WI0800444_GEO THERMAL_20201117

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 ofa geothennal heating and cooling system
CHECK ONE OF THE FOLLOWING:
__ New Application ___ Renewal* L_Moditication __ 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: __ {)_-cf.~~-'J......-::(_..____, 20 :)..() PERMIT NO. vJI 0~ btJc/1 'li.1eave blank if New Application)
A. 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 D Geothermal Well D Drinking Water Supply Well
~Other Water Supply Use-Indicate use (i.e., irrigation, etc.) \~~ \A.A....r--,,
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record {GW-30). RECEIVED
0 Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? D YES ~ NO
If yes, indicate New Owner's contact information:
ocr O 8 2020
NCOEQ/OWi
Central Office 'R
Name{s) _____________________________ _
Mailing Address: _____________________________ _
City: -----~-___ State: __ Zip Code: ______ County: ____ _
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence ~ Business/Organization __
Government: State Municipal__ County__ Federal
C. WELL OWNER(S)/PERMIT APPLICANT -F~n~::~;~;;)li st all persons listed on the
property deed. For all others1 Hst name ofbusines§/zg ency and name of person and title with delegated authority
to sign: :RO V\ tt ~ ~ C.. • :.f.. SJLO.. r-o \.\ -b., D-r vv..1,, S
Mailing Address: 3 D S: .5 ..,J-1,. 3 ,...P s-b,-of::: j
City: uJ\.(~ ... ~7b State: N:':_zipCode: ~$4-0 f County: ~v~ { ~
Day Tele No.: ""'1D 'f -j] l. ?, '-/)..,.~-Cell No.: ,tJ t -·2,34 .-;J L/ ;i.s::
EMAILAddress: J<CDcp{42~7 e_}IJL,..(OM FaxNo.: t:jJO 1,&7 ~Df7,,S':
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 1
D. WELL OPERATOR (if different from well owner) — For single family residences, list all persons listed on
the property deed. For all others, list name busine -_ -gency and name of person and title with delegated authority
to sign:
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: ' County: ft )T
(2) Physical Address (if different than mailing address):
City: County Zip Code:
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name:t- • 14 -I ?_
NC Well Drilling Contractor Certification No.: '"ire+
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
G. HVAC CONTRACTOR INFORMATION if different than driller)
HVAC Contractor's Name: ,' -A I/ ►A C
NC HVAC Contractor License No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.:
Cell No.. Fax No.:
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(I) The injection operation? YES NO
(2) Personal consumption? YES NO 1
L WELL CONSTRUCTION REQUIREMENTS —As specified in 15A NCAC 02C .0224(d):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of ISA NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 2

J.
(3)
(a) For screen and gravel -packed welts, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTING WELLS �PROPOSED WELLS
*For e isthig wells, please attach a copy of the We l Construction Record (Form GW-1) ifavailable.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
Depth of each boring below land surface
Well casing and screen type, thickness. and diameter
Casing depth below land surface
Casing height "stickup" above land surface
Grout materials) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water -bearing pones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(1ir.
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATING DATA
(1) lnjection Rate:
(2) lnjection Volume:
(3) Injection Pressure:
(4) lnjection Temperature:
Average (daily) gallons per minute (gpm).
Average (daily) gallons per day (gpd).
Average (daily) pounds/square inch (psi).
Average (January) ° F, Average (July) ° F.
L. SITE MAP — As specified in 15A NCAC 02C .02240b)t4), attach a site -specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainf eld, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107Lajt 21 located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north. south, west, or east)
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 3

NOTE: In most cases an aerial photograph of the property parcel showing properly lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a'layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021 l (e > requires that ail permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the person(s) listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
L-L(
rI l
Signature of Property O er plicant G
Print or Type Full Name and Title
Signature of Property t r Appiicant
Print or Type Full Name and Title
32\1ZQ
0C� Signature of Authorized Agent, if any
teitaaofsligice
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - [TIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 4

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 wells) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
, „ l L a _..�>�
New Application Renewal* X Modification Permit Rescission Request*
'"For Permit Renewalsµgr Rescission 1.eque vzn fete Sections A thrn E. and M
Print or Type Information and Mail to the Address on the Last Page. Illegible AppllcationaElll isvv,,nel As Inct mislete.
DATE: a ; � , 2D .O PERMIT NO. VJI0 ' ¥leave blank if New Application)
A. 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 ❑ Geothermal Well ❑ Drinking Water Supply Well
`glOther Water Supply Use- Indicate use (i.e., irrigation, etc.)
b_ Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
❑ Yes, I wish to rescind the permit
RECEIVED
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES 'NO OCT 0 3 2010
If yes, indicate New Owner's contact information:
OECVDWR
Name(s) .ird1Office
Mailing Address:
City: State: Zip Code: Couzrty:
Day Tele No.: _ Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence y Business/Organization
Government: State Municipal - County Federal
C. WELL OWNERS}/PERMIT APPLICANT — For *rile family residences, -)list all persons listed on the
property deed. For all others list name of{ businesssjagency and name of person and title with delegated authority
to sign: ` O b\ 4 k C . 4-} tLCL "- 1n —0 T. im- 5
Mailing Address: Qs mac,.• -3 A �';r -cr +y
. , 7
City: U) % (rvt4 w T 1- v, State: Zip Code: ?3 401 County: eJ�
Day Tele No.: l — 3 3 t 3 L f -S Cell No.: 7 Y— 2,3 4--3 Y 6
EMAIL Address: 7 C. D 4 mg..... ( Fax No.: (=ti U L L- -7 - D if 75-
Geothermal Water Return Well Permit Application Rev. 4-15-2M16 Pagel

D. WELL OPERATOR (if different front well owner) — For single family residences, list all persons listed on
the property deed. For all others, list name businelagency and name of person and title with delegated authority
to sign:
Mailing Address:
City: f�, State: Zip Code: County:
Day Tele No.: , Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: County: J4r Tt
(2) Physical Address (if different than mailing address):
City: County Zip Code:
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: —1/
y, �L �., . ,q 1'•-•n� -:
NC WeII Drilling Contractor Certification No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Ce11 No.: Fax No..
G. HVAC CONTRACTOR INFORMATION if different than driller)
HVAC Contractor's Name: 1- r-,` {� 2 �.� ! `' ,; -�— '/
NC HVAC Contractor License No.:
Company Name:
Contact Person; EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: CeI1 No.: Fax No.:
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO r
(2) Personal consumption? YES NO
L WELL CONSTRUCTION REQUIREMENTS — As specified in 1 NCAC 02C-022441:
(1)
(2)
The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application Rev. 4-15-201 b Page 2

(a) For screen and gravel -packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall he grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(I)
Specify the number and type of wells to be used for the geothermal heating/cooling system:
IEXISTING WELLS • PROPOSED WELLS
*For e, isting wells, please attach a copy of the Wefl Construction Record (Form GW-1) of available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram dearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(h) Well casing and screen type, thickness, and diameter
(c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e) Grout materials) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water -bearing zones with 1500
nig/L chloride or greater per 15A NCAC. 02C .W107(1) 8,
(t) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATING DATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) injection Temperature: Average (January) ° F, Average (July)
L. SITE MAP — As specified in 15A NCAC 02C .02241 b )t 41, attach a site -specific map that is sealed or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection weli(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C.01 07i alit located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 3

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 webrite. 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 he 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 .02111 J 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. fora 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 personfsj listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that 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, l believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
4Ici(t ipL44 t_c-L4-0.&-tc 3.1q144
Signatur of Property Owner Applicant
Print or Type Full Name and Title
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQR❑S)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 4-I5-2016 Page 4

