WI0800248_GEO THERMAL_20161018

PAT MCCRORY
Govenmr
DONALD R. VAN DER VAART
Secreta,y
Water Resources
ENVIRONMENTAL QUALITY
S. JAY ZIMMERMAN
Vincent and Jennifer Lopez
113 Golf Terrace Dr.
Hampstead, NC 28443
October 18, 2016
Subject: Geothermal well sampling results
Permit Number WI0800248
Pender County
Dear Mr. and Mrs. Lopez:
Director
On August 31, 2016 staff from the Division of Water Resources sampled the influent and effluent from
your geothermal heat pump system's wells. 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 except for iron (Fe). Iron was present in both samples above
the State standard of 300 ug/L. Iron is a naturally occurring metal commonly found in groundwater in
this region. A copy of the lab results are enclosed for your review.
Should you have any questions concerning this letter, please feel free to contact me at [phone] or
by email at [e-mail].
RECEIVED/NCDEQ/DWR
OCT 2 5 2016
Water Q~ality Regional
Operations Section
Enclosure: sample results
cc: DWR-WiRO files
Shristi Shrestha, DWR Central Office
Sincerely,
~RA
Geoff Kegley
Water Quality Regional Operations Section
Wilmington Regional Office
Division of Water Resources, NCDENR
State ofNorfu Carolina I Department of Environmental Quality I Division of Water Resources
127 Cardinal Drive Ext., Wilmington, NC 28405
910 796 7215
50 11
AC32122 North Carolina Division of Water Resources Water Sciences Section Laboratory Results
Loc. Descr.: WI0800248-LOPEZ
County: FENDER Collector: G KEGLEY
Region: WIRD Report To WIRD
River Basin Collect Dale: 08131 /2016
Ernergenoy Called Time: 14:00
CDC Yes/No Sample Deplh
VOID
Location ID! WIRD NLC
Priority
Sample Main x- GROUNDWATER
Loc. Type- Water Supply
Final Report
Sample Id: AC32122
PO Number #
Date Received- 09/01/2916
Time Received: 08.20
Labworks LoglnID MSWIFT
0arwery Melr0d NC Courier
Final Report Date: 9128116
Report Print Date' 0912&+2016
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
Result/
CAS # Analoe Name PQL Qualifier
LAB
Sample temperature at receipt by lab 1.0
Lir s
'C
Method Analysis
Reference Date- Valldaled by
9/1/16 MSWIFT
MIC
Coliform, MF Fecal in liquid 1 1 B221
CFU1100m1 SM 9222 0-1997 911116 ESTAFFORD1
Coliform, MF Total in liquid 1 1 B2Q1 CFUI100m1 SM 9222 6-1997 9/1/16 ESTAFFOROI
NUT
NO2+NO3 as N in liquid 0.02 0.02 U mg/L as N EPA 353.2 REV 2 916116 CGREEN
WET
Bromide 0,4 0.4 U
mg/L
EPA 300.0 r v2.1 9/1/16 CGREEN
Chloride
1.0 10
mgfL
EPA 300.0 rev2.1 9/1/16 CGREEN
Fluoride
0.4 0.4 U
mg/L
EPA 300.0 rev2.1 9/1/16 CGREEN
Sulfate 2.0 2.0 U mg/L EPA 300.0 rev2.1 9/1/16 CGREEN
Total Dissolved Solids in liquid 12 286 mg/L SM 2540 C-1997 9/6/16 CGREEN
7440-224 Ag by ICPMS 1.0
MET
1.0 U ug/L EPA200.8 Rev5.4 9/12/16 ESTAFFORD1
7429-90-5 Al by IC P
50 50 U
ug/L
EPA200.7 Rev4.4 918/16 ESTAFFORD1
7440-36-0 Antimony by ICPMS 10 10 U ug/L
EPA 200.6 Rev5.4 916/16 ESTAFFORD1
744038-2 As by ICPMS
2.0 2.0 U
ug/L EPA200.6 Rev5-4 9/6/16 ESTAFFORD1
7440-38-3 Be by ICP 10 10 U ug/L EPA200.7 Rev4.4 918118 ESTAFFORD1
7440-41-7 Be by ICP 5.0
5.0 U ug/L EPA 200.7 Rev4.4 9i'9116 ESTAFFORD1
7440-70-2 Ca by ICP 0,10 86 mg/L EPA 200-7 Rev4_4 9/8116 ESTAFFORD1
7440-43-9 Cd by ICPMS
0.50 0.50 U
ug/L EPA 200.8 Rev5:4 9/6/16 ESTAFFORDI
7440-48-4 Cobalt by ICP
50 50 U ug/L EPA 200-7 Rev4.4 918116 ESTAFFORDI
7449.47-3 Cr by ICPMS
5.0 5.0 11 ug/L EPA 200.8 Rev5.4 9/6/16 ESTAFFORDI
7440-50-8 Cu by ICPMS
2.0 2.0 U ug/L EPA 200.8 Rev5.4 916116 ESTAFFORDI
7439-89-6 Fe by ICP
50 940
ug/L
EPA 200.7 Rev4.4 9/8116 ESTAFFORDI
7440--09.7 K by 1CP 0.10 1.7 mg/L EPA 200_7 Rev4.4 918116 ESTAFFORD1
7439-93-2 Li ICP
25 25 U ug1L EPA 200.7 Rev4.4 -918116 ESTAFFORDI
7438-95-4 Mg by. ICP
0.10 2.6
mg1L
EPA 200.7 Rev4.4 9/8/16 ESTAFFORDI
7439-96-5 Mn by ICP 10 33 ug/L EPA200.7 Rev4.4 918/16 ESTAFFORDI
7439-98.7 Ma by ICPMS
10 10 U ug/L EPA 200.8 Rev5.4 9/6/16 ESTAFFORD1
7440-23-5 Na by ICP 0.10 8.0 mg/L EPA 200.7 Rev4.4 918116 ESTAFFORD1
7440-02-0 Ni by ICPMS 2.0 2.1 ug/L EPA 20D.B Rev5.4 9/6/16 ESTAFFORD1
7439-92-1
Pb by ICPMS
2.0 2.0 U ug/L EPA200.8 Rev5.4 915I16 ESTAFFORDI
7782-49-2 Se by ICPMS 1.0
1.0 U ug1L EPA 200.8 Rev5.4 9/6116 ESTAFFORDI
WSS Chemistry Laboratory» 1623 Mail Service Canter, Raleigh, NC 27699-1623 [phone]
"Not Delecled" or "U'does not }ndlcate the sample is analyte free WI that the anatyte is not detected at or above the POL.
Page 1 of 2

