Regional Office.
943 Washington Square Mall
Washington, NC 27889
william.hart @ncdenr.gov
Telephone: [phone]
Fax: [phone]
E-mail correspomfence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties.
1
Ro gers, Michael
From: May, David
Sent:
To:
Thursday, April 11, 2013 4:46 PM
Rogers, Michael
Cc: Hart, William
Subject: RE: WI0700323 Dougherty Geothermal
Received.
David May, Regional Aquifer Protection Supervisor Division of Water Quality Aquifer
Protection Section
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
E-mail: ~avid.may@ ncdenr.gov
http://portal.ncdenr.org/web/wg/
E-mail correspondence to and from this address may be subject to the North Carolina Public
Records Law and may be disclosed to third parties.
-----Original Message-----
From: Rogers, Michael
Sent: Thursday, April 11, 2013 12:20 PM
To: May, David
Cc: Hart, William
Subject: FW: WI0700323 Dougherty Geothermal
Attached is permit application for a geothermal return well and staff report request.
Thanks
-----Original Message-----
From: Michael Rogers [mailto:[e-mail]]
Sent: Thursday, April 11, 2013 10:48 AM ·
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 04.11.2013 10:48:24 (-0400)
Queries to: robin.markha m@ ncdenr.gov
1
Rogers, Michael
From:
Sent:
To:
Subject:
Hart, William
Monday, April 22, 2013 2:57 PM
Rogers, Michael
WI0700323 -Dougherty
My completed staff report is on its way to you. The well ID tag was missing from the existing supply well; I told the
contractor to make sure one is there when I return to sample.
Will Hart, Hydrogeologist
Division of Water Quality/ Aquifer Protection Section
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
[e-mail]
Telephone: [phone]
Fax: [phone]
E-mail correspondence tu and from this address may be subject tu the North Carolina Public Records Law and may be disclosed tu third parties.
1
Ro gers, Michael
From:
Sent:
To:
Bernie [[e-mail]]
Thursday, April 11, 2013 9:05 AM
Rogers, Michael
Subject:
Attachments:
Fw: WI0700323 Dougherty Geothermal Permit
Dougherty Well Permit App._pdf
Importance: High
Mr. Rogers-
Here are the responses to the questions you posed:
2. Yes. 100 feet
3. Approximately 35 feet
4. 100 feet
5. 60 feet
6. No
Please let me know what the next step(s) will be and how much longer will be needed before I
can have the work actually begin.
Thank you.
Bernard Dougherty
-----Original Message-----
From: Bernie
Sent: Wednesday, April 10, 2013 4:38 PM
To: Rogers, Michael
Subject: Re: WI0700323 Dougherty Geothermal Permit
Mr. Rogers-
My wife has signed the document and it is attached.
As for your questions, the only two that I can answer right now are :
#3: Approximately 35 feet
#6: No.
I have left a voice message for my contractor to assist in responding to your other questions
and will respond no later than tomorrow.
Thank you.
-----Original Message-----
From: Rogers, Michael
Sent: Wednesday, April 10, 2013 3:39 PM
To: choco1409 @suddenlink.net
Cc: wellman j t @centurylink.net
Subject: FW: WI0700323 Dougherty Geothermal Permit
Mr. Dougherty-
1
We received your permit application for a geothermal return well. Thank you.
I have a few questions/comments:
1. Attached is the signature page of the application. Since both you and your wife are
owners/operators of the well, we need the signature of Ella Dougherty also. Please have her
sign the page and send back. You may if you wish, scan in the page and send back in reply to
this e-mail.
2. Is the existing well going to be a supply well for the proposed injection well? If so,
please provide the well depth.
3. What is the approximate distance of the proposed well to the house?
4. What is the total depth of the well?
5. What is the depth of the casing?
6. Is there a septic tank/field on the property?
Please provide this information for us to continue to process the geothermal permit
application .
If you have any questions or comments please contact me. Thank you for your cooperation.
