WI0700473_DEEMED FILES_20180622

Permit Number
Program Category
Ground Water
Permit Type
WI0700473
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Colson SFR
Location Address
120 Dogwood Dr
Camden
Owner
Owner Name
Michael
Dates/Events
Orig Issue
6/22/2018
NC
App Received
6/4/2018
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27921
Colson
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
6/22/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Camden
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Michael Colson
120 Dogwood Dr
Camden
Issue
6/22/2018
Effective
6/22/2018
NC 27921
Expiration
5/31/2023
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
6/6/18
6/13/18
Subbasin
Permit Number
Program Category
Ground Water
Permit Type
WI0700473
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Colson SFR
Location Address
120 Dogwood Dr
Camden
Owner
Owner Name
Michael
Dates/Events
NC
Orig Issue App Received
6/4/2018
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
27921
Colson
Draft Initiated
Scheduled
Issuance
Central Files ; APS SWP
6/18/2018
Permit Tracking Slip
Status
In review
Version
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Michael Colson
120 Dogwood Dr
Camden
Region
Washington
County
Camden
NC 27921
Public Notice Issue Effective Expiration
Requested /Received Events
RO staff report requested
RO staff report received
Streamlndex Number Current Class
6/6/18
6/13/18
Subbasin
Ih
Water Resources ^
Environ natal Quality
June 22, 2018
Michael Colson & Gail Dickinson
120 Dogwood Dr.
Camden, NC 27921
Re: Issuance of Injection Well Permit
Permit No. WI0700473
Geothermal Heating/Cooling Water Return Well
Camden County
Dear Michael & Gail:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Interim Director
In accordance with your permit application received June 4, 2018, I am forwarding Permit No.
WI0700473 for the construction & operation of geothermal heating/cooling water return well(s) located
at the above referenced address. This permit shall be effective from date of issuance, until May 31,
2023, and shall be subject to the conditions and limitations stated therein.
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
cc: David May- Robert Tankard, Washington Regional Office
Central Office File, WI0700473
Camden County Environmental Health Department
- Nothing Compares`.
Stale of North Carolina i Environmental Quality I Division of Water Resources
WaterQuatity Regional operations Section
1636 Mail Service Center I Raleigh, North Carolina 27699-I636
919.707-9129

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
Michael Colson & Gail Dickinson
FOR THE CONSTRUCTION OF 1 GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S),
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 120 Dogwood Dr., Camden, Camden County, NC 27921 will
be constructed in accordance with the application submitted June 4, 2018, and conformity with the specifications
and supporting data received, all of which are filed with the Department of Environmental Quality and are
considered a part of this permit.
This permit is for construction of injection wells and shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until May 31, 2023, and shall be
subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 22nd day of June 2018.
For Linda Culpepper, Interim Director
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Permit #WI0700473 UIC/5A7
ver. 11/15/2015
Page 1 of5
PART I -PERMIT GENERAL CONDITIONS
1. The Pennittee 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 .0211(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 15A 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 that there is no interconnection of
aquifers or zones having differences in water quality that would result in degradation of any aquifer or zone.
For screened wells, grout shall be emplaced from the top of the gravel pack to the land surface. For open-
end wells, the casing shall be grouted from the bottom of the casing to the land surface [15A NCAC 02C
.0224(d)(2),(3)].
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where el~vated 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.
[15A 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 .0107(j)(2)].
Permit #WI0700473 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 VI.5 of this
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 919-807-6406 and the
Washington Regional Office Staff, telephone number 252-946-6481. [15A NCAC 02C .021 l(k)].
2. Within 30 days of injection well completion/operation, the Permittee shall contact the Washington 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 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 V -INSPECTIONS [15A NCAC 02C .021 l(k)]
1. Any duly authorized officer, employee, or representative of the Pivision 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 VI-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. Monitonng 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 )].
Permit #WI0700473 UIC/5A7
ver. 11/15/2015
Page 3 of5
3. The Pennittee 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 .0211 (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 Washington Regional Office, telephone number 252-946-6481.
(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 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(±)(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 Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
PART VII-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 effluent from the geothermal heating and cooling system associated with this
permit.
PART VIII-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.
Permit #WI0700473 UIC/5A7
ver. 11/15/2015
Page4 of5
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose, the
Pennittee shall pennanently 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).
(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 Pennittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0224(t)( 4) within 30 days of completion of abandonment.
5. The written documentation required in Part VIII (4)(F) shall be submitted to the addresses specified in
Part VI.5 above.
