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Home My WebLink AboutWI0700458_GEO THERMAL_201711081/V:ID :J-0 0 ~SJJ RECE\VEDINCDEQfDWR NOVO 8 2017 Water Quality Reg)onal Operations Section ROY COOPER Governor MICHAEL S. REGAN Secretary Water ·Resources Environmental Quality LINDA CULPEPPER Kevin Mayer 432 Mill Road November 6, 2017 Washington, North Carolina 27889 SUBJECT: Dear Mr. Mayer: Groundwater Sampling_Results UIC Permit No. WI0700458 Issued to Kevin and Denise Mayer Washington, Beaufort County, North Carolina Interim Director Staff from the Washington Regional Office of the Water Quality Regional Operations Section collected samples of the influent (supply well) and effluent (injection well) from your geothermal heat pump system on September 13, 2017. The samples were analyzed for metals, nutrients, and other inorganic constituents by the Division of Water Resources laboratory. A summary table of the analytical results, as well as the laboratory reports, field sampling forms, and definitions of laboratory data qualifiers are attached to this letter. The following five constituents were detected above state groundwater standards in both samples from your system: Parameter Units NC Groundwater Results Standard Fecal Coliform Colony Forming Units 1 3 (injection well-effluent) ~. per 100 milliliters (CFU/l00ml) Total Coliform Colony Forming Units 1 14 (supply well-influent) per 100 milliliters 33 (injection well-effluent) (CFU/lO0ml) Iron Micrograms per Liter 300 1300 (supply well-influent), (ug/L) 920 (injection well-effluent) Manganese Micrograms per Liter 50 210 (supply well-influent) (ug/L) 210 (injection well-effluent) pH Standard Units 6.5 to 8.5 6.0 (supply well-influent) 6.0 (in jection well-effluent) ..-:--__:::,,--,Nothing Compares~:... .......... State ofNor1h Carolina I Environmental Quality !Water Quality Regional Operations Section-Washington Office 943 Washington Square Mall, Washington, North Carolina 27889 252-946-6481 Kevin Mayer November 6, 2017 Page 2 of2 These exceedances should not affect the use of the wells for your geothermal heat pump system; however, it is recommended before using the water from these wells for personal consumption that you consult with the Beaufort County Health Department. If you have any questions regarding the sampling results or your pemiit, please feel free to contact me at (252) 948-3849. Attachments J#-;e4 ~~ Dwight Randy _Sipe, P.G., Hydrogeologist Water Quality Regional Operations Section Division of Water Resources, NCDEQ cc: Shristi Shrestha -DWR Groundwater Protection Unit, Central Office Beaufort County Health Department WaRO North Carolina Diets -too of Water Resources Central Laboratory (Water Sciences Section) Water Sample Collection & Submittal Form IinstK (aptmnol}- • ID Influen AC42874 tamt:al De dmioi : WI0700458 - Mayer SFR Location iCods: W10700458 . � = a?ne ieeeledr ' 'Corn iy: Beaufort , Collector., R Sipe Pt !orgy: Water• • „ F • i' wcorEbir•nipe. - a ` ;• . ''""�a ❑Ambient ❑River/Stream M Lake x^ j 7kile?R ,-r •/-¢' , u DWRRegion: WaFtO {based on county?, DWRQbke:r vvaRos WaRQ (oragencynameJ' ❑ Routine ❑ Surface ❑ Estuary ❑Starmwater ii Cabal ' i:• .R , '` li(fYier Bask' Tar - Pamlico date: 9113/2O t 7 ? OCompliance ❑ MC El Ground❑Mor ❑ Waste Mormon ❑WaterSupply ❑Effluent ❑influent :q [ :s _..''- • " • l7$6�ieiyr>64'etbpdr ; -, ' „ifs t , ;s.• h As to Courier _ j Hand Delivery ❑Other Antes: Time: - j 15 PM 4. ❑ Gflormated ❑De-chlonnated In Fed _ B Groh iJComposde Other ❑Emergency DOA ❑ Blank ❑ Solution ❑Field ❑ Blank ❑Tnp Blank Filter Lean* Other Geotherm SuppEy Wei} %�' � 'r' :yy- • T r *474 • i,�: %lrrlvnl; \s, .-. ^ ;' r `ti i ' III Olssofvedanalysis Eimer"DIS" Feared in Field in check -heals for parameters � "� Sarripdetreptne N/A Cafterxor'�Corrrir 3` •,- sample c ollected from port at well pump • Makoblology Paraineterf: - - ;- -,:5; . _ MBAS (surfactants) mg/L . . Metals Para mete -a; • -•?-, _ . '' _ = TM (Snj pg/L Acidity, as CaCO3, to pH 4.5/8 3 nt8/1 Oil and Grease, HEM, Total Recoverable mg/L X Aluminum (Al) pg/L Thamum (Ti) pg/L Alkalintty, as CaCO3, to pH 4 5/8 3 mg/L Phenols, Total Recoverable pRAL Antimony (St) PO- Vanadium (V) pg/L I HOD ax h iiicat Oxygen Demand, 5-day mg/L r Restidue Total Irani } mg/L X Arsenic (As) pg/L X Zinc (Zn) µgJL cool] Carbonaceous 800, 5-day mg/L Residue Volatile/Fixed, Total mg/L Leaman (Ba) pg/L X Coliform' Fecal MF /1DOmi Residue. Suspended ]Suspended Solids ] mg/L Beryllium (Be) pg/L Boron (B), Total Lrg/L X Calform. Total MF /100mI Residue. Volatile/Fixed, Suspended mgJi Cadmium (Cdl lfgA Mercury 1631, low-level rrg/L Conform Tube Fecal /Mpml X TD5 - Total Dissolved Solids mg/L X c um (Ca) ma Culirorm Tube Total /lOoml 58ma mg/L X _Ca Chromrum (Cs),Total pg/L ''? organics Pararrleten:.' •l,•':.i - , Specific Conductance, at 25 °C umboakm Sulfide mg/L Cobalt (Col p@IL Acid Herbicides TOC-Total Organic Carbon mg/L Tannin & Lignin rn$/L X Copper (Cu) PO- Organochlorme Pesticides :Turbidly - - NTU X ~ Iron (Fe) pg/L r Organonitrugen Pesticides OtherPa nietanc ` • X Lead (Pb) MA Organophosphorus Pestictdes Wet Chenilstry Parameters: PH s u Lithium (Le] NBA PCBs (potychlonratted bipt:enyis) ' Bromide mg/L Hardness, Total as CaOU3 - by titration mg/L X Magnesium (Mg) mglt X Chloride mar X Manganese (Mn) pg/L Semi -Volatile Organics (BNAs] Fluoride mg/L Mercury (Ng) pg/L TPH Diesel Range Sulfate mg/L • = ' Nuttietitd•Parameteis: Molybdenum (Ma) pg/L Chlorophyll a Lig/L Ammonia as N (NH3-N) mg(L X Nickel (Nil wilt Volatile Organics (VOA) Color ADM1 c u X Nitrate -Nitrite as N (NO3+NO2-N) mg/L X Patasssum (X) nas Color Platanum Cobalt c u Total l4ekdah1 Nitrogen as N (TKN) mg/L Selenium (Se) }rg/L TPH Gasolene Range COD Chemical Oxygen Demand mg/L Total Phosphorus as P rill mg/L Silver (Ag) pg/L Cyanide, Total mg/L X Nit rteasal (NO2-N) mg/L X Sodium (Na] mgli- • , •B ologicbi:•,- - _ - - , Formaldehyde mg/L Nitrate as N (NO3-N calculated) mg/L Strontium (Sr) pg/L Phytoplankton j Algae Hexavalent Chromium (Cr6+j mg/L 4Orthophosphate as P (PO4) mg/L Thallium (Til WA lA8COMMENTS : Field Pa rametersfoprionarjr •• WaterTemp (DC)- 'fi Dissolved Okygen (ppmr): f Cariductivrtyt}imlios�erri): r • ti Sallnitj�{pp]],� Revision 2106/2015 AC42874 North Carolina Division of Water Resources Water Sciences Section Laboratory Results Loe. Descr.: MAYERSFR Sample ID: AC42874 County: BEAFORT Collector: RSIPE VisltlD PO Number# Region : WARO Report To ~ Location ID: Wl0700458 Date Received : 09/14/2017 River Basin TAR Collect Date: 09/13/2017 Priority COMPLIANCE Time Received : 08:20 Emergency Collect Time: 13:15 Sample Matrix: gROUNDWATER Labworks LoginlD TASCENZO1 COC Yes/No Sample Depth Loe. Type: OTHER:GEOTHERMAL Delivery Method NC Courier Final Report Date: 10/13/17 Report Print Date: 10/30/2017 Final Re ~ort If this report Is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes. Result/ Units Method Analysis CAS# Anal yte Name PQL Qualifier Reference Date Validated by LAB Sample temperature at receipt by lab 1.1 ·c 9/14/17 MSWIFT MIC C91iform, MF Fecal in liquid 1 B2Q1 CFU/100ml SM 9222 D-1997 9/14/17 ESTAFFORD1 Coliform, MF Total in liquid 1 14 Q1 CFU/100ml SM 9222 B-1997 9/14/17 ESTAFFORD1 NUT Nitrate as N in liquid 0.02 0.02 U mg/Las N EPA 353.2 REV 2 10/13117 CGREEN Nitrite as N in liquid 0.01 0.01 U mg/Las N EPA 353.2 REV 2 9/15117 CGREEN N02+N03 as N in liquid 0 .02 0.02 U mg/Las N EPA 353.2 REV 2 9/19/17 CGREEN WET Bron,ide 0.4 0.4 U mg/L EPA 300.0 rev2.1 9114/17 CGREEN Chloride 1.0 5.2 mg/L EPA 300.0 rev2.1 9/14/17 CGREEN Fluoride 0.4 0.4 U mg/L EPA 300 .0 rev2 .1 9/14/17 CGREEN Sulfate 2.0 2.0 U mg/L EPA 300.0 rev2 .1 9/14/17 CGREEN Total Dissolved Solids in liquid 12 298 mg/L SM 2540 C-1997 9/19/17 CGREEN MET 7429-90-5 Al by ICP 50 50 U ug/L EPA200.7 Rev4.4 9/22/17 ESTAFFORD1 7440-38-2 As by ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 9/20/17 ESTAFFORD1 7440-70-2 Ca by ICP 0.10 64 mg/L EPA 200. 7 Rev4.4 9/22117 ESTAFFORD1 7440-47-3 Cr by ICPMS 5.0 5.0 U ug/L EPA 200.8 Rev5.4 9/20/17 ESTAFFORD1 7440-50-8 Cu by ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 9/20117 ESTAFFORD1 7439-89-6 Fe by ICP 50 1300 ug/L EPA 200.7 Rev4.4 9/22/17 ESTAFFORD1 7440-09-7 K by ICP 0.10 4.8 mg/L EPA 200.7 Rev4.4 9/22/17 ESTAFFORD1 7439-95-4 Mg by ICP 0.10 12 mg/L EPA 200.7 Rev4.4 9122/17 ESTAFFORD1 7439-96-5 Mn by ICP 10 210 ug/L EPA 200.7 Rev4.4 9/22/17 ESTAFFORD1 7440-23-5 Na by ICP 0 .10 13 mg/L EPA 200.7 Rev4 .4 9122/17 ESTAFFORD1 7440-02-0 Ni by ICPMS 2.0 2.0 U ug/L EPA 200 ,8 Rev5 .4 9/20/17 ESTAFFORD1 7439-92-1 Pb by ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 9/20/17 ESTAFFORD1 7440-66-6 zn·by ICPMS 10 10 U ug/L EPA 200.8 Rev5.4 9/20/17 ESTAFFORD1 WSS Chemistry Laboratory» 1623 Mall Service Center, Raleigh, NC 27699-1623 (919) 733-3908 "Not Detected" or "U" does not indicate the sample Is analyte free but that the analyte is not detected at or above the POL. Page 1 of 1 North Carolina Division of Water Resources Central Laboratory (Water Sciences Section) • Water Sample Collection & Submittal Form Vfsit �' [vptienai); Tug m.: �''� AC42875 Locution Desthptiorr:• Wl0700458 - Mayer SFR Location Code: W10700458 10700458 "' � - r. • potpReceitrac { County:: Beaufort Collector. R Sipe Prdvrrty: Wg+ter Marrfx. ❑ Surface r�ISI Ground u ❑ Waste 0 Blank ❑Solution ' s _Location Tyre: . ❑River/Stream ❑Lake ❑Estuary ❑Canal • Stormwater ❑ Momtaring Well ❑ Water supply ['Effluent ❑ Influent ['Field Mark ❑Trip Blank ❑ Fitter Blank ❑Other Geotherm injection Well • Timefierelverp ' Q'4 V DWI? Region: WaRO Acseaon county) OVIIRO ice: WC IROS - WBRD (or myencyname] . Ambient ❑ Routine • ifecOved 8y • ' • River Bashi: Tar - ParnliCB • Date: 9/13/2017 Compliance -� �airier Delivery Metho(G , ❑ and Delivery : ❑other Notes, Time: i al PM 0 ccc ❑ Emergency DOA ❑ Chlorinated ❑oe-chlorinated in Field Sampling Grab ❑Cormposda Ifdethodi _ Other -T_ emperature.