WI0800158_GEO THERMAL_20180830

Permit Number
Program Category
Ground Water
Permit Type
WI0800158
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Douglas and Hilary Schultz SFR
Location Address
175 Herring Pond Ct
Beaufort NC
Owner
Owner Name
Douglas p
Dates/Events
Orig Issue
1/9/2009
App Received
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
28516
Schultz
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
8/30/2018
Permit Tracking Slip
Status
Issued
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Douglas P. Schultz
175 Herring Pond Ct
Beaufort
Region
Wilmington
County
Carteret
NC
Issue
8/28/2018
Effective
1/1/2019
28516
Expiration
12/31/2024
Requested /Received Events
Administrative amendment request received
RO staff report requested
RO staff report received
Streamlndex Number Current Class
5/25/18
5/30118
8/20118
Subbasln
Permit Number
Program Category
Ground Water
Permit Type
WI0800158
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Douglas and Hilary Schultz SFR
Location Address
175 Herring Pond Ct
Beaufort NC
Owner
Owner Name
Douglas p
Dates/Events
Orig Issue
1/9/2009
App Received
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
28516
Schultz
Draft Initiated
Scheduled
Issuance
Central Files: APS SWP
8/21/2018
Permit Tracking Slip
Status
In review
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Douglas P. Schultz
175 Herring Pond Ct
Beaufort
Region
Wilmington
County
Carteret
NC 28516
Public Notice Issue Effective Expiration
Requested /Received Events
Administrative amendment request received
RO staff report requested
RO staff report received
Streamlndex Number Current Class
5/25/18
5/30/18
8/20/18
Subbasln
R.OYCOOPER
GOVffl'Mlf'
MICHAELS. REGAN
~Of)'
LINDA CULPEPPER
lnttrlmOit«Nr
Douglas & Hilary Schultz
175 Herring Pond Ct
Beaufort, NC 28516
Re: Issuance of Injection Well Permit
Permit No. WI0800158
NORT~ CAROUNA
Elwll'onmMtal Qwallty
August 24, 2018
Geothermal Heating/Cooling Water Return Well
Carteret County
Dear Mr. and Mrs. Schultz:
In accordance with your permit renewal application received May 25, 2018, I am forwarding Permit
No. WI0800158 for the continued operation of geothermal heating/cooling water return well(s) located
at the above referenced address. Please note that this renewed permit shall become effective on January
1, 2019, (i.e., the day after the expiration date of the existing permit), which may differ from the date
of this letter. This permit shall be effective from date of issuance, until December 31, 2024, and shall
be subject to the conditions and limitations stated therein.
Please Note:
• Samples from the influent and effluent sampling ports of your geothermal well system
were collected on August 9, 2018. Laboratory analytical results will be forwarded to you
when it becomes available.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Resources. If you have any questions regarding your permit or the Underground
Injection Control Program please call me at [phone].
North Carolina Department of Environmental Quality I Division of Water Resources I AFOGW Section
512 North Salisbury Street I 1636 Mail Service Center I Raleigh, North Carolina 27699-1636
919. 707 .9129
Best Regards,
Shristi Shrestha
Underground Injection Control (UIC)-Hydrogeologist
Division of Water Resources, NCDEQ
Water Quality Regional Operations Section
cc: Morella Sanchez-King-Geoff Kegley, Wilmington Regional Office
Central Office File, WI0800158.
Carteret County Environmental Health Department
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Douglas & Hillary Schultz
Carteret County
FOR THE CONTINUED OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defined in Title 15A North Carolina Administrative Code 2C .0224, which will be used for
the injection of heat pump effluent. This injection well is located at 175 Herring Pond Ct., Beaufort, Carteret
County, NC 28516 _and will be constructed and operated in accordance with the application received May 25,
2018, and conformity with the specifications and supporting data, all of which are filed with the Department of
Environmental Quality.
This permit is for continued 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 become effec.tive on January 1, 2019 (i.e., the day after the expiration date of the existing pennit),
which may differ from the issuance date below. This permit shall be effective, unless revoked, from January 1,
2019 until December 31, 2024, and shall be subject to the specified conditions and limitations stated therein.
~
Permit issued this the ~«a day of ~ , 2018
~ .::, . v.J?l
For Linda Culpepper
Interim Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Permit #WI0800158 Geothermal Heating/Cooling Water Return Well
ver. 8-8-2018
Pagel of5
PART I -PERMIT 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 (I SA 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 is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data [15A NCAC 02C .021 l(a)).
3. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data [15A NCAC 02C .0211(1)].
4. This permit is not transferable without prior notice to, and approval. In the event there is a desire for the
facility to change ownership, or there is a name change of the Permittee, a formal permit amendment request
must be submitted, including any supporting materials as may be appropriate, at least 30 days prior to the
date of the change [15A NCAC 02C .021 l(q)].
5. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met [15A NCAC 02C .0203].
PART II -WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed in accordance
with requirements of rule 15A NCAC 02C .0107.
2. Any injection well shall be constructed in accordance with requirements of rule 15A NCAC 02C .0107
except that the entire length of the casing shall be grouted in such a way that there is no interconnection of
aquifers or zones having differences in water quality that would result in degradation of any aquifer or zone.
For screened wells, grout shall be emplaced from the top of the gravel pack to the land surface. For open-
end wells, the casing shall be grouted from .the bottom of the casing to the land surface [15A NCAC 02C
.0224(d)(2), (3)].
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing conditions
ifbentonite is to be used [15A NCAC 02C .0225(g)(8)].
4. The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [ 15A NCAC 02C .0224( d)( 4)].
5. Each injection well shall be secured to reasonably insure against unauthorized access and use and shall be
sealed with a watertight cap or well seal, as defined in G.S. 87-85(16).
6. Each geothermal injection well shall have permanently affixed an identification plate according to [15A
NCAC 02C .0107(i)(2)].
Permit#WI0800158 Geothermal Heating/Cooling Water Return Well
ver . 8-8-2018
Page 2 of5
7. A copy of the Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 of this
permit within 30 days after completion.
PART III-OPERATION AND USE CONDITIONS
1. The Permittee shall comply with the conditions of this permit and properly operate and maintain the
injection facility in compliance with the conditions of this permit and rules of 15A NCAC 02C .0200, even
if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C .021 lG)].
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface water
or groundwater resulting from the operation of this facility. In the event that the facility fails to perform
satisfactorily, including the creation of nuisance conditions or failure of the injection zone to adequately
assimilate the injected fluid, the Permittee shall take immediate corrective actions including those actions
that may be required, such as the repair, modification, or abandonment of the injection facility [ 15A NCAC
02C .0206].
PART IV-INSPECTIONS [15A NCAC 02C .0211(k:)]
1. Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation of credentials, enter and inspect any property, premises, or place on or related to the
injection facility at any reasonable time for the purpose of determining compliance with this permit, may
inspect or copy any records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwater, surface water, or injection fluids.
2. DWR representatives shall have reasonable access for purposes of inspection, observation, and sampling
associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the injection
facility's activities.
PART V -MONITORING AND REPORTING REQUIREMENTS
1. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on-site and available for inspection [15A NCAC
02C .0224(f)(2), (4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State and
compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
.0224(f)(l)].
3. The Permittee shall report any report any monitoring or other information that indicates noncompliance
with a specific permit condition, that a contaminant may cause the injected fluids to migrate outside the
approved injection zone or area. As specified in rule 15A NCAC 02C .021 l(r), noncompliance notification
shall be as follows:
(A) Oral notification shall be given within 24 hours of the occurrence, or first knowledge of the
occurrence, to the Wilmington Regional Office, telephone number 910-796-7215.
Permit #WI0800158 Geothermal Heating/Cooling Water Return. Well
ver. 8-8-2018
Page 3 of5
(B) Written notification shall be made within 5 (five) days of the occurrence and submitted to the
addresses in Item #5 below; and
(C) The written notification shall contain a description of the noncompliance and its cause; the period
of noncompliance, including dates and times; if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and any steps taken or planned to reduce, eliminate, and
prevent reoccurrence of the noncompliance.
4. The Permittee shall record the number and location of the wells with the register of deeds in the county in
the facility is located [15A NCAC 02C .0224(f)(3)].
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
UIC Program Staff
Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
And
Water Quality Regional Operations Section
DWR Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
PART VI-PERMIT RENEWAL [15A NCAC 02C .0224(c)].
As required by rule, and application for permit renewal shall be made at least 120 days prior to the expiration of
this permit. This permit condition does not apply if the Permittee chooses to discontinue operation of the well
for injection of effluent from the geothermal heating and cooling system associated with this permit.
PART VII-CHANGE OF WELL STATUS [15A NCAC 02C .0240].
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complying with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to rule
15A NCAC 02C .0113(b) in order to prevent the well from deteriorating and acting as a source or conduit
of contamination, which is prohibited by General Statute 87-88(c).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well
seal that cannot be removed without the use of hand or power tools.
4. When injection 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
.Ol 13(b), which include, but are not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
any 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;
Permit #WI0800158 Geothermal Heating/Cooling Water Return Well
ver. 8-8-2018
Page 4 of5
(C) Each well shall be thoroughly disinfected, prior to sealing, in accordance with rule 15A
NCAC 02C .011 l(b)(l)(A), (B), and (C);
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled;
(E) In those cases when a subsurface cavity has been created as a result of the injection
operations, each well shall be abandoned in such a manner that will prevent the movement
of fluids into or between underground sources of drinking water; and
(F) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0224(f)(4) within 30 days of completion of abandonment to the addresses
specified in Part V .5 above.
Permit#WI0800158 Geothermal Heating/Cooling Water Return Well
ver. 8-8-2018
Page 5 of5
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE QUEST FORM
Date: May 30, 2018
To: Morella Sanchez-King -Geoff Kegley
From: Shristi Shrestha, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0800158
A. Applicant: Douglas & Hilary Schultz
B. Facilitv Name:
C. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: Renewal
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 30 calendar days, please return a com pleted WOROS Staff
Report.
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 Groundwater Protection Branch contact person
listed above.
RO-WOROSReviewer: __________________ Date: _____ _
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 092614 Page 1 of 1
Water Resources
Envitrmmentai Quaiity
May 30, 2018
Douglas & Hilary Schultz
175 Herring Pond Ct
Beaufort NC 28516
RE. Acknowledgement of Application No. WI0800158
Geothermal Heating/Cooling Water Return Well
Carteret County
Dear Mr. and Mrs. Schultz:
ROY COOPER
Govermui
MICHAEL S. REGAN
5eceeforl,
LiNDA CULPEPPER
lillevine Dimow.
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on May 25, 2018. Your application
package has been assigned the number listed above, and the primary reviewer is Shristi Shrestha
Central and Wilmington 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 Water Quality Regional Operations
Section (WQROS) 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 64 to
90 days after receipt of a complete application. If you have any questions, please contact Shristi
Shrestha at 919-807-6406 or email at [e-mail].
Sincerely,
For Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch Division of Water
Resources
cc: Wilmington Regional Office, WQROS
Permit File W10800158
-':7-" Nothing , . - .
Sisle of North Carolina I Environmental Quality I Division ❑f Water RtaourceF,
wikNr Quailty Regional Operatkam Section
1636 Mai SnrviceCenter I ROOigl, North Carolina 27699-1 h36
919.707-9129

North Carolina Department of Environmental Quality-Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Applicatio ~Renewal* __ Modification __ Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Sections A thru E . and M (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: _______ ___, 20 __ PERMIT NO. 1\/J..V ~ 0 0 I ~g (leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS O.,eave Blank if New Well/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as~ Geothermal Well D Drinking Water Supply Well
D Other Water Supply Use-Indicate use (i.e., irrigation, etc.) ________ _
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30). CEIVED/NCDEQ/Dv {
D Yes, I wish to rescind the permit MAY 2 5 2018
2. Current Ownership Status 'Vater Q~ality Reg_ion,.•
H h b h f hi . . 1 . d? D YES ~ NO'."lnerat1ons SRc-t1nr as t ere een a c ange o owners p smce perrmt ast issue . ~
If yes, indicate New Owner's contact information:
Name(s) ___________________________ _
Mailing Address: ____________________________ _
City: __________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: ------------~E=m=ai=l =A=d=dr=e=s=s-~: __________ _
B. STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence~ Business/Organization __
Government: State Municipal __ County__ Federal
C. WELL OWNER(S)/PERMIT APPLICANT -For single family residences, list all persons listed on the
property deed. For all others, list name ofbusiness/agency and name of person and title with delegated authority
tosign: 'J)t>t1G,LAS Is 1-1:I.l--AR..Y ,s e,.HUl-7Z..
Mailing Address: 1 l-S tt'lf..~ I t-..)(-,. f'bN ~ CJ T
City: B 'e,~ un}-(CT State:~ Zip Code:d ~S°I fu County:CA ~TV-IT
Day Tele No.: "l,.)~;}.. ~ g.?,1? • I Y. /-3-Cell No.: ::\-0?, -6 ~ <ir ~oSs:Cl~
EMAIL Address ))SCII Cl!.H td Cg@ -b: Fax No.:
3:> S C4,1 v '-~ I ,-3'ci) l,. ii\ Ai L. t&-=,,._,
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 1
D. WELL OPERATOR (if different from well owner) -For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
to sign: ~ / -A
Mailing Address:---------------------------------
City: _____________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: __________ County: _____ _
(2) Physical Address (if different than mailing address): ________________ _
City: _____________ County _________ Zip Code: ____ _
F 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.: ________ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HVACContractor'sName: ____________________________ _
NC HV AC Contractor License No.: _________________________ _
Company Name:. ________________________________ _
Contact Person'-: _______________ EMAIL Address: ___________ _
Address:------------------------------------
City: __________ Zip Code: ____ State: __ County:
Office Tele No.: Cell No.: __________ Fax No.: _______ _
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES __ _ NO ___ _
YES ___ _ NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS -As specified in l SA NCAC 02C .0224 (d):
(I) The water supply well shall be constructed in accordance with the water supply well requirements of
ISA NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of ISA NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application Rev. 4-15-20 I 6 Page2
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTING WELLS PROPOSED WELLS ----------
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107C0(8 )
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATING DATA
(1) Injection Rate: Average (daily) g allons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) __ ° F.
