WI0800022_GEO THERMAL_20010529

DMSION OF WATER QUALITY
GROUNDWATER SECTION
May 29, 2001
MEMORANDUM
To: Charles Stehman, Ph. D., L.G., Goundwater Supervisor
Groundw-ater._Se.c1ion
Wilmington Regional Office
From: Mark Pritzl f\.P [e-mail]
Hydrogeological Technician IT
UIC Group
Groundwater Section
Raleigh Central Office
Re: Issuance of a Open-Loop Geothermal Injection Well System (Type SA 7):
Permit Number WI0800022 to operate a well for the injection of an open-loop
ground-source heat pump system has been issued to Ronald Bland, in Sunset Beach, North
Carolina.
1. Please inspect the injection well site to verify that the location and construction plans
submitted in the application are accurate and the NCAC Title 15A 2C .0200 standards are
being complied with, using the enclosed Injection Facility Inspection Report (form B) as
appropriate.
2. Collect samples from the influent and effluent sampling ports and submit the results to
the CO-UIC.
You are requested to return the completed Injection Facility Inspection Report (form B) to the
CO-UIC by June 30, 2001. If the inspection can not be accomplished by this date, please
inform the CO-UIC. The UIC group greatly appreciates Diane Rossi's assistance with this
review. If you have any questions regarding this review or the UIC program, please contact
me at [phone] or Meliktu Fanuel at [phone].
cc: CO-UIC Files
Enclosures
Michael F. Easley
Governor
Williams G. Ross Jr., Secretary
Department of Environment and Natural Resources
Kerr T. Stevens
rJ vision of Water Quality
June 11,2001
Ronald Bland
1301 -01 Thomasboro Road
Calabash, NC 28467
Dear Mr. Bland:
In accordance with your application dated February 23, 2001, we are forwarding Permit No.
W10800022 for the construction and operation of a geothermal heat pump injection system at 215
Shoreline Drive, Sunset Beach, North Carolina, in Brunswick County. Water samples will be
taken at the influent and effluent sampling ports of this geothermal heat pump system after
construction is complete. Please note, if these sample results exceed groundwater quality
standards, it is the well owner's responsibility to take corrective action as stated in Title 15A
Subchapter 2C, Section .0206.
This pctiiiit shall be effective from the date of issuance until May 31, 2006, and shall be subject to
the conditions and limitations stated therein. In accordance with NCAC Title 15A, Subchapter 2C,
Section .0213(h), the well owner is responsible for submitting a record of well construction within
30 days of completion. The well construction data for every well constructed for this project should
be submitted on the GW-1 form and this form is enclosed for your convenience.
If you have any questions regarding your permit please feel free to contact me at [phone]
or Meliktu Fanuel at (919) 7I5-6165.
cc: CO-UIC Files
W IRO-UIC Files
Enclosures
sxs
Customer Service
1 800 623-7748
Sincerely,
N,c3
Mark Pritz]
Hydrogeological Technician II
Underground Injection Control Program
Division of Water Quality / Groundwater Section
163B IVtait Service Center Raleigh, NC 27699.1636
Phone: [phone] Fax. [phone] Internet: http://gw.ehnr,state.nc.us

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
Ronald Bland
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5A7 INJECTION WELL,
defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(A), which will be used
for the injection of heat pump effluent. This system is located at 215 Shoreline Drive, Sunset
Beach, North Carolina, in Brunswick County, and will be constructed and operated in
accordance with the application dated February 23, 2001, and in conformity with the
specifications and supporting data submitted, all of which are filed with the Department of
Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the
Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an
injection well shall be in compliance with Title 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 May 31, 2006,
and shall be subject to the specified conditions and limitations set forth in Parts I through X
hereof.
~
Permit issued this the JS day of ~ ,2001.
~ j vJ~
~\_, Ted L. Bush, Jr., Assistant Chief
\-Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0800022
GW/UIC-5 March 28, 2001
PAGE 1 OF 6
PART I-WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface
cannot migrate into the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each injection well shall have permanently affixed an identification plate.
8. A completed Well Construction Record (Form GW-1) must be submitted for each
injection well, to the Division of Water Quality (Division), within 30 days of completion
of well construction.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall
notify the Groundwater Section-Underground Injection Control (UIC), Central Office
staff, telephone number [phone].
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
Permit No. WI0800022
GW/UIC-5 March 28, 2001
PAGE2 OF 6
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.
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or
abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or
activity not specifically authorized by the permit.
3. At least forty-eight ( 48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Groundwater Section-Underground
Injection Control (UIC), Central Office staff, telephone number [phone].
Notification is required so that Division staff can inspect or otherwise review the injection
facility and determine if it is in compliance with permit conditions.
