WI0100004_Complete File - Historical_20220308

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue c 'Coleen H. Sullins Dee Freeman
Governor „ /q0� N``ll I r , " Director Secretary
CCEIVED
'A r r March 17, zoo9 ; MAR 18 229
J Thomas and Elizabeth Johnson orlr
2115 Cherry Laurel Drive � jamc FrjO" i Ashevilie Regional Office
Newberry, SC 29108 ',gwfer Protection
Subject: Notice of Expiration(NOE)
5A7 Geothermal Injection Well
Permit No. WI0100004 I ��
Transylvania County c 1 kP D \
Dear Mr. and Mrs. Johnson: 7
The Underground Injection Control (UIC)Program of the North Carolina Division of Water Quality (DWQ) is
entrusted to protect the groundwater quality and resources of the State of North Carolina, and is responsible for
the regulation of injection well construction and operation activities within the state. Our records indicate that
the above-referenced operating permit for the underground injection well system, which was issued on July 12,
2004, and expires on July 16, 2009,has not been renewed. This permit was originally issued to Roseann
Dorsch. If you wish to keep this permit and operate the injection well system, the permit must be renewed and
issued in your name. Our records do not indicate that the well system has been plugged and abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative Code (NCAC)
Title 15A, Subchapter 2C, Section .0211, you must submit one of the following forms:
A. Application for Permit(Renewal) to Construct and/or Use a Well(s)for Injection with Geothermal Heat
Pump System for Type 5A7 Well(s) if the injection well system on your property is still active.
-OR-
B. Status oflnjection Well System if the injection well system is inactive or has been temporarily or
permanently abandoned.
If there has been a change of ownership of the property, an Injection Well Permit Name/Ownership Change
Form must also be submitted.
AQUIFER PROTECTION SECTION
1636 Mail Service Center,Ralegh,North Carolina 27699-1636
Location:2728 Capital Boulevard,Raleigh,North Carolina 27604 ne
Phone:[phone] FAX 1:919-715-M;FAX 2:919-715-60481 Customer Service:1.877-623.6748 rt1"i�Carolina
Internet www.ncwateroualitv.om .. '�
Al Equal OppoMniiy I Affirmative Action Employer )WArN Lally

! le i
If the injection well system is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section .0214. When
each well is plugged and abandoned, the well abandonment record(Form GW-30) must be submitted to our
office to certify that the abandonment was properly conducted. If the injection well system is still active and
you wish to renew your permit,the renewal application must be submitted within 30 calendar days of the
receipt of this letter to:
Aquifer Protection Section
Groundwater Protection Unit
UIC Program
1636 Mail Service Center
Raleigh,NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties in accordance
with North Carolina General Statute 87-94. For your convenience, a renewal application and a UIC well system
status form are attached along with a self-addressed envelope. The above referenced forms are also available
on-line at the DWQ website at hgp://h2o.enr.state.nc.us/gps/gi)u/forms.htm-
Thank you in advance for your cooperation and timely response. If you have any questions,please call me at
[phone].
Sincerely, �✓
/Michael Rogers /
Environmental Specialist
Attachments
cc: Asheville Regional Office-APS w/o enclosures
APS Central Files -Permit No. WI0100004 w/o enclosures
2

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES(NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S)FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 5-A7 WELL(S)
New Permit Application OR Renewal(check one)
DATE: . 20
PERMIT NO. (leave blank if NEW permit application)
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed(if owned by a business or government agency,state name of
entity and a representative w/authority for signature):
(1) Mailing Address:
City: State:_Zip Code: County:
Home/Office Tele No.: Cell No.:
EMAIL Address:
(2) Physical Address of Site(if different than above):
City: State:_Zip Code: County:
Home/Office Tele No.: Cell No.:
EMAIL Address:'
B. AUTHORIZED AGENT OF OWNER,IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State:_Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company,if any:
GPU/UIC SA7 Well Permit Application(Revised 9/2007) Page I

C. WELL DRILLER INFORMATION
Company Name:
Well Drilling Contractor's Name:
NC Contractor Certification No.:
Contact Person: EMAIL Address:
Address:
City: Zip Code: County:
Office Tele No.: Cell No.:
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: County:
Office Tele No.: Cell No.:
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State:_ Municipal: Native American Lands:_
F. INJECTION PROCEDURE (briefly describe bow the injection well(s)will be used)
G. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO
H. WELL CONSTRUCTION DATA(Skip to Section I if this is a Permit RENEWAL)
PROPOSED Well(s) to be constructed for use as an injection well. Provide the data in (1)
through (7) below as PROPOSED construction specifications. Submit Form GW-1 after
construction.
EXISTING Well(s)being proposed for use as an injection well.Provide the data in(1)through
(7) below to the best of your knowledge. Attach a copy of Form GW-1 (Well Construction
Record)if available.
(1) Date to be constructed: Number of borings:
Approximate depth of each boring(feet):
(2) Well casing. Is the well(s)cased?(check either(a.)YES or(b.)NO below)
(a) YES If yes,then provide the casing information below.
Type: Galvanized steel_Black steel_Plastic_Other(specify)
Casing thickness:_diameter(inches): depth:from to ft. (reference to land surface)
Casing extends above ground inches
GPUNIC SA7 Well Permit Application(Revised 9/2007) Page 2

(b) NO
(3) Grout(material surrounding well casing and/or piping):
(a) Grout type: Cement_ Bentonite_ Other(specify)
(b) Grouted surface and grout depth(reference to land surface):
Around closed-loop piping;from to (feet).
Around well casing;from to (feet).
(4) Well(s)Screen Information
Depth of Screen: From to feet below land surface
(5) N.C. State Regulations (Title 15A NCAC 2C .0200) require the Permittee to make provisions for
monitoring wellhead water quality and processes. A faucet on both Influent (groundwater entering heat
pump)and Effluent(water being injected back into the well)lines is required. Will there be a faucet on:
(a) Influent line? Yes_No (b) Effluent line? Yes_No
(6) Source Well Construction Information(if the water source well is a different well than the injection well)
--- " AttedPa copy of Form GW-1-(Well-Construction'Record)-If Form GW-1 is`noravailable,provide the
following data:
Groundwater Source. From what depth, formation, and type of rock/sediment units will the groundwater
be withdrawn? (e.g.granite,limestone,sand,etc.)
Depth: Formation: Rock/sediment unit:
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR PROPOSED WELLS IF
THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
I. 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)_°F.
J. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
K. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a site map(can be drawn)showing: buildings,property lines,surface water bodies,potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing well(s)or waste disposal facilities such as`septic tanks or drain fields located within 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the.facility's location and the map name.
GPU/UIC 5A7 Well Permit Application(Revised 9/2007) Page 3

L. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments 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.."
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection*Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC SA7 Well Permit Application(Revised 9/2007) Page 4

F ' . State of North Carolina
ii Department of Environment and"Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM'
Permit Number:
Permittee Name:
Address:
Please check the selection which most closely describes the current status of your injection well system:
1) ( Well(s)still used for injection activities, or may be in the future.
2) ( Well(s)not used for injection but is/are used for water supply or other purposes.
3} ( Injection discontinued and: a) (Welf(s)temporarily abandoned
b) (Well(s)permanently abandoned
c) (Well(s)not abandoned
4) ( Injection well(s)never constructed
Current Use of Well
If you checked(2),describe the well use(potable water supply,irrigation,monitoring,etc),including pumping rate and other
relevant information.
Well Abandonment
If you checked(3)(a)or(3)(b),describe the method used to abandon the injection well. (Include a description ofhow the well
was sealed and the type ofmaterial used to fill the well ifpermanently abandoned):
Permit Rescission: "
If you checked(2),(3),or(4)and will not use a well for injection on this site in the future,you should request rescission of the
permit. Do you wish to rescind the permit?
( Yes ( No
Certification:
"I hereby certify,under penalty of law,that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
Signature Date
Revised 5/05 GWIUIC-68

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality—Aquifer Protection.Section
INJECTION WELL PERMIT NAME/OWNERSHIP CHANGE FORM
Any changes made to this form will result in the application being returned.
(THIS FORM MAYBE.PHOTOCOPIED FOR USE ASAN ORIGINAL)
I. REQUIRED ITEMS
1. Submit one original of the completed and appropriately executed Permit Name/Ownership Change Form. For a
change of ownership,the certification must be signed by both the current permit holder and the new applicant.
For a name change only,the certification must be signed by the applicant.
2. Provide legal documentation of the transfer of ownership(such as a contract,deed,article of incorporation,etc.)
for ownership changes. A copy of the Association Bylaws and Declarations should be submitted for a change of
ownership to a Homeowner's Association.
3. For injection well systems operated under a Non-Discharge pennit (Permit number starting with WQ), please
contact the Water Quality Section,Non-Discharge Permitting Unit at(919)733-7015 for the proper form.
II. CURRENT PERMIT INFORMATI,O(N ,(
1. Permit number:
2. Permit holder's name:
3. Name and title of owner or signing official:
(Person legally responsible for permit)
(title)
4. Mailing address:
City: State: Zip:
Telephone number: (_) Facsimile number:( )
III. NEW OWNER/NAME INFORMATION
1. This request for a permit change is a result of
a. Change in ownership of property/company
b. Name change only ,
c. Other(please explain):
Page 1 of 2

2. Name of new permit holder:
(Name to be used in permit)
3. Name and title of new owner or signing official:
(Person legally responsible for permit)
(title)
4. Mailing address:
City: State: Zip:
Telephone number: (_) Facsimile number:(_)
IV. CERTIFICATION --
1. Current Permitteels Certification:
I, on behalf of
attest that this application for name/ownership change has been reviewed and is accurate and complete to the
best of my knowledge. I understand that if all required.parts of this application are not completed and that if all
required supporting information and attachments are not included, this application package will be returned as
incomplete. I understand I will continue to be responsible for compliance with the current permit until a new
permit is.issued.
Signature: Date:
2. Applicant's Certification: ,
I, I .on behalf of
attest that this application for name/ownership change has been reviewed and is accurate and complete to:the
best of my knowledge. I understand that if all required parts of this application are not completed and that if all
required supporting information and attachments are not included,this application package will be returned as
incomplete. I understand that upon issuance of a new permit, I will be responsible for compliance with the
conditions of the new permit.
Signature: Date:
THE COMPLETED APPLICATION PACKAGE,INCLUDING ALL SUPPORTING INFORMATION AND
MATERIALS,SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
UNDERGROUND INJECTION CONTROL PROGRAM
By U.S.Postal Service: By Courier/Special Delivery:
1636 MAIL SERVICE CENTER 2728 CAPITAL BOULEVARD
RALEIGH,NORTH CAROLINA 27699-1636 RALEIGH,NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone] '
Page 2 of 2

WC(D aboratorySection Wesults
County: TRANSYLVANIA _ - Sample ID: AB42757
River Basin
i RECEIVED �wArrF PO Number# 9G0491
�,,0 9Q
Report To AROAP d Date Received: 04/09/2009
Collector: J VANN f AIR 2 9 2GG9 c t' Time Received: 08:10 -
r
O `C Labwadcs LoginlD SMATHIS
Region: ARO
Date Reported: 4/23/09
Sample Matrix: GROUNDWATER ' SheVliie Regional Office
Loa Type: WATER SUPPLY 9 Report Generated: 04/23/2009
Emergency Yes/No .. Aaulfer Protection
VIaiOD
CDC Yes/No
Loc.Oescr.: J THOMAS JOHNSON
Location 10: 1P088W O100004 Collect Date: 0410712009 Collect Time:: 11:00 Sample Depth t
Sample Qualifiers and Comments
Routine Qualifiers
For a more detailed description of these qualifier codes refer to www.dwqlab.org under Staff Access
A-Value reported is the average of two or more determinations
N3-Estimated cencentretion is<POL and>MDL
Bl-Countable membranes with<20 colonies;Estimated
NE-No established PQL
B2-Counts from all fillers were zem. P-Elevated POL due to matrix interference and/or sample dilution
B3-Countable membranes with more than 60 or 80 colonies;Estimated
Q1-Holding time exceeded prior to receipt at lab.
134-Filters have counts of both>60 or 80 and<20;Estimated
Q2-Holding time exceeded following receipt by lab
B5-Too many colonies were present;too numerous to count(TNTC)
PQL-Practical Quantitation Limit-subject to change due to instrument sensitivity
J2-Reported value hailed to meet QC criteria for either precision or accuracy;Estimated
J-Samples analyzed for this compound but not detected
J3-The sample matrix interfered with the ability to make any accurate determination;Estimated
Xi-Semple not analyzed for this compound
J6-The lab analysis was from an unpraserved or improperly chemically preserved sample;Estimated
Nl-The component has been tentatively identified based on mass spectral library search and has an estimated value
LAB
Laboratory Section»1623 Mail Service Center,Raleigh,NC 27699-1623 [phone] Page 1 of 2

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North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER&ECTION '
Location code IPNUN 010000LJSAMPLE TYPE SAMPLE PRIORITY
County -F U tit Water Routine Lab Number 7 ql
Soil Emergency �
❑ ❑ Johnson
Quad No Serial No. ��--r Date Received � Time: 10
Lat: Long. ❑ Other Redd By ,: From:Bus, ourier, and Del.,
❑ Chain of Custody Other:
Report To ARO RO,MRO, RRO,WaRO,WiRO, Data Entry By:I Ck:
WSRO, Kinston FO, Fed.Trust,Central Off., Other:_ Date Reported:
Shipped by: Bus, ourier, Hand Qel., Other: Purpose:
Collector(s): —T �iAhn Date Time I I W Baseline,Complaint,Com liance, LUST, Pesticide Study, Federal Trust, Other:
FIELD ANALYSES Owner J. o w "`aB0"e)
pH 40o Spec.Cond.94 at 25°C Location or Site I 0 8I SI c k�x.k f� )P Ja i G
Temp.lo °C Odor Description of sampling point_I�rl ,
Appearance Sampling Method �i1714d i— Sample Interval
Field Analysis By: Remarks I °"°' °a`a°
LABORATORY ANALYSES (Pumping time,air temp.,elm)
Boo 310 mg/L Diss.Solids 70300 mg/L Ag-Silver46566 u L 0 anochlorine Pesticides _
COD High 340 mg/L Fluoride 951 _ mg/L -Aluminum 46557 u /L Organophosphonts Pesticides
COD Low 335 mg/L Hardness:Total 900 mg/L As-Arsenic 46551 u /L Nitrogen Pesticides
Coliform:MF Fecal 31616 1100ml Hardness(nonrarb)902 mg/L Ba-Barium 46658 u IL Acid Herbicides
Colifonn:MF Total 31504 1100ml Phenols 32730 ugn Ca-Calclum 46552 mg/L PCBs
TOO 680 mg/L Specific Cord.95 pMhos/cm -Ed-Cadmium 46559 u /L
Turbidity 76 NTU Sulfate 945 mg/L L111 9r-Chromium 46559 u /L
Residue,Total Suspended 530 mg/L Sulfide 745 mg[L Cu-Copper 46562 u /L
Fe-Iron 46563 u /L I Semivolatile Organics
Oil and Grease - mg/L Hg-Mercury 71900 u L TPH-Diesel Range
pH 403 units K-Potassium 46555 mg/L
Alkalinity to pH 4.5 410 mg/L g-Magnesium 46554 mg/L
Alkalinity to pH 8.3 415 mg/L n-Manganese 46565 u /L Volatile Organics(VOA bottle
Carbonate 445 mg/L NH3 as N 610 mg/L Sodium 46556 mg/L TPH-Gasoline'Range
Bicarbonate 440 mg/L TKN as N 625 mg/LPi-Nickel u L TPH-BTEX Gasoline Range
Carbon dioxide 405 mg/L NO2+NO3 as N 630 mg/L b- d 46564 u /L
Chloride 940 mg/L P:Total as P 665 mg1L sKselenium u /L
Chromium:.Hex 1032 ug/L Nitrate(NO3as N)620 mg/L Zn-Zinc46567 u /L
Color:True80 CU Nitrite(NO2 as N)615 mg1L LAB USE ONLY ,
Cyanide 720 mg/L Temperature on arrival(°C):
Lab Comments
GW-54 REV.7103 For Dissolved Analysis-submit filtered sample and wdte'DIS'in block.

DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
April 1,2009
MEMORANDUM
To: Landon Davidson RECEIVED
Asheville Regional Office
From: Michael Rogers M� APR 03 2Co9
Central Office APS
Asf*Yfie Re,gional Office
Re: Rescission Request ;.t'Or ProteCron
5A7 UIC Geothermal Well
Permit No. WI0100004
J. Thomas Johnson
Transylvania County
The APS Central Office has received a Status of Injection Well form from Mr. Johnson requesting the
rescission of Permit No. W10100004 (copy attached). The Permittee indicates that they are no longer
using the well for injection purposes. Please determine if a rescission should be issued for this permit and
complete and return the attached Permit Rescission Form to this office.
If you have any questions please contact me at [phone].
Thank you for your cooperation.
Attachment(s)
cc: APS Central Files -Permit No. W10100004

Permit Rescission Form R
ECEIVED
Information to be filled out by Central Office: 1Cu9
Facility Name: J. Thomas Johnson(formerly Roseann Dorch) nal Office
2115 Cherry Laurel Dr.,Newberry, SC 291tection
803-276-8590
Facility Site Address: 1081 Slick Rock Rd., Brevard,NC 28712
Permit Number: WI0100004
Regional Office: Asheville RO
County: Transylvania
Date Rescission Request Rec'd: March 25, 2009
Received Original Request: 0 Central Office ❑ Regional Office
Form of Received Request: ❑ Letter 0 Checked on signed form ❑ Other email
Information to be filled out by Region:
Please Check Appro ately:
7Site Visit Performed ❑ Groundwater Concerns Addressed
Recommendations,
[ns R�
escind Permit Immediately
Reason for Approval 54/ern wc?5 in</al�j %C<Oay The yt"011 5-'47
k — -/�e wd Vie lW lS 3 OPM. l 1r)�ur,�f A �cr/„i
5 �� 9Cam�nah�7 J�If 82/lS na I- irw o5-CYqS A '527
❑ Require Renewal with Suspended Actions
Recommended Actions to be Taken

❑ Do Not Rescind/Recommend Renewal
Reason for Denial
NOTE: If rescission is approved for this permit,it will become inactive in the BIMS database and
will not be billed through the division billing system. If this permit H associated with a UST site,
some form of documentation showing that the UST Section is in agreement with our
recommendation should be attached to this letter or a UST Section representative should sign
below.
Signature of Certifier(APS Section): �CvrvrJ
Signature of Certifier(UST Section,lif
Date Certified: l h/Q 9
Return Completed and Signed Form to the Aquifer Protection UIC Program Section

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: L✓ T O!D D 0 0 4
Permittee Name: o m to S T rI n S O A
Address: /O $ ( S li GlG Qv G _0 /3 ire learrd, Al C i28-] 2-
Please check the selection which most closely describes the current status of your injection well system:
1) ( Well(s)still used for injection activities, or may be in the future.
2) \/Wells)not used for injection but is/are used for water supply or other purposes.
KIC ins-i%lleo( a reyeA /ar heaf P&o.#W to 2o4*7 and discon�inkrgl
3) ( Injection discontinued and: a)(Well(s)temporarily abandoned We"' baS eek $y s4iK.
b) (Well(s)permanently abandoned
c)(Well(s)not abandoned
4) ( Injection well(s)never constructed
Current Use of Well
If you checked(2),describe the well use(potable water supply,irrigation,monitoring,etc), including pumping rate and other
relevannformation. /
Well Abandonment
If you checked(3)(a)or(3)(b),describe the method used to abandon the injection well. (Include a description ofhow the well
was sealed and the type of material used to fill the well ifpermanently abandoned)/ a
11
Permit Rescission:
If you checked(2),(3),or(4)and will not use a well for injection on this site in the future,you should request rescission of the
permit.Do you wish to rescind the permit?
)(Yes ( No
Certification:
"I hereby certify,under penalty of law,that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true,accurate, and complete."
3 o
Sign lure Date
RECEIVED/DENR I DWQ
Aquifer Protection Section
MAR 25 2009
Revised 5/05 GWlUIC-68

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wn� unto S54 `L� , n V " J0'?5
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Department of Environment
ent end Natural Resources
Division of Water Qua Illy
Groundwater Section
II .
Well Location: .Jo{1r15on urr,C,
(Town.Community,Subdp isian and Lot No.) Date
�/ ? / WELLTYPE rtvq.
Owner: 47, 1�70>�S J�YIr)S County ��rg ' i�yof In t(A
Address: �O(( � Sack l2nr k Road/Street
�Ftltr Quad No.
(r01 NC Serial No.
Lat.
Long.
Well Contractor 1Neli Construction
ContractorCenificaion N Name ------
Check Items Meets Min.Standards
Measured Yes No Remarks • _
Permit R_ e_ n�ired_� (Y/N)�_
' ........... (Permit No.
.......
L9calion - Distance From )
Water Tight Sewage/waste collection..
Waste disposal (septic tank drain field)
Other Poll. Source
Other Poll. Source
in � •
Type ..........."" (Circle one)
Depth.......... •'•••••••••••••••• • ••••............. Plastic Carbon Galy. stain.st. Other
.......................................... �
WeighUthickness .................
Height (A.L.S.).....................
Other(
Drilling Fluids/Additives
Type ..............................
Grout
Type .................................:. r�7Ch
Thickness ..................
Depth...........................:..........
Other( h� ✓ ✓
Screens )
Screened interval ........
...........:.
Other (
Development.....•.••..... -
...........................
Total Suspended solids .:......................
Turbidity ............
Settleable Solids...............:...................
I.D. Plate y�
Well Contractor:......:.!.......................
Abandonment :................
Temporary...............
Permanent............................................
GW-36 Rev. 1/2000 Applies to wells constructed after December 1, 1992
rr:nnl nn RgVFGCRI

Check Items Meets Min.Slandards Remarks
Measured Yes No
WellTest ...............................................
Duration*................................................
Frequency/Accuracy of measurements
Other( )
Dislnfectlon...........................................
Chlorination....................................
:....
Other( )
ttn .................................................
Reports..................................................
Construction (GW-1) ............................
Abandonment(GW30) ........................
Well Head Completion
Access port........................................... ✓
Hosebib................................................
Pitless Adaptor.....................................
Pilless Adaptor Unit..............................
Suctionline...........................................
Teeael)......................:.........................
Valved flaw...........................................
Vent......................................................
Water light pipe entry ........................... ✓
Well entry ............................................. Applies to wells constructed after December 1, 1992
Date Well Constructed
m,�recr55��-
Purnpinstallation
Pump Installation Contractor
. Address Reg. a
Name
PUMP CONTRACTOR I D PLATE PRESENT ? (YIN) Date Pump Installed
Violations noted attributable to the pump installation contractor are as follcws:
(1)
(2)
(3)
INSPECTOR _ � Pi V rho X'
Name Office
Witnessfes)
(If Available) _ _ - _ _Name Address Type
a
Name Address Type
- ' I

a
N�
DIVISION OF WATER QUALITY <a c C�U
GROUNDWATER SECTION97
mo r
July 12,2004 o
7 N
D r;;
r N
o�
MEMORANDUM T Z FiiN
m
To: Landon Davidson, Regional Goundwater Supervisor
Groundwater Section
Asheville Regional Office
From: Thomas Slusser71<
Central Office r�
Re: Issuance of a Water-source Heat Pump Injection Well Permit(Type 5A7):
Permit Number W10100004 for the operation of a water-source heat pump injection well system has
been issued to Roseann Dorsch in Brevard,North Carolina. This permit was previously issued to
A.C. Bramley, so please note this name change in your files. Attached is a copy of this permit for
your files. Please contact me at(919) 715-6166 if you have any questions regarding this permit.
cc: CO-UIC Files
Enclosures

`• M
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH,NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
ROSEANN DORSCH
FOR THE OPERATION OF A TYPE 5A7 INJECTION WELL,defined in Title 15A North Carolina
Administrative Code 2C.0209(e)(3)(A),which will be used for the injection of heat pump effluent.
This injection well, previously owned by Mr. A.C. Bramley, is located at Route 1, Box 73, Slick
Rock Road, Brevard, Transylvania County, North Carolina. The injection well system will be
operated in accordance with the application submitted April 6, 2004 and in conformity with the
specifications filed with the Department of Environment and Natural Resources, which are
considered a part of this permit.
This permit is for Operation only, and does not waive any provisions of the Water Use Act or any
other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be in
compliance with Title 15A North Carolina Administrative Code 2C.0100 and.0200, and any other
Laws,Rules, and Regulations pertaining to well construction and use.
This permit shall be effective,unless revoked, from the date of its issuance until July 16,2009,and
shall be subject to the specified conditions and limitations set forth in Parts I,through VIII hereof.
Permit issued this the day of 2004.
Ted L. Bush, Jr.,Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No.WI0100004 PAGE 1 OF 5
GW/UIC-5 ver.3/01

PART I- OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature,volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by,the Director of the
Division of Water Quality(Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as maybe
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules,regulations, or ordinances which maybe
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.
PART II-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater that will render it unsatisfactory for normal use. In the
event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that maybe
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART III- OPERATION AND MAINTENANCE REQUIREMENTS ,
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
1
Permit No.WI0100004 PAGE 2 OF 5
GW/UIC-5 ver.3/01

PART IV-INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART V-MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring(including groundwater, surface water, or soil sampling) deemed necessary
by the Division of Water Quality to insure surface and ground water protection,will be
established and an acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone,within 48 hours of the occurrence or first
knowledge of the occurrence, to the Mooresville Regional Office, telephone number
[phone], any of the following:
(A) Any occurrence at the injection facility that results in any unusual
operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report to
the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the Permittee.
4. " In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
Pemrit No.WI0100004 PAGE 3 OF 5
GW/UIC-5 ver.3/01

PART VI-PERMIT RENEWAL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
PART VII- CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinuation of use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee-must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC'2C .0213(h)(1), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected,prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout,which shall be
introduced into the well through a pipe that extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have
not been removed,the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
Permit No.WI0100004 PAGE 4 OF 5
GW/UIC-5 ver.3101

(G) The Permittee shall submit a Well Abandonment Record(Form GW-30)
as specified in 15A NCAC 2C .0213(h)(1)within 30 days of completion of
abandonment.
3. The written documentation required in Part VII (1) and (2) (G) shall be submitted to:
Groundwater Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh,NC 27699-1636
PART VIII- OPERATION AND USE SPECIAL CONDITIONS
None
Permit No.WI0100004 PAGE 5 OF 5
GW[WC-5 ver.3/01

DIVISION OF WATER QUALITY
Chemistry Laboratory Report/Ground Water Quality Lab Number 4GO677
Date Received : 5/27/2004
COUNTY : TRANSYLVANIA SAMPLE PRIORITY Time Received : 9:15 AM
QUAD NO: OROUTINE EMERGENCY Received By DS
REPORTTO ARO Regional Office EJ CHAIN OF CUSTODY
COLLECTOR(S) :T MINNICK FINF Released By : AR
DATE: /2; 5/2004 W❑ SAMPLE TYPE Date reported: 718/2004
TIME:
PURPOSE: Owner: ROSEANN DORSCH
Location or Site:
Description of sampling point
Sampling Method:
Remarks:
LABORATORY ANALYSIS
BOD 310 L Diss.Solids 70300 L A -Silver 46566 ug/L Organochlorine Pesticides
COD High 340 mg/L Fluoride 951 m L X AI-Aluminum46557 50U ug/L Organophosphorus Pesticides
COD Low 335 mg/L X Hardness:total 900 7.7 mg/L As-Arsenic 46551 ug7L Nitrogen Pesticides
Coliform:MF Fecal 31616 /100ml Hardness:(non-carb)902 mg/L Ba-Barium46558 ug/L
Colifarm:MF Total 31504 /100ml Phenols 32730 ug/L X Ca-Calcium 46552 2.5 mg/L Acid Herbicides
TOC mg/I Specific Cond.95 umhos/cm2 Cd-Cadium 46559 ug/L
Turbitity NTU Sulfate mg/L X Cr-Chromium 46560 25U ug/L Semivolatiles
Residue.,Suspended 530 mg/L Sulfide 745 mg/L X Cu-Copper 1042 280 ug/L TPH-Diesel Range
Total Suspended solids mg/L MBAS mg/L X Fe-Iron 1045 50.0 ug/L
Oil and Grease mg/L H -Mercury 71900 ug/L Volatile Organics(VOA bottle)
H units Silica mg/L X K-Potassium 46555 0.68 L
Alkalinity to PH 4.5 mg/L Boron X Mg-Magnesium 927 0.35 mg/L TPH-Gasoline Range
Alkalinity to pH 8.3 mg/L Formaldehyde mg/L X Mn-Manganese 1055 IOU ug/L TPH-BTEX Gasoline Range
Carbonate mg/L NH3 as N 610 mg/L X Na-Sodium 929 3.0 mg/L
Bicarbonate mg/L TKN as N 625 mg/L X Ni-Nickel 11 ug/L
Carbon dioxide mg/L X NO2+NO3 as n 630 0.05 m9fL X Pb-Lead 46564 10U ug/L
X Chloride 5U mg/L P:Total as P 665 mg/L Se-Selenium ug/L
Chromium:Hex 1032 ug/L PO4 mg/L X Zn Zinc 46567 39 ug/L Sn11
Color:True 80 C.U. Nitrate(NO,as N)620 mg/L m0
Cyanide 720 mg/L Nitrite(NO,as N)615 mg/L z
La
COMMENTS:
z�
0
TD
T

