WI0800136_GEO THERMAL_20120523

Beverly Eaves Perdue
Governor
••• ~ ,,...,. __
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 23, 2012
Francis and Alesia Jefferson
310 Lonicera Court
Wilmington, NC 28411
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: \VI0800136
Dear Mr. and Mrs. Jefferson:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http ://portal.ncdenr.orn/web/wq/aps.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
/J n r,1--
C/4,«-~,.,..
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity\ /\.ffinnative Action Employer
No~i.c 1· 01 u1 aro 1na
;Vati,rall!I
~CC(¾
hESIDENTLL WELL CON''STRt'CTION Rib CORD
North Carolina Department of Fnviumment and Natural Row umes- Division or Water Qualit}v
WELL 63N-TRACTOR CERTIF'IC'ATION g 397I-A
Z. WELL CONTRACTOR:
William B. Jefferson
Weil Contraclar (individgal) Name
Home Enerav Inc.
Well Contractor Company Name
P.Q. BQx 23E
Street Address
Wendell nc 27591
City or Town State Zip Code
Area node phone number
2. WELL INFORMATION.
WELL CONSTRLiCTION PERMrrir W108n0136
OTHER ASSOCtATED PERMIT#{a appacahlei Geothermal
SrrE WELL ID MLtapphcabie}
3. WELL USE (Check Applicable Box): Residential Water Supply L7
DATE DRILLED August 2006
TIME COMPLETED AM ❑ PM j 1
& WELL LOCATION:
cITY. Wilmington NC ccuNTY New Hanciv e
310 lonicera Gt. _
{Street Namr. Numbm Commu". SumMsion, Lot No., Parcel, Zip Caae)
i OPOGRAPHIC ' LAND SETTING: tmeck approarime Iwx)
Slope Valley Z)Flat .4 Ridge C Other
LATITUDE 88 " DMS OR 3x_xxxxxxxxx DD
LONGrrUDE 75 • DMS OR 7x.xxxxxxxxx DD
Lanxialiongitude sourm ljRS OTopographle map
Ilocabon of well must be shown on a USGS repo map andatracned to
this form if net using GPS)
is. WELL OWNER
F A. iefferson Jr
OwnerName
1 Q I nicer r,t
Strsei Address
Wilmincton Nr 28405
Crty or Town state zip Code
[ 1 d y 686-088Q
Area oode Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: NIA
b. DOES WELLREPLACE EXISTING WELL? YES .I NO W
c. WATER LEVEL.Below Top of Casing: FT.
fuse'*' if Above Tap of Casing)
d. TOP OF CASING IS FT- Above Land Surface`
`Top of rasing terminated aVor below land surface may require
a variance in accvrdanm wllh 15A NCAC 2C .0 t 18.
e. YIELD.(gpmj: METHOD OF TEST_
f. DISINFECTION: Type Arnount
g. WATER ZONES (depth):
Top Bottom
Top
Bottarn
Top Bottom
Top
Boston
Top Bottom
Tap
8Ctt4m,
Thiekoessf
7. CASING: Depth
Diameter
Wetgnt Material
Tap Bottom
Ft.
Tap Bottom
F!.
Tap Battam
Fr.
8. GROUT: Depth
Material Method
Top Bottom
R.
Top Bottom
Ft-_
Top Bottom
rt.
9. SCREEN: Depth
Diameter
Slot Size Material
Top Bottom
Ft.
in-
in.
Tap Bottom
F1.
m-
in.
Top Bottom
Ft
in.
in
10. SAND)GRAYEL PACK:
Depth
Slag
Material
Tap Bottom
Ft.
Top 9nttnm•
Ft.
_ -- _
Top Bottorn
Ft.
11. DRILLING LOG
Tap Bottom
4 15o
• 1
1
1
1
r
1
: 1
i
r
c........u..-. r.....-...­.
12. REMARKS-
A11�aringsgrout@4-jgp to-knvm - wells laminated 4 P
below grade -No Casino = Cathodic Protection installed
I DO HEREBY. CERTIFY THAT THIS WELL WAS EdRSt UCTED IN
ACCORDANCE WITH 19A NCAC 2C WELL CONSTRUCTION
STANDARDS, A THAT A�OPY C)F THlS RFCC3RO HAS SEEM
PROVIDE - T iL OVtNP"
SIGNAT Rr= aF CERTi- 'ELL RACTOR � AA E
t 4.
II �.
PRINTED NAME OF PEf2, . N CON' G THE WELL
Submit within 34 days of Completion to: Division of Water Quality - Information Processing, FWMGvl is
1617 Mail Service Center Raleigh, NC 27699-161, Phone : [phone] Rev 2109

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FRANCIS A. JEFFERSON, III �c�,C; L
ALESIA R. JEFFERSON
LOT 98 SE',TION 6 GORMAN PLANTATION
H ARNETT TOWNSHIP NEW HANOVER COUNTY
.�f NORTH CAROLINA
pECEMBER 15, 1993
:jam"- ti ' DEED BOOK 1689 PAGE 736
MAPBOOK .3' PAGE 365 cenPERe scAss
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STLFAR- 5-'9; Z, N4 ASSOCIATES
Nr "Dwnl SIVIi S'T %ILMIT T6.4 k.::. u b . 40 IL ;SAF iswwr

