WI0100007_Complete File - Historical_20220308

ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H.Sullins Dee Freeman
Governor Director Secretary
[Asheville
CEIVED
August 2, 2010G - 3 26.0
Regional Off,06,Avery County Board of Education fer protection
775 Cranberry Street
Newland,NC 28657
Subject: Notice of Expiration(NOE)
5QM Geothermal Injection Well
Permit No. WI0100007
Avery County
,;,Dear Avery County Board of Education:
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 December 12, 2005, and expires on
December 31, 2010, has not been renewed. 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 5QM Well(s) if the injection well system on
your property is still active.
-OR-
B. Status of Injection 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 Censer,Ra"h.North Carolina 27699-1636
Locatron.2728 Capital Boulevard.Rakgh.North Carolina 27604 Cm-
Phone:9%-73332211 FAX 1:919-715-0598;FAX 291S-715-60481 Customer Service'1-8"-623b796 Nortb Cdrnilna
Internet:vnxrncwateraualilv.om `(�ra/ls,
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1
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/aps/Spu/fonns.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call me at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
Attachments
cc: Asheville Regional Office APS w/o enclosures
APS Central Files -Permit No. WI0100007 w/o enclosures
2

MA
iL
NCDENR ------- - --JDNorth Carolina Department of Environment and Na ural G I V EDivision of Water Quality
Beveriv Eaves Perdue Coleen H. Sullins CST 1 8man
Governor Director 2� etary
September 30, 2010 Asheville RegionaA uifer Protec
Danny Clark
Avery County Board of Education
775 Cranberry St.
Newland,NC 28657
Subject: Issuance of Injection Well Permit
Permit No. WIOI00007
Issued to Avery County Board of
Education
Avery County
Dear Mr.Clark:
In accordance with your application received August 30, 2010, I am forwarding Permit No. W10100007
for the continued operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well
system located at the Newland Elementary School, 750 Linville St.,Newland,NC 28657. This permit
shall be effective from the date of issuance until August 31,2015,and shall be subject to the conditions
and limitations stated therein.
Additionally, your UIC system is subject to inspection by the APS and at the time of the inspection must
display a permanently affixed identification plate identifying the presence of closed-loop geothermal
wells. This is in accordance with requirements of 15A NCAC 2C .0213(g)and Part I.4,of your permit
issued September 30,2010. In the event there are multiple wells with separate clusters,one well
identification tag per`cluster' of wells should be permanently affixed to the heating and cooling unit or
other nearby permanently fixed location in a clearly visible location.
Also,please pay special attention to Part V.2. The Permittee shall retain all records of repairs,
pressure tests,maintenance,and other activities needed to maintain normal operating conditions.
These records should be submitted with the application for permit renewal.
In order to continue uninterrupted legal use of this well for the stated purpose,you should submit an
application to renew the permit four months(120 days)prior to its expiration date. As indicated in the
permit,this permit is not transferable to any person without prior notice to,and approval by,the Director
of the Division of Water Quality. If you have any questions regarding your permit or the Underground
Injection Control Program please call me at(919)715-6166.

r
Sincerely,
Michael Rogers,P.G. (NC&FL)
Environmental Specialist
cc: Landon Davidson—Asheville Regional Office
Central Office File—WI0100007
Avery County Environmental Health Dept.
Attachment(s)

v ,
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH,NORTH CAROLINA
PERMIT FOR THE 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
Avery County Board of Education
FOR THE CONTINUED OPERATION OF TYPE 5QM INJECTION WELL(S), defined in Title 15A North
Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed-loop
geothermal-mixed-fluid heat pump system. This system is located at Newland Elementary School, 750 Linville
St., Newland, Avery County,NC 28657 and will be constructed and operated in accordance with the application
received August 30, 2010, and in conformity with the specifications and supporting data submitted, all of which
are filed with the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for operation of an injection well and shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until August 31, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through VII hereof.
Permit issued this the 30a' day of September 2010.
J�
f
een H. Sullins, Director
ision of Water Quality
By Authority of the Environmental Management Commission.

v
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 may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
4. In the event that there are multiple wells with separate clusters, one well identification tag per `cluster' of
wells shall be permanently affixed to the heating and cooling unit or otber nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
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 may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART III-OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. . The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
WI010000 i UI05QM-M.F. Renewal Page 2 of 4
Version 9/2010

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 retain all records of repairs, pressure tests, maintenance, and other activities
needed to maintain normal operating conditions. These records shall be submitted with the
application for permit renewal.
3. • The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Asheville Regional Office, telephone number(828) 296-4500, 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;
4. 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.
5. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VI—PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
WI0100007 UIC/5QM-M.F.Renewal Page 3 of
Version 9/2010

r
PART VII—CHANGE OF WELL STATUS J
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(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 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, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
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:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh,NC 27699-1636
WI0100007 UIC/5QM-M.F.Renewal Page 4 of.4
Version 9/2010

\O�O`r W ATF9QG State of North Carolina
v Department of Environment and Natural Resources
Cl) Division of Water Quality
o �c
Aquifer Protection Section
Regional Staff Report
09/28/2010
To: Aquifer Protection Section Central Office Application No.: WI0100007
Attn: Michael Rogers Regional Login No.:
From: Jonathan Stepp
Choose an item.Regional Office
I. GENERAL SITE VISIT INFORMATION
1. Was a site visit conducted?®Yes or.❑No
a. Date of site visit: 09/28/2010
b. Site visit conducted by: Jonathan Stepp
c. Inspection report attached? ®Yes or❑No
d. Person contacted: Danny Clark and their contact information: (828)387- 1580 ext.
e. Driving directions:
11. PROPOSED FACILITIES FOR NEW AND MODIFICATION APPLICATIONS
1. Facility Classification: (Please attach completed rating sheet to be attached to issued permit)
2. Are the now treatment facilities adequate for the type of waste and disposal system? ❑ Yes or❑ No
If no. explain: ___
3. ,are site conditions(soils, depth to water table, etc)consistent with the submitted reports:' ❑ Yes❑ No ❑ N A
if no, please explain:
4. Do the plans and site map represent the actual site (property lines,wells, etc.)? ❑ Yes ❑ No ❑ N;;(
If no,please explain:
5. Is the proposed residuals management plan adequate? ❑ Yes, ❑ No ❑ N/A
If no; please explain:
6. Are the proposed application rates(e.g., hydraulic,nutrient) acceptable? ❑ Yes ❑No❑N/A
If no,please explain:
7. Are there any setback conflicts for proposed treatment, storage and disposal sites? ❑Yes or❑ No
If'yes,attach a map showing conflict areas.
8. Is the proposed or existing groundwater monitoring program adequate? ❑ Yes ❑No ❑ Ni'A
if no,explain and recommend airy changes to the grounthc,ater monitoring program:
9. For residuals, will seasonal or otherresp'ictions be required? ❑ Yes ❑No ❑ N a
if ves. attach list of sites with restrictions (C'ertilication E)
FORM:APSRSR 04-10 Pagel of 3

M.EXISTING FACILITIES FOR MODIFICATION AND RENEWAL APPLICATIONS
1. Are there appropriately certified Operators in Charge(ORCs)for the facility? ❑Yes ❑No ®N/A
ORC: Certificate#: Backup ORC: Certificate#:
2. Are the design, maintenance and operation of the treatment facilities adequate for the type of waste and disposal
systeTly ❑ Yes or❑No
If no, please explain:
;. Are the site conditions (e.g., soils, topography, depth to 1xatertable.etc) maintained appropriately and adcyu tci?
assimilating the waste-? ❑Yes or❑ No
If no, please explain:
4. Has the site changed in any way that may affect the permit(e.g., drainage added,new wells inside the compliance
boundary,new development, etc.)? ❑ Yes or®No
,If yes,please explain:
5. Is the residuals management plan adequate? ❑ Yes or❑ No
if no,please explain:
6. Are the existing application rates(e.g., hydraulic, nutrient) still acceptable? ❑ Yes or❑No
If no, please explain: _
7. Is the existing groundwater monitoring program adequate? ❑ Yes❑No ®N/A
If no, explain and recommend any changes to the groundwater monitoring program:
8. ;Are there anv setback conflicts for existing,treatment,storage and disposal sites? ❑ Yes or❑ No
If yes,attach a map showing conflict areas.
9. Is the description of the facilities as written in the existing permit correct? ®Yes or❑No
If no,please explain:
10. Were monitoring wells properly constructed and located? ❑ Yes❑No ®N/A
If no, please explain:
l l. Are the monitoring welt coordinates correct. in BIMS? ❑ Yes ❑ No ®N/A
If no. please complete (lie following(expand table if necessary):
monitoring Well Latitude Longitude
I!
12. bias a review of all self-monitoring data been conducted (e.g.,NDMR, NDAR,GW)? ❑ Yes or❑ No
Please summarize any findings resulting from this review:
13. Are there any permit changes needed in order to address ongoing RIMS violations? ❑Yes or®No
If yes,please explain:
14. Check all that apply:
®No compliance issues ❑ Current enforcement action(s) ❑ Currently under JOC
❑Notice(s)of violation ❑ Currently under SOC ❑ Currently under moratorium
Please explain and attach any documents that may help clarify answer/comments(i.e.,NOV,NOD,etc.)
15. Have all compliance dates/conditions in the existing permit been satisfied? ❑Yes ❑No ®N/A
If no,please explain:
16. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit?
❑Yes ❑NoMN/A
If yes,please explain:
FORM:APSRSR 04-10 Page 2 of 3

IV. REGIONAL OFFICE RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? ❑Yes or®No
If yes,please explain:
2. List any items that you would like APS Central Office to obtain through an additional information request:
Item Reason
3. List specific permit conditions recommended to be removed from the permit when issued:
Condition Reason
4. List specific special conditions or compliance schedules recommended to be included in the permit when issued:
Condition Reason
S. Recommendation: ❑Hold, pending receipt and review of additional information by regional office
❑ Hold,pending review of draft permit by regional office
❑Issue upon receipt of needed additional information
® Issue
❑ Deny(Please state reasons: )
6. Signature of report preparers
Signature of APS region supervisor:
Date: Q1- 1-y- to l J
V. ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM:APSRSR 04-10 Page 3 of 3

t. ,MapQuest Maps -Driving Directions -Map Page 1 of 2
Notes
mapquesteffl Danny Clark(828.387.1580) A,
09/28/2010
Trip to:
Trip
Linville St 10:00 am meeting at the school
Newland, NC 28,657-8038
59.53 miles _
1 hour 25 minutes
p 3. Merge onto I-40 E via the ramp on the LEFT toward BLACK go 15.9 mi 17.5
n `WIF MOUNTAIN. mi
If you reach BUCKEYE ACCESS RD you've gone a little too far
4. Take EXIT 75 toward PARKER PADGETT RD. go 0.2 mi 17.7
mi
5. Turn LEFT onto OAKDALE RD / NC-1234. ' go 0.09 mi •. 17.7
�7 If you reach INTERSTATE 40 E you've gone about 0.1 miles too I mi
far
h 6. Take the 1st LEFT onto OAKDALE RD. go 0.02 mi i 17.8
mi
1 7. OAKDALE RD becomes GREENLEE RD. go 1.1 mi - 18.8
mi
8. Turn RIGHT onto US-70. go 6.6 mi 25.5
gad US-70 is 0.3 miles past EBENEEZER CHURCH RD mi
9. Turn LEFT onto LAKE TAHOMA RD/NC-80. go 1.9 mi 27.4
h ea' LAKE TAHOMA RD is 0.3 miles past PG SCHOOL RD mi
10. Turn RIGHT onto TOMS CREEK RD. go 2.6 mi 30.0
TOMS CREEK RD is 0.9 miles past HOLLY RDG mi
11. Turn LEFT onto US-221 / NC-226. Continue to follow US-221 go 25.2 mi 55.2
♦1 N. mi
12. Turn LEFT onto NC-1941 MILLERS GAP HWY. go 0.02 mi i 55.2
h ea' NC-194 is just past MICHELLE LN mi
13. Turn RIGHT onto MILLERS GAP HWY/ NC-194. Continue to go 3.9 mi 59.1
ga follow NC-194. mi
14. Turn RIGHT onto LINVILLE ST/ NC-181. go 0.4 mi i 59.5
f LINVILLE ST is just past ASH ST mi
15. 750 LINVILLE ST is on the RIGHT. go 0.01 mi 159.5
• Your destination is just past WATAUGA ST !, mi
If you are on STATE ROUTE 181 and reach EDMONDSON ST
you've gone a little too far
http://new.mapquest.com/print?a=app.core.d09l268f25ca666bc3c6a674 9/20/2010