L. SITE MAP-As specifi~d in ISA NCAC 02C .0224{b)(4 ), attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
( 1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in ISA NCAC 02C .0107 (a)(2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page3
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
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
1 SA NCA.0 02C .0211tre) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the person(s) listed on the progeny 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 approved specifications and conditions of the
Permit "
C. -
Signal of Property Owner/Appli t
ni 4 1 �Zj t_ c_ris j -S C. 44 IJ
Print or Type Full Name and Title
Signature of Pr perry Owner/Apt li ant
r+s
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (W QROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Wcll Permit Application Rev. 4-1 S 2416 Page 4

Water Resources
E;nvironmentdl Quality
May 14, 2018
CERTIFIED MAIL # 7017 0190 0000 1635 3139
RETURN RECEIPT REQUESTED
Douglas & Hilary Schultz
175 Herring Pend Ct
Beaufort NC 28516
Subject: Notice of Expiration (NOE)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0800158
Carteret County
Dear Mr. & Mrs. Schultz:
ROY COOPER
Governor
MICHAEL S, REGAN
scclwary'
LINDA CULPEPPER
Interim Direclo+'
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) 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
,geothermal injection well system located on your property at the above referenced address was
issued on January 1, 2014 and expires on December 31, 2018. Per permit conditions and
requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior to expiration of the permit if you wish to continue operating the injection well
on your property.
If Your Geothermal Water Return Well is Still Currendy Being Used for Injection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
httJf iortal.ncdenr.orWweb/w !a 3sl ,w rol ermit-a lications.
_­;--SYot tng Compares;..
State of North Carolina I Environmental Quality I Division of Water Resources
Water Qaality Regional Operations Section
1636 Mail SerViceCenter I Raleigh, North Carolina 27699-1636i
919-707-9129

If Your Geothermal Water Return Well is NO LONGER Beim Used for Iniection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section
.0240. When the well is plugged and abandoned, a 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 Prover-v:
If there has been a change of ownership of the property, an "Injection Well Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
(9I9) 807-6406 or by email at shristi,shrestha itgcdenr.gov.
Regards,
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Wilmington Regional Office — WQROS w/o enclosures
Central Files - Permit No. WI0800158 w/o enclosures

Domestic Mail Only
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Douglas & Hilary Schultz
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1.75 Herring Pond Ct
MAY
Beaufort, NC 28516
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DocuSign E,~velope ID: 8AE53D81-C2FA-4187-AD54-50EA652A945C
North Carolina Department of Environmental Quality-Division of Water Resources
WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
Permit No. WI0800158
Date: 8/9/2018
To: Shristi Shrestha
Central Office Reviewer
County: Caretet
Permittee/Applicant: Douglas & Hilary Schultz
Facility Name: Schultz geothermal well system
L GENERAL INFORMATION
1. This application is (check all that apply): 0 New L8J Renewal
D Minor Modification D Major Modification.
a. Date of Inspection: 8/9/2018
b. Person contacted and contact information: Doug Schultz -dschultzl [e-mail]
c. Site visit conducted by: Geoff Kegley
d. Inspection Report Printed from BIMS attached: D Yes L8J No.
e. Physical Address of Site including zip code: 175 Herring Pond Ct., Beaufort. NC 28516
a. Driving Directions if rural site and/or no physical address: From Beaufort take US 70 to Merrimon Rd to S.
River Rd to Sandy Point Dr to Herring Pond Ct.
f. Latitude: Longitude:
Source of Lat/Long & Accuracy (i.e., Google Earth, GPS, etc.):_ Google Earth
IL DESCRIPTION OF INJECTION WELL (S ) AND FACILITY
1. Type of injection system:
L8J Geothermal Heating/Cooling Water Return
D In situ Groundwater Remediation
D Non-Discharge Groundwater Remediation
D Other (Specify:_____)_
2. For Geothermal Water Return Well(s ) only
a. For existing geothermal system only:
RECEIVEDINCDEQ/DWR
AUG .2 ~ 2018
: Water Quality
Regional Operations Section
Were samples collected from Influent/Effluent sampling ports? L8J Yes D No.
Provide well construction information from well tag: Already accurately listed in BIMS
b. Does existing or proposed system use same well for water source and injection? D Yes L8J No
If No, please provide source/supply well construction info (i.e., depth, date drilled, well contractor,
etc.) and attached map and sketch location of supply well in relation to injection well and any other
features in Section IV of this Staff Report.
3. Are there any potential pollution sources that may affect injection? D Yes L8J No
What is/are the pollution source(s)? _________________________ _
What is the distance of the injection well(s) from the pollution source(s)? ___________ _
4. What is the minimum distance of proposed injection wells from the property boundary? ______ _
5. Quality of drainage at site: D Good L8J Adequate D Poor
DocuSign Envelope ID: 8AE53D81-C2FA-4187-AD54-50EA652A945C ..
6. Flooding potential of site: D Low D Moderate [8J High
7. For Groundwater Remediation Injection Systems only , is the proposed and/or existing groundwater monitoring
program (number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No.
If No, attach map of existing monitoring well network if applicable and recommend any changes to the
groundwater-monitoring program.
8. Does the map included in the Application reasonably represent the actual site (property lines, wells, surface
drainage)? [8J Yes 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.
9. For Non-Discharge Groundwater Remediation systems only (i.e., permits with WQ _____ . refix):
a. Are the treatment facilities adequate for the type of waste and disposal system? D Yes D No D N/A.
IfNo, please explain: __
b. Are the 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: __
IIL EVALUATION AND RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? D Yes [8J No. If Yes, explain. __
2. List any items that you would like WQROS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
3. 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
4. Recommendation
This review was conducted for a permit renewal request for an open loop geothermal
well system for the Shultz residence. On August 9, 2018, staff visited the home to
inspect the well system. Source well water and water prior to re-injection was
sampled for metals, total and fecal coliform, nitrates, chloride and total dissolved
solids. Sampling results will be forwarded to the Central Office when received.
System operation has been normal.
D Deny. If Deny, please state reasons: __
DocuSig"! E1velope ID: 8AE53D81aC2FA-4187-AD54-50EA652A945C
North Carolina Department of Environmental Quality-Division of Water Resources
WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
D Hold pending receipt and review of additional information by Regional Office
D Issue upon receipt of needed additional information
~DocuSigned by:
5. Sign~~;:u:f Report Preparer(s): L.:~5~
Signature of WQROS Regional Supervisor:
8/10/2018
Date: __
~DocuSigned by:
~~ s~ b~
BABA 14AC7DC434 ...
D NR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Water Quality Programs
Pat McCrory Thomas A. Reeder John E. Skvarla, III
Governor Director Secretary
November 5, 2013
Doug Schultz
175 Herring Pond Ct.
Beaufort, NC 28516 RECEIVEDIDE RIM
11,10V 15 2PI3
Subject: Geothermal well sampling results
Perm it Number W10800158 ftderPr?jec-#O11'
Carteret County
Dear Mr. Schultz:
On September 26, 2013, staff from the Division of Water Resources sampled the influent and effluent
lines of your geothermal underground injection well heat pump system. The samples were analyzed by
the Division's laboratory for coliform, total dissolved solids, metals, nitrates and other inorganic
constituents. No exceedances of the State Groundwater Standards were observed. A copy of the lab
results are enclosed for your review.
Should you have any questions concerning this letter, please feel free to contact Geoff Kegley at (910)
796-7215 or by email at eg offike levLu�7,,ncdenr.gay.
Sincerely,
Morelli..' c Ing, Ph.D., P.E,
Environmental Program Supervisor
Wilmington Regional Office
Enclosure: satnple results
cc: Michael Rogers, APS Central Office
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
tntemet: www.nCnrat0M-Qalitv.orq
An Equal Oppor#unity 1 Affirmntive Adion Employer

AQUIFER PROTECTION FIELDSHEET
Quad No
Lat-
Serial No.
Long.
Awater
❑ Soil
Cl Other
`IL ❑Chain of Custody
Report To: ARO, FRO, MRO, RRO, WaRO, iRO
WSRO, Kinston FO, Fed. Trust, Central off., Other._
SAMPLE PRIORITY
Routine
Emergency
Department of Environment and Natural Resources
OF WATER RF,SOURCES-AQUWU PROTECTION SECTION
O
Shipped by: Bus ourier bland Del., Other: _ - Purpose:
Colleator(s). Date g j_ Time .2 0 Baseline, Complaint, �t
FIELD ANALYSES Owner
PH 400. Spec. Cond.94 at 25°C Location or Site
Temp.l,c_ °C Odor Description of sampling point &Gtf a
Appearance Sampling Method
Field Analysis By: Remarks
LABORATORY ANALYSES
BOD 310 mg/L
COD High 34D M911L
COD Low 335 mglL
Colifo= WIF Feral 31616 11001r1
Colifm= MF Total 31304 h 00ml
TOC 680 M91L
Turbidity 76 NTU
Residue, Total Suspended $30 MIX
PH 403 units
Alkalinity to pH 4.5 410 mg(.
Alkalinity to pH 8.3 415 mg/L,
Carbonate 445 mgrL
Bicarbonate 440 mg/L
Carbon dioxide 405 mglL
Chloride 940 rns/1.
Chromium: Hex 1032 ug/L
Color: True 80 CU
Cyanide 720 mg/L
Lab
Dksa, Solids 70300 mglr.
Fluoride 951 mg/L
Hard ass- Total 900 _9fL
Hardness (non-carb) 902 mg/L.
Phenols 32730 ugn
Specific Cond. 95 Ambi srem
Sulfate 945 mg/L
Sulfide 745 mg/L
Gil and Grease M91L.
NH3 as N 610 mglL
TKN as N 625 mg/L
NO,+ NO, as N 630 mg/L
P: Total as P 665 mg/L
Nitrate (NO, as ivy 620 mpfL
Nitrite (NO, as N) 615 mglL
REV. 812013 For Msolved Analysis -submit filtered sample and write "DIS" in block.
i3lIS
Lab Nummber i
Date Received q- Tune:
Rec'd By: From;Bus, earner Hand Del.,
Other:
Data Entry By: Cie:
Date Reported:
Pesticide Study, Fet de l Trust, Other:
1
l.vtr,r� vre.[ C P+r �u #
Sample Interval
{Pumping lima, air temp„, etc,)
Ag-Silver 46566
u L
if
Al -Aluminum 46557
a t_
It
As -Arsenic 46551
L
x
Ba-Barium 46558
u L
JC
Ca -Calcium 46552
m rzL
Cd-Cadmium 46559
u
Cr-Chromium 46559
uq/L
Cu- Copper 46562
tlwt
X
Fe-lrou 46563
UWL
Hg-Mercury 71900
UWL
K-Patassium46555
m i
Mg -Magnesium 46554
t„ L
`jC
Mo-Manganese46565
L,
}
Nu -Sodium 46556
m
Ni-Nickel
UZ11,
Pb-Lead 46564
UWL
Se -Selenium
VWL
V
Zn-Zinc 46567
u L
rT
Orginachlorine Pesticides
Organophobphorus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCBs
Semivoiatile t7r os
T 11-Diesel Range
Volatile Or `ca (".'OA bottle
TPH-Casofine' e
TPH BTEX Gasaline Range
LAB USE ONLY
Temperature on arrival (Q: V

.AC00757
,I ' ' :NC (J)~La6oratory Sectwn <R.§sults
County : Carteret Sample ID: 'AC00757 ~
River Basin DWR. PO Number# 13G0788
Report To rl!BQAf Date Received: 09/27/2013
_,-;"' lime Received : 08:00 Collector : G KEGLEY ·~", .::;..~ ...... 'i'°. • . . ·~--~.:~~--~(;_~-;::.~. :,r.-;.~·;-: •.f'.;:J:?.' Labworks LoginlD MSWIFT Region : WIRO •' Division of Water Resources Final Report Date: 10/29/13
Sample Matrix : GROUNDWATER
Final Re port Report Print Date : 10129/2013
l.oc. Type : W(!!!iB §!,!PPL):
Emergency Yes/No VisiUD
COC Yes!No
Loe. Descr.: DOUGSCHU!,,:11;
I Location ID: WIROAPNLC I Collect Date: 09/26/2013 I Collect lime: 12:30 I Sample Depth I
ff this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
GAS# Anal vte Name PQL Result/ Units Method Analysis Validated by
Qualifier Referen~ ~
LAB
Sample temperature at receipt by lab 1.9 ·c 9/27/13 HMORGAN
MIC
Coliform, MF Fecal in liquid 1 1 B2Q1 CFU/100ml APHA9222D-20th 9/27/13 ESTAFFORD1
Coliform, MF Total in liquid 1 1 B2Q1 CFU/100ml APHA9222B-2oth 9/27/13 ESTAFFORD1
WET
Ion Chromatography TITLE mg/L EPA300.0 10/8/13 CGREEN --
Chloride 1.0 71 mg/L EPA300 .0 10/8/13 CGREEN
Fluoride 0.4 0.4U mg/L EPA300 .0 10/8/13 CGREEN
Sulfate 2 .0 2.0 U mg/L EPA300 .0 10/8/13 CGREEN
Total Dissolved Solids in liquid 12 432 mg/L APHA2540C-18TH 10/2/13 CGREEN
NUT
NO2+NO3 as N in liquid 0.02 0.02 U mg/Las N Lac10-107-04-1-c 9/27/13 CGREEN
MET
7440-22-4 Ag by ICPMS .1.0 1.0 U ug/L EPA200.8 10/1/13 ESTAFFORD1
7429-90-5 Al by ICP 50 50 U ug/L EPA200 .7 10/3/13 ESTAFFORD1
7440-38-2 As bylCPMS 2.0 2.0 U ug/L EPA200 .8 10/1/13 ESTAFFORD1
7440-38-3 Ba by ICP 10 10 U ug/L EPA200.7 1013/13 ESTAFFORD1
7440-70-2 Ca by ICP 0.10 100 mg/L EPA200.7 10/3/13 ESTAFFORD1
7440-43-9 Cd by ICPMS 0.50 0.50 U ug/L EPA200.8 10/1/13 ESTAFFORD1
7440-47-3 Cr by ICPMS 10 10 U ug/L EPA200 .8 10/1/13 ESTAFFORD1
7440-50-8 Cu by ICPMS 2.0 2.0 U ug/L EPA200 .8 10/1/13 ESTAFFORD1
7439-89-6 Fe by ICP 50 50 U ug/L EPA200.7 10/3/13 ESTAFFORD1
7440-09-7 Kby ICP 0.10 7.1 mg/L EPA200.7 10/3/13 ESTAFFORD1
7439-95-4 Mg by ICP 0.10 9.4 mg/L EPA200 .7 10/3/13 ESTAFFORD1
7439-96-5 Mn by ICPMS 10 10 U ug/L EPA200.8 10/3/13 ESTAFFORD1
7440-23-5 Na by ICP 0.10 47 mg/L EPA200.7 10/3/13 ESTAFFORD1
7440-02-0 Ni by furnace 2.0 2;0 U ug/L EPA200 .. 9 10/3/13 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0 2.0 U ug/L EPA200.8 10/1/13 ESTAFFORD1
7782-49-2 Se by ICPMS 5.0 5.0 U ug/L EPA200.8 10/1/13 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 10 U ug/L EPA200 .8 10/1/13 ESTAFFORD1
Laboratory SecUon» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
For a detaUed description of1he qualifier codes refer to htp'./J pona1.~•n r.ors/weh/wgJlj1Dfsta finfio ltech isEU!Data qµplfler Codas <b te:ll oo,tal .n cdRQ r 9CS/wtb/wq/labJatafi nfjo/trd@ssist>
Page 1 of 1
North Carolina
AQUWER PROTECTION FTFLDSHEET nnfrslaly aF qWt- ;Mt> f O e p M arcsN s>?cric>N
LocaSon eodat/'/} "&Lw J y�.L�P lV_rLi.:. fq' T• 13 SAMPLE TYPE, SAMPLE PRi�RITY
Couxuy — �/�/ws��i- M Water 25 R.CDijr,e
Quad No Serial No. _ ❑ $oil ❑ Emergency
Long. ❑ Other
13 Chain of Custody
Report. To: ARO, FRO, MR0, RRO, WaRO, I
WSRO, Kinston FO, Fed. Trust, Central O[£, Other:
Shipped by: Bus, (KjaaDel., Other: Ptlrpose:
Cnlleemm * G.- Keay' Date ! I Tirr e) ' O o Baseline, Complaam in p e, LUST
FIELD ANALYSES � Ownertt�
pH 1 _ Spec. Cond..,, at 25gC Location or Site i 7'S
Temple mC Odor _ Description of sampling point �
Appearance Sampling Method �d L&
Field Atsalysis By: _-- Remarits
LABORATORY ANALYSES
HOD 310 mWL
Cal] K%h 30 mg/L,
COD Low 335 tagfL
Coli!'mm:MFFccal3161E 1100mi
X
Coiifortm: MP TOW 115M 1i00111
Turbidity 76 NTU
Residue. Total Suspended 530 mglL
pH 403 units
Aiiwlialty to pH 4.S 410 MVL
Alkalino to pH $.3 415 awL
Catbonate 445 mg/1.