Rogers, Michael
From: [e-mail]
Sent:
To:
Thursday, August 04, 2011 4:23 PM
Rogers, Michael
Subject: Jefferson -Well Permit WI0800136
Dear Michael,
Per our phone conversation today, I am writing to let you know we did receive our renewed Injection Well
Permit WI0800136 in the mail; however, we do not have the records you needed that were suppose to be
submitted when the well was originally installed.
The records were:
Well Construction Record ( GW-1)
Triangulation Data
Well ID plate installation date
Mechanical Integrity Pressure testing data
The company who installed our well is no longer in business and I have no idea how to locate these items
above. Please accept this letter as justification for the missing information.
Thanks so much ... please let me know if there is anything else you need. Please respond to this email so that I
know we have done everything we need to do regarding this renewal process.
Alesia & Frank Jefferson
910-686-0880
.1
Smith, Eric
From: Smith, Eric
Sent:
To:
Thursday, July 28, 2011 2:41 PM
'Monte Jefferson'
Subject: RE: W 10800136 Permit Application
Monte:
Please let us know the status of the GW-ls forms for this permit. If we do not hear from you or receive these GW-ls by
August 12, 2011, you may receive a Notice of Violation.
-Eric G. Smith
Eric G. Smith, P.G.
Hydrogeologist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-6196
919-715-6048 Fax
http://portal.ncdenr.org/web/wg/aps
DISCLAIMER: Per Executive Order No . 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties .
From: Smith, Eric
Sent: Wednesday, July 06, 2011 10:29 AM
To: 'Monte Jefferson'
Subject: RE: WI0800136 Permit Application
Monte:
See attached original application . Please let us know ASAP if you will be able to provide us with the GW-1 form(s).
-Eric G. Smith
Eric G. Smith, P.G.
Hydrogeologist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-6196
919-715-6048 Fax
http://portal.ncdenr.org/web/wq/aps
1
DISCLAIMER: Per Executive Order No . 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties .
From: Monte Jefferson [mailto:montej efferson46 @g mail.com ]
Sent: Saturday, July 02, 2011 10:39 AM
To: Smith, Eric
Subject: RE: WI0800136 Permit Application
Eric
Please send me the Origina l Application -I will get you the information you need.
Than ks
William Jefferson
Consultant
From: Smith, Eric [mailto:eric.g .smith @ncdenr.g ov ]
Sent: Wednesday, June 29, 201110:14 AM
To: Monte Jefferson
Subject: WI0800136 Permit Application
Monte:
Another permit has come up with a missing GW-ls. Please check your records for the following:
Geothermal SQM Well
Permit No. WI0800136
Francis Jefferson Ill
310 Lonicera Court
Wilm i ngton, NC 28411
It looks like 15 wells were proposed .
Also, we are missing the triangulation data and mechanical integrity pressure testing data for the wells.
Please let us know the status of the missing items.
-Eric G. Smith
Eric G. Smith, P.G.
Hyd rogeo logist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-6196
919-715-6048 Fax
2
http://portal.ncdenr.org/web/wq/aps
DISCLAIMER: Per Executive .Order No. 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties.
3
Smith, Eric
From: Smith, Eric
Sent:
To:
Wednesday, June 29, 2011 10:14 AM
'Monte Jefferson'
Subject: WI0800136 Permit Application
Monte:
Another permit has come up with a missing GW-ls. Please check your records for the following:
Geothermal SQM Well
Permit No. WI0800136
Francis Jefferson Ill
310 Lonicera Court
Wilmington, NC 28411
It looks like 15 wells were proposed.
Also, we are missing the triangulation data and mechanical integrity pressure testing data for the wells.
Please let us know the status of the missing items.
-Eric G. Smith
Eric G. Smith, P.G.
Hydrogeologist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-6196
919-715-6048 Fax
http://portal.ncdenr.org/web/wq/aps
DISCLAIMER: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties.
1
Smith, Eric
From: Smith, Eric
Sent:
To:
Wednesday, July 06, 2011 10:29 AM
'Monte Jefferson'
Subject:
Attachments:
RE: WI0800136 Permit Application
W 10800136 Jefferson Application .pdf
Monte:
See attached original application . Please let us know ASAP if you will be able to provide us with the GW-1 forrn(s).
-Eric G. Smith
Eric G. Smith, P.G.
Hydrogeologist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-6196
919-715-6048 Fax
http://portal.ncdenr.org/web/wg/aps
DISCLAIMER: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties.
From: Monte Jefferson [mailto:montejefferson46 @q mail.com ]
Sent: Saturday, July 02, 2011 10 :39 AM
To: Smith, Eric
Subject: RE: WI0800136 Permit Application
Eric
Please send me the Original Application - I will get you the information you need .
Thanks
Vi/illiam Jefferson
Consultant
From: Smith, Eric [mailto:eric.q ~smith (a)ncdenr.gov]
Sent: Wednesday, June 29, 201110:14 AM
To: Monte Jefferson
Subject: WI0800136 Permit Application
Monte:
1
Another permit has come up with a missing GW-ls. Please check your records for the following:
Geothermal SQM Well
Permit No. WI0800136
Francis Jefferson Ill
310 Lonicera Court
Wilmington, NC 28411
It looks like 15 wells were proposed.
Also, we are missing the triangulation data and mechanical integrity pressure testing data for the wells.
Please let us ·know the status of the missing items.
-Eric G. Smith
Eric G. Smith, P.G.
Hyd rogeologist
NCDENR
Aquifer Protection Section
Groundwater Protection Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-6196
919-715-6048 Fax
http://portal.ncdenr.org/web/wq/aps
DISCLAIMER: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties.
2
Permit Numbe r WI0800136
Program Category
Ground Water
Permit Type
' .
Central Files : APS_ SWP_
06/28/11
Permit Tracking Slip
Status
Active
Project Type
Renewal
Injection Mixed Fluid GSHP Well System (SQM)
Version
2.00
Permit Classification
Individual
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Francis and Alesia Jefferson Ill SFR
Location Address
310 Lonicera Ct
Wilmington
Owner
Owner Name
Francis
Dates/Events
NC 28411
A Jefferson
Orig Issue
09/12/06
App Received Draft Initiated
06/06/11
Scheduled
Issuance
Permit Contact Affiliation
Major/Minor
Minor
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Francis A. Jefferson Ill
310 Lonicera Ct
Wilmington
Public Notice Issue
06/17/11
NC
Effective
06/17/11
28411
Expiration
05/31/16
_R_e ... a_u_la_t_e_d_A_c_;_t;_iv_i_ti_e_;_s ________________ ""'R=e=g=u=e=s=te,,__,d=/_,_R=e=c=e'-'---iv,....,e=d"---=E'"'"v=e,_,_nt=s=---------------
Heat Pump Injection RO staff report re ceived
RO staff report requested
Outfall NULL
Waterbody Name Stream Index Number Current Class
06/09/11
06/09/11
Subbasin
Permit Number WI0800136
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Francis and Alesia Jefferson Ill SFR
Location Address
310 Lonicera Ct
Wilmington
Owner
Owner Name
Francis
Dates/Eve nts
NC 28411
A Jefferson
Orig Issue
09/12/06
App Received Draft Initiated
06/06/11
Reaulated Activities
Heat Pump Injection
Outfall Nu:...;_
Scheduled
Issuance
Central Files: APS _ SWP_
06/10/11
Permit Tracking Slip
Status
In review
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Francis A. Jefferson Ill
310 Lonicera Ct
Wilmington NC
Public Notice Issue Effective
eauested /Rece ived E vents
RO staff report requested
RO staff report received
28411
Expiration
06/09/11
06/09/11
Waterbody Name Stream Index Number Current Class Subbasin
NCDEN R
North Carolina Department of rEnvironment and Natura
Division of Water Quality
Beverly E-aves Perdue Co€een H. Sullins
Governor Director
June 17, 2011
Francis A. Jefferson M
Alesia R. Jefferson
310 Lonicera Court
Wilmington, NC 28411
Ref: Issuance of Injection Well Permit W10800136
Issued to Francis A, Jefferson III and Alesia Jefferson
Wilmington, New Hanover County, North Carolina
Dear Mr. Jefferson and Ms. Jefferson:
Resources
Dee Freeman
Secretary
In accordance with the application received on June 6, 2011. 1 am forwarding permit number W10800136 for the
continued operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system located at the
above referenced address. This permit shall be effective from the date of issuance until May 31, 2016, and shall be
subject to the conditions and limitations stated therein,
NOTE; During the renewal process for this permit, it was noted that the following records were not submitted
when the geothermal wells were originally installed.
+ Well Construction Record (GW-1)
• Triangulation Data
• Well ID plate installation date
• Mechanical Integrity Pressure testing data (if available)
After installation, these records were required to be submitted according to requirements of 15A NCAC 2C
.0213(g) 30 days after your permit was originally issued September 13, 2006, Please submit these documents
within 30 dam of receipt of this permit renewal. If you are not able to provide as with the information, please
submit to us a written justification for the missing information.
Please be advised., in the event there are multiple wells with separate clusters, one well identification tag per
`cluster' of wells should be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location.
Also, please pay special attention to Part V.2. The Permittee shall retain all retards of repairs, pressure
tests, maintenance, and other activities needed to maintain normal operating conditions.
AOUIEER PROTECTION SECTM
1636 Mall Servn-Canter. Raleigh, NoO Carolina 27699-16H
Loeaibn 2728 ; apical 97uleriard, Raleyti, Noel, Cankno 27604
Phone: 919-73G21 ti FAX 9: 919-715-0588: FAX 2: 379-715-6048 � Customer SeNicy: 1-877.623-674E
Intsmst www.n=areraualitv.onD
wi r aal Cmporu ' y t 4 m i-.re 0.e:'n ETro5ver
(�lt`
No:=th Carolim
,A7at 'w11r

