WI0800137_GEO THERMAL_20120523

Beverly Eaves Perdue
Governor
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 23, 2012
Louis and Carol Panigutti
7777 North Wickham Road 12-121
Melbourne, FL 32934
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: \VI0800137
Dear Mr. and Mrs. Panigutti:
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 info1m 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.org/web/wg/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,
p . J ~ (/tfoL t}?tUM/-
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Pennit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Rale~h. North Carolina 27699-1636
Location : 512 N. Salisbwy St., Raleigh, North Carolina 27604
Phone: 919-S0?-64641 FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity I Af~rmative Action Employer
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Rogers, Michael
From:
Sent:
To:
Subject:
Stehman, Charles
Friday, July 15, 2011 11 :01 AM
Rogers, Michael
RE: WI0800137 Panigutti
I believe we will pass on this one, but it is an interesting installation. This system, which was reviewed by Liz Berg back
in 2006, consists of 15 directional borings set at 45 degrees to the land surface. I believe the heat exchange fluid is some
modern equivalent of Freon. Reissue the permit.
Charles F. Stehman, Ph.D.,P.G.
Environmental Program Supervisor III
NC Division of Water Quality, Aquifer Protection Section
Wilmington Regional Office, 127 Cardinal Drive Extension
Wilmington,North Carolina 28405
phone: [phone], fax: [phone]
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: Rogers, Michael
Sent: Wednesday, July 13, 2011 4:16 PM
To: Stehman, Charles
Subject: WI0800137 Panigutti
Charlie-
Attached is a renewal application for SQM geothermal system. 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)
htto://oortal.ncdenr.org/web/wq/aos/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
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~CDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Louis & Carol Panigutti
2632 St. James Drive Southeast
MAILING ADDRESS
Southpon. NC 28461
Dear Mr. and Mrs. Paniguitti:
Coleen H. Sullins
Director
July 12 , 2011
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI0800137
Carol & Louis Panigutti SFR
Injection Mixed Fluid GSHP
Well System (SQM) System
Brunswick County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on July 11, 2011. Your application package has been assigned the number listed
above, and the primary reviewer is Michael Rogers.
Central and Raleigh Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
Sincerely,
O~A.~
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Raleigh Regional Office, Aquifer Protection Section
Permit File WI0800137
AQUIFER PROTECTION SECTIOI~
1636 Mai! Service Center. Raleigh, North Carolina 27699-1636
Location: 2728 Capita l Boulevard, Raleigh. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwateraualitv .or:::
l,1 Equa; Oppon:.:;1;::,1 :L-.ffirmative Action Empioye r
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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 NHXED-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.
Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As
DATE: _ _ 20
PERMIT NO.&J) jpq6 cep( 7S`7 (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence Business/Organization
Government: State Municipal County Federal
B. PERMIT APPLICANT - For individual residences, list each owner on property deed. For all others,
/)t+,ti
state name of entity and name of person delegated authority to sign on behalf of the business of agency:
PA 11 U 17 1
Mailing Address: __7 /g.?-2Sr
ei�•r-
City. - 152_ s �oj- 4.2 f,�c-� Statc.,Ve Zip Code: �-� 6 I County: 1��
Day Tele No.: " I -.?-.aZ ' 17 Cell No.:
EMAIL Address: Fax No.:
C. LOCATION OF WELL SITE - Where the injection wells are physically located:
t 1) Parcel Identification Number (PIN) of well site: County:
(2) Physical Address (if different than mailing address): L—� _. e-
City: State: NC Zip Code:
D. 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 Tole No.: Cell No.: Fax No.:
V
GPUIUIC 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~ddr~e=ss~: ___________ _
Address:------------------------------------
City: Zip Code: _____ State: __ County:
Office Tele No.: _________ Cell No.: ___________ Fax_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 information 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)(l)(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 clearlv 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 GJS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 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 .0211(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 property deed},
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"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 roved specifications and conditions of
the Permit"
Si ature of Property O erlApplicant
V F
Print or Type Full Nine
Signature of Property Owner/Applicant
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 5Qyt Permit Application (Revised 1/24/2011) Page 3