DIVISION OF WATER QUALITY
Chemistry Laboratory Report/Ground Water Quality Lab Number 4GO678
Date Received : 5/27/2004
COUNTY TRANSYLVANIA SAMPLE PRIORITY Time Received : 9:15 AM
QUAD NO: EIROUTINE EMERGENCY Received By DS
REPORT TO ARO Regional Office LI CHAIN OF CUSTODY
COLLECTOR(S) : T MINNICK EFF Released By : AR
DATE: 5/25/2004 Wl SAMPLE TYPE Date reported: 7/8/2004
TIME:
PURPOSE: Owner: ROSEANN DORSCH
Location or Site:
Description of sampling point
Sampling Method:
Remarks:
LABORATORY ANALYSIS
BOD 310 mg/L Diss.Solids 70300 mg/L A -Silver 46566 ug/L Organochlorine Pesticides
COD High 340 mg/L Fluoride 951 m L X AI-Aluminum 46557 501.1 ug/L Organophos horus Pesticides
COD Low 335 mg/L X Hardness:total 900 7.4 mg/L As-Arsenic 46551 ug/L Nitrogen Pesticides
Coliforrn:MF Fecal 31616 /100ml Hardness:(non-carb)902 mg/L Ba-Barium 46558 ug/L
Coliform:MF Total 31504 /100ml Phenols 32730 ug/L X Ca-Calcium 46552 2.4 mg/L Acid Herbicides
TOC m I Specific Cond.95 umhos/cm2 Cd-Cadium 46559 ug/L
Turbitity NTU Sulfate mg/L X Cr-Chromium 46560 25U ug/L Semivolatiles
Residue.,Suspended 530 mg/L ISuffide 745 mg/L X Cu-Copper 1042 360 ug/L TPH-Diesel Range
Total Suspended solids mg/L IMBAS mg/L X Fe-Iron 1045 50U ug/L
Oil and Grease mg/L H -Mercury 71900 ug/L I Volatile Organics(VOA bottle)
PH units Silica mg/L X K-Potassium 46555 0.69 mg/L
Alkalinity to PH 4.5 m L Boron X Mg-Magnesium 927 0.34 mg/L TPH-Gasoline Range
Alkalinity to PH 8.3 mg/L Formaldehyde mg/L X Mn-Manganese 1055 10U ug/L TPH-BTEX Gasoline Range
Carbonate mg/L NH3 as N 610 mg/L X No-Sodium 929 3.0 mg/L
Bicarbonate mg/L TKN as N 625 mg/L X Ni-Nickel 10U ug/L
Carbon dioxide mg/L X NO2+NO3 as n 630 0.06 me/L X Pb-Lead 46564 10U ugfL
X Chloride 5U mg1l. P:Total as P 665 mg/L Se-Selenium ug/L
Chromium:Hex 1032 u L 1
PO4 mg/L Z.n Zinc 46567 37 ug/L
Color:True 80 c.u. Nitrate(NO3 as N)620 mg"I I<�
Cyanide 720 mg/L I INitrite(NO,as N)615 mg I C
COMMENTS: mY
—T N
p� N
T
T�
ro

i
DIVISION OF WATER QUALITY
Chemistry Labonmry Repave/Ground Water Quality lab Number 4GO720
Datc Received WN2004
COUNTY : TRANSYLVANIA SAMPIPPRIORITY Time Recwd 9:40AM
QUAD NO: DROLrnNE EMERGENCY Rcceival By 1 US
/ I
REPORTTO ARO Rcgional Ofhcc CLLECpOR(S) T MINNICN CHAINOFCUSTODY
DATE:
: INF cleascd By : AR 1 /
TIME: encn004 a SAMPLE TYPE Datem wed: N29/2004
PURPOSE: Owns: RO.9FANNDORSCH
location w Sim:
D nplionof sampling point
Sampling Method:
Remarks:
LABORATORY ANALYSIS -1 -�
BOD 310 nWL X Diss.Solids]Wfq 39 A -Silve4656
COD Hi 390 gfL
amhlon Pesicids
SIL uord 95 1 Dn/L AI-Aluminum 0655] aro hos horns Pesticides m JJ u U 0
COD Low J35 m Hardness:twal 9tp As-Arsenic 46551 u Nit n Pesticides C L
r C 6 r
Cwifomc MF Fccal J1616 /IOOmI Hardness:(ranaarb)902 mg/L Ba-Barium 46558 ugfLmp
Coliform:MFTmaI31504 /100m1 Pk la 32730 u Ca-Calcium 46552 m Acid Henriddes 37C
TOC m S ifm Com.95 um Wcm2 Cd-Cad..46559 'Ty I u u 11
V7
Turbitity NTU SuI(am m Cr-Chmmium 46560 u A Semwdmiles OS IV p
Residue.,Su rMed 5J0 m Sulfide 745 m Cu-Cmmr 1042 u 2 TPH-Die l Range n
Taal S.spdM solids m MBAS mIL Fe-Iron 1045 Orti
Oil eM Grease m/L H -M. 719(p a Volatik ,nits(VOA bwlk) T 5
H units Silica mEfL K-Po ium 46555 /L nz 11u11
Alkalmil to H4.5 m Bomn m
Alkalinit tH o 8.3 M -Ma nesium W7 mg/L TPH-Gasolirm Range
/ m Formaldeh de Mn-Man anew 1055 TPH-BTEX Gasoline Ran a
Bicarbate NH3 as N 610
u
mg/L Na-Sodium 929 m
Bicarbonate m TEN as N625 mgfL Ni-Nickel u R.
Carbon dioxide m NO2♦NO3 as a 630 m Pb-Laad 46564 u
Chloride m P:Twal ns P 665 mFJL Se-Selenium u
Chmmium:Hex 1032 a PO4 /L Zn Zinc 46567
Color.Tmc 80 c.u. Nitmm(NO,as N)620 mg/L
Cyanide 720 mg/L I I Nibiw(NOtas N)615 mg/L
COMMENTS:
IGarX1

• �iEf4�c-`- ��oac�c g .l�N.f� o Lti1�,Q4 ���
GROUNDWATER FIELD/LAB FORM North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
SAMPLEDYPE SAMPLE PRIORITY
County—_ SAC✓��!} f5,Water �$ Routine
Quad No � - ,2 Z / Soil Lab Number__ _ [/-
r`_QQYL__ Serial No. I,7(v__ ❑ ❑ Emeroencv �• /' J',�,-f
Lat. 3 3 6 Long.--! ¢/Z 7 Q Other 1//1� Data Receiv Q ---Tim —
Rec'd By: F om:Bus, ourier and Del.,
Report T .�R �RO, MRO, RRO,WaRO,WiRO, hain of Custody _ Other:_
WSRO,Kinston FO,Fed.Trust,Central Off., Other:_ (J / - Kew Data Entry By_ —-----—--- Ck: —
____ Data
Shipped by:B ,Courier Hand Del.,Other: ___ Pur ose: Reported:_
Collectors W^fi -----"-- --------------_
Rr _ 0¢_ Time_ U
_-- Date 11 — Baseline,Complai t Dmplianc LUST,Pesticide Study,Federal Trust,Other:_______
FIE D ANALYSES
Owner----- - -fit Win/- tUe
Idaeox( -----
Spec.Cond.a�—_--__--at 25sC Location or Sile �,QI „�{ �
-----,C _ t- $k 7�— s--�K- �1 i _--
ear - - ---- — Description of sampling poi usSC j� ���(t --
Field Analysis By:—_ _ ------'—_-- ------- Sampling Method_ _ r11� — --- -Sample 1- -----------
LABORATORY ANALYSES -- --- - Remarks-- --- iNUiZ�r-.elan------- P Interval_—........
__--__________---9_ ------
COD
`--
BOD3f0 (Pumping time.air temp.-ek.) -----------
mg/L Diss.Solids 70300 mg/L Ag-Silver 46566
High 340 mg-L Fluoride 951 ug/L Organochlonne Pesticides
COD Low 335 mg/L AI-Aluminum 46557 u /L
m9/L Hardness:Total 900 Or ono hos horns Pesticides y
Cofilorm:MF Fecal 3I616 mg/L Be-Barium
As-Arsenic 46551 ug/L Nitrogen Pesticides T G)
/100m1 Hardness(non Caro902 m /L —
Colilorm:MF Total 3150d g Ba-Barium 46558
I100m1 Phenols 32730 ' u9/L Acid Herbicides <o L
TOC 680 os/ Ca-Calcium 46552 —
mg/L Specific Cand.95 m9/L PCBs r Z lS fl
uMhosfcm Ctl-Cadmium 46559
Turbidity 76 N7U Sulfate 945 ug/L S
mg/LResidue.Suspended 530 mg/L Cr-Chromium 46559 ug/L
Sulfide 745 mg/L Cu Copper 46562 c^
ug/L z o
Fe-Iron 46563 ug/L Sem r O
ivotatile Organics
PH 403 Oil and Grease mg/L Hg-Mercury 71900
units u9/L TPH-Diesel Range T—
Alkalinity to pH 4.5 410 mg/L K-Potassium 46555 mg/L �
Alkalinity to pH 8.3 415 Mg-Magnesium 46554 m /L
mg/L Mr-Manganese 46565 Carbonate 4I5 mg/L NH7 as N 610 ug/L Volatile Organics(VOA bottle)
Bicarbonate 440 mg/L Na-Sodium 46556
m9/L TKN as N 625 mg/L TPH-Gasorine Range
Carbon dioxide 405 mg/L NI-Nickel
mg/L NOr a Nq as mg/L Pb Lead 46564 ug/L TPH-BTE%Gasoline Range
Chbride 940 mg/L P:Trial as P 665 65 °g/L
Chromium:Hex 1032 ug/L mg/L Se-Selenium ug/L
Color:True 80 CU Zn-Zinc 46567 u /L
9
Cyanide 720 mg/L LAB US ON Y
Lab Comments Temperature On am at: t
_— __—_--- _______
('w.54 For Dissolved Analysis-submit riltaretl sam le and --`—_----- Mrile"DI$"In block. -------------------------

NC DENR/DWQ Chemistry Laboratory
Report to: /jj Sample Condition Upon Receipt AnomalyReport SCUR
Lab Number: 4^^ o f--2-0 %
Sample ID: Station Location: 405eCi tM 06)Y
ounty:�f Q i V S V Region: AV
Collectocr:� M t C '(� Date collected:�/�/ Date receivcd: & t 3 / 4
Priority: Kra I. Sample Type:1 A)f, �=!1
Affected Parameter(s): 5 50 d
a
The condition of these samples were not acceptable because(check all that apply): S c>
❑ Coolers ❑ Samples(affected samples are desert low
❑ Samples were not received on wet ice ❑ Samples not received,but listed on Ed beet r—
❑ No temperature blank submitted(see comments): ❑ Samples received,but not listed on !S eet t f�Vd
❑ Sample T°reading: °C ❑ Samples not received,but listed on tv o
Cl Cooler T°reading: °C ❑ Samples received,but not listed on
❑ Temperature>6°C.T°reading: °C ❑ Mislabeled as to tests,preservatives A[,
❑ Samples frozen ❑ Holding time expired z
O Improper container used c ��
❑ Containers ❑ Insufticicnt quantity for analysis
❑ Leaking
❑ Broken Chain of Custody
lk
❑ Without labels ❑ No custody seals
❑ VOA vials with headspace ❑ Custody seals not intact
❑ Sulfide samples with headspace ❑ Not relinquished.
No date/time relinquished<
❑ Container Labels No signature
❑ Not the same ID/info.as on COC ❑ Incomplete information
❑ Not the same ID/info.as on fieldsheet
❑ Incomplete.Missing the following: ❑ Documentation
Cl Station#/Sample ID ❑ Fieldsheet wet/illegible
❑ Collection date ❑ Fieldsheet incomplete:
❑ Collector Cl Records not written in indelible ink
❑ Analysis ❑ Sample(s)submitted without fieldsheet
❑ Preservative
❑ Other: ❑ Other(specify):
❑ Markings smeared or illegible
❑ Torn
r—Comments: C r
ry
s55 50It d s4 gv �Ua�Q.
Corrective Action:
❑ Samples were rejected by DWQ Lab. Authorized by:
❑ Accepted and analyzed per collector's request after notifying the collector.
❑ Accepted and analyzed after notifying the client and determining that another sample could not be secured.
❑ Sample(s)on hold until:
❑ Sample(s)accepted and analyzed.No notification required.
Cl Other(explain):
2 Person Contacted: Date:
Form completed by: Date:
Lead Chemist Review(initial):
❑ BIOCHEM ❑ VOA ❑ resT
❑ MET ❑ SVOA
Branch Head Review(initial
QA/QC Review (initi(�\! r/' Logged into data bue by(initiVI) ,
QA 1QC Review
Receivin(initi

Reportto: Gpj— GROUNDWATER SECTION Page / of/ a
CHAIN OF CUSTODY(COC)RECORD
NC DENR/DWQ LABORATORY(check one): 11 CENTRAL I I ARO )of WaRO
For Investigation of: /) N �x Incident No.
Sample collector (print naa Ome) /
and GW-54 forms completed by: �I. Sample collector's signature: l�
Field storage conditions and location(when applicable):
Lab Use Only
NUMBER
LAB NO. SAMPLE ID UAD.NO. LOCATION DATE TIME OF
SAMPLED SAMPLED CONTAINERS
1rTF ✓/ rsa�,� Esc« ca�zs"e / if N J
Relinquished by(signature): I Date Time Received b (signature):Y Date Time
Relinquished by(signature): Date Time Received by(signature):
Date Time
Relinquished by(signature): Date Time Received b si ature
y( � ) Date Time
Method of Shi menu circle one): to Courier Hand-delivered Federal Express UPS Other:
Si c..i,2r� 7?Vr- I Sealed by: Broken by:
Security Type and Conditions:
INTRALABORATORY CHAIN OF CUSTODY - Lab Use Only
LAB NUMBERS NUMBER ANALYSES RELINQUISHED RECEIVED DATE TIME
FROM THROUGH BOTTLES REQUESTED BY: BY:
N0I13 S 7 069
QATorrns�Sample Receiving\COC font GW TOUL p — Inv 4/10/Oldbs
a
Al � r'I

DIVISION OF WATER QUALITY
Chemistry Laboratory Report/Ground Wafer Quality Lab Number 4GO719
Dau Received : 6r3/2004
COUNTY : TRANSYLVANIA SAMP1 P PIUQIU Time Reaived : 9:40AM
QUAD NO: X❑ROUTINE EMERGENCY Raceived By DS
REPORTTO : ARO Regional Office CHAINOFCUSTODY //) 9
COLLECTORS) :T MINNICK EFF Released 9y �0-AN
DATE: SQ,SQOV O SAMPLETYPE Date naponed: 6/29/2004
TIME:
PURPOSE: Owner: ROCFANN DORCClf
t ation or Site:
Description of sampling point
Sampling Mdhod:
Remarks:
LABORATORY ANALYSIS
BOD 310 X Diss,Solids 70300 44 ro /L AS-Silt' 0566 as& Ogs.hi.d.Pesticides
COD High 340 Fluoride 951 m4L AI-Aluminum 46557 a 4. Organoplmsphoms Pesticides
COD Low 335 HanInss: out 900 mp/L As-Arseaic46551 ufL Nitmen Pesfcides
Colifmm:MF Feod 31616 /100ml Hardness:(m arb)902 mM. Ba-Barium46558 ug/L
C.1ifdm:MFTdd 31504 1100.1 Phenols 32730 ugA. Cs-Calcium 46552 m Acid Heddcida
TOC speeiria,Coral.95 umhos/cm2 Cd-Cadium 46559 a /L D
CA
Turbitity NTU Svlfau m /L Cr-Chmmium 065W u 2 Semivolatiles ma
Residue.,Sus nded 530 M91L Sulfide 745 m IL Cu-Copper 1042 a TPH-Diesel Range 5 C3 L
Told Suspended solids m MBAS m Fe.Iron 1045 a TO T"
Oil and Grease m/L Hg-Memory 71900 u Volatile Organics(VOA Wde)
H units Silica K-Pdusium46555 SIL
Alkalinity to pit4.5 Boron Mg-Ma resium 927 m /L TPH-Gasoline Range
Alkalinity to PH 8.3 m Fmmaldeh de ra/L Mn-Man a ese 1055 u TPH-BTEX Gasoline Range am
Cartonate m NH3as N 610 m Na-Sodium 929 m Ory
Bicarbonate m /L TKNas N 625 m Ni-Nickel aSfL 3O
Carbon dioxide NO2+NO3 as n 630 m 2 Pb Lead 46564 a TZ y y I)
Chloride m P:Total u P 665 m Se-Selenium u /L
Chmmium:Hex 1032 a PO4 m A. Zrt_Zlnc 46567
Cola:Tice 80 C.U. Nitrate(NOa n N)620 m8/1.
Cyanide 720 mg/L INivite(NO,as N)615 mg/L
COMMENTS:
.a9no

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GROUNDWATER FIELD/1-AB FORM North Carolina
Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
I
County—_L/J 4!LV AN—/A =S =
LE PRIORITY
�/ -- utine Lab Number__ 7L
Quad No-1 5�( _ Serial No.-� 7�p— eroencv r r---'
Date Received _
Long.-- — _ _ TimReC By: BsOther —
Entry By:........—......
WSRO,Kinston FO,Fed.Trust,Central Off.,Other:__ (J412 _ ___ Data
Shipped by:Bus ouner and Del.,Other: _ .. Reported:—_____-- I
�� _ Purpose:
Collector(s):_ M7N rCC— Dale� Time_ 0 ---__----A
FIELD ANALYSES °� 1� Baseline,Complaint om lianc LUST,Pesticide Study,Federal Trust,Other:_____
Owner Q Ssan/N (ordle.) _
-400-----—_—_— Spec. Cond.e4 _—_at 250C Location or Site �f_�_2'3�Tuc�._,���� -,�,------„rz- �7 L--------
em '.
----- �_�--__— —__._—____ Description of sampling poi t___ .ZC-
e ranc s_-s,-- - ----------
P - +-- - ---� ��"L---------
Sampling Method _____ �A t� -
r
- - - l6mump illir.etcr---------_ Sample Interval--_—_--_-- ---
le nalysis By:____ Remarks--_—_—_-- --
LABORATORY ANALYSES rp
(Pumpim time,air lamp.,eta.)BOD 310ONTU
70300 mg/L Ag-Silver 46566
COO Hi h 340 ug/L Or amchlorine Pesticides9 m /L AI-Aluminum 46557COD Low 335 u /L Or am hosphorus Pesticidesy
otal 900 mg/L As-Arsenic 46551Colltorm:MF Fecan--h 902 m /L Ba ug/LNitr en Pesticides mg Barium 46555 ugA. Acid Herbicides f—C C
Colilorm:MF Total30 � ugA Ca-Cakium 46652
mg/L PCaa Mi7a
Turb 680mg/ Sulfate Cond.95 uMhoa/cm Cd-Cadmium 46559H7urbltlily 76 Sulfate 915 ug/L m>
mg/l Cr-Chromium 46559 ug/L m N Residue,Suspended 530 mail Sulfide 745
mg/L Cu-Copper 46562 ug/L �
D
Fe-Iron 46563 ug/L Semivolatile Organics ti
PH 403 Oil and Greasd. mg/L Hg-Mercury 71900 ug/L TPH-Diesel Range
units KePotassium 46555 rag/L m Y L 6
Alkalinity to PH 4.5 410 mg/L Mg-Magnesium d6554
m /L
Alkalinity to pN 8J 415 mailMV
Mn-Manganese 46565
Carbonate 445 ug/L Volatile Organics(VOA bottle)
mg/LNH'
mail Na-Sodium d6556 mg/L TPN-Gasoline Range
Bicarbonate 4d0 mailmg/L Ni-Nickel
Carbon dioxide 405 mg/L .630 m9/L Pb-Lead 46564 ugA TPH STEX Gasoline Range
Chloride 940 mg/L mg/L Se-SeleniumugfL
Chromium:Hex 1032 ug/L ug/L
Color True 80 cuZn-Zinc 46567 ug/L
Y
Cyanide 7z0 mg/L Temperature on arrival:
Lab Comments
------ --------
-------------
------------
-----------------
GW-54 For Disso----hied---Anayain-auhmil--------filtered aempla and write'DIS'in bbck. --'----------^------

NC DENR/DWQ Chemistry Laboratory
R`ort to: Sample
Condition Upon Receipt AnomalyRe ort SCUR
F
er: !1 / / '7~ �Q�� n n ��r,Station Location:
L,ounty: Region:
Collectors M �t Date collected: / /C1 Date received:� /
Priority K�� o Sample Type: I A-) —t ll
Affected Parameter(s):
a
The condition of these samples were not acceptable because(check all that apply): m�
Coolers ❑ Samples(affected samples are d Ji ed b&tv)
❑ Coo es were not received on wet ice ❑ Samples not received,but list ieldseet
❑ Samless
❑ No temperature blank submitted(see comments): ❑ Samples received,but not list ieldsltzzt
O Sample T°reading : 0C
❑ Samples not received,but list OCN o
° ❑ Samples received,but not lisle rr, OC
❑ °Cooler T°reading: C ❑ Mislabeled as to tests,presery o etc.
❑ Temperature>6°C.T° reading: C ❑ Holding time expired =Z fw
❑ Samples frozen ❑ Improper container used m
❑ Insufficient quantity for analys s U
❑ Containers
❑ Leaking Chain of Custody
❑ Broken ❑ No custody seals
❑ Without labels ❑ Custody seals not intact
❑ VOA vials with headspace ❑ Not relinquished.
❑ Sulfide samples with headspace INo date/time relinquished c 4
No signature
❑ Container Labels ❑ Incomplete information
❑ Not the same ID/info.as on COC
❑ Not the same ID/info. as on fieldsheet ❑ Documentation
❑ Incomplete.Missing the following: ❑ Fieldsheet wettillegible
❑ Station#/Sample ID ❑ Fieldsheet incomplete:
❑ Collection date ❑ Records not written in indelible ink
❑ Collector ❑ Sample(s)submitted without fieldsheet
❑ Analysis
❑ Preservative ❑ Other(specify):
❑ Other:
❑ Markings smeared or illegible
❑ Tom
r
C mments: C✓ (�
_ C
5, 5dA J�� � 7�) GIJQ/ta
Corrective Action:
❑ Samples were rejected by DWQ Lab. Authorized by:
❑ Accepted and analyzed per collector's request after notifying the collector.
❑ Accepted and analyzed after notifying the client and determining that another sample could not be secured.
❑ Sample(s)on hold until:
❑ Sample(s)accepted and analyzed.No notification required.
❑ Other(explain):
Date:
Person Contacted:
Form completed by: Date:_-&
Lead Chemist Review(initial): ❑ VOA ❑ PEST
❑ BIOCHEM ❑ SVOA
❑ MET
Branch Head Review(initial ' Logged into database by(initial): Teti,
QAVQC Review (initi
QA/QC Review
Raei.in`�SCU

Report to: W—A& GROUNDWATER SECTION Page of /
CHAIN OF CUSTODY(COP RECORD
NC DENR/DWQ LABORATORY(check one): 11 CENTRAL (I ARO )WaRO
For investigation of: Q-x�� ,t incident No.
Samplecollector (printname) �n/n![C�—
and OW-54 fortes completed by: �� Sample collector's signature:
Field storage conditions and location(when applicable): _
Lab Use Only NUMBER
DATE THE .OF
LAB NO. SAMPLE ID OUAD.NO. LOCATION SAMPLED SAMPLED CONTAINERS
:r�-fF ✓/ 4,xxw,,r sell e�zs'- / '&q
-i—QWR Gs ' J�
Relinquished by(signature): Date Time I Received by(signature): Date Time
Relinquished by(signature): Date Time Received by(signature): Date Time
Relinquished by(signature): Date Time Received by(signature): Date Time
Method of Shipment circle one), e Courier Hand-delivered Federal Express UPS Other:
77}lr- Sealed by: Broken by.
Security Type and Conditions:
INTRALABORATORY CHAIN OF CUSTODY - Lab Use Onlv
LAB NUMBERS NUMBER ANALYSES RELINQUISHED RECEIVED DATE TIME
FROM THROUGH BOTTLES REQUESTED BY: BY:
n
r�
JJ 2
tub i
H
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QA\Forns\Sample Receiving\COC form GW 4110101dbs

p
DIVISION OF WATER QUALITY
Cherdatry Labonmry Report/G..d Walee Qudily Lab Number 4GO677
Date Received : 5/27R004
COUNTY : TRANSYLVANIA SAMPI P PRIORITY Time Received : 9:15 AM
QUAD NO: EIROUTINE EMERGENCY Received By rf
is n �Q
REPORTTO ARO Regional Office X❑ CHAINOFCUSTODY / l
COLLECTOR(S) :T MINNICK INF Released By . RP
DATE: W❑ SAMPLETYPE Dalemporsed: 718O0
TIME:
PURPOSE: Owner: ROSFANN DORSCN '
location or Site:
Descrigion of sampling point
Sampling MclhM:
Remarks:
LABORATORY ANALYSIS T
<o C-
BOD 310 Diss.Solids 70300 m Ag-Silver 46366 UE& Orgiaxachlarme Pesticides C
COD HiO MO Fluorite 951 m X AI-Aluminum 46557 SOU.81L OximismIxormaras Pesticida m p r
COD law 775 X Hadness:mW 900 7.7 m As-Arsenic 46351 ug1L Nino cn Pesticides
California:ME Feeal 31616 /IOOml Hadncss:(mn-carb)902 m Ba-Barium 46558 uVLArai
Coliform:MF Total 31 M4 /100ad Phermis 32730 X Ca-Cekium 46552 2.5 /L Acid Herbicides
u Zy N
TOC m Spccific C.M.95 umhoalcm2 Cd-Cadium 46559 USA.
O
Turbitit NfU Sulfate m X Cr-Chromiumd65(A 25Uu /L lscmvawjlcs
Residue.,Sus bird 530 m Sulfide 745 X Cu-Co r IM2 280 a TPH-Diesel Ran e
—
Total Sus Mad Wide m MBAS MZIL X Fc-Imn INS 50.0 u m
Oil eM Grease H -Menu 7I900 u Volatile snits(VOA bdtle)
H units Silica m % K-Potassium 46555 TEI
Alkalinityto H 4.5 m Bomn X M -Ma oesium 927 0.35 m /L TPH-Gasoline Range
Alkalinil to BJ m a- Fomaldeh de X Mn-Man anew 1055 IOU u TPH-BTEX Gasoline Range
Carhonne na A. NH3 as N 610 % Na-SMium 929 3.0 m
Bicarlanate m TKN as N 625 m X Ni-Nickel >> u
Carton dioxide m A. X NO2 tNO3 as n 630 0.05 m /L X P L sd 46564 IOU u
X Chloride 5U m/L P:Tmal as P 665 no Se-Selenium ugfL
Chromium:Hex 1032 u PO4 m /L X Zn Lnc 46567 39 ug/L
Color T.80 c.u. Nitrate(NO,as N)620 mg/L
Cyanide 720 mg/L Nitrite(NO,as N)615 mg/L
COMMENTS:
scan