Permit No. WI0800022
GW/UIC-5 March 28, 2001
PAGE30F6
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 an acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Wilmington Regional Office, telephone number (910)
395-3900, any of the following:
(A) Any occurrence at the injection facility which results in any unusual
operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report
to the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
Permit No. WI0800022
GW/UIC-5 March 28, 2001
PAGE40F 6
PART VIII -PERMIT RENEWAL
The Permittee shall, at least three (3) months 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 ISA NCAC 2C .0213(h)(l), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
Permit No. WI0800022
GW/UIC-5 March 28, 2001
PAGE5OF6
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion
of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Groundwater Section-DIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X -OPERATION AND USE SPECIAL CONDITIONS
Water samples will be taken at the influent and effluent sampling ports from the
geothermal heat pump system after construction is complete. If the sample results reveal
violation(s) of groundwater standards, it is the well owner's responsibility to take
corrective action as stated in Title 15A North Carolina Administrative Code 2C .0206. In
addition, the well owner shall take immediate actions including those actions that may be
required by the Division of Water Quality such as repair, modification, or abandonment of
the injection facility.
Permit No. WI0800022
GW/UIC-5 March 28, 2001
PAGE60F 6
Name Date Initials Type of Permit/Comments
-Mark Pritz! -sh ,/,«,\ ,Jt Q .c:. l:featPum o ~ Remediation Other
Meliktu Fanuel ffi 111,,Ja~i ' ~
Debra Watts s L'->lo\. t;Y')v,)
APR.27.201 4:33PM NCDENR WE=C
NO.459 9,1L
Pagel of 2
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTION
REPORT -FORM A
INJECTION WELL PERMIT NO. WI DATE
NAME OF OWNER _ �,L 11 6L4r / _
ADDRESS OF OWNER Z/5 526/ d
<(, r' Eert-c4; c .7"{.(7
(Street/ road or Inc and subdNlston, county, town)
LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable)
See a5 a ba+iC.
Q 5 l,Dre.f ice- 'Pt S e/ J- /VC
(Street/ road or lot and subdivision . mow, :Awn, ►f df ereal man owner's address, plans doscrlpdon of location on site)
Potential pollution source
Potential pollution source
� �
61' ''� " Distance from well #0, yD
p', .. Jd � -� ,rfo.4-x c*-+ Distance from well e'
Potential pollution source Distance from well
Minimum distance of proposed well from property boundary '-' ❑
Quality of drainage at site 6frXrdFlooding potential of site /ow — 41
(goad,adet uate poor) prigk moderate, l ow)
DRAW sTC}I OF SITE
(Showprop8rty boundaries, buildings, wells. potential pollution sources, roads, apprazamate scgle, and north arrow)
r r• - - - _ PrQ ecel�'fl �' "� _ -
°f CAE)
5131
GW/LT1C-1 March 28, 2001

APR . 27. 2001 4 : 34PP1 NCI]ENR W I RO
NO.459 P.12
Page 2 of 2
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cont.)
GPS Data:
Latitude: Longitude:
COMMENTS
S4g is +r-t 1r1a k 1as ad a
Lo4 i1Al; � �:�, a1Lobo 5o's ejjxt.-4fi t. eir'54ett., Cr0e4.-
kx.F-10 �n. nan. -i-6 _1.0p_l i t a 4io r% i2i'id /Dr sedri .
d'�wxrp ram. tArP Il 417 ifforer
INSPECTOR . �Pse7
Office aQn�/ w5
WITNESS
Address
WITNESS
Address
GWIUTC-1 March 28, 2001

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
April 26, 2001
To: Charles Stehman, Ph.D., L.G., Groundwater Supervisor
Groundwater Section
Wilmington Regional Office
From: Mark Pritzl f1f.. . [e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section, Central Office
Re: Request review of a new injection well permit application for the operation of an open loop
geothermal heat pump system.
The CO-UIC has received an application by Mr. Ronald Bland for a new permit for the
construction and operation of an injection well located at 215 Shoreline Drive, Sunset Beach, NC.
The proposed injection well will be part of an open loop geothermal heat pump system, therefore
a type SA 7 well.
1. Please review the application and submit any comments to CO-UIC. Retain the
application for your UIC file.
2. Please inspect the proposed injection well site to verify that the location and construction
plans submitted in the application are accurate and that the NCAC Title 15A 2C.0200
standards are being complied with, using the enclosed Preconstruction Injection Facility
Inspection Report-Form (A) as appropriate.
Please return any comments immediately upon application review. You are requested to return the
completed Preconstruction Injection Facility Inspection Report-Form (A) to the CO-UIC by May
15, 2001. If the inspection can not be accomplished by this date, please inform the CO-UIC. The
UIC Group appreciates your assistance in the review and evaluation of this permit application.