Permit #WI0700473 UIC/5A7
ver. 11/15/2015
Page 5 of5
AQUIFER PROTECTION SECTION --- GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: 6/12/18 Permittee(s): Colson/Dickinson
Permit No.: W10700473
To: DWR Central Office County: Camden
Central Office Reviewer: Shristi Shrestha Proj. Name: Geothermal HeatinE(Cooling Return Well
Regional Login No:
I. GENERAL INFORMATION
1. This application is (clink all that apply): ❑ SFR Waste irrigation System ®IJ]C Well(s)
® New ❑ Renewal
❑ Minor Modification ® Major Modification
El Surface Irrigation ❑ Reuse 0 Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals
❑ Distribution of Residuals
❑ Attachment 13 included
❑ Surface Disposal
0 503 regulated ❑ 503 exempt
© Closed -loop Groundwater Remediation ® Other Injection Wells (including in sir& remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
a. Date of site visit: 5/25/18
b. Person contacted and contact information: Graham West [phone]
c. Site visit conducted by: R. Mie & D. May
d. Inspection Report Attached: ® Yes or ❑ No.
2, is the following information entered into the BIMS record for this application correct?
® Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application.
For SFR Treatment Facilities: N/A
a. Location:
b. Driving Directions: JUN 3 2018
c. USGS Quadrangle Map name and number: _ Wider quatic,
d. Latitude: Longitude: Method Used (GPS, Google'''", etc.); ►81 °Mations St:_ fir,
e. Regulated Activities 1 Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
RECE IVNCDEi/DW►i
For UIC Injections Sites: See BIMS
Of 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: Method Used (GPS, GoogleTM, etc.); Google Earth.
APS-GPU Regional Staff Report (Sept 09) Page I eel Pages

AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
JV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description of Well(s) and Facilities -New, Renewal, and Modification
I. Type of injection system:
IZl Heating/cooling water return flow (5A 7)
D Closed-loop heat pump system (5QM/5QW)
D /11 situ remediation (51)
D Closed-loop groundwater remediation effluent injection (SL/"Non-Discharge")
D Other (Specify: __J
2. Does system use same well for water source and injection? 0 Yes r8J No
3. Are there any potential pollution sources that may affect injection? D Yes [8] No
What is/are the pollution source( s )? ----'-' _W~h=at,__,i=s ...,th'-'-'e'--'d=i=st=an:.:.;c=e'---'o=f...,t=he:..1=· n,.,_.,je=c.,,_,ti=on'-'-'-'w=e=ll...,,(s=)-'-'fr=o=m._t=h=e....,p=o=ll=ut=io~n
source (s )? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? App rox. 20 ft.
5. Quality of drainage at site: D Good ~ Adequate O Poor
6. Flooding potential of site: [8] Low O 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 O No. Attach
map of existing monitoring well network if applicable . If No, explain and recommend any changes to the
groundwater monitoring program: NA
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? IZl Yes or O No . If
no or no map, please attach a sketch of the site . Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow, See attached Site Ma p.
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)?
0 Yes O No. NA. new System.
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes O No. If yes . ex plain: NA
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 gement of
the contamination incident? 0 Yes O No, If yes , ex plain: NA
APS-GPU Regional Sta!fReport (Sept 09) Page 2 of 4 Pages
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
4. Drilling Contractor: Name: Graham West -American Well & Pum p
Address: .159 Hunt Club Trail
Hertford , NC 27944
NC Certification number: 2552-A
5. 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: No issues observed with site
conditions or locations of ro osed in ·. well and existin su I well. Recommend that ermit be issued.
2. Attach new Injection Facility Inspection Form, if applicable
3. Do you foresee any problems with issuance/renewal of this permit? 0 Yes 18] 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 reco111mend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
APS-GPU Regional Staff Report (Sept 09) Page 3 of 4 Pages
AQUIFER PROTECTION SECTION - GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ issue upon receipt of needed additional information; CE
Issue; ❑ Deny. If deny, please state reasons:
8. Signature of report Preparer(s):
Signature of APS regional supervisor:
6/f 1(
Date:
VI, ADDITIONAL INFORMATION AND SITE MAP (Sketch of site showing !rouse and waste irrigation
system spray or drip field. location at wellts), and/or other relevant inJorination- SHOW NORTHARROtfJ
Site_ map will be provided once final well locations are determined by driller.