'NC <'D~ La6oratory Section CR§sufts/Samp{e Comments/Qi;c1lifier <'Definitions
Samole ID: AC32122
CAS# Anal yte Name PQL Result/ Method Analy:sis
Qualifier Units Reference Date Validated by
7440-28-0 Thallium (Tl) ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 916/16 ESTAFFORD1
7440-62-2 V by ICP 10 10 U ug/L EPA 200. 7 Rev4.4 918116 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 10 U ug/L EPA 200.8 Rev5.4 9/6/16 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
"Not Detected" or "U" does not indicate the sample is analyte free but that the analyle is not detected at or above the PQL.
Page 2 of 2
AC32121 North Carolina Division of Water Resources Water Sciences Section Laboratoi1 Results
Loc. Dearr.: WI090s248-LOPET
County: PENDER Collector- G KEGLEY Vi itID
Region: WIRO Report fo WIRO Location ID: WiRO NLC
River Basin Coliact Date: 08/31/2015 Priority ROUT1N6
Emergency Collect Time: 14115 Sample Meld : GROUNDWATER
COC YesiNo Semple Depth Loc. Type- Water Supply
Final Report
Sample 113_ AC32121
PO Number #
Date Received: 0910112015
Time Received: 08:20
Labworks LoginlO MSWIFT
❑etivery Method NC Courier
Final Report Date: 9128t14
Report Pnnt Date: 09►2SI2916
!f this report Is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
CAS # Ana to Name
Sample temperature at receipt by lab
POL
Result/
Qualifier
LAB
1.0
Units
°C
Method Analysis
Reference Cate Validated by
9/1716 MSWIFT
Conform, MF Fecal in liquid
1
MIC
1 8201 CFU1100m1 SM 9222 D-1997 9/1/16 ESTAFFORDI
Conform, MF Total in liquid
1 1 8201
CFU/100m1 SM 9222 B-1997
9/1115 ES-1AFFORD!
NO2+NO3 as N in liquid
0.02
NUT
0.02 U
mg/L as N EPA353.2 REV 2 9/8/16 CGREEN
Bromide
WET
0.4 0.4 U mg/L EPA300.0 rev2.1 9/1/16 CGREEN
Chloride
1.0 j[} mg/L EPA 300.0 rev2 1 9/1/16 CGREEN
Fluoride
0.4 0,4 U mg/L
EPA300.0 rev2.1 9/1116 CGREEN
Sulfate
2.0 2.0 U mg/L EPA 300.0 rev2.1 9/1/16 CGREEN
Total Dissolved Solids in liquid
12 279 mg/L 5M 2540 C-1997 9M/16 CGREEN
7440-22-4 Ag by ICPMS
MET
1.0 1.0 U ug/L EPA 200.8 Rev5.4 9/12/16 ESTAFFORD1
7429-90-5 Al by ICP
50 50 U ug/L EPA 200.7 Rev4.4 918116 ESTAFFORDI
7440.35-0 Antimony by ICPMS
10 10 U ug/L EPA 200.8 Rev5.4 916/16 ESTAFFORD1
7440-38-2 As by ICPMS
2.0 2.0 U ug/L EPA 200.8 Rev5.4 9/6116 ESTAFFORDI
7440-38-3 by 1CP
10 1 D U ug/L EPA 200.7 Rev4.4 918/16 ESTAFFORDI
7440.41-7 Be by ICP
5.0 5.0 U ug/L EPA200.7 Rev4.4 9/9/16 ESTAFFORD1
7440-70-2 Ca by ICP
0.10 88 mg/L EPA 200.7 Rev4.4 918116 ESTAFFORD1
7440.43.9 Cd by ICPMS
0.50
0.50 U ug/L
EPA 200.8 Rev5.4 918116 ESTAFFORD1
7440.48-4 Cabatt by ICP
50 550 U ug/L EPA 200.7 Rev4.4 9/8/16 ESTAFFORD1
7440-47-3 Cr-by ICPMS
5.0 5.0 U
ug/L
EPA200.8 Rev5A 9/6/16 ESTAFFORD1
7440-50-8 Cu by 1CPMS
2.0 2.2
ug/L
EPA200,8 Rev5.4 9/6/16 ESTAFFORD1
7439-89-6 Fe by ICP
50 940 ug/L EPA 200.7 Rev4.4 918116 ESTAFFORD1
7440-09-7 K by ICP
0.10 1.6 mgli. EPA 200.7 Rev4.4 918116 ESTAFFORD1
7439-93-2 Li ICP
25 25 U j ug/L EPA 200,7 Rev4.4 9/811 5 ESTAFFORD1
7439-95-4 Mg by ICP
0.10 2.8 mg/L EPA 200,7 Rev4.4 9/8116 ESTAFFORD1
7439--96-5 Mn by ICP
10 33 ug/L EPA200.7 Rev4.4 9/8116 ESTAFFORD1
7439.98-7 MO by ICPMS
10 10 U uglr_ EPA200.8 Rev5.4 9/6/16 ESTAFFORD1
7440-23-5 Na by ICP
0.10 8.2 mg&L EPA290.7 Rev4.4 9/8/16 ESTAFFORDI
7449-02-0 Ni by ICPMS
2.0 2.2 ug►L EPA 200.8 Rev5.4 9/6/16 ESTAFFORD1
7439-92-t
Pb by ICPMS
2.0 2.0 U ug/L EPA 200:8 Rev5.4 918/16 ESTAFFORD1
7782-49-2 Se by ICPMS
1.0 1.0U
ug/L
EPA200.8 Rev5.4 918116 ESTAFFORD1
WSS Chemistry Laboratory»- 1623 Mail Service Center, Raleigh, NC 27699-1823 t919S 733-3908
"Not Detected" cc 'U" does not indicate the sample is anatyte free but that the enalyte is not detected at or above the PQL.
Page 1 of 2

:NC <D'Wl{ La6oratory Section !J?§surts/Samp{e Comments/Qu,ififier {i)efinitions
Sample ID: AC32121
CAS# Anal yte Name PQL Result/ Method Anal:tsis
Qualifier Units Reference Date Validated by
7440-28-0 Thallium (Tl) ICPMS 2.0 2.0 U ug/L EPA 200.8 Rev5.4 9/6/16 ESTAFFORD1
7440-62-2 V by ICP 10 10 U ug/L EPA 200.7 Rev4.4 9/8116 ESTAFFORD1
7440-66-6 Znby ICPMS 10 10 U ug/L EPA 200.8 Rev5.4 9/6/16 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
"Not Detecled" or "U" does not indicate the sample is analyte free but that the analyte is not detected at or above the PQL.
Page 2 of 2
Permit Number
Program Category
Ground Water
Permit Type
WI0800248
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Vincent Lopez SFR
Location Address
113GolfTerDr
Hampstead
Owner
Owner Name
Vincent
Dates/Events
NC
Orig Issue
8/12/2011
App Received
7/15/2016
Re gulated Activities
Heat Pump Injection
Outfall
Waterbody Name
28443
Lopez
Draft Initiated
Scheduled
Issuance Public Notice
Central Files : APS SWP
9/20/2016
Permit Tracking Slip
Status
Active
Version
2.00
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Chris Deal
Drill er Well
9124 Old River Rd
Burgaw NC 28425
Major/Minor
Minor
Region
Wilmington
County
Pender
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Vincent Lopez
113 Golf Ter Dr
Hampstead
Issue
9/20/2016
Effective
9/20/2016
NC 28443
Expiration
8/31/2021
Requested !Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
7/19/16
9/12/16
Subbasin
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Water Resources
ENVIRONMENTAL QUALITY
September 20, 2016
Vincent & Jennifer Lopez
113 Golf Terrace Dr.
Hampstead NC 28443
Re: Issuance of Injection Well Permit
Permit No. WI0800248
Geothermal Heating/Cooling Water Return Well
Pender County
Dear Mr. and Mrs. Lopez:
Secretary
S. JAY ZIMMERMAN
Director
In accordance with your permit renewal application received July 15, 2016, I am forwarding Permit
No. WI0800248 for the continued operation of geothermal heating/cooling water return well(s) located
at the above referenced address. This renewed permit shall become effective on September 20, 2016
until August 31, 2021, 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 31, 2016. Laboratory analytical results will be forwarded to you
by Wilmington Regional Office 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].
Best Regards,
Shristi Shrestha
Underground Injection Control (UIC)-Hydrogeologist
Division of Water Resources, NCDEQ
Water Quality Regional Operations Section
State ofNorth Carolina I Environmental Quality I Water Resources
161 I Mail service Center I Raleigh, North Carolina 27699-1611
919 707 9000
cc: Jim Gregson -Morella King-Sanchez, Wilmington Regional Office
Central Office File; WI0800248
Pender County Environmental Health Department
Page 2 of2
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
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
Vincent & Jennifer Lopez
FOR THE CONTINUED OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defmed in Title 15A North Carolina Administrative Code 02C .0224(a), which will be used
for the injection of heat pump effluent. The injection well(s) located at 113 Golf Terrace Drive, Hampstead,
Pender County, NC 28443 will be operated in accordance with the application submitted July 15, 2016, and in
conformity with the specifications and supporting data all of which are filed with the Department of
Environmental Quality and are considered a part of this permit.
This permit is for continued operation 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 August 31, 2021, and shall be
subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 20th day of September 2016.
J1 S. Jay Zimmerman, P.G. 1 ' Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Pennit#WI0800248 UIC/5A7
ver. 11/15/2015
Page 1 of5
PART I -PERMIT GENERAL CONDITIONS
1. The Permittee shall 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). 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 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 the requirements of rule ISA NCAC 02C .0107 except as required in Item #2 below.
2. Any injection well shall be constructed in accordance with the requirements of rule ISA 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 [ISA 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.
[ISA NCAC .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 [ISA NCAC 02C .0224(d)(4)].
5. Each 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 well shall have permanently affixed an identification plate [15A NCAC 02C .0107(j)(2)].
Permit#WI0800248 UIC/5A7
ver. 11/15/2015
Page 2 of5
7. A completed Well Construction Record (Form GW-1) shall be submitted as described in Part V.5 of this
permit.
PART ID -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 the rules of 15A NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C .021 l(j)].
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 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 .021 l(k)]
L 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 samples of 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 [ISA NCAC 02C
.0224(f)(l )].
3. The Permittee shall report any monitoring or other information that indicates noncompliance with a specific
permit condition, that a contaminant may cause a violation of applicable groundwater quality standards, or
that a malfunction of the injection system 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.
(B) Written notification shall be made within five days of the occurrence and submitted to the addresses
in Item #5 below.
Permit#WI0800248 UIC/5A7 .
ver. 11/15/2015
Page 3 of5
(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
which 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 an application for permit renewal shall be made at least 120 days prior to the expiration
date of the permit. This permit condition does not apply if the Permittee chooses to discontinue operation
of the well for injection of effiuent 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 permanently abandon that injection well in accordance with the procedures specified in 15A
NCAC 02C .0113(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
such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected prior to sealing in accordance with rule 15A
NCAC 02C .011 l(b)(l)(A), (B), and (C).
Permit #WI0800248 UIC/5A7
ver. 11/15/2015
Page4 of5
(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.
(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.
5. The written documentation required in Part VII (4)(F) shall be submitted to the addresses specified in Part
V.5 above.
Permit#WI0800248 UIC/5A7
ver. 11/15/2015
Page 5 of5
North Carolina Department of Environmental Quality -Division of Water Resources
WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
Permit No. WI0800248
Date: 9/1/2016
To: Shristi Shrestha
Central Office Reviewer
County: Carteret
Permittee/Applicant: Vincent & Jennifer Lopez
Facility Name: __________ _
L GENERAL INFORMATION
1. This application is (check all that apply): 0 New IZI Renewal
0 Minor Modification D Major Modification
a. Date of Inspection: 8/31/2016
b. Person contacted and contact information: Mr. Lo pez: lo pezv123 yahoo.com
c. Site visit conducted by: GeoffKegle v
d . Inspection Report Printed from BIMS attached: D Yes fZI No.
e. Physical Address of Site including zip code: 113 Golf Terrace Dr, Hampstead, NC 28443
f. Driving Directions if rural site and/or no physical address: __
g. Latitude: 34 23 08.18 N Longitude: 77 40 44.24 W
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:
C8J Geothermal Heating/Cooling Water Return
□ In situ Groundwater Remediation
RECEIVED/NCDEQ/DWR
SEP 12 2016
D Non-Discharge Groundwater Remediation
D Other (Specify: _ __.)
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system only:
Water Quality Regional
Operations Section
Were samples collected from Influent/Effluent sampling ports? IZI Yes D No .
Provide well construction information from well tag:
b. Does existing or proposed system use same well for water source and injection? D Yes IZI 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 IZI 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: IZI Good D Adequate D Poor
6. Flooding potential of site: IZI Low D Moderate D High
WQROS StaffReportRev. 4/15/2016 Page I
7. For Groundwater Remediation Injection SZ sterns on1}, is the proposed and/or existing groundwater monitoring
program (number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ 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)? ❑ Yes ❑ 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 prefix):
a. Are the treatment facilities adequate for the type of waste and disposal system? ❑ Yes ❑ No ❑ N/A.
If No, 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? ❑ Yes ❑ No ❑ N/A. If no, please explain:
III. EVALUATION AND RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® 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
0 Deny. If Deny, please state reasons:
❑ Hold pending receipt and review of additional information by Regional Office
❑ Issue upon receipt of needed additional information
® Issue
5. Signature of Report Preparer(s); 1B ��J t
Signature of WQROS Regional Supervisor: L IL
Date: 0 9/° // t9 O '
WQROS Staff Report Rev. 4/15/2016 Page 2