MapQuest Maps -Driving Directions - Map Page 2 of 2
750 Linville St, Newland, NC 28657-8038 59.5 mi 159.5
mi
All rights reserved. Use subject to License/Copvright
Directions and maps are informational only.We make no warranties on the accuracy of their content; road conditions or route
usability or expeditiousness. You assume all risk of use. MapQuest and its suppliers shall not be liable to you for any loss or
delay resulting from your use of MapQuest.Your use of MapQuest means you agree to our Terms of Use
http://new.mapquest.com/print?a=app.core.d09l.268f25ca666bc3c6a674 9/20/2010

J
A
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 50M WELL(S)'
New Permit Application OR x Renewal (check one)
DATE: 05 20J O
PERMIT NO. 01 OI 00007 (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):ti tS�Qu C�t,n ` ]Gtt¢d D�
_:_ALC_?Q4I 8M . nnu l �QQL�
(1) Mailing Address: ? 0 PQtn pat, �,: •QaBE4.
City: State:NC.Zip ZA(p5'7 County: 14veeIS4
Home/Office Tele No.: g 2,q �/-5 -(SOD(D Cell Na Z,?- 39'7 /580
EMAIL Address: AlavNa4 Q Q.1C a7 aue"& M KL NC'l
(2) Physical 1Address of Site(if different than above): 5n �—j tAQ'mr -'C�-tPPP4
City: State:_4_C,Zip Code:. ZS[o5�/ 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 Tole No.: Cell No.:
Website Address of Company,if any:
C. STATUS OF APPLICANT
Private: Federal: Commercial:_
State:_Y_ Municipal:_ Native American Lands:_ RECEIVED I DENR I DWQ
AQUIFPR'PROTFCTION SECTION
AUG 3 0 2010
GPU/UIC 5QM Well Permit Application(Revised 7/2008) Page 1

D. 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.:
E. HEAT PUMP CONTRACTOR INFORMATION(if different than driller)
Company Name:
Contact Person: EMAIL Address:
6 Address:
City: Zip Code: County:
Office Tele No.: Cell No.:
F. INJECTION PROCEDURE (briefly describe how the injection well(s)will be used)
G. WELL CONSTRUCTION DATA(Ship to Section H if this is a Permit RENEWALI
(I) Proposed date to be constructed: Number of borings:
Approximate depth of each boring(feet):
(2) Chemical additives to be used in closed-loop system(only those chemicals indicated have been approved):
R-22 propylene glycol ethanol other(other additives will
need prior approval by NCDENR before use)
(3) Type of tubing to be used(copper,PVC,etc):
(4) Well casing. Is the well(s)cased?(check either(a.)YES or(b.)NO below)
(a) YES if yes,then provide casing information such as Woe(steel,PVC,plastic, etc.),diameter.
denth,and extent of casing appearing above ground:
(b) NO
(5) Grout(material surrounding well casing and/or piping):
(a) Grout type: Cement_ Bentonite_ Other(specify)
(b) Grout depth of tubing(reference to land surface): from to (feet)
If well has casing,indicate grout depth: from to (feet)
H. INJECTION-RELATED EQUIPMENT
D, p Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
1� piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
�/r 1 information,
GPU/UIC 5QM Well Pemit Application(Revised 7/2008) Page 2

I. 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.
J. POTABLE WATER WELL(S)
Are there any potable water well(s)on the subject property or adjacent properties? YES_kNO
If Yes,than indicate location on attached map(s).
K. CERTIFICATION
Note:This Permit Application must lie 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 Pr erty Owner/Applicant
Do_y-NYt . C Iat.P V
Print or Type dWI 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 RECEIVEDIDENR/DWQ
Aquifer Protection Section AQUIFPR PR0TF.CTIDN 3F.CTIQN
UIC Program AUG 3 0 2010
1636 Mail Service Center
Raleigh,NC 27699-1636
Telephone [phone]
GPU/UIC 5QM Well Permit Application(Revised 7/2008) Page 3

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number:W 10kM(Y-)0"I
PermitteeName: Ayeq p� OQ2A tn�' �rltac��6oK
Address: "In-5 G 1 A6eaa�Sd�¢ee4 , NO W lanj 02 Z lw�S
Please check the selection which most closely describes the current status of your injection well system:
1) jyWell(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)❑Well(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 of material 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."
aCO — rh
Signature Date
RECEIVED I DENR/DWQ
AQUIFFR'PRnTFCTIQN SECTION
AUG 3 0 2010
Revised 5/05 GW/UIC-68

O�O�C W ArF9oG Michael F.Easley,Governor
William G.Ross Jr.,Secretary
rNorth Carolina Department of Environment and Natural Resources
Q ^� Alan W.Klimek,P.E.Director
Division of Water Quality
August 1, 2005
(711
CERTIFIED MAIL X M J
RETURN RECEIPT REQUESTED `__ >
7002 2410 0003 0274 5528 �'
TT u
G J W c
Meg Julian
Newland Elementary School _.Z
750 Linville Street ri F-7
Newland,NC 28657
Ref: Notification of Expiration
North Carolina Well Construction Standards
Applicable to Injection Wells - Subchapter 2C
UIC Permit No. WI0100007Issued to Avery County Board of Education
Dear Ms. Julian:
The Underground Injection Control (UIC) Program of the Division of Water Quality is responsible for
the regulation of injection well construction and operation activities within the state of North Carolina.
Our records show that the operating permit referenced above for the injection wells at Newland
Elementary School will expire on October 31, 2005. In addition, our records do not indicate that these
wells have been abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative Code
(NCAC) Title 15A, Subchapter 2C, Section .0211, you must take one of the following actions:
A. Submit the form RENEWAL APPLICATION FOR PERMIT TO USE WELL(S) FOR INJECTION WITH A
HEAT PUMP SYSTEM (form GW/UIC-57 HPR) if the injection wells are still active;
B. Submit the form STATUS OF INJECTION WELL SYSTEM (form GW/UIC-68) if the injection wells
are inactive or have been temporarily or permanently abandoned.
If the wells are no longer being used for any purpose, they must be permanently abandoned according to
the regulatory requirements listed under NCAC Title 15A, Subchapter 2C, Section .0214. If the
injection wells are to be permanently abandoned, well abandonment records must be submitted to our
office to certify that each abandonment was properly conducted.
tCarolina
ra/!y
Aquifer Protection Section 1636 Mail Service Center Raleigh,NC 27699-1636 Phone[phone] Customer Service
Internet:http://h2o.enr.state.nc.us 2728 Capital Boulevard Raleigh,NC 27604 Fax [phone] 1-877-623-6749
Fax [phone]
An Equal Opportunity/Affirmative Action Employer—50%RecycledAO%Post Consumer Paper

Meg Julian
August 1,2005
Page 2 of 2
Please submit the appropriate form(s) within 30 days of the receipt of this letter. If you have any
questions regarding the permit and injection well rules, or if you would like assistance completing these
forms please contact Thomas Slusser at(919) 715-6166 or myself at(919) 715-6168.
Sincerely,
Jesse Wiseman
Processing Assistant
UIC Program
cc: DWQ-Asheville Regional Office w/o enclosures
CO-UIC Files w/o enclosures
Enclosures

W
F W ATF Michael F.Easley,Governor
65
61William G.Ross Jr.,Secretary
r— North Carolina Department of Environment and Natural Resources� -C Alan W.Klimek,P.E.Director
Division of Water Quality
December 12, 2005 0
M
c.�
Meg Julian, Principal
Newland Elementary School
750 Linville Street
Newland, NC 28657
Ref: Issuance of Injection Permit WI0100007
Newland Elementary School
Dear Ms. Julian:
In accordance with your application submitted on September 15, 2005 we are forwarding Permit Number
WI0100007 for the operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well
system at 750 Linville Street, Newland, North Carolina.
This permit shall be effective from the date of issuance until December 31, 2010 and shall be subject to the
conditions and limitations stated therein. In order to continue uninterrupted legal use of this well for the
stated purpose, you should submit an application to renew the permit 120 days prior to its expiration date. As
indicated in the permit, this permit is not transferable to any person without prior notice to, and approval by,
the Director of the Division of Water Quality.
Please read the permit carefully to be sure you understand all its conditions. Please contact me at 919-715-
6166 or Evan Kane at 919-715-6182 if you have any questions regarding this letter or the Underground
Injection Control (UIC) Program.
Best Regards,j� -9 t.
Thomas Slugger
Hydrogeological Technician II
UIC Program
cc: Landon Davidson,Asheville Regional Office
CO-UIC Files N°0C Carolina
?folly
Aquifer Protection Section 1636 Mail Service Center Raleigh,NC 27699-1636 Phone[phone] Customer Service
Internet:http://h2o.enr.state.nc.us 2728 Capital Boulevard Raleigh,NC 27604 Fax [phone] 1-877-623-6748
Fax [phone]
An Equal Opportunity/Affirmative Action Employer—SM.Recycled/l 0%Post Consumer Paper

0
m
NORTH CAROLINA
w
ENVIRONMENTAL MANAGEMENT COMMISSION
z ,
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH,NORTH CAROLINA
PERMIT FOR THE 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
AVERY COUNTY BOARD OF EDUCATION
FOR THE OPERATION OF A TYPE 5QM INJECTION WELL SYSTEM, defined in Title 15A
North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical
closed-loop geothermal-mixed-fluid heat pump system. This system is located at Newland
Elementary School: 750 Linville Street in Newland, Avery County, North Carolina, and will be
operated in accordance with the application submitted September 15,2005 and in conforn ity with
the specifications and supporting data submitted, all of which are filed with the Department of
Environment and Natural Resources and are considered a part of this permit.
This permit is for Operation 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 December 31,2010
and shall be subject to the specified conditions and limitations set forth in Parts I throughVlihereof.
Permit issued this the R2 day of ,QCa,. - der' , 2005.
lan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0100007 PAGE 1 OF 4
GW/UIC-5 ver. 11/04

PART I-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is
no contamination of groundwater which 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 mayberequired
by the Division of Water Quality such as the repair, modification, or abandonment of the
injection facility.
2. The Pennittee 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 II- 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.
PART III-INSPECTIONS
1. Any duly authorized officer,employee,or representative ofthe Division of Water Qualitymay,
upon presentation of credentials, enter and inspect any property, premises, or place on or
related to the injection facility ai 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.
Permit No.WI0100007 PAGE 2 OF 4
GWIMC-5 ver. 11/04