In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an
application to renew the permit 120 days prior to its expiration date. This permit is not transferable to any person
without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or michael.ro 2:ers (w,ncdenr.2:ov if you have any questions about your permit.
cc: Charlie Stehman, Wilmington Regional Office
WI0800136 Permit File
New Hanover County Environmental Health Dept.
Best Regards,
~ ~..___
Michael Rogers, P.G. (NC & FL)
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE 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
Francis A. Jefferson III and Alesia R. Jefferson
FOR THE CONTINUED OPERATION OF TYPE SQM INJECTION WELL(S), defined in Title 15A North
Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed-loop
geothermal-mixed-fluid heat pump system. This system is located at 310 Lonicera Court, Wilmington, New
Hanover County, NC 28411, and will be constructed and operated in accordance with the application received
June 6, 2011, 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 operation of an injection well and 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, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through VII hereof.
Permit issued this the 17th day of June 2011.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
WIORC'.11 36 UIC/5QM-M.F. Renewal
Version 1/2010
Page 1 of4
PART I -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. In the event that there are multiple wells with separate clusters, one well identification tag per 'cluster' of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
PART II-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that 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 III -OPERATIONS 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.
WI08001 36 UIC/5QM-M.F. Renewal
Version 1/2010
Page 2 of 4
PART IV -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 111 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 V -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 retain all records of repairs, pressure tests, maintenance, and other activities
needed to maintain normal operating conditions.
3. 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 [phone], any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
4. 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.
5. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VI -PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
WWROOB( UIC/5QM-M.F. Renewal
Version 1/2010
Page 3 of 4
PART VII-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well
Construction Standards.
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 detennines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part VII (1) and (2) (G) shall be submitted to:
WI 0800136-
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/5QM-M.F . Renewal
Version 1/2010
Page 4 of 4
Rogers, Michael
From: Stehman , Charles
Sent:
To:
Thursday, June 09, 2011 4:53 PM
Rogers, Michael
Subject: RE: WI0800136 Jefferson SQM
You can issue the renewal without a staff report from us.
Charles F. Stehman, Ph.D.,P.G.
Environmental Program Supervisor Ill
NC Division of Water Quality, Aquifer Protection Section
Wilmington Regional Office, 127 Cardinal Drive Extension
Wilmington,No.rth Carolina 28405
phone: [phone], fax: [phone];
DISCLAilv1ER: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties .
From: Rogers, Michael
Sent: Thursday, June 09, 2011 4:04 PM
To: Stehman, Charles
Subject: WI0800136 Jefferson SQM
Charlie-
Attached is a SQM renewal application. Please let me know if you wish to conduct a pre-permitting inspection or not.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications#geothermApps
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
1
9;- A
NCDENR
North Carolina Department of Environment and
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
June 8, 2011
Francis A. Jefferson M
Alesia R. Jefferson
310 Lonicera Court
Wilmington. NC 28411
Subject: Acknowledgement of Application No. WI0800136
Francis A. Jefferson III SFR
Injection Mixed Fluid GSHP Well System (5QM)
New Hanover
Dear Mr. & Mrs. Jefferson:
Natural Resources
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on June 6, 2011. This application package has been assigned the number listed above and will be reviewed by
Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests,
Please be aware that the Divisions Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days after receipt of complete
application.
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at [e-mail]. If the
reviewer is unavailable, you may leave a message, and they will respond promptly.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THUS PROJECT,
Sincerely,
for Debra J. Watts
Supervisor
cc: Wilmington Regional Office, Aquifer Protection Section
Permit Application File W10800136
AQUIFER PROTEMON SECTION
1636 Mail Service Center, Ralegh, North Garchm 27659-1636
Lennon: 2728 Capital BoWavard. Raleigh, North uarolina 275134
Phone, 919.733-3221 i FAN 1� 915.715-05K FAX [phone]' Gustorner5ervice: 1-877-623.674E
intemw: www.ncwategualiis o
F-i'cquai Oppo umly 1 Affirm!vs A.r;cil EM010e,
•

P
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP MIXED -FLUID GEOTHERMAL INJECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system
(check one) New Application Renewal * Modification
* For renewals complete Parts A-C and the signature page.
t or Type Information and Mail to the Address on the Last Page, Illegible Applications Will Be Returned As Incomplete.
rzn
DATE: 20_LL
PERMIT NO. VY UV �3� (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non-Govemment: Individual Residence ✓ Business/Organization
Goverment: State Municipal County Federal
B. PERMTI' APPLICANT — For individual residences, list each owner on property deed. For all others,
state name of entity and name of perso legated authority to sign on behalf of the business or agency:
D
Mailing Address: C31 1-1 LLC Ct ff y_�,,:
City. � 1i �Yi State: r7C—Zip Code: L County: t �AAr � Ve.V'
Day Tele No.: Cell No.:� 52.
EMAIL Address: Fa.- No.:
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcal Identification Number (PIN) of well site: _A)County
(2) Physical Address (if different than mailing address): Q 5 6__P75n VC
D.
City:
State: NC Zip Code:
WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name --
Contact Person: EMAIL Address-
Address -
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
GPU/LJIC 5QM Permit Application (Revised 112412011) Page I

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: __________________________________ _
Contact Person"--: ---------------~E=MA=-=-I=L"--"-'A=d=dr=-e=s=s"'": ___________ _
Address: ___________________________________ _
City: __________ Zip Code: State: __ County:
Office Tele No.: _________ Cell No.: ----------~F=ax~N~o~-~= _______ _
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: _____ Depth of each boring (feet): ________ _
* If existing water supply wells will be used then provide the iriformation in item ( 4) below.
(2) Chemical additives to be used: R-22 ___ Propylene glycol _~_ Ethanol __ _
Other _________ ( other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc):
(4) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, plastic, etc.), diameter, depth,
and extent of casing appearing above ground: __________________ _
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** __ Other (specify)-~• _____ _
** By selecting bentonite grout, a variance is hereby requested to ISA NCAC 2c ·.0213(d~(~)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from ___ to ___ (feet)
If well has casing, indicate grout depth: from ____ to ____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the :injection well(s). Label all features clearl v and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC SQM Permit Application (Revised 1/24/2011) Page2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C MI 1(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship; by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner {which means all persons listed on the propert ddeed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. 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 Px,4p:M'Owner/Applicant
FYD�5 �r. Bh
Print or Type Full Name
Sigaaatur f P , Owner/Applicant
A� � 0" -k d Ta�J-my)
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUMC 5QM Permit Application (Revised 1/24/2011) Page 3

MCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Govemor
Francis A. Jefferson III
Alesia R. Jefferson
310 Lonicera Court
Wilmington, NC 28411
Division of Water Quality
Coleen W. Sullins
Director
June 17, 2011
Ref: Issuance of Injection Well Permit WI0BOO136
Issued to Francis A. Jefferson III and Alesia Jefferson
Wilmington, New Hanover County, North Carolina
Dear Mr. Jefferson and Ms, Jefferson:
Dee Freeman
Secretary
In accordance with the application received on June 6, 2011, I am forwarding permit number WI0800136 for the
continued operation of a vertical closed400p geothermal mixed -fluid heat pump injection well system located at the
above referenced address. This permit shall be effective from the date of issuance until May 31, 2016, and shall be
subject to the conditions and limitations stated therein.
NOTE: During the renewal process for this permit, it was noted that the following records were not submitted
when the geothermal wells were originally installed.
0 Well Construction Record (GW-1)
• Triangulation Data
• Well ID plate installation date
■ Mechanical Integrity Pressure testing, data (if available)
After installation, these records were required to be submitted according to requirements of 15A NCAC 2C
.0213(g) 30 days after your permit was originally issued September 13, 2006. Please submit these documents
within 30 days of receipt of this permit renewal. If you are not able to provide us with the information, please
submit to us a written justification for the missing information.
Please be advised, in the event there are multiple wells with separate clusters, one well identification tag per
`cluster' of wells should be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location.
Also, please pay special attention to Part V.2. The Permittee shall retain all records of repairs, pressure
tests, maintenance, and other activities needed to maintain normal operating conditions.
AQUIFER PROTECTION SECTfON
1636 Mail Serum Center, Raleigh, North Cafnilna 27694-1636
Location 2729 Capital Houz evard, Ralaioh. North Caroiins 27604
Pnone- 915 733-32211 FAX 1; 9%-71M688; FA.; 2: 919.715-6048 I Custorner Service 1-877-623-b748
Internet www.nmateroualit�.�
Al Eaisai Upr:ar Nty t F.mtm�,'wr. Acton Err:Moypr
Oil
b Carolina
� �alla'll

In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an
application to renew the permit 120 days prior to its expiration date. This permit is not transferable to any person
without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or michael.rO!!ers @ncdenr. e:ov if you have any questions about your permit.
cc : Charlie Stehman, Wilmington Regional Office
WI0800136 Permit File
New Hanover County Environmental Health Dept.
Best Regards, ~~----
Michael Rogers, P.G. (NC & FL)
A~A
s.,1_;_,A.._·-1. -
MCD EMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdu e
Governor
Francis Jefferson
310 Lonicera Court
Wilmington, NC 28411
Co lee n H. Sullin s
Director
May 2, 2011
Subject: Notice of Expiration (NOE)
SQM Geothermal Injection Well
Permit No. WI0800136
New Hanover County
Dear Mr. Jefferson:
De e Freeman
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Quality (DWQ) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above-referenced operating permit for
the underground injection well system , which was issued to you on September 12, 2006, and
expires on September 30, 2011, is soon due for renewal. If you wish to keep this permit and
operate the injection well system, the permit must be renewed and issued in your name.
If Your In jection Well is Currentl v Inactive:
If the injection well system is no longer being used for any purpose, it must be perrhanently
abandoned according to the regulatory requirements listed under NCAC Title 15A, Subchapter
2C, Section .0214. When each well is plugged and abandoned, the well abandonment record
(Form GW-30) must be submitted to our office to certify that the abandonment was properly
conducted.
If there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form must also be submitted. The GW-30 and Name/Ownership
Change forms can be found at h ttp ://p ortal.ncdenr.or2:/web/wa /aos/!!wo ro /reoortim!-forms.
If Your In jection Well is Currentl y Active:
If the injection well system is still active and you wish to renew your permit, the renewal
application must be submitted within 120 calendar days of the expiration of your permit.
According to our records, you must submit your permit renewal by June 2 . 2011.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raieigh , North Caroiina 27699-1636
Location : 2728 Capital Boulevard , Raieigh, North Caroi;na 27504
Phone: [phone] \ FAX 1: 919-715-0588; FAX2: 919-715-6048 \ Customer Service: 1-877-623-6748
lniernet: www.ncwateraualitv.oro
,A.n EqJ~I Op;JOrtur··. \ Afnrm~tive Ac::on Employe r
NOnehC 1· _ art a!'o ma
}Vaturall!f
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit one of the following
enclosed forms:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for Injection with
Geothermal Heat Pump System for Type 5QM Well(s) if the injection well system on
your property is still active.
-OR-
B. Status of Injection Well System if the injection well system is inactive or has been
temporarily or permanently abandoned.
Please submit the appropriate forms to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
163 6 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UIC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
h ttp ://h2o.enr.state.nc.us/ap s/gp u/forms.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please contact me by phone at [phone] or by email at eric.~.smithf@ ncdenr.!!ov.
Sincerely,
~/J.J»uf
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Wilmington Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0800136 w/o enclosures
2
Michael F. Easley, Governor
William G. Ross Jr., Secretary
] North Carolina Department of Environment and Natural Resources
7, y
Coleen Sullins, Director
Division of Water Quality
November 27, 2007
Monte Jefferson
Home Energy, Inc.
PO Box 238
Wendell, NC 27591
Subject: Geothermal Well Installation Data
Dear Mr. Jefferson:
In review of our records concerning closed -loop geothermal mixed -fluid injection well systems,
classified as SQM type permits, we have found the following records have not been submitted
for permits where your company is listed as the Beat pump installers:
• Well Construction Record (GW-1)
• Triangulation Data
• Well ID plate installation date
• Mechanical Integrity Pressure testing data (if available)
In order to assist your clients (those who hold 5QM permits) in meeting the condition of their
permits, Home Energy, Inc, (specifically Brad Scheel) has agreed to provide the above
information no later than December 27, 2007. For future reference. as we discussed November
14, 2007, we recommend you provide this information to your clients as soon as construction is
complete to assist them, in meeting the condition of their permits. Also, please remember their
permits require them to keep this information on -site as well.
To assist you, we have attached a list of permits where you are listed as the heat pump installer.
We have also attached a form to fill out the results of your mechanical integrity tests. Thank you
in advance for your cooperation and timely response. If you have any questions regarding this
letter, please call me at [phone] or Michael Rogers at [phone].
Sincerely,
a" _� .
Debra J. Watts
Environmental Supervisor
Groundwater Protection Unit
Attachment(s)
cc: APS Central Files (copy to each permit file on attached list)
In
Carolina
urally
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone. [phone]
Internet: www.ncwateVAuality.vrt Ux;atio= 2729 Capital Boulovard Raleigh, NC 27604 Fax 2: (9191715-0588
Fax 2: [phone]
An Equal OppodunitylAifirrnalive Gann Employer— 50% Recycled/10% Past Consumer Paper Customer Scmwa: (8771623-6748