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
GEO'i I IERMAL 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 Renewal* Modification Permit Rescission Request*
Far Permit iienewals er Rescission Reeugst,,co uupleteSections A thru E. and MVI.(signature parr) only',
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be .Returned As Incomplete.
DATE: 0 t: , 20 . _O PERMIT NO. ar©Y 56'Yileave blank if New Application)
A. 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 ❑ Geothermal Well ❑ Drinking Water Supply Well
['Other Water Supply Use- Indicate use (i.e., irrigation, etc.)
b_ Terminate Use; If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
❑ Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES R.NO
If yes, indicate New Owner's contact information:
Name(s) _
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence y_ Business/Organization
Government: State Municipal County Federal
C. WELL OWNER(S)/PERMtT APPLICANT — For ogle family residences, .i ist all persons listed on the
property deed_ For all others list name of busines/agency and name of person and title with delegated authority
to sign: D Vs 4. L S. C.. $ C a r-D K cA� D -t' vt''- �. 5
Mailing Address: 3 ❑s _5,. -it 3,..0 S ,r < r —
+
City: 1#0 LC AA,— + State: Zip Code: $ 40f County: c.'
Day Tele No.: 714 — 2 3 L 3 q 11 Cell No.: "-r6 / — 3 G -- 3 Li _a;
EMAIL Address: -g e 1)9 32 7 e__M1-, apt_ Fax No.: £1 i L' L (. 7 0't ?
Geothermal Water Return Well Permit Application Rev. 4-15.2016 Page 1

D. WELL OPERATOR (if different from well owner) — For single family residences, Iist all persons listed on
the property deed. For alI others, list name busines -agency and name of person and title with delegated authority
to sign:
Mailing Address: _
City: State: Zip Code: _
Day Tele No.: Email Address.:
County:
E. PHYSICAL LOCATION OF WELL(S) SITE r '
(1) Parcel Identification Number (PIN) of well site: _ County: Jl1 T4•
(2)
Physical Address (if different than mailing address):
City: County Zip Code:
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: ) �� ...r='�"' 14 - i 7 it-, . 1.�j vim'►
i f�
NC Well Drilling Contractor Certification No.: '�-U; y�� CLrc
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
G. HVAC CONTRACTOR INFORMATION if different than driller)
HVAC Contractor's Name: u(„_/"Lei,
NC HVAC Contractor License No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO [�- -
(2) Personal consumption? YES NO 4
,..--
I. WELL CONSTRUCTION REQUIREMENTS — As specified in 15A NCAC 02C .0224 ):
(1)
(2)
The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
if a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application Rev, 4-15-2016 Page 2

I.
(3)
For screen and gravel -packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
(a)
WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used fo the geothermal heating/cooling system:
*EXISTING WELLS �" PROPOSED WELLS
*For etisting wells, please attach a copy of the We 1Construction Record (Form GW-1) if available,
(2)
Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
Depth ofeach boring below land surface
Well casing and screen type, thickness, and diameter
Casing depth below land surface
Casing height "stickup" above land surface
Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water -bearing zones with 1500
mg/I, chloride or greater per 15,4 NCAC 02C ,01070)18)
(f) Length of well screen or open borehole and depth below land surface
(g)
I. OPERATING DATA
(1)
(2)
(3)
(4)
Length of sand or grave] packing around well screen and depth below land surface
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
Average (daily)
Average (daily)
Average (daily)
Average (January)
Canons per minute (gpm).
gallons per day (gpd).
pounds/square inch (psi).
° F, Average (July) _ ° F.
L. SITE MAP — As specified in I5A NCAC 02C .0224jb1i4.1, attach a site -specific map that is scaled or otherwise
accurately indicates distances and orientations ofthe specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet ofthe injection well(s),
(2) Any other potential sources of contamination listed in I5A NCAC 02C .0107(a]t2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one ofthe cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application Rev. 4-15-2016
Page 3

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 he searched by
owner name or address. The location of the welts in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a `layer' can be selected showing topographic contours or elevation
data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15AA NCAC 02C .0211(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 persons i listed on the propert) deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that 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, l believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
Signature of Property Omer
lioa4nt44`)
Print or Type Full Name and Title -
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 4