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: t^-> l d 'VO 0 ( :7
Permittee Name: .� - L.:,
Address: � �� �c•n� u -�- � � �
Please check the selection which most closeiy describes the current status of your injection well system:
1) >11 Well(s) still used for injection activities, or may be in the future.
2) ❑ Well(s) not used for injection but islam used for water supply or other purposes.
3) C Injection discontinued and: a) ❑ Well(s) temporarily abandoned .
b) ❑ Weil(s) permanently abandoned
c) ❑ Well(s) not abandoned
4) ❑ Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
Ifyou checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description ofhaw the well
was sealed and the type of material used to fill the well ifpermanently abandoned). -
Permit Rescission:
If you checked (2),(3), or (4) and will not use a well for injection on this site in the future, you should request rescission of the
permit. Do you wish to rescind the permit?
❑ Yes ❑ No
Certification:
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the infonration submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
f! r
Signature V/
Da e
Revised 5105 GMIC-58

Permit Number WI0800137
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Louis and Carol Panigutti SFR
Location Address
2632 Saint James Dr SE
Southport NC
Owner
Owner Name
Louis
Dates/Events
28461
Panigutti
Orig Issue
11/20/06
App Received Draft Initiated
07/11/11
Scheduled
Issuance
Central Files: APS_ SWP_
07/21/11
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Wilmington
County
Brunswick
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Louis Panigutti
2632 Saint James Dr SE
Southport NC 28461
Public Notice Issue
07/26/11
Effective
07/26/11
Expiration
06/30/16
_R_e~g_u_la_t_e_d_A_c_t _iv_it_ie_s _______________ Reauested/Received Events
Heat Pump Injection RO staff report requested
RO staff report received
Outfall NULL
Waterbody Name Stream Index Number Current Class
07/13/11
07/15/11
Subbasin
Permit Number WI0800137
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Coastal ·SW Rule
Permitted Flow
Facilit
Facility Name
Louis and Carol Panigutti SFR
Location Address
2632 Saint James Dr SE
Southport NC
Owner
Owner Name
Louis
Dates/Events
28461
Panigutti
Orig Issue
11/20/06
App Received Draft Initiated
07/11/11
Reo ulated Activities
Heat Pump Injection
Outfall NULL
Scheduled
Issuance
Central Files: APS_ SWP_
07/19/11
Permit Tracking Slip
Status
In review
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Majc.;,r/Minor
Minor
Region
Wilmington
County
Brunswick
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Louis Panigutti
2632 Saint James Dr SE
Southport NC
Public Notice Issue Effective
Re a uested/Received Events
RO staff report requested
RO staff report received
28461
Expiration
07/13/11
07/15/11
Waterbody Name Stream Index Number Current Class Subbasin
' MA
NCDEMR
North Caro lina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Louis and Carol Panigutti
2632 St. James Drive Southeast
Southport, NC 28461
Division of Wa ter Qualit y
Coleen H. Sull ins
Di rector
July 26 , 2011
Ref: Issuance oflnjection Well Permit WI0800137
Issued to Louis and Carol Panigutti
Southport, Brunswick County, North Carolina
Dear Mr. and Ms. Panigutti:
Dee Freeman
Secreta ry
In accordance with the application received on July 11 , 2011, I am forwarding permit number WI0800137 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 June 30 , 2016, and shall be
subject to the conditions and limitations stated therein.
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.
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.!!ov if you have any questions about your permit.
cc : Charles Stehman, Wilmington Regional Office
WI0800137 Permit File
Brunswick County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 r<iail Service Center. Raleigh, Nortr1 Caro::na 27699-1630
Locafon: 2728 Capiial Boulevard, Raleigh. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588 ; FAX 2: 919-715-CO48 Customer Service: 1-877-623-6748
lnternet:-www.ncwaterauaiiiv.oro
An E □iJ E:l Cipoortun i _ \ Affirma t1vs AC;10 ~1 E:r:::::oyr,.·
~~---
Michael Rogers, P.G. (NC & FL)
None. r 1. orth ,___,aro 1na
;Jvatt1rally
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
Louis and Carol Panigutti
FOR THE CONTINUED OPERATION OF TYPE SQM INJECTION WELL(S), defined in Title ISA 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 2632 St. James Drive Southeast,
Southport, Brunswick County, NC 28461, and will be constructed and operated in accordance with the