Bicarbonate 440 tngfL.
Carbon dioxide 405 mgfL
Chloride 940 mglL
Chmmfum: Fla 1032 uglL
Color. True 80 CU
Cyanide 720 mp/L.
Lab Comments
t3& 0+g�1- Acool5(c) v.
Lab Number
Date Retaeived ' al - 3 Tim
Ree'd By: Frorrl:Bus otari `, Hand Dal.,
Other:h
Data Entry By: Ck
Date Reported:
Pesticide Study, Federal Trust, other;_
{Pumping tkm air ternp., etc-}
Disc. 3olido70300 mgl%
;C
Ag 4ilrer46566
Fluoride951 mgll
Al-Ahuainunt46557 URIL
Hawkiness: Tata1900 mg/L
Aa-wramaie 46551 u
Hardnc= (non- arb) 902 ong(L
X
Ha-Barium46558 UWL
Phaaols 32730 agfi
Ca -Calcium 46552 m L
Speeirw Coal. 95 limmalcro
X[`d—Ca
mi m 46559 u
Sulfate 945 mgfL
Cr-Chromium 46559 u gfL
Sulfide 745 mg/L,
Cu-Copper46562
X
Fe -iron 46563 L
OR and Grease mg/L
Hg-mcrcvsy 71900 u
K-Potassium 46555
Mg-Magaasium 46559 Mwil
Mn-Manganeam 46565 Mn-
NHj as N 610 mg/L
Na-odium 46556
TKN as 625 mgjL
Ni-Nickel UWL
NO, + NO, as N 630 mg/L
Pb -Lead 46559
P. TOW as P 665 mg/L.
Serge enlum ucfL
Ntmate (N� asN) 620 MVL
X
Zn-Zinc 46567 u
Nk ite {N(r M N) 615 mW
GW-54 REV. V2013 For Diwolved Analysis -submit filtered sample and write "MY' in block.
Interval
OrRanocbhminc Pesticides
Gr borus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCBs
Semivolatile OrMnics
TPH Diwei fUm e
Volatike Or VOA bottle
TPH-Gasoline Ran a
TPH-BTEX Casoline Rackgt
LA3� USE O1�LY � 1
Tempetuhtre on arrival

AC00766 NC DWRLaboratory Section W'sufts
County:
Carteret
Sample ID:
AC00756
River Basin
PO Number #
13GO78T
Report To
WIROAP
()W
Date Received:
0912712013
Time Received:
03:00
Collector:
G KEGLEY
-
Lahworks LoginlD
MSWIFT
Region:
WIRO
D of Wou Resources
Final Report Date:
10/16/13
Sample Matrix:
GROUNDWATER
Final Report
Report Print Date:
1011612013
Lac. Type:
WATER SUPPLY
Emergency Yes/No
Viswo
COG Yes1No
Loc. Descr.. DOUG SCHULTZ
Location ID:
WIROAPNLC
Collect Date: 0912612013
Collect Time: 13:00
Sample Depth
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
Validated Result/ Method Analysis Vali_b,
CAS # Anal�.te Name Pitt_ Units -
Qualifier Reference Date
LAB
Sample temperature at receipt by tab 1.9 aC 9127n3 IIMORGAI+I
MIC
C©liform, MF Fecal in liquid
1
1 l32Q1
CFU1100ml
APRA9222D-20th
9127113
ESTAFFORDI
Ccliform, MF Totai in liquid
1
1 l32Q1
CFU1100ml
APHA92228-20th
9127113
ESTAFFORDI
WET
Ion Chromatography
_TITLE_
mg1L
EPA 300.0
1a18113
CGREEN
Chloride
1.0
75
mglt,
EPA 300.0
=8I13
CGREEN
Fluoride
0.4
0.4 U
m91L
EPA300,0
1018113
CGREEN
Sulfate
2.0
2.0 U
mglL
EPA300,0
1018113
CGREEN
Total Dissolved Solids in liquid
12
434
mg1L
APRA254OC•IBTH
1012H3
CGREEN
NUT
NO2+NQ0 as N in liquid 0.02 0.02 U mg(L as N Lac10-107-04-1-c 9127113 CGREEN
MET
7440-22-4
Ag by ICPMS
1.0
1.0 U
ug1L
'EPA200.9
1011113
ESTAFFORDI
7429-90-5
Al by ICP
50
50 U
uglL
EPA200.7
1013113
ESTAFFORD1
7440.38-2
As by ICPMS
2.0
2.0 U
ug1L
EPA200.8
1011113
ESTAFFORDI
7440.38-3
Ba by ICP
10
IOU
ug1L
EPA2001
1013113
ESTAFFORDI
7440-70-2
Ca by ICP
0.10
99
mg1L
EPA 200.7
1013113
ESTAFFORDI
7440-43-9
Cd by ICPMS
0.50
0.50 U
uglL
EPA 200.8
1011113
ESTAFFORDI
7440-47-3
Cr by ICPMS
10
IOU
ug)L
EPA200.8
10111i3
ESTAFFORDI
7440-50-8
Cu by ICPMS
2.0
2.4
uglL
EPA200.8
1011M3
ESTAFFORDI
743m9-8
Fe by ICP
50
60 U
uglL
EPA 200.7
1013113
ESTAFFORDI
7440-09-7
K by tCP
0.10
7.0
mglL
EPA 200.7
1013M3
ESTAFFORD1
7439-95-4
Mg by ICP
0,10
9.1
mglL
EPA 200.7
1013113
ESTAFFORDI
7439-96-5
Mn by ICPMS
10
IOU
us°L
EPA200.8
1013113
ESTAFFORDI
T440-23-5
Na by ICP
0.10
46
rrWL
EPA 2001
1013113
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7440.02-0
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2A
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EPA200.9
1013113
ESTAFFORDI
7439-92-1
Pb by ICPMS
2.0
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EPA200.8
1011113
FSTAFFORDI
7782- 49-2
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5.0
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EPA 200.8
1011113
ESTAFFORDI
7440--6s-8
Zn by ICPMS
10
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1011113
ESTAFFORDI
Laboratory Sectionaa 1623 Mail Service Center, RHleigh, NC 27699-1623 (9191733-908
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Page 1 of 1

Permit Number WI0800158
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Oouglas and Hilary Schultz SFR
Location Address
175 Herring Pond Ct
Beaufort
Owner
Owner Name
Douglas
Dates/Events
NC
p
Orig Issue
01/09/09
App Received
08/23/13
Regulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name
28516
·schultz
'
Draft 1hitiated
Scheduled
Issuance
Central Files : APS_ SWP_
11/14/13
Permit Tracking Slip
Status
Issued
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Wilmington
County
Carteret
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Douglas P. Schultz
175 Herring Pond Ct
Beaufort NC
Public Notice Issue
'
Effective I
11/13/13 01/01/14
Re quested/Received Events
RO staff report requested
RO staff report received
Additional information requested
Additional information received
28516
Expiration
12/31/18
08/29/13
10/01/13
10/07/13
11/08/13
Stream Index Number Current Class Subbasin
Permit Number WI0800158
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facili
Facility Name
Douglas and Hilary Schultz SFR
Location Address
175 Herring Pond Ct
Beaufort
Owner
Owner Name
Douglas
Dates/Events
NC
p
Orig Issue
01/09/09
App Received
08/23/13
Regulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name
28516
Schultz
Draft Initiated
Scheduled
Issuance
Central Files: APS_ SWP_
11/08/13
Permit Tracking Slip
Status
In review
Project Type
Renewal
Version Permit Classification
Individual
Permit Contact Affiliatlori
Major/Minor
Minor
Region
Wilmington
County
Carteret .
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Douglas P. Schultz
175 Herring Pond Ct
Beaufort NC
Public Notice Issue Effective
Ii /tJ/23 tf /t'f
Re q uested/Received Events
RO staff report requested
RO staff report received
Additional information requested
Additional information received
28516
Expiration
/Jf i, / 19
08/29/13
10/01/13
10/07/13
11/08/13
Stream Index Number Current Class Subbasin
NA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory
Governor
Douglas and Hilary Schultz
175 Herring Pond Court
Beaufort, North Carolina 28516
Water Quality Programs
Thomas A. Reeder
Director
November 13, 2013
Re: Issuance of Injection Well Permit
Permit No. WI0800158
Geothermal Heating/Cooling Water Return Well
Carteret County
Dear Mr. and Mrs. Schultz: .
John E. Skvarla, Ill
Secretary
In accordance with your renewal application received August 23, 2013, I am forwarding Permit
No. WI0800158, dated November 13, 2013, for the operation of geothennal heating/cooling
water return well(s) located at the above referenced address. Please note that this renewed
permit shall become effective on January 1, 2014, (i.e., the day after the expiration date of the
existing pennit), which may differ from the date of this letter. This permit shall be effective
from January 1, 20-14, until December 31, 2018, and shall be subject to the conditions and
limitations stated 'therein. ·
The Wilmington Regional Office inspected your geothermal system on September 26, 2013.
During the inspection it was observed that sampling ports to collect influent and effluent
water samples were not installed. Per lSA NCAC .0225(g)(21) sampling ports are to be
·' installed to obtain samples prior to water being prmped from the aquifer and prior to be
returned to the aquifer. Sampling taps need to be installed in order to collect influent and
effluent water samples.
In order to continue uninter-rupted legal use of this well for the stated purpose, you should submit
an application to renew the permit 120 days prior to its expiration date. As indicated in the
perinit, this permit is not transferable to any person without prior notice to, and approval by, the
Director of the Division of Water Resources. If you have any questions regarding your permit or
the Under~ound Injection Control Program please call me at [phone].
Water Quality Regional Operations Section
1636 Mail Service Center, Raleigh , North Carolina 27699-1636
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
Internet: www .ncwaterguality.org
An Equal Opportunity I Affirmafive Action Employer
Douglas and Hilary Schultz
Page 2 of2
Best Regards,
~~~
Michael Rogers, P.G. (NC & FL)
Hydro geologist
cc: Morella Sanchez-King, Wilmington Regional Office
Central Office File, WI0800158
Carteret County Environmental Health Department
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
Douglas and Hilary Schultz
FOR THE CONTINUED OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER
RETURN WLLL(S), defined in Title,15A North Carolina Administrative Code 2C .0224, which will be used
for the injection of heat pump effluent. This injection well is located at 175 Herring Pond Court, Beaufort,
Carteret County, NC 28516, and will be operated in accordance with the renewal application received August
23, 2013, and in conformity with the specifications and supporting data, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for operation of an injection well shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0I00'and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from January 1, 2014, (i.e., the day after the expiration date of
the existing permit) until December.31, 2018, and shall be subject to the specified conditions and limitations set
forth in Parts I through VIII hereof.