ROY COOPER
Governor
MICHAELS. REGAN
Secretary
S. DANIEL SMITH NORTH CAROLINA
Environmental Quality Director
November 17, 2020
Ronald & Sharon Demas
305 South 3rd Street
Wilmington NC 28401
RE: Acknowledgement of Application No. Wl0800444
Geothermal Heating/Cooling Water Return Well
New Hanover County
Dear Mr. & Mrs. Demas:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt
of your permit application and supporting documentation received on November 3, 2020.
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 919-707-3662 or email at [e-mail].
cc: Wilmington Regional Office, WQROS
Permit File Wl0800444
Sincerely,
For Rick Bolich, Chief
Ground Water Resources Section,
NCDEQ Division of Water Resources
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street I 1636 Mail Service Center I Raleigh, North Carolina 27699-1636
919.707.9000
t•iTC On u_
WELL CONSTRI. C TiON RECORD
I ►►ell Control. 'or Infornu meow:
Robert Cramer
urliL iI 1r sung
4207-A
1L ✓,I,II .1. to,. `onOnr
Cape Fear Drilling,Services
aim
Hpl C onuruetton remit I: rV v ` 00 •
S- ►► Pit 1 u 'cheek well u.et:
HrfrrSopph ►►ell:
►�I rU 1t4r.,
.e .lhermar 1I Iedmg l ,,obog tiIMllg
;tr%IIioniti'( iMNltdtL tdl
Clmr;alislit
gMuIlh.p 11 lauhlPc
i-1kcrldrnuni ►1 ate, +,upph 1 aingtel
I.)Rc.Idctlpal ►l MCI rupldl i.hrtrnll
Non-Wµler tillppl� Hell:
]Lniimrinc 17Rc :,,rip
Inlcrlion NPII:
L..1.14Rcelt.l �.
CLlqui Pr Storage and Re ery
CDAquifer 1'1sr
lXsperimsmal Techno$ogy
❑Geothermal (Closed Loop)
2Gcashcrmal (Hestia_ Coolie_ Room.
❑[; ruunJ.l--atcl i(wtealint lJL
❑Saliniry Barrio
L]sterrnxnttcr Drainage
US•nhsideneeControl
❑Tracer
(IOih r (caldain under 423 Remarks)
#. hasps WeAil) Compleled: 11I25115Wd1I0N
So. Well Location
Ron Dames
Fmi:ify puncr!Yuwc Fw:Aey IDX fife/41i ulttel
305 S 3rd Street, Wilmington, 28401
Ithya)ott Address Like. amdrip
New Hanovet
Count, Fund Idrnlifruliva No (PIN}
Sb. I.arirade and i oii ite* in degrceL1ndnulealseetmd9 nr dcrilaal degrees:
llt'ur}I field, we Wong is wflkiarl
3413' 53' 77 56' 43"
6. is {Are) the .6e11(6): HIPorInooent nr OTeteporary
7. Is this a repair to as existing wen: :;Yes or @Ao
1/nor is u rcerrr- jilleru beam nencrwxrraeFiT rpfarntati.xwsd urcpragn I1r nurrrn of rho
rep* wrier NI rrl.wkr .r.l.lir11l ru• rue det fete* ❑ffhff 164+k
& Number of wells constructed: 1
Fnrxredly&1 Vrj: -rip•.1 r.+• nlyd-,VON, F.ppil nrl1r WILE' It1il1 /1r- aulrr roru/rrrrinr. Nor crrr
7, lu[•rlsell rlrprh Tremor land.urrare, 113
ICI %lode water km el below loll of ra.il1t: 60
I t. Flnrrhvlr Alan.rrer: 4 Il. 1
1:- ►►rlt consirurtinn niriholl' RGtaty
I• ...TO-.n.,i. ..bk 1xr.1l p,li c1. I
I Iu Iginnll 1 u I,tii .
14- N .L►I R L 1.%L* i
1 Illltt
10
d1 W 1uN11n5
101 11'
113 It
Sandstone
n,
rt.
leS. 11l 11lt
I1[1HI
0 rl,
I. 1 %st14{
1- Cti 1%1. .k.r
Ir.
86 A.
11ti1. 1111 rj'1A\s1Zrlaprrr•d
WI Ile 1ra.rd .,li 111I I.1 %I:H I v./plk.Idr)
rlr14r 111E 1111[kL1*•
4 " Sch40
rky1 l.rd-IaI
►1L11p11[
PVC
I in PM
111
111.1111.II11t tux 10IE
I41S11iU
84 rl
101 fl-
2 Ia Sch40
PVC
1L
n.
1n.
I'. sr !FAN —
114101 111 9ls r[k 11 M
51,v1 .1{I
'pm k m..+•
1 . l l kf u.
h,
A.
FL la.
n. is.
r. uR1x T
))hill
111
51.1116U8 . 1'411.116-M1.51 %II 11 ,In; ItinH tit
0 tr.
3 -
Ben! Chips Poured, 1001bs
3 fl-
21 n•
Bert. Slurry Purnped. 75 Ibs
21 rt.
101 A-
Bern- Slury Pressure Grouted, 150 Ibs
19.!•1tiD+Cl(.1►
I.1. P►r.k
trf.p+llr.bvl
Y111N1
re.
A.
11!
_. d
n.
asi l.l'Hltf• -. —
-
[Ai t,Atreste crmo-r ID6
1,Ze. DRII.IAila
LO(: India
sdallowlebeek Yprrwrtl
ka[IM
to
Mu fir Ho..In.wr.L+drr-,+. url+w.►r..T-rnl.aHr or.i
0 e•
3$ n
Sand
38 rr-
43 b
43 n•
51 n
Mud
.._Sand_-_ --
51 It
55 "
'
Limestone
55 n-
101
101 -
113 H.
—
Pee Dee Mud
Sandstone
n. n.
r.._..
217nEs1ARi(ri
22.
0:
11/25/15
Signittre ofCCnined W Contrawt bale
48niog Mfg fl10l. 1 hvlrk1 r,r1fj,- aka l In IA() lane f rr.J ,mars) l/da en u,. nrlkrrrr
with 1 S,1.NCAC 42C -A11r1 or 1 C9 NCfC UJC Amu w d! Cocernrmon Sronf , usd gee. ,r
rapt �a4ir n'[a.!/w. hornprul(ded1n 11 t1.m1!pxwer.
2.1.5ire chagrin or additional well details:
Yeu may use the back or this page to proviiTe additional well site drtsilt or well
conlinfnion detai IS- You mkt oho n110Cll additionai paws if accessary.
SI B111TF.l LTI. CTIQNS
}ur .%I ►1di.- ,-IIN1il the tient Iviilmt CllJoys a1 Pompleinoi .41 Heel
.tln,tn,dinn lu llo; Inll,�oiny
ih 1 Incision al %lterQublln. infornlarioo 1'rneesslfrg 1 nil,
1017 MAO serbier( elder, RalcIXh. tit ZT09.111,1
2Jh. For Imerinat ►►elh: In a0411 in lrndnig the morn+ 1.. the addle,. In -'4a
nl»'... ,.I+.• .1.11,01111 n 4...13) ,rl Ihh 11 Trip twlhtn 111 any. nt rnmrkti„n nt .tell
.,, n.1ni1l ran to the following:
IJ,ulen or Prater Ounlit}. 1 oderground Injection 1 anlrnl Program,
1638 Moil Sr -tiler Cruller. Rsleigh.31 :'bH4-1836
FOR %V%TER%IPPI.I H'F.I.I.tif1VI-1:
13n. 'gold i gpnl t 50
13h. 1I .1flI elian n.pr: HTH
H
►Ieolta,1 of tn.!, Air
imounl; 1 Ibs
2Jr. Fur H.Ic, Sough & In}rcunn ►►eik: h, ed,a,on r,, ,c11d1ng the 1, ni 1�•
the d,idrgs:arrt ,th:we. aso .uhmlr eve cell) nt du. norm within 10 d;y. r
.'rnplcu4n n11%01 enn.I0Ie11Pn h. Itc CiNn11) Iw ilrh d1I,:i.no :ar III the gunny
Nilr7r LAM Oructed
1d. rip 1 urdin. I ',lmarlmcM nl1 In ,lunt.+eln saki ti.ilun l l(1..l•ma. I}r1nnm, if H,Iln ,,lun'Ir1 li I'u.1,11,1

•
April 22, 2016
Ronald and Sharon Demas
3053`dStSouth
Wilmington, NC 28401
Subject: Geothermal well sampling results
Permit Number W10800444
New Hanover County
Dear Mr. & Mrs. Demas:
PAT MCCRORY
DONALD R. VAN DER VAART
S. JAY ZIMMERMAN
RECEVED/NCDEQ
WR
Quality Regional
1:.w•L6ons SectiOrt
On March 16, 20].6 staff from the Division of Water Resources sampled the influent and effluent lines of
your geothermal underground injection well heat pump system. The samples were analyzed by the
Division's laboratory for coliform, total dissolved solids, metals, nitrates and other inorganic constituents.
No exceedances of the State Groundwater Standards were observed. A copy of the lab results are
enclosed for your review.
Should you have any questions concerning this letter, please feel free to contact me at [phone] or
by email at [e-mail].
Sincerely,
Geoff' Kegley
Water Quality Regional Operations Section
Wilmington Regional Office
Division of Water Resources, NCDENR
Enclosure: sample results
cc: Michael Rogers, DWR Central Office
�j o ,-,- 6 44 M
State ofNordi Carolina E Department ofEnvuosnnental Quality I Divisen of Water Resources
127 Cardinal Drive Ext, Wilmington. NC 211405
919 7967215