Regards
-----Original Message-----
From: Michael Rogers [mailto:[e-mail]]
Sent: Wednesday, April 10, 2013 3:17 PM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
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Queries to: robin.markha rr@ ncdenr.gov
2
Ro gers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Mr. Dougherty-
Rogers, Michael
Wednesday, April 10, 2013 3:39 PM
'choco1409@suddenlin_k.net'
'[e-mail]'
FW: WI0700323 Dougherty Geothermal Permit
20130410151642492.pdf
We received your permit application for a geothermal return well. Thank you. I have a few
questions/comments:
1. Attached is the signature page of the application. Since both you and your wife are
owners/operators of the well, we need the signature of Ella Dougherty also. Please have her
sign the page and send back. You may if you wish, scan in the page and send back in reply to
this e-mail.
2. Is the existing well going to be a supply well for the proposed injection well? If so,
please provide the well depth.
3. What is the approximate distance of the proposed well to the house?
4. What is the total depth of the well?
5. What is the depth of the casing?
6. Is there a septic tank/field on the property?
Please provide this information for us to continue to process the geothermal permit
application.
If you have any questions or comments please contact me. Thank you for your cooperation.
Regards
-----Original Message-----
From: Michael Rogers [mailto:[e-mail]]
Sent: Wednesday, April 10, 2013 3:17 PM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 04.10.2013 15:16:42 (-0400)
Queries to: robin.markha m@ ncdenr.gov
1
A VA
NCDENR
North Carolina Department of Environment and.Natural Resources
Division of Water Quality
Pat McCrory Charles Wakild, P.E. John E. Skvarla,111
Governor Director Secretary
April 8, 2013
Bernard Dougherty — Owner
Ella Dougherty
1409 Potomac Dr_
Chocowinity, NC 27817
Dear Mr. Dougherty:
Subject: Acknowledgement of
Application No, WI0700323
Bernard & Ella Dougherty SFR
Injection Heating/Cooling
Water Return Well System
Beaufort County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on 03/28/2013. 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 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
Michael Rogers at (9I9) 807-6406 or [e-mail]
cerely,
1
for Debra f.W�atts
Groundwater Protection Unit Supervisor
cc: Washington Regional Office, Aquifer Protection Section
John Taylor — Taylor Well Systems, 2030 Taylor Rd., Chocowinity, NC 27817
Permit File W10700323
AQUIFER PROTECTION SECTION
1536 Mail Service Center, Raleigh, North Carolina 27699-1636
Location:512 N. Salisbury St, Raleigh, North Carolina 27604
Phone; 919-807-64641 FAX: [phone]
Internet; www,ncwateraualitv,orq
An Equal opportunity 1 Afirmalive Aclian Employer
NorthCarolina
Vatulra/4j

A QUIFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: A pril 11 , 2013
To: D Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS
D Andrew Pitner, MR.O-APS
0 Rick Bolich, RRO-APS
i:gj David May, WaRO-APS
0 Morella Sanchez King, WiRO-APS
0 Sherri Knight, W-SRO-APS
From: Michael Rogers Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E-Mail: Michael.Rogers@ ncdenr.gov
A. Permit Number: WI 0700323
B. Owner: Dougherty
C. Facility/Operation: ~
i:gj Proposed D Existing . D Facility D Operation
D. Application:
1. Permit Type: D Animal D SFR-Surface Irrigation□ Reuse D H-R Infiltration
D Recycle D 1/E Lagoon . D GW Remediation (ND)
i:gj UIC -Geothermal Heating/Cooling Water Re.turn Well
For Residuals: D Land App. D D&M D Surface Disposal
D 503 D 503 Exempt D Animal
2. Project Type: igj New D Major Mod. D Minor Mod. D Renewal D Renewal w/ Mod.
E. Comments/Other Information:
NOTE: The location of the proposed return well is approximately 35 feet from the house. If the field inspection
shows less than 25 feet, a variance may be needed. Please record all information on the well tag of the existin g
supply well, if present, and put on staff report. Thanks .
i:gj Return a completed APSARR after the site inspection. At a later date, after sampling & the lab
results are received, please send us a copy of the letter you send to the Permittee containing
laboratory analytical results.
D Attach Well Construction Data Sheet.
0 Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: --------------------
F ORM: APSARR 07/06 Page I of I
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELLS
These wells inject groundwater directly into the subsurface as part of a geothennal heating and cooling system
(check one) _L New Application Renewal* Modification ---
* For renewals complete Parts A-C and the signature page.