IV. ADDITIONAL REGIONAL STAFF REVIEW COMMENTS/ATTACHMENTS (Optional I /[Needed)
This review was conducted for a permit renewal request for a geothermal injection well heat pump
system for the Lopez residence. On _August 31, 2016, 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, sulfate and total dissolved solids. Sampling results will be forwarded to
the Central Office and owner when received from laboratory. System operation has been normal.
WQROS Staff Report Rev. 4/15/2016 Page 3
WATER Q UALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE QUEST FORM
Date: July 19 2016
To: Jim Gregson -Morella Sanchez -King
From: Shristi Shrestha, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0800248
A. Applicant: Vincent and Jennifer Lopez
B. Facility 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 W OROS 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-W OROS Reviewer: __________________ Date: _____ _
COMMENTS:
NOTES:
Please try to get a copy of GW-1 if it exists.
FORM: WQROS-ARR ver. 092614 Page 1 of 1
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
July 19, 2016
Vincent and Jennifer Lopez
113 Golf Terrace Dr.
Hampstead NC 28443
RE: Acknowledgement of Application No. WI0800248
Geothermal Heating/Cooling Water Return Well
Pender County
Dear Mr. and Mrs. Lopez:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on July 15, 2016. 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 60 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].
cc: Wilmington Regional Office, WQROS
Permit File WI0800248
Sincerely,
For Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch Division of Water
Resources
State of North Carolina I Environmental Quality I Water Resources
1611 Mail service Ccutcr I Raleigh, North Caroliua 27699-1611
919 707 9000
Director
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 Application _x_kenewal* __ 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: July 15, 2016 PERMIT NO. WI0800248 (leave blank if New Application)
A.
8.
CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as 181 Geothennal 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 weH and you wish to
rescind the pennit, check the box below. If abandoned, attach a copy of the We11 Abandonment
Record (GW-30).
0 Yes, I wish to rescind the pennit
2. Current Ownership Statu$
Has there been a change of ownership since pennit last issued? D YES 12:1 NO
If yes, indicate New Owner's contact information:
Name(s): Vincent Lopez
Mailing Address: 113 Golf Terrace Drive
City: Hampstead State: NC Zip Code: 28443 County: Pender_
Day Tele No,: 201-280-5507 Email Address: [e-mail]
STATUS OF APPLICANT (cb()OSe one)
Non-Government: Individual Residence X Business/Organization __
Government: State t--Municipal__ County __ Federal
RECEIVED/NCDEQ/DWR
JUL 1 5 7016
Wate; 1.: •
Regional Opera,,0;1:;, S0 .. ;,1
C. WELL OWNER(S)/PERMJT APPUCANT -For single family residences, list all persons listed on the
property deed. For all others, list name of business/agency and name of person and title with delegated
authority to sign: Vincent & Jennifer Lopei
Mailing Address: 113 Golf Terrace Drive
City: Hampstead State: NC Zip Code: 28443 County: Pender
Day Tele No.: NA Cell No.: 201-280-5507 or 201-321-1172
EMA1L Address: [e-mail] or [e-mail] FaxNo.:NA
Geothermal Water Return Well Permit Application Rev. 4--15-2016 Page 1
D. WELL OPERA TOR (if different from well own,r) -For single family residences, list all persons listed on
the property deed. For all others, list name busit!tess/agency and name of person and title with delegated
authority to sign: ---------------------------
E.
Mailing Address: 113 Golf Terrace Drive
City: Hampstead State: NC Zip Codi: 28443 County: Pender
Day Tele No.: 201-280-5507 or 201-321-1172 Email Address.: [e-mail]
[e-mail]
PHYSICAL LOCATION OF WELL(S) SITE
(l) Parcel Identification Number (PIN) ofwell
0
site: 3293-83-5966-0000 County: Pender
(2) Physical Address (if different than mailing ~ddress):
113 Golf Terrace Drive
City: Hampstead County: Pender Zip Code: 28443
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)
HVAC Contractor's Name: _________________________ _
NC HV AC Contractor License No.: ____ __,_ _________________ _
Company Name: ____________________________ _
Contact Person""': ----------'--___ EMAIL Acldress:. _____ ~--------
Address: _____________ '--------------------
City: ___ _ ____ Zip Code: ----State: __ County: ________ _
Office Tele No.: Cell No(: Fax No.:. ______ _ ------------------
B. WELL USE Will the injection well(s) also be used as the supply well{s) for the following?
(l) The injection operation? ;YES ____ NO ___ _
(2) Personal consumption? YES ____ NO ___ _
L WELL CONSTRUCTION REQUIREMENTS..;. As specified in 1 SA NCAC 02C .0224(d):
(1) The water supply well shall be coastructed in accordance with the water supply well requirements of
ISANCAC 02C .0107. 1
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page2
(2) If a separate well is used to inject the heat pi,lmp effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
(a) For screen and gravel-packed wells, the entire length of casing shall be grouted from the top
of the gravel packto land surface; .
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casmg
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 injecti,on.
i
J. WELL CONSTRUCTION SPECIFICATIONS j
(1) Specify the number and type of wells to be bsed for the geothennal heating/cooling system:
_ __,._ ___ *EXISTING WELLS _______ PROPOSED WELLS
*For existing wells, please attach a copy o/the Well Construction Record (Form GW-1) if available.
'
(2) Attach a schematic diagram of each water s~pply and injection well serving the geothermal
heating/cooling system. A single diagram dan be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguisµes each welt from one another.
i
Each diagram shall demonstrate complian~ 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 scree.n fy'Jbe, thickness, and diameter
(c) Casing depth below land ~rface
( d) Casing height "stickup" ali>ove land surface
i
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts ar~ prohibited/or sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(/)(8)
i
(f) Length of well screen or dpen borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERA.TING DATA I
(I) Injection Rate: Averagekdaily) _~_,,,gallons per minute (gpm).
(2) Injection Volume: Averagekdaily) gallons per day (gpd).
'
(3) Injection Pressure: Averagei(daily) __ pounds/square inch (psi).
(4) Irijection Temperature: Average,(January) ° F, Average (July) __ ° F.
L. SITE MAP-As specified in 15A NCAC 02C .0224@(4). attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specifif!d features from the injection well(s). The site map shall
include the following: !
(1) All water supply wells 1 surface waiter bodiis, 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 ofcontaminati~n listed in ISA NCAC 02C ;0107(a)(2) located within 250
feet of the proposed in)ection well(s).
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page3
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection wells) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
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
welts, 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)
15A NCAC 02C .021 I{e) 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 personl`sJ listed on the property deed,
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of Iaw, that l have personally examined and am familiar with the information
submitted in this document and ail 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 w' e proved specifications and conditions of
the Permit,"
Vincent Lovez
Print or Type Full Name and Title
kr�` is
ignaVi tre oi,
'r
_Fenn if pez
Print or Type Full Name and Tidy
:ar{l
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 -
Water Quality Regional Operations Section (WOROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 4-15-2016 ge4