APS-GPU Regional Staff Rcporl tScpt 09) Page 4 of4 Pages

Penni!: WI0700473
SOC:
County: Camden
Region: Washington
Effective:
Effective:
Contact Person: Michael Colson
Directions to Faclllty:
System Classlflcallons:
Primary ORC:
Secondary ORC(s):
On-Site Representatlve{s):
Related Permits:
Inspection Date: 05/25/2018
Primary Inspector: Dwight R Sipe
Secondary lnapector(s):
Reason for Inspection: Routine
Com p liance Ins pection Re port
Expiration :
Expiration :
Title:
Owner : Michael Colson
Facility: Colson SFR
120 Dogwood Dr
Camden NC 27921
Phone:
Certification: Phone:
Entry Time: 10:30AM Exit Time: 11 :30AM
Phone:
Inspection Type: Reconnaissance
Permit Inspection Type: Injection Heating/Cooling Water Return Well
Faclllty Status: 0 Compliant O Nol Compliant
Question Areas:
■ Other
(See attachment summary)
Page: 1
Pennlt: Wl0700473
ln1pe0tlon Date: 05125/2018
Inspection Summary:
Owner • Fac;lllty: Michael Colson
Inspection Type : Reconnaissance Reason for Vl1lt: Routine
On 5/25/18 R. Sipe and D. May w/ WaRO -WOROS performed a site visit to 120 Dogwood Dr. Camden, NC as part of the
permitting proce~s for a Geothermal Return Well (WI0700473) at the site. We met with Graham West of American Well &
Pump and reviewed the location and condition of the existing supply well and the potential location of the proposed
geothermal return well near the southeast comer of the front yard . Provided that Mr. West will obtain information concerning
the septic system at the site no issues were noted with the permit application.
Page : 2
North Carolina Department of Environment and Natural Resources
Division of Water Quality-Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700473
DATE OF INSPECTION: 5/25/18
INSPECTOR: R. Sipe and D. May w/WQROS -WaRO
NAME OF PERMITI'EE(S) Michael Colson and Gail Dickinson
MAILING ADDRESS OF PERMITIEE 120 Dogwood Drive, Camden NC 27921
PHYSICAL ADDRESS OF SITE (if different than above) _______________ _
PERSON MET WITH ON-SITE Graham West; TELE NO. [phone]
WELL(S) STA11JS:
__ Existing and operating Class V Well
__ Existing well proposed to be converted to Class V well
_X _Proposed/not constructed
LAT/LONG OF WELL(S)36.292233N, 76.150921W
Appx. distance of well to property boundaries: 20 feet
Appx. distance of well from foundation of house/structure: 50 feet
Appx. distance of well from septic tank/field (if present): 100+ feet
Appx. distance of well to other well(s) (if present): Proposed inj. well approx. 50 feet from existing supply well.
Appx. distance to other sources of pollution: __________________ _
Flooding Potential of Site: _high __ moderate _ll_low
Comments: WaRO representatives discussed the existing supply well location and construction and the proposed
inj. well location with the driller, Mr. West.
Injection Facility lnsp. Report (Rev . Sept 2009) Page I or J Pages
See attached Site Map
DRAW SKETCH OF SITE ABOVE (Show property boundaries, buildings, other wells, septic tanks/drain fields, other
potential pollution sources, roads, approximate scale, and NORTH arrow)
See inj. well diagram submitted with application
Draw Schematic of well above showing TD, casing depth, grout, etc.
Injection Facility lnsp. Report (Rev Sept 2009) Page 2 of 3 Pages
Well Construction Information
Date Constructed: TDD (proposed)
Well Contracting Company: American Well & Pump
Well Driller Name: Graham West
NC Well Cert. No.: 2552-A
Address: 159 Hunt Club Trail., Hertford, NC 27921
Telephone No.:[phone] ; Cell No.: ________ _
Email Address: [e-mail]
Proposed Depth of WeJJ(s): 70 feet
Total Depth: TBD Total Depth of Source WeJJ, if present: 58 feet (from weJJ tag)
Casing (proposed)
Depth: 0 to 50 feet; Diameter: 4 inches; Type (gav . steel, PVC, etc.): Sch. 40 PVC; Stick Up: TBD, minimum
of 12 inches.