application received July 11, 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 consid~ed a part of this
permit.
This permit is for operation of an injection well and shall be in compliance with Title lSA North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until June 30, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through VII hereof.
Permit issued this the 26th day of July 2011.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
WI08001 37 UIC/5QM-M.F . Renewal
Version 1/2010
Page 1 of 4
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.
WI0800i 3-:: UIC/SQM-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 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 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 910-796-7215, 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 RENEW AL
The Permittee shall, at least 120 days prior to the expiration 'of this permit, request an extension.
WI0800137 UIC/5QM-M.F. Renewal
Version 1/2010
Page 3 of4
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 l SA 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.
3. The written documentation required in Part VII (1) and (2) (G) shall be submitted to:
WI0800i37
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 of4
Beverly Eaves Perdue
Governor
NA
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
June 28, 2011
Louis and Carol Panigutti
7777 North Wickham Road 12-121
Melbourne, Florida 32934
Subject: Additional Information Request
SQM Geothermal Injection Well
Permit No. WI0800137
Brunswick County
Dear Mr. & Mrs. Panigutti:
Dee Freeman
Secretary
On July 1, 2011, we received your completed "Status of Injection Well System" form. However, we need
you complete the enclosed form so that we can continue processing your renewal.
Please submit the completed form to:
Aquifer Protection Section
Groundwater Protection Unit
UICProgram
1636 Mail Service Center
Raleigh, NC 27699-1636
For your convenience, a renewal application and a UIC well system status form are attached along with a
self-addressed envelope. The form is also available on-line at the DWQ website at
http://h2o.enr.state.nc.us/aps/gpu/fonns.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.!!.smitMi1ncdenr.gov.
Sincerely, a~ stf __ ~--
Eric G. Smith, P.G.
Hydrogeologist
Enclosure
cc: Wilmington Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0800137 w/o enclosures
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterauality.org
An Equal Opponuniiy I Affirmaiive Aciion Employer
r TOnehC 1. '\I ort aro 1na
Jvaturallll
KNA
HDEHR
North Carolina Department of Environment and Natura
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
June 6, 2011
Louis and Carol Panigutti
2496 St. James Dr. SE
Southport, NC 28461
Subject: Notice of Expiration (NOE)
SQM Geothermal Injection Well
Permit No. WI0800137
Brunswick County
Dear Mr. & Mrs. Panipautti:
Resources
Dee 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 located on your property, which, was issued to you on
November 20, 2006, and expires on October 31, 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,
Yourinfection Well is Currentlt Inactive:
If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed wader NCAC Title 1 5A, 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 httn://oortal.ncden.T.org/web/wk)/aTs/Lwiro/rmortinfi-forms,
If Your Injection Well is Currentl~, 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 July 3, 241L
R4ll1FER PRO7CT10;1 SECTION
1636 mall Serums Center, Ralegh, North Camlina 2769S'-1536
Lowwrti 272E Capital Bwevard. Raieig`r. Norti 3arailna 27604 ijn-
Phone: [phone]AY.1. 919-715.OM: 9 i-715-6W4 Customer Servir~. r-67
N OTI.t Car-winra
Internet; www.ncwatssuualitv.a� • FLt�}�/7� £t
•n Lgjal bpr�rrL Wmrrrzava Amw Employer Nla 6Z6 6 liLf
v

In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title ISA, 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
1636 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 tm ://h2o.enr.state.nc.us/aos /!!n 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.!.!.smith(a),ncdenr.!!ov.
Sincerely, t:~ r-!J bt;tf-·
Eric G. Smith, P.G.
Hydro geologist
Enclosures
cc: Wilmington Regional Office -APS w/o enclosures
APS Central Files -Permit No. WI0800137 w/o enclosures
2
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SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON COft.STRUCTIIfG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 276"-1617 Phone No. [phone] ext SW.
RECEIVED ! DENR ► DWO
Aquifer Protection Secttorl
JA N 2 9 2009
Form OW-ta
Rw 3107