{ *Cf l[ i 1 an Arrival : ' Dissolved analysis Eller 0I5' Pillared in Field §ciarge Depth: (VIA Fa in check -braes r parameters•1 • Cpireefrur's Comments. sample collected from spigot at well head iF ,Microbiology, Paraitietari:=, Ai _. , r r•� v_ 4:4'"r" MBAS (surfactants) mg/L -+ Mehala;Paranie r n, 7, ':-' ' S z • •. ,•, -Tin (5n) pall. Acidity, as CaCO3, to pH 4 sit 3 mg/L Oil and Grease, HEM, Total Recoverable ing/L X Aluminum (At) pg/L Titanium (Ti) pall. Alkalinity, as CdcO3, to pH 4.5/8 3 mg1L Phenols, Total Recoverable Cali Antimony (SW pg/L Vanadium M pall BOD Biochemical Oxygen Demand, 5-day mall +Residue Tutai (Tata:Solids) mg/L X Arsenic (As) pg/L )t Zinc (in) pall cBOD Carbonaceous BOD, 5-day mall Residue Volatile/Fated, Total mg/L Barium (Ba) pg/l X Coliform Feral N1F /1OOml Residue Suspended (Suspended Solids) mg/L Beryllium (Be) pall. Moran (B), Total pg/L X Coliform• Total MF /10Oml Residue Valatle/fixed, Suspended mg/i. Cadmium (Cd) pg/L Mercury 1531., low-level ngfl Coliform Tube Fei:ai /1001n1 X TDS -Total Dissolved Solids mglL X Calcium (Ca) mg/L CohFarm Tube Total /10Dm1 Silica mg/L ' X LChromIll m (Cr), Total pg/L Organics Paiarneteis: :'� ; _ . ; , ::r 'Y Specdic Conductance, at 25 `C umhesjrm Sulfide mg/L Cobalt (C:o) pg/1. Acid Herbicides TOC- Total Organic Carbon malt Tannin & Lignin mg/L X Cooper(Cul pall Organochlonne Pesticides Turbidity NTU X Iron (Fe1 {rail Organomtrogen P sbccdes ' . , Other Parameterss:- • _ - ) X Lead (Pb) Frg/L Organophosphorus Pesticides _" Wet Chemistry Parameters:. .. pH - s u Lithium (U) jtgji PCBs (polyc lonnated biphenyls) Bromide mg/L Hardness,Tota! as CaCO3- by titration mglL X Magnesium (Mg) mgJL - X Chloride mg/i. X Manganese (Mn) pg/L Semi -Volatile Organics (BNAs) Fluonde mglL Mercury (Hg) pall TPH Diesel Range Sulfate mg/L ' • • Nutria n Pararneteisi''• Molybdenum (Ma) pall Chlorophyl] a pg/L Ammonia as N (NH3-N} mall X Nickel (Nil pCll Volatile Organics (VOA) Color ADMI c,u X Nitrate -Nitrite as N (NO3+NO2-N) mall X Potassium (l(.j mg&L Color Platinum Cobalt . c u Total Kjeidahl Nitrogen as N (TItN) mglL Selenium (Se) pat TPH Gasoline Range { COD Chemical Oxygen Demand mg/L Total Phosphorus as P (TP) mall Silver (Ag) pg/L Cyanide, Total mg/L X Nitrite as N (NO2-N] mg/L X Sodium (Na) mall • Bl4146lcai: - ... _ to ' Formaldehyde mall Nitrate as N (NO3-N calculated) mall Strontium (Sr) Mall— Phytoplankton / Algae Hexavalent Chromium (Cr6+) mg/L Orthophosphate as P (PO4) mglL Thalhum (TI) }call ,—. LAB cOMMMMENTS Field Para metersloprlanoil: Wa€erTemp f ). pN•(s'u j - 6 DIsw)ired Oxygen ippm): Candii_i thiity ({rrirFias/trn}: Salinity (ppt} Revision 24%6/2015 AC42875 North Carolina Division of Water Resources Water Sciences Section Laborato [Y Results Loe. Descr.: MAYERSFR Sample ID: AC42875 County: BEAFORT Collector: RSIPE VlsltlD PO Number# Region : ~ Report To ~ Location ID: WI0700458 Date Received : 09/1412017 River Basin ms Collect Date: 09/13/2017 Priority COMPLIANCE Time Received : ~ Emergency Collect Time: ~ Sample MatriK : GROUNDWATER Labworks LoginlD TASCENZO1 COC Yes/No Sample Depth Loe. Type: OTHER:GEOTHERMAL Delivery Method NC Courier Final Report Date: 10113/17 Report Print Date: 10/30/2!117 Final Re ~ort If this report Is labeled prellminary report, the results have not been validated. Do not use for Regulatory purposes. Result/ Units Method Analy:sis CAS# Anal l1e Name PQL Qualifier Reference Date Validated b~ LAB Sample temperature at receipt by lab 1.1 ·c 9/14117 MSWIFT MIC Coliform, MF Fecal in liquid 3 Q1 CFU/100ml SM 9222 D-1997 9/14/17 ESTAFFORD1 Coliform, MF Total in liquid 33 Q1 CFU/100ml SM 9222 B-1997 9114/17 ESTAFFORD1 NUT Nitrate as N in liquid 0.02 0.02 U mg/Las N EPA 353 .2 REV 2 10/13/17 CGREEN Nitrite as N in liquid 0.01 0.01 U mg/Las N EPA3532 REV 2 9/15/17 CGREEN NO2+NO3 as N in liquid 0.02 0.02 U mg/Las N EPA 353 .2 REV 2 9/19/17 CGREEN WET Bromide 0.4 0.4 U mg/L EPA 300.0 rev2.1 9/14/17 CGREEN Chloride 1.0 5.2 mg/L EPA 300 .0 rev2.1 9/14/17 CGREEN Fluoride OA 0.4 U mg/L EPA 300 .0 rev2 .1 9114/17 CGREEN Sulfate 2.0 2.0 U mg/L EPA 300 .0 rev2 .1 9/14/17 CGREEN Total Dissolved Sol ids in liquid 12 300 mg/L SM 2540 C-1997 9/19/17 CGREEN MET 7429-90-5 Al by ICP 50 50 U ug/L EPA 200 .7 Rev4.4 9/22/17 ESTAFFORD 1 7440-38-2 As by ICPMS 2.0 2 .0 U ug/L EPA 200 .8 Rev5.4 9/20117 ESTAFFORD1 7440-70-2 Ca by ICP 0.10 64 mg/L EPA 200.7 Rev4.4 9/22i17 ESTAFFORD1 7440-47-3 Crby ICPMS 5.0 5.0 U ug/L EPA 200 .8 Rev5.4 9120/17 ESTAFFORD1 7440-50-8 Cu by ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5 .4 9/20117 ESTAFFORD1 7439-89-6 Fe by ICP 50 920 ug/L EPA 200.7 Rev4 .4 9122/17 ESTAFFORD1 7440-09-7 K by ICP 0.10 4 .9 mg/L EPA 200 .7 Rev4 .4 91221 17 ESTAFFORD1 7439-95-4 Mg by ICP 0.10 12 mg/L EPA 200 . 7 Rev4 .4 9122117 ESTAFFORD1 7439-96-5 Mn by ICP 10 210 ug/L EPA 200.7 Rev4 .4 9/22117 ESTAFFORD1 7440-23-5 Na by ICP 0.1 ,0 13 mg/L EPA 200.7 Rev4 .4 9122/17 ESTAFFORD1 7440-02-0 Ni by ICPMS 2.0 2.0 U ug/L EPA 200 .8 Rev5 .4 9/20117 ESTAFFORD1 7439-92-1 Pb by ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 9120117 ESTAFFORD1 7440-66-6 Zn by ICPMS 10 10 U ug/L EPA 200.8 Rev5.4 9/20/17 ESTAFFORD1 WSS Chemistry Laboratory» 1623 Mall Service Center, Raleigh, NC 27699-1623 (919) 733-3908 "Not Detected" or "U" does not indicate the sample is analyte free but that the analyte is not detected at or above the PQL. Page 1 of 1 Symbol A B BB C Definition NC DEQ WSS LAB DATA QUALIFIER CODES Value reported is the mean (average) of two or more determinations. This code is to be used if the results of two or more discrete and separate samples are averaged. These samples shall have been processed and analyzed independently (e.g. field duplicates, different dilutions of the same sample). This code is not required for BOD, coliform or acute/chronic metals reporting since averaging multiple results for these parameters is fundamental to those methods or manner of reporting. 1. The reported value is an average, where at least one result is qualified with a "U", The PQL is used for the qualified result(s.) to calculate the average. Results based upon colony counts outside the acceptable range and should be used with caution. This code applies to microbiological tests and specifically to membrane filter (MF) colony counts. It is to be used If less than 100% sample was analyzed and the colony count is generated from a plate in which the number of colonies exceeds the ideal ranges indicated by the method. These ideal ranges are defined in the method as: Fecal coliform or Enterococcus bacteria: 20-60 colonies Total coliform bacteria: 20-80 colonies 1. 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 ttie counts on all filters reported per 100 ml. 5. Too many colonies were present; too numerous to count (TNTC). TNTC is generally defined as >150 colonies. The numeric value represents the maximum number of counts typically accepted on a filter membrane (60 for fecal or 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 undeMepresent actual density. Note: A "B" value shall be accompanied by justification for its use denoted by the numbers listed above (e.g., Bl, B2, etc.). Note: A "J2" should be used for spiking failu.res. This code applies to most probable number (MPN) microbiological tests. 1. No wells or tubes gave a positive reaction. Value based upon the appropriate MP.N Index and reported as a less than "<" value. 2. All wells or tubes gave positive reactions. Value based upon the MPN Index and reported as a greater than ">" value. Note: A "BB" value shall be accompanied by justification for its use denoted by the numbers listed above (e.g., BBl, BB2, etc.). Total residual chlorine was present in sample upon receipt in the laboratory; value is estimated. Generally applies to cyanide, phenol, NH3, TKN, coliform, and organics. QualifierCodes07242017 8/2/2017 1:33 PM 1 OF 4 G M NC DEQ WSS LAB DATA QUALIFIER CODES A single quality control failure occurred during biochemical oxygen demand (BOD) analysis . The sample results should be used with caution. 1. 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/Land/or a DO residual of at least 1.0 mg/L. 4. Evidence of toxicity was present. This is generally characterized by a significant increase in the BOD value as the sample concentration decreases. The reported value is calculated from the highest dilution representing the maximum loading potential and should be considered an estimated value. 5. The glucose/ glutamic acid standard exceeded the range of 198 ± 30 .5 mg/L. 6. The calculated seed correction exceeded the range of 0 .6 to 1.0 mg/L. 7. Less than 1 mg/L DO remained for all dilutions set. The reported value is an estimated greater than value and is calculated for the dilution using the least amount of sample. 8. Oxygen usage is less than 2 mg/L for all dilutions set. The reported value is an estimated less than value and is calculated for the dilution using the most amount of sample. 9 . The DO depletion of the dilution water blank produced a negative value. Note: A "G" value shall be accompanied by justification for its use denoted by the numbers listed above (e.g ., Gl, 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. The reported value failed to meet the established quality control criteria for either precision or accuracy. 