GEOTHERMAL HEATINGCCOOLLNG WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxes. Fill in depths below land surface (BLS) and
details ofwell construction on the blank lines provided Use additional sheets as needed.
O en -Hole Well Design
Proposed ❑ Existing
❑ Injection; E Supply;
❑ Dual Purpose
doll itirfac
Record Depths Below
Land Surface (BLS)
an Lines Provided
Bottom of casing
(Ft. BLS)
Total Depth
(Ft BLS)
(Ft)
Screened Well Design
❑ Proposed ❑ Existing
❑ Injection; ❑ Supply;
❑ Dual Purpose
Return or Supply Line
Casing
Grout
WELL DETAILS
Casing Material:
Casing Diameter (in.):
Grout Type:
Grout Depth (BLS): -
Top of Bentonite Seal (if present):
Bottom of Bentonite Seal
Screen Material:
Screen Slot Size (in.): - - — -
Sand/Gravel Pack
Material Type:
Bedrock
Open Hole
Bentonite Seal
(tfpresent)
Sand/Gravel Pack
Screen
■
(ft.)
■
Record Depths Below
Land Surface (BLS) on
Lines Provided
(Ft BLS)
(Ft. BLS)
i3ottem of casing
(Ft. BLS)
(Total Depth
Ft BLS)
NC Certified Well Driller Name:
Certification No.:

PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Water Resources
ENVIRONMENTAL QUALITY
June 6, 2016
CERTIFIED MAIL # 7015 1520 0000 7838 3866
RETURN RECEIPT REQUESTED
Vincent Lopez
113 Golf Ter Dr.
Hampstead NC 28443
Subject: Notice of Expiration (NOP)
Geothermal Water Return/Open-Loop Injection Well
Permit No. WI0800248
Pender County
Dear Mr, Lopez:
Secretor',
S. JAY ZIMMERMAN
Director
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 August 12, 2011, and expires on July 31, 2016. 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 Currently Seine Used for Injection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 1 SA, 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
http:llportal.ncdenr.org/web/wq/aps/gwpro/permit-applications.
If Your Geothermal Water Return Well is NO LONGER Seine Used for Injection:
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.
State of North Carolina 1 Environmental Quality I Water Resources
!6t 1 Mail service Center I Raleigh, North Carolina 27699-I611
919 707 9000

Page 2 of'2,
If There has been a Change of Ownership of the Property:
If there has been a change of ownership of the property, an "Injection Well Permit
Namc/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
LiIC 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
[phone] or by email at shristi_shresthaicenedenr.gov_
Regards,
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
co: Wilmington- Regional Office — WQROS w/o enclosures
Central Files - Permit No. WI0800248 w/o enclosures

71315 1520 0000 7838 3866
U.S. postal Service'
CERTIFIED MAIL® RECEIPT
Domestic ?hei1 only
For delivery information, visit our website at www.usps.com".
Certified Mall Fee
FXt R Serves & Fees [coeckdar,, add kneaaapw nrfeae)
❑seta n RocelPt RuwCoPY} S
❑ Ronan Racelpr (vIRcfonfc) $
❑ Grui1 Mail Rw,raS J 043EvEny $
❑ Aa,:lt $ gearura Flagged
❑Adult Stgruuae Restrlctud Delkcry $ _
Passage
Toth) Po
Vincent Lopez
senrro 113 Golf Ter Dr
Sfreet EilHampstead NC 28443
CIF al:
Postmark
Hare
PS Farm : GO, p! r Pew ruEs-oz-vea- F7 See Reverse lot Instructions

Permit Number
Program Category
Ground Water
Permit Type
WIO8O0248
Injection Heating/Cooling Water Return Well (5A7)
Primary Reviewer
michael. rogers
Coastal SW Ru le
Permitted Flow
Facilitv
Facility Name
Vincent Lopez SFR
Location Address
113 GolfTer Dr
Hampstead
Owne:
Owner Name
Vincent
Dates/Events
C
NC 28443
Lopez
Orig Issue
08/12/11
App Received Draft Initiated
08/01/11
Scheduled
Issuance
Central Files: APS_ SWP_
08/17/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Chris Deal
Driller Well
9124 Old River Rd
Burgaw
Major/Minor
Minor
NC
Region
Wilmington
County
Pender
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Vincent Lopez
113 Golf Ter Dr
Hampstead
Public Notice Issue
08/12/11
NC
Effective
08/12/11
28425
28443
Expiration
07/31/16
c...R.;;.ce-"a'-'-u-"'!a;;,;_t;;,;;;e...;;.d;...;;A....cc;;_tcc..iv_i_ti"'e---"s----------------.:..;R:..:e:.:o:..::u:..:e:.:s..:.;te:..:d::.:c/-'-'R.,.e:..::c:..::ec:...iv..,e:e,:d=--=E..:.v=-e,.,_nt""s:,__ _________ _
Heat Pump Injection Additional information requested
Outfall NL
Waterbody Name
RO staff report requested
RO staff report received
Additional information received
Stream Index Number Current Class
08/02/11
08/04/11
08/08/11
08/08/11
Subbasin
Permit Number WI0800248
Program Category
Ground Water
Permit Type
Injection Heating/CoolingWater Return Well (5A7)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Vincent Lopez SFR
Location Address
113 Golf Ter Dr
Hampstead
Owner
Owner Name
Vincent
Dates/Event!r
NC 28443
Lopez
Orig Issue App Received Draft Initiated
08/01/11
Re a ulated Activities
Heat Pump Injection
Outfall r,1LJLL
Scheduled
Issuance
Central Files: APS_ SWP_
08/09/11
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Chris Deal
Driller Well
9124 Old River Rd
Burgaw NC
Major/Minor
Minor
Region
Wilmington
County
Pender
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Vincent Lopez
113 GolfTer Dr
Hampstead NC
Public Notice Issue Effective
Reauested/Received Events
RO staff report requested
RO staff report received
28425
28443
Expiration
08/04/11
08/08/11
Waterbody Name Stream Index Number Current Class Subbasin
ATA
NCDEN R
North Carolina Department of Environment and Natural Resources
Division of Water Duality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
August 12, 2011
Vincent Lopez
113 Golf Terrace Dr.
Hampstead, NC 28443
Re: Issuance of Injection Well Permit
Permit No. WI0800248
Issued to Vincent Lopez
Pender County
Dear Mr. Lopez:
In accordance with your application received August 1, 2011, I am forwarding Permit No. W10800248 for the
operation of a 5A7 geothermal underground injection control (UIC) well heat pump system located at the
above referenced address. This permit shall be effective from the date of issuance until July 31, 2016, and
shall be subject to the conditions and limitations stated therein.
Please contact Jim Bushardt with the Wilmington Regional office at 910-796-7215 within 30 days after the
geothermal system becomes fully operational with influent and effluent sampling ports. Water samples will
then be collected, and sent to the Division of Water Quality's laboratory for analysis. Results will be
forwarded to you when received by the regional office.
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
Quality. If you have any questions regarding your permit or the Underground Injection Control Program
please call me at [phone].
Best Regards,
Michael Rogers, P.G_ (NC
Environmental Specialist
cc: Art Barnhardt, Wilmington Regional Office
Central Office File - W10800248
Pender County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1836 Mail Servi:k Cenie:, Raeigh. North Carolina 27699.1636
Location: 2728 Capital Boulevard, Raleigh. North CarolrnE 27804
Phone:[phone]FAZ 1 919-715-058B: FAX 2: 91S-715 6O48 customer Service: 1-S77-523.6746
Internet rww.nswatemgalitv.ar•.'.
Fn Eau Rf,n 1ouer
.N6rtb Carolina
E' r i.�i•id..i �4r.e•1�.