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
-- AMPLE TYPE SAMPIL PRIORITY
County—7;�C✓A^1/A--_-------- KWater q Routine Lab Number-41 _ __ _
Quad No - ✓� _ Serial N T� Z47C soil ❑ Emereencv /'
Date Receive 7 0 Time: --_
Lat. /Orb/7$:' Lang._ d7TC T6_3 ° ❑Other — Rec'd By: ��J�1�y� rom:Bu ourle Hand Del.,
Chain of Custody Other:------
Report J—_-- ---_—
To4g�`FRO,MRQ RRO,WaRO, WiRO, Data Entry By:_______________
WSRO,Kinston FO,Fed.Trust,Central Off.,Other:_ U� — / o Data
FIELD ANA Y — -- -- Reported:___--_—____---
Shipped O Bu oD��7C n�Del.,Other._—DateQl�- ----- Purpose:
Y
Collector s — �ze Time_101�_ 6 saline,Comp In Compliant LUST,Pesticide Study,Federal Trust,Other:______
Owner_____�t�?rJ>✓ L�iXrel,f__ dd+onef ---- /�
Sec.Cond. ------------ ---- -------- --
_ p —_ at25`C Location orSitD_—_ r e_7J3 Scrc9_Zpc�c �h ✓ fL�c
em _Q—_—°C�tT� =Y_---==—__ ___ Descriptionoisampling mt__
bJ
pearan Sampling Method—__�hN/iy
P 9 1__ �___ _ Sample Interval—------—
--
Fie nalysis By:—__ 7�/iY✓•vie —_— Remarks—__—____ �'""° `"`�--- -----
--
LABORATORY ANALYJE (Pumprg am+.+k temp..ekl
BOD 310 mg/L Dias.Solids 70300 mg/L Ag-Silver 46566
u 2 Or arwchlorine Peslkdea
COD High 340 mg/L Fluoride 951 mg/L AI-Aluminum 46557 u /L Or anophosphorus Pesticides _
COO Low 335 mg/L Hardness.Total 900 mg/L As-Arsenic 46551 ull Nitro en Pesticides
Coliferm:MF Fecal 31616 /100ml Hardness(non carb 902 mg/L Ba-Barium 46556 ug/L Acid Herbicides — ---
Coliform:MF Total 31504 /100ml Pfrenols 32730 1196 Ca-Calcium 46552
mg/L PCBs 4 z,
TOC 680 mglL Specific Cond.95 uMhos/cm Cd-Cadmium 46559 ug/L
Turbidity 76 NTU Sulfate 945 mg/L -.2S, Cr-Chromium 46559 ug/l m%9 r
Residue.Suspended 530 mgfL Sulfide 745 mg/L Y Cu-Capper 46562 ug/L 7111
Fe-Iron 46563 ug/L Sernwolalile Organics
r Oil and Grease'. mglL Hit-Mercury 71900 uglL TPH-Diesel Range
pH 403 units K-Polesslum 46555 rgg/L c L
Alkalinily to pH JIS 410 mg/L Mg-Magnesium 46554 m /L T�i
Lli
Alkalinity to pH 63 415 mgll ' Mn-Manganese 46565 utift. Volatile Organics(VOA bo0le) m I
Carbonate 445 mg/L NH,,as N 610 mg/L Na-Sodium 46556 mg/L TPH-Gasoline Range
Bicarbonate 440 mg/L TKN as N 625 mg/L X Ni-Nickel ug/L TPH-BTE%Gasoline Range
Carbon dioxide 405 m91L E NO,as N'.630 mg/L Pb Lead 46564 ug/L
Chloride 940 mg/L P:Total as P 665 mg/l. Se-Selenturrl ug/L
Chromium:Hez 10J2 ug/L Zn Zinc 46567 uglL
Cater:true; Cu LAB V3LN Y
mg/L Temperature on arriv al: a
Cyanide 720 '
Lab Comments
------ ------------ ----- --------------------------- ----�—
GW-54 For Dissolved Anal y sis-submit filtered sample and wrile'DIS'In block. _-------------_-----
_—__

DIVISION OF WATER QUALITY
Chemistry Laboratory Report/Ground Water Quality Lb Number 4G0678
Date Received W7200,1
COUNTY : TRANSYLVANIA eAMPI F PRIORITY Time Received : 9:15 AM
QUAD NO: E]ROUTINE EMERGENCY Reecceiilveel B/y�� DSI
REPORTTO ARO 4 Regional Office X� CHAIN OF CUSTODY `/` ' J q I D
COLLECTOR(S) :T MINNICK EFF Released By A
DATE: 56S11B09 W❑ SAMPLETYPE Dale.,omi: 7/8/2MM
TIME:
PURPOSE Owner: ROeFANN DORSCti
Location or Site:
Description of sampling point
Sampling Me":
Remarks.
LABORATORY ANALYSIS P�6,
BOD 310 m Dies.Solids 70300 m A -Silver 46566 u amchlPdns Pesticides COD Hi M1 l40 m 2 Fluoride 951 m X AI-Aluminum 4G59 SOU a mhos boors Pesticides COD Low 335 mg/L X Hardness:toml 900 7A m As-Arsenic 46551 a Nitrogen PestcidesColiferm:MF Fm131616 /100m1 Hardness:(nm-cerb)W2 Ba-Barium 46558 u Cofferm:MF Tmal tISM 1100" P cols 32 30 X Ca-Caleium46552 2.4 m Acid Herbicides y 0❑TOC S ific CoM.95 umhns/cm2 Cd-Cadium 46559 u /L toTurbilit NTU Sul(aIe m % CrvChmmium 165b0 25U a ScmivdalilesResidue..Sus mkil 510 m Sulfide 745 m A X Cu-C r IM2 360 u TPH-Dkml Ran eTotal Sus ndcd solids m MBAS m X Fe-Iron IM5 SOU u ��Oil and Grease m H -Memo 71900 a Volatile Owm,x(VOA hauls) 00
H units Silica A X K Main Magnesium
034 m/L
Alkalinityto N4.5 Boron % ME-Ma nesium 927 0.3d m TPH-Gasoline Range
Alkalinity to pH 8_3 & Fmmaldch de m X Mn-Man amu 1055 IOU u TPH-BTEX Gasoline Range
Carbonate m NH3 as N 610 m X Na.Sodium 9N 3.0 rngtL
Bicarbonate m/L TKN as N 625 m /L X Ni-Nickel 10U u
Carbon dioxide X NO2+NO3 as n 610 0.06 m A X Pt Lead 46.564 10U a
X Chloride 5U m P:Total as P665 in Se-Selenium u
Chromium:Hex 1032 a PO4 m Zn_Zim 46567 37 u
Color:Tore 80 c.u. Niwte(NOa as N)620 mgR.
Cyanide 720 mg(L I Nioim(NOa as N)615 mg/L
COMMENTS:
acoe"I

i
I
North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
SAMPLETYPE SAMPLE PRIORITY / yS
County=R+4N��✓Mv"/A - —_—��—/- [Water 2g, Routine LabNumber_ QID�V
Quad No—����L-- Serial No.__�2 Z4,74 0 Soil ❑ Emeraencv
Lat. 3 (o 6 ___ Lon Z Z p�Other ��� Date Received [19 Time
- g•---�-----�---- Rec'd By: (\ From:Bu ourie , Hand Del.,
VChain of Custody Other:—___ ----
Report T �f20,MRO, RRO,WaRO, WiRO,
— Data Entry By:____—_ Ck:
WSRO,Kinston FO,Fed.Trust,Central Off.,Other:-L)I C 1 /ZCp Data
---- Reported:___
Shipped(s)Bus, ourier Hand Del.,Other:--__ � Pi ose: --- --------_ /
Collector(s): r VnPrc-(' _ — Date pSy[zo Time /d Baseline,Compl. int ompliance LUST,Pesticide Study,Federal Trust,Other:___--___
FIELD ANALYSES I Owner--__&FILL, ! ��t°b°°°1
S eo. Cond.91__ a125°C LocalionorSile_ ,�iT3 73 ic,��o�- 'l�,CE✓i.p.�pT-- -----
em ,/b•(o --°C or —Zftd�___--__ Descri tionofsam lin inl__ iC EF'ezc - - ----- --`--
P P 9 P I1-=-----------^ �_�Frat.vl SsG il-----------
e —_ '� — -- Sampling Method—�uMfF�____—_ Sample Interval_—______________
Field Anal sis B :--__ 7 rnfMrC Pum°.4aTr.Biel---
-- --------
Y Y __ --_---_—_ _t Remarks ___
LABORATORY ANALYSES -----
__—_—_� p 9 __—_—_v_______—__--___—___—_--_--
i um In time,air lem eicJ
BOD 310 mg/L Olss.Solids 703.00 mall Ag-Silver 46566 ug/L Organochlorine Pesticides
COD High 340 mg/L Fluoride 951 1 mg/L x AI-Aluminum 46557 ug/L Organophosphoms Pesticides
COD Low 335 mg/L Hardness:Total 900 mg/L As-Arsenic 46551 ug/L Nitrogen Pesticides
Coliform:MF Fecal 31616 /100ml Hardness(non-carb 902 mg/L Be-Barium 46558
ug/L Acid Herbicides
Coliform:MF Total 31504 /100ml Phenols 32730 ; ug/I Ca-Calcium 46552 mg/L Pcas
TOG 680 mg/L Specific Cond.95 uMhos/cm Cd-Cadmium 46559 ug/L
Turbidity 76 NTU Sulfate 945 mg/L Cr-Chromium 46559 uglL
Residue.Suspended 530 mg/L Sulfide 745 mg/L Cu-Capper 46562 ug/L
x Fe-Iron 46563 ug/L Semivolalile Organics
Oil and Greases mg/L Hg-Mercury 71900 ug/L TPH-Diesel Range
pH 403 units K-Potassium 40555
mg/L
Alkalinily'lo pH 4.5 410 mg/L j Mg-Magnesium 46554 mg/L
Alkalmlly to pH 8.3 415 mg/L Xt4o Mn-Manganese 46565 ug/L Volatile Organics(VOA bottle)
Carbonate 445 mg/L NH,as N 610- mg/L Na-Sodium 46556 mg/L TPH-Gasoline Range
Bicarbonate 440 mg/L T��+
KN.as N 625 mg/L NI-Nickel ug/L 7PH-B7EX Gasoline Range
Carbon dioxide 405 mg/L qW4 NO.,as M630 mg/L Pb-Lead 46564
ug/L
Chloride 940 mg/L P:Total as P 665 mg(L Se-Selenium _ ug/L
Chromium:Hex 1032 ug/L Zn-Zinc 46567 ug/L
Color:irue eo cu I LAB USE ONLY
Cyanide 720 mg/L Temperature on arrival: ,C
Lab Comments
--------------------------------------------------
--------------------- --
--- ------------------------------------------------- ------
GW-54 For Dissolved Analysis-submit filtered sample and,write'DIS'in block. ,
I
I
- I

D
M
/� m�
Report to: �YW'^^�( /oo^^ rz a 11
GROUNDWATER SECTION Page
CHAIN OF CUSTODY(COC)RECORD N
oDoco
NC DENR/DWQ LABORATORY(check one): (CENTRAL I I ARO I I WaRO n m ti
n O
For Investigation oi: /p/�������� � \ __ N U C Qf.�M
lr-rit.4A/nl 1k-t�3[ T- WrOf 00004 Incident No.
Sample collector (print name) (Tjj
and GW-54 forms completed by:_. :17MIAIWI C J�--_ Sample collector's signature: c
Field storage conditions and location(when applicable):
Lab Use Only
NUMBER
LAB NO. SAMPLE R) UAD.NO. LOCATION DATE TIME OF
SAMPLED SAMPLED CONTArNE
e/{ o¢ f
/F"M
Relinquish by.(signa ): Date Time cc ed by(signature
�e e
O IN -Relinquished by(signs ): at T[me Received b (signature): 7 y( gnazure): Date Time
Relinquished by(signature): Date Time Received b si y( gnamre): Date Time
Method of Shi ment circle one : to l CI ' Hand-delivered Federal Ex res UPS Other-
Se
1 TY TA Seal foe b .
Security Type and Conditions: 07�
INTRALABORATORY CHAIN OF CUSTODY - Lab Use Oniv
LAB NUMBERS NUMBER ANALYSES RELINQUISHED RECEIVED
FROM THROUGH BOTTLE REQU : BY:ESTED BY DATE TIME
I � �
OG7 1� z-764 q:
y � 4 5 z�l°Y gt4rRr�
5�7rN/ � f`Yi i
QATormsVSample Receiving\COC form GW
4/10

Environmental Testing Solutions, Inc.
PO Box 7565 Phone: [phone]
Asheville,NC 28802 Fax: [phone]
�O C-
A
O m
May 26, 2004 C
m C
Mr.Ted Minnick m
North Carolina Dept. of Environment and Natural Resources --'
Asheville Regional Office
Division of Water Quality—Laboratory Certification
2090 US Highway 70
Swannanoa,NC 28778
Dear Mr. Minnick,
RE: ETS PROJECT NUMBER: 040525504
Enclosed are the results for samples received by Environmental Testing Solutions,Inc. on
May 25, 2004.
If you have any questions concerning these results, please feel free to contact me.
Sincerely,, 5 wjn
alv—
Kelley E. K nan
Laboratory Director

• r:y;. ' ti E k' 17T
at
r� iy � �_• �Y � a h eF � r-ern �"'�i�i
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Environmental Testing Solutions, Inc.
PO Box 7565 Phone: [phone]
Asheville, NC 28802 Fax: [phone]
Certificate of Analysis
Project name: NC DENR-Divison of Water Quality Project number: 040525.504
Collection date: 25-May-04
Date received; 25-May-04
Results:
Sample identification: R.Dorsch-Influent Sample number: 15282
Parameters Method Result MDL Units Analyzed Date
Analyst Footnotes
Bacteria,Fecal Coliform SM 9222-D <1 1 wrt0aw 25aaoy-w CAJ
Bacteria,TotalColiform 312/316 ABSENT 25-n5ay-0e KEK
Results:
Sample identification: R.Dorsch-Effluent Sample number: 15283
Parameters Method Result MDL Units Datelyz
Analyst Footnotes
Bacteria,Fecal Colifotm SM 9222-D <1 1 rnvtoa 25-may-a CAJ
Bacteria,TotalColifomi 312/316 ABSENT 25-May-04 KEK
NC Certification Number: 600 NC Dnnldng Water Certification Number. 37796

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Environmental Testing Solutions, Inc.
PO Box 7565 Phone: [phone]
Asheville,NC 28801 Fax: [phone]
Bacteriological Analysis
Please refer to the back of this form for sampling instructions. n lniu
Client name: N C D,=N
2
Owner of water system(if different): -e-
n�, o
Address of water system: 4�-
r,z
n
Location where collected: 1 �,u�.>r}- Collected by: 1`n i/l n i'c-
Date collected: o-cs—ZS-c4 Time: I C� ® PM
Type of water supply: Well: ❑ Spring: ❑ Other:
Mail Results to: Payment type: Cash: ❑
Check#:
Phone: Fax:
Laboratory Results
Contaminant Method number Present Absent N/A
Total Colijorm 312 ❑ ❑
Fecal Colijorm 316 ❑ ❑
Analysis start: Date: / Time: l
Analysis complete: Date: Zl a-a Time: 1 (y
ETS project number: tc4(5Z5. 4j- ETS sample number: is Ift
Certified by: L-"4,2--
Comments:
Drinking Rater Laboratorc Certification 'Number: 'NC-37786

r >
Instructions for Collecting Samples
for Bacteriological Analysis
The sarrple must be collected in a sterile bottle supplied by the laboratory, wltich contains a
dechlorinating agent(sodium thiosulfate). Do not rinse the sample bottle if a white crystalline material
is visible inside the bottle, this is normal. If the bottle is damaged or the lid is loose, do not use the
bottle. Contact the laboratory for a replacement.
When collecting a distribution tap sample, the water in the service line should be completely flushed.
Samples should not be taken from drinking fountains or rest rooms. Do not sample from taps
surrounded by excessive foliage(leaves and flowers) or taps that are dirty, corroded, or leaking. Never
collect a sample from a hose or any other attachment fastened to a faucet. The sample bottle should
never come in contact with the faucet. Do not lay the sample container lid down, splatter water on the
lid container, or touch the inside of the container or lid.
Sample Collection
Sample should be taken from a frequently used distribution tap such as a kitchen faucet.
Before collecting the sample,you may flame the tap with a cigarette lighter after removing any strainers
or aerators and after making sure the faucet will not be damaged by flaming (taps which are plastic
may melt under high temperatures). After you flame, let the water run from the tap for 5 minutes. If
you do not flame, still let the water run from the tap for 5 minutes.
When taking the sample, let nothing but the water itself come in contact with the mouth of the bottle or
inside of the cap. Fill sample container to the line indicated on the side of the bottle. Containers
received by the laboratory with less than the indicated amount will be rejected.
Forward all samples to the laboratory immediately after collection. Samples must be analyzed within
30 hours of collection to be reliable.
Complete all information indicated at the top of the form, above the Laboratory Results section.

Environmental Testing Solutions, Inc.
PO Box 7565 Phone: [phone]
Asheville,NC 28801 Fax: [phone]
Bacteriological Analysis
Please refer to the back of this form for sampling instructions.
Client name: n) L Dt=NR-
Owner of water system(if different): E
Address of water system:
Location where collected: LL(-rik Collected by: 7 n' ) , n n r—
Date collected V✓'z`�—�`1 Time: I O`�S PM
Type of water supply: Well: ❑ Spring: ❑ Other:
Mail Results to: Payment type: Cash: ❑
Check#:
Phone: Fax:
Laboratory Results
Contaminant Method number Present Absent N/A
Total Coliform 312 ❑ 6 ❑
Fecal Coliform 316 ❑ Z� ❑
Analysis start: Date: 106-Z6-CY4 Time 6,31
Analysis complete: Date: b'5-2(0-0q Time: 134(
ETS project nurnber: N Q67 Sg) ETS sample number: 16 283
Certified by: SIAVrX d yL
Comments:
Drinking Water Laboratory Certification Number: NC-37786

Instructions for Collecting Samples
for Bacteriological Analysis
The sample must be collected in a sterile bottle supplied by the laboratory, which contains a
dechlorinating agent(sodium thiosulfate). Do not rinse the sample bottle if a white crystalline material
is visible inside the bottle, this is normal. If the bottle is damaged or the lid is loose, do not use the
bottle. Contact the laboratory for a replacement.
When collecting a distribution tap sample, the water in the service line should be completely flushed.
Samples should not be taken from drinking fountains or rest rooms. Do not sample from taps
surrounded by excessive foliage(leaves and flowers) or taps that are dirty, corroded, or leaking. Never
collect a sample from a hose or any other attachment fastened to a faucet. The sample bottle should
never come in contact with the faucet. Do not lay the sample container lid down, splatter water on the
lid container, or touch the inside of the container or lid.
Sample Collection
Sample should be taken from a frequently used distribution tap such as a kitchen faucet.
Before collecting the sample, you may flame the tap with a cigarette lighter after removing any strainers
or aerators and after making sure the faucet will not be damaged by flaming(taps which are plastic
may melt under high temperatures). After you flame, let the water run from the tap for 5 minutes. If
you do not flame, still let the water run from the tap for 5 minutes.
When taking the sample, let nothing but the water itself come in contact with the mouth of the bottle or
inside of the cap. Fill sample container to the line indicated on the side of the bottle. Containers
received by the laboratory with less than the indicated amount will be rejected.
Forward all samples to the laboratory immediately after collection. Samples must be analyzed within
30 hours of collection to be reliable.
Complete all information indicated at the top of the form, above the Laboratoiy Results section.

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
$AMPL TYPE :�S�AMPLEP IRORITY N06Z'60✓�i✓/f� Water Routine �zgZI hDpp --- Lab Number _ ___________ _Quad Nog_k V �_ Serial No.T� Z!q ❑Soil Ememencv Lon 2 2 ❑Other Date ReceivedO5 54-1—Time:_ ____g'- 4LZRec'd By: (�(� From:Bus,Courier,Hand Del.,
❑Chain of Cust Other:_ __ _ __
Report T RO RO,MRO, RRO,WaRO,WiRO, Data Entry By _ _ CIC
WSRO,Kinston FO,Fed.Trust,Central Off.,Other: 2&0- UL C Data
--------------Shipped by:by: Bus,Courier and De ,Other. --___— Purpose: `---`----'--- ----
Collector(s):---�1Ni�[ / _---__ Date aogk4 TirrkB__/jQjr gaseline,Corn ain omplianc LUST,Pesticide Study,Federal Trust,Other:-_______
F ANALYSES Owner___ C-AVA! _— tdb4pnet -
4°0---- -- - - Sea Cond.ea—_ - =------- ---- --------
_ _ P at 25pC Location or Site I __ 7J at,re< ene _ --'`--`—
e .to_T------eC o NFr--------- -- a ---t---- - ---- . - ygad�NL --- Z
1'� �____—_____—____—_ Description of sampling inl__J„f�C- � �L`_---
earanc C�C•iL. ,,iq�� �+✓ _ZIL�----------------
Rempling Method--C
_ Sample Interval__—_______ _
Fiel naysisBy: TAT�.✓nc�.� ---'-films'---------
--------------- Remarks--__--
—-----
LAB T ----------------- -----------ORY ANALYSE (Pumping lime,air temp.,erso.,
BOO 310 mg/L Diss.Solids 70300 mg/L Ag-Silver 46566 ug/L Or anochlorine Pesticides
COO High 340 mg/L Fluoride 951 mg/L Al-Alummum 46557 u /L Or anophosphorus Pesticides
COD Low 335 mg/L Hardness.:Total 900 mg/L As-Arsenic 46551 u /L Nitrogen Pesticides _
Coliform:MF Fecal 31616 /100m1 Hardness(non-carb 902 mg/L Ba-Barium 46556 ug/L Acid Herbicides
Coliform:MF Total 31504 Mond Phenols 32730 uga Ca-Calcium 46552 mg/L PCBs
TOC F80 mg/L Specific Cond.95 uMhos/cm Cd-Cadmium 46559 ug/L -
Turbidity 76 NfU Sulfate 945 mg/L Cr-Chromium 46559 ug/L
Residue.Suspended 530 mg/L Sulfide 745 mg/L Cu-Copper 46562 ug/L
Fe-Iron 46563 ug/L Semivolatile Organics
Oil and Grease in Hg-Mercury 71900 uglL TPH-Diesel Range
pH 003 units K Potassium 46555 mg/L
Alkalinity to pH 4.5 410 mg/L Mg-Magnesium 46554 mg/L
Alkalinity to pH 8.3 415 mg/L Mn-Manganese 46565 ug/L WRange
ttle)
Carbonate 445 mg/L NHS as N 610 mg/L Na-Sodium 46556 mg/L Bicarbonate 440 mg/L TKN as N 625mg/L Ni-Nickelug/L e
Carbon dioxide 405 mg/L NO,+NO,as N 630 mg/L Pb-Lead 46564
u /L
Chloride 940 mglL P:Total as P 665 mg/L Se Selenium ug/l
Chromium'.Hex 1032 ug/L ZmZlnc 46567 u /L
Color:True 80 CU
LAB NLY
Cyanide 720 mg/L Temperature on arrival:
Lab Comments
GW-54 For Dissolved Analysis-submit filtered sample and write"DIS'In bock. ------------------------

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North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
SAMPLETYPE SAMPLE PRIORITY
County--____1�Z7+±1lS t//lj+ Ja [-Water Routine (!>z63 D�fo SAS SD'�
/ � Sarial No. �� s^I�e 7 ❑ ❑ EmeroencvS
Lab Number________—_______________________
Ouad No_-___ ✓� Soil
- --------- DateReceived � �Lat.— (0 ��--- Lon9._� �Z ❑Other Time:--- Rec'd By: 144,k. From:Bus,Courier,Hand Del.,
❑Chain of Custody Other:_ _
Report T .AR RO,MRO, RRO,WaRO,WiRO, Data Entry
WSRO,Kinston FO,Fed.Trust, Central Off.,Other:_
— Data
------ ------- - Reported'----
Shi ed b :Bus,Courie nd ---------------- --
PP Y then:__—__—__ __ __--_ purpose:
Collector(s):_ C.✓n/_ie _--_ Date_Q Q¢ Tini - baseline,Comp in om hand LUST,Pesticide Study,Federal Trust,Other:____---_
FIELD ANAL YSES Owner—__ W�461nf __ 1°"f .) _
Pe Z. _ S .Cond.9a---—------at 25°C Location or Site_ lt_�F l�---- �� ,�yc� W-3/Ay 40 -
----
- --_-___,___— Description of sampling p ' t—_ �C _g6f�/C-V-r iV gF_ _-----_-
ear�n Ct t_ + = Sampling Method _ _- _ Sample Interval__
Field Analysis By:
ANAL -- ---- ----- Remarks----- — -------'7� _caraT_emF---------------
------- --- -
----------------
ABORATORY ANALYSES (Pvrtrprg 4ma.air temp...k.)
BOD 310 mg/L Diss.Salida 70300 mg/L Ag-Silver 46566 ug/L Organochlorine Pesticides
COD High 340 mg/L Fluoride 951 mill AI-Aluminum 46557 u /L Or an rphosphorus Pesticides
COD Low 335 mg/L Hardnesv:Total 900 mg/L As Arsenic 46551 ug/L Nitrogen Pesticides
Coliform:MF Fecal 31616 /100ml Hardness(non-carb 902 mg/L aa-Barium 46556 ug/L Acid Herbicides
Coliform:MF Total 31504 /100ml Phenols 32730 ug/I Ca-Calcium 46552 mg/L PCBs
TOC 680 mg/L Specific Curd.95 uMhos/em Cd-Cadmium 46559 ug/L
Turbidity 76 NTU Sulfate 945 mg/L Cr-Chromium 46559 ug/L
Residue.Suspended 530 mg/L Sulfide 745 mg/L Cu-Copper 46562 ug/L
Fe-Iron 46563 ug/L Semivolatile Organics
Oil and Grease mg/L Hg-Mercury 71900 ug/L TPH-Diesel Range
pH 103 units K-Potassium 46555 Mpg/L
Alkalinity to pH 4.5 410 mg/L Mg-Magnesium 46554 m /L
Alkalinity to pH 8.3 415 mg/L Mn-Manganese 46565 ug/L Volatile Organics(VOA bottle)
Carbonate 445 mg/L NH,t as N 610 mg/L He Sodium 46556 mg/L TPH-Gasaline Range
Bicarbonate 440 mg/L TKN as N 625 mg/L NI-Nickel ug/L TPH-BTEX Gasoline Range
Carbon dioxide 405 mg/L NOr t NO,as N 630 mg/L Pb.Lead 46564 ug/L
Chloride 940 mg/L P:Total as P 666 mg/L Se-Selenium ug/L
Chromium:Hex 1032 ug/L Zn-Zinc 46567 tig/L
Color:True 80 CU y
Cyanide 720 mg/L Temperature on arrival:
Lab Comments
--------------------------------------------------
GW-54 For Dissolved Analysis-submit filtered sample and writ."DIS'in block. -------- ------------

North Carolina Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WI pio00o¢ DATE��Z��D¢
NAME OF OWNER 49c-4 yn! LsCF/
ADDRESS OF OWNER m me ; Po 6,,r- e.,--D.nz- ,t l;,v7 A!G 2T7tX
,0fY5-1CAL : 94LI , Etc 73, Sztcl� /Zn�� kn. Svc da�,/✓C zS'9/Z
(Street/road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable)
�Siamc /dr "ac✓E� Z4-7— 36-0/0 ' /7f'l
tomb ?2°41 '46.3 '1
(Streed road or lot and subdivision, county, town, if different than owner's address,plus description oflocation on site)
Potential pollution source dagilga- sue,le —1;W4 Distance from well > ZOO
Potential pollution source ,E sFPnc ?3an/e Distance from well >Z-601
Potential pollution source Distance from well
Minimum distance of well from property boundary Irl
Quality of drainage at site ah Flooding potential of site Gdu1
(good,adeguate,poor) (high,moderate,low)
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells,potential pollution sources, roads; approximate scale, and
arrow.)
IJ-
E
Suh /K6�4*ate
N T-S
DESCRIBE INJECTION SYSTEM (vertical closed loop, uncased borehole or cased water well;separate source well and injectio
combination source and injection well; or other description as applicable)
COI-t 13rnrA--17rr,A/ Sol/kcE f 7nrfCC77&V WeU—
ChSLC7) 6 " kiiEa &Wtt