Permit issued this the day of , 2013
Lr-
� t
1 � l
'homas A. Reeder, Director
Division of Water Resources
By Authority of the Environmental Management Commission.
Permit #WI0800158 UIC/Retum Well - RENEWAL Page 1 of 5
per. 1012013

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Pennittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface cannot migrate into
. the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be sealed with a watertight cap or well seal, as defined in G.S. 87-85(16).
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.01070).
8. Copies of the Well Construction Records shall be retained on-site and available for inspection.
PART II-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 Resources (Director). In the event there is a desire for the facility to change ownership, or there is
a name change of'lhe Permittee, a formal permit amendment request musl be submitted to the Director,
including any sup~orting materials as may be appropriate, at least 30 days Prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
Pennit #WI080015 8 DIC/Return Well-RENEWAL
ver. 10/2013
Page 2 of5
PA.f.t,TIIl~PERFORMANCESTANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater which will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Pennittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Resources 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 IV -OPERATION AND MAINTENANCE REQIDREMENTS
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. Sampling taps need -to be installed in order to collect influent and effluent water samples.
PART V -INSPECTIONS
1. Any duly authorized officer; employee, or representative of the Division of Water Resources 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, sw;[ace water, or injection fluids. .,.
I I
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 VI -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Resources 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 staff, telephone number 910-796-7215, any of the
following:
Permit #WI0800158 DIC/Return Well-RENEWAL
ver. 10/2013
Page 3 of5
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4 . In the event that the permitted facility fails to perform satisfactorily, the Permittee shall tak:,e such
immediate action as may be required by the Director.
PART VII -PERMIT RENEW AL
The Permittee shall, at least 120 days priO'r to the expiration of this permit, request an extension.
PART VIII-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0240,
Abandonment and Change-of-Status of Wells.
2. When operations have ceased at the facility and a well will no ·longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0240, 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 1of each well shall be sounded before it is sealed to insule 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.
Permit #WI0800158 VIC/Return Well-RENEWAL
ver. 10/2013
Page 4 of5
/
(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 .0224(f)( 4) within 30 days of completion of abandonment.
3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
Permit #WI0800158
Division of Water Resources-DIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
DIC/Return Well-RENEWAL
ver. 10/2013
Page 5 of5
,LIP
Existine Permit No.: kAST aC�+�_ _ ys -3
Assigned Date:
Reviewer: jL � Date to Processigg:�� _ AM PM
S
Owner: C2�l-xisting Owner Tv i)e Non -Government 1p .S individual ❑ Organization
❑ Unknown ❑ Government —► ❑ Municipal ❑ Federal ❑ County ❑ State
Facility: ❑ Proposed Facility Tvn [ cility FacilitX Regulated Activities:
27.1 xisting ❑ Operation _
Permit TM: Deemed Individual
❑ Aquifer Test Wells ❑ Aquifer Storage and Recovery Wells
❑ Geothermal Aqueous Closed Loop Wells Geothermal Heating & Cooling Water Return Wells
❑ Geothermal Direct Expansion Closed Loop Wells ❑ In Situ Groundwater Remediation Wells
❑ In Situ Groundwater Remediation Wells circle one: ❑ Experimental'Teehnology Wells
{ air sparse, passive, small scale, pilot test }
❑ Stormwater Drainage Wells ❑ 'Tracer Wells
❑ Tracer Wells ❑ Aquifer Recharge Wells
❑ Other Wells ❑ Subsidence Control Wells
❑ Salinity Barrier Wells
Annlictioa Tire: ❑New ❑ Major Modification ❑ Minor Modification ❑ Name Change
❑ Ownership Change Renewal ❑ Renewal wl Mod (major/minor) ❑ Rescission
Notes:
— 0
UIC BIMS Entry Form August 12, 201.3

AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: September 27, 2013 Permittee(s): Schultz, Douglas & Hilla rv
Permit No.: WI0800158
To: APS Central Office County: Carteret
Central Office Reviewer: Michael RogersProject Name: Shultz UIC WI08000158
Regional Login No: Geoff Kegley
L GENERAL INFORMATION
1. This application is (check all that apply): 0 SFR Waste Irrigation System X UIC Well(s)
New [8] Renewal
0 Minor Modification O Major Modification
RECEIVED/DENR/OWQ
OCT O I 2013
Aquifer Protection Section
0 Surface Irrigation O Reuse D Recycle D High Rate Infiltration O Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
D Attachment B included
0 Surface Disposal
D 503 regulated D 503 exempt
0 Closed-loop Groundwater Remediation ~ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IZJ Yes or D No.
a. Date of site visit: Se ptember 26 . 2013
b. Person contacted and contact information: Mr. Shultz: dshultz(a)ida.or g
c. Site visit conducted by: GeoffKegle v
d. Inspection Report Attached: [8] Yes or O No.
2. Is the following information entered into the BIMS record for this application correct?
D Yes or IZJ No. If no, please complete the following or indicate that it is correct on the current application.
For SFR Treatment Facilities:
a. Location:
b. Driving Directions: __
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __ Method Used (GPS, Google™, etc.); __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For UIC Injection Sites:
(If multi ple sites either indicate which sites the information a pp lies to . co py and paste a new section into the
document for each site. or attach additional pa ges for each site )
a. Location(s): 175 Herring Pond Ct., Beaufort, NC 28516
b. Driving Directions: From Beaufort take US 70 to Merriman Rd to S. River Rd to Sandy Point Dr to
Herring Pond Ct.
c. USGS Quadrangle Map name and number: __
d. Latitude: N34 58.938 Longitude: W 76 36.39 _Method Used (GPS, Google™, etc.); GPS
APS-GPU Regional Staff Report (Sept 09) Page I of 6 Pages
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description of Well(s) and Facilities -New, Renewal, and Modification
I. Type of injection system:
[8:1 Heating/cooling water return flow (SA 7)
D Closed-loop heat pump system (SQM/SQW)
D In situ remediation (SI)
0 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 [8:1 No
3. Are there any potential pollution sources that may affect injection? D Yes [8:1 No
What is/are the pollution source( s )? ---'-' _Wh-'--'--'-'=a.:..._t =is'-"t=he;:;....=::d=is=ta=n=c-=-e...::oc=..f ...:::th=e'-i=n:.,..:je=-=c=ti=o-=-=-n_,_w_,._,e..,,1 .... 1(=-s )'-'fi=ro=m=--=t=h=e -<=p=o=ll=ut=io=-:.n
source (s)? ft .
4. What is the minimum distance of proposed injection wells from the property boundary? 25Jt
5. Quality of drainage at site: D Good [8:1 Adequate D Poor
6. Flooding potential of site: OLow [8:1 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)? [8:1 Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow. See attached map of wells
Injection Well Permit Renewal and Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes [8:1 No. If ves . 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 yes . ex plain:
3. For renewal or modification of groundwater remediation permits {of an y typ e ). will
continued/additional/modified in iections have an adverse im pact on mi gr ation of the plume or management of
the contamination incident? D Yes O No . If yes . ex plain:
APS-GPU Regional Staff Report (Sept 09) Page 4 of 6 Pages
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
4. Drilling Contractor: Name: David Quinn -cyclone Well Drilling
Address:
NC Certification number:
Complete and attach NEW Injection Facility Inspection Report, if applicable
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the Application:
This review was conducted for a permit renewal request for a type SA7 underground
injection geothermal well heat pump system for the Shultz residence. On September
26, 2013, staff visited the home to inspect the well system. Source well water and
water prior to re-injection was sampled for Metals, total and fecal coliform, Nitrates,
Chloride and Total Dissolved Solids. Sampling results will be forwarded to the Central
Office when received. System operation has been normal. An inspection report and a
map ofthe site with well locations are attached .
Well Tag Information:
Source well:
Construction date:
Casing depth:
Well depth:
Static water level:
Yield:
In jection well:
Construction date:
Casing depth:
Well depth:
Static water level:
7/28/2000
280 ft
315'
12 ft?? (well tag is corroded and hard to read)
35GPM
7/28/2000
40 ft
175' ??
101 ft?? (well tag is corroded and hard to read)
2. Attach new Injection Facility Inspection Form, if applicable
3. Do you foresee any problems with issuance/renewal of this pennit? D Yes !Z1 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:
APS-GPU R egional Staff Report (Sept 09 ) Page 5 of 6 Pages
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition
Reason
Install influent and
effluent sampling taps
Currently not available
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
7. Recommendation: ❑ HoId, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
S. Signature of report Preparers):
Signature ofAPS regional supery
Date: Q A+ / 3
VI. ADDITIONAL INFORMATIONAND SITE MAP (Sketch of site showing house and waste irr' ,a tion
system, sprat or drip held location of well U. and/or other relevant information- SHOW NORTHARRO 1J
APS-GPU Regional Staff Report (Sept 09) Page 6 of 6 Pages

Permit: Wl0800158
SOC:
County: Carteret
Region: Wilmington
Compliance Inspection Report
Effective: 01/09/09 Expiration: 12/31/13 Owner: Douglas P Schultz
Effective: Expiration: Facility: Douglas and Hilary Schultz SFR
175 Herring Pond Ct
Beaufort NC 28516
Contact Person: Barry E Sn ipes Title: Phone: [phone]
Directions to Facility:
From Wilmington Non US70. Stay straight to Merriman Rd. Slight Lon Merrimon/NC1300. Becomes Silver Dollar Rd/NC1318. Lon
Sandy Point Dr . R on Herring Pond Ct.
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 09/26/2013
Primary Inspector: Geoff Kegley
Secondary lnspector(s):
Entry Time: 11 :30 AM
Certification: Phone:
Exit Time: 01 :00 PM
Phone:
Reason for Inspection: Routine Inspection Type: Compliance Sampling
Permit Inspection Type: Injection Heating/Cooling Water Return Well
Facility Status: 0 Compliant O Not Compliant
Question Areas:
■Wells ■ System Operations
(See attachment summary)
Page: 1
Permit: WI0800158
Inspection Date: 09/26/2013
Owner -Faclllty: Douglas P Schultz
Inspection Type: Compliance Sampling Reason for Visit: Routine
Inspection Summary:
This inspection was performed for a permit renewal request. Well head is properly completed. Source well water and
water prior to re-injection was sampled for Metals, total and fecal coliform, Nitrates, Chloride and Total Dissolved Solids.
Sampling results will be forwarded to the Central Office when received. System operation has been normal.
Well Tag Information:
Source well:
Construction date: 7/28/2000
Casing depth: 280 ft
Well depth: 315'
Static water level : 12 ft?? (well tag is corroded and hard to read)
Yield: 35 GPM
Injection well :
Construction date: 7/28/2000
Casing depth : 40 ft
Well depth: 175' ??
Static water level: 101 ft?? (well tag is corroded and hard to read)
System Operation
Is same well used as source well and injection well?
Is injection well capable of assimilating injected fluid?
Injection flow rate at time of inspection (gpm)
Has system owner/operator noticed any abnormalities (turbidity, air in system, poor heating/cooling, etc) in
system operation?
Comment on system operation
Is system operation and construction consistent with that described in application?
Describe inconsistencies between application and observed operation/construction
Comment:
Yes No NA NE
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Rogers, Michael
From: Rogers, Michael
Sent:
To:
Subject:
Friday, November 01, 2013 2:08 PM
'[e-mail]'
Well Construction Record (GW-1)
Would you please provide the GW-1 for the following geothermal water return well installed
in 2009:
Douglas Schultz
175 Herring Pond Court
Beaufort, NC 28516
We are renewing their geothermal permit. You can scan and send back as an attachment to
this email. The UIC program never received a copy of the GW-1 for this project as required per
the permit. The driller proposed to install the injection well was David Quinn #2395.
Thanks
Michael Rogers, P.G. (NC & FL)
Hydrogeologist
NCDENR-DWR
UIC Program
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http:ljportal.ncdenr.org/web/wg/aps/gwpro/reporting-forms
NOTE: 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
Ro gers, Michael
From:
Sent:
To:
Subject:
Attachments:
Schultz, Douglas P [[e-mail]]
Monday, October 07, 2013 3:57 PM
Rogers, Michael
RE: WI0800158 Douglas Schultz Geothermal Permit
Subject: Renewal Application for Geothermal Permit WI0800158
I have no records or permits from the builder for the wells, see
attached. The builder is no longer in business but I will call both
the builder and drilling company to see if they have a copy. I
noticed you emailed them too.
Thanks
Doug
-----Original Message-----
From: Rogers, Michael [mailto:[e-mail]]
Sent: Monday, October 07, 2013 2:13 PM
To: Schultz, Douglas P; creeksideconstructioncompan y@ hotmail.com
Cc: Kegley, Geoff; c yclonewelldrilling@ hotmail.com
Subject: FW: WI0800158 Douglas Schultz Geothermal Permit
Douglas-
We are just about complete with renewing your geothermal permit.
However, we do not have the as-built well construction record (GW-1)
for the return well. Attached is the GW-1 for the supply well, but we
did not receive a copy of the GW-1 for the injection well after it was
constructed, as per permit requirements. Please provide this so we
can input the well construction into our database.
You can scan and send as attachment in reply to this email.
Thanks
-----Original Message-----
From: Michael Rogers [mailto:michael.rog [e-mail]]
Sent: Monday, October 07, 2013 12:18 PM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
1
Ro gers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Douglas-
Rogers, Michael
Monday, October 07, 2013 2:13 PM
'[e-mail]'; '[e-mail]'
Kegley, Geoff; '[e-mail]'
FW: WI0800158 Douglas Schultz Geothermal Permit
20131007121804458.pdf
We are just about complete with renewing your geothermal permit.