' . 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
Vincent Lopez
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 113 Golf Terrace Dr., Hampstead, Pender County, NC 28443. and will be
constructed and operated in accordance with the application received August 1, 2011, and in conformity with
the specifications and supporting data submitted, all of which are filed with the Department of Environment and
Natural Resources and are considered a part of this permit.
This permit is for operation of an injection well 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 July 31, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through VIII hereof.
~
Pennit issued this the \l day of_..,.~'--+------' 2011.
Dh l 0th Y' Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0800248 UIC/SA7
ver. 03/2010
Page 1 of 5
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 sealed with a water-tight cap or well sealed, 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
.0213(g).
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 Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local , state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of · this permit does not imply that all
regulatory requirements have been met.
4. 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.
Permit #V/10800 2.48 UIC/SA7 Page 2 of 5
ver. 03/2010
.
PART III-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART IV -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
PART V -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 VI-MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
Permit #WI08Cl0748 UIC/SA7 Page 3 of .5
ver. 03/2010
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Wilmington Regional Office, telephone number 704-663-1699, 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;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VII -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 to its expiration date.
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 .0213(h)(l), Well
Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
Permit #WI0800248 UIC/SA7
1;1er. 03/2010
Page 4 of 5
(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
l SA NCAC 2C .02 l 3(h)( 1) within 30 days of completion of abandonment.
• 3. The written documentation required in Part VIII (1) and (2) (G) shall be submitted to:
Permit #W!080G2L:8
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
UIC/5A7
ver. 03/2010
Page 5 of 5
AQUIFER PROTECTION SECTION REGIONAL OFFICE STAFF REPORT
To: AQUIFER PROTECTION SECTION CENTRAL OFFICE
Central Office Reviewer: Michael Rodgers
Application No.: WI0800248
Permittee: Vincent Lopez
Regional Login No.: lopezwell.811
GENERAL INFORMATION
Project Name: same
County: Pender
1. This application is (indicate all that apply):
X New Renewal Minor Modification Major Modification
Surface Irrigation Reuse
Evaporation/Infiltration Lagoon
503 Regulated 503 Exempt
Recycle
Land Application of Residuals
Distribution of Residuals
Closed Loop Groundwater Remediation
High Rate Infiltration
Attachment B included
Surface Disposal
X Other Injection Wells
2. Was a site visit conducted in order to prepare this report? X Yes No
a. Date of site visit: 08/04/2011
b. Person contacted and contact information : Chris Deal 604-0624 , Michael Lopez 259-5808
c. Site visit conducted by : Jim Bushardt
d. Inspection report attached: Yes X No (see report summary)
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 : 113 Golf Terrace Drive, Hampstead
b. Driving directions :
c. USGS Quadrangle number and map name : Hampstead, NC
d. Latitude: 34 .23.08 Longitude: 77.40.43
e. Regulated activities/type of wastes : (e .g ., subdivision, food processing, municipal
wastewater): HVAC injection well
RECEIVED I DENR / DWQ
AOUIFl=R ·PROTFr.T/ON SECTION
AUG O 8 7.0H
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. f',ttach
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
If yes, attach list of sites with seasonal restrictions (Certification B?)
No N/A
RENEWAL AND MODIFICATION APPLICATIONS (use previous section for new or
major modification systems)
DESCRIPTION OF WASTE(S) 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 NIA
9. Are there any buffer conflicts (new treatment facilities or new disposal sites)?
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 NIA
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 JOG
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 , JOG, etc. been
complied with? Yes No NIA 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:
X Heating/cooling water return flow (5A7)
Closed-loop heat pump system (5QM/5QW)
In situ remediation (51)
Closed-loop groundwater remediation effluent injection (5L nondischarge)
Other (specify)
2. Does the system use the same well for water source and injection? Yes X No
3. Are there any pollution sources that may affect injection? Yes X No If yes, what are
the pollutant source(s) and distance(s) from the closest injection well : existing well is 105
ft from sanitary sewer, 36 ft from house foundation, 20 ft from back yard shed (portable
type with no permanent foundation).
4 . What is the minimum distance of proposed injection wells from the property boundary?
Approx 10 ft
5. Quality of drainage at the site: Good X Adequate Poor
6. Flooding potential of site: X Low Moderate High
Back yard location has topography and well head area should not impound stormwater.
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.n/a
AQUIFER PROTECTION SECTION REGIONAL OFFICE STAFF REPORT
8. Does the map presented represent the actual site (property lines, wells, surface
drainage)? Yes X 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. No topographic map provided , but visual observation
shows adequate drainage capability around existing well head.
In jection Well Permit Renewal And Modification Only :
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.This report is
being prepared based upon an application to reconfigure an irrigation well into an
injection well to support a water to air heat pump system. The existing well was installed
in 2001 into the Castle Hayne (confined) aquifer approximately 85 ft BLS. The well has a
concrete apron and is grouted to an undetermined depth. There are no buffer issues with
this existing well. The applicant will install a water supply well into the Pee Dee (confined)
aquifer, approximately 180 ft BLS . It will not require well construction permitting.
Therefore, the applicant will be creating a comingled aquifer condition . However, the
Castle Hayne aquifer is more salty than the Pee Dee and the writer does not see any
adverse issue with placing Pee Dee aquifer water into the Castle Hayne aquifer.
2. Attach well construction data sheet, as needed information is available. N/A
3. Do you foresee any problems with issuance/renewal of this permit? Yes X No
If yes, please explain:
4 . List any items that you would like the APS Central Office to obtain through additional
information request. Please provide a reason with each item . None
5. List specific permit conditions that you recommend to by removed from the permit when
issued. Please provide a reason for each recommendation . None
AQUIFER PROTECTION SECTION REGIONAL OFFICE STAFF REPORT
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
None
Recommendation:
Hold, pending receipt and review of additional information by the regional office;
Hold, pending review of draft permit by the regional office.
* X Issue
Deny If denied, please state reasons J
Signature of report preparer: ' 'Y► ��i
Signature of APS regional supervisor: } yy �,� � tr 2 C-f]Rrh/I95 Srle/!►
Date:
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
The well driller signed the submitted application. The homeowner has signed the application and this
newly signed page is enclosed in mailed (signed) report copy. Well driller not authorized to sign
application.
Jb:€opezwell.811
Cc: Wilmington APS Files
Central Office APS Files

(Ai_rogooYa
DE-NR/
AUG 0 201/
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FORA PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 1 SA NCAC 02C _0200
OPEN -LOOP GEOTHERMAL INJECTION WELLS
These wells discharge groundwater directly into the subsurface as part of a geothermal heating and cooling system
(check one) New Application Renewal* Modification
' For renewals complete Parts A-C and the signature page,
Print or Type Information and Mail to the .4ddress an the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE tt j at-4 -. 20 I I
PERMIT NO.
(leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence 1I Business/Organization
Government: State Municipal County Fedcrai
0 172 PO !i1b
H. PERMIT APPLICANT - For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency
1 ir1c r.-V L0p — p tOLr11'1p •L
Mailing Address: k l j cl
City: t (� •4�J State: f 1 ..Zip Code: 9- y c- County: Riv1t L t
Day Tele No.: LO - i! cc11 No.: 910 ri Cro
EMAIL Address: C v Fax No.: t
1 ►l l r-r-Q7 • CC) wt
C. LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site:3�%C2ounty vt27
(2) Physical Address (if different than mailing address): I [ 3 (-6 ""O rt-o e
City: ‘.--\ A rrl P rT State: M Zip Code: 49-c6 4
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Ly�-t e,
NC Well Drilling Contractor Certification No.: r9- v W6` 1�
Company Name: CApQ. ►lrti Z ,QrL, t"s t ` r►� . `
Contact Person: i` i S Q EMAIL Address: C' .V\ne;P i o eelvtrx,i1 r 1 , Ct9u�
Address:CttH O VI l/2 C1
City: Ar-C -t.. Zip Code: i S5"StatetUC -County: lip rti�P V�
Office Tele No.; C 1.0 7`` --ris d. Cell No.: 470-(dX/ UCe LFax No,:9/0 -' SI-S flS(
GFU/UIC 5A7 Permit Application (Revised 3/18/2011) Page I

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: C A c7 t� E et f`% rJ r-L L�' 'S./& Contact Person: -) i_ n-Vt j
Address:- -CD . k 1 � -51-11 I
City: \th \+M1- y Zip Code:1 /O Stat -Lt.- County: /4p v l-i-4 ru] v e r-
OfficeTeleNo.. q10 —(At-.)._ Cell No.:°fP—ixrj`S-QO'a0 Fax Nd/C3-(20a—/ D '
F. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(I) The injection operation? YES NO Ve
(2) Personal consumption? YES NO
G. WELL CONSTRUCTION DATA
PROPOSED Well(s) to be constructed for use as an injection well- Provide the data in (1) through
(6) below as PROPOSED construction specifications. Submit Form OW-1 after construction.
t/ E?QSTII�iG Well(s) being proposed for use as an injection well. Provide the data in (I) through (6)
below to the best of your knowledge. Attach a copy of file Well Construction Record (Form
GW-1) if available. �4�21k%!10
Well Construction Date: AFFrok. 0 / Number of borings:
Depth of each boring (feet):-
(2) Well casing type: Galvanized steel Black steel Plastic Other (specify)
Casing thickness (in,):T.I.ILIO Diameter (in.): _
Well depth: from: 0 to: IFS._ feet below land surface
Casing extends above ground ,)-Q inches
(3) Grout material surrounding well ing:
(a) Grout type: Cement t/ Bentonite* Other (specify)
*By selecting bentonite grout, a variance is hereby Togvo ted to 15A NCAC 2C-Q213(d)(1XA), which regruses a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from !) to .207 feet
r rt, •
(4) Well Screen ar Open Borehole depth (relative to land surface): from 67O to Fri feet
(5) N.C. State Regulations (Title l SA NCAC 2C .0200) require the Perrnittee to make provisions for
monitoring wellhead processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Is there a faucet an:
(a) Influent line? Yes ✓No (b) Effluent line? Yes 1-•'"No
(t)
EMAIL Address: A-ke ti) OAr1ra1rnA-EnFq
Suers 1� ."`a Ce7 r►-
(6) Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Form GW-1). If Form GW-1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment units will the groundwater be withdrawn? (e.g.
granite, limestone, sand, etc.)
Depth: SID I Formation: - 'E Rock/sediment unit:
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF THIS
INFORMATION IS OTHERWISE UNAVAILABLE. ,
l;Lfr 1 i'; ?iii
Vk()
OPLUIUIC 5A7 Permit Application (Revised 3/1MUII)
AUG !)l .i Cull
Page 2

ki. OPERATLNG DATA
(1) Injection Rate: Average (daily) %9-- gallons per minute (gpm).
(2) Injection Volume: Average (daily) 900 gallons per day (gpd).
(3) injection Pressure: Average (daily) dam-- pounds/square inch (psi)
(4) Injection Temperature: Average (Ja.nuexy) ) !Q ° F, Average (July) f 3 ° F
1. WELL LOCATIONS— Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clean' and include a north arrow_
(1) Attach a site -specific rnap showing the locations of the following:
* Proposed injection wells
*Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, dram fields, or repair areas
# Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 114 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most eases, an aerial photograph of the property parcel showing property lines and structures can he
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the welts in relation to property boundaries, houses, septic tanks, other
wells, ese, can then he drawn in by hand Also, a 'layer' can be selected showing topographic contours or
elevation data.
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AUG 01 2011
OPUIU[C 5A7 Pertmt Application (Revised 3/18/2011) Page 3