List of Issued Permits to Home Energy, Inc.
Permit No. Name Heat Pump Contractor Date Permit Issued
WI0400082 Braden Monte Jefferson 11/20/2006
WI00800137 Panigutti Monte Jefferson 11/22/2006
WI0500145 Clark Monte Jefferson 10/9/2006
WI0800140 Belanger Monte Jefferson 2/13/2007
Vl/I0500157 S. Martin Monte Jefferson 3/9/2007
WI0100086 Combs Monte Jefferson 4/18/2007
WI0700105 Cherrillo Monte Jefferson 5/17/2007
WI0500161 Stein Monte Jefferson 6/27/2007
WI0500162 Lauer Monte Jefferson 7/6/2007
WI0500163 Blachowicz Monte Jefferson 8/20/2007
WI0500166 Manning Monte Jefferson 8/17/2007
WI0500169 Maloney Monte Jefferson 10/12/2007
WI0700107 Latta Monte Jefferson 9/21/2007
WI0800150 Duan Monte Jefferson 9/20/2007
WI0500171 ENT Audiology Monte Jefferson 9/20/2007
WI0500170 Griffin Monte Jefferson 10/11/2007
WI0700094 Harris Monte Jefferson 7/30/2006
WI0800136 Jefferson Monte Jefferson 9/12/2006
WI0500139 Essick Monte Jefferson 1/6/2006
WI0800135 Wilson Monte Jefferson 9/12/2006
WI0700096 Stolar Monte Jefferson 9/22/2006
WI0500143 Kahn Monte Jefferson 8/4/2006
WI0700093 Young Monte Jefferson 7/3/2006
WI0700095 Turner Monte Jefferson 9/22/2006
WI0500173 Bell Monte Jefferson not permitted as of 11/20/07
WI0500174 Wilson Community _College Monte Jefferson 11/20/2007
November 20, 2007
Mechanical Integrity Test Record
(For SQM Geothermal Heat Pump Injection Well System)
Owner/Permittee Name: Permit Number: WI ----------------~'---------
Facility Address: _____________________________ _
Home Phone: Cell Phone:
Heat Pump Contractor Name: ___________________________ _
Office Phone: Cell Phone: -----------------==-=-=-==-=------------------
Test er Name: _______________ Signature: _______________ _
Date of Test: --------
Loo p Initial Pressure (p si) Final Pressure (p si) Duration (minutes)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Any additional loop testing add to back of this form
Comments:
Pass (Yes or No)
----------------------------------
Other Test Methods and Results:
This form must be filled out and signed by the tester. The record must be received by Aquifer Protection Section 24 hours
prior to the initiation of the operation of the facility . You can send the form by mail: UIC Program, Mail Service Center 1636,
Raleigh, NC 27699 or by fax: [phone].
Mechanical Integrity Test Form 11/2007
y�ibx�-4
r
J
September 13, 2006
Francis Jefferson, III
c/o Monte Jefferson
Home Energy, Inc.
P.D. Box 238
Wendell, NC 27591
Dear Mr. Jefferson:
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
Ref: issuance of Injection Well Permit
Permit # WI0800136
Issued to Francis Jefferson, III
In accordance with your application submitted on July 6, 2006, I am forwarding Permit
#WI0800136 for the operation of a vertical closed -loop geothermal mixed -fluid hear pump
injection well system to be located at 310 Lonicera Court in Wilmington, New Hanover County,
North Carolina. This permit shall be effective from the date of issuance until September 30,
2011 and shall be subject to the conditions and limitations stated therein.
Pay special attention to the well construction standards in Parts I and 11 of your permit.
You shall notify this office at least 48 hours prior to beginning construction and at least 24 hours
prior to initiating operation of the injection well system.
In order to continue uninterrupted legal use of this well for the stated purpose, you should
submit an application to renew the permit three months prior to its expiration date. As indicated
in the permit, this permit is not transferable to any person without prior notice to, and approval
by, the Director of the Division of Water Quality.
If you have any questions regarding your pennit or the Underground Injection Control Program
please tail Mr. Qu Qi at [phone] or me at [phone].
Best Regards,
__7y'4_11�0 IJL'�_'1
Thomas Slusser, L.G.
Environmental Specialist III
cc: Charlie 5tehrrtan, Wilmington Regional Office
'1VlrlS5073,6 permir file
Enclos=
Npi Caro na
NaA 711if
Aquifer Protection Section 1636 Mail Service Center Ralcigh, NC 27699-1636 Telephone: [phone]
Internet. hlWr h1wv►vw.ncwa1vNuahty.org 2728 Capital Bouievard RaIcigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal ❑pportunitylAf irnalwe Action Employer-50% Recycledll0%Post Cons urner Paper Customer Service: [phone]

NORTH CAROLINA
9.0 : r ►r�► r ►Y ►► : a : ►► r ►M rlr7►T► r�i MIL
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
' : ►► • mI11016 .YIf1'M IIa�1I� ►1:�r�i�I� ' _ ` :4 iI►�[f��:l�f �ifLi ra ��►1
In accordance with the provisions of Article 7, Chapter 97; Article 21, Chapter 143, and other
applicable Laws, Rules, and Regulations
' 'i�►►S•Y•"lli��Y�� 7�]:��C�IT�i:Ir1�7fILr�
F'RANCIS A. JEFFERSON, III
FOR THE CONSTRUCTION AND OPERATION OF 15 TYPE 5QM INFECTION WELLS,
defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of
operating a "direct expansion" type vertical closed -loop geothermal -mixed -fluid heat pump system.
This system is located at 310 Lonicera Court in Wilmington, New Hanover County, North Carolina,
and will be constructed and operated in accordance with the application received July 6, 2006, 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 September 30, 2011,
and shall be subject to the specified conditions a4d limitations set forth in Parts I through X hereof.
Permit issued this the day of S,i`CI" , 2006.
tAlan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0800136 PAGE 1 OF 7
GWUC-5 ver. 9/06