Mechanical Integrity 'Vest Record
(For 5QM Geothermal Heat PumnInjection Well System)
Owner/Permittee Name: (-k t Yl' t ,4 - -Permit Number: WI
Facility Address: A `-j 1 L42 "7T • �N ( I VvSk I J i . r _
Home Phone: k cj- aG-3 — :h i A Cell Phone: �!
Heat Pump Coutractor Name:
Office Phone:
Tester Name:
Date of Test:
1!2*p
MUM Prewu m i
Fbal Pressure(psi)
Dumfien minutes
Pass es or No
2
r4
'►
3
4
5
6
-
7
S
S
14
11
12
13
14
15
�.�
_ LT
Ito
Co` ents:
Other T
[ ice Any additionallIoo t s add to back ofis form
ods and Results:
This form [rust be filled out and signed by the tester. The record must be received by
prier to the initiation of the operation of the facility. You can send the form by mail- l IIC Program, Mail Service Center 1636,
Raleigh, NC 27699 or by fax: [phone].
Mechanical Integrity Test Form i IY2007

{ ...
.,
/
i "
'
DF W A TAR
Michael F. Easley, Governor
November ?7, 2007
Monte Jefferson
Horne Energy, hic.
PO Box 238
Wendell, NC 27591
Subject: Geothermal Well Installation Data
Dear Mr, Jefferson:
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coteen Sullins, Director
Division of Water Quality
In review of our records concerning closets -loop geothermal mixed -fluid injection well systems,
classified as 5QM type its, we have found the following records have not been submitted
for permits where your company is listed as the heat 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,
'D�' _� �A
Debra J. Watts
Environmental Supervisor
Groundwater Protection unit
Attachment(s)
cc: APS Central Files (copy to each permit file on attached list)
O
N_v��.r�Carolina
Naturally
Aquifer Protection Section 1636 Mail 5crvice Center Raleigh, NC 2 76 99 -1636 Telephone: [phone]
Internet: www.newateMuality.nrg Location: 2729 Capital Boulevard Raleigh, NC 27604 Fax l ; [phone]
Fax 2: t919)715.6048
An Equal OpportunitylA[firmaNe Aclton trnpiayer- 50% Recycledl14% Past Consumer Paper Customer Service: [phone]

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
WI0500157 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
Wl0700094 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/Pennittee Name: Permit Number: WI
-------------------'-'c;,___ _____ _
Facility Address: _____________________________ _
Home Phone: Cell Phone:
Heat Pump Contractor Name: ___________________________ _
Office Phone: Cell Phone: -----------------~----------------
Test er Name: _______________ Signature: _______________ _
Date of Test: --------
Loop Initial Pressure (n si) Final Pressure (p si) Duration (minutes) Pass (Y es or No)
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: ----------------------------------
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 orby fax: [phone].
Mechanical Integrity Test Form 11/2007
Permit Number WI0800137
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Permitted Flow
Facilit
Facility Name
Carol & Louis Panigutti SFR
Location Address
2632 Saint James Dr SE
Southport NC
Owner
Owner Name
Louis
Dates/Events
28461
Panigutti
Orig Issue App Received Draft Initiated
11/20/06 09/25/06
Scheduled
Issuance
Central Files: APS_ SWP_
11/30/06
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Wilmington
County
Brunswick
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Louis Panigutti
2496 Saint James Dr SE
Southport NC
Public Notice Issue
11/20/06
Effective
11/20/06
28461
Expiration
10/31/11
_R_e_...9._u_la_t_e_d_A_c_t_iv_it_ie_s _______________ Re quested/Received Events
Heat Pump Injection RO staff report requested
RO staff report received
Outfall -",;• __ ·_
Waterbody Name Stream Index Number Current Class
09/27/06
10/23/06
Subbasin
d��F W H rER�G Michael F. Easley, Governor
C►} William G. Ross Jr., Secretary
> Worth Carolina Department of Environment and Natural Resources
y
Alan W. Klimek, P.E. Director
Division of Water (Nality
November 20, 2006
Louis and Carol Panigutti
2496 St. James Dr. SE
Southport, NC 28461
Re: Issuance of Injection Well Permit
Permit No. WI0800137
Dear Mr. and Mrs. Panigutti:
In accordance with your application dated August 8, 2006, and received September 25, 2006, l
am forwarding Permit No. WI0800137 for the operation of a vertical closed -loop geothermal
mixed -fluid heat pump injection well system to be located at 2632 St. James Drive SE,
Southport, Brunswick County, North Carolina. This permit shall be effective from the date of
issuance until October 31, 2011, and shall be subject to the conditions and limitations stated
therein. Pay special attention to the well construction standards in Parts H and V of your permit.
You must notify this office (Raleigh Central Office) and the Wilmington Regional Office at
least forty-eight (48) hours prior to constructing the system, and forty-eight (48) hours prior to
initiation of the operation of the 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 permit or the Underground Injection Control Program
please call Mr. Qu Qi at [phone] or me at [phone].
Best Regards,
A"Atp g7e�
Michael Rogers
Hydrogeological Technician II
cc: Charlie Stehman -- Wilmington Regional Office
Central Office File
Attachment(s)
t
Cara��'na
urall{�
Aquifer Protection Section 1636 Mail service Center Raleigh, NC 27699-1636
lntemet: tin://www ncwaWMualitv.org 2728 Capital Boulevard Raleigh, NC 27644
An Equal 0pportunitylAfflrmalve Action Employer— 50% Recycled? 10% Post Consumer Raper
Telephone, [phone]
Fex L [phone]
Fax 2- [phone]
Customer Service. [phone]