However, we do not have the as-built well construction record (GW-1)
for the return well. Attached is the GW-1 for the supply well, but we
did not receive a copy of the GW-1 for the injection well after it was
constructed, as per permit requirements. Please provide this so we
can input the well construction into our database.
You can scan and send as attachment in reply to this email.
Thanks
-----Original Message-----
From: Michael Rogers [mailto:michael.rog [e-mail]]
Sent: Monday, October 07, 2013 12:18 PM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 10.07.2013 12:18:04 (-0400)
Queries to: [e-mail]
1
A QUIFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: August 29 , 2013
To: D Landon Davidson, ARO-APS
0 Art Barnhardt, FRO-APS
0 Andrew Pitner, MRO-APS
0 Rick Bolich, RRO-APS
0 David May, WaRO-APS
!ZI Morella Sanchez King, WiRO-APS
0 Sherri Knight, W-SRO-APS
From: Michael Ro gers Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E-Mail: Michael.Ro!!ers ncdenr. ov
A. PermitNumber: WI0800158 -'--'-'-'-"-'-~'--'-------
B. Owner: Schultz
C. Facility/Operation: =
D Proposed !ZI Existing D Facility D Operation
D. Application:
1. Permit Type: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D 1/E Lagoon !ZI GW Remediation (ND)
!ZI UIC -Geothermal Heatine/Cooling Water Return Well
For Residuals: D Land App. D D&M D Surface Disposal
D 503 0 503 Exempt D Animal
2. Project Type: D New D Major Mod. D Minor Mod. !ZI Renewal D Renewal w/ Mod.
E. Comments/Other Information:
NOTE: During the site ins pection please record all well construction info from the well tae., if present, on the staff
re port. Thanks.
!ZI Return a completed APSARR after the site inspection. At a later date, after sampling & the lab
results are received, please send us a copy of the letter you send to the Permittee containing
laboratory analytical results.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as · additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: -------------------Date: _____ _
FORM: APSARR 07/06 Page 1 of 1
Smith, Eric
From:
Sent:
To:
Cc:
Subject:
Eric
Schultz, Douglas P <[e-mail]>
Friday, August 23, 2013 2:35 PM
Smith, Eric
[e-mail]; Schultz, Douglas P
Subject: Renewal Application for Geothermal Permit WI0800158
Attached are the forms for injection well renewal. Thanks for the effort of tracking us down. I do not have a copy of the original
application/permit; can you provide me a copy of direct me to the source.
1
A'VA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory
Governor
Douglas P. Schultz -Owner
175 Herring Pond Ct.
Beaufort, NC 28516
Dear Mr. Schultz:
Water Quality Programs
Thomas A. Reeder
Director
August 28, 2013
John E. Skvarla, Ill
Secretary
Subject: Acknowledgement of
Application No. WI0800158
Douglas and Hilary Schultz -
SFR
Iajection Heating/Cooling
Water Return Well System
Carteret County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on August 23, 2013. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Wilmington 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.
, :f lease note that processing standard review permit"1,pplicati01~s may take as long as 60 to 90 days
1 after r~ceipt of a complete application. If ypu have I any questions, please contact
Michael Rogers at [phone] or [e-mail].
Sincerely,
O(J~~
for DebraJ. Watts
Groundwater Protection Unit Supervisor
cc: Wilmington Regional Office, Aquifer Protection Section
Permit File WI0800158
AQUIFER PROTECTION SECTION
1636 Mail Seivice Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: http://portal.ncdenr.org/web/wq/aps
An Equal Opportunity\ Affirmative Action Employer
Pr
AUG 2 $ 2013
0 71',2,- - -
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECITON WELLS
In Awordanre Wide the Provisions of 15A NCAC 02C .0200
OPEN -LOOP GEOTHERMAL INJECTION WELLS
These veils discharge groundwater directly into the subsmiam as part of a g+enthermal hcating and cooling system
(cheek one) New Application _'Re1wal* Modification
* For renewals o nnpiete Pacts A-C and the signature page.
nl ar Tvpe InfarmaVon aadMail to tlreAddress an the Last Page. Illegible Appl+catfans Will Be PeturaedAs lncom,
DATE: - 41 20101
PERMFF NO. _Vf C0.rD0j K7,? .{leave blank ifNew Application)
A. STATUS OF APPLICANT (choose one)
Non -Government. Individual Residence Business/Organization
Government: State _ Municipal County Federal
B_ PER€ UT APPLICANT — For individual residences, list each owaer on wdeed. I -or all others,
state name of entity Mdd name of person delegated authority to sign on behalf of the business or agency;
Mailing Address:
City: 1 E 4�4 _ S>>ft zip:Cndc.-Ac ' Ao Co,usty-_
Day Tale Nn.: _ , _ _ Ceil No. -
EMAIL Address:_ �.E � Fax No.:
C. LOCATION OF WELL SIT F: — VVhere the injection wells are physically locatod: �,r �'
(1) Parcel Identification Number (PIN) of well site- r �dun��� �� P�
ty_ 11('
(2) Physical Address (if different than mau7in address):
Y. V eAtz s Er._ state: NC Zip Cade_
D. WELL DRILLER INIZORMATION
Well Drilling Contiactnes Name:
NC Well Drilling Contractor Certification No_. —
Company Name:
Contact Person:

CF. 17MCATION (to be signed as requinA below or by that persods authmized agent)
15A NCAC 02C 41211(b) requires that alt pmnit applications shall be signed as £oIiows!
1. for a corporisiow by a respomm-ble aaporate of ow,
2. fir a partnership or sale prupricbmship: bya omwal pmttra orthe pmpdctu. respa,cpivcly;
3_ for a municipality or a slate, federal, or other public agemy.. by c0cr a principal owcutive
officer or ranking pubkicly elected official;
4. for all others, by *c well owner (which gkp-ev-oAg-listed on the_pmpgnrdeed).
If an autherkwd ngrat is siCniog on behalf of the applicant, then supply a tether signed by the
applicant that naives and authorises their agent to sips this application an their behalf.
" I hereby certify, wider penalty of law, that I have personalty examined and am familiar with Zirt information
submitted in this doeument and all attaehmcnts duzem and that, based on my mgwy of those individuals
immediatoly responsible far &Wnmg said infarneation, 1 believe that the information is true, accmaic and
complete- 1 aw aware that there are sigm&mnt penaldes, mcludiag the pomability of f nos end imposeamcet,
for submitting Use irdorxwatiu� I arp}ee to contact; open maintain, repair, and if applicable, abandon tie
injection well and all related appoReoances in aoaa<dsace with tbie approved spccilaaa<ions and conditions of
the l?eraait."
r
$igaatur 1�roperiy Uwserl i leant
Print or Full Naa
Signad" of party Oweer cant
Print or Tygie�/nliName
���•--
Signature of Autheriaed Agem, if any
Print or Type Fa1113aaoe
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mal Service Center
Raleigh, NC 27699L1636
Tdephene [phone]

State of North Carolina
Deparkment of Environment and Natural Saourtxa
Ilioisbm of Water Quality
STATUS OF INJECTION WELL. SYSTEM
Please check the selechon which most ckn* describes the cement a d= of ytmr ugecW m well systm-
1) �Well(s) still used for injection ectivitiM nrmay be in die fuhum
2) ❑ Well(s) not used for nUeedon but islate used for water supply or outer purposes.
3) ❑ Wactim diseoapuued and: a) ❑ Well(s) tempmarily ebamdmed
b) ❑ Wells) permanently ahmilmied
c) ❑ Wedl(s) not abmrdamd
4) ❑ injectim wells) never constracted
Qmm use of Well
if you ❑hacked (2), describe the well use (potable water supply. u ate. monitoring, eta). mcludimg pumping rate and othff
relevant information_
Well Abandonment
I£yon checked (3)(a) or (3)(bX describe the method mod to abandon the injecOm well (Include a descripliom of how the well
war sealed and rho type ofrrwtermal used toll! LW well ifpernmammntly ahmdan4:
Penn-M
Ifyonchecked (2),(3), orl4) and will notmse a well For injection calhis site in thefutute,youshould request rescission of the
pasmiL Ito yen wish to rescind the PM=O
❑ yes Q No
gcgifi :
"l hereby certify, under penalty of Jaw, that I have pmomally examined and am fandlfarwitlt the imfomuttion Submitted
in this document, and that to the hest of my knowledge the information is true, accurate, and complete_"
OF 4 JMMA Mg

NA
NCDENR
North Carolina Department of Environment and Natural Resource
Division of Water Qual ity
Pat McCrory
Governor
Thomas A Reeder
Acting Director
July 19, 2013
CERTIFIED MAIL# 7012 1640 0000 9792 4381
RETURN RECEIPT RE QUESTED
Douglas and Hilary Schultz
4 319 Granada Street
Alexandria, Virginia 22309
Subject: Notice of Expiration (NOE)
SA 7 Geothennal Injection Weli
Permit No. WI0800158
Carteret County
Dear Mr. and Mrs. Schultz:
John E. Skvarla, Ill
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 at 175 Herring Pond Court in Beaufort, NC, which was issued
to you on January 9, 2009, and expires on December 31, 2013, 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 Currently 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 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 http://portal.ncdenr.org/web/wq/aps/ gwpro/reporting-forms.
If Your In iection Well is Currentl y Active:
If the injection well system is still active and you wish to renew your pennit, 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 Se ptember 2 , 2013.
AQUIF ER PROTECTION SECTION
1636 Mail Service Center, Raleigh , North Carol ina 27699-1636
Location : 512 N. Salisbury St, Raleigh , North Carolina 27604
Phone : 919-{!07-6464 \ FAX: 919-{!07-6496
Internet www .ncwaterquality.org
An Equal Opportunity I Affirmative Action Emplo yer
Ni~h Carolina lvatural!g
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 a Permit to Construct or Operate Injection Yells — Open Loop Geothermal
Injection Wells (Renewal) if the injection well system on your property is still active.
",
13. 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 enclosed. The above referenced forms are also available on-
line at the DWQ website at h"://portal.nedenr.orWweb/wq/apslMypro/permit-
a licatio s# othermA s.
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.g smith[r7ncdenr.g`ov.
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
CC-' Wilmington Regional Office - A.PS w/o enclosures
APS Central Files - Permit No. W10800158 w/o enclosures
2

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U.S. Postal Servicern
CERTIFIED MAILm RECEIPT
(Domestic Mail Only; No Insurance Coverage Provided)
11••" ...... . ... • ,,.,_--,. # .
" ·-~ ,, " <= '
Postage $
Certified Fee
Postmark Retum Receipt Fee
(Endorsement Required) Here
Restricted Delivery Fee
(Endorsement Required)
.JJ Total I Dou g las and Hilar y s ,ultz
.-=t
rtJ SentTo
.-=t Street;
orPOB C
I"-
4319 Granada Street
Alexandria, VA 22309
PS Form 3800, August 2006 See Reverse for Instructions
I
A
NCDENR
North Carolina Department of Environment and Natural Resource
Divisions of Water Quality
Pat McCrory Thomas A, Reeder
Govemor Acting Director
July 19, 2013
CERTIFIED MAIL # 70121640 0000 9792. 4381
RETURN RECEIPT REQUESTED
Douglas and Hilary Schulte:
4319 Granada Street
Alexandria, Virginia 22309
Subject: Notice of Expiration (NOE)
5A7 Geothermal Injection Well
Permit No. W10800158
Carteret County
Dear Mr. and Mrs. Schultz:
John E. Skvarla, Ill
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water Quality
(DWQ) is entrusted to protect the groundwater duality 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 pennit for the underground injection
well system, located on your property at 175 Herring Pond Court in Beaufort, NC, which was issued
to you on January 9, 2009, and expires on December 31, 2013, 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 Irniect,ion Well is Currenth, 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 under NCAC Title 15A, Subchapter 2C,
Section .0214. When each well is plugged and abandoned, the well abandonment record (F'on-n GW-
30) [rust 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 Farm must also be submitted. The GW-30 and Name/Ownership Change forms can be
found at htta://nortal.nedeur.or weblwd/aRs/vwprq/report%n -forms.
If Your Injection Well is Currently 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 September 2.2013E
AQUIFER PROTECTION SECTION
1636 Mail 5ervire Center, Raleigh, North Carolina 27699-1636 n�
Lxaton: 512 N, Salisbury St., Raleigh, North Caro4na 77604 NoMiCarolina
Phone: 91"07-6464 l I=AIC: 919-807-6496 �i' ��L��L��
Internet! yrbMsiavalerrtualilv.ora
An Equal opportunity I Affirmative Adion Emooyer

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 far a Permit to Construct or Operate Injection Wells — Open Loop Geothermal
Injection Wells (Renewal) if the injection well system on your property is still active.
-DR-
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
[TIC 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 U1C well system status form are enclosed. The above referenced forms are also available on-
line at the DWQ website at httn://portal_ncdenr.or weblwit-
appliggionskeothermApps.
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 ericg.smith&cdenr.g.