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Rogers, Michael
From: Rogers, Michael
Sent:
To:
Friday, August 12, 2011 11 :46 AM
'[e-mail]'
Subject:
Attachments:
FW: Lopez Geothermal Permit WI0800248
Lopez Permit.pdf
Please find attached the geothermal permit.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wq/aps/qwpro/permit-applicat ions#geothermApps
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Rogers, Michael
Sent: Thursday, August 11, 2011 5:43 PM
To: '[e-mail]'
Cc: '[e-mail]'
Subject: Lopez Geothermal Permit WI0800248
Please find attached the geothermal permit for the above project. Please notify Mrs. Lopez that you got this permit.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wg/aps/gwpro/permit-applications#geothermApps
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
1
Rogers, Michael
From:
Sent:
To:
Cc:
Subject:
Rogers, Michael
Monday, August 08, 2011 11 :43 AM
'[e-mail]'
'[e-mail]'
WI0800248 Lopez Geothermal permit
We still have not received the revised signature page from Mr. Lopez.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wq/aps/qwpro/permit-applications#qeothermApps
E-mail correspondence to and from this address may be subject to the Norlh Carolina Public Records Law and may be disclosed to third parlies
1
Ro gers, Michael
From:
Sent:
To:
Subject:
Godwin,Tonya
Monday, August 08, 2011 11 :05 AM
Rogers, Michael
RE:WI0800248, lopez, pender
As of this morning, I have not received the signature page. I was informed by Chris that he would have Mr. Lopez sign
and email the signature page to me.
Thanks
Tonya Godwin
NC Dept of Environment and Natural Resources
Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-5348 (Office)
919-715-6048 (Fax)
[e-mail]
Email correspondence to and from this address may be subject to the North Carolina Public Records Law and
may be disclosed to third parties.
From: Rogers, Michael
Sent: Monday, August 08, 2011 10:53 AM
To: Godwin, Tonya
Subject: FW: WI0800248, lopez, pender
Tonya-
I am working on this permit. Did you ever get signature page for this permit? You e-mailed Chris at Cape fear drilling
indicating that he needed to send you and authorization letter or revised signature page with Vincent Lopez signature.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wq/aps/gwpro/perrnit-applications#geothermApps
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Bushardt, Jim
Sent: Thursday, August 04, 2011 4:14 PM
To: Rogers, Michael
Cc: Bushardt, Jim
Subject: WI0800248, lopez, pender
Pis see the attached. Mailed copy with report signature and a proper application signature will follow.jb
1
Jim Bushardt, P.E.
Environmental Engineer
Division of Water Quality, Aquifer Protection Section
127 Cardinal Drive Ext., Wilmington, NC, 28405
Office Phone: [phone], Email: jim.bushardt @ncdenr.gov
Email correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
2
Rogers, Michael
From: Bushardt, Jim
Sent: Thursday, August 04, 2011 10:36 AM
To: Watts, Debra; Kegley, Geoff
Cc: Rogers, Michael �� } ,; 0+° R
Subject: RE: 5A& permit review [�
I'll need the permit number to enter my report in birns
From: Watts, Debra
Sent: Thursday, August 04, 2011 9:47 AM
To: Bushardt, Jim; Kegley, Geoff
Cc: Rogers, Michael
Subject: 5A& permit review
Hi Jim and Geoff
Not sure who at WiR❑ is doing the review for Underground Injection Control wells, so thought I would email to both of
you, and hopefully you can sort it out. The attached application is for a heating and cooling system t5A7j where the
home owner has no air. The driller called me and asked if there was any way we could expedite the permitting process,
so I'm passing on this request. Do your best to get a response back to us quickly. Mike Rogers is your point of contact,
and I've copied him. Thanks!
Debra J. Watts. Supervisor
Groundwater Protection Unit
Aquifer Protection Section
919-715-6699
DISCLAIMER: Per Executive Order No. 150.all a -mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties.

Godwin, Ton ya
From: Godwin, Tonya
Sent:
To:
Wednesday, August 03, 2011 9:59 AM
'[e-mail]'
Cc: Watts, Debra
Subject: FW: injection well permit
Attachments: injection well permit 1044.pdf; injection well permit 2045.pdf; injection well permit 3046.pdf;
injection well permit 4047.pdf; injection well permit 5048.pdf; injection well permit 6049.pdf
Good morning Chris. I see that you have signed on behalf of Mr. Lopez. Before we can move forward with processing
this application request, we need the property owner, Mr. Vincent Lopez, to sign the application, or, a signed letter from
Mr. Lopez authorizing you to sign on his behalf. This information is stated on the application form. Debra Watts is out
of the office today, so if you have any questions, please contact Mrs. Watts tomorrow, 8/4/11, at 919-71~
Thank you for your assistance and cooperation. Have a nice day. 3.1-{ Q p {IL ~1 ~ \I -~
Tonya Godwin \.. . ..... /",~~~ l Dr-L
NC Dept of Environment and Natural Resources ~~-. ~ ~ ~ n L . w; \l _ \J\@-L
Aquifer Protection Section r\ \_' ~ " OJ<'.. \ )R_ ~ I rf\/J-;
1636 Mail Service Center L'\\\, ~ ~-· I _ ,..,_J_:, (, ~ L.
Raleigh, NC 27699-1636 · ~ S\ ~ C'JP_ \\ <JP-\ t5)l · _ fD
919-715-5348 (Office) \\. \ ~ \ ,....rv.:--L.--\ \ L\-" L f\(J.C-,(2'.
919-715-6048 (Fax) \'"'~ , ~l n.cD. C§Xll5Y'-u:::;x-\ cf_)
Ton ya.Godwin @ ncdenr.gov ~~\\ ~ v\ \ \
~ ~
Email correspondence to and from this address may be subject to the North Carolina Public Records Law and
may be disclosed to third parties.
From: Godwin, Tonya
Sent: Tuesday, August 02, 2011 4:16 PM
To: '[e-mail]'
Subject: FW: injection well permit
Chris,
I have printed off the application. However, this request is for a 5A7 open-loop geothermal injection well. SA7 injection
wells are not deemed permitted. It will have to first go to the Supervisor. The Supervisor will then assign it to a
Reviewer. Then the Reviewer will forward the application to Processing. I cannot give you a timeframe for this. I have
placed your SA7 application request with Debra Watts, the Groundwater Protection Unit Supervisor. Please contact
Debra @ 919-715-6699 if you have any questions.
Thank you
Tonya Godwin
NC Dept of Environment and Natura l Resources
Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-5348 (Office)
919-715-6048 (Fax)
Tonya.Godwin @ ncdenr.gov
1
Email correspondence to and from this address may be subject to the North Carolina Public Records Law and
may be disclosed to third parties.
From: Chris Deal [mailto:ca pefeardrillin g@g mail.com ]
Sent: Tuesday, August 02, 2011 3:05 PM
To: Godwin, Tonya
Cc: chris (cil ca pefeardrillin g .com
Subject: injection well permit
Cfiris 'Dea( President
Cape Fear Drilling Services Inc.
Phone: [phone]
Fax:[phone]
Burgaw, NC 28425
2
AirA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freean
Governor Director Secretary
August 4, 2011
Vincent Lopez
113 Golf Terrace Dr.
Hampstead, NC 28443
Subject: Acknowledgement of Application No. W10800248
Vincent Lopez SFR
Injection Heating/Cooling Water Return Well (5A7)
Fender
Dear Mr, Lopez:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on 08/01/2011. This application package has been assigned the number listed above and will be reviewed by
Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to fmal 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 organizational chart, go to htrr:llh2o,enr.state.ne.us/documents/dwq_orechart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT_
for Debraatts
Supervisor
cc: Wilmington Regional Office, Aquifer Protection Section
Chris Deal (Cape Fear Drilling Services, Inc., 9124 Old River Rd., Burgaw, NC 28425)
Nate Carr (Carolina Energy Services, P.O. Box 12547, Wilmington, NC 28405)
Permit Application File WI0800248
AQUIFER PROTECTION SECTION
1C36 Mail Service Center, Raleigh, North Carolina 27699-1636
Lo aPon: 2722 Capital $oiiievard, Raleigh, North Carolina 27604
Phone: [phone] l FAX 1: 919-715-0586: FAX 2: a19-715-6048 ! Customer Servic.1-ST7-623-674B
Intarn6ir www.newatemualitv.er, ,
F•h EGaz.i Op pnti r.t':7r. coyt.r •
North
Na all '