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 3 /4 ~ . 2013 RECEIVED/DENR/DWQ
I
PERMIT NO. w::t,,6 fJ)J 3J.J (leave blank if New Application) MAR 2 8 20i3
A. STATUS OF APPLICANT (choose one) Aquifer Protection Section
Non-Government: Individual Residence~ Business/Organization __
Government: State Municipal __ County __ Federal
B. WELL OWNER/PERMIT APPLICANT -For individual residences. list owner(s) on property deed. For all
others. list name of entity and name of person delegated authority to sign on behalf of the business or agency: _
b e.4'~R/l-n ~ Yu.A o ov11✓~1t1Y
-7
Mailing Address: /y'!J f J'o 10MAC, "])Alt/I[
City: ' V.oww,J ✓r State:..VC.,,zip Code:~~~~t~l Z~ ___ County ~flt.J;'d'it?
Day Tele No.: ,.,<, ., Z... ·• Y'. • 'Z. 7 p Cell No.:
EMAIL Address:CA'PCO /ff!J ") e_, 5v i)?)t,-Jt.11..1,t',.~ax No.:
C. WELL OPERA TOR (if different from well owner) -For individual residences. list owner(s) on property
deed. For all others. list name of entity and name of person delegated authority to sign on behalf of the
business or agency: :5 /'J~ ~:, /l ,1)?1//i
Mailing Address: _____________________________ _
City: ____________ State: __ Zip Code: ______ County : _____ _
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
D. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1) Parcel Identification Number(PIN) ofwell site:L~63/ County: 8 1:;;11tJr O~>°
(2) Physical Address (if different than mailing address): 50l'tlf'. /Is ..#{7t}YI{
City: _______________ State: NC Zip Code: ________ _
GPU/UIC 5A7 Permit Application (Revised 2/13/2013) Page 1
E. WELL DRILLER INFORMATION
F .
G.
H.
Well Drilling Contractor's Name: 7a 1/0 Y' w~ II f y J fe. m .f Io l ,J E1 lol
NC Well Drilling Contractor Certification_ No.: _1,_L/_?__,_r__,_f/ _______________ _
Company Name: L1/a., 1,ye.,,/1 (.j; J-t..h !
Contact Person: 5;.. l .,.; Tc'1 / o ✓
&1h1 Rd
EMAIL Address: 1,,ve./1 lbc-c! T f {;) e-4,,)h/ J;,)
Address: ) O ) Q
City: C ) (.,1<f-' Zip Code: _J. 73 / 7 State: }JL.::.1.,,_ County: ~B~<_c~t_(,;.,_,_f_-____ _
Office Tele No.:.,2 C:2. -'j if.]-[$ -12 Cell No.: ________ Fax No.: _______ _
~~Sr¼6¥r1-
HV AC CONTRACTOR INFORMATION (if different than driller) ~-~) ~-
HY AC Contractor's Name: 3!lf ~ /Z.~A-
NC HVAC Contractor License No.: ________________________ _
CompanyName: D . /S ~ ~ J-~-
Contact Person: -6V?. A. EMAIL Address: ___________ _
Address: B ;u.,/ )/e/U? ' '--' /2..[)
City: J~_,.,, k-. Gf<--. 'p Code: ;),rB Jlt/ State~ounty: _______ _
Office Tele No.: (t,~1,) ~~-7--:99' fe llNo.: ________ FaxNo.: _____ _
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?
NO X
NO X
YES ___ _
YES ___ _
WELL CONSTRUCTION REQUIREMENTS-As specified in ISA NCAC 02C .0224(d ):
(I) The water supply well shall be constructed in accordance with the water supply well requirements of
ISA 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.
GPU/UIC SA 7 Permit Application (Revised 2/13/2013) Page 2
•JJ.
o/
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 geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(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) ? C gallons per minute (gpm).
(2) Injection Volume: Average (daily)~< gallons per day (gpd).
(3) Injection Pressure: Average (daily) la pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
K. SITE MAP-As specified in I SA NCAC 02C .0224 (b)(4 ). attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in I SA NCAC 02C .0107(a )(2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the pare.el 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: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GJS 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.