Please contact me if you have any questions or comments at [phone] or Meliktu Fanuel at
[phone].
cc: UIC Files
Enclosures
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NA TIJRAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type ~A 7 and SQM Wells
In Accordance with the pl'Ovisions ofNCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
TO: DIRECTOB-, NORTH CAROLINA DMSION OF WATER QUALITY
DATE: fe..'o \ S l , 20 0\
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
B.
C.
( 1) v" Type SA 7 wells inject watel" used to provide heating or cooling fol" structures.
(2) Type SQM wells contain a subsurface system of continuous piping, that is
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes and/or corrosion
inhibitorS.
(3) Type 5QW wells contain a subsurface system of continuous piping, that is
isolated from the environment and only circulates potable water. ff you selected '
this well type, then complete fotm GW-57 CL, Notifwlltion Of Intent To S:. 0
G'>-Construct A Closed-Loop Geothermal-Water Only In.ject/.on Well System. ~ §E
PERMIT APPLICANT ~ ·:::: --:.
N8!l\e: 9,.c,.\o, .. s,,w,, W~\\. 1:)c .. \\1 'C3 ,:: ~;'.
Address: 1'b<="l\, °'t>c~~Q.~c,\,ec\t U 5 ~ ~~~
City: ~\ :;;:i State: "JC. Zip Code~'!.l\li/-, COW1ty:.$<-.11!,lii1c,k ~ ~
Telephone: °t\ -~~bj<t<:>
PROPERTY OWNER {if different froR1 applicant)
Name: ~V'\O\ \ (\ ~\C\'1\~
Address: --Zt ~ ~kt..,~t bl.,
City: s ..... ~ i>~H Sate: .!1C... Zip Code: lelf fo8 County: il-lv~w u)(
Telephone: 'Jro--51',,.S-(i{go
D. STATUS OF APPLICANT
Private: L
State:
GW-57 HP (Jan, 2000)
Federal:
Municipal: __
Commercial:
Native American Lands:
Page 1 of4
E. FACILITY (SITE) DATA
F.
G.
H.
I.
(Fill.out om y if the Status of Owner lS Federal, State, Municil)i:tl BF Cammercial).
Name of B1.1smess or Faeilit/:
Address~:--:::=::=;;;;;;;;;:;::=================-:=-:_ __ _ --==== City: 6ip Cade· County·
Telephone: _________ Contact Person: ----------
HEAT PUMP CONTRACTOR DATA
Name: \"' '< Y..<\ %~ \\e.etl.r,c@"" ~' C-
Address: ~ ~ 'f.. 'l 3
City:5~ ~~<A'\l\~~c\l Zip Code: d.~l\""TO County : ~'f\A~~\t.,\(.
Telephone: 0\\()--5~°'-:Z,'l t:§l Contact Person: l..A{f~3"''"'°'?_J'<--
INJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.) \
-::Y-.A.~ o'-"~ o'C\e... \J.)e\ \ 4-" l>ctc.~ ~"' ~e( we\
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES X NO -~--
(2) Personal consumption? YES____ NO _)'. __ _
CONSTRUCTION DATA (check one)
(l)
(2)
(3)
EXIS'fffl<'.i W"ELL being pxoposed for Use as an injection well. Provide the data in
(1) through (7) below ch a copy of Form GW-
e Construction Record) if available.
)G PROPOSED WELL to be constructed for use as an injection well. Provide the
data in (1) through (7) below as PROPOSED construction specifications. Submit
Form GW-1 after construction.
Well Drilling Contractor's Name: ~b'n\"'"!,Oll\S ~\ \1),i\\~\v\.~
NC Contractor Certification number: __,'d,;""---'--'b=-~~~-------
Date to be constructed: O" --'O \ Number of borings: "J... "'~~ ".!:>
Approximate depth of each boring (feet): ~-SQ
Well casing: Is the well(s) cased?
(a) YES . V If yes, then provide the casing information below.
Type: Galvanized steel~_ Black steel __ Plastic___:f_ Other (specify) ______ _
Casing depth: From -+ \ to 30 ft. (reference to land surface)
Casing extends above ground , o-.. inches
(b) NO _
GW-S7 HP (Jan, 2000) Page:Z of4
(4) Grout (material surrounding well casing andfor piping):
(a)
(b)
Grout type: Cement Bentonite 7 Other (specify)
Grouted surface and grout depth (reference to land surface):
around closed loop piping; from to - (feet).
CevoleAtaround well casing; from 0 to 3%0 (feet).
(S) Screens (for Type SA7 wells)
(a) Depth: From J6 to 5o feet below ground surface.