k-
�,+13
LCEVEU,UE ' Mt.
AQUIFFA PRfT'Gfr-..''
.47" (2_66_,.
0 AUG 4 2 ?oil
NOF TF !' -• Rti'.FitiA ► EPART E ;T or'htVi ti i r:'ti`;1 N AT-Li-R' A RLSOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLY
In A.ccorda lee With the Provisions of 15A NC AC 02C .02O0
OPEN -LOOP GEOTHERMAL INJECTION WELLS
These wells discharge groundwater dtrecti► into the subsurface as part of a geo iermat heating and coulinrt system.
(check_ one) New Application _ Renewal' Modification
For retie wais complete Parts A-C and the srgnaurre page
Print' or I ype Inlrirmation and Mail to the Address on the , .asi Page. Illegible , npiieatronr Will Be Returned A.: Inanmpeew
DATE \
PERMIT NO y L fit] )' 8 heave blank if-Ne . Appi cationk
STATUS OF APPLICANT (choose- erne,
Non -Government' Individual Residence Business.TOrganixatin.
Gcwernment State Municipal County Federa
B. PERMIT APPLICANT — Fur individual residence:. lest earn owner ondeed. For all omer-
state name of calf: and name of person deIeQated alit -homy to sign on behalf of t13eZsi c$r agency. 1 � C
ut t
w L Dp .
1..y �' —
ir)rti ,
RrLrT!sFl� Address: '"'t 1 t}"t .e i ,_ tU 'elm _atV • — �
City . , } 7 State•: f L�. C i*n Code:
Da-r Tell No.. 01 I — 5s. - y � Cell No Q - J 41o e9. V"
EMAIL Address: —
eS �-tC F ax N:- �? I} ( c'f
t . evw►
C. LOCA.TIO1 OF' WELL SITE — Where chn inaertion welts are pnysica1h. located:
(1) Farce! l.dentilicatior Number (PIN) of well site:3. - ourty:
(2 Physical Andres. 'ifdif£erenr '•n o
t178I: t'L.�l�;r-au!1-es � I� l��` 1� /'t`e r-i`.i ..
Sate 711F` Zip Code y
D. WELL i)RILLEI? INFORMATION
4tie11 Drilitng Contractor"! Name: C
f } --- -- --
NC Well Drilling Contractor Certification No.: 9-5-4-115— A
Cornpsm Marne: C.A¢ ftt� t^i 1-1.1.1e.<e. -1 t L�
Contact Person: t.' \P t 'vI ` IL y nre;s rt �`a
p ����77 ,n yy .�.�_ � L`‘1 5��[� iYF"P�Y��I�� � I a+.C? . Co1rt
" dress. �-t `-{ °'tike. V . Yy :"1
Zip Code: , `./ ctate2l.i
C1ff,. 'i eke. 15 g. r;:11 No.. '('� -(.;,CWi Q._C.o t' iti i.' 9/C -P S -5-
•n

E. 'HEAT PUMP CONTRACTOR INNORMATIMlti ! i "differentthat, driller
t
Company Nance: AY2L.L DA-
Contact Person: /�.� Or t� C r : - EMAIL Address: .! Ah r' eS' Arrt nn.-@ "k
Address. . + ' X
Y. -- » Zit" C oac:k -IO County. ► i '1.4 ex() v e v
Office Tete No. Sr) C ell Nc.- 9[D— — �?C]t0 Fay �vc%'0/Q `GI0 -- SW
F. WELL USE Wilt the injection well(s) also ue used as the suppty- wellisl for the folkg?
t 11 The injection operation'. YTS
1 Personal consurriptior_" YES NO
G. R'EL.I 'CitiNSTR1 ECT1U\ DATA
PROPOSES? Wel1i,s1 in oe construct: for use at an infection ell Provide the dad sn [ ' thrown
(o) below as PROPOSED construction specifications_ Suomi: Form GW-1 after cortstrnetian
1� E [STING ik elllsj being proposed fo- use as an injection well. Provide the data in 'F . through .6)
belov, to the best of your latnwled2e. Attach a copv of the Well Construction Record fTorrr
GW-i1 if available- — i and ikuPL 10.
[ t 1 Well Construction Date• 260 I Numoer of borings: I
Depth of e eh boring (feet )-'
(2 + Well cast= type- Galvanized steel. Slack steel Plastic Other I spe:: •
Casing thickness ( in.).X.INLY3 Diameter im l ' 9
Weis depth: from: 0 tc5- feet below land surface
Casing extends above ground -O inches
i3: Grout material surroundini well casing-
s a j Grout type: Cenneat Bentnnite ° Other (specify.
*by ie1 thig r+etti to emu_ variam: IS =OA rs .5,, ►. C'A= 2C..G2t11 t11.1 I Ai a Wien rcature.; u umi�t t. r� km
(hi Depth of grout around welt casing 'relative to land suriacey from Jr) to o? lee'
t4 Wel Screen or Open Borehole depth trela;tive to Jana stria-ce). from Co hi TsS lee.
State Regulations (line ! 5 A NCAC ?C 020() i require the Permitte to make provisions for
munitorinE wellhead processes. A faucet on how influent (groundwate- enterinE heat pumps and Ef'flueui
t water being infected back into the well i lines is reouired. Is there a faucet on
rat Influent une? Yes lb, Effluent fine" Yes
tit Source ill ell Construct tor: luformatior. the water source well is a aiferent w>11 Mar the inje Lion
well attach a corn. of the well construction record (Tom GV - i 1, if Form OW- is riot avatianle. pro (tie
the following data,
From wit depth 't,rmattnn, any woe or - d ...,: unit me proundwar o the.L
granite, limestone sand etc
eel r r.k Roc unal.
NOTE: THI W't:t.f. ntzr:., 0!V* r c 1tT Tu':
'3m4ATIO : is l�r
• •'&JP in• Arr iwa Ttc�•i r

II OPERATING DATA
(I.) injection Rate: Average tdaily 1` ;zalions per minute iipm
(2) In iection Volume- averaize ,c0e4 ual tins per day [gad
(3) Iniecrion Pressure: Average (etas]► j pounds,sivarc inch %psi o.
(4 Injection TemperatureAverage (Januar l 130 r Aver4 (]ulv I/30 F
I. WELL LOCATIONS — Maps muse he scaled or otherwise accurate], indicate distance, and ortesrtauons o`'
features located within 1000 feel ofthe imection weilisi. Lahti all features clearly and inciuoe : narih arm
Attach a site -specific map showing the locations of the tol:owing-
Proposed injection wells
c Buildings ' Propem• bpundarre�
Surface water bodies W ate- supply well:
Septic ranks and associated sperm irrigation sitesdrain fields, o- repair area.
" Existing or potential sources of groundwater contamination
{2 i Attach a topographic map of the area extending 1/4 mile. from the infection welt site that indicxes t.
racilitn -s location and the map name
NOTE. in drat] case,., an atrial photograph of the prrtperr► parcel showing property lines and s:TMuelure'+ can he
obtainer; and downloaded from 1hE applicable cotton' GIS weftsne Typically, the property can he searched hi
owner startle or udth- '.,,,- The location of the wells In relation to property boundaries. houses. sq&k tanks. Miler
wells, etc. can their be drown in fly hang Also. a `]deer' can he selected showing topographic contour
el cation data.
•i r r +i..ati. , (R .er.13/[S,2fl

CERTIFICATION Ito be sumed as required below or by to person's authorized anent!
1 SA NCAC 02C .0211 fbi requires that all permit applications ,ha11 be signed as follows:
1 for a corporation ON a responsible corporate officer
for a partnership or sole m . prietorstiip. b.. a general partner or the proprietor. respective]
3 for a municipality era site, federalor other public agency to either a principal executive
officer or ranking publicly elected official.
4, for all others- bv the well owner !which means al? persons listen or the nnerrdeed)
if an authorized agent is sighing 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 lay., that 1 hay:: personally examined and am familiar with the information
submitted in ibis document and al! attachments thereto and Mai based nn my main) of those indivionals.
immediately responsible for obtarnm.. said information. 3 nelieve that the information is true. accurate and
complete. 1 am aware that there are sienifscant penalties. inciudi% the possibility of fines and imprisonment
for submitting false information 1 agree to constntet_ operate. maintain, repair; and if applicable, abandon the
injection wet] and all related appurtenances in accordance will-, the specifications and condition of
t,te Permit_
Sr.naurre of PaSperty OwnerfApoltcant
Pnnt or Type Full Name
Signature of -Property Owner.'Apphcan- —
Print or Type Full Name
S ; anature of Authorized Agen' if any
Pont (Tr Type Fun Name
two copies t5 f the completed appi I canon package to:
DWQ - Aquifer Protection Sechatt
1636 Mail Service Center
kaieigh. NC 7.7699-1636
Telephone [phone]