F
DIVISION OF WATER QUALITY
GROUNDWATER SECTION j
April 13, 2004
v,
MEMORANDUM
To: Landon Davidson, Groundwater Supervisor
Groundwater Section
Asheville Regional Office
From: Thomas Slusser-;�
Central Office
Re: Renewal of Permit#WI0100004,Roseann Dorsch, formerly A.C. Bramley; Request for
inspection and routine sampling of Ms. Dorsch's geothermal injection well in Brevard,
North Carolina.
1. Please review the application and submit any comments to CO-UIC group. Retain the
application for your UIC file.
2. Please inspect the injection well site to verify that the location and construction plans
submitted in the application are accurate and that the NCAC Title 15A 2C.0200 standards
are being complied with,using the enclosed Injection Facility Inspection Report(Form
B) as appropriate.
3. Collect samples from the influent and effluent sampling ports and submit the results
to the CO-UIC.
You are requested to return the completed Injection Facility Inspection Report(Form B) to the
CO-UIC by May 7, 2004. Ms. Dorsch has informed me that she is regularly out of town on
business Monday through Friday, so scheduling may be a problem. She also informed me that
she will be home the week of May 31 to June 4,which may be her best time for the inspection.
Please make the best arrangements possible to get the permit reissued in a timely manner.
The UIC group appreciates your assistance with this review. If you have any questions regarding
this review or the UIC program,please contact me at(919) 715-6166.
cc: CO-UIC Files
Enclosures

w
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT,HEALTH,AND NATURAL RESOURCES
RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM
Type 5A7 and 5QM Wells
In accordance with the provisions of NCAC Title 15A:02C.0200
complete application and mail to address on the back page. v —
TO: DIRECTOR,NOJLTH CAROLINA DIVISION OF WATER QUALITY `" -
y
DATE: �'j 20P _ o i
A. PERMIT APPLICANT `
Permit N ber: W- om4wo ! /I (WIO######,listed at the bottom of each page dfyonr permit)
Name: f A .9Q < < I ) in C�(A
Address:Q. c
City: State: NC- _ Zip code: a 97/y� y
County: TQAf1S t)►a ►fir Telephone: gag' �6-9 -Ld ee�Yr1�
Ce LL _ ga�', (oCNo-�Cov 1- Dtlrir<
B. PROPERTY OWNER(if different from applicant) u eP
(� "e-n bur 04-
Name: 11 T0o1
Address:
City: State: Zip code:
County: Telephone:
C. STATUS OF APPLICANT
c
Private:L_ Federal: Commercial: State: Public:
r
Native American Lands: v �?
D. FACILITY(SITE)DATA(Fill out ONLY if the Status of Owner is Federal,State,Public or Comrgcialr:
Name of Business or Facility: N 0'
m
o m
Address: c�
w --
City: State: Zip code: o
County: Telephone:
Contact Person:
Standard Industrial Code(s)which describe commercial facility:
ver. 10/03 GW/UIC-57 HPR Page 1 of 3

E. INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
F. WELL USE Is(are)the injection well(s)also used as the supply well(s) for either of the following?
(1) The injection operation? YES !� NO_
(2) Your personal consumption? YES NO—
G. CONSTRUCTION DATA
(1) Specify any and all modifications to the well casing, grout or screens since the issuance of the previous
injection permit.
r af�Hr L
(2) NC. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes. A faucet on both influent (groundwater entering heat pump) and
effluent(water being injected into the well)lines is required. Is there a faucet on:
(a) the influent line? YES ./ NO—
(b) on the effluent line? YES NO—
H. CURRENT OPERATING DATA
(1) Injection rate: Average(daily) gallons per minute(gpm)
(2) Injection volume: Average(daily) t? (? gallons per day(gpd)
(3) Injection pressure: Average(daily) pounds per square inch(psi)
(4) Injection temperature: Annual Average `� degrees Fahrenheit(°F)
I. INJECTION-RELATED EQUIPMENT VA
Attach a diagram showing any modifications to injection equipment since the issuance of the previous injection
permit including the engineering layout of the (1) injection equipment, and (2) exterior piping/tubing associated
with the injection operation. The manufacturers brochure, if detailed,should satisfy(1).
J. LOCATION OF WELL(S)Attach a map
Include a site map(can be drawn)showing: the orientation of and distances between the injection well(s)and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
ground-source heat pump well system;include buildings,property lines,surface water bodies,any other potential
sources of groundwater contamination. Label all features clearly and include a north arrow to indicate
orientation.
Vv
K. PERMIT LIST: Attach a list of all permits or construction approvals, received or applied for by the applicant
that are related to the site. Examples include:
(1)Hazardous Waste Management program permits under RCRA
(2)NC Division of Water Quality Non-Discharge permits
(3)Sewage Treatment and Disposal Permits
L. OTHER MODIFICATIONS: Indicate any other modifications to the injection well system (equipment, fluid,
operation, etc.) that have occurred since the issuance of the previous injection permit and have not been noted
elsewhere on this application.
ver. 10/03 GW/UIC-57 HPR Page 2 of 3

M. CERTIFICATION
"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 operate, maintain, repair, and if applicable, abandon the injection well
and all related appurtenances in accordance with the a roved specifications andconditions of the Permit"
(Signature of Well Owner or Authorized Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
N. CONSENT OF PROPERTY OWNER(Owner means any person who holds the fee or other property rights in the
well(s). A well is real property and its construction on land rests ownership in the land owner in the absence of
contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the
applicant to operate an injection well(s) as outlined in this application and that it shall be the responsibility of the
applicant to ensure that the injection well(s) conform to the Well Construction Standards (Title 15A NCAC
Subchapter 2C.0200)
(Signature of Property Owner if Different From Applicant)
Please return the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
(Telephone: [phone])
ver. 10/03 GW/UIC-57 HPR Page 3 of 3

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State of North Carolina
Department of Natural Resources and Community Development
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor R. Paul Wilms
S. Thomas Rhodes, Secretary birector
November 16 1988
Mr. A.C. Bramley
Rt. 1 , Box 73
Brevard, NC 28712
Dear Mr. Bramley:
RE: Permit 87-0104-WO-0002 for heat pump injection well in
Transylvania County
In accordance with your application dated July 1 , 1988 we
are forwarding herewith Permit No. 87-0104-WO-0002 for the
operation and Use of a well, for the purpose of injecting heat
pump effluent in Transylvania County.
This Permit shall be effective from the date of issuance
until November 1 , 1993 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 make application for permit
renewal at least two (2) months prior to its expiration date.
Sincerely,
Roy Davis
Regional Supervisor
/tej ---
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Attachment
cc: UIC Files n
ARO Files
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Pollution Prevention Pays
�P.O. Box I7687, Raleigh, North Carolina 27611-7687 Telephone [phone] - '
An Equal Opportunity AHirtnative Action Empbycr

e
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION/USE OF A WELL OR WELL SYSTEM FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87;
Article 21, Chapter 143, and other applicable Laws , Rules and Regula-
tions
PERMISSION IS HEREBY GRANTED TO
A. C. Bramley
FOR THE OPERATION AND USE OF AN INJECTION WELL/WELL SYSTEM located
at Slick Rock Mtn. Rd. , Brevard, North Carolina in Transylvania
County in accordance with the application dated July 1 , 1988 and in
conformity with the specifications and supporting' data submitted, all
of,which are filed with the Department of Natural Resources and
Community Development and are considered a part of this Permit.
This Permit is for Operation and Use only, and does not waive
any provisions or requirements of the Water Use Act or any other
applicable Laws, Rules or Regulations. Operation and use of a well
or well system shall be in compliance with Title 15 North Carolina
Administrative Code 2C, 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 1, 1993 and shall be subject to the
specified conditions and limitations set forth in Parts I and II
hereof.
Permit issued this the IST,day of 1988 .
Roy Davi � a
Regional upervisor
By Authority of the Environmental Management Commission.
PERMIT NO. 87-0104-WO-0002

PERMIT NO. 87-0104-WO-0002
PART I
A. GENERAL CONDITIONS
1 . The Permittee must comply with all conditions of
this Permit and with the standards and criteria
specified in 15 NCAC 2C . 0200 . Any Permit
non-compliance constitutes a violation of the
appropriate Act and is grounds for enforcement
action; for Permit termination, revocation and
reissuance or modification; or for denial of a
Permit renewal application.
2 . It shall not be a defense for a Permittee in an
enforcement action that it would have been
necessary to halt or reduce the permitted
activity in order to maintain compliance with the
conditions of this Permit.
3 . The Permittee shall take all reasonable steps to
minimize or correct any adverse impact on the
environment resulting from noncompliance with
this Permit.
4 . The Permittee shall give advance notice to the
Director of any planned changes in the permittee
facility or activity which may result in
noncompliance with the Permit.
5 . The Permittee shall report all instances of
noncompliance, not reported under condition, 1. of
this Part, at the time monitoring reports are
submitted_
6 . Where the Permittee becomes aware of a failure to
submit any relevant facts in a permit
application, or of any incorrect information
submitted in said application or in any report to
the Director, the relevant and correct facts or
information shall be promptly submitted by the
Permittee.
7 . The Permittee shall give notice to the Director
as soon as possible- of any planned physical
alterations or additions to the permitted
facility.
8 . In the event that the permitted facilities fail
to perform satisfactorily, the Permittee shall
take such immediate action as may be required by
the Director.

PART I (continued) PERMIT NO. 87-0104-WO-0002
9 . The injection system shall be effectively
maintained and operated at all times so that
there is no contamination of groundwaters , or
other actions or occurrences which renders them
unsatisfactory for normal use. In the event the
facilities fail to perform satisfactorily,
including the creation of nuisance conditions,
the Permittee shall take such immediate
corrective action as may be required by the
Director.
10. Department representatives shall have reasonable
access for purposes of inspection, observation
and sampling associated with injection and
related facility.
11. This Permit is not transferable without prior
notice to, and approval by the Director.
12 . An application for modification, renewal or
transfer of this Permit shall be filed with the
Department at least 30 days prior to the
expiration date of this Permit.
13. Provisions shall be made for collecting samples of
facility effluent, both prior to its entrance to
treatment devices and subsequent to leaving the
treatment devices but before entering the
injection well.
PART II
A. SPECIFIC CONDITIONS
N O N E -

R.Dorsch well sampling
Subject: R Dorsch well sampling
Date: Mon, 17 May 2004 09:14:20 -0400
From: Landon Davidson<[e-mail]>
Organization: NC DENR-Asheville Regional Office
To: Ted Minnick<[e-mail]>
Ted-
Here is the information on the Dorsch UIC permit renewal.
Neighbors to contact when scheduling sampling and inspection event:
(1) Larry and Racheal Smith 883-3653 or
(2) Herb Carlyle 885-2222
She says she has blue bathwater also so she would like your -thoughts on
that issue as well.
The information packet on UIC I had Carol copy you on should indicate
what analyses are to be ran on the well during this renewal. Please ask
me about the forms and sampling if you have any questions. I'm here
today and only the morning of tomorrow. Thanks Ted.
Landon
Landon Davidson - [e-mail]
North Carolina Dept. of Environment and Natural Resources
Asheville Regional Office
Division of water Quality - Groundwater Section
2090 U.S. 70 Highway
Swannanoa, NC 28778
Tel: [phone]
Fax: [phone]
I of 1 5/17/2004 9:25 AM

1 North Carolina
RiirUNDWATER FIELD/LAB FORM " 1V OF CUSTODY Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
Count _ I ro P 10 Lab Number Q
Y
Quad No 288 vf L Serial No.-1♦ 2.41, ater outine .��- �j •�
❑ soil ❑Emergency Dale Received Time _7i
Lat. 3 S r tN zta Long. 1Z24 1217 ❑Other Rec'd by: From: Bu Courier nd Del.,
�, � Other:
Report T :ARO)FO,
RO, MRO, FRO, WaRO LpChaln of Custody Data Entry By: Ck:
WSRO, K Fed.Trust, Central Of Oth : - Dale Reported:
Shipped by: Bus, tie Hand Del., Other- Purpose:
f f Collector(s): ,, 6 f� 'Cj rA Date�Time jl. .4 Baseline,Complaint, mplian L ,Pesticide Study,Federal Trust,Other:
FIELD ANALYSES Owner
pH400 7.2�!� Spec. Cond.94 —{�at 250 C Location or site
Temp.10 �oC Odor lVQ1 0 - Description of sampling point LU
Appearance__ i2¢e ✓ Sampling Method Q#S_ (o Sample Interval NIA s
Y Y �tllWe��ro. ��. :r6
Field Analysis B : Remarks =J." c��l�a lielklk
LB ORATORY ANALYSESANALYSES °` W
BOD 310 m /I Diss Solids 76 00 mall A -Silver 46566 u Or anochlorine Pesticides
COD High 340 mg/I Flouride 951 m I At-Aluminum 46557 u Organophosphorus Pesticides
COD Low 335 m 1 H r n t l m As-Arsenic 46551 u Nitrogen Pesticides
Coliform:MF Fecal 31616 /loom] Hardness non-carb 902 m Be-Barium 46558 u Acid Herbicides
Coliform: MF Total 31504 /loom] Phenols 3273 u / Ca-CalCium 46552 m /I PCB's
TOC 680 m Specific n . M ' d-Cadmium 46559 uqA
Turbidity 76 NTU Sulfate 945 m A Cr-Chromium 46560 u i
Residue.,Suspended 530 mgA Sulfide 745 m A Cu-Copper 46562 UgA
Fe-Iron 46563 u A Semivo]atile Organics
Oil and Grease m /I H -Mercury 71900 u A TPH-Diesel Range
pH 403 unit K-Potassium 46555 m /I
Alkalinity to pH 4.5 410 mgA RNa
-Ma nesium 46554 m /I
Alkalinity to pH 8.3 415 mgA n-Manganese 46565 u /I
Carbonate 445 mg/I NH as N 610 m -Sodium 46556 m /I Volatile Organics(VOA bottle)
Bicarbonate 440 m A TPH-Gasoline Range
Carbon dioxide 405 mgA +NO as N 630 m A -'Pb-Lead 46564 u A TPH-BTEX Gasollre Range
Chloride 940 mgA P:Total as P 665 me-Selenium u A
Chromium:Hex 1032 u A n-Zinc 46567 uco
Color:True so CU
Cyanide 720 mgA
Lab Comments:
�ii�
GW-54 REV. 12M' For Dissolved Analysis-submit filtered sample and write"DIS"In'

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DIVISION OF WATER QUALITY
Chemhvy Laboralary Report/Oeouad Water Qaallty Lnb Number 8432031
Unte Received 9111199
COUMY - TRANS. SAMPLE PRIORITY Time Received : 9X
QUAD NO: EIROMME EMERGENCY Received By JG
REPORT TO ARO Regional Once X� CHAIN OF CUSTODY
COLLECTORS) r JAB/33EM Released By : DS
DATE: 9MM9 l SAMPLETYPE Daze repotted: IL4/98
TIME
PURPOSE: Owner. ROSEANN DORSCH
Lacazicn or Sit,
Description of sampling point
Sampling Method
Remvb
LABORATORY ANALYSIS
BOD310 mg/L Diu.Solids 703W mg4. AgSilver46566 ug/L Organochlorine Pesticides
COD High 340 mWL Fluoride 951 mg(L AI-Aluminum 46557 u94. Or ganaphospharus Pesticides
COD Low 335 mS/L Haol..ta1a1900 mg/L As-An enic 46551 ug/l, ll,liuwn Pesticides
Colif.mn MF Fed 31616 /100mI Hardness:(mwo- b)902 mg/L Ba Sswium 46558 ug/L
Colifamn MP Total 31504 /I(xwd Ph..[,32730 ug/L Cs-Calcium 46552 mg/L Acid Hetbicides
TOC .'l Specific Cond.95 umMV.2 Cd-Cdium 46559 ug/L
Turbility MU Sulfate mg/L X CrChromium 46560 <25 ug/L Semivoluiles
Residue.Suspended 530 mg/L Sulfide 745 mg/L % Cu-CWM 1042 290 ug/L TPH-Diesel Range
TotalSuspended solids mg/L MBAS mg/L X Fe-Imn 1045 11—= L. 110 ug/L
Oil and Grease ro" Hg-Mercury 71900 ug/L Volatile Organics(VOA bottle)
PH units Silica mg/L K-Potassium 46555 mg/L
Alkalinity to pH 4.5 mg/L Buron X Mg-Magnesium927 0.41 mg/L TPH-Gasoline Range
Alkalinity to PH 8.3 mS/L Formaldehyde mg/L X Mn-Manganese 1055 <10 ug/L TPH-BTEX Gasoline Range
Carbmsue mg/L NIB u N 610 <0.01 mWL Ns Sodium 929 mp/L
ektubmus. mg/L TKN as N 625 mg/L X Ni-Nickel <10 ugh
Carbon dioxide mg/L % NO2-NO3 as o 630 0.02 mg/L X Pb-Lesd46564 L= 15' 56 ug/L
Chloride mWL P,Twal"P665 my/L Se-Selenium ug/L
Chromium lien 1032 uWL PO4 mg/L X Zn_Zine46567 100 ug/L
Col..True 80
Cysnide 720 mg/L
COMMENTS: L
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0� CUSTODY
MAIN North Carolina
ROUNDWATER FIELD/LAB FORM Department of Environment,Health,and Natural Resources
DIVISION OF ENVIRONMENTAL MANAGEMENT-GROUNDWATER SECTION
County AaA C,4V)40M,e, - Lab Number 4`7 a�o2
Quad No P—r'9v Serial Nn 1 2471 SAMPLE PRIORITY Date Rec�eived9 —fi�Time ff;
Lat. Z{ in witn Long. 5Z 4fl 2.7 Rec'd b r y From: B Courier, H d Del.,g OUTINEEMERGENCY by
OF CUSTODY Other:
Report To: RO, F O, MRO, RRO,WaRO,WiRO, Data Entry ey: Ck:
WSRO, Kitson FO, Fed.Trust,Central OII., they 12Cn—I A IC Date Reported:
Shipped by: Bus, ourier Hand Del.,Other
Purpose:
Collector(s): .f 6 tte nA Date q /3/�Time 11.W Baseline,Complaint, lian LUST,Pesticide Study,Federal Trust,Other:
Owner
FIELD ANALYSES "W..)
pH4co (o,0c Spec.Cond.94 at 250 C Location or site 1
Temp. °C Odor �h Ox¢. Description of sampling point — t Z
Appearance lJLetw Sampling Method 0"Wo ample Interval N
WT badar,ac.)
Field Analysis By: Remarks
LABORATORY ANALYSES )pumpbp bmb,br Unp.Mn)
BOD, 310 mg/I _ Diss.Solids 70300 ma4 A Silver 46566 uco Organochlorine Pesticides
_ COD High 34o mg/I _ Flouride 951_ mail At-Aluminum 46557 UgA _ Organophosphorus Pesticides
COD Low 335 - _ Hardness:Total goo _ _ maA As-Arsenic 46551 ucyl Nitrogen Pesticides
Coliform:MF Fecal 31616 M ooml Hardness non-carb 902 Ba-Barium 46558 uco
Coliform:MF Total 31504 /100m1 _ Phenols 3273o uco Ca-Calcium 46552 mg/ Acid Herbicides
TOC 680 .WI Specilic Cond.95 uMhos/cm' Cd-Cadmium 46559 ug/1 _
_ Turbidity 76 NTU Sulfate 945 mail r-Chromium 46560 uqA Semivolatile Organics
Residue.,Suspended 530 m94 Sulfide 745 -Copper 46562 ugA
Fe-Iron 46563 u9/1
_ H -Mercury 71900 u 1 _ Volatile Organics(VOA bottle)
PH 403 unit_ K-Potassium 46555 mg/I _
Alkalinity to pH 4.5 410 mg/I _ Mg_Magnesium 46554 mg/I _ TPH-Gasoline Range
Alkalinity to PH 8.3 415 mg4 Mn-Manganese 46565 uqll TPH-BTEX Gasoline Range
Carbonate 445 m9V1 NH, as N 610 mail Na-Sodium 46556 m I _
Bicarbonate 440 mM TKN as N 625 mati Ni-Nickel u 1
_ Carbon dioxide 405 m9A A +NO as N 630 Wl Pb-Lead 46564 u I
Chloride 940 mgA P:Total as P 665 mqA e-Selenium u I
_ Chromium:Hex 1032 ugA Zn-Zinc 46567 uQ11
Color:True eo PI-CO
Cyanide 720 m94
Lab Comments:
I S:renpd ai,wai.ntrlrr
GW-54 REV.6,• For Dissolved Analysis-submit filtered sample and write"DIS"in blL

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/G70 �"
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DIVISION OF WA7"ER QUALITY
P, Che nhir,Laboratory Repnrl/Ground Water Quality lab Number 8G2032
Date Received : 9/1INS
COUNTY : TRANS. SAMPLE PRIORITY Time Received : 9p0
QUADNO'. X❑ROUi1NEEMERGENCY Received By JG
REPORTTO ARO Regional ORCe X❑ CHAIN OF CUSTODY
COLLEROR(S) :JABMEM ` Released By DS
El DATE: 9mms SAMPLE TYPE r Dntc minulcd 12/4/98
TIME:
PURPOSE: Owner: ROSEANN DORSCH
Location or Site
Description of sampling point
Sampling Method:
Remarks.
LABORATORY ANALYSIS
BOD 310 mg/L Dis.Solids 703W %/L AgSiNce 46566 WL Otgenochlmine Pesticides
COD High 340 mg/L Fluoride 951 mg/L AI-Aluminum 46557 ug/L Organophosphours Pesticide
COD Low 335 mg/L Hardman:total 900 mg/L As-Arsenic 46551 ug/L Nitrogen Pesticides
Coliform:MF Fein 31616 /100m1 Hvdnes:(nonsrb)902 m8M1. Ba-Barium 46556 ug/L
Coliforen M F Total 31 SW /100m1 Phenols 32730 ug/L Ca-Calcium 46552 mg/L Acid Herbicides
TOC mHA Specific Cond.95 umhos/em2 Cd-Cadium 46559 ug/L
Turbaity NTU Sulfate -9/1- X Cr-Chromium4 i5W <25 ug/L gemivolmilrs
Residue.Suspended 530 mP/L Sulfide 745 -8/1, X Co.Copper 1042 160 ug/L TPH-Died P.,
Total Suspended solids mg/L IMBAS mg/L X Fe-Iron 1045 em ug/L
Oil and Grease mg/L H,Mercury 71900 ug/2. Valsile Organiee(VOA boule)
PH units Silica mg/L K-Pmsasium 46555 mg/L
Alkalinity to pH 45 m1/1. Boron X Mg-Magnesium 927 0.37 m8/1, TPHCsoline Range
Alkalinity to pH 83 mg/L Formaldehyde mg/L X Mn-Manganese 1055 <10 ug/L TPN-BTEX Grandame Stop
Carbonate mg/L NH3 ra N 610 e0.01 mg/L Na-Sodium 929 mg/L
Bicerbonne mg/L TKN ra N 625 mg/L X Ni-Nickel q0 ug(L
Carbon dioside mg/L X NO2+NO3 ran 630 0.01 mg/L X Pb-Lead 05" Q0 ug/L
Chloride mWL P'.Total ss P 665 mp/L 1 Sc-Selenium ug/L
Chromium:Hex 1032 ug/L PO4 mgA. X Zn Zinc 46567 83 WX
Color:True 90 ou.
Cyanide 720 mg/L
COMMENTS:
3 DEG -7
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Division of Environmental Management d d R
1/(� GROUNDWATER SECTION JUN - 119% I�
CHAIN OF CUSTODY RECORD
Grou ate,Section
For Investigation ofJ�lC uC7ewm Incident ionalOffice___-_.__
Samples collected and GW-54 forms completed by: `,
Lab Only Quad No. of
Lab No. No. Location Date Time Conttainers
(ll-1 ` VVT),r
(Z o (kM -
Be n >7ished ¢y(Signature): R ceived by(Signature): Da�te/Time
/ 4 0
R c '
Rel. Rec. by /
Rel. Rec. by /
Method of Shipment: j,'v��o, C o u. v e v'
Seal by: �'+ Broken by.
Security Type and Condition: Lock b : Open by: _
LAB USE ONLY
Lab No. No.
From Through Containers Analysis Relinquished by Received by Date / Time
as lqa 1.9y /
Fj
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White copy - GW Headquarters Canary copy Lab , Pink copy Region
GW-63 Revised 9/87

DIVISION OF WATER QUALITY V e. C`
COUNTY TRANS Chemist"Lalmram-y Repo"/Ground\Vales Quality
QUAD NO lab Number
SAMPLE PRIORITY 9C075S
—� X❑ROUTINE Date Received 4/21/99
REPORT TO ARO []EMERGENCY Time Received : 9:30
COLLECTOR S —�Regimul Office Received By DS
f ) JAR/HEAL CHAIN OF CUSTODY
DATE: Q/IS/99� ❑
TIME: SAMPLE TYI'L'
PURPOSE- kdusN fly pS
Owmr: 0-le 4/22/99
ROSEANN DORSC}t iNF.
Location or Site: r:ROLDLNO Tua NOT)—TM-- NON-
Description of m-pling point COMA,
Sampling Meow:
Remarks:
LABORATORY ANALYSIS
BOD 310
COD If 340 mg(L Dom.Solids 70300
COD Law 735 ns8/L Fluoride 951 mom- Ag-Silver 46566
H
mg/L mg/L AI-Ammitmm 46557 u L Organs Idmo,Nwicides
Cdifum:MF Feca131616 ardness:total earl ug/L
/IOgnl nog/L As-Arsenic 46551 Organwphosplrorsu Potkides
C011f&m:MF Ttaal 31YA Hardness;(swr.cart)902 ug/L Nioo en Pestkides
TOC
/I Woo Phemis 12730 ug/lmg( Ba-Barium 46558
Turbitity mg/1 Specific Coed,95 ug/L Ca-Calcium d6352 u L
Residue.. rN ed 530 NTU Sufa(e WW)Wan2 Cd-Cadiu n69 m/L Acid lerbicide
m/L Sufide 745 m Cr Cfnonsn u92
Teal SuVcdcd olis m8n- MBAS od Cu-Capper 1042
ug/L Semivdrtiles
mg/L Fe-Iron 1045 ug/L TPH-Diesel Range
PH OR and Crease u ug/L
nits Silica rag/L US-Mercury 719W Alkalinity t0 H 4.5 mg/L ug/i. milc Ufganics(VOA btatic)
urg/1. ldaon K-1'oassimn 46555 Vul
Alkaline to II 8.3 nsg(L
m8/L FonmldGs e M -Magnesium 927 Carinate Mn-Mon Gasoline Ran
m/L .811 mg/L TPII-
Bicarlxanate 8 NH3N113 as N 610 IOSS Bc
Carbon dioxide mg/L 'TKN as N 6$ tug/L Na.Sodium 929 u8/I- TPH BTEX Gasoline Range
m Ni-Nkkel mg/L
02+NO3 as n 630 ug/L
CNuide mg7L N mg/L X PI,L d 46564
CManun:He.1032 mg P:T
/L rial asP 665 - ug/L
Colo:True W ug/L PO4 nng/L Se-Selenann .
c.u. L Zn Z;rc 46567 u L
Cyanide 720 mg/L ug/L
COAMIENTS:
APR 2 7 1999
Cfoundwatef Section
Asheville Re�onal Office WATER OUAILIY
AS III REGIONAL OFFICE
ats0rze.am

as OUNDWATER FIELD/LAB FORM n
s7 North Carolina
dw�" , Department of Environment.Health,and Natural Resources
C unty 'fVOj,�H1� y "DIVISION OF WATER QUALITY-GROUNDWATER SECTION
r
Quad No p�8 A L T P SAMPLE PRIORITY
^o '4 Serial No. �'�afer r—�,��'—
Lat. /p'�/ E OUtine Lab Number
—�—_Long._�' y/ Z� ❑ Soil ❑Emergency Date Received El _Other Time
Report T :AR , FRO, Rec'd by: rom: Bus, ourie Hand Del.,
MRO, RRO, WaRO, WiRO �►�� Other:
WSRO, Kinston FO, Fed. Trust, Central Off., th 2fsain of Custody
Shipped by: Bus, ouri - Data Entry By:_ Ck:
�, Hand Del., Other- Date Reported:
FIELD ANAL Date Time t7A�� Purpose: --- "
ES Baseline,Complaint,
�f=,.Lueo"ei' Pesticide Study,Federal Trust,Other:-
pH400 Spec. Cond. Owner
Temp.fo r;C Odor at 250 C Location or site z
Appearance Description of samplin oint 1
Field Analysis By: Sampling Method .Ao
LABORATORY ANALY E Remarks t/ P ample Interval//a
BOD 310
m /1 IT,2.8P IBRR BIC)
COD High 340 Diss. Solids 70300
mgn m Flourtde 951 A A Silver 4656s
COD Low 335 m A m A u A Organochlorine Pesticides Colilorm: MF Fecal 3i6t6 Hardness:Total 900 AI Aluminum 4oi u A Organophosphorus Pesticides
/100ml Hardness non-carb 902 m A As-Arsenic 4655t
Coliform:MF Total 3isw /100ml m A u Nitrogen Pesticides
TOC 680 Phen015 32730 ea-Barium 46558 0 A
- m n u n Ca-Calcium 46552 Acid Herbicides
Turbidity 76 - � yifi n -. 6 m A PCB's
NTU Sulfate 945 Cm2 Cd-Cadmium 46559
m
Residue.,Suspended 530 m A u A
F gn Sulfide 745 Cr-Chromium 46560 u A
.. in A Cu-Co er g6562
PH 403
Fe-Iron 46563 u A
OII and Grease m /1 ugA Semiv0latile Organics
Alkalinity to pH 4.5 qip unit Hg-Mercury 71900
mg/I _ K-Potassium 46555 ugA TPH-Diesel Range
Alkalinity to pH 8.3 415 mgA
Carbonate 445 mgn M Ma nesium gs554
m9A
car Mn-Man anese 46565 m A
Bibonate aqo NH as N sto u A -
m A m A Na .Sodium 46556
Carbon dioxide 405 _ m A Volatile Organics(VOA bottle)
Chlorlde 940 mgA NO +NO as N 630
Ch
m A Pb-
46564 TPH-Gasoline an e romium:Hex 1032 mgn P:Total as P 665 u A
ugA m A Se-Selenium TPH-BTEX Gasoline Range
Color:True 8o CU Zn-Zinc 46567 u A
Cyanide 720 u /1
mgA
Lab Comments:
GW-54 RE1, 7m6 For Dissolved Analysis-submit filtered sample and write"DIS"in binck.
�' p