North Carolina Division of Water Resources
Water Sample Collection & Su bm ittal Form
Central Laboratory (Water Sciences Section)
VisielD::.
61 H4:4 ''ll'
.;,-1/ ..= ..2.
//? '
• - I
1 --.." .:..-
12X.,: - ;I:lah .LlselOn V.. _--
.e.tv
ELI
L ,..1 AC27284
it
"-----7.-- —
- •
Date pecetfe dirt vbi C
- • • . •-• 7
ricatiDn Descriptioi W ( 0 300 4414
A. . .
ocation Code
) "4- •-t.:i
L County: - ill
. ;
Coliector: j G. Kegley
• - Prlopty:
_
'
_ -••
.
Water Matrix'
.,, • _ •
CI Surface
Ed GrOund
0 Waste
0 Blank
0 Solut on
.6.400atiop,Typp: '
_T_i__- -- _. :- —.. •,• - --
URver/Stream ,Lake—
0 Estuary 0Canal
0Storrnwater
0Moniloring Well OVVater SupplA._
'Veliiiiy.Meihc.p8i
['Effluent 01r:fluent
0Fietd Blank
OTrip Blank
0 Filter Blank
0 Other:
164-46A..d: ! Yrs
DWRRtvion:
- - —iRO
(based oreaourityl
DWR Offce:
DWR-WQQROS
(oi ageney mune):
bi
0Aent
El Routine
OCompliance
0 coc
Lir—rarnergency
DaA
Received By:. i lifNe
River basin.- ' '•
L::. Dap: .: 3 )11, L201 G
• i LState Courier
['Hand Delivery
4, ....i nOther:
Notes: Geothermal Injection Wells
..1.... - ,-is ....3
Time: '' . t v. 0 0
0 Chlorinated • De -chlorinated in Field
Sampfing 10-Grab : . Composite
Method: - i 0 other:
. . ,.,
Temperabiri, -
.... ro .......;•'. 'Z'
rori Arrival :
Dissolvedn aalysis: Enter DIS''
0 Filtered in Field
in cheek -boxes for parameters
• •
Sample Depth:
Conecror's Canurfeltis:
. 4 (e level ‘ — irl-Pluthsri--
Microbiology Parameters:
MBAS (surfactants) mglL Il
Metals Par.ameters:
Tin (Sri) pg/L
--Alkalinity,
Acidity. as CaCO3. to pH 4.518.3 mg/L
Oil and Grease, HEM, Total Recovers! mg&
X
Aluminum (Ai) pg/L
Titanium (Ti) pg/L
as CaCO3, to pl-I 4.5/8.3 mg/L
Phenols, Total Recoverable pg/L
X
Antimony (Sb) pg/L
X
V2 nad I UTI1 (V) pg/L
BOO: elocnemical Oxygen Demand, 5-day mg/L
Residue: Total (Total Solids) mg/L
X
Arsenic (As) lJg1-
X
Zinc (Zn) 141/L]
cBOD: Carbonaceous BOD. 5-day mgfL
Residue: Volatile/Fixed, Total mgfL
X
Barium (Ba) 1-10-
X
Conform: Fecal MF /100mi
Residue: Suspended (Suspended Soli( mgtL
X
Beryllium (Be) pg/L
Boron (B), Total pg/L
X
Coliforn: Total MF /100mi
Residue: Volathe/Frxed, Suspenclecl mg/L
X
Cadmium (Cd) pg/L.
Mercury 1631, low-level ng/L
Conform: Tube Fecal /100mi
X
TDS - Total Dissolved Solids mg/L
X
Calcium (Ca) mg(L
Conform: Tube Total /100m1
Since mglL
X
Chromium (Cr), Total P911-
Organics Parameters:.
----'
Specific Conductance, at 25 ''C viol-tot/ern
Sulfide mg/L
X
Cobalt (Co) PO-
Auid Herbicides
TOC - Total Organic Carbon mg/L
Tannin & Lignin rng/L
X
Copper (Cu) pg/L
Organochlorine Pesticides
Turbidity NTU
X
Iron (Fe) PO-
Organonitmgen Pesticides
Other Parameters:
X
Lead (Pb) pg/L
Organophosphorus Pesticides
Wet Chemistry Parameters:
pH s.u.
X
Lithium (Li) pg/L
PCBs (polychlorinated biphenyls;
Bromide mgfL
Hardness, Total as C2CO3 - by tilraliot mg/L
X
Magnesium (mg) mg/L
X
--'
Chloride mg/L
X
Manganese (Mn) pg/L
Semi-Volable Organics (BNAs)
Fluoride mg/L
Mercury (Fig) 141-
TPH Diesel Range
x
Sulfate mglL
Niitriefit's PS-rameters: "1
X
Molybdenum (Mo) pg/L
Chlorophyll a pg/L
Ammonia as N (NH3-N) mg/L
X
j. Nickel (Ni) pg/L
Volatile Organics (VOA)
Color: ADMI C.U.
X
Nitrate -Nitrite as N (NO3+NO2-N) mg/L
X
Potassium (K) rng/L
--T
Color: Platinum Cobalt c.u.
Total Kjeldahl Nitrogen as N (TKN) mg/L
X
Selenium (Se) ugh.
TPH Gasoline Range
COD: Chemial Oxygen Demand mg/L
Total Phosphorus as P (TP) mg&
X
Silver (Ag) pg/L
Cyanide, Total mg/L
Nitrite as N (NO2-N) mg1L
X
Sodium (Na) mg/L
Biological: ......
Formaldehyde mg/1
Nitrate as N (NO3-N calculated) mg/L
Strontium (Sr) pg/1.-
Phytoplankton / Algae
Hexavalent Chromium (Cie+) rng/L
Orthophosphate as P (PO4) mg/L
X
Thallium (T1) IV&
LAB COMMENTS :
ParameterVoorrona9
Water Temp (°C):
pH (s.u.)•
Dissolved Oxygen(ppm):
Conductivity (prnheisforn):
Salinity (ppt):
Revision: 210612015