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
LOUIS AND CAROL PANIGUTTI
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 2632 St. James Drive SE in Southport, Brunswick County,
North Carolina, and will be constructed and operated in accordance with the application received
September 25, 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 October 31,
2011, and shall be subject to the specified conditions and limitations set forth in Parts I through
IX hereof,
Permit issued this the day of , 2006.
Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Page I of 7

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-Division 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.
Page 2 of7
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 15A
North Carolina Administrative Code 2C .0100) shall be pumped via tremie pipe 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 of the 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 post-installation pressure or vacuum test record (initial pressure reading. final pressure
reading, and the duration of the test) shall be submitted to the Aquifer Protection Section.
The test records must be received by the Aquifer Protection Section at least twenty-four (24)
hours prior to the initiation of the operation of the facility 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 , para gr aphs (10 ) and (11 ) shall be submitted to :
Aquifer Protection Section-DIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Page 3 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). fu 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.
PARTIV-PERFORMANCESTANDARDS
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. fu 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 Aquifer Protection Section's
Underground fujection Control (UIC) Program Central Office staff, telephone number
[phone], and the Wilmington Regional Office Aquifer Protection Section Staff,
telephone number [phone]. · Notification is required so that Division staff can
Page 4 of7
inspect or otherwise review the injection facility and determine if it is in compliance with
permit conditions.
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 ofrefrigerant 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.
Page 5 of7
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an
extension.
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .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.
Page 6 of7
(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:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Page 7 of7
from: southport nc to: +33° 56' 2.04", -78° 6' 42.84" (33.933900,-78.111900) - Google W. Pagel of 1
GoIle Start Southport, NC
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2496 Saint James Dr Se
Southport NC
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33.9339N 78.1119W - Google Maps
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AH--
AQUIFER PROTECTION REGIONAL STAFF REPORT
IL r1�l5c4r_ k
Date: 10/17/2006 County:
To: Aquifer Protection Central Office Permittee: Carol and Louis Panigutti
Central Office Reviewer: Mike Rogers Project Name: New Well Permit Application
Regional Login No: Application No.: W10800137
L GENERAL INI'ORMATION
1. This application is (check all that apply): ® New ❑ Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation ® 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: 10/13/2006
b. Person contacted and contact information: Carol Paninitti t9101_Z53-7917f Monte Jefferson {2521205-1251
c. Site visit conducted by: Liz Bens
d. Inspection Report Attached: ❑ Yes or ® No.
2. is the following information entered into the BIMS record for this application correct?
® Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities: RELM J DENR� DV(Q
a. Location: AtXA1=FR'MnTs:f'Tl(J0t SFCTIIN
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:
i If multiple sues either indicate which sites the infarrnat7'on an.Plies to. cnpt and haste^a new section into the
document for each site, or attach additional pNes for each site
a. Location(s): 2496 St. James Dr. SE
b. Driving Directions:
c. USGS Quadrangle Map name and number:
a F
d.'katitude: Longitude: = S M V P14
yr �� `",, 4- t
FORM: Staff Report- M0800137