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 not be located in an area generally subject to flooding. Areas that are
generally subject to flooding include those with concave slope, alluvial or colluvial soils,
gullies, depressions, and drainage ways.
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: DENR-bivision of Water Quality, Aquifer Protection Section UIC-Staff, 1636 Mail
Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well construction.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. Prior to constructing the injection well system, the permittee or his agent shall test the pH of the
soil at a depth of three feet at the planned well location. If the resulting soil pH is less than 6
standard units or greater than 11 standard units, the well system shall be equipped with a
compatible cathodic protection system. All testing results shall be kept on site available for
inspection.
2. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff,
telephone number [phone] and the Wilmington Regional Office Aquifer Protection
Section Staff, telephone number [phone].
3. All underground tubing shall be refrigeration grade copper tubing.
Permit No. WI0800136
GW/UIC-5 ver. 9/06
PAGE20F7
4. Prior to installation, all tubing to be placed in boreholes ("loops") shall be checked for leaks by
pressurizing the loop to a gage pressure of at least 350 pounds per square inch (psig), immersing
the loop in water and examining it for leaks. Loops with leaks shall not be installed.
5 . Prior to installation, each loop shall be visually inspected for damage such as kinks, dents, and
scrapes. Each loop shall be checked to verify that the nitrogen charge applied to the loop by the
manufacturer before shipping is still present at a pressure of at least 300 psig. The loop
manufacturer shall be notified in the event of damage or pressure loss, and the manufacturer's
instructions shall then be followed. The nitrogen charge may be released only when the loop is
installed and ready to be connected to the manifold.
6. Boreholes shall be large enough to allow insertion of the loop plus a tremie pipe for grouting.
7. After insertion of the tubing into the boreholes, an approved grout ( as defined in Title l SA North
Carolina Administrative Code 2C .0100) shall be pumped via tremiepipe into the annular space
of each borehole so as to completely fill it from bottom to top.
8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material shall
have a galvanic potential as close as practicable to that ofthe tubing material.
9. Dry nitrogen shall be circulated through the tubing during brazing to prevent oxidation.
10. After installation and prior to operation of the system, a mechanical integrity test shall be
conducted by pressurizing the injection well system to 400 psig with dry nitrogen and monitoring
for leaks using an ultrasonic or other leak detector of equal sensitivity and monitoring pressure in
the system for at least 2 hours. Alternatively, an equivalent vacuum test is acceptable. Any
pressure fluctuation other than that due to thermal expansion and contraction of the testing
medium shall be considered a failed mechanical integrity test. Any leaks shall be located and
repaired prior to charging the system with refrigerant. A copy of the p ost-installation pressure or
vacuum test record (initial p ressure readin g, final pressure reading. and the duration of the test)
shall be submitted to the A quifer Protection Section. The test records must be received b y the
A quifer Protection Section at least twenty-four (24) hours prior to the initiation of the o peration
of the facili ty for injection.
11. The location of each of the system manifolds shall be recorded by triangulation from two
permanent features on the site (e.g., building foundation comers). The permittee shall retain a
copy of the triangulation records. The permittee shall also submit a copy of the triangulation
records to the Aquifer Protection Section within 30 days of completion of well construction.
12. The written documentation required in Part II, p aragra phs (10) and (11) shall be submitted to:
PermitNo. WI0800136
GW/UIC-5
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
ver. 9/06
PAGE3 OF7
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to change
ownership, or there is a name change of the Permittee, a formal permit amendment request
must be submitted to the Director, including any supporting materials as may be appropriate, at
least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying
with any and all statutes, rules, regulations, or ordinances which may be imposed by other
local, state, and federal agencies which have jurisdiction. Furthermore, the issuance of this
permit does not imply that all regulatory requirements have been met.
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 that 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, thePermittee 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 (24) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section's
Underground Injection Control (UIC) Program Central Office staff, telephone number (919)
715-6935. 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. WI0800136
GW/UIC-5 ver. 9/06
PAGE4 OF7
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 [phone], any
of the following:
(A) Any occurrence at the injection facility that results m 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;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
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.
PennitNo. WI0800136
GW/UIC-5 ver. 9/06
PAGES OF 7
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an
extension.
PART IX-CHANGE OF WELL STATUS
1. The Pennittee shall provide written notification within 15 days of any change of status of an
injection well. Such a change would include the discontinued use of a well for injection. If a
well is taken completely out of service temporarily, the Permittee must install a sanitary seal.
If a well is not to be used for any purpose that well must be permanently abandoned according
to 15A NCAC 2C .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.
(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.
Permit No. WI0800136
GW/UIC-5 ver. 9/06
PAGE 6 OF7
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X-PERMIT SPECIAL CONDITIONS
None.
PermitNo. WI0800136
GW/UIC-5 ver. 9/06
PAGE 70F7
Subject: Re: staff reports needing your approval
From: Charles Stehman <[e-mail]>
Date: Tue, 12 Sep 2006 11 :51: 1 7 -0400
To: Thomas Slusser <[e-mail]>
CC: Liz Berg <[e-mail]>
Thomas,
I have approved the two permit staff reports for John Wilson,
WI0800135 and Francis A. Jefferson III, WI0800136.
Charlie Stehman
Thomas Slusser wrote:
Greetings Charlie,
Last month I received 2 staff reports that did not have your
signature of approval, although they did indicate recommendation
for permit issuance. The reports are for preconstruction
inspections for UIC permits WI0800135 and WI0800136.
Can you send me an email stating your approval or not for the
issuance of these permits? This is all I need to proceed.
Thanks for your help,
~Thomas Slusser
Charles F. Stehman <charles.stehman @ncmail.net>
Environmental Regional Supervisor II
NC Department of Environment and Natural Resources
Division of Water Quality
f
AQUIFER PROTECTION SECTION Fri�
1
APPLICATION REVIEW PXOUEST FUIZ
Date: July 13, 2006
To: ❑
Landon Davidson, ARO-APS
❑
Art Barnhardt, FRO-APS
❑
Andrew Pieter, MRO-APS
❑
Jay Zimmerman, RRO-APS
JUL 17 2006
❑ David May, tVWFj0N REG110j" AL OFFICE
® Charlie Stehman, WiRO-APS
❑ Sherri Knight, WSRO-APS
From: Thomas Slusser, , Groundwater Protection Unit
Telephone: �919} 715-6629 Fax. C919) 715-058$
c�
E-Mail: thomas.slusserancmail.net
r
V =
A. Permit Number: WI0800136 n
B. Owner: Francis A. Jefferson III
C. Facility/Operation: Francis A. Jefferson III SFR �n
® Proposed ❑ Existing ❑ Facility ❑ Operation h
D. Application:
I. Permit Tjpe: ❑ AnimaI ❑ Surface In-i.gation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Rernediation (ND)
® UIC - {5QM) closed loop mixed fluid geothermal
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type: ® New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ RenewaI wl Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 15 calendar days, please take the following actions:
® Return a Completed Form APSSRR.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU_
❑ Issue an Attachment B Certification from the RO*.
Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer:' ' Date:
FORM: APSARR 02/06 Page i of 1

AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: 08/09/2006 County: New Hanover
To: Aguifer Protection Central Office Permit -tee: Francis A. Jefferson III
Central Office Reviewer: Thomas Slusser Project Name: New Well Permit Application
Regional Login No: Application No.: W10800136
I. GENERAL INFORMATION
1. This application is (check all that app3y): ® New ❑ Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate infiltration ❑ EvaporatiordInfiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Rernediation ® Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
a. Date of site visit: 08/09/2009
b. Person contacted and contact information: Francis Jefferson 111, [phone]/ Monte Jefferson 12521205-1251
c. Site visit conducted by: Liz Bere
d. Inspection Report Attached: ❑ Yes or ® No.
2. Is the fallowing 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 Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
e. Regulated Activities 1 Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For Disposal and Injection Sites:
(If multiple sites either indicate which sites the information_ applies to. cop% and caste a new section into the
document for each site, or attach additional Hayes for each site
a. Location(s): 310 Loniceria Ct, Wilmington NC 28411
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
It. NEW AND MAJOR MODIFICATIONAPPLICATIONS (this section not needed far renewals or minor
mo4U ataons,skip to next sectioUl
Descriirdon Of Waste(S) And: Facilities
1. Please attach completed rating sheet. Facility Classification:
2. Are the new treatment facilities adequate for the type of waste and disposal system?
FORM: Staff Report- W10800136