PART IIII- MONITORING AND REPORTING REQUIREMENTS
L. 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 Asheville Regional Office,telephone number(828) 296-4500,any of
the following: `
(A) Any occurrence at the injection facility which results in anyunusual 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 anyreport to the
Director, the relevant and correct facts or information shall be promptly submitted to the
Director by the Permittce.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take
such immediate action as may be required by the Director.
PART V- PERMIT RENEWAL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
PART VI - CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an
injection well. Such a change would include the discontinued use of a well for injection. If a
well is taken completely out of service temporarily,the Permittee must install a sanitary seal.
If a well is not to be used for anypurpose 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:
Pernut No.WI0100007 PAGE 3 OF 4
GW/UIC-5 ver. 11/04

(A) All casing and materials may be removed prior to initiation of abandonment
procedures if the Director finds such removal will not be responsible for,or
contribute to,the contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do .so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have not
been removed, the casing shall be perforated opposite the gravel pack, at
intervals not exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner that
will prevent the movement of fluids into or between underground sources of
drinking water and in accordance with the terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record(Form GW-30) as
specified in 15A NCAC 2C .0213(h)(1) within 30 days of completion of
abandonment.
3. The written documentation required in Part VI(1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh,NC 27699-1636
PART VII- OPERATION AND USE SPECIAL CONDITIONS
None
Permit No.WI0100007 PAGE 4 OF 4
GW[MC-5 ver. l 1/04

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: County: flv/
To: Aquifer Protection Section Central Office Permittee: Alcw L'.�r:�.y Sr yEtGS
Central Office Reviewer: Project Name: e-wiWo tte-,tt srefaet
Regional Login No: Application No.: WZ o i 00 00 7
I GENERAL INFORMATION
1. This application is (check an that apply): ❑New g Renewal
❑ Minor Modification❑ Major Modification
❑ Surface Irrigation❑ Reuse ❑ Recycle ❑High Rate Infiltration❑Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑Attachment B included ❑ 503 regulated ❑ 503 exempt
❑Distribution of Residuals ❑ Surface Disposal
❑ Closed-loop Groundwater Remediation ❑ Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? DgYes or❑No. .
a. Date of site visit: Zoo /l/30
b. Person contacted and contact information: aJ .."
c. Site visit conducted by:
d. Inspection Report Attached: ❑ Yes or❑No.
2. Is the following information entered into the BIMS record for this application correct?
❑ Yes or❑No. If no,please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
e. Regulated Activities/Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For Disposal and Injection Sites:
(If multiple sites either indicate which sites the information applies to, copy and paste a new section into the
document for each site or attach additional pages for each site
a. Location(s): LtNvtuE S—� y l8t �/ /faz+lta.�/�
b. Driving Directions: T 4040E -,-a er,r F6 Lt5 ZZ/ n� -'-a Cr°^faA'c NC 194W To WVW144 -R.r-a✓WCt?
O.2 u r o,d/fir
c. USGS Quadrangle Map name and number: I4EW6grrb
d. Latitude: 3.W'SS.4" Longitude: 8l°VVZZ.3"
IL NEWAND MAJOR MODIFICATIONAPPLICATIONS(this section not needed for renewals or minor
modifications, skin to next section)
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification:
2. Are the new treatment facilities adequate for the Type of waste and disposal system?

e.
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
❑ Yes ❑No ❑N/A. If no, please explain:
3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by
the soil scientist and/or Professional Engineer?❑ Yes ❑No ❑N/A. If no, please explain:
4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? ❑
Yes ❑No ❑N/A. If no,please explain:
5. Is the proposed residuals management plan adequate and/or acceptable to the Division. ❑ Yes ❑ No ❑
N/A. If no, please explain:
6. Are the proposed application rates for new sites (hydraulic or nutrient)acceptable?
❑ Yes ❑No ❑N/A. If no, please explain: ,r
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
0
❑ Yes ❑ No ❑ N/A. If yes, please,gttp a map showing areas of 100-year-floodplain and please explain
and recommend any mitigative measures/special conditions in Part IV:
8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? ❑ Yes or ❑No. If yes, please
attach a map showing conflict areas or attach any new maps you have received from the applicant to be
incorporated into the permit:
9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring,
monitoring parameters, etc.) adequate? ❑ Yes ❑ No ❑ N/A. Attach map of existing monitoring well
network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any
changes to the groundwater monitoring program:
10. For residuals, will seasonal or other restrictions be required? ❑ Yes ❑No ❑N/A If yes, attach list of sites
with restrictions (Certification B?)
III. RENEWAL AND MODIFICATIONAPPLICATIONS(use previous section for new or major modification
systems)
Description Of Waste(S) And Facilities
1. Are there appropriately certified ORCs for the facilities? ❑ Yes or No.
Operator in Charge: Certificate
Backup-Operator in Charge: Certificate#:
2. Is the design, maintenance and operation (e.g. adequate aeration, sludge wasting, sludge storage, effluent
storage, etc) of the treatment facilities adequate for the type of waste and disposal system? ❑ Yes or ❑ No.
If no,please explain:
3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? ❑Yes or❑No. If no, please explain:
FORM: Doc4.doc 2

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
4. Has the site changed in any way that may affect permit (drainage added, new wells inside the compliance
boundary,new development,etc.)? If yes, please explain:
5. Is the residuals management plan for the facility adequate and/or acceptable to the Division?
❑ Yes or❑No. If no, please explain:
6. Are the existing application rates (hydraulic or nutrient) still acceptable? ❑ Yes or ❑ No. If no, please
explain:
7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring
parameters, etc.) adequate? ❑ Yes ❑ No ❑ N/A. Attach map of existing monitoring well network if
applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the
groundwater monitoring program:
8. Will seasonal or other restrictions be required for added sites? ❑ Yes ❑No ❑N/A If yes, attach list of sites
with.restrictions (Certification B?)
9. Are there any buffer conflicts (treatment facilities or disposal sites)? ❑ Yes or ❑ No. If yes, please attach a
map showing conflict areas or attach any new maps you have received from the applicant to be incorporated
into the permit:
10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? ❑
Yes or❑No. If no, please explain: '
11. Were monitoring wells properly constructed and located? ❑ Yes or ❑ No ❑ N/A. If no, please explain:
12. Has a review of all self-monitoring data been conducted (GW,NDMR, and NDAR as applicable)? ❑ Yes or
❑No ❑N/A. Please summarize any findings resulting from this review:
13. Check all that apply: ❑ No compliance issues; ❑ Notice(s) of violation within the last permit cycle; ❑
Current enforcement 'action(s) ❑ Currently under SOC; ❑ Currently under JOC; ❑ Currently under
moratorium. If any items checked, please explain and attach any documents that may help clarify
answer/comments(such as NOV,NOD etc):
14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) beer' complied with? ❑ Yes
❑No ❑Not Determined ❑N/A.. If no, please explain:
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? ❑
Yes or❑No ❑N/A. If yes, please explain:

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
IY INJECTION WELL PERMITAPPLICATIONS(Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells,in situ remediation injection wells,and heat
pump injection wells.)
Description Of Well(S) And Facilities—New,Renewal,And Modification
1. Type of injection system:
❑ Heating/cooling water return flow (5A7)
N Closed-loop heat pump system(5QM/5QW)
❑In situ remediation(5I)
❑ Closed-loop groundwater remediation effluent injection(5LP'Non-Discharge")
❑ Other(Specify:
2. Does system use same well for water source and injection? ❑ Yes Pg No
3. Are there any potential pollution sources that may affect injection? ❑ Yes X No
What is/are the pollution source(s)? What is the distance of the injection well(s) from the pollution
source(s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? ft.
5. Quality of drainage at site: 0 Good ❑ Adequate ❑Poor
6. Flooding potential of site: ®Low ❑ Moderate ❑High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program:
8. Does the map presented represent the actual site(property lines,wells, surface drainage)? ❑Yes or❑No. If
no or no map, please attach a sketch of the site. Show property boundaries,buildings, wells,potential pollution
sources,roads,approximate scale, and north arrow.
Infection Well Permit Renewal And Modification Only:
1. For heat pump systems,are there any abnormalities in heat pump or injection well operation (e.g.turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
❑ Yes 7X No. If Yes, explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? ❑Yes jSNo. If yes, explain:
I For renewal or modification of groundwater remediation permits (of any type),will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? ❑Yes ❑No. If yes, explain:
4. Drilling contractor: Name:
-4
FORM: Doc4.doc

P
AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address:
Certification number:
5. Complete and attach Well Construction Data Sheet.
FORM -Doc4:doc

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
/V. EVALUA TIONAND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet- if needed information is available
3. Do you foresee any problems with issuanceenewal of this permit? ❑ Yes Z No. If yes,please explain
briefly.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
7. Recommendation: ❑Hold,pending receipt and review of additional information by regional office;❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny,please state reasons:
8. Signature of report preparer(s):
Signature of APS regional supervisor: �5�
Date: i o/ zvo
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: Doc4.doc 6

newland uic
Subject: newland uic
Date: Mon, 16 Oct 2000 14:04:24 -0400
From: Tina Parsons <[e-mail]>
Organization: NC DENR-Asheville Regional Office
To: MARK PRITZL <[e-mail]>, [e-mail],
Tina Parsons <[e-mail]>
Hi Mark:
Three more questions. '
Will there be a waiting period after the permit is issued, or can they
proceed with drilling immediately upon permit issuance (say, end of the
week) ?
Will the consultant (in this case Padgett & Freeman) also receive a copy
of the permit (they would like to and I wasn't sure how that worked) ?
Will I receive a copy of the permit for my files (again, not sure what
that procedure is) ?
Thanks again. tina.
Tina Parsons - [e-mail]
North Carolina Dept. of Environment and Natural Resources
Asheville Regional Office
Division of Water Quality - Groundwater Section
59 Woodfin Place
Asheville, NC 28801
Tel: [phone]
Fax: [phone]
1 of 1 10/16/2000 3:12 PM

Re:newland uic
.Subject: Re: newland uic
-Date: Mon, 16 Oct 2000 14:25:27 -0400
From: Mark Pritzl<[e-mail]>
To: Tina Parsons<[e-mail]>
Tina,
You will be getting a copy of the UIC permit for the ARO-UIC files. I will
cc "Padgett & Freeman" if you send me their address. There is a slight
waiting period, time for Ted Bush to review and sign the permit, then they
can drill.
Mark
Tina Parsons wrote:
> Hi Mark:
> Three more questions.
>
> Will there be a waiting period after the permit is issued, or can they
> proceed with drilling immediately upon permit issuance (say, end of the
> week) ?
> Will the consultant (in-this case Padgett & Freeman) also receive a copy
> of the permit (they would like. to and I wasn 't sure how that worked) ?
> Will I receive a copy of the permit for my files (again, not sure what
> that procedure is) ?
> Thanks again. tina.
> Tina Parsons - [e-mail]
> North Carolina Dept. of Environment and Natural Resources
> Asheville Regional Office
> Division of Water Quality - Groundwater Section
> 59 Woodfin Place
> Asheville, NC 28801
> Tel: [phone]
> Fax: [phone]
1 of 2 10/18/2000 1:53 PM

newland school uic
Subject: newland school uic
Date: Mon, 16 Oct 2000 13:59:11 -0400
From: Tina Parsons <[e-mail]>
Organization: NC DENR-Asheville Regional Office
To: MARK PRITZL<[e-mail]>, [e-mail],
Tina Parsons <[e-mail]>
Hi Mark:
Gene Edwards, his engineer, and Sam Shanks were here this afternoon.
They brought in all the information that I had asked for and/or had
remaining questions on. I am satisfied that they have met all the
conditions—to_meet_permit_requirements.._tina.. --
Tina Parsons - [e-mail]
North Carolina Dept. of Environment and Natural Resources
Asheville Regional Office
Division of Water Quality - Groundwater Section
59 Woodfin Place
Asheville, NC 28801
Tel: [phone]
Fax: [phone]
1 of 1 10/16/2000 3:11 PM

d;Re:`hewland uic]
u
Subject: Re: [Fwd: Re: newland uic]
Date: Tue,24 Oct 2000 13:08:56 -0400
From: Gene Edwards<[e-mail]>
To: Tina Parsons<I'[e-mail]>
Will do.
Tina Parsons wrote: '
> thanks gene. have them give me a call so i can visit the site one day while they are'
> drilling/installing casing. t.
> Gene Edwards wrote:
> > Tina,
> > Have passed- this on to our contractor.
> >- Thanks,
> > Gene LL
> > Tina Parsons wrote:
> > > fyi. i think we forgot to discuss this particular aspect. thanks. t.
> > > t
> > > -------- Original Message --------
> > > Subject.: Re: newland,uic
> > > Date: Fri, 2,0 Oct 2000 10:28:17 -0400
> > > From: Mark Pritzl <[e-mail]>
> .> > To: Tina Parsons <[e-mail]>
> > > References: <[e-mail]>
> > > <39EB4816.B935EA040ncmail.net> <39F031C0. 7C6601C30ncmail.net>
> > > Thought you were out today? Please, will you stay on top of reminding
> > > them. Also,
> > > if they are not using casing then have them grout into the bedrock a
> > > couple feet.
> > > Tina Parsons wrote: '
> > .> > mark: spoke to ted minnick about uic wells (post permit) for newland, he said i
> > > > should remind those guys that the casing's 'should be set to bedrock if 20ft
> >. > > doesn 't get there. going to be out of office today and monday. will i or u need
> > > > to contact them? they will be starting to drill on monday. t.
> > > > Mark Pritzl wrote:
1 of 3 10/31/2000 10:00 AM

