WI0800182_GEO THERMAL_20120517

Beverly Eaves Perdue
Governor
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 17, 2012
Linda Robuck
Post Office Box 17102
Raleigh, NC 27609
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI08001 82
Dear Ms. Robuck:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http ://p ortal.ncdenr.org/web/wg/aps.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity\ Affirmative Action Employer
NOnel c· 1· ort1 aroma
;Vat11rall11
� � F 11
RESIDENTIAL WELL CONSTRICTION RECORD
-�� North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 397I-A
1. WELL CONTRACTOR:
William B. Jefferson
Well Contractor (Individual) Name
Geo Design Group Inc.
Well Contractor Company Name
10025 HWY 264A - PQB 9
Street Address
Middlesex NC 27557
City or Town State Zip Code
252 ) 235-2209
Area code Phone number
2t WELL INFORMATION, ���l
WELL CONSTRUCTION PERMIT#WI oft 0 2-
OTHER ASSOCIATED PERMiT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 3' l ` I U
TIME COMPLETED '5 - 3 " 1 C� AM ❑ PM Y
-
3 v 2 G� t I
rg. WATER ZONES (depth):
Top
Bottom
Top
Bottom
Tap
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thicknessl
• 7. ASING.
Depth
Diameter
Weight Material
Top
Bottom
Ft._
Top
1�t m
ft.
Top
Bottom
Ft.
8. GROUT:
Depth
Material
Method
TOP()
Bottom701
Ft.Mix Thermex Grout
. Top
Bottom
FLBentonite
& Silica
Top
Bottom
Ft Sand__
S.. EEN:
Depth
Diameter Slot Size Material
: Top
ottom
Ft. in.
in.
Top
Sot,
Ft. in.
in.
Top
Bottom
Ft. in.
in.
4. WELL LOCATION: N�,SANDIGRAVEL PACK:
�_
CITY_ Atlantic Beach COUNTYCarteret Size
Top Depth pth Ft.
280 Cakleaf Drive 28512 Top BRttO Ft.
(Street Name, Numbers, Community, Subdivision, Let No., Parcel, Zip Code) Top Bottom Ft,
T OGRAPHIC 1 LAND SETTING: (check appropriate box)
©Slop -Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE S " DMS DO
LONGITUDE 75 Z: ° " DMS DD
Latitude/longitude source-. PS Dr'opcgraphlCmap
(location of well must be shown on a USGS tope map andattached to
this form if not using GPS)
5. WELL OWNER
Linda H. Robuck
Owner Name
280 Oakleaf Drive
Street Address
Pine Knoll Shores NC 28512
City or Town State Zip Code
s� 19 , 876-1970
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH'70' + -
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ge
C. WATER LEVEL Below Top of Casing: N/A _ _ FT,
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS NIA Fr. Above Land Surface'
"Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC ZC ,011S.
e. YIELD (gpm): N/A METHOD OF TEST
f. DISINFECTION: Type Amount
f1. DRILLING LOG
Top Bottom
y
0 1
1
1
1
1
1
1
1
1
1
1
1
Material
Formation Description
r
A weds tour Ir e'd 4'-5' below grade and grouted bottom to tap.
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH5A NC �iL�ItyELL CONSTRUCTION
STANDARDS, AND THATA C PY OFT IS RECORD HAS BEEN
PROVIDED TO THE WE yy ER_
SIGNATURE OF CERTIFIED WEERACTOR DATE
William S. Jefferson
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone, (919) 8074300 Rev, 2109

Mechanical Integrity Test Record
(For 5QM Geothermal. Heat Pump Injection Well System)
nwner/Permittee Name: Linda H. Robuck Pen -nit Number: W1 V30 01? 2--
Facility Address: 280 Oakleaf Drive Pine Knoll Shores, NC 28512 _
Home Phone: [phone] Cell Phone:
Heat Pump Contractor Name: Geo Design GroW Inc. _
Office Phone: [phone] Cell Phone:
Tester Name: _William B. JeffersonSignature:
Date of Test:
Loop
Initial Pressure si
Final Pressure(psi)
Duration (minutes)
Pass (Yes or No
1
400
400
24 Hrs.
Yes
2
3
ti
4
5
6
7
8
9
10
11
12
13
14
15
9 b t Any addKonalloop testing add t€ kk of this form
Comments: All loops held 400 psi for min. of 24 hogs.
Other Test Methods and Results:
Prior to install all loops held in water for 5 min.
This form must be filled out and signed by the tester. The record must be received by Aquifer Protection Section 24 hours
prior to the initiation of the operation of the facility- You can send the forth by mail: UIC Program, Mail Service Center 1636,
Raleigh, NC 27699 or by fax: [phone]_
Mechanical Integrity Test Foam 1112007

(GDG) Geo Design Group Inc.
Earth Loop Equipment & Drilling Information Sheet
Project Site Owner: --=Li..=n-d=a H. =R=-ob=u=c=k _________ _ Date: ___ 3_--_i_l_-_\_'v __ _
Address: __ =2=8=0 Oakleaf ..... D=ri~v~e ____________ _ Prepared By: ?c&vo .~·rc~s
______ P:...:i=n=e Knoll Shores, NC =2=85=-1=2 _________ _
Earth Loop Installer: GEO DESIGN GROUP INC POB 9 MIDDLESEX, NC 27557 PH. 252-235-2209
Driller/ Excavator: GEO DESIGN GROUP INC POB 9 MIDDLESEX, NC 27557 PH. 252-235-2209
Grout Installer: GOG-GEO DESIGN GROUP INC POB 9 MIDDLESEX, NC 27557 PH. 252-235-2209
Earth Loop Model Number: E ·T f\ i:10 3
CPS Model Number: -----------
Soil PH: S .--5 ---"---=----
Earth Loop System Seal Test: ( 40'0. psi) ve{,~r No (circle one)
/,, ,,/·
Triangulation Map Attached: (requirid) Ye'; or No (circle one)
X-Fine Silica Sand Used: 4 I (Bags)
i3e-n tc)nif(_~ --~'{J~-)
9 (cl,j+ \I.