AQUIFER PROTECTION REGIONAL STAFF REPORT
D Yes D No D N/A. Ifno, please explain: __ .
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No D N/ A. If no, please explain: __
( Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes D No D N/ A. If no, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No0
NI A. If no, please explain: __
6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable?
D Yes D No D N/ A. If no, please explain: __
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
D Yes D No D N/A. If yes, please attach a map showing areas of 100-year floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV: __
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit: __
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program: __
10. For residuals, will seasonal or other restrictions be required? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
Ill RENEWAL AND MODIFICATION APPLICATIONS (use previous section fo r new or mai or modification
systems)
Descri ption Of Waste(S) And Facilities
l. Are there appropriately certified ORCs for the facilities? D Yes or D No.
Operator in Charge: __ Certificate #: __
Backup-Operator in Charge: __ Certificate #: __
2. Is the design, maintenance and operation (e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D No.
If no, please explain: __
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? D Yes or D No. Ifno, please explain: __
FORM: StaffReport-WI0800136 2
\
AQUIFER PROTECTION REGIONAL ST AJ?F REPORT
4. Has the site changed in any way that may affect permit (drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain: __
5 . Is the residuals management plan for the facility adequate and/or acceptable to the Division?
D Yes or D No. If no, please explain: __
6. Are the existing application rates (hydraulic or nutrient) still acceptable? D Yes or D No. If no, please
explain: __
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Will seasonal or other restrictions be required for added sites? D Yes D No D N/A If yes, attach list of sites
with restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, please attach a
map showing conflict areas or attach any new maps you have received from the applicant to be incorporated
into the permit: __
1'0 . Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? D
Yes or D No. Ifno, please explain: ____ _
11 . Were monitoring wells properly constructed and located? D Yes or D No D N/A. If no, please explain :
12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? D Yes or
D No D N/A. Please summarize any findings resulting from this review: __ _
13 . Check all that apply: D No compliance issues; D Notice(s) of violation within the last permit cycle; D
Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments (such as NOV, NOD etc): ____ _
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? D Yes
D No D Not Determined D N/A .. If no, please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? D
Yes or D No D N/A. If yes, please explain: __
FORM: Staff Report-WI0800136 3
AQUIFER PROTECTION 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.)
Descri ption Of Well(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
D Heating/cooling water return flow (5A 7)
[8J Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (SL/"Non-Discharge")
D Other (Specify: )
2 . Does system use same well for water source and injection? D Yes [8J No
3. Are there any potential pollution sources that may affect injection? D Yes [8J No
What is/are the pollution source(s)? There is not a pollution sources at this site , the pro posed well is a Closed-
Loo p Geothermal-Mixed-Fluid In jection Well. What is the distance of the in jection we ll(s) from the pollution
source(s)?
4 . What is the minimum distance of proposed injection wells from the property boundary? 5 ft
5 . Quality of drainage at site: D Good [8J Adequate D Poor
6 . Flooding potential of site: D Low [8J Moderate D High
7 . For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells , frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: __
8 . Does the map presented represent the actual site (property lines, wells, surface drainage)? [8J Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources , roads, approximate scale, and north arrow.
In jection Well Permit Renewal And Modification Only:
l. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes D No. If yes, explain:
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 y es, explain:
3 . For renewal or modification of groundwater remediation permits (of any type ), will
continued/additional/modified in'ections have an adverse im act on mi 0 ration of the lume or mana ement of
the contamination incident? Yes D No. If y es , explain:
FORM: Staff Report-WI0800136 4
AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Drilling contractor: Name: __
Address:
Certification number: __
5. Complete and attach Well Construction Data Sheet.
FORM: Staff Report-WI0800136 5
..
AQUIFER PROTECTION REGIONAL STA.eF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.: None.
2. Attach Well Construction Data Sheet -if needed infonnation is available
3. Do you foresee any problems with issuance/renewal of this pennit? D Yes IZI No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional infonnation request.
Make sure that you provide a reason for each item:
Item Reason
None
5. List specific Pennit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
None
6. List specific special conditions or compliance schedules that you recommend to be included in the pennit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
None
7. Recommendation: D Hold, pending receipt and review of additional infonnation by regional office; D Hold,
pending review of draft pennit by regional office; D Issue upon receipt of needed additional information; IZI
Issue; D Deny. If deny, please state reasons:
8. Signature of report preparer(s): ________________________ _
Signature of APS regional supervisor: _____________________ _
Date: _______ _
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM : Staff Report-WI0800136 6
AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FO
Date: Jul-, 13.2006
7h: ❑ Landon Davidson, ARO-APS
❑ Art Barnhardt, FRO-APS
❑ Andrew Pitner, MRD-APS
❑ Jay Zimmerman, RRO-APS
CE11WE
JUL 17 2006 S
❑ David May, VN fftbUNAL OFFICE
® Charlie Stehman, WiRO-APS
❑ Sherri Knight, WSRO-APS
From: Thomas Slusser, , Groundwater Protection Unit
Telephone: i 9191 715-6629 Fax: r 919 f 715-0588
E Afail: thomas.slusse.rc'tinemail.net
A. Permit Number: WI0800136
B. Owner: Francis A. Jefferson M
C. Facility/Operation: Francis A. Jefferson III SFR
® Proposed ❑ Existing ❑ Facility ❑ Operation
D. Application
1. Permit Type: ❑ AnimaI ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Remediation (ND)
® UIC - (5QM) closed Ioop mixed fluid geothermal
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animai
2. Project Type: ® New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for- your
review, comment, and/or action. Within 15 calendar days, please take the following actions: Z3'
® Return a Completed Form APSSRR.
❑ Attach Well Construction Data Sheet. CIO
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO*. -
* Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment.'D for
certification. Refer to the RPP SDP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to tht, appropriate Central Office -Aquifer Protection Section contact person
listed above. i
/.
I�p
RO-APS Reviewer: Date:
FORM: APSARR 02106 Page 1 of 1

Permit Number WI0800136
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
thomas.slusser
Permitted Flow
Facilit
Facility Name
Francis A. Jefferson Ill SFR
Location Address
310 Lonicera Ct
Wilmington
Owner
Owner Name
Francis
Dates/Events
NC
A
28411
Jefferson
Orig Issue App Received Draft Initiated
07/06/06
Re g ulated Activities
Outfall NULL
Scheduled
Issuance
Central Files: APS_ SWP_
07/13/06
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Francis Jefferson, Ill
310 Lonicera Ct
Wilmington NC
Public Notice Issue Effective
28411
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Michael P. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Deparrm ant or Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
July 13, 2006
Francis A. Jefferson III
c/o Home Energy, Inc.
P.O. Box 238
Weddell, NC 27591
Subject: Acknowledgement of Application No. WI0800136
Francis A. Jefferson III SFR
Injection Mixed Fluid GSHP Well System (5QM)
Now Hanover County
Dear Mr. Jefferson:
The Aquifer Protection Section (APS) of the Division of Water Quality (DWQ) acknowledges the receipt
of your permit application package on July 6, 2006_ This application has been assigned the number listed
above and will be reviewed by Thomas Slusser.
The reviewer will perform a detailed review of your application package and, if necessary, may request
additional infornation relevant to the permitting process. To expedite the processing of your permit
application, the APS requests your prompt and complete response to any additional information requests.
Please be aware that DWQ's Wilmington Regional Office must provide its approval prior to the issuance
of the proposed permit.
If you have any questions, please call Thomas Slusser at [phone], or email him at
Thomas.S lusser ii'ncmail.net.
PLEASE REFER TO THE SUBJECT APPLICATION NUMBER WHEN MAKING INQUMIES
ON THIS PROJECT,
Sincerely,
for Debra J_ Watts, Supervisor
Groundwater Protection Unit
cc: Home Energy, Inc. - Monte Jefferson
Wilmington Regional Office - APS
APS Central Files
4 `r Carolina
�tumllil
Aquifer Protection Section 1636 Mail Service Center
Internet: WWW.ncwnterquality.ora Location: 2728Capital Boulevard
An Equal opportunllylAf iimiative Action Employer— 60% Recycled/10% Post Consumer Paper
Raleigh, NC 27699-1636 Telephones [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: (919) 7154l4$
CU910Mer5crviee: [phone]