-1w:Re:`newland uic]
> >> > > Tina,
> > > > > You will be getting a copy of the UIC permit for the ARO-UIC files. I will
> >, > > > cc "Padgett & Freeman" if you send me their address. There is a slight
> > > > > waiting period, time for Ted Bush to review and sign the permit, then they
> > > > > can drill. . `
> > > > > Mark '
> > > > >
r
> > > > > Tina Parsons wrote: -
> > > > > > Hi Mark:
> > > > > > Three more questions.
> > > > > > Will there be a waiting period after the permit is issued, or can they
> > > > > > proceed with drilling immediately upon permit issuance (say, end of the,
> > > > > > week) ?
> > > > > >
> > > > > > Will the consultant (in this case Padgett & Freeman) also receive a copy
> > > > > > of the permit (they would like to and I wasn 't sure how that worked) ?
> > > > > > Will I receive a copy of the permit for my files (again, not sure what
> > > > > > that procedure is) ?
> > > > > > Thanks again. tina.
> > > > > > Tina Parsons - [e-mail]
> > > > > > North Carolina Dept. of Environment and Natural Resources.
> > > > > > Asheville Regional Office
> > > > > > Division of Water Quality - Groundwater Section
> > > > > > 59 Woodfin Place
> > > > > > Asheville, NC 28801
> > > > > > Tel: [phone]
> > > > > > Fax: [phone]
> > > > > ------------------------------------------------------------------------
> > > > > Name: Mark.Pritzl.vcf
> > > > > Mark.Pritzl.vcf Type: VCard (text/x-vcard)
> > > > > Encoding:. 7bit
> > > > > Description: Card for Mark Pritzl
> > > > Tina Parsons - [e-mail]
> > > > North Carolina Dept. of Environment and Natural Resources
2 of 3 10/31/2000 10:00 AM

Re: [F¢!d: Re:'newland uic]
> > > > Asheville Regional Office
> > > > Division of Water Quality - Groundwater Section
> > > > 59 Woodfin Place
> > > > Asheville, NC 28801
> > > > Tel: [phone]
> > > > Fax: [phone]
> Tina Parsons - [e-mail]
> North Carolina Dept. of Environment and Natural Resources
> Asheville Regional Office
> Division of Water Quality - Groundwater Section
> 59 Woodfin Place
> Asheville, NC 28801
> Tel: [phone]
> Fax: [phone]
3 of 3 10/31/2000 10:00 AM

Re:newland uic
Subject: Re: newland uic
Date: Fri, 20 Oct 2000 10:28:17 -0400
From: Mark Pritzl<[e-mail]>
To: Tina Parsons <[e-mail]>
Thought you were out today? Please, will you stay on top of reminding them. Also,
if they are not using casing then have them grout into the bedrock a couple feet.
Tina Parsons wrote:
> mark: spoke to ted minnick about uic wells (post-permit) for newland, he said i
> should remind those guys that the casing's should be set to bedrock if 20ft
> doesn 't get there. going to be out of office today and monday. will i or u need
> to contact them? they will be starting to drill on monday. t.
> Mark Pritzl wrote:
> > Tina,
> > You will be getting a copy of the UIC permit for the ARO-UIC files. I will
> > cc "Padgett & Freeman" if you send me their address. There is a slight
> > waiting period, time for Ted Bush to review and sign the permit, then they
> > can drill.
> > Mark
> > Tina 'Parsons wrote:
> > > Hi-Mark:
> > > Three more questions.
> > > Will there be a waiting period after the permit is issued, or can they
> > > proceed with drilling immediately upon permit issuance (say, end of the
> > > week) ?
> > > Will the consultant (in this case Padgett & Freeman) also receive a copy
> > > of the permit (they would like to and I wasn 't sure how that worked) ?
> > > Will I receive a copy of the permit for my files (again, not sure what
> > > that procedure is) ?
> > > Thanks again. tina.
1 of 2 10/24/2000 9:19 AM

Re:newland uic
e _:.
> > > Tina Parsons - [e-mail]
> > > North Carolina Dept. of Environment and Natural Resources
> > > Asheville Regional Office
> > > Division of Water Quality - Groundwater Section
> > > 59 Woodfin Place
> > > Asheville, NC 28801
> > > Tel: [phone]
> > > Fax: [phone]
> > ------------------------------------------------------------------------
> > Name: Mark.Pritzl.vcf
> > Mark.Pritzl.vcf Type: VCard (text/x-vcard)
> > Encoding: 7bit
> > Description: Card for Mark Pritzl
> Tina Parsons - [e-mail]
> North Carolina Dept. of Environment and Natural Resources
> Asheville Regional Office
> Division of Water Quality - Groundwater Section
> 59 Woodfin Place
> Asheville, NC 28801
> Tel: [phone]
> Fax: [phone]
Name: Mark.PritzI.vcf
�Mark.PritzI.vcf Type: Ward (text/x-vcard)
Encoding: 7bit
Description: Card for Mark Pritzl
2 of 2 10/24/2000 9:19 AM

Newland Elementary Ground Water Permit
Subject: Newland Elementary Ground Water Permit
Date: Thu, 19 Oct 2000 13:35:43 -0400
From: Gene Edwards<[e-mail]>
To: MARK PRITZL<[e-mail]>, Tina Parsons <1'[e-mail]>
Mark, Tina,
Thanks for all your help in processing the permit. The driller plans to
begin work on Monday, October 23.
Gene Edwards
I of 1 12/20/2000 9:31 AM

Re: [Fwd: Re: newland uic]
> > Thanks again. tins.
> > Tina Parsons - [e-mail]
> > North Carolina Dept. of Environment and Natural Resources
> > Asheville Regional Office
> > Division of Water Quality - Groundwater Section
> > 59 Woodfin Place
> > Asheville, NC 28801
> > Tel: [phone]
> > Fax: [phone]
2 of 2 12/20/2000 9:31 AM

Re: [Fwd:Re:newland uic]
Subject: Re: [Fwd: Re: newland uic]
Date: Mon, 16 Oct 2000 14:41:30 -0400 1
From: Gene Edwards <[e-mail]>
To: Tina Parsons <[e-mail]> J`
Thanks, Tina. Our address is on my business card. How long a waiting period
are we expecting? ' Sam has drillers get up and can start on Wednesday if all
is in order. Let me know.
Gene
Tina Parsons wrote:
> -------- Original Message --------
> Subject: Re: newland uic
> Date: Mon, 16 Oct 2000 14:25:27 -0400
> From: Mark Pritzl. <[e-mail]>
> To: Tina Parsons <[e-mail]>
> References: <39EB4328..D382083C0ncmail.net>
> Tina,
> You will be getting a copy of the UIC permit for the ARO-UIC files. I
> will '
> cc "Padgett & Freeman" if you send me their address. There is a slight
> waiting period, time for Ted Bush to review and sign the permit, then
> they
> can drill.
>
> Mark
> Tina Parsons wrote:
> > Hi Mark-:
> > Three more questions.
> > Will there be a waiting period after the permit is issued, or can they
> > proceed with drilling immediately upon permit issuance (say, end of the
> > week) ?
> > Will the consultant (in this case Padgett & Freeman) also receive a copy '
> > of the permit (they would like to and I wasn't sure how that worked) ?
> > Will I receive a copy of the permit for my files (again, not sure what
> > that procedure is) ?
1 of 2 12/20/2000 9:31 AM

Re:Newland
Subject: Re: Newland
Date: Wed, 06 Dec 2000 07:10:42 -0500
From: Gene Edwards <[e-mail]>
To: Tina Parsons <[e-mail]>
Can you meet with me at 11:00 today. I will be at the hospital til 10:30.
Message me back if you can meet. Should not take too long. Thanks.
Gene
Tina Parsons wrote:
> Gene: I will be out of the office on business on Thursday and Friday. I
> will be here today (Tuesday) and Wednesday. tina.
> Gene Edwards wrote:
> > Tina,
> > I need to meet with you ASAP to discuss the drilling at Newland. I can
> > meet on Friday 1218 at any time.
> > Gene
> Tina Parsons - [e-mail]
> North Carolina Dept. of Environment and Natural Resources
> Asheville Regional Office
> Division of Water Quality - Groundwater Section
> 59 Woodfin Place
> Asheville, NC 28801
> Tel: [phone]
> Fax: [phone]
1 of 1 12/20/2000 9:32 AM

Newland
Subject: Newland
Date: Tue, 05 Dec 2000 05:54:15 -0500
From: Gene Edwards<[e-mail]>
To: Tina Parsons <[e-mail]>
Tina,
I need to meet with you ASAP to discuss the drilling at Newland. I can
meet on Friday 12/8 at any time.
Gene
1 of 1 12/20/2000 9:31 AM

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
19 September 2000
To: Mark Pritzl
UIC Group,CO
Through: Landon Davidson
Asheville Region Supervisor
From: Tina Parsons
Hydrogeologist- Asheville Region
Re: UIC Inspection for Newland Elementary School
I have reviewed the UIC application and visited this site on Monday 18 September 2000. I
have the following comments:
1. Applicant needs to supply a complete area schematic to scale showing all the details of the
construction layout.
2. Applicant needs to supply a working schematic of the HVAC system, properly labeled, and
indicating those parts that are to be in contact with the groundwater.
3. Applicant needs to provide the results of mechanical integrity tests including a description
of the test(s)and the method(s) used, prior to injection,after installation.
4. Applicant needs to supply complete information,specifications,and schematics of all test
wells on property.
5. Applicant needs to supply name,address,and details of all groundwater users identified in
the area.
6. Applicant needs to indicate property owner on application.
7. Applicant needs to supply boring logs for'test wells.
8. Applicant needs to indicate the construction details of injection wells in well field.
9. Applicant needs to identify all potential pollution sources in this area. Please identify on map
of area and provide name'and addresses of source.
10. What is the percentage of propylene glycol to potable water in the system?
11. Is this area part of federal Indian lands?
Please see file 616W/Data/6ISprojects/UIC/uicnewland and 616W/Data/UICZn5pection Pictures
for complete details

v
SEP 2 7I
LETTER OF TRANSMITTAL
NOR-WELL COMPANY, INC. Date: 25-Sep-00
136 East Elk Avenue
Elizabethton, TN 37643 Attn: Mr. Landon Davidson
Telephone: [phone], Fax: [phone]
For: Neland Elementary
School
TO: UIC Program
Groundwater Section
59 Woodfin Place
Asheville, NC 28801
We are sending you the following items:
QTY . Description Description
1 Additional information per UIC
inspection comments for Newland
Elementary School geothermal
system.
These are transmitted as: For approval
For your use
XX As requested
Approved as submitted
Approved as noted
Returned for corrections
Comments attached
Returned for deposit
Sent by: Sam Shanks