Grout: (proposed)
Depth: 0 to 45 feet; Type (cement, bentonite, etc.): Bentonite; Placement (pumping, press. etc.):TBD
Well ID Plate Present (Y or N): _NA_; Heat Pump ID plate present (Y or N): _NA_
Influent spigot (Y or N): __ TBD_ ; Effluent spigot (Y or N): ---'Y~CP ...... ro ..... p_o~s~ed~) __
Well Sampled? (Y orN): _NA_; If Yes, Lab Sample ID numbers:
Static Water Level: _TDD_
Injection Information (if applicable): (as available from existing HVAC system)
Injection Rate: __ 25 ____ GPM
Injection Pressure: __ 45 ___ PSI , ·
Injection Volume: __ 4500 ___ GPD
Temperature-Summer: _unknown ___ F0
Temperature-Winter: _unknown ___ F°
Comments/Notes: Proposed inj. well to use 20 feet of 0.020 screen with #2 gravel sand pack. Supply well info,
taken from well tag.
Injection Facility lnsp. Report (Rev . Sept 2009) Page 3 of3 Pages
WATER Q UALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE Q UEST FORM
Date: June 6, 2018
To: David May-Robert Tankard
From: Shristi Shrestha, WQROS-Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0700473
A. Applicant: Michael Colson & Gail Dickinson
B. Facilitv Name:
C. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: New
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 completed WOROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: __________________ Date: _____ _
COMMENTS:
NOTES: Please make sure to get site map as stated in page 3 during the site visit.
FORM: WQROS-ARR ver. 092614 Page 1 of 1
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQ UEST FORM
Date: June 6, 2018
To: David May-Robert Tankard
From: Shristi Shrestha, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0700473
A. Applicant: Michael Colson & Gail Dickinson
B. Facility Name:
C. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: New
E. Comments/Other Information:
__ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review , comment, and/or action . Within 30 calendar days, please return a com pleted WOROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROSReviewer: __________________ Date: _____ _
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 092614 Page 1 of 1
Water Resources
Environmental Quality
June 6, 2018
Michael Colson & Gail Dickinson
120 Dogwood Drive
Camden NC27921
RE: Acknowledgement of Application No. W10700473
Geothermal Heating/Cooling Water Return Well
Camden County
Dear Michael & Gail:
ROY COOPER.
MICHAEL S. REGAN
Secreruiy,
LINDA CULPEPPER
Jiu • 4 ri Director
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on June 4, 2018. Your application
package has been assigned the number listed above, and the primary reviewer is Shristi Shrestha
Central and Washington 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 Qualify 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].
Sincerely,
For Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch Division of Water
Resources
cc: Washington Regional Office, WQROS
Permit File WI0700473
�� t+farhing Compares
State of North Carolina I Environmental Quality j Division of Water Resources
Water Quality Regional Operations Section
1636 Mail Service Center J Raleigh, North Carolina 27699-1636
919-707-9129

North Carolina Department of Environmental Quality - Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATINGICOOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of s geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
XNew Application Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address an the Last Page. Illegible Applications Will Re Returned As Incomplete.
DATE: 3- - 20 f 8 1PERM[T NO. 10 0O11'i3(leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New WellfPermit 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 ❑ 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 X
Government: state Municipal
Business/Organization
County Federal
C. WELL OWNER(S)IPERMIT APPLICANT - For single family residences, list all persons listed an the
property leed. For all others. list name of b inessla ency an4 name of erson d title with delegated authority
to sign: 1i� 1-( It PI /i ° k kst l e L-a��' l i
Mailing Address: 1LC f r i .Nrc1 b4 f'
City: L nki4_ ►�-SState: iVC Zip Code: 27 .Cf./ County: 1pi c'e Ij
Day Tele No.: 7 51 i` 7 1 11 if 6 Cell No.: S ct ►►? r
EMAIL Address: 'LL p * f 1st, bc,e S Isi-Faxro
Geothermal Water Return Well Permit Application Rev. 3-1-2016
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 bus i ~ss/agency and name of person and title with delegated authority
to sign: ---------fi--1--+--1+,--------------
Mailing Address: _____ -1--_ _,___'1--+------------------
City: ----------1--______ County: ____ _
Day Tele No.: ----------------=E=m=ai..._l ....,A=dd=re=s,,,,s::.:..: __________ _
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: _________ County: ____ _
(2) Physical Address (if different than mailing address): l.:20 lX>§-r lA/c,o o n-e..
City: CAt11 bE.AI County (;.AM bE N Zip Code: · ;J.7 q 2. i
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: _PL..-:....G ... nu....,_,-'W"-"'-'E..._S.....,_1 --=ITG-=---------------
NC Well Drilling Contractor Certification No.: _.2~5~5~~~-~A ____________ _
Company Name: AM 1:. R ,c A-N \AIE.L.L 5 fu/VlP
Contact Person: Gr R/4 ~AM ,,.,,/1:,. $ -r
Address: 15 '1 /.-/£/NT CL.v O 18,L
EMAIL Address: AMt;.R1c.AAI wc,Ll J4Nl:J fvM.~ {j:J yA Hoo. <aM..