3. The sample matrix interfered with the ability to make any accurate determination. 4 . The data is questionable because of improper laboratory or field protocols (e.g ., composite sample was collected instead of grab, plastic instead of glass container, etc .). 5. Temperature limits exceeded (samples frozen or >6°C) during transport or not verifiable (e.g., no temperature blank provided}: non-reportable for NPDES compliance monitoring. 6. The laboratory analysis was from an unpreserved or improperly chemically preserved sample. The data may not be accurate . 7. This qualifier is used to identify analyte concentration exceeding the upper calibration range of the analytical instrument/method . The reported value should be considered estimated. 8. Temperature limits exceeded (samples frozen or >6QC) 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 PQL and greater than the laboratory method detection limit. 10. Unidentified peak; estimated value. 11. The reporte·d value is determined by a one-point estimation rather than against a regression equation . The estimated concentration is less than the laboratory PQL and greater than the instrument noise level. This code is used when an MDL has not been established for the analyte in question. 12 . The calibration verification did not meet the calibration acceptance criterion for field parameters . Note: A "J" value shall be accompanied by justification for its use denoted by the numbers listed above (e.g ., Jl, J2, etc.}. A "J" value shall not be used if another code applies (e.g., N, V, 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 analyses of a sample. QualifierCodes07242017 8/2/2017 1:33 PM 2 OF 4 N Q p s u uu V X y z NC DEQ WSS LAB DATA QUALIFIER CODES Presumptive evidence of presence of material; estimated va lue . 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 est imated concentration is less than the laboratory PQL 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. Th is code is used when an MDL has not been established for the ana/yte in question . 5. The component has been t~ntatively identified based on a retention time standard. 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 . Elevated PQL due to matrix interference and/or sample dilution. Not enough sample provided to prepare and/or analyze a method-required matrix spike (MS) and/or matrix spike duplicate (MSD). Indicates that the analyte was analyzed for, but not detected above the reported PQL. The number value reported with the "U" qualifier is equal to the laboratory's PQL *. Indicates that the analyte was not detected by a screen analysis. The number value reported with the "UU" qualifier is equal to the laboratory's PQL. The number value was determined by a one-point estimation at the PQL, rather than against a regression equation. Indicates the analyte was detected in both the sample and the associated blank . Note : The value in the blank shall not be subtracted from the associated samples . 1. The analyte was detected in both the sample and the method blank. 2. The analyte was detected in both the sample and the field blank 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 analys is lost or not performed-lab error. Note : an "X" value shall be accompanied by justificati on for its use by the numbers listed. Elevated PQL due to insufficient sample size. The sample analysis/results are not reported due to: 1. Inability to analyze the sample. 2. Questions concerning data reliability. The presence or absence of the analyte cannot be verified . QualifierCodes07242017 8/2/2017 1 :33 PM 3 OF 4 MDL ML PQL Supporting Definitions listed below NC DEQ WSS LAB DATA QUALIFIER CODES A Method Detection Limit (MDL) is defined as the minimum concentration of a substance t hat can be measured and reported with 99 percent confidence that the true value is greater than zero and is determined in accordance with 40 CFR Part 136, Appendix B. Minimum Levels are used in some EPA methods. A Minimum Level (ML) is the lowest level at which the entire analytical system must give a recognizable signal and acceptable calibration point for the analyte . It is equivalent to the concentration of the lowest calibration standard, assuming that all method -specified sample weights, volumes, and cleanup procedures have been employed . The ML is calculated by multiplying the MDL by 3 .18 and rounding the result to the nearest factor of 10 multiple (i.e., 1, 2, or 5). For example, MDL= 1.4 mg/L; ML= 1.4 mg/L x 3.18 = 4.45 rounded to the nearest factor of 10 multiple (i.e ., 5) = 5 .0 mg/L The Practical Quantitation Limit (PQL) is defined as the lowest concentration that can be reliably achieved within specified limits of precision and accuracy during routine laboratory operating cond itions. PQLs are subjectively set at some multiple of typical MDLs for reagent water (generally 3 to 10 times the MDL depending upon the parameter or analyte and based on the analyst's best profess ional judgement, the quality and age of the instrument and the nature of the samples) rather than explic itly determined . PQLs may be nominally chosen within these guidelines to simplify data reporting and, where applicable, are generally equal to the concentration of the lowest non-zero standard in the calibration curve . PQLs are adjusted for sample size, dilution and % moisture . For parameters that are not amenable to MDL studies, the PQL may be defined by the sample volume and buret graduations for titrations or by minimum measurement values set by the method for method-defined parameters (e.g ., BOD requires a minimum DO depletion of 2.0 mg/L, fecal coliform requ i res a minimum plate count of 20 cfu, total suspended residue requires a min i mum weight gain of 2.5 mg, etc .). Additionally, some EPA methods prescribe M i nimum Levels (Mls) and the lab may set the PQL equal to this method-stated ML. Determination of PQL is fully described in the laboratory's analytical Standard Operating Procedure (SOP) document. QualifierCodes07242017 8/2/20171:33 PM 4 OF 4 Water Resources Environmental Quality July 5, 2017 Kevin and Denise Mayer 432 Mill Road Washington, NC 27889 Re: Issuance of Injection Well Permit Permit No. WI0700458 Geothermal Heating/Cooling Water Return Well Beaufort County Dear Mr. and Mrs. Mayer: ROY COOPER Governor MICHAEL S. REGAN Secretary S. JAY ZIMMERMAN Director In accordance with your permit application received June 27, 2017, and additional information received July 3, 2017, I am forwarding Permit No. WI0700458 for the construction and operation of geothermal heating/cooling water return well(s) located at the above referenced address. This permit shall be effective from date of issuance, until June 30, 2022, and shall be subject to the conditions and limitations stated therein. Please Note: • Please contact the Washington Regional Office (WaRO) of the Division of Water Resources (252-946-6481) within 30 days after the geothermal well becomes operational to arrange to collect samples from the influent and effluent sampling ports. Laboratory analytical results will then be forwarded to you when it becomes available. • Also, please send copies of the Well Construction Record (GW-1), which is signed by the well contractor, to the WaRD and Central Office in Raleigh within 30 days after constructed (addresses are available on attached permit). You may email the copy to my attention at my email address referenced below. In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this permit is not transferable to any person without prior notice to, and approval by, the Director of the Division of Water Resources. If you have any questions regarding your permit or the Underground Injection Control Program, please call me at (919) 807-6412, or email at Michael.Rogers@ncdenr.gov. hing Compares -- State of North Carolina E Environmental Quality ; Division of Water Resources Water Quality Regional operations Section 1636 Mail Service Center I Raleigh Norrli Carolina 27699-1636 919-707-9129 Best Regards, ~ R---- Michael Rogers, P.~. ~ & FL) Underground Injection Control (UIC) Manager -Hydrogeologist Division of Water Resources, NCDEQ Water Quality Regional Operations Section cc: David May & Randy Sipe, Washington Regional Office Central Office File, WI0700458 Beaufort County Environmental Health Department Page2 of2 NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION DEPARTMENT OF ENVIRONMENTAL QUALITY RALEIGH, NORTH CAROLINA PERMIT FOR THE USE OF A WELL FOR INJECTION In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable Laws, Rules, and Regulations PERMISSION IS HEREBY GRANTED TO Kevin and Denise Mayer FOR THE CONSTRUCTION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S), defined in Title 15A North Carolina Administrative Code 02C .0224(a), which will be used for the injection of heat pump effiuent. The injectionwell(s) located at 432 Mill Road, Washington, Beaufort County, NC 27889, will be constructed in accordance with the application submitted June 27, 2017, and conformity with the specifications and supporting data received July 3, 2017, all of which are filed with the Department of Environmental Quality and are considered a part of this permit. This permit is for construction 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 June 30, 2022, and shall be subject to the specified conditions and limitations set forth in this perniit. Permit issued this the 5th day of July 2017 <}v\ S. Jay Zimmerman, P.G. ~ Director, Division of Water Resources By Authority of the Environmental Management Commission. Permit #W[0700458 UIC/5A7 ver. 11/15/2015 Page 1 of5 PART I -PERMIT GENERAL CONDITIONS 1. The Permittee shall comply with all conditions of this permit and with the standards and criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Noncompliance with conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is grounds for enforcement action as provided for in N.C.G.S. 87-94 2. This permit is effective only with respect to the nature, volume of materials and rate of injection, as described in the application and other supporting data [15A NCAC 02C .021 l(a)]. 