DIVISION OF WATER QUALITY
COUNTY : T'RANS Cheniatry Laboratory Report/Ground N'Ater
QUAD NO: Quality
----- SAMPLE PRIORITY Lab Number 9G0759
REPORT TO EJROUTINE Date Received 420/99
AR1/ ❑EMERGENCY Time Received
COLLECTOR(Sl lAB/IIE5, Regional Office 9:30
—�-- %� CHAIN OF CUSTODY El
Received By US
DATE; 4/15/99
TIME:
PURPOSE:
SAMPLE TYPE
��_ Dauer. Released By : US
- --ROSEANN Dale reported: 41221"Location ar Sit,: fl13R.4CITEFF. - --
Dexripiat of sannp0ng -�H07�8AG IDS NDT MET NONCpB�,' _ _
Sampling Meow
Remarks:
LABORATORY ANALYSIS
ROD 310
COD NO 340 mg/L Disc.Solids 70300
COD Low 335 Ing/L Noaid,951 Ing/L AS-Silver 46566
Cdif o"a H AI-Al
Hardness:send got utg/l. u turf.141557 uwl- UrgaoeNmbe 14slkidcs
am:h1P Peca131616 mg/L
Colifram:hit:Topl 31, /IOUnI llardsess:(noncarb)902 As-Arsenk 465$1 ug/L (hga ro 5 Pe511[MIL`i
TOC /Il10nd 111coals 32730 nn A" Ba.Barium 46558 ug/L Ngrn rn Pesticides
Turbony nog/1 ife Cond.95 ug/L Ca-Calcium 46552 /L
Residue..Sutpnaled 530 NTU Striate 'uldns/ent2 Cd-Cadwor 46559 mg/L Acid Herbicides
Taal$uspny0 solids mg/L Sulfide 745 mg/1" Cr-Cbron, 46%0 ug/1"
mg/L MBAS mg/L Cu-Capper 1042 ug/L Semivdafle,
OH Oil and Grease mg/L Fe.Iron 1045 ug/L TPH-Diesel Ran e
Alkalinity to PH 4.5 mnils Silica -8/1- H u 1.
g-Mercury]I90p
Alkalinity to pit 8.3 ntg/L Rom nwL K-Pmassiunt ug/L Volatile
nt /L iu,9 Organics(VOA boWc)
g m /L
Csrbonale FornyWehyrle M -Magnesium 927
Bicarbonate mg/L N113 as N 610 m/L MwMansto ese{095 - nIg/L TPH-Gasoline Ran e
Carbon ditaide to/L 7RN as N 625 mg/L 929 ug/L TPH Gasoline Range
Chloride an NO2+NO3 as n 630 mg/L Ni-Nickel mg/L -Gand
Chromium: iea 1032 mg/L P:Total as P 665 mg/L X PbLead 465o i- ng/L
Color:Truebll ug/L POI mg/1' Se-Selenium ug/L
CYanide 720 C.U. mg/L n Z.%46567 ug/L
COALAIENTS: mg/L ug/L
APR 2 7 1%9
CmmRlwates Section '
Asheville Re 'onal Office h' °
t

i GR UNDWATER FIELD/Lqg FORM
I
_
4. C unty V1 Vlt.l�i • ' /'C J •.`f y.T Depattment of Environment, Health,and Natural Resources
1 No w MPLE T PE DIVISION OF WAFER QUALITY-
Lat. o D r „ Serial No. D [`�Water AMP E p O TY , , GROUNDWATER SECTION
Long.� C 7= 0 Soll routine Lab Number
Report ❑Other Emergency Date Received
ARO FRO, MRO,
WSRO, Kinston F RRO, WaRO, WIRp Rec'd by: -Tim
O, Fed. Trust, Central Off. �hain of Custody urluew rom:Bu
Shipped by:Bus, then Other: Courier Hand Del.,
ourier Hand Del., Other• _ Data Entry D By:
FIELD ANgLY ES Date / Date Reported: Ck:
Time. ' Ported: -
Purpose:
Temp. 0 oc Cond. Baseline,Complaint,Owner Nh m Ilan UST Pesticide Study,0 94 at 25o C Location or site rorolo�P
Appearanc- C Odor 1 Y Federal Trust,Other:-
Field Analysis By: Description of sam tin
Sam tin p 9 Point
LAB RAT RY ANALY E p g Method I
BOD 310�5 S Remarks ^
P '0a1p p" am le I
COD High 340 m n P nterval �
COD L Diss. solid_
70300 '��'°41°'""p•p"�pmo.eicl ! �
ow 335 mgn Flouride g57 m n -
Colilorm: mgn Hardness:Total goo A 'Silver 46566
MF Fecal 31616 m 0 Al-Aluminum 46557 u n Colilorm:MF Total 31504 /t OOmI m n Organochlorine Pesticides
/100m1 Hardness non-carb gp2 u Organophosphorus Pesticides
TOC 680 As-Arsenic 4s557
PhPnols 32730 m n Ba-Barium 46558 u n Turbitlity 76 mon 9 Nitro en Pesticides
Residue., Sus NTU a c Cond Ca-Calcium 46552 u n Acid Herbicides
Suspended 53o Sulfate 945 Mho m2 Cd-Cadmium 46558
mgn Sulfide 745 m n m A PCBs
Cr-Chromium 46560 u n
m n Cu-Co u /I lk 403 011 and Grease er 46562
Alkalinity to unit Fe-Iron 4s5s3 u n
Y PH 4.5 410 m /I u �
Alkalinity to PH 8.3 115 mgn I-Mercury 71goo SemivOlatile Or
K-Potassium 46555 ugq TPH- Organics
Carbonate 4q8 mgn Diesel Range
Bicarbonate 440 mgn M -Ma nesium 46554 mg,
NH as N 610 Mn-Man Press 46565 m n
Carbon dioxide 405 m n m AChlorlde 940 mgn Na-Sodium 4s556 u n
NO +NO as N 630 m n Chromium:He 1032 mgn P:Total as P 665 Inn Volatile Or ganics(VOA bOffle)
Color.{True so ug/I m n t b-Lead 48564 TPH-Gasoline Ran e
Cyanide 720 CU Be-Selenium U A BTEX 13asollre Ra
mg/I Zn-Zinc 46567 e9e
ab Comments: u n
�
J For Dissolved Analysis-submit filtered sample and write"l in block.

Division of Environmental Management
GROUNDWATER SECTION
CHAIN OF CUSTODY RECORD
For Investigation of 1&Seay&) L # 'V bl /I1(— Vklli >RY✓ 4 Incident No. .
Samples collected and GW-54 forms completed by:
Lab Only Quad No. of
Lab No. No. Location Date Time Containers
V r - JN ILA o vL+ 5 1
,/ fi,. -myN - L /J`
Relinquished by(Signature): Received by(Signalure): Date/Time
Rec. by /
Rel. Rec. by /
Rel. Rec. by /
Method of Shipment:
Seal by: Broken by:
Security Type and Condition: Lock by: Open by:
LAB USE ONLY
Lab No. No.
From Through Containers Analysis Relinquished by Received by Date / Time
.p;
/
D /
—R-
APIR2799 /
White copy GW Headquarters Canary copy Lab , Pink copy Region
GW-63 Revised 9/87

i
I' I
o? Ll kxsld @ S(&ffb CeQot,
i
�aess
r r
.��► I c �
/gyp 'Co
r

INCIDENT NUMBERS ASSIGNED NON-UST SOURCES
03-Dec-98
INCIDENT# INCIDENT LOCATION/NAME COUNTY REGION DATE ENTERED
19224 GS LABORATORY EQUIPMENT BUNCO ASH 11/18/98
19263 LAIRD PACKAGING MCDOW ASH 12/1/98
, I II DFC a 19a99 �, I
i
1

GROUNDWATER SECTION
November 6, 1998
MEMORANDUM
TO: Amy Axon
UIC Group
Central Office
FROM: Julie Berrey'Ob
Groundwater Section
Asheville Regional Office
SUBJECT: Roseann Dorsch UIC inspection
On November 5, 1998,1 reinspected Roseann Dorsch's injection well. The two problems
discovered during the first inspection have been corrected: the well ID tag is present and an
effluent sampling port has been installed at the wellhead. If you have any questions, don't
hesitate to call me at(828)251-6208,ext. 203. Thank you for all your help.

Division of Environmental Management
GROUNDWATER SECTION
CHAIN OF CUSTODY RECORD
For Investigation of (Ai(, Pwm'+ Lisa Incident No.
Samples collected and GW-54 forms completed by:
Lab Only Quad No. of
Lab No. No. .Location Date Time Containers
Relinquished by(Signature): Received by(Signature): Date/Time
Rel. Rec. by /
Rel. Rec. by /
Rel. Rec. by
Method of Shipment:
Seal by: Broken by:
Security Type and Condition: Lock by: Open by:
LAB USE ONLY
Lab No. No.
From Throu h Containers Analysis Relinquished by Received by Date / Time
/
White copy - GW Headquarters Canary copy - Lab , Pink copy - Region
GW-63 Revised 9/87

Division of Environmental Management
GROUNDWATER SECTION
CHAIN OF CUSTODY RECORD
For Investigation of t mC T--(�rmi f (Ljl"'oce. Sam lives, Incident No.
Samples collected and GW-54 forms completed by: ti
Lab (Jrly Cued No. of
Lab o. No. Location Date Time Containers
Relinqui had b (Signature):. AeLelved by
Sip lure): ^Date/Time
RPI. Rec. by /
Rel. Rec. by /
Rel. Rec. by /
Method of Shipment:
Seal by: _ Broken by:
Security Type and Condition: Lock b Open by:
AB USE ONLY
Lab No. NO.
From Thr u h Containers Analysis Relinquished by Received by Date / Time
/
,aV
' �tE
1
/
White copy - GW Headquarters Canary copy Lab , Pink copy Region

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
SAMPLE TYPE SAMPLE PRIORITY
County r� Lab Number %6 7 6
Quad No R-$8 &1 Serial No. r 2 7b Later El Emerge Date Received 9-9 >X Time J vo
Lat. 3S 10 3l0 ❑ soil El Emergency
Long.-� �� 27 ❑ Other Rec'd by: From: Bus, Courie , Hand Del.,
�� Other:
L+3
Report To:ARO, FRO, MRO, FRO, WaRO,WiRO, Chain of Custody 0 Data Entry By: S Ck: S
WSRO, Kinston FO, Fed.Trust,Central Off., ther - Date Reported: ' 'N
Shipped by: Bus, Courier, I �QI Other
^ Purpose:
Collector(s): N�rJA Hj�]M Date Time W`I S Be eline,Complaint, lion LUST, Pesticide Study, Federal Trust,Other:
FIELD ANALYSES Owner lion
eAlie Cond.B4 at 250 C Location or site Y r �1rc 2
Temp.10 l,9 9C Odor BJovt,, Description of sampling point - C ' vrcu
Appearance Cj&q,�(- Sampling Method I terva ample l
Field Analysis By: JQ Remarks i_ few hzfar� t fir a�(i`�ii,. 1 oY aAe't Sler�It zcQ 1 ^
LABORATORY ANALYSES u�ept, e,er ""4.mc.1
BOD 310 m /I "15ISS.Solids 70300 mall A -Silver 46566 u /I Or anochlorine Pesticides
COD High 340 mgA FI ride 951 m At-Aluminum 46557 u /I Organophosphorus Pesticides
COD Low 335 mgA r n :Total 9 As-Arsenic 46551 u A Nitrogen Pesticides
Coliform: MF Fecal 31616 < / 1100ml Hardness non-carb 902 m A Ba-Barium 46558 u /I Acid Herbicides
Cofiform: MF Total 31504 < ( /100ml Phenols 32730 u A Ca-Calcium 46552 m /I PCB's
TOG 680 mgA Specific Cond. 95 uMhos/cm2 Xd-Cadmium 46559 u A
Turbidity 76 NTU Suffate 945 m /I r-Chromium 46560 u /I
Residue., Suspended 530 mgA Sulfide 745 m A u-Copper 46562 u A
Fe-Iron 46563 u /I Semivolatile Organics
Oil and Grease m 11 H -Mercury 71900 u A TPH-Diesel Range
PH 403 q unit K-Potassium 46555 m /I
Alkalinity to pH 4.5 410 mgA yq-Magnesium 46554 m /I
Alkalinity to pH 8.3 415 mgA Mn-Manganese 46565 u /I
Carbonate 445 mgA NH as N 610 m /I Na-Sodium 46656 mgA Volatile Organics(VOA bottle)
Bicarbonate 440 m A TPH-Gasoline Range
Carbon dioxide 405 m /I +NO as N 630 m AZk
Pb-Lead 46564 u /I TPH-BTEX Gasollm Range
Chloride 940 mgA P:Total as P 665 m Se-Selenium uqA
Chromium: Hex 1032 ugA Zn-Zinc 46567 u A
Color:True 80 CU
Cyanide 720 mgA
Lab Comments:
GW-54 REV.12/0' For Dissolved Analysis-submit filtered sample and write"DIS"in I•' I sum

X �g FILE COPY
?aa«.3i Gz -.
;1 NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WASTE MANAGEMENT
bcI{r' b. ASHEVILLE REGIONAL OFFICE
cv� J 1
DIVISION OF WATER QUALITY
1� �Y�,:,� � °l
AV- r k ,t?;` September 21, 1998
Roseann Dorsch
JAMEE B.HUNY Jp: x
r{yGOVERNOR j Post Office Box 605
i;. Cedar Mountain,North Carolina 28718
' t K SUBJECT: Well ID Tag
CDEVI ��" P,
Dear Ms. Dorsch:
� : Ted Minnick found a well to and filled it out for you with all of our well information. It is enclosed. Please attach this at the wellhead. The adhesive on the
LL'�I�IFI G ML^'Ek: 45`e`sl
back of the tag is rarely enough to keep it on the well for long. Please try to find a
better way to adhere it to the wellhead such as using tape or glue.
�tk��`f YsYF3 N�r . , -cX',I§•' I will be out of town on Friday, September 25, 1998, so please talk to Amy
Axon in the Raleigh Central Office at(919) 715-6165 to give her an update on the
•,et: v / , status of the effluent sampling port. I will return on Monday, September 28, 1998,
so if you have any questions you can reach me then at 828 251-6208, ext. 203.
�., Sincerely,
{ 1 a
Julie Berrey
l Hydrogeological Technician
I JAB/dorsch.uic
nk�4'.R4r�•_1`im�'
4US
°°Lr�' a �
d
UST SECTION
�� Ix•,Y,gS jet `� I INTERCHANGE BUILDING,59 WOODFIN PLACE,ASHEVILLE,NC 28801-2414
� {` `• PHONE [phone] FAX [phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER-50q RECYCLED/IOq POET-CONSUMER PAPER

NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
r;
1.' ,:;� � DIVISION OF WATER QUALITY
y ASHEVILLE REGIONAL OFFICE
NCDENR
GROUNDWATER SECTION
JAMESS.HUNTJR. J] j August 6, 1999
GOVERNOR awl
�l
Ms. Roscann Dorsch
P. O. Box 605
5��{WATNE MCDEVIA.. 1 -
f,�SECRETARY e.b ;'.;ni��jf Cedar Mountain, NC 28718
1 +,i
Subject: Water Sample Results
KEHRT STEYENe '� 4 tE RRl Box 73, Slick Rock Road
DIRECTOR �✓ ,.iF Brevard, North Carolina
s'
Dear Ms. Dorsch:
t. ''} Enclosed please find a copy of the lab results for the water samples we
took from your well. No lead was detected at levels above the lab detection limit.
If you have any questions, please call me at [phone] ext 228.
1 P 4 ti
�i
:t
`- 8 } �Sincerely,
rJa t LI I
}l.l 0
_ 1 Ilydrogeologist
Asheville Regional Office
w^+
fw „l INTERCHANGE BUILDING, 59 WOODFIN PLACE. ASHEVILLE. NC 28801-24I4
PHONE[phone] FAX 828-2S1-
6452
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER - 50% RF.CYCLEO/IOy POST-CONSV MF.R PAPER

DIVISION OF WATER QUALITY
Chemistry Laboratory Report Ground Water Quality Lab Number : 9G0996
Data Received: V26/99
COUNTY: TRANS. SAMPLE PRIORITY Time Received: 9,00
QUAD NO: X�ROUTINE EMERGENCY Received By DS
REPORTTO ARO Regional Office X❑ CHARJ OF CUSTODY
COLLECTOR(S) : JAB/QQ INF Released By: DS
DATE: 5/id199 W❑ SAMPLE TYPE Date reported: 7114199
TIME:
PURPOSE: Owner ROSEANN DORSCH INF
Location or Site:
Description of sampling point
Sampling Method:
Remarks:
LABORATORY ANALYSIS
BOD 310 m /L Diss.Solids 70300 m /L A SBver46566 a /L Organochlorina Pesticides
COD High 340 en /L Fluoride 951 m /L AI-Aluminum46557 u /L Or ano hos horns Pesticides
COD Low 335 m /L Hardness:total 900 an /L As-Arsenic 46551 a /L NitrogenPeaticides
Calif..-MF Fecal 31616 /100ml Hardness: noncarb 902 ro /L Ba-Barium 46558 a /L
ColJomc MF Total 31504 /100ml Pheno102730 u /L Ca-Cn1cmm 46552 au /L Acid Herbicides
TOC mg/1 Specific Cond.95 umhos/ant Cd-C dium46559 u /L
Tmbitity NTU Sulfate m /L Cr-Chromium 46560 u /L Semivolatiles
Residue.,Suspended 530 en /L Sulfide 745 m /L Cu-Copper1042 u /L TPH-Diesel Range
Total Sus ndedsolids m /L MBAS m /L Fe-Iron1045 u /L
Oilaod Grease m /L H -Memory 71900 u /L JVolatfle Organics(VOA bottle
H units Silica m /L K-Potassimn46555 m /L
Alkalinity to pH4.5 m /L Baron ll-Ma sium927 m /L TPH-Gasoline Range
Alkalinity to FIT8.3 an /L Formaldehyde m /L Mn-Man enese 1055 u /L TPH-BTEX Gasoline Ran
Carbonate m /L NH3 as N 610 m /L No-Sodium 929 m /L
Bicarbonate m /L TKN as N625 m /L Ni-Nickel u /L
Carbon dioxide m /L NO2+NO3 as n 630 m /L X Pb-Lead46564 -10 u L
Chloride m L P:Total as P 665 m /L SeSelenium u /L
Chromium:Hex 1032 u L PO4 m /L Zn_Zmc46567 u /L
Color.Tme BO cu.
erdde720 m /L
COMMENTS:
960996.may

DIVISION OF WATER QUALM
Chemistry Laboratory Report/Ground Water Quality Lab Number : 9GO997
Date Received: 526199
COUNTY: TRANS. SAMPLE PRIORITY Time Rereived: 9;00
QUADNO: X�ROUIINE EMERGENCY Received By DS
REPORTTO ARO Regional Office X❑ CHAIN OF CUSTODY
COLLECTOR(S): JAB/QQ EFF. Released By: US
DATE: snero9 W❑ SAMPLETYPE Data reported: 7/14/99
TIME:
PURPOSE: Owner. ROSE ANNDORSCH
Locafion or Site:
Desorption of sampling point
Sampling Method:
Remarks:
LABORATORY ANALYSIS
BOD310 ra /L Diss.Solids 70300 m /L A Silwr46566 a /L Or anocldadne Pesticides
COD High 340 m /L Fluoride 951 m /L AI-Aluminum 46557 v /L Or ano hos horns Pesticides _
COD Low 335 m /L Hardness:total 900 na /L As-Arsenic 46551 n /L Nitrogen Pesticides
Cohform:MF Fecal 31616 /100m1 Hardness: ra srb)902 en /L Ba-Barium 46558 u /L -
Colif..:MF Total 31504 /100m1 Phenols 32730 a /L Ca-C.Icium 46552 m /L Acid Herbicides
TOC mg/1 Specific Cond.95 umhos/cm2 Cd-Cadium 46559 a /L
TmInfiLy NTU Sulfate m /L Cr-Chmmium46560 u /L Semivolatiles
Residue.,Sus nded530 m /L Sulfide 745 an /L Cu-Co r1042 u /L TPH-Diesel Range _
TotaliSuspandedsolids m&IL IMBAS m /L Fe-Iron 1045 u /L
Oil and Grease m /L H-Mercu 71900 u L Volatile Organics(VOA bottle _
H umb Silica en /L K-Potassium 46555 m /L
Alkalinity to PH4.5 m /L Bman Mg-Ma esium 927 m /L TPHGwoline Range
Alkalinity W PH8.3 m /L Foranaldeh de m /L Mn-Manganese 1055 a /L TPH-BTFX Gasoline Range
Carbonate en /L NH3 as N 610 m /L No-Sodium 929 m /L
Bicarbonate na /L TKN as N625 nn /L Ni-Nickel u /L
Carbon dioxide m /L NO2+NO3 as n630 m /L X Pb�Lead 46564 <10 u /L
Chloride m L P:Totalas P665 m /L Se-Selenium u /L
Chromium:Hea1032 u /L PO4 m /L 1Zn_Zinc46567 u /L
Color.True 80 Co.
C anide720 m /L
COMMENTS:
9g099).may

n-
Ch,rdV,
DIVISION OF WATER QUALITY
: Croundlif TbNam r 9G0996
Laborvmry Be""Re rtlGronnd Wveer 0
ASh_91i1f 0c i0, i Qt(iC'
—ti)ateR ed : SR6199
CT8!Nh- : 1 RANG SAAII'LF.Pft1ORI'IY r- Time Rmeived : 9,110
QUAD NO X❑ROUI Mr. EMERGENCY !V Received By is
RFIORT 10 ARO ft.gimmlt Nlke 'T❑ CI IAIN OF CUSfODY O
C VLITC-R)Rlul 3AN(p) INF
Releaavl By : US
l I%IF S'Am lV NA611'LIf'IV19i ❑ah•relwreed: 711499 i
PLROST, (hvrrr: ROSEANN IR)RSCII INV.
I.v Mion or Site
I sev riplimr of sampling Poim
S.vnpling hlelhnd: .. v
Remarks:
LAUORA I ORV ANAIA"SIS
BOOM ea /I. Diss.Selids70.300 m /L A -Silver46566 u /L Ur anochloritse Pesticides
COD IIi l,Id0 m /L Fluoride951 m /L AI-Aluminum 46557 u /L Q eno hos horua Pesticides
COU I me 115 a, /L I lardmss:total 9W m {L As-Aeaenicd6551 a /L Nil en Pesticides
Celilarm Mt Ir.11t616 /IOtMJ Iludm•ss: non<arb 902 m L Oa-
/ Oar'um 46558 uFJL
Colilnmr hIF IotaU1411 Iw.I Plvx unls 32730 u /L Ca-Calcium 46552 L Acid herbicides
TM m /I S ilk Coml.95 uenhos/cm2 Cd-Cadium 46559 u L
IurlroNm NIU Senate ri /L Cr-Chmmium46560 u L Sendeolmiles
Fn61u,•.Su,, mndd 5N, ns /1. Sulfide 745 m /L Co.Copper10f2 u /L 'IPI{_Uiescl Ran e
Total 5usw„led sol.k m /1. MONS m L Fe-Iron 1045 a /L
Oil and Grease nn /L Hz-Nle..ev 719DO a /L W.Wito Or asks fVOA Wilk
•II onib Silk ra m /I. K-I'olassinm d6555 m /L
AlMtnnly 1., •1145 m 1. N4..nr I Id,hi nesium 927 m /L INI-Gasoline R..
dlkdinarw dl 83 m /1. 1'....etAdehede ra /L hle,h/an arrese 1055 u L IPI I-91 EX Gasoline Ran e
C.A.•...ne m /I. NI❑as N 610 m /L Na-Sodium 929 m /L
nkad.mne m /I. I KN as N 625 m L Ni-Nickel u /l.
C.,I.mdiu•0, m /I. NOl.NO3 as n 630 m /L X PLLead 46564 <10 a /L
0&,ide tar./I. I':'I utnl as l'665 m /L Se-Selenium a /L
ch,ominm Ile.In)2 v /I. I14 un /L Zn_Zia46567 u L
Cole,hueml
cu...&T81 nr 1/I.
Ctg1a1F.NIS:
91io9%sur

_r 26� A/'1�� North Carolina
G OUNDWATER FIELD/LAB FORM OF cus-rODY Department of Environment,Health,and Natural Resources
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
\ County
SAMPLE TYPE SAMPLE PRIORITY I S Lab Number ,.
`/ No Serial No. [3Vater 0-Woutine Date Received Time
/Quad
❑ Soll ❑ Emergency R 'd b �_ From: Bus ourier Hand Del.,
Lat. °/U -� Long. ❑ Other ec Y
Other:
Report T ARO FRO, MRO, RRO, WaRO. Wi %ain of Custody Data Entry By: Ck:
WSRO. Kinston FO. Fed. Trust, Central Off. lher — Date Reported:
Shipped by: Bus, ourier and Del., Other
Purpose: �f
Colleclor(s): Date Time Baseli Complaint, ompliance,CUSM, Pesticide Study, Federal Trust,Other:
FIELD ANALYS S Owner
pH4., Spec. Cond.,, at 250 C Location or site 1
Temp.10 oC Odor Description of samplingpoinl
Appearance Sampling Method / Sam p a Interval
(°emp.caret.etc.)
Field Analysis By: Remarks
ANALYSES ma"c one.e"iemn.em.i
LABORATORY
BOD 310 mall Diss. Solids 70300 m A A -Silver 46566 u /I Organochlorine Pesticides
COD High 340 mgA Flouride 951 m /l At-Aluminum 46557 u A Organophosphorus Pesticides
COD Low 335 m9A Hardness,Total goo m A As-Arsenic 46551 u /I Nitro en Pesticides
Colilorm:MF Fecal 31616 /100ml Hardness non-carb 902 moll Ba-Barium 46558 u A Acid Herbicides
Coliform: MF Total 31504 /100ml Phenols 730 u /l Ca-Calcium 46552 m /I PCB's
TOC 680 moll Specific Cond. 95 uMhos/cm2 Cd-Cadmium 46559 urill
Turbidity 76 NTU Sulfate 945 m /l Cr-Chromium 46560 u /l
Residue..Suspended 530 moll Sulfide 745 m /I Cu-Copper 46562 u A
Fe-Iron 46563 u /I Semivolatile Organics
Oil and Grease m /I H -Mercury 71900 ugll TPH-Diesel Range
pH 403 unit K-Potassium 46555 m ll
Alkalinity to pH 4.5 410 mall M -Ma nesium 46554 m A
Alkalinity to pH 8.3 415 mgA Mn-Man anese 46565 u /I
Carbonate 445 mgA NH as N 610 moll Na-Sodium 46556 m /I Volatile Organics(VOA bottle)
Bicarbonate 440 m A i-Nickel uoll TPH-Gasoline Range
Carbon dioxide 405 mgA NO +NO as N 630 m /I Pb-Lead 46564 u A TPH-BTEX Gasoline Range
Chloride 940 mall P:Total as P 665 m /1 Se-Selenium u /I
Chromium:Hex 1032 u /I Zn-Zinc 46567 u A
Color:True 80 CU
Cyanide 720 mgA
Lab Comments:
GW-54 REV.7'^5 For Dissolved Analysis-submit filtered sample and write"DIS"in blr,k.