No. Holes Drilled: __ "-" ______ _
Depth -Length Holes: _ .. l...;_V.;c._· ,<----
o ·5-])') .~ .. Angle Holes: 2 • 1. /f"X (( e_
0
Earth Formation Description For:
TOP to Bottom
Sand: __ o_· ____ ,)---=()_1_· __
Drill Start Date: 3 ·-; ·-I c)
Clay: ________ _
Rock: ________ _ Drill Completion Date: ·3 ·· 3 ·· i Cl
mre
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PFRVIOUS SUR C {cAixm
TOTAL ACMGE-1.17-50,906.lom (PEMOM)
W-IKRPq!LSL $S7RFA E GgCi]%JS,
SLRLO= POOTFRINT DFCLOD%O GARAGE~ 5.35B.72M
Mn MFLOSED AM E7Q$ G=5..W.23M
I&M. ]HPERMUS SURFACE a 10,579.D5
% UIPEWOUS COVERAM = 20.D5%
% WERV;DUS AUOWABU = SM
% DfpB,Rvsws PAILU" = 0.05T.
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SRE PLAN
L-2

RESIDENTIAL WELL CONSTRUCTION RECORD
Nortli Carolina Departinent of Environment and Natural Resources- Division of'Wales- Quality
RECEIVED 1 DENIM 1 t0WQ
f 3971-A AQi M'N0T'rrP�?N SFCfm
WELL CONTRACTOR CERTIFICATION #
--- APR 14 2010
1. WELL CONTRACTOR:
William B. Jefferson
Well Contractor {Individual} Name
Geo Design Group Inc.
Well Contractor Company fume
10025 HWY 264A - PQB 9
Street Address
Middlesex
City or Town
2552 235-2209
Area code Phone number
2. WELL INFORMATION'
WELL CONSTRUCTION PERMIT#Wl
OTHER ASSOCIATED PERMIT#(irappfica
SITE WELL ID#(irapolicable) _
NC 27557
State Zip Code
S. WATER ZONES (depth):
Top Bottom
Top
Bottom
Top Bottom
Top
Bottom
Top Bottom
Top
Bottom
Thickness)
7. \CASING: Depth
Diameter
Weight Material
Top Bottom Ft.
Top ItettQm 1=t.
Top Bottom Ft.
& GROUT: Depth Material Method
Topo Sottom70' Ft.Mix Thermex Grout
e'Is Top Bottom Ft-Bentonite & Silica
blei Top Bottom FI.Sand
3. WELL USE (Check Applicable Box): Residential Waler Supply F1
DATE DRILLED i I
TIME COMPLETED ) =: AM ❑ PM AV
4. WELL LOCATION:
CITY: Atlantic Beach covNTYCarteret
280 aaklea€ Drive 28512
(Street Name, Numbers. Community, Subdivision, Lit ND., Parcel, ZIP Code)
-U3POGRAPHiC 1 LAND SETTING: (check appropriate box)
❑ Slope.) j)Valley ❑Fiat ©Ridge []Other
LATITUDE ` 3E _ " DMS DID
LONGITUDE 75 � DMS DD
Latitude/longitude scurce:YnPS ❑Topographic map
()ocarion of welt must be shown on a USGS tope map andettached to
this fora{ if not using GPS)
S. WELL OWNER
Linda H. Robuck
Owner Name
280 Gakleaf Drive
Street Address
Pine Knoll Shares NC 28512
City or Town Stale Zip Code
(919 ) 876-1970
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:79' +
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Mr
C. WATER LEVEL Below Top or Casing: N/A FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING Is NIA FT. Above Land Surface'
-Top of casing terminated at/Dr below land surface may require
a variance in accordance with I SA NCAC 2C 0118,
e. YiELD (gpm): N/A — METHOD OF TEST
t. DISINFECTION: TYPI—W Amount
9. $'GREEN: Depth Diameter Slot Size Material
Top -.Bottom Ft- in- in.
TOP Bottt7n�— FI. in. in.
Top Bottom Ft. in. in.
19,,SANDIGRAVEL PACK.,
Depth Size Material
Top -- bottom Ft.
Top Sottorr_, Ft.
Top Bottom ~� Ft-
11. DRILLING LOG
Top Bottom Formation Description
1 V t. !S(
1
1
1
1
1
1
1
1
1
1
A WeWS 0u red 4'-5' below grade and grouted bottom to top -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITHA- A NCAC2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF TPJIS RECORD HAS BEEN
PROVIDED TO THE WELT OWNER.
SIGNATURE OF CERTIFIED WE .l ,GONTRACTOR DATE
William S. Jefferson
PRJNTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 3D days of completion to: Division of Water Quality • information Processing, Form GW-1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone] Rev. 21g9

Mechanical Integrity Test Record
(For 5QM Geothermal Heat Pump Injection Well System)
RECEIVED I DENR r DWQ
AQU1FFR 'PP0TFVT10N SECTION
APR 142010
Owner/Permittee Narne: Linda H. Robuck Permit Nw -Tiber: WI
Facility Address: 280 Oakleaf Drive Pine Knoll Shores. NC 28512
Horne Phone: [phone] Cell Phone:
Heat Pump Contractor Name: Geo Design GrouW. Inc.