AC27284 North Carolina Division of Water Resources Water Sciences Section Laborato ry Results
Loe. Descr.: WIO800444 Sample ID : AC27284
County: Collector: G KEGLEY VisitlD PO Number# ~
Region: WIRO Report To WIRO Location ID : WIO800444 Date Received : 03/17/2016
River Basin Collect Date: 03/16/2016 Priority -NONE-nme Received : 08:05
Emergency Collect Time: 11 :00 Sample Matrix: GROUNDWATER Labworks LoginlD TASCENZO1
COC Yes/No Sample Depth Loe. Type: WATER SUPPLY Delivery Method NC Coy[!!![
Final Report Date: 4113/16
Report Print Date: 04/1312016
Final Re 12ort
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
Result/ Units Method Anal~sis
CAS# Anal '.t!eName PQL Qualifier Reference Date Validated b~
LAB
Sample temperature at receipt by lab 2.2 ·c 3/17/16 MSWIFT
MIC
Coliform, MF Fecal in liquid 1 1 82Q1 CFU/100ml SM 9222 D-1997 3/17/16 ESTAFFORD1
Col iform, MF Total in liquid 1 B2Q1 CFU/100ml SM 9222 B-1997 3/17116 ESTAFFORD1
NUT
NO2+NO3 as N in liquid 0.02 0.02 U mg/Las N EPA 353.2 REV 2 3/29/16 CGREEN
WET
Bromide 0.4 0.4U mg/L EPA 300.0 rev2.1 3/17/16 CGREEN
Chloride 1.0 25 mg/L EPA 300 .0 rev2 .1 3/17/16 CGREEN
Fluoride 0.4 0.4U mg/L EPA 300.0 rev2 .1 3/17/16 CGREEN
Sulfate 2.0 16 mg/L EPA 300.0 rev2 .1 3/17/16 CGREEN
Total Dissolved Solids in liquid 12 170 mg/L SM 2540 C-1997 3/18/16 CGREEN
MET
7440-22-4 Ag by ICPMS 1.0 1.0 U ug/L EPA200.8 3/30/16 ESTAFFORD1
7429-90-5 Al by ICP 50 50 U ug/L EPA200.7 3/30/16 ESTAFFORD1
7440-36-0 Antimony by ICPMS 10 10 U ug/L EPA 200.8 3130/16 ESTAFFORD1
7440-38-2 As by ICPMS 2 .0 2.0 U ug/L EPA200.8 3/30/16 ESTAFFORD1
7440-38-3 Ba by ICP 10 10 U ug/L EPA 200.7 3/28/16 ESTAFFORD1
7440-41-7 Be by ICP 5.0 5.0 U ug/L EPA200.7 3/30/16 ESTAFFORD1
7440-70-2 Ca by ICP 0.10 49 mg/L EPA200.7 3/28/16 ESTAFFORD1
7440-43-9 Cd by ICPMS 0.50 0.50 U ug/L EPA200.8 3/30/16 ESTAFFORD1
7440-4~ Cobalt by ICP 50 50 U ug/L EPA200.7 3/30/16 ESTAFFORD1
7440-47-3 Cr by ICPMS 5 .0 5.0 U ug /L EPA200.8 3/30/16 ESTAFFORD1
7440-50-8 Cu by ICPMS 2.0 2.0 U ug/L EPA200.8 3/30/16 ESTAFFORD1
7439-89-6 Fe by ICP 50 120 ug/L EPA200;7 3/30/16 ESTAFFORD1
7440-09-7 K by ICP 0.10 1.2 mg/L EPA 200 .7 3/28/16 ESTAFFORD1
7439-93-2 Li ICP 25 25 U ug/L EPA200 .7 3128/16 ES TAFFORD1
7439-95-4 Mg bylCP 0.10 1.9 mg/L EPA 200.7 3/28/16 ESTAFFORD1
7439-96-5 Mn by ICP 10 12 ug/L EPA 200.7 3/30/16 ESTAFFORD1
7439 -98-7 Mo by ICPMS 10 10 U ug/L EPA200.8 3/30/16 ESTAFFORD1
7440-23-5 Na by ICP 0 .10 15 mg/L EPA200.7 3/28/16 ESTAFFORD1
7440-02-0 Ni by ICPMS 2.0 2.0 U ug/L EPA200.8 3130/16 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0 2.0 U ug/L EPA200.8 3/30/16 ESTAFFORD1
7782-49-2 Se by ICPMS 1.0 1.0 U ug/L EPA200.8 3/30/16 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mall Service Center, Raleigh, NC 27699-1623 [phone]
"Not Detected" or "U" does not indicate the sample is analyte free but that the analyte ·;s not detected at or above the POL.
Page 1 of 2
!NC,~ La6oratory Section !R§su{ts/Samp{e Comments/QuaEifier (J)efinitions
Sample ID : AC27284
CAS# Analy te Name POL Result/ Method Analysis
Qualifier Units Reference Date Validated b 1
7440-28-0 Thallium (Tl) ICPMS 2.0 2.0 U ug/L EPA200.8 3/30/16 ESTAFFORD1
7440-62-2 V by ICP 10 10 U ug/L EPA200 .7 3/30/16 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 10 U ug/L EPA200.8 3/30/1 6 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 analyte is not detected at or above the POL.
Page 2 of2
166 07v
North Carolina Division of Water Resources
Central Laboratory(WaterScience-3Section) Water Sample Collection & Submittal Form
r• 4Vi si
lec ronalj '
7fig
ID G
_L_L h f 1ce-COnlu: .:.-";
i1 AC27285
_� —
Dee Received 1 Ti ) 1 r
/ d/+^
.
ocarion ❑escriptio► W (0 S0 0 t+44
i
beatio �-Gode
r County:
Collector:1 G. Kegley
._ Priority:
,
y
Water Matrix
❑ Surface
Q Ground
❑ Waste
El
❑ Solution
5 LocationTypo:
❑RiverlStream
DEstuary
❑Stamlwaler
❑Monitoring Well
❑Effluent
['Field Blank
❑Filter Biar•.k
DOther:nn.Arrival
,
, : ,...,
�_._�_ ._
Lake
El Canal
0 Water 5uppl
'�?elivery
❑Influent
❑Trip 8iank
.
;erne. Received SeJC
O
DWR Region: '
WiR❑
(based On county)
DWR-Of{ae:!
- ,. + i DWR-WQQROS
(or agency name),
❑Ambient
❑� Routine
❑ Compliance
❑ coc
❑ Emergency
rg
DOA
l ��I
Received By: I a
_ _
' -RiverBasln:
._ ,- • i
- Date_
It .[JY
' U State Courier
i
Method: ❑Hand Delivery
i ❑Other_
Notes: Geothermal injection Wells
7ir�iae_ 11 1 S
Chlorinated ❑De -chlorinated in Field
Sa►nplrng_ ❑Grab UGornpostte
Method:' l ❑ Other:
{
r Temperature -
II
Dissolved analysis: Enter "DI5"
❑ Filtered in Field
in check•boxes for parameters
R
Sa►nple L pilr.'•
, VA Id, ds :
Calledar's Commons: 12-{ Dr +D Re r iee-1-+ a•+ — t >f I v e tl-
Microbiology Parameters: ._ .- -r - 1-
MBAS (surfactants) mg/L
Metals Parameters;:, 4. .i. -, r
Tin (Sn) pgfL
Acidity, as CaCO3, to pH 4.5/8.3 mg/L
Oil and Grease, HEM, Total Recoverat rng/L
X
Aluminum (Al) pg/L
Titanium (Ti) pg1L
Alkalinity, as CaCO3, to pH 4.518.3 mg/L
Phenols, Total Recoverable }IgIL
x
Antimony (Sh) pg/L
X
Vanadium (V) pgJL
BOO: Biochemical Oxygen Demand, 5-day mg/L
Residue: Total (Total Solids) mg/L
X
Arsenic (As) pglL
X
Zinc (Zn) pg11_
cBOD: Carbonaceous BCD, 5-day mg/L
Residue: Volatile/Fixed, Total mg/L
X
Barium (Ba) pg1L
JC
Coliform: Fecal ME llobml
Residue: Suspended (Suspended So/it mg/L
X
Beryllium (De) pg/L
Boron (B), Total pg&
X
Coliform: Total MF /100ml
Residue: Volatile/Fixed, Suspended mg/L
X
Cadmium (Cd) pglL
Mercury1631. low-level ng1L
Coliform: Tube Fecal I1OOm1
x
TDS - Total Dissolved Solids mg/L
X
Calcium (Ca) . mg/L
Coliform: Tube Total 1100ml
Silica mg/L
X
Chromium (Cr), Total PO-
Organics Parameters: • w
1Specific
Conductance, at 25 °C umhasrcmi
Sulfide mg/L
X
Cobalt (Co) pglL
Acid Herbicides
TOG - Total Organic Carbon mgfL
Tannin & Lignin mg/L
X
Copper (Cu) pgIL
Organochlorine Pesticides
Turbidity NTU
X
Iron (Fe) NgIL
Drganonitrogen Pesticides
Other Pararfieters--r
x
Lead (Pb) pgIL
0rganophosphorus Pesticides
Wet Chemistry Parameters: • -
pH s.u.
X
Lithium (Ll) pg1L
PCBs (polychlorinated biphenyis:
Bromide mg/L
Hardness, Total as CaCO3 - by titratioi mg/L
X
(Mg) mg/L
X
Chloride mg/L
X
_Magnesium
Manganese (Mn) pgJL
Semi -Volatile Organics (BNAs)
Fluoride mglL
Mercury (Hg) pg/L
TPH Diesel Range
x
Sulfate mg/L
: fdtitrientsiParameters: "• . -
X
Molybdenum (M❑) pglL
Chlorophyll a PO-
Ammonia as N (N113-N) mgfL
X
Nickel (Ni) pg/L
Volatile Organics (VOA)
Color. ADMI c.u.
X
Nitrate -Nitrite as N (NO3+NO2-N) mg/L
X
Potassium (K) mg&L
Color: Platinum Cobalt c.u.
Total Kjeldahi Nitrogen as N (TKN) mg/L
X
Selenium (Se) PO-
TPH Gasoline Range
COD: Chemical Oxygen Demand rng&L
Total Phosphorus as P (TP) mg/L
X
Silver (Ag) pglL
Cyanide. Total mg/L
Nitrite as N (NO2-N) mgfL
X
Sodium (Na) mg/L
Binlcgicat:.
Formaldehyde mg/L
Nitrate as N (NO3-N calculated) mglL
Strontium (Sr) t.ty1L
Phytopiankton 1 Algae
Hexavalenl Chromium (Cr6+) mg/L+
Orthophosphate as P (PO4) rng1L
X
Thallium (11) pgfL _
I
LAB COMMENTS :
'ield Paranieters(oplional)
-Water Temp (°C):
FH (s
Dissolved Oxygen (pprn)_ , Conductivity (pmhoslcm)
Salinity (ppt):
Revision: 210612015