3. This permit shall become voidable unless the facility is constructed in accordance with the conditions of this permit, the approved plans and specifications, and other supporting data [15A NCAC 02C .0211(1)]. 4. This permit is not transferable without prior notice and approval. In the event there is a desire for the facility to change ownership, or there is a name change of the Permittee, a formal permit amendment request must be submitted, including any supporting materials as may be appropriate, at least 30 days prior to the date of the change [15A NCAC 02C .021 l(q)]. 5. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all regulatory requirements have been met [15A NCAC 02C .0203]. PART II -WELL CONSTRUCTION GENERAL CONDITIONS 1. The well supplying water for the geothermal heating and cooling system shall be constructed in accordance with the requirements of rule 15A NCAC 02C .0107 except as required in Item #2 below. 2. Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC 02C .0107 except that the entire length of the casing shall be grouted in such a way that there is no interconnection of aquifers or zones having differences in water quality that would result in degradation of any aquifer or zone. For screened wells, grout shall be emplaced from the top of the gravel pack to the land surface. For open- end wells, the casing shall be grouted from the bottom of the casing to the land surface [15A NCAC 02C .0224(d)(2),(3)]. 3 . Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are probable, such as coastal areas, chloride levels shall be verified in the field to determine existing conditions. [15A NCAC .0225(g)(8)]. 4. The injection well system shall be constructed such that a sampling tap or other collection equipment approved by the Director provides a functional source of water when the system is operational. Such equipment shall provide the means to collect a water sample immediately after emerging from the water supply well and immediately prior to injection into the return well [15A NCAC 02C .0224(d)(4)]. 5. Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed with a watertight cap or well seal as defined in G.S. 87-85(16). 6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .01070)(2)]. Permit #Wf0700458 UIC/5A7 ver. 11/15 /2015 Page 2 of 5 7. A completed Well Construction Record (Form GW-1) shall be submitted as described in Part VI.1 of this permit. PART III -WELL CONSTRUCTION SPECIAL CONDITIONS 1. At least forty-eight ( 48) hours prior to constructing each injection well, the Perm.ittee shall notify the Underground Injection Control (UIC) Central Office staff, telephone number 919-807-6496 and the Washington Regional Office Staff, telephone number 252-946-6481. [15A NCAC 02C .021 l(k)]. 2. Within 30 days ofinjection well completion/operation, the Permittee shall contact the Washington Regional Office Staff in order to have samples collected at the source well and injection well. [15A NCAC 02C .021 l(k)] PART IV -OPERATION AND USE CONDITIONS 1. The Permittee shall comply with the conditions of this permit and properly operate and maintain the injection facility in compliance with the conditions of this permit and the rules of 15A NCAC 02C .0200, even if compliance requires a reduction or elimination of the permitted activity [ 15A NCAC 02C .0211 G)]. 2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface water or groundwater resulting from the operation of this facility. In the event that the facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective actions that may be required, such as the repair, modification, or abandonment of the injection facility [15A NCAC 02C .0206]. PART V-INSPECTIONS [15A NCAC 02C .0211(k)] 1. Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may, upon presentation of credentials, enter and inspect any property, premises, or place on or related to the injection facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or copy any records that must be maintained under the terms and conditions of this permit, and may obtain samples of groundwater, surface water, or injection fluids. 2. DWR representatives shall have reasonable access for purposes of inspection, observation, and sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90. 3. Provisions shall be made for collecting any necessary samples of tlie injection facility's activities. PART VI-MONITORING AND REPORTING REQUIREMENTS 1. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of such activities. Copies of such records shall be retained on-site and available for inspection [15A. NCAC 02c .0224(±)(2), (4)J. 2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State and compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C .0224(f)(l)]. Permit #Wl0700458 UlC/5A7 ver. 1 I /J 5/2015 Page 3 of5 3. The Permittee shall report any monitoring or other information that indicates noncompliance with a specific permit condition, that a contaminant may cause a violation of applicable groundwater quality standards, or that a malfunction of the injection system may cause the injected fluids to migrate outside the approved injection zone or area. As specified in rule 15A NCAC 02C .021 l(r), noncompliance notification shall be as follows: (A) Oral notification shall be given within 24 hours of the occurrence, or first knowledge of the occurrence, to the Washington Regional Office, telephone number 252-946-6481. (B) Written notification shall be made within five days of the occurrence and submitted to the addresses in Item #5 below. (C) The written notification shall contain a description of the noncompliance and its cause; the period of noncompliance, including dates and times; if the noncompliance has not been corrected, the anticipated time it is expected to continue; and any steps taken or planned to reduce, eliminate, and prevent reoccurrence of the noncompliance. 4. The Permittee shall record the number and location of the wells with the register of deeds in the county in which the facility is located. [15A NCAC 02C .0224(f)(3)]. 5. All forms, reports, or monitoring results required by this permit shall be submitted to: UIC Program Staff Division of Water Resources 1636 Mail Service Center Raleigh, NC 27699-1636 and Water Quality Regional Operations Section DWR Washington Regional Office 943 Washington Square Mall Washington, NC 27889 PART VII-PERMIT RENEW AL [15A NCAC 02C .0224(c)] As required by rule an application for permit renewal shall be made at least 120 days prior to the expiration date of the permit. This permit condition does not apply if the Permittee chooses to discontinue operation of the well for injection of effluent from the geothermal heating and cooling system associated with this permit. PART VIII -CHANGE OF WELL STATUS [15A NCAC 02C .0240] 1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 1 SA NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of complying with all applicable regulatory requirements. 2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to rule 15A NCAC 02C .0113(b) in order to prevent the well from deteriorating and acting as a source or conduit of contamination, which is prohibited by General Statute 87-88( c ). 3. If a well is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well seal that cannot be removed without the use of hand or power tools. Permit #Wl0700458 UIC/5A7 ver. 11 /I 5 /20 l 5 Page 4 of 5 4. When injection operations have ceased at the facility and a well will no longer be used for any purpose, the Pennittee shall permanently abandon that injection well in accordance with the procedures specified in 15A NCAC 02C .0113(b), which include, but are not limited to, the following: (A) All casing and materials may be removed prior to initiation of abandonment procedures if such removal will not be responsible · for, or contribute to, the contamination of an underground source of drinking water. (B) The entire depth of each well shall be sounded before it is sealed to insure freedom from obstructions that may interfere with sealing operations .. (C) Each well shall be thoroughly disinfected prior to sealing in accordance with rule I SA NCAC 02C .011 I(b)(I)(A), (B), and (C). (D) Each well shall be completely filled with cement grout, which shall be introduced into the well through a pipe which extends to the bottom of the well and is raised as the well is filled. (E) In those cases when a subsurface cavity has been created as a result of the injection operations, each well shall be abandoned in such a manner that will prevent the movement of fluids into or between underground sources of drinking water. (F) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in ISA NCAC 2C .0224(f)(4) within 30 days of completion of abandonment. 