Office Phone: [phone] Cell Phone:
Tester Name: William B. Jefferson ___Signature:
Date of Test: , - j I
Loop
Initial Pressure si
Final Pressure(psi)
Duration (minutes
Pass Yes or No
1
400
1400
24 Hrs.
Yes '
; f
��2
3
4
i
5
i
6
�
7p
1
O
+
9
i
t
10
1
12
1
[
1
}J
1
14
f
} 7
15
}
i, L Any adcli inal loop testing add to baek of this form Y
Comments: All loops held 400 psi for min. of 24 hours.
Other Test Methods and Results:
Prior to install all loops held in water for S ruin.
This form must be filled out and signed by the tester The record must he received by Aquifer Protection Section 24 hours
prior to the initiation of the operation of the facility. You can send the form by mail; SIC Program, Mail Service Center 1636,
Raleigh, NC 27699 or by fax: [phone].
Mechaiiicai Intcgrlty Test Form 11/2007

(GDG) Geo Design Group Inc.
Earth Loop Equipment & Drilling Information Sheet
Proiect Site owner: Linda H. l?vhuck _ Date:
Address: 280 Dakleaf Drive Prepared By:
Pine Knoll Shores. NC 28512
RECEIVE.[] I I?ENR I DWa
A0U1P1:wPPoTrr'nnN ,F_CTV1
3 -_ 3 APR 14 2010
Pf4 V 1 : A'M i_ •i: �3
Earth Loop installer: GE❑ DESIGN GROUP INC POB 9 MIDDLESEX, NC 27557 PH. 252-235-2209
Driller / Excavator: GE❑ DESIGN GROUP INC POB 9 MIDDLESEX, NC 27557 PH. 252-235-2209
Grout Installer: GDG -- GEO DESIGN GROUP INC PO 9 MIDDLESEX, NC 27557 PH. 252-235-2209
Earth Loop Model Number:
CPS Model Number:
soil PH: 5-
Earth Loop System Seal Test: (400 psi) Yes or No (circle one)
Triangulation Map Attached: (required) Yes or No (circle one)
Drill Start Date: '_ i C Drill Completion Date: 3_�
X-Fine Silica Sand Used: [Bags]
No. Holes Holes Drilled:
Depth -Length Hales: �.
Angle Holes:
Earth Formation Description For:
TOP to Bottom
Sand:
Clay:
1_ �`_ Rock:

K�CEJVED / DENR r DWQ
A0V;FFR•pQrin'rnj)M SMTA'W
APR 14 2010.
iti....rlxrr�
S
v � lL �Nr y�.nxf+vMl A'�
Bpi P SWxfllli
6N..:Krl�rfr.Mll.e w� �. rl � � � •L�
r S�.SR•:1 _. ✓' n� `i r � i �� � � � � ._� � Ltll+r-ft df��a�n�r.:l� r ;•
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,..nrr. n�we...n•. ;.: N �.aR►'la�¢_-"•._tiiZ�R�.F cl1i.�3?F'7��#L�-? " OZ
.»•.-.... r... �u �r...r '.:�,-:r:... •: x ar�r..r.. .�R-•:.r TOTAL ACREAGE=1.17 �OAoa.-D m (MKv10oS) w < n2
::►.:.";: s .b. i.o,w.racTri'KF :� f y m nK
� IMPERVIOUS_ SLRFAC$ CALCGLAro:NS LL
BUXOM MTr8Iti7 I!i CUMING GARAGE MSO.:,.i�'i- .
Ir�.rrr,• n. ""r.n..r.xrr�...,,.,.r.,. ,. ¢ �� •� DR1vE pplrvsfap AND E*9MG s5,929.73v1� .•• }iilliE.w�- —
.ter:. �.. rr..,.r.rr",•••,•�+••` ,_ .;y TOTAL P,Q'SRSTOUS SMIWACA = 10,8799'a bE3Ii39l4_�
OtnMOG5 COVERAGE a ME=
j : IMPB'dvlOirS ALLOFASLE
1MFE"1OMi AVAaAstE - 9.05,
.,.-..-�-
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•Im•I"- ar.w.r r N.. b n,.w-w...w«,� rSME PLAN
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Permit Number WI0800182
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Linda H. Robuck SFR
Location Address
280 Oakleaf Dr
Pine Knoll Shores
Owner
Owner Name
Linda
Dates/Events
NC 28512
H Robuck
Orig Issue
02/17/10
App Received · Draft Initiated
01/13/10
Scheduled
Issuance
Central Files: APS_ SWP_
03/02/10
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Wilmington
County
Carteret
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Linda H. Robuck
Owner
6821 Greystone Dr
Raleigh NC 27615
Public Notice Issue
02/17/10
Effective
02/17/10
Expiration
01/31/15
_R_e-g_u_la_t _ed_A_c_ti_v_it_ie_s ___________ ----,-___ Re a uested/Received Events
Heat Pump Inj ection RO staff report reques ted
RO staff report received
Outfall NULL
Waterbody Name Stream Index Number Current Class
02/02/10
02/05/10
Subbasin
Pe r mit Number WI0800182
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit,
Facility Name
Linda H. Robuck SFR
Location Address
280 Oakleaf Dr
Pine Knoll Shores
Own r
Owner Name
Linda
Dates/Events
NC 28512
H Robuck
Orig Issue App Received Draft Initiated
01/13/10
Req ulated Activities
Heat Pump Injection
Outfall
Scheduled
Issuance
Central Files : APS_ SWP_
02/10/10
Permit Tracking Slip
Status
In review
Version
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Wilmington
County
Carteret
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Linda H. Robuck
Owner
6821 Greystone Dr
Raleigh NC 27615
Public Notice Issue Effective Expiration
~ln\lD l[~ \ \.S
Reauested/Receive e vent,;
RO staff report requested 02/02/10
RO staff report received 02/05/10
Waterbody Name Stream Index Number Current Class Subbasin
i .&i .