AQUIFER PROTECTION REGIONAL STAFF REPORT
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section )
Description 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?
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: __
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D
Yes D No D N/A. Ifno, please explain: __
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes 0No0
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. Ifno, 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 O 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: __
l 0. 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?)
III. RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or major modification
s vstems)
Description Of Waste (S) And Facilities
1. Are there appropriately certified ORCs for the facilities? D Yes or D No.
Operator in Charge: __ Certificate#: __
Backup-Operator in Charge: Certificate #:
FORM: Staff Report-WI0800137 2
AQUIFER PROTECTION REGIONAL STAFF REPORT
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. If no, please explain: __
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: __
10. 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 .. Ifno, 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-WI0800137 3
AQUIFER PROTECTION REGIONAL STAFF REPORT
I1! INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed -loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well(S And Facilities — New. Renewal, And Modification
1. Type of injection system:
❑ Heating/cooling water return flaw (5A7)
® Closed -loop heat pump system;t5QM/4QW)
❑ In .situ remediation (51) Y -
❑ Closed -loop groundwater remediation effluent injection (5U74on-Discharge")
❑ Other [Specify_
2. Does system use same well for water source and injection? ❑ Yes ® No
3. Are there any potential pollution sources that may affect injection? ❑ Yes ® No
What is/are the pollution source(s)? There is not a pollution sources at this site. the_prolI sed well is a Closed -
Loop Geothermal -Mixed -Fluid Iniection Well,
4. What is the minimum distance of proposed injection wells from the property boundary? >5 ft
5. Quality of drainage at site: ❑ Good ® Adequate ❑ Poor
6. Flooding potential of site: ❑ Low ® Moderate ❑ High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program:
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? 9 Yes or ❑ No. If
no or no map, please attach a sketch of the site. Shaw property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
gLection Well Permit Renewal And Modification Onl%;
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
❑ Yes ❑ No. If vas. explain:
2. For closed -loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? ❑ Yes ❑ No. 1 f .� es.. exp lain.: _ _
3. For renewal or modification of groundwater remediation permits,of anN tNye), will
continued/additional/modified ed n ections have an adverse impact rot miggt o of the Flume or manaeement of
the contamination incident? ❑ Yes ❑ No. If ves. explain_
FORM: Staff Report- W10840137 4

AQUIFER PROTECTION REGIONAL STAFF REPORT
4. Drilling contractor: Name: __
Address:
Certification number: __
5. Complete and attach Well Construction Data Sheet.
FORM: Staff Report-WI0800137 5
AQUIFER PROTECTION REGIONAL STAFF 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 information is available
3. Do you foresee any problems with issuance/renewal of this permit? D Yes ~ No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
None
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
None
6 . List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
None
7 . Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft perm it by regional office; D Issue upon receipt of needed additional information;
~ Issue; D Deny. If deny, please state reasons: __
8. Signatureofreportpreparer(s): JJ.,J ~ ~
Signature of APS regional supervisor: = ~
Date: !1?(t7106
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
None.
FORM: StaffReport-W10800137 6
OCT 0 4 2U&QUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: September 27. 2006
To: ❑ Landon Davidson, ARO-APS � David May, WaRO APS
El Art Barnhardt, FRO-APS f — Charlie Stehman, WiRO-APS
❑ Andrew Pitner, MRO-APS ❑ Sherri Knight, WSRO-APS
❑ Jay Zimmerman, RRO-APS
From: Tkcemas Slusser ; Groundwater Protection Unit 04G
Telephone: [phone] Fax: [phone]
E-Mail: dgbEL6w a ncmaii.netrdPi?yf -,. , r-nr, fly- f� tt � • r t?
A. Permit Number: _ �,eljl I -�-
B. Owner: PANIGUTTI SFR
C. Facility/Operation:
® Proposed ❑ Existing ❑ Facility
D. Application
RECEIVED Om 1(YwQ
AOUiPPO PPMION SFU;0N
OCT 10 2006
❑ . Operation
1. Permit Type: ❑ Animal ❑ Surface Irrigation ❑ Reuse ❑ H-R infiltration
❑ Recycle ❑ IIE Lagoon ❑ GW Remediation (ND)
® UIC - (5QM) closed loop mixed fluid geothermal DIRECT EXPANSION
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type: ® New ❑ Maj or Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal 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, anchor action. Within N 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: J. Date: 10 �
J
FORM: APSARR 02106 Page 1 of 1