5. The written documentation required in Part VIII (4)(F) shall be submitted to the addresses specified in Part VI.S above. Permit #Wl0700458 UIC/SA7 ver. 11/15/2015 Page 5 ofS AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT REGIONAL STAFF REPORT Date: 7/3/17 Permittee(s): Kevin & Denise Mayer Permit No.: TBD - To: WQROS Central Office County: Beaufort Central Office Reviewer: Shristi ShresthaProject Name: Geothermal HeattngCooling Return Well Regional Login No: f. GENERAL INFO.RIILI TION 1. This application is (check nti that apply): ❑ SFR Waste Irrigation System ® UIC Well(s) ® New ❑ Renewal ❑ Minor Modification ® Major Modification ❑ Surface irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/infiltration Lagoon ❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 503 exempt ❑ Distribution of (Residuals n Surface Disposal ❑ Closed -loop Groundwater Remediation ® Other Injection Wells (including in situ rernediation) Was a site visit conducted in order to prepare this report? ® Yes or ❑ No. a. Date of site visit: 7/3117 b. Person contacted and contact information: Kevin Mayer (252) 945-5921 c, Site visit conducted by: R. Sipe & D. May d. Inspection Report Attached: ® Yes or ❑ No. ?. Is the following information entered into the BIMS record for this application correct? ® Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application. For SFR Treatment Facilities: a. Location: b. ❑riving Directions: c. USGS Quadrangle Map name and number: d. Latitude: _ Longitude: Method Used (GPS, GoogleTM, etc.); c. Regulated Activities 1 Type of Wastes (e.g., subdivision, food processing, municipal wastewater): For U1C Injection Sites: (if multiple sites either indicate which sites the information applies to. cop, and paste a new section into the document for each site. or attach additional Pages for each site) a. Location(s): 432_Mi 11 Rd. Wasl)ingfon NC 27889 b. Driving Directions: From Hwy 17 go approx. 0.5 mi. east on Mill Rd. and site is on left. c. USGS Quadrangle Map name and number, d. Latitude: 35.624735N Longitude: 77.056401 W Method Used (GPS, GoogleTM, etc.); Google Earth. APS•CPU Regional Staff Report (Sept (19) Page I of ('ages AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT REGIONAL STAFF REPORT IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat pump injection wells.) Description of Well(s) and Facilities -New, Renewal, and Modification I . Type of injection system: ~ Heating/cooling water return flow (SA 7) 0 Closed-loop heat pump system (SQM/SQW) 0 In situ remediation (SI) 0 Closed-loop groundwater remediation effluent injection (SL/"Non-Discharge") 0 Other (Specify: ___j 2. Does system use same well for water source and injection? 0 Yes ~ No 3. Are there any potential pollution sources that may affect injection? 0 Yes ~ No What is/are the pollution source( s )? --~·-W~h=a~t =is'--t=h=e-=d=is=t=an=c=e'-'o=f--'t=h=-e __,_,in-'-'j=ec=t=io=n'----\'"'""'=-e=ll(""sc.L) ~fr=o=m~th=e ...... p"'"'o=l=lu=ti=o~n source(s)? ft. 4 . What is the minimum distance of proposed injection wells from the property boundary? ,._;20 feet. 5. Quality of drainage at site: ~ Good O Adequate D Poor 6. Flooding potential of site: ~ Low D Moderate D High 7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes O No. Attach map of existing monitoring well network if applicable . If No, explain and recommend any changes to the groundwater monitoring program: NA 8. Does the map presented represent the actual site (property lines, wells, surface drainage)? l8J Yes or D No. If no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and north arrow. See ma p in Ins pection Re port Injection Well Permit Renewal and Modification Only: 1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e .g. turbid water, failure to assimilate injected fluid, poor heating/cooling)? 0 Yes O No. NA new S 1stem. 2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance or last inspection? D Yes D No. If yes , ex p lain: NA 3. For renewal or modification of g roundwater remediation permits ( of an y type), wi 11 continued/additional/modified in ·ections have an adverse impact on mi gration of the plume or mana gement of the contamination incident? 0 Yes D No . If yes . ex p lain: NA /\PS -GPU Regional Slaff Report (Sept 09) Page 2 of 4 Pages AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT REGIONAL STAFF REPORT 4. Drilling Contractor: Name: Jay Gurganus Jr. Address: 9369 Us mw 264 East Washington , NC 27889 NC Certification number; 2180-A S. Complete and attach NEW Injection Facility Inspection Report, ifapplicable See attached ins pection re port. V. EVALUATION AND RECOMMENDATIONS I. Provide any additional narrative regarding your revit!w of the Application: Based on observations made durin l$ the site visit, discussions with the a pplicant and driller. and review of the a pp lication ; WaRO recommends that permit be issued. 2. Attach new illjectio11 Facility l1tspectio11 Form, if applicable 3. Do you foresee any problems with issuance/renewal of this permit? D Yes !8:] 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 Stire 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 --~--·· /\I'S-GPU Regional Staff Repon (Sept 09) Page 3 of 4 Pages AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT REGIONAL STAFF REPORT 7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ hold, pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information; El Issue; ❑ Deny. Elderly, please state reasons; S. Signature of report Preparers): !, �(A-1 { R , Signaturee of APS regional supervisor: Dale; / _-- /! s-f // W. ADDITIONAL INFORMATION AND SITE MAP (Sketch of site showi►ne house and waste irrikatio►r system, sprat} or drip field, location of well(s), and/or other relevant information- SNOW NORTH ARROi J Ai'S-GI'IJ Regional StaffRepor (Sept 09) 'age. 4 of4 rages North Carolina Department of Environment and Natural Resources Division of Water Quality -Aquifer Protection Section INJECTION FACILITY INSPECTION REPORT PERMIT NO. TBD DATE OF INSPECTION: 7/3/17 INSPECTOR: R~ Sipe and D. May w/WQROS WaRO NAME OF PERMITTEE(S) Kevin & Denise Mayer MAILING ADDRESS OF PERMITTEE: 432 Mill Rd,, Washington, NC 27889 PHYSICAL ADDRESS OF SITE (if different than above) _______________ _ PERSON MET WITH ON-SITE Jimmy Morris; TELE NO. (252)945-5921 WELL(S) STATUS: __ Existing and operating ClassV Well __ Existing well proposed to be 'converted to Class V well _X_Proposed/not constructed LAT/LONG OF WELL(S) 35.624735N, 77.056401 W Appx. distance of well to property boundaries:~ 20 feet Appx. distance of well from foundation of house/structure: ~ 60 feet Appx. distance of well from septic tank/field (if present):~ 150 feet Appx. distance of well to other well(s) (if present): Proposed inj . well approx. 100 feet from supply well. Appx. distance to other sources of pollution: __________________ _ Flooding Potential of Site: _high __ moderate ____K_low Comments: Based on observations made during the site visit, discussions with the a pp licant and driller. and review of the a pp lication , WaRO recommends that permit be issued Injection Facility Insp. Report (Rev. Sept 2009) Page I ofJ Pages DRAW SKETCH OF SITE ABOVE (Show property boundaries, buildings, other wells, septic tanlcr/drain fields, other potential pollution sources, roads, approximate scale, and NORTH arrow) See schematic submitted with application. Draw Schematic of well above showing TD, casing depth, grout, etc. Injection Facility Insp. Report (Rev. Sept 2009) Page 2 of' 3 Pages . Well Construction Information Date Constructed: TBD Well Contracting Company: Jay Gurganus Well Driller Name: Jay Gurganus NC Well Cert. No.: 2180-A Address: 9369 Us Hwy 264 East, Washington, NC 27889 Telephone No.:(252)923-8251 Email Address: NI A Proposed Depth ofWell(s): 120 feet Total Depth: TBD Casing (proposed) Depth: 0 to 98; Diameter: 2 inches; Type (gav. steel, PVC, etc.): Sch. 40 PVC; Stick Up: TBD, Est. 18 inches. Grout: (proposed) . Depth: 0 to 98 feet minimum); Type (cement, benton~te; etc.):Bentonite; Placement (pumping, press. etc.):TBD Well ID Plate Present (Y or N):. _NA_; Heat Pump ID plate present (Y or N): _NA_ Influent spigot (Y or N): __ N_· _ Effluent spigot (Y or N): __ Y __ Well Sampled? (Y or N): _NA_; If Yes, Lab Sample ID numbers: Static Water Level: TBD Injection Information (if applicable): Injection Rate: GPM ------- Injection Pressure: PSI Injection Volume: GPD Temperature-Summer: F° Temperature-Winter: F0 Comments/Notes: Inj. well to be constructed similar to existing supply well with the exception that its annular space is proposed to have bentonite grout from ground surface to the base of the well casing. fnjection Facility lnsp. Report (Rev. Sept 2009) Page 3 of3 Pages Rogers, Michael From: Sipe, Randy Sent: Monday, July 03, 2017 3:13 PM To: Rogers, Michael; Shrestha, Shristi R Cc: May, David; Watts, Debra Subject: RE Geothermal Return Weil Application - Kevin Mayer Residence - Washington, Beaufort County WI0700458 called Mr. Mayer and he stated he checked with the system manufacturer and he had given the wrong pressure on the application. The correct pressure is a maximum of 20 psi. Dwight Randy Sipe P.G. Hydrogeologist II Water Quality Regional Operations Section Division of Water Resources 252 948 3849 office randy.sipe a{�ncdenr.gov North Carolina Department of Environmental Quality 943 Washington Square Mall Washington. NC 27889 .r Noti ing Cctnpares Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed to third parties. From: Rogers, Michael Sent: Monday, July 03, 2017 2:52 PM