SEP 2
rea QvAaTy
I SECTION
/ - (� ;r 2000
To'.
Throe �liFT- RL�4✓ Gon'yi�`/S—i
Or,
From YZ1l�1'f1cs�
Ra UIC InspeKon;or gcwland iaeTantary School
I have reviewed the UIC eppl cation and visited this site on Monday tB September 2000.I
have the following comments:
✓yi Applicant needs to supply a c-mpicte area schematic To scale showing all 1 he details of the
construcilonlayouT.
��Appllcant needs to supply a w:-king schematic of the HVAC system, properly labeled,and
indical Ing 1 hose ports that are to be In contact with the groundwater.
Applicant needs to provide+he results of mechanical integrity tests including a description
of the test(s)and the methed;s)used. ^ > Oa'eQ to ="'t&cT%` 1 A� To I`
ti-f1. Applicant needs to supply cx;lete Information,specifications,and schematics of all test
wells on property.
v Applicant needs to supply ner..e,address, and details of oil groundwater users identified in
the area.
✓i7 Applicant needs To Indicate property owner on application,
✓,�Applicant needs I supply boning logs for test wells,
i9 Applicant needs to indicate the construction details of injection wells in wall field.
,,,�.P, 'Applicont needs to identify c9 potential pollution sources in this area, Please identify on mop
of area and provide name one addresses of source.
✓✓di- Is this area port of federal :ndion lands)1
S
Please see file 6/C>W1Dn6tn/ LSpro,ectslurclo/cnewland and 6/GW104te/VIC Inspection v crures
for complete details70
DRAFT
...END...

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
19 September 2000
^, 1L
�Ta: Landon Davidson
From: Tina Parsons
Re: UIC Inspection for Newland Elementary School
I have reviewed the UIC application and visited this site on Monday 18
September 2000. I have the following comments:
1. Applicant needs to supply a complete area schematic to scale showing all the
details of the construction layout.
2. Applicant needs to supply a working schematic of the HVAC system, properly
labeled, and indicating those parts that are to be in contact with the
groundwater.
3. Applicant needs to supply complete information, specifications, and
schematics of all test wells on property.
4. Applicant needs to supply chemical analysis of groundwater on site.
5. Applicant needs to supply name, address, and details of all groundwater
users identified in the area.
6. Applicant needs to indicate property owner on application.
7. Applicant needs to supply boring logs for test wells.
8. Applicant needs to indicate the construction details of injection wells in well
field.
9. Applicant needs to identify all potential pollution sources in this area. Please
identify on map of area and provide name and addresses of source.
Please see file 616WIData/615projects/UIC/uicnewland and 616W/Data/UIC
Inspection Pictures for complete details.

10/09/00 10:42 $423 543 7109 NOR-WELL 0001
MECHANICAL -CONTRACTORS
136 East Elk Avenue
Date: Elizabetht6n,TN 37643
Time: w. -A!5- pp-A [phone]
Fax: [phone]
To; n1c n��t�Fdtlllrwx,JY,F��Gk'acHlb .JIHlfld�°1�
Atten: �1s P, tis
From: Swm -VowkS
Number of pages, including cover sheet: 2
if you do not receive all pages, please call as soon as possible.

10/09/00 10:42 e423 543 7109 NOR-WELL 0002
r
MWEU
MECHANCAL CONTRACTORS October 9 2000
North Carolina Dept.of Environment&Natural Resources
Division of Water Quality
(around Water Section
Asheville,NC
Attn:Ms. Tina Parsons L 1
1 P� �
Re: Newland Elementary School,Newland,NC 'l V
Perrtut Application to Construct Wells for a Heat Pump ystem
Details on existing wells within or near 1000"radius from site per Braswell Well Drilling.
W Vohm Rcsk Ins CgftDcrthGroot
D.n.Rubber 500IL w @. S GPM mc&Hard Saodff Appn 50 3 Oft,
MuymalMmtkw MOIL 260 H. 30 GPM 721L 208
Martha Mal®er 3001L 125 R. 1 GPM Sa R 20$
M.1c Bledm 125 Ff- 5 GPM App me 3011 0 8
us Ireaa& 300 a 200 to250 9. 90 OPM Bloc SI rc 4o fL 20 IL
in reference to item #10 of UIC inspection comments, items that may be considered
Potential pollution sources in the ama-
1. Sanitary sewer lines on school property and city Sewer lines.
I 3,000-gallon temporary fuel oil tank above ground just outside the school's boiler
room_ The tank is double wall, the outer wall serving as secondary containment
and is provided with an anti-sypon valve.
Please give me a call if you have any questions or need additional information
Sincerely;
i
Sam Shanks
Project Manager
SS/klw
cc: Mr.Mark Prit4 Groundwater Section,Raleigh,NC
136 East Elk Avenue• Elizabethtcn,Tennessee 376Q •[phone]•[phone]•Fax[phone]
LICENSED IN TENNESSEE.VIRGINIA 5 NORTH CAROLINA

MOZ-WELL
MECHANICAL CONTRACTORS October 9, 2000
North Carolina Dept. of Environment &Natural Resources
Division of Water Quality
Ground Water Section
Asheville,NC
Attn: Ms. Tina Parsons
Re: Newland Elementary School,Newland,NC
Permit Application to Construct Wells for a Heat Pump System
Details on existing wells within or near 1000'radius from site per Braswell Well Drilling.
Property Owner Well Depth Water Zone Volume Rock Type Casing Depth Grout
Dorin Robbins 500 ft. 460 ft. 8 GPM Med.Hard Sandstone Approx.50 ft. 0 ft.
Margaret Mortimer 300 ft. 260 ft. 30 GPM 72 ft. 20 ft.
Martitia Mortimer 300 ft. 125 it. I GPM 8o ft. 20 ft.
Marie Bledsoe 125 Fr. 5 GPM Approx.30 It 0 ft.
US Textile 300 ft. 200 to 250 ft. 80 GPM Blue Slate 80 ft. 20 it.
In reference to item #10 of UIC Inspection comments, items that may be considered
potential pollution sources in the area.
1. Sanitary sewer lines on school property and city sewer lines.
2. 3,000-gallon temporary fuel oil tank above ground just outside the school's boiler
room. The tank is double wall, the outer wall serving as secondary containment
and is provided with an anti-sypon valve.
Please give me a call if you have any questions or need additional information.
Sincerely,
PIS �. 4J<,
Sam Shanks
Project Manager
SS/kiw
cc: Mr. Mark Pritzl, Groundwater Section, Raleigh,NC
r
136 East Elk Avenue • Elizabethton, Tennessee 37643 • [phone] • [phone] • Fax [phone]
LICENSED IN TENNESSEE,VIRGINIA&NORTH-'CAROLINA

Cr
!L w
MECHANICAL CONTRACTORS
136 East Elk Avenue
Date: Elizabethton, TN 37643
Time: wr,
[phone]
To: Nc. �61c"17 Fax: [phone]
Atten: 9s. PPse7�s
From: S)q" sPAt411,s
Number of pages, including cover sheet: z
If you do not receive all pages, please call as soon as possible.
MECHANICAL CONTRACTORS
136 East Elk Avenue
Date: (o-c(-o--0 Elizabethton, TN 37643
Time: i i :�s am
[phone]
TO: n)c, ofJ'l. �F f-NY(BK^1, &- � Gew'w G)4;ie s ue✓ Fax: [phone]
Atten: thR, rnRlzK PALL
From: .SA,4t -sPAilKs
Number of pages, including cover sheet: 2-
If you do not receive all pages, please call as soon as possible.

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
lId17'ttyy��aa A!✓��S 19 September 2000
To: fVlarkNrITzl H P4L VCSSt31 - /� vc�i
Er✓e)CG'1
UIC Group, CO cf(`►.gsl. 4o2y
Through: Landon Davidson
Asheville Region Supervisor
From: Tina Parsons
Hydro olo i ville Region
Re: UIC Inspec ion tor Newland Elementary School
I have reviewed the UIC application and visited this site on Monday 18 September 2000. I
have the following comments:
�1. Applicant needs to supply a complete area schematic to scale showing all the details of the
construction layout.
-2. Applicant needs to supply a working schematic of the HVAC system, properly labeled,and
indicating those parts that are to be in contact with the groundwater.
✓3. Applicant needs to provide the results of mechanical integrity tests including a description
of the test(s)and the method(s) used. 7 PRtDti 7D =NTec:Mw4 I ,4PTVIrL 1PSTp�L ti�i`. _t
"4. Applicant needs to supply complete information, specifications,and schematics of all test
oe'e� wells on property.
�aI rA'P' 6. Applicant needs to supply name,address,and details of all groundwater users identified in
the area.
"7. Applicant needs to indicate property owner on application.
v8. Applicant needs to supply boring logs for test wells.
_ 9. Applicant needs to indicate the construction details of injection wells in well field.
�10. Applicant needs to identify all potential pollution sources in this area. Please identify on map
of area and provide name and addresses of source.
11. Is this area part of federal Indian lannds? l I Q�(t
(y'"-�n- . , �,�cr� �1— " �
Please see file 6/6W/Datal6l5projects/UIC/uicnewland and l/6W/Data/UlClnspection Pictures
for complete details D �Ct1,40 - sa'f --
rt"O'Cy - Z�
11 , Zo c7d 7-IP�, N�6nF `'e"S/7't POl1'IpiCJP1 ti
S1trUNr7 "?dj ` PI(�M, ` A:-e- pcc ffSAi'
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3