GPU/UIC SA 7 Permit Application (Revised 2/13/2013) Page 3
L. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NICAC 02C .0211(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer,
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by 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.
"1 hereby certify, under penalty of Iaw, 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 for obtaining said information, I believe thatthe information is true, accurate and
complete. r am aware that there are sigriifcant 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 and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Print A Type Full Name
Signature of Property Own
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:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636 RECEIVEVIDEgRIDWQ
Telephone [phone] MAR 28 20i 3
Aquifer Protection Section
GPU/UIC 5A7 Permit Application (Revised 2/13/2013) Page 4

L. CERTIFICATION (to be signed as required below or by that person's authorized agent)
"A NCAC 02C .0211(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
for a partnership or sole proprietorship: by a general partner or the proprietor, respectiv
3. br a municipality or a state, federal, or other public agency: by either a princip executive
icer or ranking publicly elected official;
4, for 11 others: by the well owner (person's) listed on the property deed).
If an authori d agent is signing on behalf of the applicant, then supply a tter signed by the
applicant that n , es and authorizes their agent to sign this application on th ' behalf.
"1 hereby certify, undL
submitted in this docun
immediately responsible
complete, I am aware that t
for submitting false informatio
injection well and all related ap
the Permit."
Submit two copies
penalty of law, that I have personally examined and am
-.nt and all attachments thereto and that, based on
obtaining said information, 1 believe that the
re are significant penalties, including the p
. 1 agree to construct, operate, maintain
rtenances in accordance with the a
ignature of rip
.miliar with the information
inquiry of those individuals
formation is true, accurate and
sibility of fines and imprisonment,
epair, and if applicable, abandon the
roved specifications and conditions of
plicant
eyeA, 'to %-7 0.4,10-aleet7
Print r Ty Full Name
S' • nature of
roperty Owner/Applicant
Print or Type Full • me
Signature of Authorized Ag
Print or Type Full Name
the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
it, if any
RECEIVE r ' ENRIDWQ
MAR 2 2
Aquifer Protection
GPUJUIC 5A7 Permit Application (Revised 2J13/2013)
Page 4

GEOTHERMAL HEATING/COOLING 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.
open -Hole Well Design
Proposed ❑ Existing
,Injection; ❑. Supply;
❑ Dual Purpose
Lod Surface
Record Depths Below
Lund Surface on Lines
Provided
f Q c? (FL)
10D
(Ft.)
Return or Supply Line
Casing
Grout
Screened Well Design
[rProposed ❑ Existing
❑ Injection; ❑ Supply;
❑ Dual Purpose
WELL DETAILS
Casing Material:
f
1'
Casing Diameter (in.): 5�
Casing Thickness (in.): 5-4il e 110
Grout Type:. "Lr+7o,-,)T-€ 5 ,l'
(cement, bentonite, or mix)
Screen Material:
Screen Slot Size (in.):
Sand/Gravel Pack
Material:
PAC4
Bedrock
Open lloie
Bentonite Seal
(if presen0
Sand/Gravel Pack
Screen
i
(Ft.)
Record Depths Below
Land Surface no Lines
Provided
(FL)
(Ft.)
(Ft.)
(Ft.)
NC Certified Well Driller Name Lro r)
f a .fA / Certification # _2 y3i ,

PERMITTED 6,056 SF
❑FF1SITE 187 SF
PQ.CoMP,C DR -�
C]R1V 1,348 SF
h
27 MAR 2006
40'
WALK 268 SF
SITE PLAN NO.4
3ERNIE & ELLA DOUGHERTY
LOT 331 © 1409 POTOMAC DRIVE
CYPRESS LANDING, CHOCOWINITY, NC
(RVS METS AND BOUNDS PER BOOK RE G52 PAGE 5
DOCUMENT NO. 2005002634 MAP 2 PGS 04/08/2005)
0 40' 80' 1201
SCALE: 1 " = 40.0'
3036.31
r I1�3
\ -6" \‘.6
31 8
orf tit‘
CL .3D. SB
160'
LOT 332