D d �
JUL
DIVISION OF WATER QDALFP
Y ? 0 IG
Iheml+try l..Ler.leq Rr8erl J Gr..nd W.Ier Q.0h, la Number 9(;0997
Gmundwate• Secdo DTI RemirrJ : SR699
C[H7NIl' : TRANS. SAMPLE,PRIORITY Asheville Re Irma" 0 e 1 i.X Rnroivesl : 9181
QUAD NO "ROM INr: EMERGENCY meived By DS
REPORTTO ARO Rrgimndt Mur 0 CIIAINOFCUSIODY
COLLECTOR(g) ' JABIN) EFF.
DATF' 914a9 1V SAMI'LE1YI•F. Ralexsl•<I By : 1
TIMIR Uxtr n•lwrllvl 7/14ro9
PURPOSE: U.Isrr. ROSEANN DORSCII
1.a'x1M11 or Site.
Ibscril.tion nl s.mPltng 1'ohit
SamPlinp,W11, 1:
R....
LAIIORMORY ANALYSIS
BOD 310 m /L pus.Solids 70300 m /L A -Silver 46566 u /L ,t whlorine Peslkidus
CODIIi h340 m /I. flooride951 m /L AI-Aluminum 46557 a /L O ano hm home Prsk:ide
M)1.-315 m /I. I Mrdnrss:1.1.1900 m /L As-Arsenic 46551 L Nit en Pestkides
Cnlif.. MI I-1111,11, /IN)... I 902 m /L Ba-Barium 46558 u L
C.M.. Mt Im.11174)I /I(X).nt I•henols 32730 a /L Ca-Cakium 46552 m /L Add Herbicides
I(K m /1 5,,ilk Cmul.95 umhm/cm2 Cd-Cadium 46559 u L
IarFilin NI'U Sullalr m /L CrLhromium 46560 a /L Semivolaliks
m /I. Sullide745 m /L Cu-C.pp,1042 0 /L T'PH-Diesel Ran e
fool Su+vmlyd.ob.l+ m /1. MBAS m /L I Fe-Iron 1045 u L
Oil it.0 Grrase m /L II -hlercury 71900 u L IV.I.tile Or anks(VOA bottle
11 nn1+ Silk. m /L K-P.Mviium 46555 m /L
Al"Imew t.pl14 i m /1. Bonin hl -hta resium 927 m /L ITPHGasoliimm Ranxe
Alkalinity In pl183 m /I. F•nnJJnc�de m /1. hln-Alan anew 1055 a /L 'IPH-BTFA Gxmlirle R.,,"
CuhmT4 m /L NI 11 xs N 610 nI /L NT-Sadium 929 I L
Bkarlon.4 nI /I. 1'KN xs N625 m /L Ni-Nkke1 u L
Gdon dkr+idr m /I. NO2 WO3 xs n610 m /1. ] I'b-LeTd 46564 q0 n /L
Chlorkle ., /I. I•:Tu1T1a+P665 m /L Se-Selenium u /L
Unnmimn Ile.InQ a /1. 1114 uI /1. 7.n Zim46567 a 1.
C'oMr I rue MI
Oonkle720
I
COMMENTS:
9C 7.1

1 !' rl ' `•''�•' '• �� J, Department of Environment,Health,and Natural Resources
GROUNDWATER FIELD/LAB FORM
DIVISION OF WATER QUALITY-GROUNDWATER SECTION
MPLE TYPE SAMPLE PRIORITY r U
CJ unty r,-'-,`� Lab Number
\/Quad No Serial No. ater Lrrtoutlne Date Rec ed Tim
"Lat. 35 °/0 r 36 ' Long. �2 y/ L 7 Solt ❑ Emergency
❑ Other Rec'd by /—� From: Bus Couri r, Hand Del.,
�11 Ira Other:
Report To FRO. MRO. RRO. WaRO. WiRO LY Chaln of Custody Data Entry By: Ck:
WSRO, Kinston FO. Fed. Trust. Central Off., then: - Date Reported:
Shipped by: Bus, ourier and Del.. Other
Purpose:
Collector(s): Dale Time �l[ _Baseline,Complaint,C lian eST, Pesticide Study, Federal Trust,Other: L)fG
onep
FIELD ANALYSES Owner
pH4DO Spec. Cond.,, at 250 C Location or site
Temp.,, OC Odor Description o1 samplin,4�point�
Appearance Sampling Method �y �l Sam Interval
Field Analysis By: Remarks U (Pump.oaieq e¢.I
LABORATORY ANALYSES Dump np ivne.en remo.etc.)
BOD 310 moll Diss.Solids 70300 m A A -Silver 46566 u A Organochlorine Pesticides
COD High 340 mg1l Flouride 951 m A At-Aluminum 46557 u A Organophosphorus Pesticides
COD Low 335 m A Hardness:Total 900 moll As-Arsenic 46551 u /l Nitrogen Pesticides
Coliform:MF Fecal 31616 /100ml Hardness non-carb 902 m A Be-Barium 46558 u A Acid Herbicides
Coliform:MF Total 3150-' 1100m1 Phenniq 39730u /l Ca-Calcium 46552 m A PCB's
TOC 68o m0A Snprifir.Crind 9s uMhp5/CM2 Cd-Cadmium 46559 u /l ,J
Turbidity 76 NTU Sulfate 945 moll Cr-Chromium 46560 u /l
Residue.,Suspended 530 mg/I Sulfide 745 m /l Cu-Copper 46562 U A
Fe-Iron 46563 u /I Semivolalile Organics
Oil and Grease m -11 H -Mercury 71900 uglf TPH-Diesel Range
DH 403 unit K-Potassium 46555 mg/1
Alkalinity to pH 4.5 410 mg/I M -Ma nesium 46554 m /I
Alkalinity to pH 8.3 415 mg1l Mn-Manganese 46565 u /l
Carbonate 445 mgA NH. as N 610 m /l Na-Sodium 46556 m A Volatile Organics(VOA bottle)
Bicarbonate 440 m /INi-Nickel uon TPH-Gasoline Range
Carbon dioxide 405 mgn NO +NO as N 630 m /I Pb-Lead 46564 u A TPH-BTEX Gasoline Range
Chloride 940 mg1l P:Total as P 665 m A Se-Selenium u A
Chromium: Hex 1032 ug/l Zn-Zinc 46567 u /I
Color:True 60 CU
Cyanide 720 mgA
Lab Comments:
GW-54 REV 7'^5 For Dissolved Analysis-submit filtered sample and write"DIS"in blo,k.

-North Carolina Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WI U=oioLL-, o-cco2DATE q
A AV
NAME OF OWNER :Qova„r 11n s cln.
ADDRESS OF OWNER (l G
1 r 2 t
(Street/road or rot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable)
fz2 1 TI)y 7-:� ja &k- PA
(Street/road or lot and subdivision, county, town, ifdii ferent than owner's address,plus description oflocation on site)
Potential pollution source (\l e e. ov S�2t c k Distance from well >2oo
Potential pollution source r7, c;tr S>'04', - t M I'c Distance from well 5 yvo -
Potential pollution source Distance from well
Minimum distance of well from property boundary I; r
Quality of drainage at site�Flooding potential of site 0 W
(good adequate poor) (high,moderate,low)
DRAW SKETCH OF SITE (Show property boundaries, buildings, wells,potential pollution sources, roads, approximate scale, and
arrow.)
1
ii
i
u�ll
.lam 5k .
DESCRIBE INJECTION SYSTEM (vertical closed loop, encased borehole or cased water well;separate source well and injectio
combination source and injection well;or other description as applicable)
� r�vN{hrYlt�trn C'aur(e u i � IP(7tiinn LUr?ll. ea(ed 1,0611

INJECTION FACILITY INSPECTION REPORT -FORM B (CONTINUED)
WELL CONSTRUCTION
Date constructed [I(9 7
Drilling contractor:Name
Address
Registration number
Total depth of well 09 Total depth of source well �J A—
(iifapplicable)
Inspection point Measurement Meets minimum standards Comments
{( Yes No /
�
Casing V ( DW%
Depth ✓ _ `&��f abcev"
Diameter c, — nfogzn r.
Height(A.L.S.) � ✓ r�bc�r�re{
Grout
Depth
Screens
Depth(s) —
Length(s)
I.D. Plate ,
t
Static water level q V /hem L im�g� i�,Soec,i.,`1_9
Well yield
Enclosure ✓ cT�JP
Enclosure floor
(concrete)
Sampling port yn�lua�,! �x� c l wel l kea d w c-t so
(labeled) EwIua,#
�m(ol,,��qq po-r�- otated in (7.ou.Y.,arr
Water tight pipe entry ✓ ba ck s c� of pu�„p. 1 `W�
Well enclosure entry ✓ IWxJ
Vent ✓ —
Functioning of heat pump system (Determine from the owner if heat pump functions properly.) CU.3Kc,r se_&S ,eA W kwfp,.,,.yp
INSPECTOR Office r
WITNESS Address
WITNESS Address ��� March 1998

-7, ?01

• - i
Division of Environmental Management G D
GROUNDWATER SECTION n15
CHAIN OF CUSTODY RECORD
. •. �°Ctlee
For investigation of LAIC- h1r n � C�µ�Luv ce SLLmyel via incident No.
Samples collected and GW-54 forms completed by:
�� �Y
Lab y Quad No. of
Lab 01. No. Location Data Time ners
t
ReIinq 'she b (Signature):• Pecolved by(Si nature): Date/Time
Li RR LL R by
Rel. Rec. /
Ref. Rec. y /
Method of Shipment:
Seal by: v 9 Broken
Security Type and Condition: Lock by. Open by:
A F Y
Lab No. °' Analysis Relinquis d by Receiv"DateFrom Thr u h Containers Y
/
/
/
White copy GGW Headquartert Canary copy - Lab , Pink copy Region

GROUNDWATER SECTION D D
August 31, 1998
Groundwater Section
Asheville Re Tonal GfFce 1
MEMORANDUM
To: Julie Berry
Groundwater Section
Asheville Regional Office
From: MV MarkPritzl [phone] [e-mail]
Hydrogeological Technician II
UIC Group
Central Office
Re: Request for review of an injection well renewal permit application and routine
sampling/inspection of Roseann Dorsch's geothermal injection well in Brevard,
Transylvania County.
1. Please review the application and submit any comments to CO-UIC. Retain the
application for your UIC file.
2. Please inspect the injection well facility to visually determine the integrity of wellhead
construction,the presence and accessibility of effluent and influent taps, and other
requirements for compliance with the NCAC T15A:02C.0200 standards,using the
enclosed Injection Facility Inspection Report(form B) as a guide.
3. Please sample the influent and effluent using the Sampling/Inspection Procedure for
Injection Wells as a guide. Complete the enclosed Groundwater Field/Lab Report(form
GW-54).
4. Please return any application review comments and sample and inspect the injection
well facility by September 15, 1998 (If sampling and inspection cannot be accomplished
by this date, please inform RCO-UIC). Send a copy of the completed Iniection Facility
Inspection Report(form B)to RCO-UIC and request the DWO lab to send a copy of the
Groundwater Field/Lab Report(form GW-54) to RCO-UIC.
The UIC group greatly appreciates your assistance with the completion of UIC program
activities.
cc: UIC Files
ARO Files
Enclosures

i
✓' NORTH CAROLINA DEPARTMENT OF
s "•" ENVIRONMENT AND NATURAL RESOURCES
`••' •��s. DIVISION OF WATER QUALITY
1 lee
GROUNDWATER SECTION
NCDENR August 31, 1998
DAMES B.HUNT JR:_., j
II GOVERNOR S �1
Roseann Doresh
t W Route 1, Box 73
Slick Rock Road
Brevard NC 28712
WAYNE MCUEVITT"— ,._ n
SECRETARY I` •i� lT,
rl -i • `t -Dear Ms. Doresh:
..'"A.PREBTONHOWARD,
I Eafl Your application for a renewal permit to use a well for the injection of
geothermal heat pump effluent has been received and is under review. A member of
the Groundwater Section's Asheville Regional Office staff will be contacting you to
arrange an inspection of the injection well and collect water samples as part of the
"}0`0::4 review.
-,•cam ,,, �1q"rc_-;
r "' If you have an questions regarding the permit or injection well rules lease
•� ,.i r"`•",_ ,., {�- Y Y 4 g g P j P
contact me at [phone] or Amy Axon at [phone].
j Sincerely,
- . —�—_-- Mark Pritzl
Hydrogeological Technician H
Underground Injection Control Program
cc: UIC Files
ARO Files
-" - _fir"• _ —_.
GROUNDWATER SECTION
P.O BOX 29578,RALEIGH,NC 27626-CS78 - 2728 CAPITAL BLVD., RALEIGH,NC,27604
% •N „' ' PHONE [phone] FAX [phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER-50q RECYCLEWIOi POST-CONSUMERPAPER

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT,HEALTH,AND NATURAL RESOURCES
APPLICATION FOR PERMIT RENEWAL TO USE A WELL(S) FOR INJECTION WITH
A HEAT PUMP SYSTEM
Type 5A7 and 5QM Wells
In accordance with the provisions of NCAC Title 15A: 02C.0200
complete application and mail to address on the back page.
TO: DIRECTOR,NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: g 1o?J'
i
A. SYSTEM CLASSIFICATION: Does the system re-circulate only potable water without any additives such as
corrosion inhibitors or antifreezes in continuous piping which isolates the fluid from the environment?
YES _ If yes,do not complete this form. A form G W-57 CL,(Notification Of Intent To Construct A
Closed-Loop Geothermal-Water-Only Injection Well System),should be completed.
NO _A/ If no,then continue completing this form.
B. PERMIT A ICANT G
Name:Address: O 3 Sk 1Gl\J OG(C AA.
City: Bgcu' to C> State: fVC Zip code: Q 87/ a
County: / A/ysy 1J'4 er/� Telephone:
C. PROPERTY OWNER(if different from applicant)
c J
Name: o2AM F_
Address:
City: State: Zip code: U
County: Telephone:
D. STATUS OF APPLICANT
L'i
Private:Z Federal:_ Commercial: State: Public: rn
Native American Lands: _ _ _ _ _ _ _ _
E. FACILITY(SITE)DATA(Fill out ONLY if the Status of Owner is Federal, State,Public or Commercial).
Name of Business or Facility:
Address:
City: State: Zip code:
County: elephone: Contact Person:
Standard Industrial C� e(s)which describe commercia ility:
GW-57 HPR (May 1998) Paget of 3

F. INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous injection permit)
A)t I��OOi �lC.� UIt�S �jl1Co �AS% G�f7c' �T/Or
G. WELL USE Is(are)the injection well(s)also used as th supply well(s)for either of the following?
(1) The injection operation? YES NO
(2) Your personal consumption? YES I,-- NO
H. CONSTRUCTION DATA
(1) Specify any and all modifications to the well casing,grout or screens since the issuance of the previous
injection permit.
(2) NC. State Regulations (15A NCAC, 2C, Section .0200) require the permittee to make provisions for
monitoring well head processes. A faucet on both influent (groundwater entering heat pump) and
effluent(water being injected into the well) lines is required. Is there a faucet on:
(a) the influent line? yes V"'no_
(b) on the effluent line? yes ✓ no_
I. CURRENT OPERATING DATA
(1) Injection rate: Average(daily)gallons per minute(gpm)
(2) Injection volume: Average(daily) 30 O gallons per day(gpd)
(3) Injection pressure: Average(daily) pounds per square inch(psi)
(4) Injection temperature: Annual Average degrees Fahrenheit('F)
J. INJECTION-RELATED EQUIPMENT f01,9
Attach a diagram showing any modifications to injection equipment since the issuance of the previous injection
permit including the engineering layout of the(1) injection equipment, and (2) exterior piping/tubing associated
with the injection operation. The manufacturer's brochure, if detailed,should satisfy(1).
K. LOCATION OF WELL(S)Attach a map
Include a site map (can be drawn) showing: the orientation of and distances between the injection well(s) and
any existing-well(s)or waste disposal facilities such as septic tanks or drain fields located within I000 feet of the
ground-source heat pump well system; include buildings, property lines, surface water bodies, any other
potential sources of groundwater contamination. Label all features clearly and include a north arrow to indicate
orientation.
L. PERMIT LIST: Attach a list of all permits or construction approvals, received or applied for by the applicant
that are related to the site.
Examples include:
(I)Hazardous Waste Management program permits under RCRA
(2)NC Division of Water Quality Non-Discharge permits
(3)Sewage Treatment and Disposal Permits
M. OTHER MODIFICATIONS: Indicate any other modifications to the injection well system
(equipment,fluid, operation,etc.)that have occurred since the issuance of the
previous injection permit and have not been noted elsewhere on this application.
OW-57 HPR (May 1998) Page 2 of 3

I
N. CERTIFICATION
"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 operate, maintain, repair, and if applicable, abandon the injection well
and all related appurtenances in accordance with t roved specifications
nand
_conditions of the Permit."
(Signature of Well Owner or Authorized Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
1 authorizing the above agent.
O. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property rights in
the well(s).A well is real property and its construction on land rests ownership in the land owner in the absence
of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the
applicant to operate an injection well(s)as outlined in this application and that it shall be the responsibility of the
applicant to ensure that the injection well(s) conform to the Well Construction Standards (Title 15A NCAC
Subchapter 2C .0200)
(Signature of Property Owner if Different From.Applicant)
Please return the completed Application package to:
Underground Injection Control Program
Groundwater Section
North Carolina DEHNR-DWQ
PO. Box 29578
Raleigh,NC 27626-0578
(telephone: [phone])
G W-57 HPR (May 1998) Page 3 of 3

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Pri E 53-/'/._r,';fro \
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y1u�ry7 6 2 6UE.sr.
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TRAM.S11-VA/11A COUNT e
11041-H CAf10l. #,vA :

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY, GROUNDWATER SECTION
STATUS OF INJECTION WELL SYSTEM
Date: Jr/�/Sk Permit Number: WI
Name: // 0� /:)A// /�
Address: /,P l i30x 73 a/,U:,k iqO 1�6-t /UL Q(f2/-q
Please check the selection which most closely describes the current status of your injection well.
In addition, p ase provide the requested information.
1) V Well is still used for injection activities.
2) _ Injection discontinued;
a) _Well temporarily abandoned b) _ Well permanently abandoned
Describe the method used to properly abandon the injection well. (Include a description of how the
well was sealed and the type of material used to fill the well if permanently abandoned):
/9 `
Certification: (For well abandonment)
"I hereby certify, under penalty of law, that I am personally responsible for the proper
abandonment of any injection well as required in Title 15A NCAC 2C .0214 Criteria and Standards
Applicable to Injection Wells."
(Signature)
Certification: (For information verification)
1 hereby certify, under penalty of law, that I have personally examined and am familiar with
the information submitted in this document, and that to the best of my knowledge the information is
true, accurate, and complete."
(Signature)
GW- 68 C:\MYFT_LES\FORMS\IWSTATUS 6/10/98

Qtie w A ` P(�_1607�1 oWvko( C+
NORTH CAROLINA Ax P,.r
ENVIRONMENTAL MANAGEMENT COMMISSION a�- 3
/ DEPARTMENT OF ENVIRONMENT,HEALTH,AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A HEAT PUMP SYSTEM
Class 5 Wells
TO: DIRECTOR,NORTH CAROLINA DIVISION OF ENVIRONMENTAL MANAGEMENT
DATE: 19
In accordance with the provisions of Article 7,Chapter 87;Article 21,Chapter 143,and regulations
pursuant thereto,APPLICATION is hereby made for a PERMIT to construct and/or use a well or well
system as described below and in any accompanying data submitted as part of this APPLICATION.
Please type or print clearly.
A. OWNER DATA
Name: A, t; . T?1? A t/
Business:
Address:
City: Zip code:
County:
Telephone:
Ownership f
Federal State Private fife
Public Commercial Other(specify)
Native American Lands
B. FACILITY DATA (Fill out ONLY if the injection well(s)is(are) for the purpose of serving a
business or industry.)
Name:
Business:
Address:
City: Zip code:
County:
Tele
C. HEATING CONTRACTOR DATA
Name: e C R c
Address: e rA 1W VW .s
City: Zip code: 7 9
County:
Telephone: 0 3/i
Contact Person: A e
D. 1NIF�'ION PROCEDUREL (Bricfly describe how the injection well(!)will be used.)
�19Ul � U //P✓s li LY e.J .dT S . iJinL. GJl�1`!w
GW-57 HP (June 1993) Page 1 of 4

E. WELL USE Will the injection well(s)also be used as the supply well(s) for either of the
following?
(a) The injection operation? YES ✓ NO
(b) Your personal consumption? YES NO
F. CONSTRUCTION DATA (CHECK ONE)
EXISTING WELL being proposed for use as an injection well. Attach a copy of Form
GW-1 (Well Construction Record)and furnish(7&8)below. If Form GW-1 is not
available,furnish the data in(1)through(8)below to the best of your knowledge.
PROPOSED WELL to be constructed for use as an injection well. Famish
the data in(1)through(8)below as PROPOSED construction
specifications.
(1) Well Drilling Contractor's Name:
NC Driller Registration number:
(2) Date to be constructed: /M 14- ' Approximate depth:_0�!
(3) Well casing:
(a) Type:Galvanized steel Black steel Plastic ✓Other(specify)
(b) Inside diameter: inches; Wall thickness inches or schedule#
(c), Casing depth: From to ft. (reference to land surface)
// Cas' g extends above ground inches(must be at least 12 inches)
�J`iiS Iry ai- �, o r/ 1c,,a 4. G,/ Ft 1.a YOC,'-
(4) Cement grout:
(a) Around inner or"primary"casing: From to ft.
(b) Around outer(pit)casing,if present: From to ft.
(5) Screens(if applicable):
(a) Type: ; Inner diameter: inches
(b) Depth: From to feet below land surface
(6) Gravel(if applicable): From-to-feet below land surface
(7) N.C.State Regulations (15A NCAC,2C,Section.0200)require the permittee to make
provisions for monitoring well head processes. A faucet on both influent(groundwater
entering heat pump)and effluent(water being injected into the well)lines is required. Will
there be a faucet on:
(a) the influent line?- yes�no_ (b) the effluent line? yes no_
(8) Attach a diagram showing the location of the injection well and sampling faucets relative to
primary building on property.
G. PROPOSED OPERATING DATA
(a) Injection rate: Average(daily) J•6 gallons per minute(gpm)
(b) Injection volume: Average(daily)l&6 gallons per day(gpd)
(c) Injection pressure: Average(daily) " pounds/square inch(psi)
(d) Injection temperature: Winter Average J a degrees F
Summer Average a c/ degrees F
GW-57 HP (June 1993) Page 2 of 4

H. INJECTION FLUID DATA
(1) Fluid Source. If underground,from what depth and what type of rock/sediment does the fluid
to be injected derive(e.g.,granite,limestone,sand). —
y�� 6 j 41 GT!/G�
/QL CPIQ� (2 C !
(2) Chemical Analysis of Source Water. The following chemical characteristics MIDST
accompany this application:
pH ; Total hardness ppm (parts per million or mg/1);
Iron ppm; Chloride ppm; Nitrate ppm;
Coliform bacteria counts/100ml
fed AfAl lvigeJ 6, P0//Ad,b/ ,t/e!/ q- &T91eJ h,e- 41,W 64U 12&st,Gr yacrf
NOTE: Assistance in determining these values may be obtained by contacting(a)your c9��LCFa
local or county health offical,(b)a commercial water-testing laboratory,(c)your
well drilling contractor,or(d) the regional Hydrogeologist,North Carolina Dept.
of Environment, Health,and Natural Resources.
I. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the(1)injection equipment,and
(2)exterior piping/tubing associated with the injection operation. The manufacturers brochure,
if detailed,should satisfy(1)above
J. LOCATION OF WELL(S)
Attach a detailed map showing the orientation of and distances between the proposed well(s),
any existing well(s)that will in any way be involved in the injection operation,and at least two
(2)nearby reference points such as roads,road intersections,streams,etc. The roads should be
identified by US,NC or SR(county secondary roads)numbers,and streams should be named.
In addition,the diagram should show the direction and approximate distance to any existing
water-supply and/or injection wells within 1,000 feet of the proposed injection well.
K. CERTIFICATION
"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 operate and use the injection well and all related appurtenances in accordance with the
approved specifications and conditions of the Permit."
(Signat re of Owner or rW,_on#Agent)
Please supply a letter signed by the owner
authorizing the above agent,if authorized agent is signer.
GW-57 HP (June 1993) Page 3 of 4

NORTH CAROLINA JUL £3
ENVIRONMENTAL MANACEVEWPCOMMISSION GR0UfJE;
-1-� iJil
Pay
DEPARTMENT OF NATURAL RESOURCES AND CC624JNITY DEVFWPMENT
APPLICATION FOR PEfIIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
CLASS 5 WELLS
T0: DIRECTOR, NORTH CAROLIM DIVISION OF ENVIRONMENTAL MANAGEMENT
DATE: �(J l / , 19 " 11
In accordance with the provisions of Article 7, Chapter, 87; Article
21, Chapter 143, and regulations pursuant thereto, APPLICATION is hereby
made for a PERMIT to construct and/or use a well or well system as described
below and in any acccnganying data submitted as a part of this APPLICATION.
A. OMER DATA: Name: � y � �. �i2 )�'4-
Address:
County Telephone: 70�/ 5,Z 319
OTAmership Status: Federal State Private
Public Commercial
Other (Specify)
B. FACILITY DATA (Fill out ONLY if the injection well(s) is (are) for
the purpose of serving a business or industry) :
Business/Corporate Name: I//g
Address:
ZIP:
County: Telephone:
C. BEATING CONTRACTOR DATA (For heat pump systems only. Please give
information for the contractor that
installed or will install your system) :
Name:
Address:
i
ZIP: 72-�/ Telephone: `/ as 1

D. INJECTION PROCEDURE:
Briefly describe how the injection well(s) will be used. P T Cook
E. WELL USE: Will the injection well(s) also be used as the supply well(s)
for either of the following?:
(a) The injection operation? YES ❑� NO
im ❑
(b) Your personal consption? YES Ili) NO
U ❑
F. CONSTRCTION DATA: (check one) '""rr'
❑ EXISTING WELL being proposed for use as an injection well. Attach a
copy of Pbrn CST-1 (Well Construction Record) and furnish (7 & 8)
below. If Form Gw-1 is not available, furnish the data in (1)
through (8) below to the best of your knowledge.
❑ PROPOSED WELL to be constructed for use as an injection well.
Furnish the data in (1) through (8) below as PROPOSED construction
specifications.
NOTE: THE WELL DRIMLwr_ CONTRACTOR CAN SUPPLY THE DATA FOR EITHER
EXISTING OR PROPOSED WELLS IF THIS INFORMATION IS UNAUAI ABLE BY
OTHER MEANS. �{ r
(1) Well Drilling Contractor's Name: /-L
(2) Date (to be) Constructed AloC �� ; Approx. Depth/
(3) Well Casing:
(a) Type: Galvanized Steel ❑ Black Steel ❑
Plastic D-� Other (Specify)
�`�`-
(b) Inside Diameter: ��y inches; Wall thickness (inches)
or schedule # 49?,2 _
i. �o��to—
�
(c) Casing Depth: From to _. /9 ft. (referenced to land surface)
(4) Cement Grout:
(a) Around inner or "primary" casing: Fran _� to o/-! ft.
(b) Around outer (pit) casing, if present: From y �/ G� , s ft��

n r
(5) Screen(s) : (if applicable)
(a) Type: Inner Diameter: inches
(b) Depth: Flom to feet below land surface
(6) Gravel: (if applicable)
From: to feet below land surface
(7) N.C. State Regulations (15, 2, 2C, Section .0200) require the
permittee to make provisions for monitoring well head processes. A
faucet on both the influent (water from well) and effluent (water
into well) lines 1i-s-I required. Is there a faucet on ((a;'J) �the influent
line VYES Q u NO , or (b) the effluent line 1BS L,7 ,vo L^_I ?
(8) Attach a diagram showing the details of construction of the existing
and/or proposed well(s) .
G. PROPOSED OPERATING DATA: (The manufacturer's brochure should include
this information.)
(a) Injection Rate: Average (Daily) _3 gallons per minute (gpm)
N (b) Injection Volume: Average (DailyrL�3�' gallons per day (gpd)
(c) Injection Pressure: Average (Dai1y)�y e P �pouunts/square inch (psi)
(d) Injection Temperature: Winter Average (Daily) degrees F
Summer Average (Idly) degrees F
H. INJECTED FLUID DATA:
(1) Fluid Source (From what depth and what type of rock/sediment unit
does the fluid to be injected derive, i.e. granite,
limestone, sandf etc.)
Depth: ,Q/J✓J
Rock/sediment unit:
(2) Chemical Analysis of Source Water: The following chemical
characteristics MUST accompany this application;
PH ; Total Hardness ppm (parts per million or mg/1)
Iron ppm; Chloride ppm; Nitrate ppm
Coliform. bacteria counts/100 ml
NOTE: Assistance in obtaining these values may be facilitated by
contacting (a) your local or county health official, (b) a
commercial water-testing laboratory, (c) your well drilling
contractor, or (d) the Regional Hydrogeologist, North Carolina Dept.
of Natural Resources & Community Development.
NOTE: If injection system is not for a heat pump, then a detailed
'E�ysis of both the source water and the injection fluid may be
required.