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industry requires a piping material wn:c- :=s Oriscopipe 5300 is inert to most chemic_
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Performance-proven Oriscopipe 5300 -Guard performance of Climate Guard.Dnsc::::e
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it the unqualified choice for either vecca :--:nzontal Assured Longevity
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You benefit from the thermal
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The relative thermal efficiency of vancus = als is Climate Guard.These outstanding ccaases
expressed by their respective k-values.=.r-=er combined with the heat fusion methcc cr=-r_ar-
k-value reflects greater heat trans=r cue i:— Phillips Oriscopipe's commitment to cua.::r:._::ce a
Driscopipe 5300 Climate Guard provides ectional piping material which offers oerfcrmanc
heat transfer capabilities when comcarec:::e longevity in earth coupled heat pumo a::.=— ,is.
average k-value of other thermoplastic.-a: = . The security of a Climate Guard system:s:—:ed'by
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various thermoplastics are listed below:
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Polybutylene 0.125 Carefully inspect the pipe to detect ar;::_C_e
Oriscopipe 53ooClimate Guard . . . . . . 0.225 that may have occurred during shiccirc -a
'expressed in STUH/ft-'F result of excessive abuse at the job site_
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P-ooertv �^�'•t n ten Units Nominal Values
Material Designation PPMIIASTM - PE3408
Material Classification. ASS 0-1248 - III C 5 P34
call classification A= 0-3350 - 345434C f
Density (3) AS_3 0-1503 gmsits) 0.955
Malt Flow (4) ASTS D-L238 qa/10 min 0.11 1 2.16 kq..0
Flex Modulus (5) ASM 0-790 psi 135,000.........a
Tensils, 5tr. (4) AS= 0-63a psi 3200............+
ESCt (3) AS= 0-1693 F , Mrs F,> 5000
NOB i 73°r (4) AaT+ 0-2837 psi 1600
O-V Stabilizer (C) AST)f O-1603 %C 2.5
Hardness A=,0-2240 Shorn •0• 65 .'
Compressive Strength
(Yield) AS= D-695 psi 1600
Tensile Strength 8 A:�C D-638 _
Yield (Type IV Spec.) (:- sin) psi 3200
Elongation f! Yield Aim 3-638 1, minimum 8
Tensile Strength !
Break (Type IV Spec.) A5=! 0-638 psi 50200
Elongation i Break .lid 3-638 i, minimum 750
Modulus of Elasticity A.S^t 3-638 psi 130,000 v
ESCR:
(Cand A,B,C: Mold. Slab) D-1693 F„Hrs P>5000--
(Compressed Ring (Pipe)) AS-n! ?-1248 Fla,Hrs F54>1000
Slow Crack Grawth Ba=ilia Method Days to Fa>64
Failure
Impact strengths (2200) ASS 0-256 In-lb/in
(.125• TIM) (Ms_cd A) Notch 42
.Linear Thermal
Expansion Coef. A___= D-696 in/in/•F 1.2 X 10'4
Thermal Conductivity AS= C-177 BTU-in/ 2.7
Ft:/hrz/•F
Brittleness Temp. ASS 0-746 °r <-180•F
Vicat Soft. Tom 0-1525 °F +257
Heat Fusion Cand. - psi 8 OF 75 Y 400"?
+ This list of Typici Physical Properties is intended for basic
characterization of tta pipe, and does not represent specific
determinations or sp.c• at!ana.
•• Tests were d!scont!.-ued because no failures and no indication of stress
crack initiation.
p Average Melt Index Vase with a standard deviation of 0.01.
Average Tensile Stress at Yield with a standard deviation of 150 psi
• Average 7lsxural.Modi:.s with a standard deviation of 2000 psi
Phrleps 0nscoplae.Inc.(heremaner called-Pnillics 0:tscopce7 1..Phrllias O0=13,00 will replaCe free of Charge and 5W
warrantsas Onscoeioe t 5000 Climate Guard-pipe anc 3-g prepaid•a quantity of new Onscoai0e 6=C2mwe Guam:pica, ..
for a period of 50 years against rust.rot.Wx.roryoc�.,ra or tubing equal to mat proved to be defecti
defects in workmanship and materials when utilized anti rsauea 2. Phillips Onscopme will pay all direct labor Ghtargelup
ur.' s; aS.3Z
io closed Iwo earn coupled water source heat po syn per linear toot mcurred on the too site in removing Me
accordance with ine,nuallanan guidelines poorer in cx pipe or cubing•and replacing the same will new Orappx
brochure.This warranty applies only to 0nscopiceS70QCrate 5=Climate Guard pipe or nutting. . .
Guard pipe and tubing.It does not apply to any luson[xgCESSar
other memos or device used to loin the pica or tutvg.Wi�m Suess cle anger an applicable
shwa main goodsPhillip it quesa e-
aces it apply to the design and installation of me system or=ary Me
.sales order aria epplfcanti to the sp thes, goods n CaapL
athercomponent at the system. the foregoing n or oral.
are in Ilea of as other eaareawama0t¢
whethfair to on tua oLIn rhoeventshoor=ns4gLwdpips.lepm
4ynen installed and utilized as indicated above.Pnnfies liable lw bss of use orother!rxidMW wtmnsegwrsat carages
Onscceipe will.if its 54100Climate Guard pipe cr.ruzisng ram 4o whether or rot caused try w resulting from use of ClieQNipeMW
50 years from me date of purcnase.supply me Ipildweg=y Climate Guard pipe or tubing.whether used sing Will
anginal purchaser combination with other producm or materials.Same sees dva
allow mis axwuswn,so it may nor apply!d you.not warrants
gives me purchaser specific legal rights and there may be oli
rights which vary from state to state.
To Secure Product Information or Leave a
Message for a Sales Engineer orTec^ri m Phone:
Service Representative: U.S.Domestic Toll Free(800)527-0662
Malt: TWX: Fax:
Attn:Customer Service Department 910-867-4818 214-783-2689
P.O.Boo North
Central
p�=CS WITH
2929 North Central Expressway Fx)wtn
Suite 100 D/1UMn T>r1 unn e ,

BALL
ZZ
777W - .
z �
sr _a�T Y . UNION
T�( C'AL -HEADER DETAIL
, .
Nor . A �` srArnlisss sn
- s_>:,BRAIDED"HOSE
WELL BORE
._..l -1
_ LLJ
uj
HEADER TRENCH - - w
SUF
�r Z co
SAND BACKFILL ;I 6" MIN.
OT T(
SUPPLY HEADER -
RETURN HEADER
TO BE REMOVED - -
CONCRETE OR
N
BENTONITE PLUG
BORE HOLES ARE 1166- '
--- ": F7 OR THE DEPTH AND
NUMBER/OF.BORE
U-BEND ASSEMBLY' - t HOLES SPECIFIED BY -
USE 'DRILL CUTTINGS OR .SAND =; - A CERTIFIED CALCULATION
FOR GROUTING. USE BENTONITE _-„" •. FROM. THE GSC INSTALLERPLUG WHERE REQUIRED FOR 5'=I; BASED SITE ,SOIL '
AQUIf1ER PROTECTION - - - CONDITIONS AS TEETER
.
B RE :`HOLE PIPING- DETAIL
.. 1`l.. � ° F .. I c:. + . . .I. .__ 'i:.. {. .._x .. Y. . . .'7.1'. �1."t - -. _.e-�-t•r}L2� �...

C_ Coordinate the laying of header piping with existing utilities,new mechanical and electrical
utilities.
2. INSTALLATION OF PIPING:
—� A. - Install piping in accordance with manufacturer's written instructions.
B. The pipe and pipe fittings tm:st be joined using socket or butt heat fusion process. No other
method is acceptable. Exer_ise extreme caution to completely remove the cutout material.
Bell reducer fittings shall be used at all pipe reductions to eliminate trapped air_
C_ Avoid sharp bends in pipin_installation and install elbow fittings if necessary.
D. Connect geothermal water pining through to flow header center manifold in the mechanical
room. Manifold to be provided by the Mechanical Contractor.
3. TESTING AND CLE.-5LND�G:
A. Cleanliness: During installation,trash, soil, and small animals shall be kept out of the pipe.
Ends of the high density polyethylene pipe shall be taped or capped until the pipe is joined
to the circuit.
B. Pressure Testing: Each polyethylene loop assembly shall be pressure tested prior to
installation. Testing shall be by air or water pressure, at up to 100 psi for a mini um of half
hour. Results of all tests shall be recorded and supplied to the Contracting Otncer upon
completion of the Project.
C. Cleaning and Operation Tasting:
1) , Cleaning: Flush systems and apparatus upon completion of pressure and
miscellaneous tests_ Completely open valves and flush each system with clean water
prior to any chemical cleaning. Repeatedly flush at short intervals until twice the
system water capacity has been flushed thoroughly. Chemically clean system
immediately following flushing operations. Circulate a solution consisting of
trisodium phosphate, in a proportion of one pound of chemical to ever:50 gallons
of water in the system. Completely fill system with cleaning water solution; vent
system and place in operation with automatic controls operating and valve fully open.
Circulate the solution through the system for a minimum of 4 hours; immediately
drain system and flush with clean water until the PH at the farthest drain match the
clean water input. Deep strainers unplugged during cleaning operation.Refill system
with clean water.
15513-7

E w b a n k
and associates
GEO SYSTEMS PROFESSIONALS
P.O. Box 1¢8,Fairview, Okla:�.+nta 73737 Phone/Fay 580-227-3352 E-mail ewtiank^fain�ewok.net
Thermal Conductivity Test Results
Newland Elementary School
Newland, North Carolina
Earth Energy Engineering perfb a thermal conductivity test at the Newland Elementary
School in Newland, North Caroiira on November 10, 1999. Testing was done by Bill Nagle with
a Ewbank portable test unit.
The test borehole was 275 feet :n =pth and 6" in diameter. A 1" inch loop was insta''ed and the
borehole was backfilled with =S stone. Static water level was not reported. The for-=_tions
encountered were primarily hard -�-it with 17 feet of overburden.
The thermal conductivity (k) values for this borehole is 1.7 btu/degree F-hr-foot. This is an
average conductivity per foot for-e borehole. This value represents the rate at which the
�. T o accurately measure the thermal conducti
borehole and rock will transfer hevity of the
formation a borehole should be driled and grout with a bentonite grout to prevent any flow of
water through the borehole.
All test equipment, methods. p.-oc=dures, calculations, and interpretation is done in accordance
with the recommendations and __'delines of the International Ground Source Heat P-mp
Association.

e �
Drill Log for Newland Elementary School
Hole # 1 Hole #2
West end of field Eastern end at bail -field
27 ft PVC casing inserted and remo•:=_d 56 ft PVC casing inserted and removed
From To Material GPM From To Material GPM
ft ft ft ft
0 17 Sandy clay 0 2 Topsoil
17 48 Gray flinty rock soft 5 10 Rock layer
48 52 Broken 40 10 28 Clay & gravel
52 285 Gray flinty rock hard (granite; 28 80 Sandstone
80 81 Water 25
Total water make 40 80 295 Gray flinty rock hard (granite)
Total water make 25

o6me
IT1ail
Iu
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It . 'tits A"-Iq is r4dV eri f7cp6#4j(— If4owN cmrjhs
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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 DATE : 9.18.00
NAME OF OWNER: Avery County Board of Education
ADDRESS OF OWNER 75 Cranberry Street,Newland,NC 28657
Contact. Bob Tatum,Superintendent of Schools
828.733.6006
(Street/road or lot and subdivision, county, town)
LOCATION OF INJECTION WELL(and source well(s), if applicable:
Newland Elementary
750 Linville Street, Newland, NC 28657
Contact. Mrs Meg Julian
828.733.4911
(Street/road or lot and subdivision, county, town, if different than owner's address,plus description of location on site)
Potential pollution source : unknown, not enough data Distance from well
Potential pollution source 'Distance from well
Potential pollution source Distance from well
Minimum distance of well from property boundary : <100,
Quality of drainage at site: unknown, no soil tests available(goodadequatepoor)
Flooding potential of site: hi-mod (high,moderate,low)
DRAW SKETCH OF SITE (Shaw property boundaries, buildings, wells,potential pollution sources, roads approximate scale, and
north arrow.)