NCDENR
North Carolina Departr.nent of. Environment and Natural Resources
Division of Water Qualiiy
Beverly Eaves Perdue
Governor
Linda H. Robuck
682 l Greystone Drive
Raleigh, NC 27615
Dear Ms. Rob uck:
Coleen H. Sullins
Director
February 17, 2010
Subject: Issuance oflnjection Well Permit
Permit No. WI0800 182
Issued to Lind& H. Robuck
Ca rteret County
Dee Freeman
Secretar,·
In accordance with your application received Ja:nua ry 13 , 2010, I am forwarding Permit No . Wl08001 S2
for the construction and operation of a vertical closed-loop geothermal 'Direct Expansion' heat pump
injection well system to be located at 280 Oakleaf Dri v e, Pine Knoll Shores, Carteret County, NC '.28512 .
This permit shall be effective from the date of issuance until January 31. 2015, and shall be subject to the
conditions and limitations· stated therein.
Please pay special attention to Part VII.2 of the permit and submit copies of the Well Construction
Completion form (GW-1) after construction. Please submit all data within 30 calendar days of
completion of installation of geothermal well(s) to the following address:
Aquifer Protection Section (APS)
Underground Injection Control (UIC) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
Additionally, your UIC system is subject to inspection by the APS. Per special condition Part 11.13, in
the event that there will be multiple wells with separate clusters, one well identification tag per "cluster'
of wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit three months prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Quality. If you have any questions regarding your permit or the Underground lnj ection
Control Program please call me at [phone].
cc: Charlie Stehman -Wilmington Regional Office
Central Office File -WI0800182
Carteret County Environmental Health Dept.
Marie Melton -Geo Design Group, Inc.
Attachment( s)
Sincerely,
AA -,I fl /)_
,/// Pl.~-f'L-~. /Jlry ~--
.Michael Rogers, P.G. (NC & FL)
Environmental Specialist
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
Linda Itobuck
FOR THE CONSTRUCTION AND OPERATION OF 16 TYPE SQM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a "direct expansion"
type vertical closed-loop geothermal-mixed-fluid heat pump system. This system is located at 280 Oakleaf
Drive, Pine Knoll Shore s, Carteret County, NC 28512, and will be constructed and operated in accordance with
the application received January 13, 2010, and in conformity with the specifications, all of which are filed with
the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation of an injection well and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until January 3 L 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 1 ?'ii day of ;;-ebruary 20 0.
kD'Coleen H. Sullins, Director
\ Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0800182 UIC/SQM-DX
ver. 10/2009.
Page 1 of 6
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of th'is permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. Soil from a depth of at least three feet at the planned well location shall be tested for pH prior to
constructing the injection well system. The well system shall be equipped with a compatible cathodic
protection system if the soil pH is less than 6 standard units or greater than 11 standard units. All testing
results shall be kept on site to be made available for inspection.
2. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone], and the \Vilmington Regional Office Aquifer Protection Section Staff, telephone
number [phone] .
3. All underground tubing shall be refrigeration-grade copper tubing.
4. Prior to installation, all tubing to be placed in boreholes shall be checked for leaks by pressurizing the loop
to a gauge pressure of at least 350 pounds per square inch (psig), immersing the loop in water and
examining it for leaks. Loops with leaks shall not be installed.
5. Prior to installation, all tubing shall be visually inspected for damage such as kinks, dents, and scrapes.
Each tubing "loop" shall be checked to verify that the nitrogen charge applied to the loop by the
manufacturer before shipping is still present at a pressure of at least 300 psig. The manufacturer shall be
notified in the event of damage or pressure loss, and the manufacturer's instructions shall then be
followed. The nitrogen charge may be released only when the tubing is installed and ready to be
connected to the manifold.
6. Boreholes shall be large enough to allow insertion of the tubing plus a tremie pipe for grouting.
7. After insertion of the tubing into the boreholes, an approved grout (as defined in Title 15A North Carolina
Administrative Code 2C .0100) shall be pumped via tremie pipe into the annular space of each borehole so
as to completely fill it from bottom to top.
Permit #WI0800182 UIC/SQM-DX
ver. 10/2009
Page 2 of 6
8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material shall have a
galvanic potential as close as practicable to that of the tubing material.
9. Dry nitrogen shall be circulated through·the tub'ing during brazing to prevent oxidation.
10. After installation and prior to operation of the system, a mechanical integrity test shall be conducted by
pressurizing the injection well system to 400 psig with dry nitrogen and monitoring for leaks using an
ultrasonic or other leak detector of equal sensitivity and monitoring pressure in the system for at least 2
hours. Alternatively, an equivalent vacuum test is acceptable. Any pressure fluctuation other than that due
to thermal expansion and contraction of the testing medium shall be considered a failed mechanical
integrity test. Any leaks shall be located and repaired prior to charging the system with refrigerant.
11. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
12. Boreholes shall not connect separate aquifers or zones that have differences in water quality (e.g., shallow
surficial aquifers, saprolite, :fractured bedrock, etc.) as specified in 15A NCAC 2C .0213(d)(8)(C) and
shall be filled with b entoni te grout from the lowermost water bearing zone to land surface as specified in
the permit application.
13. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the
heating and cooling unit in a clearly visible location in accordance with 15A NCAC 2C .0213(g).
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, voiume 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.
Permit #W I0800182 UIC/SQM-DX
ver . 10/2009
Page 3 of 6
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number (919) 71.5-6166. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in complianc_e 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. Division 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.
Permit #WI080018:? UIC/SQM-DX
ver. 10/2009
Page 4 of 6
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section -UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
WilmingtoL Regi~mE:.J Office
127 Cardina'. Drive Extension
\Vilming:ton, NC 284e5:
(9l0j 796-7215
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the 'Wihnir.gton Reg ional Office within 30 days of
completion of well construction. Copies of the GW-1 form(s) shall also be given to the Permittee and
retained on site to be made available for inspection.
3. Mechanical integrity testing data required in Part II. IO of this permit shall be recorded on the attached
Mechanical Integrity Test Record form and submitted to the Aquifer Protection Section Central Office and
the \Viimington Ref,'J Onal Office at least 24 (twenty-four) hours prior to initial operation of the injection
facility. A copy of this fom1 shall also be retained on-site for inspection.
4. A copy of the site map updated with manifold locations required in Part II.11 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Wilmington Regional Office within 30
days of completion of well construction.
5. Documentation for change of well status as described in Parts IX.I and IX.2(G) of this permit.
6. 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.
7. The Pennittee shall report by telephone , within 48 hours of the occurrence or first knowledge of the
occurrence, to the Wilmington Regional Office, telephone number [phone], any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
8. Where the Pennittee 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.
9 . 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.
Perm it #\1\110800182 UIC/SQM-DX
ver. 10/2009
Page 5 of 6
PART VIII -PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior tb its expiration date.
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l).
Notification shall be submitted to the addresses given in Part VII.1 of this permit.
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 1 SA NCAC 2C
.0214, including but not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to msure 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 that extends to the bottom of the well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit #WI0800182 UIC/SQM-DX
ver. 10/2009
Page 6 of 6
Mechanical Integrity Test Record
(For SQM-DX Geothermal Heat Pump Injection Well System)
Owner/Permittee Name: ________ Permit Number: ~W;.a.1 _____ _
Facility Address: _____________________________ _
Home Phone: Cell Phone:
Heat Pump Contractor Name:
Office Phone: __________________ C=-e=l-=-1 P'-h:..:..;o:.:.n.:.:e:.:..: _________ _
Tester Name: _______________ Signature: ____________ _
Date of Test: ______ _
Loop Initial Pressure (psi) Final Pressure (psi) Duration (minutes) Pass (Yes or No)
1 I
2 I
3 I I
4 I I
5 I I
6 I I
7 I I I
8 I
9 I I
10 I
11 I
12 I
13 I
14
15
Add any additional testing data to back of this form
Comments: ____________________________________ _
Other Test Methods and Results:
This fonn shall be completed and signed by the tester. The record shall be received by Aquifer Protection
Section 24 hours prior to the initiation of the operation of the facility. You can send the form by fax to 919-
715-0588 or by mail to the following address:
5QM-DX Mechanical Integrity Test Record
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Page 1 of 2
Loop Initial Pressure (psi) Final Pressure (psi) Duration (minutes) Pass (Yes or No)
'
I
I
I
I
I
I I
I
I
5QM-DX Mechanical Integrity Test Record Page 2 of 2
Rogers, Michael
From: Stehman, Charles
Sent:
To:
Subject:
Attachments:
Friday, February 05, 2010 3:56 PM
Rogers, Michael
nondisstaffreport-1.doc
nondisstaffreport-1.doc
Attached is a staff report forWI0800182. My responses are in RED.
We did not visit the site because I have been to this location in the past. There was a house on the property at that
time. The drawing attached to the application, which is dated 08/04/09, indicates a "proposed dwelling" which looks
different from what I observed during my visit. I recommend issuance of the permit, however the array locations are
very close to the property boundary. I am not familiar with property boundary setbacks in Carteret county.
cfs
Charles F. Stehman, Ph.D.,P.G.
Environmental Progrnn1 SupeTvisor III
NC Division of Water Qualtiy, Aquifer Protection Section
Wilmington Regional Office, 127 Cardinal Drive Extension
Wilmington,N orth Carolina 28405
phone: [phone], fax: [phone]
DISCLAIJ'v1ER: 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
AQUIFER PROTECTION SECTION REGIONAL OFFICE STAFF REPORT
To: AQUIFER PROTECTION SECTION CENTRAL OFFICE
Central Office Reviewer:
Application No.: WI0800182
Permittee: Linda H. Robuck
Regional Login No.:
GENERAL INFORMATION
Project Name: same
County: Carteret
1. This application is (indicate all that apply}:
New Renewal Minor Modification Major Modification
Surface Irrigation Reuse Recycle
Evaporation/Infiltration Lagoon
503 Regulated 503 Exempt
Land Application of Residuals
Distribution of Residuals
Closed Loop Groundwater Remediation
2. Was a site visit conducted in order to prepare this report? Yes
a. Date of site visit:
b. Person contacted and contact information:
c. Site .,;,isit conducted by:
d. Inspection report attached: Yes No
High Rate Infiltration
Attachment B included
Surface Disposal
Other Injection Wells
No
3. Is the following information entered into the BIMS record for this application correct? Yes No
If no, please complete the following information or indicate that it is correct on the current
application .