ojev)N�
V" Y 001 1�
NORTH CARQLINA - - - -
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELLS)FOR-INJE'C'FjO WT"TII-i4-$EAT`fVMP`Svs-Tv,m,
Type 5A7 aiid 5QM Wel)es ''
In Accordance with the provisions ofNCAC Title 15A: 02C.0200
Complete application and mail to address on the rack page.
TO: DIRECT. NORTH CAROLINA DION OF WATER QUALITY
DATE: DIRECT.
(L 2U
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1) = Type 5A7 wells inject water used to provide heating or cooling forsftctures.
(2) Type 5QM wells contain a subsurface system of continuous piping, that is
isolated $am the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes andlor corrosion
inhibitors. _
L.
r�
rI
(3) Type 5QW wells contain a subsurface system of continuous piping, that is
isolated Tram the environment'aiid only circulates potable water. If you selected
this well type, then complete form GW-57 CL 1Votifcation Of Intent Tn
Construct A Closed Loop Geothermal -Water Only I►rjectio►t Well System.
PEPjhft APPLICANT za
Name: FgAA 6 s A • �L,pTr 9.5 orl
Address: '31 a Lo 4 t G ak C-T• ---
City, W11.fA%a (rT0Q State: Zip Code, S A-11 i(Countty. 41f�r1�►��R
Telephone: �� 1�) 6$�G - D $$ MGM% L 3"e►rtA'V+ cotc
PROPERTY OWNER (if different applicant} 1- � t� S =,A el
Name: C� aFt� •� t1�=L r
Address: 11 i, L , 21Sl 1
City:
Telephone:
STATUS OF APPLICANT
Private: V Federal:
State:
Sate:
Municipal:
Zip Code: County:—
t r VV". E C,'� "
r4orJf0RUU30,_,rV4Jc4.'0A
Commercial:
Native American Lands:
Revised 5105 GWlUIC-57 HP Page 1 of 4

E.
F
G.
1XV
1.
FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility:
Address:
City:
Telephone:
Name:
Zip Code: County:
Contact Person:
Address: .7 riz
BOX -
City: Zip Code: g l County:
Telephone: ':Jn— 5ta(o— 0-%Lntact Person:
INJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.)
1 C,
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO
CONSTRUCTION DATA (check one)
EXISTING WELL being proposed for use as an injection well. Provide the data in
(1) through (7) below to the best of your knowledge. Attach a copy of Form GW -
1 (Well Construction Record) if available.
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.
A
UL
(1) Well Drilling Contractor's Name: "V� 6 '' LL t Lot, Contractor Certification number: (\ C, , A Y_ 61
(2) Date to be constructed: Number of borings_
Approximate depth of each boring (feet): ri 5
(3) Well casing: Is the wel(s) cased? ,jy1
(a) YES If_ s, the ovide the casing information below.
Type: Galvani d teel Bl tee) Plastic Other (specify)
Casing depth: From o ft. (reference to land surface)
Casing extends above ground inches
(b) NO
Revised 5105 GWMC-57 BP Page 2 of 4

(4) Grout (material surrounding well casing and/or piping):
(a) Grout ty e: Cement "entonite Other (specify) �--
(b) Gm ed surface and grout depth (reference to land surface): U.)
around closed loop piping; from to (feet). �O Jr -
around well casing; from to (feet)-
(5) Screens (for Type 5A7 wells)
(a) Depth: From to feet below ground surface.
(6) N.C. S lations (Title 15A NCAC 2C .0200) require the permittee to make provisions
form i - ellhead processes. A faucet on both influent (fluid entering heat. pump) and
effluelr fl being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? yes no (b) the effluent line? yes no
(7) SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well).
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available.
provide the data in part K (1) of this application form to the best of your knowledge.
NOTE: THE WELL DR.ILI.ING CONTRACTOR CAN SUPPLY THE? DATA FOR EITHER EXISTM OR
PROPOSED WELLS W THIS TWORMATiON IS UNAVAILABLE BY OTHER MEANS-
J. PROPOSED OPERATING DATA (for Type 5A7 wells)
(1) 1njectiorn ra Average (daily) gallons per minute (gpm).
(2) Inje V Average (daily) gallons per day (gpd)-
(3) Inject- n .+u�: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ' F, Average (July) ° F.
IC.
L.
INJECTION FLUID DATA
(1) Fluid source (for Type SA7 wells) If underground, from what depth, formation and type of
rock/sediment unit will the fluid be drawn (e.g., granite, limestone, sand, etc.).
Depth: Formation: Rocki"ment unit:
(2) Chemical Analysis of Source Fluid (far Type 5QM wells)
Provide a complete listing of all
f7 _ -y -� 1
INJECTION -RELATED EQUIPMENT
added to th circulating heat transfer fluid:
r --
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-
M. LOCATION OF WELL(S) Attach twn reaps.
Revised 5105 GWfUIC-57 HP Page 3 of

(1) Include a site map (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 map 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 I have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the
information is true, accurate and complete. 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."
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner authorizing the above agent
P . 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 well(s) conforms to the Well
Construction Standards (Title 15A NCAC 2C .0200)
Revised 5/05
Please return two copies of the completed Application package to:
UICProgram
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW/UIC-57 HP Page 4 of4
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ALESIA R. JEFFERSON
LOT 98 SECTION 6 GORMAN PLANTATION
vJ+�' •'4 HARNETT TOWNSHIP NEW HANOVER COUNTY `, 4
NORTH CAROLINA Q
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L DECEMBER 15, 1993
x DEED BOOK 1689 PAGE 736
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from: 302 east 3rd street wendell, nc to: 310 Lonicera Ct, Wilmington, NC 28411, USA -... Page I of I
1. Head west from E 3rd St -go 0.1 mi
2.: Tum right at N Pine St -go 0.2 mi
3. Tum left at Wendell Blvd -go 3.4 mi
4. Tum right at Rolesville Rd -go 0.4 mi
5. Tum right into the US-264 W/US-64 W entry ramp to Raleigh/Knightdale -go 10 mi
6. Take the 1-440 E ramp to Durham (I-40)/Benson -go 0.7 mi
7. ; Merge into 1-440 S -go 1.8 mi
8. Take the 1-40 E exit 16 to Wilmington/Benson -go 120 mi
9.1 Take the NC-132 N exit 420 -go 0.3 mi
, 10 .. Tum right at Gordon Rd -go 2.7 mi
..... ·---1-
, 11. 1 Tum right at Military Cutoff Rd -go 0.2 mi
12. Tum left at Covil Farm Rd -go 0.7 mi
13. Continue on Hawk Rd -go 0.1 mi
14. Tum right at Red Cedar Rd -go 0.1 mi
15. Tum left at Lonicera Ct-go 229 ft
These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road
conditions to differ from the map results .
Map data ©2006 NAVTEQ™
http://maps.google .com/maps?saddr=302%20east%203rd%20street%20wendell%2C%20nc... 7/6/2006