AC27285 North Carolina Division of Water Resources Water Sciences Section Laboratoa Results
Loe. Descr.: WIO800444 Sample ID : AC27285
County: Collector: G KEGLEY VisitlD WIO800444 PO Number# 16G0074
Region: WIRO Report To WIRO Location ID: WIROAPTB Date Received: 03/17/2016
River Basin Collect Date: 03/16/2016 Priority -NONE-nme Rece ived: 08:05
Emergency Collect nme: 11 :15 Sample Matrix: GROUNDWATER Labworks LoginlD TASCENZO1
COC Yes/No Sample Depth Lac . Type : WATER SUPPLY Delivery Method NC Courier
Final Report Date: 4/13/16
Report Print Date: 04/13/2016
Final Report
If this report is labeled preliminary report, the results have not been validated. Do not use for Regulatory purposes.
Result/ Units Method Analy:sis
CAS# Anal y:t e Name POL Qualifier Reference Date Validated b:t
LAB
Sample temperature at receipt by lab 2.2 "C 3/17/16 MSWIFT
MIC
Coliform, MF Fecal in liquid 1 B201 CFU/100ml SM 9222 D-1997 3117/16 ESTAFFORD1
Coliform, MF Total in liquid 1 B201 CFU /100ml SM 9222 B-1997 3/17/16 ESTAFFORD1
NUT
NO2+NO3 as N in liquid 0.02 0 .02 U mg/Las N EPA 353.2 REV 2 3/29/16 CGREEN
WET
Bromide 0.4 0.4 U mg/L EPA 300.0 rev2.1 3/17/16 CGREEN
Chloride 1.0 25 mg/L EPA 300.0 rev2.1 3/17/16 CGREEN
Fluoride 0 .4 0.4U mg/L EPA 300.0 rev2.1 3/17/16 CGREEN
Sulfate 2.0 16 mg/L EPA 300.0 rev2 .1 3/17/16 CGREEN
Total Dissolved Solids in liquid 12 174 mg/L SM 2540 C-1997 3/18/16 CGREEN
MET
7440-22-4 Ag by ICPMS 1.0 1.0 U ug/L EPA200.8 3/30116 ESTAFFORD1
7429-90-5 Al by ICP 50 sou ug/L EPA200.7 3130/16 ESTAFFORD1
7440-36-0 Antimony by ICPMS 10 10 U ug/L EPA 200.8 3/30/16 ESTAFFORD1
7440-38-2 As by ICPMS 2.0 2.0 U ug/L EPA200.8 3130/16 ESTAFFORD1
7440-38-3 Ba by ICP 10 10 U ug/L EPA 200.7 3/28/16 ESTAFFORD1
7440-41-7 Be by ICP 5 .0 5.0U ug/L EPA200.7 3/30/16 ESTAFFORD1
7440-70-2 Ca by ICP 0.10 49 mg/L EPA200.7 3128/16 ESTAFFORD1
7440-43-9 Cd by ICPMS 0.50 0.50 U ug/L EPA200.8 3/30/16 ESTAFFORD1
7440-48-4 Cobalt by ICP 50 50 U ug/L EPA200.7 3/30/16 ESTAFFORD1
7440-47-3 Cr by ICPMS 5.0 5.0 U ug/L EPA200.8 3/30/16 ESTAFFORD1
7440-50-8 Cu by ICPMS 2.0 14 ug/L EPA200.8 3130/16 ESTAFFORD1
7439-89-6 Fe by ICP 50 120 ug/L EPA200.7 3/30/16 ESTAFFORD1
7440-09-7 K by ICP 0.10 1.2 mg/L EPA 200.7 3/28/16 ESTAFFORD1
7439-93-2 Li ICP 25 25U ug/L EPA200 .7 3/28/16 ESTAFFORD1
7439-95-4 Mg by ICP 0.10 1.9 mg/L EPA200.7 3/28/16 ESTAFFORD1
7439-96-5 Mn by ICP 10 12 ug/L EPA200.7 3/30/16 ESTAFFORD1
7439-98-7 Mo by ICPMS 10 10 U ug/L EPA200.8 3t3on6 ESTAFFORD1
7440-23-5 Na by ICP 0.10 15 mg/L EPA200.7 3/28/16 ESTAFFORD1
7440-02,0 Ni by ICPMS 2.0 2.0 U ug/L EPA200.8 3/30/16 ESTAFFORD1
7439-92-1 Pb by ICPMS 2.0 2.0U ug/L EPA200.8 3130/16 ESTAFFORD1
7782-49-2 Se by ICPMS 1.0 1.0 U ug/L EPA200.8 3/30/16 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 analyte is not detected at or above the PQL.
Page 1 of2
:NC ll)'WIJc La6oratory Section !J?gsu{ts/Sa.mpfe Comments/Quafi-(ier ll)efinitions
Sample ID: AC27285
CAS# Ana lyte Name PQL Result/ Method Analysis
Qualifier Units Reference Date Validated by
7440-28-0 Thallium (Tl) ICPMS 2.0 2.0 U ug/L EPA200.8 3/30/16 ESTAFFORD1
7440-62-2 Vby ICP 10 10 U ug/L EPA200.7 3/30/16 ESTAFFORD1
7440-66-6 Zn by ICPMS 10 42 ug/L EPA200.8 3/30/16 ESTAFFORD1
WSS Chemistry Laboratory» 1623 Mail Service Center, Raleigh, NC 27699-1623 [phone]
"Not Detected" or "U" doe~ 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 WI0800444
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
geoff.kegley
Coastal SWRule
Permitted Flow
Facility
Facility Name
Ronald and Sharon Demas SFR
Location Address
305 3rd Si S
Wilmington
Owner
Owner Name
Ronald
Dates/Events
Orig Issue
12/2112015
NC
C
App Received
11/23/2015
Regulated Activities
Heat Pump In jection
Outfall
Waterbody Name
28401
Demas
Draft Initiated
Scheduled
Issuance
Central Files : APS SWP
12/21/2015
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Public Notice
Owner Type
Individual
Owner Affiliation
Ronald C . Demas
I
MD
305 3rd St S
Wilmington
Issue
12/21/2015
Requested /Received Events
RO staff re port received
Additiona l information requested
Additional information received
Streamlndex Number Current Class
Effective
12/21/2015
NC 28401
Expiration
11/30/2020
12/6/1 5
12/1 1/1 5
12/15/15
Subbasin
PAT MCCRORY
Govemor
DONALD R. VAN DER VAART
Secretary
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
Dr. Ronald and Sharon Demas
305 3rd Street South
Wilmington, NC 28401
Re: Issuance of Injection Well Permit
Permit No. WI0800444
December 21, 2015
Geothermal Heating/Cooling Water Return Well
New Hanover County
Dear Dr. and Mrs. Demas:
Director
In accordance with your permit application received November 23, 2015, and additional information
received December 15, 2015, I am forwarding Permit No. WI0800444 for the construction and
operation ofgeothemial heating/cooling water return well(s) located at the above referenced address.
This permit shall be effective from date or issuance until November 30, 2020, and shall be subject to
the conditions .and limitations stated therein.
Please Note:
• Please contact the Wilmington Regional Office.(WiRO) of the Division of Water
Resources (910-796-7215) within 30 days after the geothermal well becomes operational
to arrange to collect samples from the influent and effluent sampling ports. Laboratory
analytical results will then be forwarded to you when it becomes available.
• Also, please send copies of the Well Construction Record (GW-1) to the WiRO and
Central Office in Raleigh within 30 days after constructed (addresses are available on
attached permit).
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the pennit 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].
State of North Carolina I Envir~runental Quality I Water Resources
161 J Mail service Cenler -1. Raleigh, North Carolina 27699-161 J
919 707 9000
Best Regards,
~~
'Michael Rogers, P.G. (NC & FL)
Underground Injection Control Manager (UIC) -Hydrogeologist
Division of Water Resources, NCDENR
Water Quality Regional Operations Section
cc: Jim Gregson and Morella Sanchez-King, Wilmington Regional Office
Central Office File, WI0800444
New Hanover County Environmental Health Department
Page2 of2
2
'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 HERESY GRANTED TO
Dr. Ronald and Sharon Demas
FOR THE CONSTRUCTION AND OPERATION OF 1 GEOTHERMAL HEATING/COOLING WATER
RETURN WELLS), defined 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 305 PI Street South, Wilmington, New
Hanover County, NC 28401 will be constructed and operated in accordance with the application submitted
November 23, 2015, and conformity with the specifications and supporting data received December 15, 2015, all
of which are filed with the Department of Environmental Quality and are considered a part of this perrni t.
This permit is for construction and 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 November 30, 2020, and shall
be subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 21st day of December 2015_
Att;44)
S. Jay Zimmerman, P.G.
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Perrnit #W I(JN0O444
L I IC/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 ofthis 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 Pennittee, 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 riot 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 1 SA NCAC 02C .0107 except as required in Item #2 below.
2. Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC 02C ,.0107
except that the entire length of the casing shall be grouted in such a way tp.at 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.
[l5A 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 [15A 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 .0107G)(2)].
Pennit #Wl0800444 UlC/5A7
ver.11/15/2015
Page 2 of 5
7. A completed Well Construction Record·(Forth GW-1) shall be submitted as described in Part VI.5 ofthis
permit.
PART III -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall notify the
Underground Injection Control (UIC) Central Office staff, telephone number 919-807-6496 and the
Wilmington Regional Office Staff, telephone number 910-796-7215. [15A NCAC 02C .021 l(k)J.
2. Within 30 days of injection well completion/operation, the Permittee shall contact the Wilmington Regional
Office Staff in order to have samples collected at the source well and injection well. [15A NCAC 02C
.021 l(k)]
PART IV-'--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 ofl5ANCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C .021 l(j)].
2. The issuance ofthis 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 [ISA NCAC 02C .0206].
PART V -INSPECTIONS [15A NCAC 02C .021 l(k)]
1. Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation of credentials, enter and inspect any property, premises, or place on or related to the
injection facility at any reasonable time for the purpose of determining compliance with this permit, may
inspect or copy any records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwat~r, 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 san1ples of the injection facility's activities.
PART VI-MONITORING AND REPORTING REQUIREMENTS
l. Records of well construction, repair, or abandonment shall be submitted·within 30 days of completion of
such activities. Copies of such records shall be retained on-site and available for inspection [ 15A NCAC
02C .0224(f)(2), (4)].
2 . Monitoring of any well may be required to ensure protection of the groundwater resources of the State and
compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
.0224(f)(l)].
Pennit #Wl0800444 UJC/5A7
ver. 11 /15/20 I 5
Page 3 of5
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 l SA 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.
(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 Pennittee 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 VII--' PERMIT RENEWAL [ISA 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 effluent from the geothermal heating and cooling system associated with this
permit.
Permi t #WT0800<144 UIC/5A7
ver. 11/15 /2 015
Page 4 of5
PART VIII-CHANGE OF WELL STATtJS [151\ NCAC 02C .0240]
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule I SA
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
ISA NCAC 02C .0l 13(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 I SA
NCAC 02C .0113(b), which include, but are not limited to, the following:
(A) All casin.g 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 ISA
NCAC 02C .011 l(b)(l)(A),(B), and (C).
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In those cases when a subsurface cavity has been created as a result of the injection
operations, each well shall be abandoned in such a manner that will prevent the movement
of fluids into or between underground sources of drinking water.
(F) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
ISA NCAC 2C .0224(f)(4} within 30 days of completion of abandomnent.
5. The written documentation required in Part VIII (4)(F) shall be submitted to the addresses specified in
Part Vl.5 above.
l?e11nit #Wl0800444 UlC/5A7
ver. l 1/l 5/2015
Page 5 of5
Ro gers, Michael
From:
Sent:
To:
Cc:
Subject:
Dear Mr. Rogers,
[e-mail]
Tuesday, December 15, 2015 6:30 PM
Rogers , Michael
rogerscorp@ec. rr. com
305 South 3rd Street geothermal well project.
I am authorizing Chris Deal to sign necessary paperwork regarding the work done on the geothermal new well project at
our home at 305 S. 3rd Street, Wilmington, NC, 28401 , completed about 2 weeks ago .
If there are any quest ions, please contact me.
Ronald C. Demas, MD
305 S. 3rd Street
Wilmington , NC 28401
phone Cell 704-236-3425
1
Ro gers , Michael
From: Rogers, Michael
Sent:
To:
Subject:
Tuesday, December 15, 2015 1:39 PM
'Tommy Rogers'; [e-mail]
RE: Geothermal well
Thanks. Also, please provide estimated psi for injection of return water. I don't think O psi is accurate.
From: Tommy Rogers [mailto:[e-mail]]
Sent: Tuesday, December 15, 2015 12:49 PM
To: [e-mail]
Cc: Rogers, Michael <[e-mail]>
Subject: Geothermal well
Ron,
Would you please send Michael Rogers w/NCDENR ([e-mail]) authorization for Chris Deal our well
driller to sign the paper work related to the geothermal well we just did at you house?
Thanks,
Tommy Rogers
Rogers Building Corporation
1013 South 16th Street
Wilmington, North Carolina 28401
910 279 1381
1
Ro gers, Michael
From:
Sent:
To:
Tommy Rogers <[e-mail]>
Tuesday, December 15 , 2015 12 :49 PM
[e-mail]
Cc: Rogers, Michael
Subject: Geothermal well
Ron,
Would you please send Michael Rogers w/NCDENR ([e-mail]) authorization for Chris Deal our well
driller to sign the paper work related to the geothermal well we just did at you house?
Thanks,
Tommy Rogers
Rogers Building Corporation
1013 South 16th Street
Wilmington , North Carolina 28401
910 279 1381
1
Division of Water Resources
Water Quality Regional Operations Section
REGIONAL STAFF REPORT ~ ~
Date: 11/30/2015 Permittee(s): ...::r owm y Rog ers 3 Permit No.: WI -PENDIN ~Se~ /J-.ir,rdf'l•v-, • ~
To: Michael Rogers
Project Name: Geothermal Open-Loop lniection Well
Regional Login No: Geoff Kegley
County: New Hanover 4> c.,J;Co8u<J'-f'-I <-f
I. GENERAL INFORMATION
1. This application is (check all that apply):0 SFR Waste Irrigation System IZI UIC Well(s)
IZI New O Renewal
D Minor Modification D Major Modification
RECEIVED/OENR/DWR
DEC O 6 2015
Water Quality Regional
Operations Section
D Surface Irrigation O Reuse O Recycle D High Rate Infiltration O Evaporation/Infiltration Lagoon
D Land Application of Residuals
0 Distribution of Residuals
D Attachment B included
0 Surface Disposal
D 503 regulated D 503 exempt
D Closed-loop Groundwater Remediation IZI Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IZI Yes or O No.
a. Date of site visit: 11/24/2015
b. Person contacted and contact information: Chris Deal 910-604-0624
c. Site visit conducted by: Geoff Kegley
d. Inspection Report Attached: D Yes or IZI No.
2. Is the following information entered into the BIMS record for this application correct?
0 Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For SFR Treatment Facilities:
a. Location:
b. Driving Directions: __
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __ Method Used (GPS, Google™, etc.); __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For UIC Injection Sites:
(If 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): 305 S. 3rd Street Wilmington, NC 28401
b. Driving Directions:
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: Method Used (GPS, Google™, etc.);
APS-GPU Regional Staff Report (Sept 09) Page I of 4 Pages
Division of Water Resources
Water Quality Regional Operations Section
REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description of Well(s) and Facilities -New, Renewal, and Modification
1. Type of injection system:
[8J Heating/cooling water return flow (SA 7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
0 Closed-loop groundwater remediation effluent injection (SL/''Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes [8J No
3. Are there any potential pollution sources that may affect injection? D Yes [8J No
What is/are the pollution source(s)?. What is the distance of the injection well (s) from the pollution source (s)?
ft.
4. What is the minimum distance of proposed injection wells from the property boundary? ~40Jl
5. Quality of drainage at site: [8J Good D Adequate D Poor
6. Flooding potential of site: [8:ILow D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? [8J Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal and Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes D No. If yes , explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes, explain:
3. For renewal or modification of g roundwater remediation permits (of an y type). will
continued/additional/modified in jections have an adverse im pact on mi gration of the plume or mana!!ement of
the contamination incident? D Yes D No. If yes . explain:
APS-GPU Regional Staff Report (Sept 09) Page 2 of 4 Pages
Division of Water Resources
Water Quality Regional Operations Section
REGIONAL STAFF REPORT
4. Drilling Contractor: Name: Chris Deal -Cape Fear Drillin g Services
Address: 111 E. Fremont St
Burgaw . NC 28425
NC Certification number: 2548A
Complete and attach NEW Injection Facility Inspection Report, if applicable
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the Application:
This review was conducted for a new permit for an open loop underground injection
geothermal well system for the subject residence . On November 23, 2015, an application
was hand-delivered to the regional office. An urgent request was made to allow
permission to drill a new injection well to serve an existing geothermal system that had
been used as a pump-and-dump style system for years. The City of Wilmington was
threatening to turn off the heat pump system after discovering the water was discharging
to the storm drains. Due to the situation and pending cold weather a quick site visit was
performed, the situation was discussed with the well driller, and after discussion with
central office (Debra Watts) verbal permission was granted to proceed with drilling and
that the permit was to be issued after construction. The well site meets buffer setback
requirements and the new injection well will be constructed to approximately the same
depth as the source well (Peedee aquifer). The WiRO recommends issuance of the
permit. Original permit application is attached with copies remaining at the regional
office.
2. Attach new Injection Facility Inspection Form, if applicable
3. Do you foresee any problems with issuance/renewal of this permit? 0 Yes [8J No . If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
APS-GPU Regional Staff Report (Sept 09) Page 3 of 4 Pages
Condition
Division of Water Resources
Water Quality Regional Operations Section
REGIONAL STAFF REPORT
Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7 . Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information; ~
Issue; D Deny. If deny, please state reasons: __
8. SignatureofreportPreparer(s):
2
4.~ t0 ¥ i?f?/tS"
\ ~ Signature of;ld'Sregional supervisor: c-4-b-06
Date: 1.J /0-:l-,/~ ✓S-
~ .
VI. ADDITIONAL INFORMATION AND SITE MAP (Sketch of site showin g house and waste irrigation
s vstem, spra v or drip field. location ofwell(s), and/or other relevant information-SHOW NORTH ARROW)
APS-GPU Regional Staff Report (Sept 09) Page 4 of 4 Pages
Fe gat Waw Fanxleia TOOK 1{dP
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Ownership Information:
>^'C: 14.05405-U.21.1-001-000
„F•=+]• 21.1712-£E.968.000
DEMAS RONALD C SHARON A
3053ROST5
L10:LHINGTOr1, NC 784Cl
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RECEIVED
Nov 23 2215
DATE:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELLS
These wells inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
(check one) ANew Application Renewal* Modification
* For renewals complete Parts A-D and I, the signature page.
Prod or Type Inf yillation and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete,
RECEIVEC/NCDENR/DwR
1�- 20
INS- /3
PERMIT NO. D2 0 0 A`; (leave blank if New Application) NOV 2 3 Z015
A.
B.
C.
STATUS OF APPLICANT (choose one) Water Quality Regional
Operations Section
Non -Government: Individual Residence L- Business/OrganizationWilminpton Regional Office
Government:
State Municipal County Federal
WELL OWNER/PERMIT APPLICANT — For individual residences, list owner(s) on property deed. For all L_
others, list name of entity and name of person delegated authority to sign on behalf of the business or agency: _
Mailing Ad ss: 3 0
City: State: Zip Code: a ! l County: — 0
Day Tele No.: 9 f 0 -?9 ' ! M 7C Cell No.: ' PO -- ' J — f ' '- I
EMAIL Address: Fax No.:
WELL OPERATOR (if different from well owner) — For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the
business or agency;
At its
.1 '-
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
D. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: County:
(2) Physical Address (if different than mailing address): `).0 t ;
ti
City: 1 ' ►•st:� ,ti•� �� J State: NC Zip Code:
GPUIt3IC 5A7 Permit Application (Revised 5/23/1014) Page 1
,

E. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: L. i
._ )
NC Well Drilling Contractor Certification No.: �`). LI' ' :'-
Company Name: _� �u' ,' 1 ,; k, i1 sle ; "� r s E e j FF
Contact Person: 1( \ rrk% .C; -,� ) EMAIL Address: 0_� ,.' e s> q.,i-, 1. Ft r- L1,
Address: I 1 \ L . l' �><12k0 L 'i ' 1 r C.Uirr i �1
City. C D v r' q Li a Zip Code: p bj v� /L Slate: .county: tl 4 l S CI")
Tele No.: 1cif c2^ a 5 Veil e11 No.: p1,��"' p V Fax No.: ?*�]rp2 0
F. HVAC CONTRACTOR INFORMATION (if diflere nth i driller)
HVAC Contractor's Name: _3 ; r1...- i t.. 11.— ' t' 1 ,' ..-/- (i,1 r.,
NC HVAC Contractor License No.:
Company Name:
I,
Contact Person p P 1L i r11 i L r i .IA- S EMAIL Address: 0, R g R) Qp r q2.cn S,vt zi cue
L3 t�1.,-t
Address: -510-' _,� 1 t- Cr-. j^ r l e tt
-
l!
City: � ! . , '\. M L LO 4 ' -.-c-.' 't•t iip Code: c9 s.-A-149 State: p(4 County: LIP tE 3 11r4-Fn ri IJQ vt.
Office Tele No.: ' Ur 2f — (c6 / r Ce11 No.: 9/cy )9 9— (( Fax No.:
G. WELL USE Will the injection well(s) also be used as the suppl well(s) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO
H. WELL CONSTRUCTION REQUIREMENTS — As specified in 15A NCAC 02C .0224id1:
(3)
The water supply well shall be constructed in accordance with the water supply well requirements of
I5A NCAC 02C .0107.
If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 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 pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
GPLWUIC 5A7 Permit Application (Revised 5/23/2014) Page 2

I. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
.,:Z *EXISTING WELLS :f: PROPOSED WELLS
* For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b)
(c)
(d)
Well casing and screen type, thickness, and diameter
Casing depth below land surface
Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(1)(8)
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
J. OPERATINGDATA
(1)
(2)
(3)
(4)
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
Average (daily) / b gallons per minute (gpm).
Average (daily) 1-f.:!!lall~ms per day (gpd).
Average ( daily) 0 pounds/square inch (psi).
Average (January) 7 t../ ° F, Average (July) 'Jo'° F.
K. SITE MAP-As specified in 15A NCAC 02C .0224(b )(4 ), attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a)(2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, eic. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5A 7 Permit Application (Revised 5/23/2014) Page3
L. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211 t e f 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 (person's) listed on the property deed)
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediatciy responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
4_
Signature of Authorized Agent, if any
1�`_
1
Print or Type Full Name
Submit two copies of the completed application package to:
Underground Injection Control Program
NC Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPCJIIJIC 5A7 Permit Application (Revised 5/23/2014) Page 4

GEOTHERMAL HEATING/COOLING WELL CONSTRUCTION DETAIL
Choose applicable injection Well design and check the appropriate boxes. Fill in depths and details of well construction on
the blank lines provided. Use additional sheets as needed.
=Hole Well Design
osed ❑ Existing
jection; ❑ Supply;
❑ Dual Purpose
Land Surface
Record Depths Below
Land Surface on Lines
Provided
I iFt.,
(Ft.)
•
f�% I ! Return or Supply Line
1-tr
Screened Well Design
❑ Proposed L Existing
❑ Injection; ❑ Supply;
❑ Dual Purpose
Casing
4,_ " n' Grout
WELL DETAILS
S
Casing Material: , O P V t
Casing Diameter (in.):
Casing Thickness (in.): ► ,!
Grout Type:Jh �63,
(cement, bentonite, or mix)
Screen Material:
Screen Slot Size (in.):
Sand/Gravel Pack
Material:
Bedrock
Open Hole
Bentonite Seal
cif present)
Sand/Gravel Pack -►
Screen
(Ft)
Record Depth Below
Land Surface on Lines
Provided
(Ft)
(Ft)
(Ft)
(Ft)
NC Certified Well Driller Name73.-1 Certification #±y L

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