City: /.it;. BI Fo&D Zip Code: .27'1 L/~ State: /11.<!..county: i>E Ra,, u11t-1 4:1\1 S
OfficeTeteifo:-f2 -J./,2~-75 7~ CeUN~.l-::'/f7-5/q(e;L FaxNo.:._N.~,,,...Ll"'---'A-___ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HV AC Contractor's Name: p 4 M Co;,{rRftefr;,(l
H.
L
NC HV AC Contractor License No.: __.3.c:..::o:....:3=--=:l-=-i<;L=---------------------
Company Name: B ~ M CoN,R.8CToR.. S ..IN f •
Contact Person: MU A-NI f.. Mi ,z..bt,Q.... EMAIL Address:. _________ _
Address: 790 P 1 T IS CH A ~E..L R "C> •
City: £Lt2A BF::r:H (i-ry Zip Code: ;2.7~0 9 State: N.k_County: ?A-.S(iu c T'AN k
Office Tele No.: 1S:Z.-338 -4,0 9o Cell No.: _______ Fax No.: _____ _
WELL USE Will the injection welJ(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _
YES __ _
NO X
NO X: I
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 I SA NCAC 02C .0107. except that:
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page2
(a) For screen and gravel-packed wells, the entire length of casing shall be' grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a ftmctional 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:
l *EXISTING WELLS l 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 geothennal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(!){8)
(f) Length of we11 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)
(2)
(3)
Injection Rate:
Injection Volume:
Injection Pressure:
Average ( daily) _2S_gallons per minute (gpm).
Average ( daily) '+5 oo gallons per day (gpd).
Average (daily) J../.5 pounds/square inch (psi).
(4) htjection Temperature: Average (January) __ ° F, Average (July) __ ° F. e,: 1· ,;-fo-~Gr\ ':>If s·r~ v , .. u<.No w l'1
L 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 ISA NCAC 02C .0107(a )(2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page3
NOTE: fn most cases an aerial photograph of the properly parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the properly 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 persons authorized agent)
15A NCAC 02C .021 lj 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 personfs) listed on thepropertydeed.
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 taw, that t 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. [ 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 al! related appurtenances in accordance with the approved specifications and conditions of the
Permit."
Signature of Property Owner/Applicant
Cllnt C C )
Print or Type Full . ame and Tit e
Signature of Prope
CA
Print or Tv
Owner/Applicant
tA)'b$14
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 - [TIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 2709-1636
Telephone [phone]
Geothermal Water Return We11 Permit Application Rev. 3-1-2016
Page 4

GEOTHERMAL HEATING/COOLING WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxer. Fill In depths below land surface (BLS) and
details of well construction on the blank lines provided. Use additional sheets as needed_
5 ,y'fdy \o,SELL. tx�s i-0-16, d nit-a � t���/ l3
r aufm �vR : Scar -Ft -A i j S f Ai a - R
Open -Hole Well Designa'7H Screened Well Desna
❑ Proposed It Existing Yfi4 Proposed ❑ Existing
0 Injection; ❑ Supply;
❑ Dual Purpose
litid Surface
❑ Injection; CS Supply; C�S+r.6t 1=Csar4ti't
❑ Duai Purpose H 8 t+ 7
CAP a_,
Record Depths Betow
Lund Surface (BLS)
nn Lines Provided
1
Bottom of casing
(Ft. BLS)
(FL)
Return or Supply Line
Casing
Total Depth
(Ft. BLS) ycy.,c N
Grout
WELL DETAIIS
Casing Material: Bch 44Q Pk, (�
If
Casing Diameter (in.): 1/
rtV
Grout Type: ntiEA) t>Sv.►�
Grout Depth (BLS): ❑ - _ FT
Top of Bentonite Seal (if present):
Bottom of Bentonite Seal f 'r
Screen Material: p►t,
Screen Slot Size (in.): ,0 c,,
Sand/Gravel Pack
Material Type: f>t £AvE
Bedrock
Open Hole
Bentonite Seal
(if present)
Sand/Gravel Pack
Screen
Fl
(Ft.)
Record Depths Below
Land Surface (BLS) on
Lines Provided
i
5G
70
(FL BLS)
(Ft- BLS)
Bottom of casing
(Ft. 91..S)
(Total Depth
FL BLS)
NC Certified Well Driller Name: ? . Certification No.: a5.5 ,Z -

Name
4,4..ohiL5
SEPTIC TANK INSPECTION
Permit # DgQ so2T' Power Co.