F
o,,'Ui ij%_1 r,;r I If:, C)1 %111-11,Wk" tA,O
Qj 1:1
I I
1,01G GI 19 1 i rif)(TI r01!L.r
A pa
CA 'If i".:).c iO,�!
,K_Y-* Il'S'16 13
Yr
_JE�v D
C T `V I
.1 �AE
,mlTqm;,l

o(y1t
fJ
,( 6 wl• v.• . � � Neand to ert �
9 j 1f l
'I.r \ i �� • 111 Newland Elementary
1J Well Field
J o• o
F \1
\ U.S.Textile Co !�
.� ter— • • \ I . `� f 1 .W'
DESCRIBE INJECTION SYSTEM (vertical closed loop, uncased borehole or cased water well;separate source well and
injection well;combination source and injection well;or other description as applicable)
Final construction unknown. Injection system, as described by applicant will be vertical closed loop. Site to have
55, approximately 316'deep holes to be used for heat exchange to cool system fluids only. System fluids will not
be in contact with groundwater unless leakage or breakage of system lines occurs.
INJECTION FACILITY INSPECTION REPORT -FORM B(CONTINUED)
WELL CONSTRUCTION
Date constructed : 3 test wells constructed, no well records provided
Drilling contractor: Name: Braswell Well Driping
Address
Registration number: 2133
Total depth of well Total depth of source well
(if applicable)
Inspection point Measurement Meets minimum standards Comments
Yes No
Casing
Depth
Diameter

Q"Sf;11 Lili:i•'li JIG' : ' .il W!WRIV a%IOf';il.gA t rii i'P6OQ
.d:>:;,; t�=itii �.i , : �, - -- ,_ t �� qr•i}•�, ;;a 'rsrr,r.G 7'.fs: -- --- - '
}
P nl.:(i; ja`v ., 1 . .. ,.Or., a"ili . %1.0 • •St ['. `�' ..•'tt1'1 '
A C.`-a r,6`.•A 0TO 'r, L 130 (+�t�} r; .st.i yr ci,
�F. t1: �iSi i(tbi, ; :_1 ,. i•'.\?Si:;•ice .., . i!'tSlf:r� ;',iPiai�: .:4'i)S.".C'..tt;',:, (��:.ithr`. 'iaiS-. :dC t.-iil�.
not (iS:i G.: io , }o•L ,lvq G, t onTh o irdf}', d r:,i:' ;i'itC1 t^s+�i„1)1.7.i\>.�'•'..i i'i9 .',.fit '••.li
0:�'.:Q.�i.' �"Ver-,i.a!')tl Ji '.t:, l: y� ^.iF2C _'.}(a; i,l. ;-;v'}.fri:'.�\ i:i;l, ' G 1.::il�li`l
Iwo,( i d: t'Cf i:.,V ,,.. �.',i} ,.fir. nic,
`'-'r _� _ .s JL� ,,._ .5� ../�f� tSJ�-/ i' � 7 t� �J •� ,1 t\ �{1.�,\i_,-,,
�+ . 1 '\' `\j � J4J a i� 111•it yr a i "♦,
� f l .ijl
1 i
4 \ (j
'`-�`!Lt �1 1 i �•rAl
L( + e :`1„ I i 4 iV
i ``..�i + , , ! f i l -! .. J ri 1 1 � I 1' � 4• � i
' i �...i j, j �i•�• "i � iYi. .. . _c�• t i i./I �ft j j1J: "J I . \-�-�.;
,

Grout
Depth
Screens
Depth(s)
Length(s)
I.D. Plate
Static water level
Well yield _
Enclosure
Enclosure floor _
(concrete)
Sampling port
(labeled)
Water tight pipe entry
Well enclosure entry _
Vent
Functioning of heat pump system (Determine from the mvner ifheat pump functionsproperly.)
INSPECTOR Office
WITNESS Address
WITNESS Address March 1998

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
19 September 2000
To: Mark Pritzl
UIC Group,CO
Through: Landon Davidson
Asheville Region Supervisor
From: Tina Parsons
Hydrogeologist - Asheville Region
Re: UIC Inspection for Newland Elementary School
I have reviewed the UIC application and visited this site on Monday 18 September 2000. I
have the following comments:
1. Applicant needs to supply a complete area schematic to scale showing all the details of the
construction layout.
2. Applicant needs to supply a working schematic of the HVAC system, properly labeled,and
indicating those parts that are to be in contact with the groundwater.
3. Applicant needs to provide the results of mechanical integrity tests including a description
of the test(s)and the method(s) used, prior to injection,after installation.
4. Applicant needs to supply complete information,specifications, and schematics of all test
wells on property.
5. Applicant needs to supply name,address,and details of all groundwater users identified in
the area.
6. Applicant needs to indicate property owner on application.
7. Applicant needs to supply boring logs for test wells.
8. Applicant needs to indicate the construction details of injection wells in well field.
9. Applicant needs to identify all potential pollution sources in this area. Please identify on map
of area and provide name and addresses of source.
10. What is the percentage of propylene glycol to potable water in the system?
11. Is this area part of federal Indian lands?
Please see file 616W/Data/6ISprojects/UIC/uicnewland and 616W/Datalurcrnspection Pictures
for complete details
Post-it®Fax Note 7671. Date i p A.o o pages Z
To From
CoMept Co.
Phone# T Llo Phone# LSk.U? ()?) AkZ03
Fax# `�L3 Fax#
S4 S `��`3

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
6 October2000
To: Mark Pritzl
UIC Group, CO
Through: Landon Davidson
Asheville Region Supervisor
From: Tina Parsons
Hydrogeologist- Asheville Region
Re: UIC Inspection for Newland Elementary School
I have reviewed the UIC Application and visited this site on Monday 18 September
2000. I have the following comments:
Injection system, as described by applicant, will be a vertical closed loop Earth
Coupled Heat Pump. Site will have 55,approximately 316' deep heat exchange wells
to cool system fluids in pipes only. System fluids will not be in contact with
groundwater unless leakage or breakage of system lines or joints occurs.
Mixture of propylene glycol to potable water used in the system is 30:70, or
approximately 30%glycol. Glycol is food grade and poses no threat to human
health or the environment.
Applicant still needs to provide details and schematics of possible receptors,
contaminant sources, & complete detailed schematics of heat pump system.
Applicant provides no geologic control except for the two test holes on site.
Applicant should address this somehow and indicate groundwater flow directions.
Applicant needs to address flooding issue with site. Word of mouth history
indicates no flooding events, but applicant should check USGS & DWQ stream
gauge data for confirmation of said history to insure system well heads will not
act as conduits for contamination during flood events.

° i ; � HILE ��
,r fY NOI2TM CAROLINA bEPAR7MENT OF
r" ENVIRONMENT AND NATURAL RESOURCES
1
Aski lt-LE REGIONAL OFFICE
�m
1 AME6 UNT.III
41 DIVIsION Or WATER QUALM
.I C3 H .�,
1 12iOVERNOR GROUNDWATER sECTION
6 October 2000
• f t
nfcia v To: Mark Pritzl
^� UIC Group, CO
Through: Landon Davidson
Asheville Region Supervisor
i g { /
ro Front Tina parsons C
+ Hydrogeologist- Ash We e Region
R8: UIC Inspection for Newland Elementary School
I Have reviewed the UIC Application and visited this site on Monday 18 September
;r 2000. I have the following comments:
y.
Injection system,as described by applicant,Will be a vertical closed loop Earth
Coupled Neat Pump. Site Will have 55,approximately,316' deep heat exchange wells
to cool system fluids in pipes only. System fluids Will not be in contact With
groundwater unless leakage or breakage of system lines or joints occurs.
w Mixture bf propylene glycol to potable water used in the system is 30:70, or
approximately 30% glycol. Glycol is food grade and poses no threat to human
health or the environment.
v Applicant still needs to provide details and schematics of possible receptors,
+ contaminant source's, A complete detailed schematics of heat pump system.
Applicant provides no geologic control except for the two test holes on site.
i Applicant should address this somehow and indicate groundwater flow directions.
t- Applicant needs to address flooding issue with site. Word of mouth history
indicates no flooding events, but applicont should check USGS & DWQ stream
gauge data for-confirmation of said history to insure system Well heads will not
act as conduits for contamination during flood 'events.
* •1 1 l INTERCHANGE BUILDING,69 WOOOFIN PLACE,ASHEVILLE,NORTH CAROLINA 28801
' - 1 PHONE B28-251-6208 FAX [phone]
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER-50%RECYCLED/10q POST-CONSUMER PAPER

Page t of 2
r_ North Caroling Department of Ettvirontuent acid Natural Itesources
Division of Water Qtiality-GrotindWateh Section
P "CONSTRUCTION INJECTION FACILITY INSPECTION
REPORT-FORM A
INJECTION WELL, PERMIT NO. Wl) / DATE / /o.OU
NAME OF OWNER tl j ev,L
ADDRESS OF OWNER S (fvAK l>a 5 ✓re>` Ne.)Iaµd/ Y/CioI81(,,S
UK rtiT 'Vv(J (El 4N{ ' �4�I.1'�CNdbK t' •-7 �JGNGC)I�
PALS• �33 •(nCbCn
(Streetl road or lot and suddivision,county,,torn)
LOCATION OF PROPOSED IrJJECTcIION W/ LL (and source well(s), if applicable)
•� S O L N V' ✓e¢ ecJ bN )
w Yvlvs. Vhe N1, 4K L;r8 . 333. 9l
(Streell road or lot and suddivision, ounty, town,if different than owner's address,plus description of location on si(e)
Potential pollution soutce G(•5• %X F- le_ Como Distance from well
Potential pollution source Distance from well
Potential pollution source Distance from well
Minimum distance of proposed well from property boundary -'- /00
Qttality of drainage at site O je r`Flooding potential of site Mod- 1t
(good,ad Ira e,poor) (high,moderate,low)
DRAW SKETCH OF SITE
(Show property boundaries, buildings, wells,potential pollution sources,roads,approximate scale,and north arrow.)
r
March 98

Page 2 of 2
PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cotit.)
COMMENTS J
,K-t ou5 ✓vd-&,tIiP rsln� 2.d \✓i Cl
b a �• C W Ci Ir°r e to d �o0 1� 0.7 k `//ow� l ICl IIea
'_�-G �-v �to rC. 6J nrrJ r�J(_ 3110* CI� Ia�e1�5 ''-0 x \+htr� tu✓ �D T
e -� uelbo e -I^l-:ca o,-I 511.-- II� IN;cI �i / kal
[4 G rJ/ea/l! S [u1
r I of . G.1 -1 ✓ � 11
O fOV\ 6\`5 T SC 0.l0.\\C O�j Ibl Nor- CO ` I
1 N1Gw•M4-
owr Ar co le t cif>•�e 5c�v.-a \cs ba4� \,, ` o c�lo��.-c.
,V {'lbw �.vf.GlieN�3� .
INSPECTOR
Office tJCpENR�p�4� �UJ - qRo
WITNESS
Address
WITNESS
Address
March 98

t ,f
r
r ,
561

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
October 18, 2000
O�
MEMORANDUM " tea �O
To: Landon Davidson, L.G.
Groundwater Section $
Asheville Regional Office
From: Mark Pritzl I_` . [e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section
Raleigh Central Office
Re: Issuance of a Closed-Loop Geothermal-Mixed-Fluid Injection Well System
(Type 5QM.):
Permit Number WI0100007 to operate 55 wells for the injection of a closed-loop
ground-source heat pump system has been issued to Avery County Board of Education, in
Newland,North Carolina. This is a new permit and the Underground Injection Control
Group appreciates Tina Parsons' assistance with the THOROUGH inspection and review
tasks. Please retain the application and paper work for the ARO-UIC files. If you have any
questions regarding this permit or the UIC program, please contact me at(919) 715-6166.
cc: CO-UIC Files
Enclosures

z' q ..
�� NORTH CAROLINA DEPARTMENT OF
©�y; ENVIRONMENT AND NATURAL RESOURCES
NCID�AENR DIVISION OF WATER QUALITY
October 17, 2000
Mrs. Meg Julian
JAMES B. HUNT JR. Newland Elementary School
GOVERNOR 750 Linville Street ACT --
Newland,NC 28657
SILL HOLMAN
SECRETARY Dear Mrs. Julian:
In accordance with your application submitted on September 7, 2000, we
KERR T. STEVENS forwarding Permit No. WI0100007 for the construction and operation of a ve cal
DIRECTOR closed-loop geothermal-mixed-fluid heat pump injection well system at 775
Cranberry Street,Newland,NC in Avery County.
This permit shall be effective from the date of issuance until October 31,2005, and shall
be subject to the conditions and limitations stated therein, including the requirement to
notify this office by telephone 48 hours prior to initiation of operation of the facility. In
accordance with NCAC Title 15A, Subchapter 2C, Section .0213(h),the well owner is
responsible for submitting a record of well construction within 30 days of completion.
The well construction data for every well constructed for this project should be
submitted on a GW-1 form and this form is enclosed for your convenience.
In order to continue uninterrupted legal use of this well for the stated purpose,you
should submit an application to renew the permit three months prior to its expiration
date.
If you have any questions regarding your permit please feel free to contact me at
[phone].
Sincerely,
mi P+
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
cc: CO-UIC Files
ARO-UIC Files .► e
Enclosures
- GROUNDWATER SECTION
1.636 MAIL SERVICE CENTER, RALEIGH, NC 27699-1636 - 2728 CAPITAL, BLVD., RALEIGH, NC 27604
PHONE [phone] FAX [phone]
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED/10% POST-CONSUMER PAPER