Sincerely,
�" 0,
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Wilmington Regional Office - APS w/o enclosures
APS Central Files - Permit No.'W'10800158 w/o enclosures
2

Permit Number WI0800158
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael.rogers
Permitted Flow
Facilit
Facility Name
Douglas and Hilary Schultz SFR
Location Address
175 Herring Pond Ct
Beaufort
Owner
Owner Name
Douglas
Dates/Events
NC
p
28516
Schultz
Orig Issue
01/09/09
App Received Draft Initiated
09/29/08
Scheduled
Issuance
Central Files: APS_ SWP_
01/13/09
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Barry Snipes, Agent
106 Taylors Creek Ln
Beaufort
Major/Minor
Minor
NC
Region
Wilmington
County
Carteret
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Douglas Schultz
4319 Granada St
Alexandria
Public Notice Issue
01/09/09
VA
Effective
01/09/09
28516
22309
Expiration
12/31/13
_R_e -g ~u_la_te_d_A_c_ti_v_it_ie_s _______________ """R=e..,.g=u=es=t=e=d,,_,/R'-"-e=c=e=i-=--ve=--d=---=E=--=v--=e'-'--'n=ts=------------
Heat Pump Injection RO staff report requested
Outfall NU L L
Waterbody Name
Additional information requested
RO staff report received
Additional information received
Stream Index Number Current Class
10/03/08
10/03/08
12/11/08
12/11/08
Subbasin
Central Files: APS SWP
01/13109
�',Mt_ r W10800158 Permit Tracking Slip
Program Category Status Project Type
Ground Water In review New Project
Permit Type Version Permit Classification
Injection HeatinglCoeling Water Return Well (5A7) Individual
Primary Reviewer
michael.rogers
Permitted Flow
Permit Contact Affiliation
Barry Snipes, Agent
106 Taylors Creek Lri
Beaufort INC 28516
ri J
Facility Name MajorlMinor Rogion
Douglas and Hilary Schultz SPR Minof Wilmington
Location Address
175 Herring Pond Ct
Beaufort INC 28516
Owner Name
Douglas P Schultz
County
Carteret
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Douglas Schultz
4319 Granada St
Alexandria
VA 22309
Scheduled
arig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
09/29/08 ,i q I og 19,1 % 1113
Rectuldted cti,iti, , s d1 er:eivert
Heat Pump injection RO staff report requested 10/03/08
Additional information requested 10/03/08
RO staff report received 12111/08
Additional information received 12/11/08
Waterbody Name Stream index Number Current Class 5ubbasln

Beverly Eaves Perdue, Governor
Dee Frmnan, Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
r I
January 9. 2009
Douglas and Hilary Schultz
4319 Granada Street
Alexandria, VA 22309
Re: Issuance of Injection Well Permit
Permit No. W1080015-8
Issued to Douglas and Hilary Schultz
Dear Mr. and Mrs. Schultz:
In accordance with your signed and completed application received September 29, 2009, 1 am
forwarding Permit No. W10800158 for the operation of a 5A7 geothermal underground injection
well (UIC) heat pump system located at 175 Herring Pond Court, Beaufort, Carteret County,
North Carolina. This permit shall be effective from the date of issuance until December 31,
2013, and shall be subject to the conditions and limitations stated therein.
Please pay special attention to the bolded language in the permit. In order to continue
uninterrupted legal use of this well for the stated purpose, you should submit an application to
renew the permit four (4) 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.
The water samples collected from the source well on October 13, 2008, had exceedances in the
maximum contamination level (MCL) for the following parameters): total coliforin (copy
attached). This well must be re -chlorinated as soon as possible.
Additionally, please notify the Wilmington Regional Office at 910-796-7215 when the
geothermal injection well is installed and is operational in order for groundwater samples to be
collected from the influent and effluent sampling spigots.
If you have any questions regarding your permit or the Underground Injection Control (UIC)
Program please call me at [phone].
Best Regards,
Michael Rogers
Environmental Specialist
GPU — UIC Control Program
North Caro a
,Nat.. I/Y
Aquifer Protection 5ectian 1636 Mail Service Center Raleigh. NC 27699-I636 Telephone: [phone]
Internet- iium:!iwww.nrwtiemuality-org 2728 Capital Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal Opportunity)Affirmatme Arden Employer— 50% Rec+clW0% Post Consumer Paper Customer Service: [phone]

cc: Charlie Stehman -Wilmington Regiona1 Office
Central Office File-WI0800158
Carteret County Environmental Health Department
Attachment(s)
WI0800158 Page2
Beverly Eaves Pudue, Governor
Dee Freeman, Secretary
i North Carolina Department of Envirtmmert and Natural Resaurces
Coleen H. Sullins, Director
Division of Water Quality
January 9, 2009
Douglas and. Hilary: Schultz
4319 Granada Street
Alexandria. VA 22309
Re: Issuance of Injection Well Permit
Permit No. WIO800158
Issued to Douglas and Hilar'° Schultz -
Dew Mr. and Mrs. Schultz,
In accordance with your signed and completed application received::a€pternber 29, 2008, 1 am
forwarding Permit No. WIOSOO158 for the operation of a 5A7 geothermal underground injection
well (UIC) heat pump system located at 175 erring; Pond !_.r�urt, Beaufort. Carteret County,
North Carolina. This permit shall be effective %from the date of issuance until December 31,
2013, and shall be subject to the conditions and lirriitatinxs stated therein.
Please pay special attention to the hoided language in the permit. In order to continue
uninterrupted legal use of this well for the stated pu4ose, you should submit an application to
renew the permit four (4) months prior tt) fts expiration date. As indicated in the permit, this
permit is not transferable to any person vOthout prior notice to, and approval by, the Director of
the Division of Water Quality.
The water samples collected from the source well on Octobi�.-t- 13, 2009, had exceedances in the
maximum contamination level (MCL) for the following pararneter(s): total coliform (copy
attached). This well must be re -chlorinated as soon as possible,
Additionally, please notify the Wilmington Regional Office ,at 910-796-7215 when the
geothermal in) -pet' ion well is installed and is operational in order for groundwater samples to be
collected from -the influent and effluent sampling spigots.
If you have any questions regarding your permit or the Underground Injection Control (UIC)
Program please call me at [phone],
Best Regards,
42m
Michael Rogers
Environmental Specialist
GPU — UIC Control Program
Nod hcarolina
Aotgrallry
Aquifer Protection Section 1636 Mail service Center Raleigh NC 27599.163E Telephone: [phone]
Internet: hnnJeivww_ncwaterLjualitto_ 2728 Capital Boulevard Raieiglt. NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal opportunkylAlilmlalive Acllon Employer— 50% Recyded110% PW Consumer Rapes Customer Semee: [phone]

cc: Charlie Stehman -Wilmington Regional Office
Central Office File-WI0800158
Carteret County Environmental Health Department
Attachment(s)
WI0800158 Page 2
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
DOUGLAS .AND HILARY SCHULTZ
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North
Carolina Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat
pump effluent. This injection well is located at 175 Herring Pond Court, Beaufort. Carteret
County, North Carolina, and will be operated in accordance with the application received
September 29, 2005, 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 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 December 31,
2013, and shall be sub eel to the specified conditions and limitations set forth in Parts I through
VM hereof.
Permit issued this the 13 day of ; 2009
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
wtasoo 1Ss Page 3

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface
cannot migrate into the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each geothermal well injection system shall have permanently affixed an
identification plate according to 2C .0213(g).
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection
well to:
Aquifer Protection Section -UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Vlilmington Regional Office
127 Cardinal Drive Ext.
Wilmington, NC 28405-2845
GW-1 s must be submitted within 30 days of completion of well construction. Copies of
the GW-1 form(s) shall be retained on-site and available for inspection.
9. Well construction records must also be. submitted for any existing water supply wells on-
site as well as a site map showing any water supply wells on adjacent properties as
specified in NCAC .021 l(d)(l)(D).
Wl0800158 Page 4
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight ( 48) hours prior to constructing each injection well, the Permittee shall
notify the Aquifer Protection Section-Underground Injection Control (UIC), Central Office
staff, telephone number [phone] and the Wilmington Regional Office, telephone
number [phone].
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
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.
PARTIV-PERFORMANCESTANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater, which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance ofthis 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.
WI0800158 Page 5
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-
Underground Injection Control (UIC), Central Office staff, telephone number (919) 715-
6166. 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.
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. The Permittee shall report by telephone to the Wilmington Regional Office at 910-
796-7215 when the geothermal injection well is installed and is operational in order
for groundwater samples to be collected from the influent and effluent sampling
spigots.
2. 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.
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, which results in any unusual
operating circumstances;
Wl0800158 Page 6
(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 VIII-PERMIT RENEWAL
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 discontinuation of 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 ]?e 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.
WI0800158 Page 7
(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 ISA NCAC 2C .0213(h)(l) within 30 days of completion
of abandonment.
3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-DIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X-OPERATION AND USE SPECIAL CONDITIONS
None.
WI0800158 Page 8
LABORATORY ANALYTICAL RESULTS
5A7 GEOTHERMAL UNDERGROUND INJECTION CONTROL (UIC) WELL
PERMIT NO.: WI 0800158
PERMITTEE: Douglas and Hilary Schultz
SAMPLE COLLECTED DATE : 10/13/2008
Coliform, total Coliform , fecal p H
1 CFU/100ml 1 CFU/100ml units
MCL=1 MCL=1 MCL = 6.5-8.5
73 1 na
NO2-+ NO3-as N Phos phorus Nitrate
ma/L mg/L mg/L
MCL= 10 MCL= nss MCL= 10
na na na
Calcium, Ca Cadmium,Cd Chromium, Cr
mg/L ua /L ua/L
MCL= nss MCL = 1.75 MCL= 50
90 <1 <10
Man ganese, Mn Sodium, Na Nickel, Ni
µg /L m all µg /L
MCL=50 MCL= nss MCL = 100
<10 na na
MCL = Maximum Contamination Level per NCAC 2L .0200 (GA Standards)
nss = no state standard
na = not analyzed
Source Well
Total Dissolved Solids
mg /L
MCL=500
na
Nitrite
m g/L
MCL=1
na
Coooer, Cu
ua/L
MCL = 1000
<2
Lead, Pb
µg /L
MCL= 15
<10
'The laboratory sample matrix interfered with the abil ity to to make any accu rate determination; Estimated
Chloride, Cl
ma/L
MCL=250
na
Silver, Ag
ua/L
MCL = 17.5
na
Iron, Fe
ua/L
MCL=300
100
Selenium, Se
ua/L
MCL=50
na
Flouride
ma/L
MCL=2
na
Aluminum, Al
ua /L
MCL= nss
na
Mercu ry , Ha
ua/L
MCL = 1.05
na
Zinc, Zn
µg/L
MCL =1050
24
Sulfate Ammonia, NH3 TKN*
ma/L mg/L mg /L
MCL=250 MCL=nss MCL=nss
na na na
Arsenic,As Barium, Ba
µg/L ua/L
MCL= 50 MCL=2000
na <10
Potassium, K Ma g nesium, Ma
mg/L mg /L
MCL= nss MCL= nss
na 11 .
.
AQUIFER PROTECTION SECTION·REGIONAL STAFF REPORT
Date: December 9, 2008
To: A quifer Protection Section Central Office
Central Office Reviewer: Michael Ro gers , GPU
Regional Login No: Rebecca Gerhart
County: Carteret
Permittee: Dou glas & Hila ry Schultz
Project Name: WI0800158
Application No.: ..._W.....___0.;..0;;...._ __ _
I. GENERAL INFORMATION
1. This application is (check all that apply): cgi New D Renewal
D Minor Modification D Major Modification
D Surface Irrigation D Reuse D Recycle D High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
0 Attachment B included
D Surface Disposal
0 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation cgi Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? cgi Yes or D No.
a. Date of site visit: 10/13/2008
b. Person contacted and contact information: Douglas Schultz. 703-780-8117
c. Site visit conducted by: Rebecca Gerhart
d. Inspection Report Attached: t8J Yes or D No.
2. Is the following information entered into the BIMS record for this application correct?
cgi Yes or D 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/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For Dis posal and Injection Sites:
(I f multi ple sites either indicate which sites the information a pp lies to , co py and paste a new section into the
document for each site , or attach additional pa ges for each site )
a. Location(s): 175 Herrin g Pond Court. Beaufort. NC 28516
b. Driving Directions: N on US-70. Stay strai ght to go onto Merriman Rd. just before Bettie, NC (US-70
veers to the Eas t). Sli ght left on Merrimon Rd. NC-1300. Becomes Silver Dollar Rd. NC-1318. Left on
Sand y Point Drive. Ri ght on Herrin g Pond Court.
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next section )
Descri ption Of Waste (S) And Facilities
1. Please attach completed rating sheet. Facility Classification: __
FORM: StaffReport
RECEIVED/ DENR / DWQ
Aquifer Protection Section
DEC 1,12008
AQUIFER PROTECTION SECTION·REGIONAL STAFF REPORT
2. Are the new treatment facilities adequate for the type of waste and disposal system?
D Yes D No D N/A. lfno, 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. Ifno, 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. 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 NIA. 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 NIA. 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 NIA. 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 NIA If yes, attach list of sites
with restrictions (Certification B?)
III. RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or mai or modification
s ystems)
Descri ption 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 #: __
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:
FORM: StaffReport 2
AQUIFER PROTECTION SECTION'REGIONAL STAFF 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: __
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. If no, 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: StaffReport 3
AQUIFER PROTECTION SECTION·REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities -New, Renewal, And Modification
1. Type of injection system:
~ Heating/cooling water return flow (SA 7)
D Closed-loop heat pump system (SQM/SQW)
□ In situ remediation (SI)
D Closed-loop groundwater remediation effluent injection (5Lf'Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes ~ No
3. Are there any potential pollution sources that may affect injection? D Yes D No
What is/are the pollution source(s)? . W hat is the distance of the in jection well (s) from the pollution
source(s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? --~ft=.