For Treatment Facilities:
a. Location:
b. Driving directions:
c. USGS Quadrangle number and map name:
d. Latitude: 34 42' 10.96" Longitude: 76 48' 55.81"
e. Regulated activities/type of wastes: (e.g., subdivision, food processing, municipal
wastewater):
AQUIFER PROTECTION SECTION REGIONAL OFFICE STAFF REPORT
For Dis posal Sites:
(If multiple sites either indicate which sites the information applies to, copy and paste a new
section into the document for each site, or attach additional pages for each site)
a. Location(s):
b. Driving directions:
c. USGS Quadrangle map name and number:
d. Latitude: Longitude :
NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals
or minor modifications, skip to next section)
DESCRIPTION OF WASTE(S) AND FACILITIES
1. Please attach a completed rating sheet. Facility classification:
2. Are the new treatment facilities adequate for the type of waste and disposal system?
Yes No N/A If no, please explain:
3. Are the new site conditions (soils, topography, etc.) consistent with what was reported by the
soil scientist and/or professional engineer? Yes No N/A
If no, please explain:
4. Does the application (maps, plans, etc.} represent the actual site (property lines, wells,
surface drainage)? Yes No N/A If no, please explain:
5. Is the proposed residuals management plan adequate and/or acceptable to the Division?
Yes No N/A If no, please explain:
6. Are the proposed application rates for the new sites (hydraulic or nutrient) acceptable?
Yes No N/A If no, please explain:
7. Are the new treatment facilities or any new disposal sites located in the 100 year floodplain?
Yes No N/A If yes , please attach a map showing the areas of
the 100 year floodplain and explain and recommend any mitigative measures/special
conditions in Part IV:
8. Are there any buffer conflicts (new treatment facilities or new disposal sites}? Yes 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 the proposed or existing groundwater monitoring program (number of wells, frequency of
monitoring, monitoring parameters, etc.) adequate? Yes No N/A Attach
map of monitoring well network if applicable. Indicate review and compliance boundaries.
If No, explain and recommend any changes to the groundwater monitoring program. Attach
map of existing monitoring well network, if applicable, indicating the review and
compliance boundaries.
AQUIFER PROTECTION SECTION REGIONAL OFFICE STAFF REPORT
10. For residuals, will seasonal or other restrictions be required? Yes No N/A
If yes, attach list of sites with seasonal restrictions (Certification B?)
RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or
major modification systems)
DESCRIPTION OF WASTE($) AND FACILITIES
1. Is there an appropriately certified ORC for the facility? Yes No
Operator in Responsible Charge: Certificate # :
Back-up Operator : 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? Yes No If no, please explain:
3. Are the new site conditions (soils, topography, etc.) maintained appropriately and
adequately assimilating. the waste? Yes No If no, please explain:
4. Has the site changed in any way that may affect the permit (drainage added, new wells
installed inside the compliance boundary, new development, etc.). Yes No
If Yes, please explain:
5. Is the residuals management plan adequate and/or acceptable to the Division?
· Yes No If no, please explain:
6. Are the existing application rates (hydraulic or nutrient) still acceptable?
Yes No If no, please explain:
7. Is the existing groundwater monitoring program (number and location of monitoring wells,
frequency of monitoring, monitoring parameters, etc.) adequate?
Yes No N/A Attach map of existing monitoring well network if
Applicable. Indicate review and compliance boundaries. If No, explain and provide
recommended changes to the groundwater monitoring program:
8. Will seasonal or other restrictions be required for added sites? Yes
If yes, attach list of sites with restrictions (Certification B?)
No
9. Are there any buffer conflicts (new treatment facilities or new disposal sites)?
N/A
Yes No If yes, attach a map showing the 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?
Yes No If no, please explain:
11. Were monitoring wells properly constructed and located? Yes No N/A
If no, please explain:
12. Has the review of all self-monitoring data been conducted (GW, NDMR, and NDAR as
applicable)? Yes No Please summarize any findings from the review:
Compliance
AQUIFER PROTECTION SECTION REGIONAL OFFICE STAFF REPORT
13. Check all that apply: No compliance issues
Notices of violation within the last permit cycle
Current enforcement action(s)
Currently under SOC
Currently under JOC
Currently under moratorium
If any items are 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? Yes No N/A If no, please explain:
15. Are there any issues related to compliance/enforcement that should be resolved before
issuing this permit? Yes No If yes, please explain:
INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that
use injection wells, including closed loop groundwater remediation effluent injection wells, in situ
remediation injection wells, and heat pump injection wells.
Descri ption of well (s) and Facilities -New, Renewal , and Modification
1 . Type of injection system:
Heating/cooling water return flow (5A7)
Closed-loop heat pump system (5QM/5QW)
In situ remediation (51)
Closed-loop groundwater remediation effluent injection (SL nondischarge)
Other ( specify)
2. Does the system use the same well for water source and injection? Yes No
3. Are there any pollution sources that may affect injection? Yes No If yes, what
are the pollutant source(s) and distance(s) from the closest injection well:
4. What is the minimum distance of proposed injection wells from the property boundary?
2ft.
5. Quality of drainage at the site: Good Adequate Poor
6. Flooding potential of site: Low Moderate During Hurricanes High
7. For groundwater remediation systems, is the proposed and/or existing groundwater
monitoring program (number of wells, frequency of monitoring, monitoring parameters,
etc.) adequate? Yes No Attach map of monitoring well network if
applicable. If no, explain and recommend any changes to the monitoring program.