To: Sipe, Randy <randy.sipe@ncdenr.gov>; Shrestha, Shristi R <shristi_shrestha@ncdenr.gov> Cc: May, David <david.may@ncdenr.gov>; Watts, Debra <debra.watts@ncdenr.gov> Subject: RE: Geothermal Return Well Application - Kevin Mayer Residence - Washington, Beaufort County WI0700458 I processed the revised app. Permit number assigned is WI0700458. I have one question; the proposed pressure is 411 to 509 PSI. This is high. Is this correct? From: Sipe, Randy Sent: Monday, July 03, 2017 2:04 PM To: Rogers, Michael <michael.roe,ersidincdenrj ov>; Shrestha, Shristi R <shristi.shrestha ncdenr.. ova Cc: May, David <david.may@ncdenr.gov> Subject: RE: Geothermal Return Well Application - Kevin Mayer Residence - Washington, Beaufort County Please see attached scanned copies of a revised application and staff and Inspection reports. The reports do not reference a permit number because I could not find one in BIMS. When one is assigned could you please let me know. Please give us a call if you have any questions. Dwight Randy Sipe P.G. Hydrogeolagist Il Water Quality Regional Operations Section Division of Water Resources 252 948 3849 office randy-sipe(cncden r. qov North Carolina Department of Environmental Quality 943 Washington Square Mall Washington, NC 27889 t do Capmparts Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed to third parties. From: Rogers, Michael Sent: Wednesday, June 28, 2017 1:55 PM To: May, David <david.may@ncdenr.gov> Cc: Shrestha, Shristi R <shristi.shresthaf ncdenr.gov>; Sipe, Randy <randy.sipe@ncdenr.gov>; Tankard, Robert <robert.tankard@ncdenr.eov>; Watts, Debra <debra.watts@ncdenr.gov>; pirateship41@yahoo_com Subject: RE: Geothermal Return Well Application - Kevin Mayer Residence - Washington, Beaufort County OK. Since you are already in the loop on this and are already doing a review, I'll forgo sending a formal staff report request. From: May, David Sent: Wednesday, June 28, 2017 1:44 PM To: Rogers, Michael <michael.roe,ersnncdenr.gov> Cc: Shrestha, 5hristi R <shristi.shrestha@ncdenr.eov>; Sipe, Randy <randy.sipe@ncdenr-eov>; Tankard, Robert <robert,tankardr«)ncdenr.kov>; Watts, Debra <debra.wattsCa)ncdenr.gov>; pirateship41@vahoo.com Subject: RE: Geothermal Return Well Application - Kevin Mayer Residence - Washington, Beaufort County Well work to coordinate with Mr. Mayer to update the application as we perform our review. We'II plan to forward the updated information to you soon. Thanks David May Regional Supervisor - Water Quality Regional Operations Section Department of Environmental Quality — Division of Water Resources 252-948-3939 office david. may [a�ncde nrgpv 943 Washington Square Mall Washington, NC 27889 Email correspondence to and from this address is subject to the North Carolina Public Records Law and maybe disclosed to Hurd parries. 2 From: Rogers, Michael Sent: Wednesday, June 28, 2017 10:51 AM To: Watts, Debra <debra.watts @ncdenr.gov>; pirateship41@yahoo.com Cc: May, David <david.may@ncdenr.gov>; Shrestha, Shristi R <shristi.shrestha @ncdenr.gov>; Sipe, Randy <randy.sipe@ncdenr.gov>; Tankard, Robert <robert.tankard @ncdenr.gov> Subject: RE: Geothermal Return Well Application -Kevin Mayer Residence -Washington, Beaufort County We received the application for the geothermal well, thank you. However, it is not complete. We need the following to continue the permitting process: • Signature of Denise Mayer on page 4 if she is on the property deed. • Complete well construction information including depths of casing, screen, grout, bentonite seal and sand pack if any, etc. • You indicate the existing supply well is open hole and the geothermal well will have a screen/sand pack? Is this correct? You can scan and send back info in reply to this email. Thank you for your cooperation. From: Watts, Debra Sent: Tuesday, June 27, 2017 5:10 PM To: Rogers, Michael <michael.rogers @ncdenr.gov> Subject: FW: Geothermal Return Well Application -Kevin Mayer Residence -Washington, Beaufort County From: May, David Sent: Tuesday, June 27, 2017 10:29 AM To: Watts, Debra <debra.watts @ncdenr.gov>; Shrestha, Shristi R <shristi.shrestha @ncdenr.gov> Cc: Sipe, Randy <randy.sipe@ncdenr.gov>; Tankard, Robert <robert.tankard @ncdenr.gov> Subject: Geothermal Return Well Application -Kevin Mayer Residence -Washington, Beaufort County Shristi and Debra, The attached application was hand delivered in Washington this morning. The applicant asked for help with expediting the permitting process so that he could get his air conditioning system up and running as soon as possible. The original application is in the courier to you. Please let us know if there are any questions in the mean time. Thanks David May Regional Supervisor -Water Quality Regional Operations Section Department of Environmental Quality -Division of Water Resources 252-948-3939 office 3 david .may@ncdenr.gov 943 Washington Square Mall Washington, NC 27889 Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed to third parties. 4 North Carolina Department of Environmental Quality — Division of Water Resources APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S) hi .1ccoutanve With Hra Pun ilium pl' i.4et N(' %c: ex .0224 g OTHERMAL J-IEATINQIQQQ ,JJ*IG WATER_TURN WELL(S>! Those well(s) inject groundwater directly into me subsurface as part of a fWuIHeiniut heating arid cooling syslnn► CHECK ONE, OF THE FOLLOWING: • Now Application Renewal' Modification Pormlt Rescission Requut• `For Permit Renewals or Rescission claques!. complete Pages 1 end 4 (signature page) only Print or Type Infar►'rnsiori and Mall in the Address on the L47'a Poge.. illegible Applications Will Ile Retained As incomplete. 04- DATE: , 20 PERMIT NO. �� (leave blank if New Application) A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application) 1. Current Use of Well a. 1wish to continue to use the well as Geothermal Weil 0 Drinking Water Supply Well 0 Other Water Supply the- Indicate use (i.e., irrigation, etc.) b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment Record (GW-30). 0 Yes, 1 wish to rescind the permit 2. Current Ownership Status I las there been a change of ownership since permit last issued? 0 YES 0 NO Iryes, indicate New Owner's contact inforntalion: Name(s) Mailing Address: City: State: Zip Code: ❑ay'1'ele No.: JI inail Address.; B. STATUS OF APPLICANT (choose one) Non•Governmcrit: individual Residence _/ Government: Stale Municipal ^_ 13 u9iness/Organixaliott RECEIVEDINCDEN RIDWA JUN 27 2017 Water Cluality Regional Operations Section Washington Raglans! Of lc® County:, C.� Pic e /ff vim. l •tic=- 6 M County Federal — LJ l2 0 C. WELL OWNER(S)IPERMIT APPLICANT - For single family residences, list all persons listed on the property deed. For all others, list name of business/agency and name of person gad title with delegated authority to sign: Col - 2 to fito. ,:k ram: f . !(- Ell_ Mailing Address: Il'Jr- (ti11 it I`Q t'.�a��.. fJ„„ .c_. Geothermal Water Return Well Perrnii Application Rev. 3• 1.2016 Page i City: ,/,P(t, „nib,, Slate: , �_ Lill Code: ) 7 V ip County:_ EAi4 t Day Tele No,: 3 (2 g;t►<- r7d- Cell No.; S••"r. EMAIL Address: rrR.p�E ��. le I>J �J,•.. Fax No.: D. WELL OPERATOR (If different front well owner) — For single family residences, list all persons listed on the property deed. For all others, list name business/agency i415( name of person and title with delegated authority to sign: _ Mailing Address: City: State: Zip Code: County:_ Day Tele No.: &fait Address,: E. PHYSICAL LOCATION OF WELL(S) SITE (I) Parcel Identification Number (PIN) of well site: County: (2) Physical Address (if different than mailing address): `J City: LIest, t��, •�, County `Lip Codc: 1 F WELL DRILLER INFORMATION Well Drilling Contractor's Name: J 4 l f 0'4.4 °Z Q" L 5 NC Wcll !]titling Contractor Certification No.; a I dO - 117 Company Name: act y 8,4 rgci n L 5 ')I t tit.; \l'i►tg Contact Person a t+ G.wrrlanu5 EMAIL Address:,,_, Address: +t3& ci us, H City: FA. ra►7tn. bn Zip Codc: a7ge Slate: AN> e-i- ❑ff-ice Tele No.: r?5 - 9 -. .25') Cell No,: Fax No.: Llnc.1 (QI/ qf'2-. 83 3 G. HVAC CONTRACTOR INFORMATION (ifdifferent than dri kr) 1 IVAC Contractor's Name: NCI IVAC Contractor License No.: Company Name: Contact Person; Address: City: Zip Code: Office Tele No.: Ce1I No.. EMAIL Address: State: Coiinly: Fax No.: H. WELL USE Will the injection well(s) also be used as the supply►Yell(s) for She following? C;cmherma1 Wrier Return Well Pennil Applicaiion Rev. 3.1-2016 Page 2 (1) The injection operation? YES (2) Personal cnnslnnption? YES I. WELL CONSTRUCTION REQUIREMENTS - As specified in 151jNCAC 02C,0224(dl: (I) The water supply well shall he coustnicted in accordance with the water supply well requirements of 15A NCAC 02C ,0107. (2) If a aeparatc well is used to inject the heat pump eiflucnt, then the injection well shall be constructed in accordance with the water supply well requirements of IAA NCAC 02C ,¢, QL except that: (a) For screen and grave! -lacked wells, the entire length of'easing shall be grouted from the top of the grave! 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 oiler water erncrgcs from the supply well and immediately prior to injection. 