Septic Tank Serial # 3 3 0 gallons / 0 a C Tee c�
Pipe from tank to nitrification lines schedule 40
Distribution box outlets level
Grade
Rock
Length
Width
Remarks
Line 1
Line 2
Line 3
Line 4
11
Line .5
Any changes from the original permit to be drawn below:
Date c-9-3U
-/-eiti
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(a) For screen and gravel-packed wells, the entire length of casing shall be' grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a ftmctional 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:
l *EXISTING WELLS l 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 geothennal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
( c) Casing depth below land surface
( d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C .0107(!){8)
(f) Length of we11 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)
(2)
(3)
Injection Rate:
Injection Volume:
Injection Pressure:
Average ( daily) _2S_gallons per minute (gpm).
Average ( daily) '+5 oo gallons per day (gpd).
Average (daily) J../.5 pounds/square inch (psi).
(4) htjection Temperature: Average (January) __ ° F, Average (July) __ ° F. e,: 1· ,;-fo-~Gr\ ':>If s·r~ v , .. u<.No w l'1
L 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 ISA NCAC 02C .0107(a )(2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page3
NOTE: fn most cases an aerial photograph of the properly parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the properly 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 persons authorized agent)
15A NCAC 02C .021 lj 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 personfs) listed on thepropertydeed.
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 taw, that t 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. [ 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 al! related appurtenances in accordance with the approved specifications and conditions of the
Permit."
Signature of Property Owner/Applicant
Cllnt C C )
Print or Type Full . ame and Tit e
Signature of Prope
CA
Print or Tv
Owner/Applicant
tA)'b$14
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 - [TIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 2709-1636
Telephone [phone]
Geothermal Water Return We11 Permit Application Rev. 3-1-2016
Page 4

GEOTHERMAL HEATING/COOLING WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxer. Fill In depths below land surface (BLS) and
details of well construction on the blank lines provided. Use additional sheets as needed_
5 ,y'fdy \o,SELL. tx�s i-0-16, d nit-a � t���/ l3
r aufm �vR : Scar -Ft -A i j S f Ai a - R
Open -Hole Well Designa'7H Screened Well Desna
❑ Proposed It Existing Yfi4 Proposed ❑ Existing
0 Injection; ❑ Supply;
❑ Dual Purpose
litid Surface
❑ Injection; CS Supply; C�S+r.6t 1=Csar4ti't
❑ Duai Purpose H 8 t+ 7
CAP a_,
Record Depths Betow
Lund Surface (BLS)
nn Lines Provided
1
Bottom of casing
(Ft. BLS)
(FL)
Return or Supply Line
Casing
Total Depth
(Ft. BLS) ycy.,c N
Grout
WELL DETAIIS
Casing Material: Bch 44Q Pk, (�
If
Casing Diameter (in.): 1/
rtV
Grout Type: ntiEA) t>Sv.►�
Grout Depth (BLS): ❑ - _ FT
Top of Bentonite Seal (if present):
Bottom of Bentonite Seal f 'r
Screen Material: p►t,
Screen Slot Size (in.): ,0 c,,
Sand/Gravel Pack
Material Type: f>t £AvE
Bedrock
Open Hole
Bentonite Seal
(if present)
Sand/Gravel Pack
Screen
Fl
(Ft.)
Record Depths Below
Land Surface (BLS) on
Lines Provided
i
5G
70
(FL BLS)
(Ft- BLS)
Bottom of casing
(Ft. 91..S)
(Total Depth
FL BLS)
NC Certified Well Driller Name: ? . Certification No.: a5.5 ,Z -

Name
4,4..ohiL5
SEPTIC TANK INSPECTION
Permit # DgQ so2T' Power Co.
Septic Tank Serial # 3 3 0 gallons / 0 a C Tee c�
Pipe from tank to nitrification lines schedule 40
Distribution box outlets level
Grade
Rock
Length
Width
Remarks
Line 1
Line 2
Line 3
Line 4
11
Line .5
Any changes from the original permit to be drawn below:
Date c-9-3U
-/-eiti
Sanitarian
4#16,1,10

.ECEEREICE-
. . MALI TV DUI LDERS-SEa. RAPER
P. D. BOX.
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DATE., ISSUED.: 03. 18.88
DATE. 1:MR1'11:NED 8' 2
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