8. Does the map presented represent the actual site (property lines, wells, surface
drainage)? Yes No If no, or no map, please attach a map of the site
showing property boundaries, buildings, wells, potential pollution sources, roads,
approximate scale, and north arrow.
AQUIFER PROTECTION.SECTION REGIONAL OFFICE STAFF REPORT
In jection Well Permit Renewal And Modification Onl y:
1. For heat pump systems, are there any abnormalities in the heat pump or injection well
operation (e.g. turbid water, failure to assimilate injected fluid, poor heating/cooling)?
Yes No If yes, please explain:
2. For closed loop heat pump systems, has the system lost pressure or required make-up
fluid since permit issuance or last inspection? Yes No If yes, please
explain:
3. For renewal or modification of groundwater remediation permits, will
continued/additional/modified injections have an adverse impact on migration of the
plume or management of the contamination incident? Yes No If yes,
please explain:
4. Drilling contractor: Name
Address
Certification Number
5. Complete and attach well construction data sheet:
EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.
2. Attach well construction data sheet, as needed information is available. Not needed.
3. Do you foresee any problems with issuance/renewal of this permit? Yes No
If yes, please explain:
4. List any items that you would like t~e APS Central Office to obtain through additional
information request. Please provide a reason with each item.
5. List specific permit conditions that you recommend to by removed from the permit when
issued. Please provide a reason for each recommendation.
6. List specific special conditions or compliance schedules that you recommend to be
included in the permit when issued. Please provide a reason for each recommendation.
7. Recommendation:
Hold, pending receipt and review of additional information by the regional office;
Hold, pending review of draft permit by the regional office;
Issue
Deny If denied, please state reasons
Signature of report preparer: Charies F. Stehman
Signature of APS regional supervisor: Charles F. Stehman
Date: February 5, 2010
ADDITIONAL REGIONAL STAFF REVIEW ITEMS·
The proposed locations for the thermal well arrays (8 wells per each of two arrays) are extremely ciose to
the property boundary. This is not an issue with respect to our rules. However, Carteret County
ordinances may prohibit construction at these locations. I assume tho applicant or the cont,actor has
cleared this with the county
" C-*
+�"rrrrr�
NCDENR
North Carolina Qepallment of Environment and Natural Resources
uivisiori of Water Quality
Beverly Faves Perdue careen H Sullins
Governor Clirector
February 1.2010
Linda H. Robuck
6871 Greystone Dr,
Raleigh. NC 27615
Sul?iect: Acknowledgement of Application No. WI0800182
Linda H. Robuck SFR
Injection Mixed Fluid GSHP Well System (5QM)
Carteret
Dear Ms. Robuck:
Dee Freeman
Secretarl
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on January 13, ?010, This application package has been assigned the number Iisted 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 a -mail at rnichael.rogersCa�.ncdenr.gov. 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 organizational chart, go to litiT,:#h2o.enr.state. nc_usidocuntentsidw,� orvchart.rndf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQ[. MES ON THIS PRO.iECT
Since�ly,
NJ
for for Debra atts
Supervisor
cc: Wilmington Regional Office, Aquifer Protection Section
Marie Melton (Geo Design Group, Inc.; P.Q. Box 9, Middlesex, NC 27557)
Permit Application File W10800182
AOOEFEP, PROTECTION SECTiON
1636 Mao Service Center, Raleigh, North Carolina 276N-1636
LcGettorc 2728 Capital Boulevard, RsoMh. Norm Carolina 27644
Phone, 919.733.3221 , FAX 1� 919-715-0558; FAX 21, 912-71W48 t Castemer Sesvics• 1-877.623•674W
Int?met www,ncvvaleraual".ara
A n c4a'51 Cwcn ;[7i'y i .d.`hrrnl Ffte An an _Ripb ier
On:
T% of -,h Caroliria
Natuna illy

Dec. 29., 2009 11: 28AM Robuc k Homes No. 2519 P. 1
, NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A Wli1L(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FORi
TYPE 5 0 M WELL(S)
___ _,New Permit Application OR --~-Renewal (check one)
DATE: _______ , 20_
PERMIT NO. _______ (leave blank if NEW permit application)
A. PROPERTY OW$R.(S)/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/imthoriLy for signaturo); L {N.Jlt !l.&. J2\a(o(4_
(1) Mailing Address: h g ,J. I Cw <bfd-,, II c~ L M I t/.£..
City: ~!j 1h State: f.Jc._Zip Code: 2:1 t,IL County:
Hom.leNo.: 9161-8'?'1··l~'1li CellNo.: 9J'o/-11J-tJ30 J
EMML Address: ( 'hr0b~rni~ELt-.lj • CO fh.