1. WELL CONSTRUCTION SPECIFICATIONS (1) Specify the number and type of wells to be used for the geothermal heating/cooling system: EXISTING WELLS PROPOSED WELLS PM' existing wells, please attach u copy of the Well Ce►►asrrtrction Reran! (Form GW 1) if aw llable. (2) Attach a scltcmatii; diagram of each water supply and ireclion 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. Finch diagram shall demonstrate compliance with the well construction requirements specified in Part 11 above and shall include, at a minimnrn, the following well construction specifications: (f) (g) Depth ofcach boring bcin►v land surface Well casing and screen type, thickness, and diameter Casing depth below land surface Casing height "stickup" above land surface Grout material(s) surrounding casing and depth below land surface Note: be►►to►rite groats are prohibited for sealing water -bearing zones u'lth 1500 mg11. chloride or Realer per UldicacjaCLOIZallel Length of well screen or open borehole and depth below land surface Length of sand or gravel packing around well screen and depth below land surface K. OPERATING DATA (1) injection Rate: Average (daily) 1 _gallons per minute (gpm). (2) Injection Volume: Average (daily)g &O gallons per day (gpd). (3) Injection Pressure: Average (daily) pounds/square inch (psi). y2l -5 S Geothermal Water Return Well Permit Application Rcv. 3-1.2016 Page 3 NOTE: In most cases an aerial photograph of the properly parcel showing properly lines and structures can be obtahted and downloaded from the applicable county GIS website. 7)rlcally, the properly can he searched by owner name or address. The location of the wells In relation 10 p►oper1y boundaries, houses, septic tanks, other wells, etc. can then be drawn In by har!. Also, a Payer' can be selected showing topographic contours or elevation data M. CERTIFICATION (to be signed as required below or by that person's authorized agent) 15A NCAC 02C .021 lfej requires that all permit applications shall be signed as follows: 1. for a corporation: by a responsible corporate officer; 2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively; 3. for a municipality or a state, federal, or other public agency: by either a principal executive officer or ranking publicly elected official; 4. for all others: by all the person(s) listed on the properly 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. "l 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, l believe that the information is true, accurate and complete. l 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 and all related appurtenances in accordance wi thpproved specif cations and conditions of the Permit." S 1 l a tire,,ff Property Owner/Applicant r Print or 'Fgpe FullName and rile % ARAI Lei Signature of Property O ner/Applicant 1.2 / E ?{ra-YE, R, Print or Type Full Name and Title Signature of Authorized Agent, if any Print or Type Full Name and Title Submit two copies of the completed application package to: Division of Water Resources - UIC Water Quality Regional Operations Section (WQROS) 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 807-6464 Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 4 Signature of Authorized Agent, it'any Print or Type Pull Name m1'l '11tlc Submit two copies of the completed application package to: Division of Water Resources -UIC Water Quality Regional Opc.-ations Section (WQROS) 1636 Mail Service Center H.aleigh, NC 27699-1636 Telephone (919) 807-6464 Geothermal Water Return Well Pcnnit Application Rev. 3-1-2016 Pages GEOTHERMAL HEATING/COOLING WELL CONSTRUCTION DETAIL Choose applicable injection Well design and check the appropriate boxes. Fill In depths below land surface (BLS) and details of weld construction on the blank lines provided. Use additional sheers as needed. O yen -Hole Well Design Proposed ❑ Existing Injection; ❑ Supply; ❑ Dual Purpose 1 •ltI LS UlL1S5: Record Depths Below Land Surface (BLS) on Lines Provided Bottom of easing pgt (Ft. BLS) - ff Total Depth (it. BLS) 4 - } r� 1� 4 (Ft.) Return or Supply Line Casing Grout Screened Well Design ❑ Proposed ❑ Existing ❑ injection; ❑ SuppIy; ❑ Dual Purpose WELL DETAILS Casing Material: poc- i Casing Diameter (in.): .3 Grout Type: 1 ilET :ill.: Grout Depth (13LS): 4_ Top of Bentonite Seal (if present): GAtAi,al' Bottom of Bentonite Seal (; r Screen Material: 111/4 Screen Slot Size (in.): 11 Sand/Gravel Pack Material Type: i Bedrock Open Hole NC Certified Well Driller Name: Bentonite Seal (if present) Sand/Gravel Pack - Screen f (Ft.) Record Depths Below Land Surface (R3.S) on Lines Provided 1 try , t l (_,} (( A't Certification No,: •w2lM (Ft. BLS) (Ft, BLS) Bottom of casing (Ft. 131.51 (Total Depth Ft. BLS) 13121:120t7 ComectGIS Feetrre Report q Parcels Proper?, tart O rers imerior TracLines 84;iltJir.g Foo;prirs 2CC7 CDLr:y Lire Lour: Line (Solid) Map Grid httpslTheadortcorr s.cO n/Dcmi doarlFile ashx1 _ags map1f7719f71888481d8e21dc966711300xAm8t9xint 1!2 612012017 CorriectGIS Feature Report Parcels Propery Lard O:.rers r:erior Trot': Lines &:ildirg Footprirs 2X7 Courzy Line L—; CoLr:;e Lire (Solid) Map Grid Sa:e r psr/b rcmrsvalgis.00ruroownloedFileashx?i= ags mapdirrP3rr,&a948Fe8.21drC9asr,130ax.htre&-print 112 tieautolt COIJnlq, NC $119/17, 9:35 PM ■ fJILiURinllm 1 QPB{LORO =6ait-7014O13 RA MET J A (EVIN P RANE2 !MAYL7Rmist c ADORE Miapittisse CITY �wm3Hpf6TOt1 UTE Nelml 1,utL511 A AOOR2 432 MILL ROM vP 2788a 1 LOT SI RALPH PROP„ CESC LFGr TTRHEL C LEGGETT LARD VAL 15960 BtA4_VAL 7135 T97 VAL 23096 DEFFLYAL a PREY,ASSf9 23099 ACRES O.57 PROP,AOCR 4521.ULL ke TOWNSHIP 2 HEL 56780051 PW_1 2064700 RATE 21122005 Duo 1707A05a3 STAMP! 42 SALE,PICCE 2ta00 REtDI 41127 • 3ntaz: - eubrapl AC7edAd m 1 toyed's) http:/lm a ps.s admap s. c ominc/beau for El 1. 1623.4793 922 05 ■ 974-97 tit) mAkc • ■ starititt Addrraaa Enter Ad dross {Ex: 1213 IIIScp!•] 432 Mill A Rvad Find Rega l of 1 • Beaulor1 County, NC 9/19117, 9:35 PM finatttiolin:, t a AtIr16+As VIA/6 „irepro !14ftlft-J a GPINLONO : 2D7876-79003 PAAIE1 f ' ER KEVIN P NANIE2 MAYERDENISEC 1iDOm rigkixftwadi l!CITY R1,11'0'101097011 LATE ,ypl',NLYfI 1MIRni•• A00112 412M1LLROA0 EP 27062 1 LOT a1 RA[Pli PROP_0E$C LEGGETT/MELG LEGGErr LARD VAL 16960 BL120_171‘L 7130 TO_ VAL 73008 DEPR_VAL 0 PREV,ASSES 23069 ACRES 057 PRDP_A DOR 462 MUM TOWN 2 MWL 60790051 PIN_I 2004790 DATE 21.12200e DELP 1707,701S93 57A1IPS 12 SALE,PRICE 21000 RE101 41127 aneap;:•: LEEDI 1 fearu'e!e) 6eeersedm 1 lay4 441 ht t a:llmaps. a pdma es , cominclbe auto rt► 1: 791 seas 4131113></aa 40170 Thak s 1 • •Jlr Address Enter Address (Ex: 1213 Maple) 432 Mill A Road Hod Page 1 Of 1 North Carolina Department of Environmental Quality — Division of Water Resources APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S) in ArcirrtIaince With iIrc PIuvisitmi ui' t iA NC -AC 0.0 .0224 GEOTHERMAL HEATING/COOLING WATER RETURN WELL{S1 Thes\ well(s) inject groundwater directly into the subsurface as part of a geothermal heat' g and cooling system CHECK ONE OF THE FOLLOWING: ' _New pplication Apia Renewal* Modification Perim Rescission 'For Perm' - enewais or Rescission Request, complete P g s 1 and 4 (s nature page) only Print or Tv pe Information an Mail to the Address an the Las! Page. Illegible Application. Will Be Returned As Incomplete. DATE: , 20 PERMIT NO. (]Lave blank if New Application) A. CURRENT WELL USE .: OWNERSHIP STATUS (Leave B1: a If New Well/Permit Application) 1. Current Use of Well a. I wish to continue to use ie well as l2 Geotherrnal W l ❑ Drinking Water Supply Well ❑ Other Water Supply Use- Indic. e use (i.e., irrigation, et b. Terminate Use: If the well is t longer being u d as a geothermal injection well and you wish to rescind the permit, check the box low. if al ndoned, attach a copy of the Well Abandonment Record (GW-30). ❑ Yes, I wish to rescind the pt. lit 2. Cgr•rent Ownership Status Has there been a change of ownership since pe nit last iss ied? ❑ YES ❑ NO 1 f yes, indicate New Owner's contact inform ion: Name(s) Mailing Addtmss: City: State: Zip Code: Day Tele No.: Email Adt ss B. STATUS OF A PPLICA (choose one) Non -Government: Individual Residence / Bus iness/Orgtnizatin Government. Stale Municipal County RECEIVED/NCDENRIDWR JUN 27 2017 Water Quality Regional Operations Section Washington Regional dfftce County:_ Federal ti C. WELi.. O% 'ER(S)IPERMIT APPLICANT — For single family residences, list all pil.c,ions listed on the property cd. For all others,, list name of husipess/agency and name of pcmen and tilk, with delegated authorit to sign: f L.ui t' 14 ��`• ��r�. �, ►`l •M 4y6 J °c sl - C- I44Al M ai I ng Address; IUD- [ 4a ,...(Au ,, 4 GeolllermL! Water Return Well Permit Application Rev. 3-1-2016 Page 1 City: Lidad,a,l:}v., State:/IL Zip Code: -)VT Day Tele No.: a (1 I t 5 9a1 U Cell No,: EMAIL Address: �]i tri.