5. Quality of drainage at site: ~ Good D Adequate D Poor
6. Flooding potential of site: D Low ~ 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)?~ 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 Onlv :
I. 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 , ex plain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes . explain:
3. For renewal or modification of groundwater remediation permits (of an y typ e ). will
continued/additional/modified in jections have an adverse im pact on mi gration of the plume or management of
the contamination incident? Yes D No. If yes , explain:
4. Drilling contractor: Name:
FORM: Staff Report 4
AQUIFER PROTECTION SECTION·REGIONAL STAFF REPORT
Address:
Certification number: __
5. Complete and attach Well Construction Data Sheet.
FORM: Staff Report 5
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.: The existing water supply well on
this property was inspected as part of the review process for application for permit WI0800158, constuction of
a UIC-5A 7. This well would be the source well for the system. The injection well was not installed at the time
of this inspection. Water samples from the WS were analyzed for Cu, Zn, Cr, Cd, Pb, Fe, Mn, Total Hardness,
Fecal Coliform and Total Coliform. Calcium: 90 mg/I, Cu: 0. I mg/I, Mg: 11 mg/I, Zn: 0.024 mg/I. Other metal
concentrations were below the detection limit/not present. This well was found to be in violation of 15A NCAC
2C Well Construction Standards. Although grout was present around the 4" casing, there was no grout from O'
to -3'. The top 3 ft. of the casing stood in a cavity several inches wide. After several attempts to contact him, a
Notice of Violation was sent to well contractor David Quinn (#2395) on November 181
\ 2008. A response was
received from Mr. Quinn on November 25 1
\ 2008 indicating that he had revisited the site and grouted the
casing up to the land surface. With this issue resolved, this water supply well is in compliance with 2C
Standards. Section IV, no.6 indicates this well is in an area with "moderate"· susceptibility to flooding; the well
is set-back 100-125' from the high water line of the Neuse River.
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 1:8] No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
FORM: StaffReport 6
AQUIFER. PROTECTION SECTION REGIONAL STAFF REPORT
7. Recommendation. ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please
8. Signature of report preparers);
Signature of APS regional supe
Date;
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM:. Staff Report 7

\\l\tm'YiltNt ~~;, / l.D~ $~
10( 13 I zo0 f
North Carolina
Department of Environment and Natural Resources
Division of Water Quality
Groundwater Section
Well Location: t✓ Hate IV113 Zvi
(Town, Corso4unity, Subdivision and Lot No.) rI M f jp WELL TY E
�tL L
Owner: CountyRoad/Street Uefb &ei (QuLf
Address: Quad No.
'VA aid Serial No.
Lat. Long.
] �} Well Construction ' 20
Well Contractor s�� d t �v I vt r1 (k'ldn-1 &1h- 7'A W 14 A, A) AlAv�4 1IK,
Name
Contractor Certl#ICaion #
37J
Permit Re aired ? (YIN)
Location - Distance From: ...................
Water Tight Sewagelwaste collection ..
Waste disposal (septic tank drain field)
Other Poll. Source + }
I A3arass
Check Items
Measured
Meets Min. Standards
Yes No
Remarks
(Permit No. j
I .................
,
Y�
Other Poll. Source ( }
CaSj'U
Type .....................................................
Depth................... ...............................
Weight/thickness..................................
Height (A.L.S.)..—.................................
Other ( } ,
Drilling Flu-ids/Additives
Type.....................................................
Grout
Type........,. ............... ..........................
Thickness ,,,,,,,,,,,,,,,,..... .,....................
Depth....... ...................... .......................
Other ( } .
Screens
Screened interval .................................
Other ( 1.
Development .........................................
Total Suspended solids ........................
Turbidity...............................................
Settleable Solids .. .................................
I.D. Plate
Well Contractor ............................... . . . ..
Abandonment
Temporary .........................................
Permanent ............. ............ .....,,,,.....,
r
%
(Circle one)
Plastic Carbon Galy. Stain, St, Other
-
2W
I ✓'I
—
GW-36 Rev. 112000
Applies to wells constructed after December 1. 1992
1i not n n Rnvnrsa]

ICheck items I Meets Min. Standards I Remarks
WellTest ...............................................
Duration................................................
FrequencytAccuracy of measurements
Other ( ) , -
Disin&Ction..........................................
Chlorination ..........................................
Other ( ) .
Cuttings............................................... - ---
Reports..................................................
Construction (GW-1) I ...........................
Abandonment (G W-30) ........................
Well H2ad Completion
Access port ...........................................
Hosebib ...............................................
Pitless Adaptor .....................................
Pitless Adaptor Unit ..............................
Suction line ...........................................
Tee{jet} ...............................................
Valved flow ...........................................
Vent......................................................
Water tight pipe entry ...........................
Wellentry .............................................
Applies to wells constructed after December 1, 1992
Date Well Constructed (yp ` c'c � �,�
Pumo Installation
Pump Installation Contractor
Name Address
PUMP CONTRACTOR I.D. PLATE PRESENT-7- (YIN) Date Pump Ins atte4
Violations noted attributable to the pump installation contractor are as follows-
(1)
Reg, #
_ .
(2)
(3)
INSPECTOR
I es
Name
Office
(If Available)
Name
Address
Type
Name
Address
Type
7�2
o - .,) S

-')EC-18-2008 THU 11',01 Ali RCDER FAX NO, 910 350 2004 P. 01/03
"*4 %
i4i Nartfi Carolina oepartmerit of tcnvlronmenk aiid Natural Resources (NC1']EN RjI
Wilmington Regional Office
[phone]
hllebael F. Easley, Governor
FA: COVER SHEET
William G. Rm Jr., Secretary
Date ��1�.� ,/ t5---------_ ------
#pa�e
To; -__^_____—_- --- From: #`._ _
Fax: ` ,� ' 7I!5 -- Q _ Fax: # [phone]
n a� .n. llJ I/YIf Y 9C- e� YaA i/MA
Ca
Revised 71-008
inn*j%ft NArth C'arniinn'PQAAe%_'AlZdC i
a t /

DEC-18--2O08 'THU 11: 01 AEI NODENR
Dec 0S UP 05:27p Envfrochem
Y
1
ANA Y-MA1 & CONSULTING
CHEMWS
CuOorner:
NYCDENR-DWQ
127 N. Cardinal Drive Ext
WjhTtingtan, NC 2840
Attn: Rebecca Gerhart
FAX NO, 910 350 2004 P. 02/03
2103924424 p.1
Environmental Chemists, Inc.
6602 Windmill Ways ■ Wilmington, NC2
[phone] (Lab) • [phone] (Fax)
710 Bowserbowm Road • Manua, NC 27954
{M 473.5702
G� a ..
NCDENR: P4WQ CERTU-TCATE 99C P45 = +�377-Sr
REPORT OF ANALYSIS
Date Sampled: 10/13/08
Sampled By; Rebecca Gerhart
WATEP--' fvlers Rnn
Sample W Lai+
1 t 22912
Date Aaaty7e
Method Code
Comments:
Fecal Coliferm,
colonlesIOD mL
< 1 est_
10/13/08
SM 9222 D
1D' . - ---
Date of Report: octobw 17, 2008
Ptirchase Order #:
Report number. 8-9644
Report To., Rebecca Gerhml
Email: [e-mail]
Reviewed by:�'
Total Coliforrm,
a coloniesllW wL
73 est.
10AWN
SM 9222 R

d
CIO
4=
Al,atPGM & Consulttng Chemists
CLIENT:
COLLECTED IIY:
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CIO im Ternpamturs vitreceivs* ` Accepted: Rejected:
Delivered 8y, ' I}' t' 1 � Received Byr'
L.L'
A
ENVIRONMENTAL CHEMISTS, INC
NCf17`NR- DWO CorltifeaLion 8 94 NCDHHS: OLS Cartificatlan ei 37729
Sample Collection and Chain o1 Cus"
9"PLE TYPE: t = Intllummir- go Effluent IN ra Wall_ ST : B[erann_ S� as 3oi9. 9L � 9ludea_ [kttiar:
6602 Windmill Way
Wilmington, NC 28405
[phone]
[phone]
NO.
;alteptll ldsrittfkattOn
Evliectlale
I,�,
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PRESERVAMN
AliALY31S tiG1iE3El7
Dote
Time Tam
7.
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0
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0
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g
G
G
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NOTICE - DIECHLORINATIQN' Samples for Ammonia, TKN, Cyranl'ds, Phenol and BUterla must be doctllorinated {O.2 ppnl or toss) In the Itt W at the time
of colteetlom 8" reverse for inalruc#ions
Yrarrsler
Relinquished [3aiodTirrse
Recehr�d
DetelTils
2
Ti

DEC-18-2008 THU I1:00 AM NODENR FAX NO, 910 350 2004 P. 01
Dec 49 t]B 05:27P l-nvir-aahem 910392 4424 p• 1
Environmental Chemists, Inc+
y , - 6602 Windmill Way • Mm4tcn, NC 28405
[phone] (Lab) - [phone] j sx)
710 Bowwwwn Road + Mantea, PVC 27954
(2p) 473✓57132
t�[aEr+lt Narttt Carolina Oetsa-trnertt 0( EnvIrOnr Brit anu Natural Resvumes (NCDENR)
Wilmington Regionzl Office
(910) 196-7`2 t 5
Michael F..Casky, Governor William G. Ross Jr., Secretary
FAX COVE, R /��0215 SHETT..J-
Date:2-O.� -- ----------- #pa cs---- _-..�._ .--_--- ---------------- _-
! � G _ _ ------ From: hwe--c� =_*--1_4
Co: ------------------ .._._.._------------ Division: --- ----------- ----- ----------_
Fa,Y: � 1 � Fu. # 91©- 350- 2004_ -
RCMIlIks: It& f�Ae &nvi&
127 Cardinal Drive Ext, Wilmin-ton. North Carolina 2940538.35 :k as#.- 91 0-(}_25fl4
Revisal 712008
CQmrmeats:
4
I
Reviewed by: -,ri- - t * _ ..�.

r
CIO
CL:
Analytcai & Consulting Chemisls
CLIENT.• i I� AV !'—
COLLECTED BY. "�? b C#& !
_-
ENVIRONMENTAL CHEMISTS, INC
NCDENR: Dii Q Certification 9 94 MCDHHS: OLS Gild kaWn 9 37729
Sample Collection area Chain of Cuatody
'- /5
REPORT NG:
6602 Windmifi Way
Wilmington, NC 20405
[phone]
[phone]
ry 0 ,Ll
.
Sample Identification�
Corllection
� 4 �
n
b.
� S
PRESERVATION
� � ANALYSIS R;raLIf-srEC
°
Date
Time
Temp
1
$
_
�
�
}
P
i
C
P
G
G
C
P
G
G
C
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G
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G
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_
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G
o- NOTICE - GECHLORINATION: Samples for Ammonia. TKN, Cyanide, Phenol and Bacteria must he dschlorinated j9.2 ppm or boas) In the field at the time
w 40 collodion. See memo for Instructions
LD
p
W
G
TrerAter
Roll r► ulehed B
Dstet iffle Recalved
Dau ima
Z.
in Temperature scelr Rejected: � Resampte Requested:
De�livared By: Receirved Sy - pate, IC Time 5,
a Comman I
ra

NC Division of Water Quality Laboratory Se~tion Results
Loe. Descr.: HERRING POND COURT
Location ID: WIROAPNLC
Sample ID: County: CARTERET
PO Number# River Basin
VisitlD
Report To WIROAP
Region : WIRO Date Received:
Collector: RGERHART Time Received:
Sample Matrix: Surfacewater Labworks LoginlD Loe. Type :
Sample Depth Date Reported:
Collect Date : 10/13/2008
Collect Time :: 13:00
nalyte Name PQL Result Qualifier Units
LAB
Sample temperature at receipt by lab 1.7
MET
Ba by ICP 10 10 u
Ca by ICP 0.10 90
Cd by ICPMS 1.0 1.0 u
Crby ICPMS 10 10 u
Cu by ICPMS 2.0 2.0 u
Fe by ICP 50 100
Mg by ICP 0.10 11
Mn by ICP 10 10 u
Pb by ICPMS 10 10 u
Zn by ICPMS 10 24
Laboratory Section» 1623 Mail Service Center, Raleigh, NC 27699-1623 (919) 733-39_08
Page 1 of 1
·c
ug/L
mg/L
ug/L
ug/L
ug/L
ug/L
mg/L
ug/L
ug/L
ug/L
AB36501
8G1398
10/14/2008
08:00
HPARKER
11/04/2008
Approved By
HPARKER
EST AFFORD
EST AFFORD
EST AFFORD
EST AFFORD
ESTAFFORD
ESTAFFORD
EST AFFORD
EST AFFORD
ESTAFFORD
EST AFFORD
Re: WI0800158 Si:!::mltz
1 of2
Subject: Re: WI0800158 Schultz
From: "Rebecca S. Gerhart" <[e-mail]>
Date: Thu, 18 Dec 2008 11:02:09 -0500
To: Michael Rogers <[e-mail]>
CC: "[e-mail]"
<[e-mail]>, [e-mail],
[e-mail]
Michael-
1) I have faxed the EnviroChem lab results to you. The lab report has mistakenly
identified the site as "50 Tylers Run". The field sheet that I submitted (page 2 of
2) correctly lists "Herring Pond Court" and shows the sample ID/report# as
8-9644. This number matches the report # on the results. I have been assured that
the quantitative results listed are for the sample submitted on 10/13/2008 for
Herring Pond Court. In a telephone conversation this morning, Mr. Quinn agreed
to rechlorinate the well and repeat disinfection.
The well water was analyzed for Total Hardness. The DWQ chemistry lab
reports this as two separate values: [Ca] and [Mg] which must be plugged into an
equation: 2.497[Ca mg/I] +4.118[Mg mg/I]= Total Hardness. In this case, Total
Hardness is 270.03 mg/I. Very high. For whatever reason, the lab prefers that the
sample collector check Ca and Mg on the lab sheet instead of Total Hardness, and
they always report these two separate values instead of one value for Total
Hardness.
2) Yes, I'd be happy to sample the influent and effluent after the IJ well is
installed and the system is complete.
3) A "Compliance Assistance" inspection has now been entered in BIMS. It
details the events related to this inspection. The information was previously
entered under Incident# 200803124/ NOV-2008-2C-0041 associated with the
facility 'Schultz Residence'.
4) The GW-36 form (Well and Pump Inspection Report) is available through the
Groundwater Protection Unit website, under "Permit Applications and Other
Forms". Here's the link, and I will attach a .pdfto this e-mail.