(2) Physical Address of Site (if differentthan abovo); d i O ({)41:, /e.,d J,~ I 11 :<"'"
City: ~OJV~KJQ f /5.~·1u5 State: PC-Zip Code: _____ County: ____ _
Home/Office Tele No.: :£~ Clt>=:t~ Cell N,o.: ~
EMAIL Address;_~=-•-------------
B, AUfflORIZED .AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subjectpropecty,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
ConipanyName: ________________________ _
ContactPerson . .._: -----------~E-M=-A=IL~A=d=d=res=s~=---------
Address: ___________________________ _
City: ________ State: _Zip Code: _____ County: ______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: ____________ _
c.. STATUS OF APPUC.ANT
Private: :x: Federal:
State: Municipal:_
D, WELL DRILLER INFORMATION
OPU/UIC 5QM Well Permit Appliciiliou (Revis~ 7/2008)
Commercial:
Native American lands;
RECEIVED/ DENR / DWQ
Aquifer Protection Section
JAN 13 2010
Pagel
Dec. 29. 2009 11: 28AM Robuck Homes No. 2519 P. 2
Company Name: ~e,o ·ve&\~ n ~
Well Drilling Co11tractor's Na.me: Williaml3. Jefferson
NC Contractor Certification No.: 3971-A
Contact Person: mruv, e_ EMAIL Address: '(Y\f'ne\~\""\~ <ae.,c J)e&ibn [jn:n...r. ne..t
Address: PO BOX~
City; m,c\c\\e..-t;.e)l ZipCode: a'l50'7 County: °\',.\.OI.S'rl
Office Tele No.: JSa 1.l3.~-.;ia-c9 Cell No.: n/a
E, HEAT PUMP CONTRACTOR INFORMA'flON (if different than driller)
CompanyName: ·~e.,o ·-oe~-.;\~-0 G-n:,u~
Well Drilling Contractor's Name: William B. Jefferson
NC Contractor Certification No.: 397l"A
Contact Pei-son: l('{\OJ<\e-_ EMAILAddress: rn~ \•\-1:)(\e .5eocles6n~Yb~, ne....+
Address: {{)·13, q
City: •<'(\\&, \e.se.~ Zip Code: ;l.'1 i&S 1 County: ~ \-t
Office Tele No.: ~'59--Bi3S'·~09 Cell No.: n/a
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Geothetll!al HV AC with closed loop copper piping
G. WELL CONSTRUCTION ltATA (Skip to Section ll if this Is a Permit RENEW AL)
(I) Proposed date to be constructed: ,;l.\ \ ~ \ \ 0 Number of borings: / k,
Approximate depth of each boritlg (feet): 5 Gfo '70 1
(2) Chemical additives to bo used in closed-loop system (only those chemicals indicated have beou approved);
.JL. R-407C propylene glycol __ ethanol -~-----other (other additives will need prior
approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): Qq>~
(4) Well casing. Is the well(s) cased? (check either (a.) YES fil: ~low)
(a) YES ___ if yes, then provide casing information such as !JM (steel, PVC, plastic, etc.), diameter.
depth, and extent of casing appearing above ground: --------~------
(b) NO X
(5) Grout (material SUITOunding well casing and/or piping): r/
(a) Grout type: Cement__ Bentonite _L Other (specify)----~--
(b) Grout depth oftubing (reference to land surface): from .,._ to '1V (feet)
If well has casing. indicate grout depth: from _na_ to __ na __ (feet)
H. lNJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
-piping/tubing associated with the injectioo Operation. The manufucturer's brochure may provide supplernentllt)'
inf()Illlation.
I. LOCATION OF WELL(S)
GPU/OIC SQM Well Permit Application (Revised 712008) Page2
Dec. 29. 2009 11: 28AM Robuc k Homes No. 2519 P. 3
Attach two copies of maps showing the following infonnation:
(1) Includo a site map (can be drawn) showing; buildings, property lines, surface wat:er 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 inclu de a norlh arrow.
(2) Include a topographic inap of the area extending one mile from the property boundaries and
indicate the facility 's location and the map name.
J, POTABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties7 __ YES X-NO
If Yes, than indicate location on attached map(s).
K. CE:R.TIFICATION
Note: This Permit Application must be signed by um person appearing on the recorded legal propel'ty deed,
"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 theret.o and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, l believe that the information is true, accurate and complete.
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 Pennit."
~'tvi kl 9J ~ Signa ~fPropertyOwner/A Jicant
L1 tJM Id. '12 owvk.
Print or Type Full N~me -
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UICProgram
1636 Mail Service Center
Raleigh, NC 27699-163(;
Telephone [phone]
OPU/UlC SQM Woll Permit Application (Revl~td 7/2008)
RECEIVED/ DENR / owa
AquHer Protection Sedion
JAN 13 2010
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ConnectGIS Page 1 of 1
Parcels (Updated 1/05/2010)
OWNER: ROBUCK,LINDA PIN15: 635515634965000 HOUSE NUMBER (7
0000280 H Digit EX. 0000812):
STREET NAME: OAKLEAF
NEIGHBORHOOD
CODE: 530006 STREET TYPE: DR
CITY: PINE KNOLL ZIP: MAILING ADDRESS
SHORES
28512 HOUSE NUMBER:
MAILING MAILING ADDRESS MAILING ADDRESS ADDRESS STREET: STREET TYPE: DIRECTION:
MAILING
RALEIGH
MAILING ADDRESS
NC
MAILING ADDRESS
27609 ADDRESS CITY: STATE: ZIP:
MAILING
ADDRESS PO BOX: PO BOX 17102 TOTAL ACRES: 1.332 DEED DATE OLD: 0
DEED BOOK: 0649 DEED PAGE: 00340 TOWNSHIP: MOREHEAD
BEDROOMS: 0 BATHROOMS: 0 TOTAL SQUARE
FEET: 0
YEAR BUILT: CITY LIMIT: PINE KNOLL LEGAL L50 BW PINE 0
SHORES DESCRIPTION: KNOLL SHORES
FIRE DISTRICT: RESCUE DISTRICT: MOTHER: 0
CONDO_: PDOT: 4965 STRUCTURE VALUE: 0
LAND VALUE: 948246 TAX VALUE: 993245 OTHER VALUE: 44999
SALE PRICE: 0 BLT_CONDO: 0 PRID: 13038J0202
ROLL_TYPE: R Noise: aicuz:
Risk_level:
1:430 feet
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