I. INJECTION-RELATED EQUIPMENT:
Attach a diagram showing the engineering layout of the (1)
injection equipment, And (2) exterior piping/tubing associated
with the injection operation.
NOTE: The manufacturer's brochure, if detailed, should satisfy (1) above
if the system is a heat pump.
J. LOCATION OF WELL(S) :
Attach a detailed map showing the orientation of and distances
between the proposed well(s) , any existing well(s) that will in
any way be involved in the injection operation, and at least two
(2) nearby reference points such as roads, road intersections,
streams, etc. The roads should be identified by U.S., N.C. or SR
(county secondary road) numbers, and streams should be named. in
addition, the diagram should show the direction and approximate
distance to any existing water-supply and/or injection wells
within 1,000 feet of the proposed injection well.
K. CERTIFICATION:
"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 operate and use the injection well and all
related appurtenances in accordance with the approved specifications and
conditions of the Permit."
(Signatur' of Owner or Autho ed ent)
L. FOR OFFICE USE ONLY: V
1. Initial Application: Complete Incomplete
If INCOMPLETE, Date of Notification and Resukmittal
2. Standard Industrial Code(s) which best reflect the principal products
or services provided by this facility - if applicable.
(a) (b) (c) (d)
3. APPLICATION NO.

,lJ1iC �F% rt .1
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
Aa
NCDENR August 7, 1998 N D
Ms. Roseanne Dorsch AUG1 0
DAMES B.HUNT JR. Rural Route 1,Box 73
GOVERNOR Slick Rock Road ",nI iiER SECTION
Brevard,NC 28712 _AINAL OFFICE
Dear Ms. Dorsch:
WAYNE MCDEVITT
SECRETARY Our records show that the operating permit for the heat pump injection well on your property will expire
on September 20, 1998. In addition,our records do not indicate that the well has been abandoned. In
order to comply with the regulatory requirements for permitted injection facilities (15A NCAC 2C
0211),you must either apply for a renewal to continue using your injection well or notify us if the well
A.PRESTON HOWARD,
J R..P E. is no longer being used for injection.
DIRECTOR
If you plan to continue using your well for injection,the enclosed Application for Permit Renewal to Use
a Wells)for Injection with a Heat Pump System(form GW-57 HPR)must be completed and submitted
to this office. For your convenience,I have enclosed the last two permit applications submitted by the
previous owner. While filling out the GW-57 HPR form,you my want to use these enclosures as a
reference. Please note that the GW-57 HPR form has been revised over the years. Therefore,there may
be new information requested that was not previously included Please attempt to complete the form as
thoroughly as possible so that our review process can be expedited
If you are no longer using or plan to stop using your well for injection, submit the enclosed Status of
Injection Well System(form GW-68)that certifies that the injection well is no longer in use. If the well
is no longer to be used for arry purpose,it must be permanently abandoned according to the regulatory
requirements(15A NCAC 2C .0213),and you must submit the enclosed Well Abandonment Record
(form GW-30).
The appropriate form(s)should be forwarded to this office by August 20, 1998,to allow adequate time
for well water sampling and analysis. If you have any questions regarding the permit and injection well
miles or would like assistance completing these forms,please contact me(919)715-6165.
Sincerely,
Amy Ax ,Program Manager
Underground Injection Control
Enclosures
cc: UIC Files
ARO
GROUNDWATER SECTION
P.O BOz 29578, RALEIGH, NC 27626-0578 - 2728 CAPITAL BLVD., RALEIGH, NC,27604
PHONE [phone] FAX 919-71S.0588
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER-50% RECYCLED/10 POST-CONSUMER PAPER

NORTH CAROLINA DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT FOR OFFICE USE ONLY
DIVISION OF ENVIRONMENTAL MANAGEMENT-GROUNDWATER SECTION Oo
P.O.BOX 27687-RALEIGH,N.C.27611.PHONE[phone] Ouad. No. h i a V i Serial No, r Z
t Lat. 3S /O S6 Long.AZ I z PC-
1 - Minor Basin 1
U WELL CONSTRUCTION RECORD Basin Code
Header Ent. GW-1 Ent.
DRILLING CONTRACTOR
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER PERMIT NUMBER:
1. WELL LOCATION: (Show sketch o the location below)
N rest To County: 7,c,e„a,.G,Lw' a 7
Depth DRILLING LOG
(Road, m ity, or Su division a Lot No.)
From To Formation Description
2. OWNER
ADDRESS / I
(Stfeet or Routs No.
City or T wn State Zip Code
3. DATE DRILLED USE OF WELL
4. TOTAL DEPTH 41&?e CUTTINGS COLLECTED Yes 0 .�°61(L--.55'�
5. DOES WELL REPLACE EXISTING WELL? El Yes -;No _
6. STATIC WATER LEVEL: �>9
FT. ❑ el
ole TOP OF CASING,
TOP OF CASING IS FT. ABOVE LAND S RFACE. .�
7. YIELD (gpm): � METHOD OF TEST ` :•y F r E .I y Ej .f
8. WATER ZONES (depth): A.
9. CHLORINATION: Type Jl r E{- Amount '32
1987
_ c .ya�
10. CASING: It additional space ia; J a d ,_ �gp®I6t0orm. .
Wall Thickness _t1P �� c
Depth Diameter or Weight/Ft. Mat ri I
��/ ��/""" _L_OCATION SKETCH Y;
From To��Ft. (Show direction and distance from at least two State Roads,
From To Ft. / or other map reference points)
From To Ft.
11. GROUT:
Depth Material Method
From ,�_ To o—'9D Ft: 12j.,...�
From To Ft.
12. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. In.
From To Ft. kL In.
From To Ft. In. in.
13. GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
14. REMARKS:.
=-- I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15 NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED.TO THE WELL OWNER
- SIGNATURE-OF CONTRACTOR 09 AGENT _ D E —

North Carolina
Department of Environment,Health,and Natural Resources
GROUNDWATER FIELD/LAB FORAM DIVISION OF ENVIRONMENTAL MANAGEMENT•GROUNDWATER SECTION
County 72A.�t y�s/,q„/1,6L Lab Number 8
Quad No Serial No. SAMPLE PRIORITY 0 Date Received Time.
�� Rec'd by::� From: Bu - ourier
Lat. Long. ROUTINE EMERGENCY
Other
Report T :AR FRO, MRO, RRO,WaRO, WiRO, Date Entry By: 3 Ck.
WSRO, Kinston FO,Other Date Reported'
Shipped by: B , ours Other / E/rJ L
Collector(s)7 a Date .? Time Purpo .B Comb plaint o�mplian UST,Other
FIELD ANALYSES Owner ►t- �i' �3 a C 2P7/L
PH aoo Spec. Cond.94 at 250 C Location or site l b
i
Temp.l o °C Odor Description of sampling point Sample Interval
Appearance Taste Sampling Menod p� p,�,ipr,etc.
Field Analysis By: Remarks o ,D,,,,4mg ,.,r»mp.WJ
LABORATORY ANALYSES
mgA A -Silver 1077 Or anochlorine Pesticides
BOD 310
ugA
COD High 340 mgA Flouride 951 m A All-Aluminum 1105 u Organophosphorus Pesticides
COD Low 335 mgA Hardness:Total 900 m A Ba-Barium 1007 u Nitro en Pesticides
Coliform: MF Fecal 31616 /100m1 Hardness non-car! 902 m A Ca-Calcium 916 rn A Acid Herbicides
Coliform:MF Total 31504 /100ml Phenols 32730 u A Cd-Cadmium 1027 u A
TOC 680 m A S fic Cond. 95 uMhos/cm2 Chromium:Total 1034 u A Base/Neutral Extractable Or anics
Turbidity76 NTU Sulfate 945 m A Cu-Co 1042 u Acid Extractable Organics
Sulfide 745 mgA e- Iron 1045 UqA
H . Mercury71900 u A
PH 403 units K-Potassium 937 m A Purgeable Organks(VOA bottle)
Alkalinity to pH 4.5 410 mgA M • Ma nesium 927 m
Alkalinity to PH 8.3 415 mgA Mn- Man anese 1055 u 1,2-Dibromoethane(EDB)
Carbonate 445 mgA Na-Sodium 929 m A
Bicarbonate 440 mgA NH3 as N 610 mgA Ni-Nickel 1067 u A
_ .. _.
Arsenic:Total 1002 u A -TKN as IN 625 mgA Pb- Lead 1051 u A
Carbon dioxide 405 mign NO +NO as N .630 O m A Se-Selenium 1147 u A
Chloride 940 mgA P:Total as P 665 m A Zn -Zinc 1092 u A
Chromium: Hex 1032 u A
Color:True 80 Pt-Co
a
Cyanide 720 mgA /
Lab Comments: -)e,4gLa., �plw
GW-54 REV.3/92 For Dissolved Analysis-submit filtered sample and write"DIS'in block
White Copy-Groundwater Central Office Yellow Copy-Regio"-'Office Pink Copy-Central Files Goldenrod Copy-Lab

FF•OM ,- 01.01.2¢00 BBP00 P. 1
Facsimile Cover
NC DEHNR
DEMrQrottndwnter• Section
512 N, Salisbury Sheet Italei h,NC 27604
Phone: (919)7p,3221
- Fax: (919j?15�,058$
From; KAr@11 ttL��'mo/1,
ComPenY• ' AAdttxiDate. �,� 1C l99U
Phone•
Pax: , Pages inclgding thi§ cover page: 2—
'
comm ow

F,R011. 01.01.2000 00199 F.
State oWNorth C :irollna
Art aht of E rivironment,
Health ndNaftirdl Resources
DIvIii' n of t6viroin'q pirital Management
James B. Ount, Jr., overnor
Jonpthon:B. Howes,Secretary "I' FRI
A I * i ri Howard, Jr., P.E., Director
Prq.to rd Jr.'
GROUNDWATER SECTION
April 25, 1994
MEMORANDUM
To: Fred i@LpXip;!oq
Grouniwater 'Section
Regional
From: Karen A. Harmon
,A- 74
Under' ;gupd Injection Control Proqr4tp
Gro,un- water Section
Rale- i h"Ce'lltia"l Office
Re: Searc for injection well sample analysis rpportq
L
have no fL-Mpxq #Aqxypis record (fom GWT54) within the
last 5 ypgrq f9r qlum. Pleas check -th6­k!lj i 'Please c c r q; a report
re164sgd, later :hap 1989 and fax it to me (qW fa* number, is a 919
?j5�'!-d$6,0. )­Than i­you very much.
I hays not been successful in contactingHenning q§Pqt
his permit rep' application. Also 1 have not received the
i"ple i6iiiiiisi reports from you for 'Nabors
.1 .1 1.. — - —1-- , - ' d
I undeksta' 44 Y04 are d t leaving' the Groundyater Section at
the a - f�tfiisl we-1— I I certainly
E.44 0 - 'ek. That rtainly " is noi' V994 fp; the PiC
of,-00 we 41l miss you. Best ucic.
cc: UIC Files
V;a i RP F as
Enclos
P.O.Box 29535.Rolel(.ih.North Ccirollno.27626-0535 Telephone FM919-?15-0588
An Equal Opportur Ity Atfirmotive Action Employer 60%recycled/10%Post-Consumer paper

arm_ !o
NORTH CAROLINA DEPARTMENT OF
5 4 ENVIRONMENT, HEALTH & NATURAL RESOURCES
59 woodfin Place, Asheville, North' CaTglina '28801
7041251-6208 (Phone) 704/251-W2 (FAX)
TO: KGY�eve ttarw�n v\
FAX NO.: �l�q � ►�- 05���
FROM: ye(-
DATE: 5 -2- -Ci '�
Number of Pages, including cover page: 3
I
COMMENTS:
r 2us)- L. C�-w..
-gC1
U n CA y ri CV-0-

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment,Health,and Natural Resources
DIVISION OF ENVIRONMENTAL MANAGEMENT-GROUNDWATER SECTION
County­;rr'�'I e th1jd Lab Number 8 f 7 C
Quad No Serial No. SAMPLE PRIORITY Date Received "?I ° Time
Lat. Long. I
ROUTINE EMERGENCY Rec'd by: From: Bus-Courier
Other
Report To:ARO�FRO, MRO, RRO, WaRO, WiRO, Date Entry By: 5 Ck.
WSRO, Klston FO er Date Reported: 9 `
Shipped by: Bus,. ouri Other
Collector(s)rc ��� Dated 3i ! Time Purpose:Baseline, Complaint,_ om�plianr , LUST, Other �C p`ENfr✓AL_
FIELD ANALYSES OwneAA C • ljz, �1VL Fa< 1p�T<1c14 EMU
pH 400 Spec. Cond. 94 at 25o C Location or site
Temp.10 OC Odor Description of sampling point
Appearance Taste Sampling Method Sample Interval
Field Analysis By: Remarks pun°'Daimmpin
LABORATORY ANALYSES (pumping 4me,air temp.etc.)
BOD5 310 m A I Diss. Solids 70300 m A A -Silver 1077 u A Or anochlorine Pesticides
COD High 340 mgA Flouride 951 mgA Al -Aluminum 1105 u A Organophosphorus Pesticides
COD Low 335 mgA Hardness:Total 900 m /I Ba- Barium 1007 u /I Nitrogen Pesticides
Coliform: MF Fecal 31616 /100m1 Hardness non-carb 902 m A Ca-Calcium 916 m A
Coliform: MF Total 31504 /100ml Phenols 32730 u /I Cd-Cadmium 1027 u A Acid Herbicides
TOC 680 mgA Specific Cond. 95 uMhos/cm2 Chromium:Total 1034 u A
Turbidity 76 NTU Sulfate 945 m A Cu - Cooper 1042 u /I Base/Neutral Extractable Organics
Sulfide 745 mgA I Fe - Iron 1045 u A Acid Extractable Organics
H - Mercu 71900 u /I
pH 403 units K- Potassium 937 m /I Purgeable Organics(VOA bottle)
Alkalinity to pH 4.5 410 mgA M - Magnesium 927 m /I
Alkalinity to pH 8.3 415 mg/I Mn - Manganese 1055 u A 1,2- Dibromcethane(EDB)
Carbonate 445 mgA Na- Sodium 929 mqA
Bicarbonate 440 mgA NH3 as N 610 mgA Ni - Nickel 1067 u /1
Arsenic:Total 1002 u A TKN as N 625 m /I Pb-Lead 1051 /I
Carbon dioxide 405 m A NO +NOq as N 630 m A Se-Selenium 1147 u /I
Chloride 940 < I mg/I P:Total as P 665 mqA Zn -Zinc 1092 u /I
Chromium: Hex 1032 u A
Color:True 80 Pt-Co
Cyanide 720 mgA
Lab Comments:
GW-54 REV. 3/92 For Dissolved Analysis-submit filtered sample and write"DIS"in block
White Copy-Groundwater Central Office Yellow Copy- Regional Office Pink Copy-Central Files Goldenrod Copy-Lab

State of North Carolina
---'� Department of Environment,
•. Health and Natural Resources
Division of Environmental Management
James B. Hunt,Jr.,Governor 1 ■
Jonathan B. Howes, Secretary
A, Preston Howard,Jr., RE„ Director
' I
September 20, 1993
Mr. A.C. Bramley
Rt. 1 Box 73
Brevard, NC 28712
Dear Mr. Bramley:
In accordance with your application received September 13,
1993,` we are forwarding Permit No.87-0104-WO-0002R1 for the
Operation and ,Use of a well, for the purpose of injecting heat
pump effluent, in Transylvania County.
This Permit shall be effective from the date of issuance
until September 20, 1998 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 make application for permit
renewal at least 30 days prior to its expiration date.
Sincerely,
Roy Davis
Regional Supervisor
Attachment
cc: UIC Files
ARO Files
P.O.Box 29535,Raleigh.North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative.Action Employer 50%recycled/10%post-consumer paper

ti
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION/USE OF A WELL OR
WELL SYSTEM 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
A.C. Bramley
FOR THE OPERATION AND USE OF AN INJECTION WELL/WELL SYSTEM
located at Rt. 1 Box 73, Brevard, North Carolina, Transylvania
County, in accordance with the application dated August 31 , 1993,
and in conformity with the specifications and supporting data
submitted, all of which are .filed with the Department of
Environment, Health, and Natural Resources and are considered a
part of this Permit.
This Permit is for Operation and Use only, and does not
waive any provisions of the Water Use Act or any other applicable
Laws, Rules or Regulations. Operation and use of a well or well
system shall be in compliance with Title 15 North Carolina
Administrative Code 2C, 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 September 204998 and shall be subject
to the specified conditions and limitations set forth in Parts I
and II hereof.
Permit issued this the �1 day of 1993 .
Roy D� s
Regional Supervisor
By Authority of the 'Environmental Management Commission.
PERMIT NO. 87-0104-WO-0002R1

3
PERMIT NO. 87-0104-WO-0002R1
PART 1
A. General Conditions
1 . The Permittee must comply with all conditions of this
Permit and with the standards and criteria �specified
in 15 NCAC 2C . 0200 . Any Permit noncompliance
constitutes a violation of the appropriate 'Act and is
grounds for enforcement action; for Permit
termination, revocation and reissuance or
modification; or denial of a Permit renewal
application.
2 . The Permittee shall be required to comply with the
terms and conditions of this permit even if
compliance requires a reduction or elimination of the
permitted activity.
3. The Permittee shall take all reasonable steps to
minimize or correct any adverse impact on the
environment resulting from noncompliance with this
Permit.
4 . The Permittee shall give advance notice to the
Director of any planned changes in the permitted
facility or activity which may result in
noncompliance with the Permit.
5 . The Permittee shall report all instances of
noncompliance, not reported under condition 1 . of
this Part, at the time monitoring reports are
submitted.
6. Where the Permittee becomes aware of a failure to
submit any relevant facts in a permit application, or
of anv incorrect information submitted in said
application or in any report to the Director, the
relevant and correct facts or information shall be
promptly submitted by the Permittee.
7. The Permittee shall give notice to the Director as
soon as possible of any planned physical alterations
or additions to the permitted facility .
S . In the event that the permitted facilities fail to
perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
9 . The injection system shall be effectively maintained
and operated at all times so that there is no
contamination of groundwaters, or other actions or

occurrences which renders them unsatisfactory for
normal use. In the event the facilities fail to
perform satisfactorily, including the creation of
nuisance conditions, the Permittee shall take such
immediate corrective action as may be required by the
Director.
10 . Department representatives shall have reasonable
access for purposes of inspection, observation and
sampling associated with injection and related
facility.
11 . This Permit is not transferable without prior notice
to, and approval by, the Director.
12 . An application for modification, renewal or transfer
of this Permit shall be filed with the Department at
least 30 days prior to the expiration date of this
Permit.
13 . Provisions shall be made for collecting samples of
facility effluent, both prior to its entrance to
treatment devices and subsequent to leaving the
treatment devices but before entering the injection
well .
14 . When operations have ceased at the facility, the
Permittee shall abandon the injection well in
accordance with the procedures specified in 15 NCAC
2C .0214 :
(A) All casing and materials may be removed prior to
initiation of abandonment procedures if the
Director finds such removal will not be
responsible for, or contribute to, the
contamination of an underground source of
drinking water.
(B) The entire depth of the well shall be sounded
before it is sealed to insure freedom from
obstructions that may interfere with sealing
operations .
(C) The well shall be thoroughly chlorinated, prior
to sealing, if the Director determines that
failure to do so could lead to the contamination
of an underground source of drinking water.
(D) The well shall be completely filled with cement
grout, which shall be introduced into the well
through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the
casing and screens have not been removed, the
casing shall be perforated opposite the gravel
pack, at intervals not exceeding 10 feet, and
grout injected through the perforations .

(F) In those cases when, as a result of the injection
operations, a subsurface cavity has been created,
the well shall be abandoned in such a matter that
will prevent the movement of fluids into or
between underground sources of drinking water and
in accordance with the terms and conditions of
the permit.
PART II
A. SPECIFIC CONDITIONS

DIVISION OF ENVIRONMENTAL MANAGEMENT
GROUNDWATER SECTION
September 17, 1993
MEMORANDUM
To: Don Link
From: Kathy Grant 40�
Subject: UIC Permit Renewal
The central office has completed its review of the application for renewal of UIC permit
#87-0104-WO-0002 for the injection facility operated by A.C. Bramley. Attached you
will find a copy of this application along with the draft permit and transmittal letter. ( I
have learned that some regional offices use their own shell documents to prepare the
permit and transmittal letter; if this is also the case with your region please advise me of
this so that I will not duplicate your efforts (and waste my time!) sending drafts of these
documents in the future.)
According to the application, �( - Hankinson, of your office, has already completed
sampling of this facility; please forward copies of the sample results to this office as soon
as you receive them.
Once you have reviewed and approved this application, please complete the permit and
transmittal letter and forward them to the applicant. Please remember to make copies of
the completed documents and forward them to this office. Thank you.
KG/BRAMLEY.MEM

Y l LQ•�i e w /I L .
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT,HEALTH,AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
WITH A HEAT PUMP SYSTEM
Class 5 Wells
TO: DIRECTOR,NORTH CAROLINA DIVISION OF ENVIRONMENTAL MANAGEMENT
DATE: 19
In accordance with the provisions of Article 7,Chapter 87;Article 21,Chapter 143,and regulations
pursuant thereto,APPLICATION is hereby made for a PERMIT to construct and/or use a well of well
system as described below and in any accompanying data submitted as part of this APPLICATION.
Please type orprint clearly.
'A. OWNER DATA ��// 7
Name: H•. (s . Zv 7[
_ Business:
Address: l
City: ! r VA 2 j� Zip code: ;L /
County: A3 a 1,,Q q!'4
Telephone: ey q5:4�= e
Ownership
Federal State Private lo?'A"t
Public Commercial. Other(specify)
Native American Lands
B. FACILITY DATA (Fill out ONLY if the injection well(s)is(are)for the purpose of serving a
business.or industry.)
Name:
Business:
Address:
City: Zip code:
County:
Tele
C. HEATING CONTRACTOR DATA /
Name: B 5
Address:
City: A a Zip code: 7 p u
County:
Telephone: a 3 S
Contact Person: $V Ar'
D. INJECTION PROCCEDURE / (Briefly/des'cr/ibe how the injection well(1)will be used)
6i /7o✓s hdLJ` (,J -rCl� . ��
GW-57 HP (June 1993) Page 1 of 4

E. WELL USE Will the injection well(s)also be used as the supply well(s)for either of the
following?
(a) The injection operation? YES ✓ NO
(b) Your personal consumption? YES NO
F. CONSTRUCTION DATA (CHECK ONE)
EXISTING WELL being proposed for use as an injection well. Attach a copy of Form
GW-1 (Well Construction Record)and furnish(7&8)below. If Form GW-1 is not
available,furnish the data in(1)through(8)below to the best of your knowledge.
PROPOSED WELL to be constructed for use as an injection well. Furnish
the data in(1)through(8)below as PROPOSED construction
specifications. ���,�,//
(1) Well Drilling Contractor's Name: / <: C 1V i4 n%/ L)01J
NC Driller Registration number.
(2) Date to be constructed: f9 Approximate depth: O S
(3) Well casing:
(a) Type:Galvanized steel_Black steel_Plastic ✓Other(spccify)
(b) Inside diameter: inches; Wall thickness inches or schedule#
(c)_ Casing depth: From to ft.(reference to land surface)
� Cas g extends above ground inches(must be at least 12 inches)
( ) Cement grout: G f -4
(a) Around inner or"primary"casing:.From to ft.
(b) Around outer(pit)casing,if present From to fL
(5). Screens(if applicable):
(a) Type: ; Inner diameter. inches
(b) Depth: From to feet below land surface
(6) Gravel(if applicable): From—to—feet below land surface
(7) N.C.State Regulations(15A NCAC,2C,Section.0200)require the permittee to make
provisions for monitoring well head processes. A faucet on both influent(groundwater
entering heat pump)and effluent(water being injected into the well)lines is required. Will
there be a faucet on:
(a) the influent line? yes-f-:::�no_ (b) the effluent line? yes✓no
(8) Attach a diagram showing the location of the injection well and sampling faucets relative to
primary building on property.
G. PROPOSED OPERATING DATA
(a) Injection rate: Average(daily)-gallons per minute(gpm)
(b) Injection volume: Average(daily) 3D6 gallons per day(gpd)
(c) Injection pressure: Average(daily) pounds/square inch(psi)
(d) Injection temperature: Winter Average J degrees F
Summer Average -Lc./ degrees F
GW-57 HP (June 1993) Page 2 of 4

H. INJEMON FLUID DATA
(1) Fluid Source, If underground,from what depth and what type of rock/sediment does the fluid
to be injected derive(e.g.,granite,limestone,sand).
s a ei Ly �s,1 � rr9Wf-12
J
(2) Chemical Analysis of Source Water. The following chemical characteristics MUST
EE accompany this application:
IN,
pH Total hardness ppm(parts per million or mg/1);
Iron ppm; Chloride.. rpm; Nitrate ppm;
Coliform bacteria counts/1GOml
&--Vtr
Aldl q- 6ro�e-,( ke- 410a 6 oUt
NOTE: Assistance in determining these values may be obtained by contacting(a)your
local or county health offical,(b)a commercial water-testing laboratory,(c)your
well drilling contractor,or(d)the regional Hydrogeologist,North Carolina Dept
of Environment, Health,and Natural Resources.
I-D,- INJECTION-RELATED EQUIPMENT
Attach a diagram sh6wingkthe engineering layout of the(1)"injection equipment,and
(2)exterior piping/tubing associated with the injection operation. The manufacturer's brochure,
if detailed,should satisfy(1)above
J. LOCATION OF WEII(S)
a—'Atiach'.a tietaflqd-tilap showing the orientation of and distances between the proposed well(s),
any e)SisfiuA-5�611(s)that will in any way be involved in the injection operation,and at le�ast two
points such as roads,road intersections,streams,etc. The roads should be
f2),if6Ay rcfgenb�l
Wimifieil•by US,NC or SR(county secondary roads)numbers,and streams should be named.
In addition,the diagram should show the direction and approximate distance to any existing
water-supply and/or injection wells within 1,000 feet of the proposed injection well.
K. CERTIFICATION
iii
"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 operate and use the injection well and all related appurtenances in accordance with the
approved specifications and conditions of the Permit."
(Signal re of Owner or Agent)
Please supply a letter signed by the owner
authorizing the above agent,if authorized agent is signer.
GW-57 HP (June 1993) Page 3 of 4