fix permit number
Subject: fix permit number
From: [e-mail]
Date: Tue, 3 Oct 2006 15:18:36 -0400 (EDT)
To: [e-mail]
Ticket: 12818
Status: CLOSED
Username: dennis_rogers
RequestType: SOFTWARE
ProblemType: BIMS
Detail: A new SQM injection well permit application
(WI0700101) was entered into BIMS and assigned
to the Washington RO, which was the wrong
regional office. It was forwarded to the
Wilmington RO. Therefore, a new number needs to
be assigned showing the correct ROM (08).
Resolution: WI0700101 has been changed to W~0l37
HandledBy: jennifer_hiser
10/3/2006 3:28 PM
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Dcpatment of Environment and Naural Resources
Alan W. Klimek, P.E. Dirrctor
Division of Water Quality
September 27, 2006
Carol & Louis Panigutti
Cln Monte Jefferson
Home Energy Incorporated
P.O. Box 238
Wendell, NC 27591
Ref: Injection Permit Applica on Receipt
Permit Application #WI T" e
�T
Dear Mrs. and Mr. Panigutti.,
Your application for a permit to construct and use a well for the injection of geothermal heat pump effluent has
been receivers and is under review. A member of the Aquifer Protection Section's Washington Regional Office
staff will be contacting you to arrange an inspection of the injection well site as part of the review.
If you have any questions regarding permit or iri_jection well rules please contact me at [phone] or Qu Qi
at [phone].
Sincerely,
Mike Rogers
Hydrogeological Technician II
Underground Injection Control Program
Cc: David May, Washington Regional Office
W10&101 permit file
B
h� a Carolina
,�tura!!y
Aquifer Protection Section 1636 )Mail Service Center Raleigh, NC 27699-i636 Phone [phone] Customer Service
Internet http7//h2o.enr.sWe.no.us 2728 Capital Boulevard Raleigh, NC 27604 Pax [phone] I-877-623-6748
Fax [phone]
An Equal OpportuntlylAifirmative Action Employer — 50% Recycle cV10% Post Consumer Paper

NORTH CAROLINA
DEPARTMENT OF ENVIRONMI3NT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type SA? and 5QM Wells
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
TO: DIRECTOR CAROLINA D T ION OF WATER QUALITY
DATE: 20
A. SYSTEM CLASSIFICATION Please check column which matches proposed systern.
(1) Type SA7 wells inject water used to provide heating or cooling for structures.
(2) Type 5QM 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 enviroun=t and only circulates potable water_ If you selected
this well type, then complete form GW-57 CI., Nafifrcadva Of Intent To
Cons truel A Closed -Loop Geothermal --Wafer Orly Injection Well System.
B. PERMIT APPLICANT
Name: �. o :� g _ vti u 1► 1
�'�� f Address: Z 7 � S�`• "3`n-� •�.� C.g � -- � �'
Q[{ ' City: � 'Ttt e:, ,r- T— _ State Zip Code:z 1 County: P,
��r f Telephone: `� 4 U �•� 3� t 7 �- n� � �� � r
C. PROPERTY OWNER (if different from applicant)
Name:---
O4Ci ddress: 6 �. `i a+wa
+ Ci , .r • Code: �o County: ti 1
c re ss ty- ^�
Telephone:
D. STATU OiPPLICANT
Private: �% Federal:
State: Municipal:
Revised 5105 GWAX[C-57 R
Mail Permit To:
Home Energy Inc.
P.O. Box 238
302 E. Third Street
Wendell, NC 27591
.9 rfi
lern
et„ rsCl
T.+
a�
n
i�
a
GV5