12/18 /2008 11 :31 AM
Re: WI0800158 ~chultz
2 of2
http ://h2o.enr.state.nc.us/ap s/gpu/documents/GW-36we11ins p ection.p df
I'll be out of the office ( today-12/31/2008) but please do let me know if you need
any additional information regarding this permit.
Thank you! Enjoy the holiday--
Rebecca Gerhart
Michael Rogers wrote:
Rebecca-
1. There was no coliform and hardness lab results for the
above. You indicated the well was analyzed for these
parameters.
2. Do you want me to put in permit for the permittee to contact
you after IJ well is installed for you to sample influent and
effluent?
3. Would you please enter inspection info into the Inspection
Tab in BIMS.
4. Also, would you please email me and the CC above a blank
form GW-36 that you attached to the staff report.
Thanks
Rebecca Gerhart <[e-mail]>
Environmental Senior Technician
Department of Environment and Natural Resources
Division of Water Quality, Aquifer Protection
~ Content-Type: application/pdf 1
GW-36wellinspection.pdf b 64 · Content-Encoding: ase
----======
12/18/2008 11:31 AM
RE: Schultz UIC geothermal permit WI0800158
1 of 1
Subject: RE: Schultz UIC geothermal permit WI0800158
From: Creekside Construction Company
<[e-mail] >
Date: Wed, 17 Dec 2008 09: 39: 00 -0500
To: <[e-mail]>
> Date: Tue, 16 Dec 2008 16:32:28 -0500
> From: [e-mail]
> To: [e-mail]
> CC: [e-mail]; [e-mail]; [e-mail]
> Subject: Schultz UIC geothermal permit WI0800158
>
> Barry-
>
> I am processing the permit for the above. For the proposed well casing
> depth(s) there is no info. Would you please provide this via this email
> and I will attach to the Application and continue to process.
>
> Thank you.
>
> Michael Rogers
> NCDENR
> DWQ
>
Michael,
We expect the well casing depth to be approximately 300 feet. Please feel free to let me know if
you have any further questions.
Sincerely,
Barry E. Snipes, President
Creekside Construction Company
12/17/2008 12 :51 PM
.
A QUIFER PROTECTION SECTION
APPLICATION REVIEW RE QUEST FORM
Date: October 3, 2008
To: D Landon Davidson, ARO-APS
□ Art Barnhardt, FRO-APS
□ Andrew Pitner, MRO-APS
D Jay Zimmerman, RRO-APS
From: Michael Ro gers Groundwater Protection Unit
Telephone: (919 ) 715-6166
E-Mail: [e-mail]
A. Permit Number: WI 0800158
B. Owner: Douglas and Hilarv Schultz
C. Facility/Operation: __
[8] Proposed [8] Existing
D. Application:
□ David May, WaRO-APS
[8] Charlie Stehman, WiRO-APS
□ Sherri Knight, W-SRO-APS
Fax: (919 ) 715-0588
D Facility D Operation
1. Permit Type: D Animal D SFR-Surface Irrigation □ Reuse D H-R Infiltration
D Recycle D 1/E Lagoon D GW Remediation (ND)
[8] UIC -5A 7 Open Loop
For Residuals: D Land App.
□ 503
0 D&M
D 503 Exempt
D Surface Disposal
D Animal
2. Project Type: [8] New D Major Mod. D Minor Mod. D Renewal D Renewal w/Mod.
E. Comments/Other Information: D I would like to accompany you on a site visit.
NOTE: Site has existing well (source) and has submitted an A pp for an in jection well. Please
attach laborator y analytical results and staff re port at same time.
Thanks.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within_ calendar days, please take the following actions:
[8] Return a Completed APSARR Form.
D Attach Well Construction Data Sheet.
D Attach Attachment B for Certification by the LAPCU.
D Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: -------------------Date: _____ _
FORM: APSARR 07/06 Page I of 1
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins Director
Division of Water Quality
October 1, 2008
Douglas P. Schultz
Hilary Schultz
4319 Granada Street
Alexandria, VA 22309
Subject: Acknowledgement of Application No. W10800158
Douglas P. & Hilary Schultz SFR
Injection Heating/Cooling Water Return. Well (5A7)
Carteret
Dear Mr. and Mrs. Schultz:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on September 29, 2008. 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 Division's 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 a 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. Also note that the Division has reorganized. To review our new organisational chart, go to
hit_://h2o.enr_state.nc.usfdocuments/dwq or�chartsdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS
PROJECT.
Sinc rely,
for Debra JZatts
Supervisor
cc: Wilmington Regional Office, Aquifer Protection Section
Coastal Carolina Corporation (Attn: Gene Garner, 411 Live Oak Street, Beaufort, NC 28516)
Permit Application File W10800158
Aquifer Protection Section 1636 Mail Serwee Center
Internet; www.newateraualitw.ore Location: 2728 Capital Souievard
An Equal OpporiunWAl6mrative Action Employer- 50% Recycledh0% Post Consumer Paper
Do�►Cam1�a
�1Va,fura�`�
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27644 Fax 1: [phone]
Fax 2. [phone]
Customer Service: [phone]

RECEIVED ! DENR 1 DWQ
ACIUM RI nTPrTION SF-CTION
NORTH CAROLINA SEP 2 8 2008
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 5-A7 WELL
� New Permit Application OR Renewal (check one)
DATE: 20 446
PERMIT NO. -(leave blank if NEW permit application)
A. PROPERTY OWNERS)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature):
(1) Mailing Address: ._.Tr/ [� A�YCJ�(d .J! f7`
City: >'f� State:w Zip Code: County:
Home/Offce Tele No.: (D 460 " Cei1 Na A �
EMAIL Address:
(2) Physical Address of Site (if different than above): / /J1 A.0
arez
City: State: / eZip Code: / County- ZfZeAWK
Horne/Office Tele No.: Cell No.:
EMAIL Address,
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not awn the subject property,
attach a letter from the property owner
Company Name:
Contact Person_
Address: le
City..
Office Tele No.:
Website Address of Company, if any:
Agent to install and operate UIC well)
GPUIU[C 5A7 Well Permit Application (Revised 912007) Page i

prrC�lu�Q � 0SV4R t 'DVIQ�pN
SEp
C. WELL DRILLER INFORMATION
Company Name: L /C:C
Well Drilling Contractor's Name:
NC Contractor Certification No.:
Contact Person: JVrId K
Address: 796 7" "-rK /fa4u
City:Zip Code: ".f7rfo Cou ty: i:fyw
Office Tele No.:' Z Cell No,:
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:
Contact Person:
Address:
City:
Office Tele No.:a
E. STATUS OF APPLICANT
Private: V Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTION PROCE�DUU�RjE/ (briefly describe how
/the injection well(s) will be used)
N4 X2:2e
G. 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
yA&'y
H. WELL CONSTRUCTION DATA {Skin to Section I if this is a Permit RENEWALI
Y PROPOSED Well(s) 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.
EXISTING Well(s) 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-I (Well Construction
Recurd) ifavail abl .
(1) Date to be constructed: , Number Z;9�
`
Approximate depth of each boring (feet): ,YQ O
(2) Well casing./Is the well(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES ►f If yes, then provide the casing information below,
Type: Galvanized steel Black steel Plastic Other (specify), m Z 40
Casing thickness: diameter (inches): depth: from to R. (reference to land surface)-
'.
Casing extends above ground _ inches
OPUIMC 5A7 Well Permit Application (Revised 9/2007) P 7/VV rage 2

DECEIVED I DENR 1 DWO
Xj"R`ppn7F(110hl sEr.TICN
(b) NO SEP S 9 2008
(3) Grout (material surrounding well casing and/or pipin
(a) Grout type: CementSentonite Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
Around closed -loop piping; from to (feet).
I
Around well casing; from to met).
(4) Well(s) Screen information
Depth of Screen: From AA feet below land surface
(5) N.C. 'State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead water quality and processes. A faucet on both Influent (groundwater entering heat
pump) and Effluent (water being injected tock into the well) lines is required. Will there be aucet on:
(a) influent line? YesNo (b) Effluent line? Yes No
(6) Source Well Construction Information (if the water source well is a different well than the injection well)
Attach a copy of Form GW-I (Well Construclion Record). If Form GW-I is not available, provide the
following data: ____~ '1
Groundwater Source_ From what depth, formation, and type of rock/sediment units will the groundwater
be withdrawn? (e.g_ gra9c, limestone, sand, ete.
Depth: �'� Formation:/ Rock/sediment unit:
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR PROPOSED WELLS IF
THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
1. OPERATMG DATA
(1) Injection rate: Average (daily) gallons per minute (gpm),
✓` �%
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi). ("
(4) Injection Temperature: Average (January) o F, Average (July) o F.
J. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
K. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(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.
GPUMC 5A7 Well Permit Application (RcAsed 9/2007) Page 3

Sap 23 08 01:12p Hilary and Doug
SEF-23-20ee 11:15 FROM:
703-780-8117 p 'l
Ta:170378MI17 P.1
L. CERTIFICAVON
Note: This Permit Application must be signed by ILeb person appearing on the
recorded logo[ property deed.
RECENED) DENR I9WQ
AO Ul;pR-,pRnTr- TInN 9, FCTlON
SEP 3920
-1 hmby certify, under penalty of law, that I have peraonaily exaamired and am familiar with Om information
submitted in this document and all anachumnis thereto and that., bawd on my inquiry of those individuals
1mawdliamly responsible for otrraining said information, I believe: OW the information is true, amwate and eWffip?cte.
I am aware that theme are significant peaaltaes, including the possibility of firms and imprimnment, for submitting
false information. I agree to consnwz, operate, maintain, repair, acid if applicable. abandon the injeadon walk and
at] relied aMttenartoes in accordance with the atppr+oved specifications and conditions of d w Ptsntit."
Signa �Oferty OwnerlAAp W
Print -or Type Full Nacre
Sigmatur+e of FroWty Qwner/Applic
Print or Typo Fall Name
Signature ur Ui r�iZcd�Agent, if aAll
Friat pa Full Name
Please return two capits of dw— completed Application package to:
North Carolina D1NR DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
'telephone [phone]
CPUNIC WWI pmnit ApprwAdivn (PrwiBrA sQOM Page 4

Sep 23 08 01 :12p Hilary and Doug
September 23, 2008
Nortl, Carolina DENR-DWQ
Aquifer Protection Program
UJCProgram
1636 Mail Service Center
Douglas and Hilary Schultz
4319 Grllltada Street
Alexandria, Virginia 22309
Raleigh, North Carolina 27699-1636
Subject: Authorization for Represewtation
Dear Sirs,
703-780-8117 p,1
I, Douglas and Hilary Schultz, hereby authorize Barry E. Snipes, President of
Creekside Construction Comptmy to act as my represelllative in the process of
application for a. Type 5-A7 injection we.II for a geotkerlllil.l heat pump system for the
property listed below:
175 Herring Pond Court (Lot #26)
Beaufort (Merrimon TownshipANorth Carolina 28516
PIDN# 7415 0267 9505 000
In addi.ion to the above, tire North Carolin.a DENR-DWQ, has .my pennlssloR to access
the above mentioned property. Shoul.d you need additional information, pletUe feel
free to cfJntact us at the following address or telephorre number:
Dougllls and Hila.ry Schultz
4319 Grana.da Street
Alexandria Virginia 22309
[phone]
Sincerely.
,7vN c;.r VO Va.v6M
RESIDEN77AL w) f L eoNSrR[I rLC-M RECOF-D
k+l'arlh c�rolian pc�ers4 �Envisssosa�L and NQi1u�+ R�ea+�rr- Aitssrtue nfVl1'dter QIuiI ity
0117
wgl,L CoNTRACron CgRTMICATI N #
i. YVE].i_ c0KMC.MK: -
wa 4 ww% m
C f o-t lj4 r l'
w1w Cciaa Gwnpgm lq pin
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ConnectGIS Page I of I
1:1481 feet
http://carteret.connectgis.com/Map/PrintWindow.aspx?Map=http://carteret.connectgis.com... 9/25/2008
COASTAL CAROLINA
CORPORATION.
HEATING AND AIR CONDITIONING
411 UVF,OAK ST-RFA[1FOKLNC
1-252.729.5717
SEPT 26, 2008
BARRY SN['PES,
CREEKSEDE CONSTRUCTION CO
AS THE SUPPLIED CHART SHOWS THE TOTAL FLOW RATE FOR THE TWO
HEAT .PUMPS IS 27 GALLONS PER MINUTE.
THE WAY WE NORMALLY PIPE THESE UNITS IS TO RUN 15 GALLONS PER
MINUTE INTO THE LARGER 5 TON UNIT AND THEN RUN THE SAME WATER
THROUGH THE SMALLER UNIT.
THE WATER ENTERING THE FIRST UNIT IS 60 DEGREES AND THE WATER
ENTERING THE SECOND UNIT IS 70 DEGREES. AS THE CHARTS SHOW TIES
IS WELL WITHIN THEIR DESIGN SPECIFICATIONS AND DECREASES THE
WATER USAGE BY ABOUT HALF.
THIS MARES THE TOTAL WATER USED WHEN ETHER SYSTEM I5 RUNNING
15 GALLONS PER MINUTE.
THE TOTAL, WATER USAGE PER DAY WILL DEPEND ON OUTSIDE AND
INSIDE TEMPERATURE.
WHEN THE UNIT IS UNDER MAXIMUM LOAD IT COULD USE UP TO 16,200
GALLONS PER. DAY.
15 X 60 X 18 HOURS = 16,200
THE AVERAGE WOULD PROBABLY BE 15 X Gil X 12 HOURS s 10,800 GPD
THE MOST THE SYSTEM COULD PUMP IS 15 GALLONS PER MINUTE X 60
MINUTES X 24 HOURS = 21,600 GALLONS PER DAY
THIS IS A SUMMED DESIGN SPECIFICATION, THE UNIT WILL RUN LESS IN
THE WINTER.
THANKS,
GENE GARNER
�/3

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252-728-5848 PHONE OR FAX EMAIL j1p39caasinlnef.com
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