North Carolina '
GROUNDWATER FIELD/LAB FORM Department of Environment,Health,and Natural Resources
DIVISION OF ENVIRONMENTAL MANAGEMENT-GROUNDWATER SECTION S
County rl,4111, %;'I_kwd Lab Number 8 9 7 0
Quad No Serial No. SAMPLE PRIORITY Date Received 9 - ?1 -9 3 Time 3 1 o 0
Lat Long. ,ROUTINE EMERGENCY Rec'd by: S From: Bus-Courier
Other
Report o:ARO FRO, MRO, PRO,WaRO, WiRO, Date Entry By 5 r Ck.
WSRO, Inston FO,Jltper Date Reported: 9 - 6-43
Shipped by: Bus-, Courier, Other
Collector(s)_.� _OA) Datec�'>/'-y/ o71 Time t/U �'- Purpose:Baseline, Complaint, Comp Ial ^�, LUST, Other s - ✓CCwEI��'�
FIELD ANALYSES �— _ Owner\ C dZ'��(C L` % 4� �c�� 17.1, 6-JAee AR •:.�C'Z/Z•
i T
PH 400 Spec. Cond. 94 at 25o C Location or site
Temp.10 oC Odor Description of sampling point
Appearance Taste Sampling Method Sample Interval
Field Analysis By: Remarks p°�°'"("'a"I
LABORATORY ANALYSES WumF^9 maa,auump.em.)
BODS 310 m /I Diss.Solids 70300 m /I A -Silver 1077 u /I Or anochlorine Pesticides
COD High 340 mgA Flouride 951 m /I At -Aluminum 1105 u A Organophosphorus Pesticides
COD Low 335 m A Hardness:Total 900 -7 m A Ba- Barium 1007 u /I Nitrogen Pesticides
Coliform: MF Fecal 31616 /100ml Hardness non-carb 902 m A Ca-Calcium 916 m A
Coliform: MF Total 31504 /100ml Phenols 32730 u /1 Cd -Cadmium 1027 u A Acid Herbicides
TOC 680 m /I Specific Cond. 95 uMhos/cm2 Chromium:Total 1034 u A
Turbidity 76 NTU Sulfate 945 m A Cu-Copper 1042 u A Base/Neutral Extractable Organics
Sulfide 745 mgA Fe- Iron 1045 u A Acid Extractable Organics
H - Mercury 71900 u A
pH 403 !o units K- Potassium 937 m /I Purgeable Organics (VOA bottle)
Alkalinity to pH 4.5 410 mgA M - Magnesium 927 m I
Alkalinity to pH 8.3 415 mg/I Mn- Man anese 1055 uclA 1,2- Dibromoethane(EDB)
Carbonate 445 mgA Na-Sodium 929 mgA
Bicarbonate 440 mgA NH3 as N 610 mgA Ni-Nickel 1067 uqA
Arsenic:Total 1002 u A TKN as N 625 m /I Pb-Lead 1051 u A
Carbon dioxide 405 mgA NO +NOq as N 630 m A Se-Selenium 1147 u A
it Chloride 940 < 1 mgA P:Total as P 665 m A Zn-Zinc 1092 u /I
Chromium: Hex 1032 u A
Color:True 80 Pt-Co
Cyanide 720 mg/I
Lab Comments:
GW-54 REV. 3/92 For Dissolved Analysis-submit filtered sample and write'DIS'In block
White Copy-Groundwater Central Office Yellow Copy-Regional Office Pink Copy-Central Files Goldenrod Copy-Lab

NORTH CAROLINA JUL 2-3
ENVIRON1AENTAL MANAG14EZ,1T COt1MISSION
DEPARTMENT OF NATURAL RESOURCES AND COMMITY DEVELOPMENT
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
CLASS 5 WELLS
TO: DIRECTOR, NORTH CAROLINA DIVISION OF ENVIRONMENTAL MANAGa4E2NT
DATE: 19
In accordance with the provisions of Article 7, Chapter, 87; Article
21, Chapter 143, and regulations pursuant thereto, APPLICATION is hereby
made for a PERMIT to construct and/or use a well or well system as described
below and in any acconpanying data submitted as a part of this APPLICATION.
A. OMER DATA: Name: V
Address:
V"el-iperA11,4 ZIP:
County:- .4,/<7Q 2ao Telephone: 70 4,1
Ownership Status: Federal State El Private
Public E] ComnercialF1
Other (Specify)
B. FACILITY DATA (Fill out ONLY if the injection well(s) is (are) for
the purpose of serving a business or industry) :
Business/Corporate Name:
Address:
ZIP:
County: Telephone:
C. BEATING CONTRACTOR DATA (For heat pump systems Only. - Please give
information for the contractor that
installed or will install your system) :
Name: �Q g5"�S
Address: /
-r/1 4v
ZIP: Telephone.-

-- T
D. INJECTION PROCEDURE:
Briefly describe how the injection well(s) will be used. p T Co aL
E. WELL USE: Will the injection well(s) also be used as the supply wells)
for either of the following?:
(a) The injection operation? YES ❑ NNo ❑
(b) Your personal consumption? YES k NO ❑
F. CONSTRUCTICN DATA: (check one)
EXISTING WELL being proposed for use as an injection well. Attach a
copy of Form GW-1 (Well Construction Record) and furnish (7 & 8)
below. If Form GW-1 is not available, furnish the data in (1)
through (8) below to the best of your knowledge.
❑ PROPOSED WELL to be constructed for use as an injection well.
Furnish the data in (1) through (8) below as PROPOSED construction
specifications.
NOTE: THE WELL DRIIJANG CCNTRAC70R CAN SUPPLY THE DATA FOR EITHER
EXISTING OR PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY
OTHER MEANS. ,(
(1) Well Drilling Contractor's Name: � (� 2'a 4 `/
(2) Date (to be) Constructed iS/a!,/ Approx. Depth ft. ✓
(3) Well Casing:
(a) Type: Galvanized Steel ❑ Black Steel ❑
Plastic Er Other (Specify)
(b) Inside Diameter: �y inches; Wall thickness (inches)
"7- or schedule #
(c) Casing Depth: From to 9 ft. (referenced to land surface)
(4) Cement Grout:
(a) Around inner or "primary" casing: Fran to P-0_ ft.
(b) Around outer (pit) 'casin if //
9. Present: FYan y ft.

(5) Screen(s) : (if applicable)
(a) Type: Inner Diameter: inches
(b) Depth: From to feet below land surface
(6) Gravel: (if applicable)
From: to feet below land surface
(7) N.C. State Regulations (15, 2, 2C, Section .0200) require the
perm ttee to make provisions for monitoring well head processes. A
faucet on both the influent (cater from well) and effluent (water
into well) lines is required. Is there a faucet on (a) the influent
line YES 0 NO , or (b) the effluent line YES L_ I NO u ?
(8) Attach a diagram showing the details of construction of the existing
and/or proposed well(s) .
G. PROPOSED OPERATING DATA: (The manufacturer's brochure should include
this information.)
(a) Injection Rate: Average (Daily) Z gallons per minute (gpW
N� (b) Injection Volume: Average (Dai1-V�-q32*4 gallons per day (gpd)
(c) Injection Pressure: Average (Daily)���F pouun'7s/square inch (psi)
(d) Injection Tenperature: Winter Average (Daily) degrees F
Summer Average (Daily) degrees F
H. INJECTED FLUID DATA:
(1) Fluid Source (Fran what depth and What type of rock/sediment unit
does the fluid to be injected derive, i.e. granite,
Depth:
limestone, sand etc.)
Rock/sediment unit: - �
(2) Chemical Analysis of Source Water: The following chemical
characteristics MUST acca<pany this application;
PH Total Hardness ppm (parts per million or mg/1)
Iron pFm; Chloride ppm; Nitrate
ppm
Coliform bacteria counts/100 ml
NOTE: Assistance in obtaining these values may be facilitated by
contacting (a) your local or county health official, (b) a
conmarcial water-testing laboratory, (c) your well drilling
contractor, or (d) the Regional Hydrogeologist, North Carolina Dept.
of Natural Resources & Commanity Development.
NOTE: If injection system is not for a heat punp, then a detailed
=ysis of both the source water and the injection fluid may be
required.

P
I. INJECTICN-RELATED EQUIPMENT:
Attach a diagram showing the engineering layout of the (1)
injection equigelt, and (2) exterior piping/tubing associated
with the injection operation.
NOTE: The manufacturer's brochure, if detailed, should satisfy (1) above
if the system is a heat pump.
J. IO ATICN OF WELLS) :
Attach a detailed map showing the orientation of and distances
between the proposed well(s) , any existing well(s) that will in
any way be involved in the injection operation, and at least two
(2) nearby reference points such as roads, road intersections,
streams, etc. The roads should be identified by U.S. , N.C. or SR
(county secondary road) numbers, and streams should be named. In
addition, the diagram should show the direction and approximate
distance to any existing hater-supply and/or injection wells
within 1,000 feet of the proposed injection well.
K. CERTIFICATION:
"I hereby certify, under penalty of law, that I have personally
examined and am familiar with the -information submitted in this - -
docanent 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 operate and use the injection well and all
related appurtenances in accordance with the approved specifications and
conditions of the Permit."
(Signatur Owner or Autho Dent)
L. FOR OFFICE USE CNLY:
1. Initial Application: Complete Inoaplete
If INCOMPLETE, Date of Notification and Resutmittal
2. Standard Industrial Code(s) which best reflect the principal products
or services provided by this facility - if applicable.
(a) (b) (c) (d)
3. APPLICATION NO.

UJ@rLtcauP@errjrviiccf9 ilnco
P.O. Box 18029 . Asheville, North Carolina 28814.0029 • 7041254-5169
June 7, 1988
Mr. A.C. Bramley
Rt. 1 , Box 73
Brevard, NC 28712 re: B - In
Dear Sir:
Please find the results of analysis of your water listed below.
Parameter Units 'MCL 'Results Parameter Units 'MCL Results Comments
Aluminum m 11 Nitrate mg/1 10.0 0.56 Date Samples
Arsenic ma/1 0.05 Nitrate-Nitrite mg" Collected:
6-3-88
Barium mg/1 1.0 Phenol u /I Date Received:
Cadmium m tl 0.010 Phos ate mg/1 6-3-88
Calcium mg/1 Phosphorus ma/I - Date Sample
Chromium mg/1 0.05 Selenium Mgt 0.01 1 Analyzed
Color I Silver m /1 0.05 6-3,6-88
Copper thrill Sodium mg/I Date Reported
Cyanide mcill I Turbidity NTU
Flouride m ll Zinc mg/1 6-6-88
Iron mg/1 0.3 0.044 Corrosivity Analyst
Lead Mgt 1 0.05 Hardness Cal i(Jm ma/1
Manganese mgll 0.05 Total Coliform 0100m1 0 Magnesium mg/I H 6.5 Certified by:
Langlier
Mercury mg/1 0.002 Saturation Index
Molybdenum Mal I Alkalinity mg/I Dr. Fred Holtkamp
M.B.A.S.(Detergents) m /i Ortho Phosphate mg/I
Nickel Mgt Chloride mg/1 2.5
Beryllium mg/I
Thelium mg/I
It is a pleasure serving you. If you have any questions, or if we can be of further service,
please let us know.
Yours truly,
6Xo?ate
Wastewater Service, Inc.
Complete Wastewater Treatment Services • Consulting • Start-ups • Operation • Maintenance • Monitoring • Reporting
State Certified Laboratory • Charter Member Commercial Laboratories Association of N.C.

UUj @��tQaUju@ r fcrr\v,-cc:cf9 Ilnca
P.O. Box 18029 . Asheville, North Carolina 28814-0029 • 7041254-5169
June 7, 1988
Mr. A.C. Bramley
Rt. 1 , Box 73
Brevard, NC 28712 re: A - Out
Dear Sir:
Please find the results of analysis of your water listed below.
Parameter Units 'MCL 'Results Parameter Units 'MCL Results Comments
Aluminum m /l Nitrate Mg/1 10.0 0.60 Date Samples
Arsenic Mal 1 0.05 Nitrate-Nitrite Mai I Collected:
6-3-88
Barium Mg/1 1.0 Phenol u ll Date Received:
Cadmium Mg/1 0.010 Phos ate m II 6-3-88
Calcium Mal I Phosphorus —Mal 1 Date Sample
Chromium Mal 1 0.05 Selenium Mai 1 0.01 Analyzed
Color Silver Mg/1 0.05 6-3,6-88
Copper m i l Sodium m I I Date Reported
Cyanide Mal I Turbidity NTU 6-6-88
Flouride Mal I Zinc Mal 1
Iron Mal 1 0.3 0.04 Corrosivity Analyst
Lead Mai 1 0.05 Hardness, Calcium /1 17.5
Manganese mg/I 0.05 Total Coliform 0
L 100m1
Magnesium Mal I H 6.4 Certified by:
Langlier
Mercury Mal 1 0.002 Saturation Index
Molybdenum Mal I Alkalinity mil Dr. Fred Holtkamp
M.B.A.S. (Detergents) mail Ortho Phosphate m ll
Nickel Mal I Chloride mg/l 3.0
Beryllium Mai I
Thalium mg/I
It is a pleasure serving you. If you have any questions, or if we can be of further service,
please let us know.
Yours truly,
Wastewater�6 Service, Inc.
Complete Wastewater Treatment Services • Consulting • Start-ups • Operation • Maintenance • Monitoring • Reporting
State Certified Laboratory • Charter Member Commercial Laboratories Association of N.C.

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"zr"TMI1XT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
DIVISION OF ENVIpOMMMAL NAMAGEMENT
WELL AND PUMP INSPECTION REPORT
,� / // Date Nett' a3,
Well location 1C4. Area
Town, Comm., Subdivision and Lot No.
County
Owner . A MIA, 'i_
b v / Road/Street g'A// /.S38:S&kr.,k
Address _ / Lay J3 �2 � /V C Z8 7/a ' Mtv, Esf..t-r
T7— r Quad No. 8 V
Serial No. Tr 2'476
35/O 3!0
CO STRll N Lat. Lons,B 2 4/2
17
---Drilling Contractor—t -
LAame Address Reg.
Meets Min. Standards j
Measure Yes No Remarks
Permit � ) /
Location
Distance from
Pollution-source % 3QQ i/
i
Other location standards
Total Depth (gQs, V/
Casing
Depth
Diameter
Weight/thickness &2574/�
Height
Drive shoe VN/`
Exception approved by owner ,J�}
Grout:
Type
Thickness - Z-3 " !/
Depth
Screens
DevelopmenttV'K—
i
1 . D. Plate
Abandonment (temporary/permanent)
Water level
afford;n, o i era well test
Chlorination
Cuttings
Reports
W^t^�^ (appearance)

Name Address Reg. I7
Meets Min. Standards
Measure Yes No Remarks
Enclosure l�
Enclosure floor
Casing height
Access Dort
Valved floe �(� (—
Water tight pipe entry J�
Well entry
Vent
Hose bib
e 'et - r
Suction line
Chlorination
Temporary Aband. ivA
Date Well Constructed 02
Date Pump Installed ( ��
Signature
Witness
Name Address Type
Name Address Type
i
i
i
i

NORTH CAROLINA JUL 25 Iq
ENVIRONMENTAL MANAGEMENT COMMISSION GROUND lid A�"'R
RALEGH,
DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
APPLICATION FOR PEWIT TO CONSTRUCT AND/OR USE A WELL FOR INJECTION
CLASS 5 WELLS
TO: DIRECTOR, NORTH CAROLINA DIVISION OF ENVIRONMENTAL MANAGEMENT
DATE: 19
In accordance with the provisions of Article 7, Chapter, 87; Article
21, Chapter 143, and regulations pursuant thereto, APPLICATION is hereby
made for a PER61IT to construct and/or use a well or well system as described
below and in any accouparying data submitted as a part of this APPLICATION.
rr A. OWER DATA: Name: 'D 1,4-2 (',' d/y ,1!� /Y z I,,f;, lz
Address: k'r I/ R174 .7 S /
IP:
County: ,-
4U"- ,fA7r,,1a0 Telephone: 7051 'a 52317
Omership Status: Federal [] State El Private [N
Public n Commercial FJ
Other (Specify)
B. FACILITY DATA (Fill out ONLY if the injection well(s) is (are) for
. the purpose of serving a business or industry) :
Business/Corporate Name: Al 14
Address:
ZIP:
County: Telephone:
C. HEATING CONTRACTCR DATA (For heat pump systems only. Please give
information for the contractor that
installed or will install your system) :
E C E I V ED Name: Z22 ,0�-�5- A) X//r-'0
Address:
JUL 2,. 1988
Groundwater Section
Asheville Regional Office ZIP: 2fz Telephones

D. INJECTION PROCEDURE:
Briefly describe how the injection well(s) will be used. P T Coal
&1 n ,4T ht�7 w
E. WELL USE: Will the injection well(s) also be used as the supply well(s)
for either of the following?:
(a) The injection operation? YES No ❑
(b) Your personal consumption? YES NO ❑
F. CONSTRUCTICN DATA: (check one)
❑ EXISTING WELL being proposed for use as an injection well. Attach a
copy of Form Cal-1 (Well Construction Record) and furnish (7 & 8)
below. If Form GW-1 is not available, furnish the data in (1)
through (8) below to the best of Your knowledge.
❑ PROPOSED WELL to be constructed for use as an injection well.
Furnish the data in (1) through (8) below as PROPOSED construction
specifications.
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER
EXISTING OR PROPOSED WELLS IF THIS INFORMATICN IS UNAVAILABLE BY
OTHER MEANS.
(1) Well Drilling Contractor's Name: /
(2) Date (to be) Constructed Aloof ; Approx. Depth/aAft.
(3) Well Casing:
(a) Type: Galvanized Steel ❑ Black Steel ❑
Plastic B-� Other (Specify)
(b) Inside Diameter: inches; Wall thickness (inches)
or schedule # _
(c) Casing Depth: From to ft. (referenced to land surface)
(4) Cement Grout:
(a) Around inner or "primary" casing: From to �/.O ft.
(b) Around outer (pit) casing, if present: From y ! Y 1/ ' S ft V4

(5) Screen(s) : (if applicable)
(a) Type: Inner Diameter: inches
(b) Depth: From to feet below land surface
(6) Gravel: (if applicable)
From: to feet below land surface
(7) N.C. State Regulations (15, 2, 2C, Section .0200) require the
permittee to make provisions for monitoring well head processes. A
faucet on both the influent (water from well) and effluent (water
into well) lines 1Ii-s- required. Is there a faucet on (a) the influent
I YES Q NO U , or (b) the effluent line YES L,71' Iw V ?
(8) Attach a diagram showing the details of construction of the existing
and/or proposed well(s) .
G. PROPOSED OPERATIW DATA: (The manufacturer's brochure should include
this information.)
I11 (a) Injection Rate: Average (Daily) L gallons per minute (gpcO
Nw (b) Injection volume: Average (Dailyl _ 26 gallons per day (gpd)
(c) Injection Pressure: Average (Daily)�o�P Kpoun'lc square inch (psi)
(d) Injection Tenperature: Winter Average (Daily) degrees F
Summer Average (Daily) degrees F
H. IN,SECIPED FLUID DATA:
(1) Fluid Source (Fran what depth and what type of rock/sediment unit
does the fluid to be injected derive, i.e. granite,
limestone, sand etc
Depth'
Fuck/sediment: G✓�/3iL/ ��
(2) Chemical Analysis of Source Water: The following chemical
characteristics MUST a000mpany this application;
PH ; Total Hardness ppm (parts per million or mg/1)
Iron ppm; Chloride ppin; Nitrate PPM
Coliform bacteria counts/100 ml
NOTE: Assistance in obtaining these values may be facilitated by
contacting (a) your local or county health official, (b) a
commercial water-testing laboratory, (c) your well drilling
contractor, or (d) the Regional Hydrogeologist, North Carolina Dept.
of Natural Resources & Comminity Development.
NOTE: If injection system is not for a heat pub, then a detailed
iiaysis of both the source water and the injection fluid may be
required.

M
M'
I. INJECTION-RELATED EQUIPMENT:
Attach a diagram showing the engineering layout of the (1)
injection equipment, and (2) exterior piping/tubing associated
with the injection operation.
NOTE: The manufacturer's brochure, if detailed, should satisfy (1) above
if the system is a heat pump.
J. IOCATION OF WELL(S) :
Attach a detailed map showing the orientation of and distances
between the proposed well(s) , any existing well(s) that will in
any way be involved in the injection operation, and at least two
(2) nearby reference points such as roads, road intersections,
streams, etc. The roads should be identified by U.S., N.C. or SR
(county secondary road) numbers, and streams should be named. in
addition, the diagram should show the direction and approximate
distance to any existing water-supply and/or injection wells
within 1,000 feet of the proposed injection well.
R. CERTIFICATION:
"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 inr�»*y 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 operate and use the injection well and all
related appurtenances in accordance with the approved specifications and
conditions of the Permit."
(Signatur Owner or Autho ent)
L. FOR OFFICE USE ONLY:
1. Initial Application: Complete Incomplete
If INOWLETE, Date of Notification and Resutmittal
2. Standard Industrial Code(s) which best reflect the principal products
or services provided by this facility - if applicable.
(a) (b) (c) (d)
3. APPLICATION No.

M@rrl�J@jt@ujmr1cmf9 Ilnco
P.O. Box 18029 • Asheville, North Carolina 28814-0029 • 704/254-5169
June 7, 1988
Mr. A.C. Bramley
Rt. 1 , Box 73
Brevard, NC 28712 re: B - In
Dear Sir:
Please find the results of analysis of your water listed below.
Parameter Units 'MCL 'Results Parameter Units 'MCL Results Comments
Aluminum mg/I Nitrate Mgt 1 10.0 0.56 Date Samples
Arsenic m /l 0.05 Nitrate-Nitrite Mgt I Collected:
6-3-88
Barium Mgt 1 1.0 Phenol u 11 Date Received:
Cadmium Mgt 1 0.010 Phos ate Mgt 1 6-3-88
Calcium Mgt I Phosphorus Mgt I Date Sample
Chromium Mgt I 0.05 Selenium Mgt 1 0.01 Analyzed
Color I Silver Mgt 1 0.05 6-3,6-88
Copper Mgt I Sodium Mgt I Date Reported
Cyanide m /1 Turbidity NTU
Flouride m /I Zino Mgt 1 6-6-88
Iron m /I 0.3 0.044 Corrosivity Analyst
Lead m /l 0.05 Hardness Cal ium m l 10.0
Manganese Mgt 0.05 Total Coliform p D
L 100m1
Magnesium m it I pH 6.5 Certified by:
Langlier
Mercury m /I 0.002 Saturation Index
Molybdenum Mgt[ Alkalinitym /f Dr. Fred Holtkamp
M.B.A.S. (Detergents) Mgt I Ortho Phosphate m /l
Nickel Mgt I Chloride m l 2.5
Beryllium Mgt I
Thalium m ll
It is a pleasure serving you. If you have any questions, or if we can be of further service,
please let us know.
Yours truly,
(;'40?all_�
Wastewater Service, Inc.
Complete Wastewater Treatment Services • Consulting • Start-ups • Operation • Maintenance • Monitoring • Reporting
State Certified Laboratory • Charter Member Commercial Laboratories Association of N.C.

MUJc�fLt@urv1c nco
P.O. Box 18029 • Asheville, North Carolina 28814-0029 • 704/254-5169
June 7, 1988
Mr. A.C. Bramley
Rt. 1 , Box 73
Brevard, NC 28712 re: A - Out
Dear Sir:
Please find the results of analysis of your water listed below.
Parameter Units 'MCL 'Results Parameter Units I 'MCL Results Comments
Aluminum Mgt I Nitrate mall 10.0 0.60 Date Samples
Arsenic Mgt 1 0.05 Nitrate-Nitrite mail Collected:
6-3-88
Barium Mgt 1 1.0 Phenol u /I Date Received:
Cadmium mail 0.010 Phos ate mg)1 6-3-88
Calcium Mgt I Phosphorus mall Date Sample
Chromium Mgt 1 0.05 Selenium mail 0.01 Analyzed
Color Silver mail 1 0.05 6-3,6-88
Copper 1 Mal I Sodium Mal I Date Reported
Cyanide , Mgt I Turbidity NTU 6-6-88
Flouride m /I Zinc Mgt 1
Iron mall 0.3 0.04 Corrosivity Analyst
Lead ! mall 0.05 Hardness, Cal i um /1 17.5
Manganese mg;I 0.05 Total Coliform o
100m1
i
Magnesium Mgt 1 H 6.4 Certified by:
Lan
glier
Mercurymall 0.002 Saturation Index
Molybdenum i Mgt I Alkalinity Mgt i Dr. Fred Holtkamp
M.B.A.S. (Detergents) Mgt Ortho Phosphate m II
Nickel m n Chloride m9
/1 3.0
Beryllium Mgt I
Thalium m /I t I1
It is a pleasure serving you. If you have any questions, or if we can be of further service,
please let us know.
Yours truly,
Wastewater Service, Inc.
Complete Wastewater Treatment Services • Consulting • Start-ups • Operation • Maintenance • Monitoring • Reporting
State Certified Laboratory • Charter Member Commercial Laboratories Association of N.C.

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4 Y
•via:
State of North Carolina
Department of Natural Resources and Community Development
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor R. Paul Wilms
S. Thomas Rhodes, Secretary Director
November 16 , 1988
Mr. A.C. Bramley
Rt. 1 , Box 73
Brevard, NC 28712
Dear Mr. Bramley:
RE: Permit 87-0104-WO-0002 for heat pump injection well in
Transylvania County
In accordance with your application dated July 1 , 1988 we
are forwarding herewith Permit No. 87-0104-WO-0002 for the
operation and Use of a well, for the purpose of injecting heat
pump effluent in Transylvania County.
This Permit shall be effective from the date of issuance
until November 1, 1993 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 make application for permit
renewal at least two (2) months prior to its expiration date.
Sincerely,
Roy Davis
Regional Supervisor
/tej
Attachment
cc: UIC Files
ARO Files
Pollution Pret Lion Povs
PQ Box 27617, Raleigh, North Carolina 27611-7697 Telephone 919,733 M5
An Equal Opportunity Afhrrative Action Employer

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
RALEIGH, NORTH CAROLINA
PERMIT FOR THE OPERATION/USE OF A WELL OR WELL SYSTEM FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87;
Article 21, Chapter 143, and other applicable Laws , Rules and Regula-
tions
PERMISSION IS HEREBY GRANTED TO
A. C. Bramley
FOR THE OPERATION AND USE OF AN INJECTION WELL/WELL SYSTEM located
at Slick Rock Mtn. Rd. , Brevard, North Carolina in Transylvania
County in accordance with the application dated July 1 , 1988 and in
conformity with the specifications and supporting data submitted, all
of which are filed with the Department of Natural Resources and
Community Development and are considered a part of this Permit.
This Permit is for Operation and Use only, and does not waive
any provisions or requirements of the Water Use Act or any other
applicable Laws, Rules or Regulations. Operation and use of a well
or well system shall be in compliance with Title 15 North Carolina
Administrative Code 2C, 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 1, 1993 and shall be subject to the
specified conditions and limitations set forth in Parts I and II
hereof.
Permit issued this the 2 IStday of ��r 1988.
Roy Davies
Regional upervisor
By Authority of the Environmental Management Commission.
PERMIT NO. 87-0104-WO-0002

PERMIT NO. 87-0104-WO-0002
PART I
A. GENERAL CONDITIONS
1 . The Permittee must comply with all conditions of
this Permit and with the standards and criteria
specified in 15 NCAC 2C . 0200 . Any Permit
non-compliance constitutes a violation of the
appropriate Act and is grounds for enforcement
action; for Permit termination, revocation and
reissuance or modification; or for denial of a
Permit renewal application.
2 . It shall not be a defense for a Permittee in an
enforcement action that it would have been
necessary to halt or reduce the permitted
activity in order to maintain compliance with the
conditions of this Permit.
3 . The Permittee shall take all reasonable steps to
minimize or correct any adverse impact on the
environment resulting from noncompliance with
this Permit.
4 . The Permittee shall give advance notice to the
Director of any planned changes in the permittee
facility or activity which may result in
noncompliance with the Permit.
5 . The Permittee shall report all instances of
noncompliance, not reported under condition 1. of
this Part, at the time monitoring reports are
submitted.
6 . Where the Permittee becomes aware of a failure to
submit any relevant facts in a permit
application, or of any incorrect information
submitted in said application or in any report to
the Director, the relevant and correct facts or
information shall be promptly submitted by the
Permittee.
7 . The Permittee shall give notice to the Director
as soon as possible of any planned physical
alterations or additions to the permitted
facility .
8 . In the event that the permitted facilities fail
to perform satisfactorily, the Permittee shall
take such immediate action as may be required by
the Director.

PART I (continued) PERMIT NO. 87-0104-wO-0002
9. The injection system shall be effectively
maintained and operated at all times so that
there is no contamination of groundwaters , or
other actions or occurrences which renders them
unsatisfactory for normal use. In the event the
facilities fail to perform satisfactorily,
including the creation of nuisance conditions,
the Permittee shall take such immediate
corrective action as may be required by the
Director.
10. Department representatives shall have reasonable
access for purposes of inspection, observation
and sampling associated with injection and
related facility.
11 . This Permit is not transferable without prior
notice to, and approval by the Director.
12 . An application for modification, renewal or
transfer of this Permit shall be filed with the
Department at least 30 days prior to the
expiration date of this Permit.
13. Provisions shall be made for collecting samples of
facility effluent, both prior to its entrance to
treatment devices and subsequent to leaving the
treatment devices but before entering the
injection well.
PART II
A. SPECIFIC CONDITIONS
- N O N E -