€ ID 41 7.nl-a, Fax No.: County:__ u E,a“° >). WELL OPERATOR (if different from well owner) — For single family residences, fist all persons listed on the property decd. For all others, list name business/agency and name of person and title with delegated authority to sign: Mailing Address: City; State: Zip Code: County:__ Day Tele No.: Ismail Address.: E. PHYSICAL LOCATION OF WELL(S) SITE (I) Parcel Identification Number (PIN) of well site: County: (2) Physical Address (if different than mailing address): ' J C.2 r M ill Rd City: (Lip s + .n� • (' .c County Zip Code: 5 WELL DRILLER INFORMATION Well Drilling Contractor's Name: •, c J IYu f..j0 n 5 NC Well Drilling Contractor Certification No.:) g)C )19 - Company Name: Jc j &Li +"i5Gn S Le 1► r115rng Contact Person: �^,G `( '( AIrtV US EMAIL Address:,_ Address: 1 ,3Zo us. r 4 u`21,1}-t City: LSE h t itto Zip Code: a700 9 State: i.1C-Bounty: &LI ufOr Office Tele No.: c25 9c23- i��SJ Cell No.: Fax No.: G. HVAC CONTRACTOR INFORMATION (ifdiflerent than driller) I ]VAC Contractor's Name: NC HVAC Contractor License No.: Cotnpany Haim: Contact Person: Address: City: Zip Code: Office Teie No.. Cell No.. EMAIL Address: State: _County. Fax No.. II. WELL USE Will the injection wells) also he used as the supply well(s) for the following? Geothermal Wier Retura Writ Per„1ii Applion Rev. ;-I-2O16 Page 2 The injection operation? Persona] consumption? YES YES I. WELL CONSTRUCTION REQUIREMENTS— As specified in 1 5A NCAC 02C .0224(41: (1) The water supply well shall he constructed in accordance with the water supply well requirements of 15A NCAC- 02C .0107. (2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed in accordance with the water supply well requirements of ) SA NCAC 02C .01 i$7, 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; (I)) 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 funetional source of water during system operation for the collection of water samples immediately after water emerges from the supply well and immediately prior to injection. J. WELL CONSTRUCTION SPECIFICATIONS (1) Specify the number and type of wells to be used for the geothermal heating/cooling system: *EXISTING WELLS PROPOSED WELLS *For existing wells, please attach a copy °faze Well Construction Record (Form GW-I) i[availabk. (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 Iong as the diagram clearly identifies or distinguishes each well from one another. Each diagrarn shall demonstrate compliance with the well construction requirements specified in Part II above and shall include, al a minimum, the following well construction specifications: Depth of each boring below laud surface Well casing and screen type, thickness, and diameter Casing depth below land surface Casing height "stickup" above Iand surface Grout ntatcrial(s) surrounding casing and depth below land surface Note: bentonite grouts are prohibited far sealing water -bearing wnr:s with 1500 mrrglL chloride or greater per 15A NCAC 02C .01070)fAr') (f) Length of well screen or open borehole and depth below land surface (g) Length of sand or gravel packing around we11 screen and depth below land surface K. OPERATING DATA (1) Injection Rate, Average (daily) 7 gallons per minute (gprn). (2) Injection Volume: Average (daily)g&O gallons per day (gpd). (3) Injection Pressure: Average (daily) pounds/square inch (psi). /1; Cealhernial Water Return Well Permit Application Rev 3-I-20Iti rage 3 (4) Injection Temperature: Average (January) ° H, Average (July) ° F. L. SITE MAP — As specified in 15A NC AC f12C ,0224t4rJt41, 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 drainfreld, waste application area, and repair area located within 250 feet of the injection well(s). (2) Any other potential sources of contamination listed in I5A NCAC 02C .010714)(21 located within 250 feet of the proposed injection well(s). (3) Property boundaries located within 250 feet of the parcel on which the proposedinjectionwell(s) are to be located. (4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east) NOTE; In must cares an aerial photograph of the property parcel showing property lines and structures can be obtained and downloaded from the upplicahle county CIS website. Typically, the properly can be searched by owner name or address. The location of the wells in relation to properly boundaries, houses, septic tanks, other wells, etc. can then be drawn in by hand. Also, a `layer' Can be selected showing topographic contours or elevation data M. CERTIFICATION (to be signed as required below or by that person's authorized agent) 15A NCAc 02C .0211 (e) requires that all permit applications shall be signed as follows: 1. for a corporation: by a responsible corporate officer; 2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively; 3. for a municipality or a slate, federal, or other public agency: by either a principal executive officer or ranking publicly elected official; 4. for all others: by $Il_thp ersonfs) listed on the nronerty 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 law, that t have personally examined and am familiar with the information submitted in this document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible for obtaining said information, I believe that the information is true, accurate and complete. l am aware that there are significant penalties, including the possibility alines and imprisonment, for submitting false information. f agree to construct, operate, rains n, repair, and if applicable, abandon the injection well and all related appurtenances in accordance wi . th . rproved specifications and conditions of the Permit." Sigt lure P• ipe y Owner/Applicant I .y1 147y ~ 01e4/e/Z— Print or Type Full Nance and Title Signature of Property Owner/Applicant Print or Type Full Name and Title ( i.s 1I wrmal Water Return Weil Permit Application Rev. 3-1-201tr I' g.: 4 Tien -Hole Well Design Proposed 0 Existing ❑ Injection; 0 Supply; ❑ Dual Purpose I_3nd Surface Iteeard IhpIIi IkInn Land tlrral'C (11I.5) cm I.inex I'ra+,idcd !lotion I I:1 11I M } rtr.a Urinh tl l_ I11.5I 1 tit I Return or Supply Line Casing 'Grout Screened Well Design___ ❑ Proposed 0 Existing 0 injection; 0 Supply; 0 Dual Purpose Wr.l.L DETAILS [ .snit! )11:+terial: Casing Diameter tin.): (ifcutl 'l ype: [hoot Depth (131.S): Top o1' Bentotlilr Sral Of present): Botliiil nt i3cnulnitr Seal Seri:ell Material: Screen Slot Size(310: SandAiric el rack ]Material Type: licdroek Open Holt: Geothermal Water Return Well I'enttil Application Rev 3-1-2016 lie t1L'nilc Seal trl pra•e, n(i ti:t111111171 k CI rack Screen } f rka tlti tirrnrd ikpthi Rehm l.and tiurfarc MIS) nn Lines Provided ;Ft.IILSI it:t. 111 St I otolo or i.s ie 41'1 111 ti7 n rota! 1) h 01--I'"' It tSLti{ fK q ( �nGl#.0 Cl 5ct a� f Page 6 Signature of Authori:r..ed Agent, if any Print or Type Full Name illlll Title Submit two copies of the completed application package to: Division of Water Resources -UIC Water Quality Regional Operations Section (WQROS) 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 807-6464 Geothcrnrnl Water Return Well Permit Application Rev. 3-.1-2016 Page 5 6/2 2017 CcmectGlS Feature Report CON NEC GIS tiv is 'CS1•riG .01 Beaufort Printed June 26, 2017 See Below for Disclaimer Parcels Property Lard Owners Interior Tract Lines Buiidira Footprirts 2C07 County Lire 0 County Lire (Solid) • Map. Grid State https:llhaaufort.ccnnectgis.com/Down[oadFile.asinc7f wags mapdt7719f7188940c16e21dfo9p6741300x.hCm&t=p41nt 1/2 6/20/2017 ConnectGIS Feature Report CONNECTGIS Beaufort Printed June 20, 2017 See Below for Disclaimer Parcels Property Lard Owners interior Tract Lines Building Footprirts 2CC7 Courty Lire County Line (Solid) Map Grid State https:/lbeaufort.connectgis.catreadvnloadFile.ashx?it _agsin ap177f91718.8848fd8e2idt5b6711300x.htrn &1= print la Beaufort County, NC 609/17, 9:35 PM T;Iskc tvogjecliop =' - glVlbcaa Yak* 41 PARfifitPNARrCc GPINLON:G-5970-773.9[763 aANE1 1-A frR KEV€N P NAME? M ?Efr DENISE. C !DDRI 1<�. CITY --W[IIASHINGTON 17ATE 'p�, IL'S'1}3 l•[H1111ICS ADDRZ 432 iNILL ROAD ZIP 771949 LOT 01 RALPH G PROP_DESC LEGGETTITHELC LANE] YAL 15950 BLOG_YAL 7136 T0T_11AL 23096 DEFR_VAL 0 PREV_ASSES 29096 ACRES 0.57 PROP ADDR 452 MU RD TOWMSi11P 2 MBL 5370051 PIN_I 2094793 DATE 23.123008 OS_PO 1707/00543 STAMPS 42. SALE PRICE 21030 REID1 41177 Wi wl11'r • Print Mak • 1 leaarom wipe -tog en Slayer's.) hT ED: ffmaps.agdmaps.com/ncldeaufofl) 1: 1523.976E 822-05 x 974.67 (RJ 1 • Address Enter Address (Ex: 1213 maple) 432 MA Road FRCS Pagel of 1 Beaufort County, NC 6/19/17, 9:35 PM Fr k< • 1 aCro • 1 kjni MAR Attribute 7 VaIW —' •sP{N 141111-11-Pailunl GPiNLDNG=507e-79e003 • Sialtatz Address iIAMEI J k $ER ICEVt14 P NAi4F2 I. MAYER DENISE C 1 1 XDOR1 MAW EURgili CITY �"W"eSHINGTQN n5 STATE escr Rs i_ouss.V9 AOOR2 432 MIL ROAD 21P 27Sas 1 LOT 01 RALPH G PROP DFSC LEGGETrm EL G LEGGETT LAND VAL 15900 BLDG VAL 7119 TOT VAL 23095 DEPR_VAL 0 PREV_ASSES 23006 ACRES 0-57 PROP_lDOR 402MILL RD TOWNSHIP 2 MEL 59760051 Pat_1 2004790 DATE 23.122009 OH_PG 1707/00593 STAMPS 42 SALE_PWCE 21000 REIDI 41127 1 fret,..re(e) selectee on 1 feyer(r) 1/01.9$90 ee1.03 ■ 497.49 in) • Enter Address (Ex: 1213 Maple) 43P Mill A Road Find htto://maps.agdmaas.cvrnlncldeaufortl Page 1 of 1 G213 r_t;17 classic auto body washington nc - Google Search Go gle classic auto body washington nc Ail Maps Shopping News forages More About 634,000 results (0.82 seconds) Settings Tools Classic Auto Body 1516 W 5th St Washington, NC Auto Body Shops ... https://www.rnapquest corn/us/north-carolinai..washington/classic-auto-body-324346... Get directions, reviews and information for Classic Auto Body in Washington, NC. 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We are a family owned and operated collision and repair center_ Classic Auto Body - Better Business Bureau https:i/www.bhb org/..Jauto-body.../classic-auto-body-in-washington-nc-6045981 - Rating: 5 - 1 review BBB's Business Review for Classic Auto Body, Business Reviews and Ratings for Classic Auto Body in Washington, NC. IT in fit / 06 far � © a,o � Hardee's el) Ar See outside Classic Auto Body and 24 Hour Towing 0 [T431[ Directions 5.0 3 Google reviews Auto body shop in Beaufort County, North Carolina Address; 2403 W 5th St, Washington, NC 27889 Hours: Open today - 8AM-5PM Phone: (252) 940-1373 Suggest an edit Own this business? Add missing information Add website Reviews write a review 3 Google reviews Add a photo r+ttpsl/www.google,corntsearch?q=Classic+Auto+Body&oq=Classic+AtJto+Body&aqs=chrome..89i57&sourceid=chrome&ie=lJTF-84q=classic+ o+, y+washington+nc 1/3