Page of
.Im ii~ s.p lercoti 'J gm ·n -_1 c:nc ;.-sp l .. ,. •
'
'
\
\
J. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .02I 1(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others; by the well owner (which means all persons listed on theproperty 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.
"1 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_ 1 am aware that there are significant penalties, including the possibility of tines 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." '
l UY I , L
Si +nature of Proper ]wirer/Applicnit
Print or Type Full Nano
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Auoriied Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
(1PUMC 5A7 Permit Application (Revised 3118/2011) Page 4

Godwin, Tonya
From:
Sent:
To:
Subject:
Attachments:
Chris,
Godwin, Tonya
Tuesday, August 02, 2011 4:16 PM
'[e-mail]'
FW: injection well permit
injection well permit 1044.pdf; injection well permit 2045.pdf; injection well permit 3046.pdf;
injection well permit 4047.pdf; injection well permit 5048.pdf; injection well permit 6049.pdf
I have printed off the application. However, this request is for a SA7 open-loop geothermal injection well. SA7 injection
wells are not deemed permitted. It will have to first go to the Supervisor. The Supervisor will then assign it to a
Reviewer. Then the Reviewer will forward the application to Processing. I cannot give you a timefrarne for this. I have
placed your 5A7 application request with Debra Watts, the Groundwater Protection Unit Supervisor. Please contact
Debra @ 919-715-6699 if you have any questions.
Thank you
Tonya Godwin
NC Dept of Environment and Natural Resources
Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
919-715-5348 (Office)
919-715-6048 (Fax)
Ton ya.Godwin @ncdenr.gov
Email correspondence to and from this address may be subject to the North Carolina Public Records Law and
may be disclosed to third parties.
From: Chris Deal [mailto:[e-mail]]
Sent: Tuesday, August 02, 2011 3:05 PM
To: Godwin, Tonya
Cc: chris @ca pefeardrilling .com
Subject: injection well permit
Chris Vea( President
Cape Fear Drilling Services Inc.
Phone: [phone]
Fax:[phone]
Burgaw, NC 28425
1
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
in Accordance With the Provisions of 1 5A NCAC 02C 0200
OPEN -LOOP GEOTHERMAL INJECTION WELLS
These wells discharge groundwater directly into the subsurface as part of a geothermal heating and cooling system
(check one) New Application Renewal* Modification
* For renewals complete Parts A-C and the signature page.
Pant or Type Information and Marl to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE 20 k k
PERMIT NO. amp f3 ? 1 (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence I/ Business/Organization
Government: State Municipal County Federal
B. PERMIT APPLICANT For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency-
�_L� f7
C� rti _77t=' - l - \JPIVDr�`I_� ,a, ra,r. 1eT-ked AU -I- ,dr�t:.
Mailing Address: Ck I'�`t () i Q. QvL Y2.„-a..OD'a
City: ■ State:li� dip Cade: '� ��� County. f vi 1�4i 2
N U Day Tele No.: i L�J �'� � �5 Cs11 No.: 97o r60�l - G y
1 lfp' EMAIL Address: Fax No.: ci t b -'2_ Sc
Pe,
r, e�w,
°t C. LOCATION OF WELL SITE - Where the injection wells are physically located:
(I) Parcel Identification Number (PIN) of well site: 43 2s13 (vf9. aunty e_p e..Y
Physical Address (if different than mailing address): [ t 3 ( O 1r .r (VACS �►-tea e t�)
445
CAI
City: yvvi �S h State: NC Zip Code: D-c6y L
WELL DRILLER INFORMATION��Il
Well Drilling Contractor's Name: C.IIN'i` j e la- l
NC Well Dulling Contractor Certification No.: Q�-4--t— A
���r
Company Name: �� t't'; Lk 1Y\ Q r -4 2 t
Contact Person: i S _t4 ` I , EM4 Address: rv7s.P1 j-eiIri. ,1I ril tccov,..,
Address:O A j2►V eet , (1
r City: r�C /��{_2 - — Zip Code: S`�r+}s`State C.-County: 1�'P N e..s ...
Office Tele No.:lCiLO ` -as- _ Cell No.: 570 -(00//-0(na1FaxNo.:9fC.) -a S-5-5-1-oce
OPUICUIC 5A7 Permit Application (Revised 3/1 Rl201 l )
Page 1

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: C A Y2 c,J \ (Y'.'\A--C o :fH''-;_ ¥ Se C\ 1 ,' c__e <,;;,,
Contact Person: ),J M-e.... C.. A-VL i/l, EMAJL Address: UM e @ C' A:t'.4: 2l oo ~e n,&q y
Address: }?-.cJ . ~o X l d:'SL\) "b~ru cc....~ CD #'I'\
City: \LJ { \M\'0-~+P V". Zip Code:~l/O 5; State}...lC,_. County: xJ P.., -l !-l.-\ V\0 u e. r-
Office Tele No.: '1.10 -"$C\-~;SI) Cell No.: 9r0-&::5'!:.~ 00~C) FaxNo.:9/0--too d -I ~~
F. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES ____ NO V
(2) Personal consumption? YES ____ NO i.7"
G. WELL CONSTRUCTION DATA
(2)
(3)
(4)
(5)
(6)
____ PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1) through
(6) below as PROPOSED construction specifications. Submit Form GW•l after construction. ✓EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (6)
below to the best of your knowledge. Attach a copy of the }Veil Construction Record (Form
GW-1) if available. C':::::-(v -:J.. 1""'-:::, t'\o\--J\U~~\ol~
Well Construction Date: ~X ,Jt){) I Nwnber of borings: __ I __
Depth of each boring (feet):_~'R5~~----
Well casing type: Galvanized steel __ Black steel __ Plastic V Other (specify) _____ _
Casing thickness (in.):~ Diameter (in.): l--{
Well depth: from: 0 to: %:~ feet below land surface
Casing extends above ground /t: 0 inches
Grout material surrounding well casing:
(a) Grout type: Cement V Bentonite* __ Other (specify) ______ _
*By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(dXIXA), whichreqwres a cement type grout.
(b) Depth of grout around well casing (relative to land surface): from (<) to 20? feet
~tdC-•
Well Screen or Open Borehole depth (relative to land surface): from (oO to ~S--feet
N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water being injected back into the well) lines is required. Is there a faucet on:
(a) Influent line? Yes v' No__ (b) Effluent line? Yes v'No __
Source Well Construction Information. If the water source well is a different well than the injection
well, attach a copy of the well construction record (Form GW-1). If Form GW-1 is not available, provide
the following data:
From what depth, formation, and type of rock/sediment units will the groundwater be withdrawn? (e.g.
granite, limestone, sand, etc.)
Depth: 18:Q ' Formation; ~I::' ~E Rock/sediment unit: ______ _
NOTE: THE WELL DRILLING OR HEAT PUMP CONTRACTOR CAN HELP SUPPLY THE DATA IF TIIlS
INFORMATION IS OTHERWISE UNAVAILABLE.
REG_EIVEO I DENR I DWQ
Aqwfer Proti;r.fion Section
GPU/UIC SA7 Permit Application (Revised 3/18/2011) AUG O 1 2011 Page2
H. OPERATINGDATA
(1)
(2)
(3)
(4)
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
Average (daily) /{)-. gallons per minute (gpm).
Average (daily)~ gallons per day (gpd).
Average (daily) ;J.f2_ pounds/square inch (psi).
Average (January) I ~o ° F, Average (July)/30 ° F.
I. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s ). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In ttuJSt 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.
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GPU/UIC 5A7 Permit Application (Revised 3/18/2011)
REC_EIVEO / DENR / DWQ
Aquifer ProtP.ciion Section
AUG O 1 2011
Page3
J. CERTIFICATION (to be signed as required below or by that persons authorized agent)
15A NCAC 02C .021 I(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner twhich means all persons listed on the oroper 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.
"l 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, 1 believe that the information is true, accurate and
complete. 1 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 j rove specifications and conditions of
the Permit. r
Signature ofPra(aperty Owner/Applicant
CA-N. ,
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPI7MC 5A7 Permit Application (Revised 3/1812011)
Page 4

Page 1 of 1
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RECEIVED I DENR I DWQ
Aquifer Protection Section
AUG 0 1 2011
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J. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1, for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"1 hereby certify, under penalty of law, that 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete_ I am aware that there are significant penalties, including the possibility of tines 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 "
S iig utture of F°rope _ er/App ' t
Print or Type Full Nam
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies oldie completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
(iPiURFIC 3A7 Permit Appliwa1iun (Revised 311S/20I1) Page

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