(6) N.C. State Regulations (Title 15A NCAC 2C .0200) require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent (fluid being injected intothewell) lines is required. Will there be a faucet on:
(a) the influent line? yes 1/ no (b) the effluent line? yes 1/' no
(7) SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well).
Attach a copy of Form OW-1 (Weil Construction Record). If Form OW-1 is not available.
provide the data in part K (1) of this application form to the best of your knowledge.
NOTE: THE VIBLL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSER w%LLS IF THIS INFORMATION IS LT NAvAIL.A.BLr BY OTHER R MEANS.
J. PROPOSED OPERATING DATA (for Type 5A7 wells)
Injection rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
Average (daily) gallons per minute (gprn).
Average (daily)Po ° gallons per day (gpd).
Average (daily) 3 pounds/square inch (psi).
Average (January) i$ ° P, Average (July) ° F_
K, INJECTION FLUID DATA
(1) Fluid source (for Type SA7 wells) If underground, from what depth, formation and type of
rode/sediment unit will the fluid be drawn (e.g., granite, limestone, sand, etc.).
Depth: 30_ S) Format,on:5+rncVerr ix4ek Rock/sediment unit;
(2) Chemical Analysis of Source Fluid (for Type SQM wells)
Provide a, complete listing of all chemicals added to the circulating heat transfer fluid:
L. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
GW-57 HP (Jan, 2000)
rage 3 of 4

M. LOCATION OF WELL(S) Attach two maps.
(1) include a site reap (can" be drawn) showing: buildings, property lines, surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks or
drain fields located within 1000 feet of the geothermal heat pump well system. Label all
features clearly and include a north arrow.
(2) Include a topographic reap of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
0. CERTIFICATION
"I hereby certify, under penalty of law, that 1 have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the information
is true, accurate and complete. I am aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting false information. i agree to construct, operate, maintain,
repair, and if applicable, abandon the injection well and all related appurtenances in accordance with
the approved specifications and conditions of the Permit"
(Signature of Well Owner or Authorized Agent)
ff authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner authorizing the above agent
l'. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the injection wellE>`tforms to the Well
Construction Standards (Title 15A NCAC 2C .0200
(Signature Of Property Owner 11- Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mall Service Center
Raleigh, NC 27699-1636
Telephone (919) 71 S-6165
GW-57 HP (Jan, 2000) Page 4 of 4

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Live Oak D6va
I, Randy D. word, o ProfesaronoI Land Survr.)dr. certify That tho
Ratko of Prmislon h t; 10,0004 and that this mop roots Ore minlmum
Stagar Practice,H.- 5urvsyt In Barth Carolina.
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NOTES: v .
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This pmaert is subject to any anal
all restrictive covenants, easements
and mineral rights, if o pppFcable,
rewarded in tha 8runawiak County
Rsetstar of Coeds.
Property Is subject to all Zoning
nqulnrnants of Sunset Bench , NC,
EIP
N 81-01'197 140.49'
Lot 164
t ❑0.02'
EIP
Lot 172
N 81'01'12"E
11
Dogwood Drive
L Nognala Ortve
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rie
1,MR iio_ J A2aioi Ct
sue.
SET
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Sho reline Drive
N 80'32'43"ESP 10' Drainage If _ Earemen
f 4
— I 55 4r Ca1c. N. 44.34'
Pr&ppettal 1 23' Setback
I i�,
15' TY `m,I L {
-- -1
en 25.2'
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4s
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60' Setback
51.O.34 Acres
55.48' Cala. Pt. 44.34'
0
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Lot 166
ier
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Rahar Fd.
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N 81'a4' 16 t
Pinar Fd 5 81.04' 15"W S 8011.33'W R.har r6
Shoreline Drive
Foundation H-Bdllt For
Ronald K. & Ashley H. Bland
Let 105. Shoreline Woods
5hallotto Toari.Mp
For additional tie end r.fennes sae a
prop of Moraltno Woods recorded In IJC. J.
PC. 101. Seale t' . 40'
40'
&l twkk County. N.L.
80' 120' Based on 1110 Town al Sullen Baaoh Flood
Ifrerrarroa Rots Yaps this pored apppsun
to ba located th Flead Zane AE (6 13 ).
MIMIi—=Ii
January I4N, 2001
Stan V. Mork, PS&
lamad,, O. ■Rrd. P..6.
NORRIS & WARD
Land Surveyars,PA
mad. Thososairan 1f1a. Colabsah., 1f.C. 284E1
803 Y.upem hare, Oak Irma H.O. 2d4Id
Yee Dtfb
(e1 e) 571~5soI
943) UM -MU
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erodes OMks
[phone]
910) 291-1410
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