E. FACQ,ITY (SITE) DATA
(Fill out ONLY if the Statists of Owner is Federal, State, Municipal or Counnercial).
Name of Business or Facility: _
Address:
City: Zip Code: _ County: _ -T
Telephone: _ _ Contact Person:
F
HEAT PU`W CONTRACTOR DATA
Name:
Addre;
City: �� j,�-V��� t _ Zip Code: d!,. County:
Telephone: —36V�(0 o1 Contact Person:,n M�,�s���I
INFECTION PROCEDURE (Briefly describe bow the injection well(s) will be used.
01
H_ WELL USE Will the injection well(s) also be as the supply well(s) for the following?
(1) The injection operation? NO
(2) Personal consumption? ANO
1, 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 Constriction Record) if available.
'h 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-i after construction.
(l) WelI Drilling Contractor's Name:
NC Contractor Certificatioa number.
(2) Date to be constructed. Number of borings: L J 6C) t'G «7VV:W
Approximate depth of each boring (feet):
(3) Well casing_ is the well(s) cased?
(a) YES
Type: Galvanized
If yes, then provide the casing info t>n below.
I_ Black steel tic Other (specify)
Casing depth: From
Casing extends abo
(b) N=
reference to land surface)
inC
�0%
Revised 5105 GWIMC-57 HP Paget of

(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement 13entonite )�_ other (spe( ify)
(b) Gro ted surface and grout depth (referent ati�and CA
around closed loop piping; fion� €tti `��eet)- '�QM
amend well rasing, firm to (feet).
(5) Screens (for Type 5A7 was) ram} lIt
(a) Depth: From to feet below ground surface.
(6) N.C- State a lati Title 15A NCAC 2C .0200) require the permittee to make provisions
for monitr_ ng f I seas. A faucet on both influent (fluid entering heat pump) and
effluent (flit -d bei 1~jij into the well) lines is required. Will there be a faucet on:
(a) the iaxfluent I i rib yes no (b) the effluent line? yes no
(7) SOURCE u . 101� IrrFOR1vIATI4rr (i different fmtn injettinn well).
Attacb a y £ F G -1 (Weil Construction Record). If Form GW-1 is not available,
provide the to } o this application form to the best ofyour knowledge.
NOTE: THE DR- tt3G CQNTRACI QR CAN SUPPLY THE DATA FUR 1 IIElZ EXISTING OR
PROPOSED WE IF THIS INFORMATION IS UNAVArLABLE BY OTHER MEANS.
J. PROPOSED OPERATING DATA (for Type SA7 wells)
(1) Injecti - rate Average (daily) gallons per minute (gpm).
(2) j o Vol Average (daily) gallons per day (gpd)-
(3) l ec n tire: Average {daily} pounds/square inch (psi).
(4) Injection 'emperature: Average (January) ° F, Average (July) ° F.
K. IN.IECTION FLUID DATA
(1) Fluid source (for Type 5A7 wells) If underground., from what depth, formation and type of
roeWsediment unit will the fluid be drawn (e.g., granite, limestone, sand, etc.).
Depth:--- - Formation_-- — Rock/ ment unit, �L
(2) Chemical Analysis of Source Fluid (for Type 5QM W4`� 1]
Provide a complete listin T all chemicals ed I circ dating Iz t transfer fluid` 1
7 y
1
L, INJECTION -RELATED E UIPNj
Attach a diagram showing the engineering layout of the injection equipment and exterior pipi ig/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
M. LOCATION OF WELLS) Attach two maps.
Revised 5/05 GWMC-57 HP Page 3 of 4

(I) 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 geothernnal heat pump well system Label all
features clearly and include a north auvw.
(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
O. 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- 1 agree to construct,
operate, maintain, repair, and if applicable, abandon the injection well and all related appurtenances in
accordance with the approved specifications and condition s of the Pcrrntt: '
(Signature of6!�i or Authorized Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner authorizing the above agent
R 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 ensm that the injection well( conforms to the Well
Construction Standards (Title 15A NCAC 2C .0200)
If Different From
Please return two cp6ies of the completed Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Revised 5/05 CYWIMC-57 HP Page 4 of 4

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