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
Avery County Board of Education
FOR THE CONSTRUCTION AND OPERATION OF AN INJECTION WELL SYSTEM for
the purpose of operating a vertical closed-loop geothermal-mixed-fluid heat pump system. This
system is located at 775 Cranberry Street,Newland,North Carolina, in Avery County, and will
be constructed and operated in accordance with the application dated July 27, 2000, and in
conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and 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 October 31,
2005, and shall be subject to the specified conditions and limitations set forth in Parts I through
X hereof.
Permit issued this the day of , 2000. '
Gi
Ted L. Bush, Jr., Assistant Chief
Groundwater Section
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No.WI0100007 PAGE 1 OF 6

PART I-WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface
cannot migrate into the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each injection well shall have permanently affixed an identification plate.
8. A completed Well Construction Record(Form GW-1) must be submitted for each
injection well, to the Division of Water Quality(Division), within 30 days of completion
of well construction.
PART II-WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight(48) hours prior to constructing each injection well,the Permittee shall
notify the Groundwater Section-Underground Injection Control (UIC), Central Office
staff, telephone number [phone].
PART III- 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.
Permit No.WI0100007 PAGE 2 OF 6

2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances which may be
imposed by other local, state, and federal agencies which have jurisdiction. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
PART IV- PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or
abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater resulting from the operation of this facility.
PART V- OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or
activity not specifically authorized by the permit.
3. At least forty-eight(48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Groundwater Section-Underground
Injection Control (UIC), Central Office staff, telephone number(919) 715-6165.
Notification is required so that Division staff can inspect or otherwise review the injection
facility and determine if it is in compliance with permit conditions.
Permit No.WI0100007 PAGE 3 OF 6

PART VI-INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place
on or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. 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 VII-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 Asheville Regional Office, telephone number(828)
251-6208, any of the following:
(A) Any occurrence at the injection facility which 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.
Permit No.WI0100007 PAGE 4 OF 6

PART VIII-PERMIT RENEWAL
The Permittee shall, at least three (3) months prior to the expiration of this permit,
request an extension.
PART IX- CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose 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 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, 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.WI0100007 PAGE 5 OF 6

(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 IX (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 X- OPERATION AND USE SPECIAL CONDITIONS
NONE
Permit No.WI0100007 PAGE 6 OF 6

i
AQUIFER PROTECTION SECTION r"o CE-"
APPLICATION REVIEW REQUEST FORM
Date: September 19, 2005 o c
cs+
To: ® Landon Davidson, ARO-APS ❑ David May, WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Charlie Stehman,WiRO- S —!
❑ Andrew Pitner, MRO-APS ❑ Sherri Knight, WSRO- S ��
❑ Jay Zimmerman, RRO-APS
From: Thomas Slusser,, Groundwater Protection Unit
Telephone: [phone] /-47Y— Fax: [phone]
E-Mail: thomas.slusser(o),nemail.net
A. Permit Number: WI0100007
B. Owner: AVERY COUNTY SCHOOLS
C. Facility/Operation: NEWLAND ELEMENTARY SCHOOL
❑ Proposed ® Existing ❑ Facility ❑ Operation
D. Application:
1. Permit Type: ❑ Animal ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Remediation (ND)
® UIC - (5QM)closed loop mixed fluid geothermal
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
1. Project Type: ❑ New ❑ Major Mod. ❑ Minor Mod. ® Renewal ❑ Renewal w/Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
® Return a Completed Form APSARR.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO*.
* Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above. /
RO-APS Reviewer: Date: 04 G J�
T�
FORM: APSARR 09/04 Page 1 of 1

OF W ATF9 Michael F.liuslcy.Governor
. �.... Q
\Villiam G.Ross.Ir.,Secretary
NUI'th CJI'Dhlra Delti nnient UI I]Iwhon llent alhl NatUlal RCSUPI'CCS
Alan W.Klimek,P.E.Diredur
Division of,waler Quality
September 19, 2005
Wg Rllian, Principal
Newland Elementary School
750 Linville Street
Newland, NC 28657
Ref: Permit Renewal Application Receipt
Injection Permit W10100007
Newland Elementary School
Dear Ms. Ledford:
YoL-n- renewal application for a permit to use a well for the injection of geothermal heat pump effluent has
been received and is under review. A member of the Aquifer. Protection Section's Asheville Regional Office
staff will be contacting you to arrange an inspection of the injection well as part of the review.
Please contact me at 919-715-6166 or Evan Kane at 919-715-6182 if you have any questions regarding this
transmittal or the Underground Injection Control Program.
Best Regards,
Thomas Slusser
Hydrogeological Technician 11
UIC Program
cc: Landon Davidson, Asheville Regional Office
CO-UIC Files
0IK
NonliCarolina
111'aftin lly
Aquifer Protection Section 1636 Mail Service Center Raleigh,NC'27699-1636 Phone[phone] Customer Service
Internet:hup://h2o.cneslaledle.uS 2728 C'apilul nouleval"d Raleigh,NC 27604 Fax [phone] 1-877-623-6748
Fax [phone]
An Equal Opportunity/Affirmative Action Employer—50%Recycled/10%Post Consumer Paper

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 an QM lls
In accordance with the provisions of NCAC Title 15A: 02C.0200
complete application and mail to address on the back page. j
RECEIVED/DENRI DWO
TO: DIRECTOR,NORTH CAROLINA DIVISION OF WATER QUALITY AWIFER PROTECTION SECTION
DATE: ,20 U SEP 15 ?005
A. PERMIT APPLICANT y
Permit Numbe : Ql DUO v ( (WIo######, listed at the bottom of each page of your permit)
Name: e(N 6,✓D. /L�C� �����
Address:
City: �� �VQ C State: Zip code:
County: Telephone: �� 7��—
B. PROPERTY WNER(if different from applicant) /
Name: v� 4911"
Address:
City. �� State: Zip code: /
County: F17 JenGI Telephone: SP.2A- 73.Y �Odre
C. STATUS OF APPLICANT
Private: Federal: Commercial: State: Public:
Native American Lands:
D. FACILITY(SITE)DATA(Fill out ONLY if a tatus of Owner is Federal,State,Public or Commercial).
Name ofBusinesorr Facility:
./
Address: �/✓ /c1 L� /n�J! ST� �
City ��1f �'� State: AC Zip code:
County: j �� Telephone
Contact Person:�Xeq d�w
Standard Industrial Code(s)which describe commercial facility:
Revised 5/05 GW/UIC-57 HPR Pagel of 3

E. INJECTION PROCEDURE (specify any modifications to the injection procedure since the issuance of the
previous in ection permit)
U/1 �
F. WELL USE Is(are) the injection well(s) also used as the supply well(s) r 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.
(2) NC. State Regulations (15A NCAC, 2C, Section .0200) require the pemuttee 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) 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
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.
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.
Revised 5105 GW/UIC-57 HPR Page 2 of

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 approved specifications and onditions of the Permit."
17
(Sign tore of Well Owner or Authorized Agent)4
G�
If authorized agent is acting on behaf of the well owned✓,, _
please supply a letter signed by the owner S J
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
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Revised 5105 GWIUIC-57 HPR Page 3 of

SEP 1 12000
@roundwate+Section
Ilsheville R al OfF^^
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
September 7, 2000
MEMORANDUM
To: Landon Davidson, L.G.
Groundwater Section
Asheville Regional Office
From: Mark Pritzl KP [e-mail]
Hydrogeological Technician II
UIC Group
Central Office
Re: Request for review of a closed-loop geothermal-mixed-fluid-injection well system permit
application and a routine inspection of Avery County Board of Education's geothermal
injection wells in Newland,NC, Avery County.
1. Please review the application and submit any comments to CO-UIC. Retain the
application for your UIC file.
2. Please inspect the proposed injection facility to verify the location and construction
plans specified in the application and to also verify compliance with NCAC
T15A:02C.0200 standards, using the enclosed Injection Facility Inspection Report (form
B)as a guide.
3. Return any application review comments and the completed Injection Facility
Inspection Report (form B) by September 30, 2000. If the inspection cannot be
accomplished by this date, please inform RCO-UIC promptly. The UIC group greatly
appreciates your assistance with the completion of UIC program activities.
After the permit has been issued and operation is about to commence, the RCO-UIC may request
the ARO to inspect the facility in operation

I
I ;....=..r NORTH CAROLINA DEPARTMENT OF
• ENVIRONMENT AND NATURAL RESOURCES
NCDENR DIVISION OF WATER QUALITY
JAMES B. HUNT JR. +
GOVERNOR
September 7, 2000
BILL HOLMAN
SECRETARY Mrs. Meg Julian
Newland Elementary School
,'750 Linville Street
KERR T. STEVENS , -Newland,NC 28657
DIRECTOR �
= Dear Mrs. Julian:
IYour application for a permit to construct and/or use a well for a"Closed-Loop
Geothermal-Mixed-Fluid-Injection Well System"has been received and is under
_:Ereview. A member of the Groundwater Section's Asheville Regional Office staff will
'cbe contacting you to arrange an inspection of the geothermal injection system as part
`of the review.
FA If you have any questions regarding the permit or injection well rules please
`,zKcontact me at [phone] or Amy Axon at [phone].
r k f ,
y�
Sincerely,
.n
Mark Pritzl
Hydrogeological Technician II
`= Underground Injection Control Program
I-
�Cc: UIC Files
'j ARID Files
GROUNDWATER SECTION
1636 MAIL SERVICE CENTERS RALEIGH. NC 27699-1636 -2728 CAPITAL, BLVD., RALEIO H. NC 27604
PHONE [phone] FAX [phone]
-• AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED/10% POST-CONSUMER PAPER

i
NORTH CAROL INA
DEPARTMENT OF FVVIRONNIENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PU-N1P SYSTEM
Type 5A7 and 5QNI Wells
in Accordance with the provisions of NCAC Tide 15A: 02C.0200
Compie:e arolieation and mail to address on the back page.
TO: DIRECTOR,NORTH CA-ROLL�A DIVISION OF WATER QUALITY
DATE: 7-27 . 2000
A. SYSTEIM CLASSIFICATTON Please check column which matches proposed sy'ster:.
(1) _ Type 5A- •.vexes inject water used to provide heating or cooling for s.:-_crures.
(2) X Type 5QM we'" contain a subsurface system of continuous piping. ;pat is
isolated fron :he environment and circulates a fluid other than pota=a w-ater.
This includes s+_terns that circulate additives such as antifreezes any or=ososion
inhibitors.
(3) _ Type 5Q,V we'.:s contain a subsurface system of continuous piping,
isolated om a environment and only circulates potable water. If you selected
this well type, then complete form GW-57 CL.Notification Of Intent To
Construct A Closed-Loop Geotlterntal-;Pater Only Injection ;Yell Srsrent.
B. PERMIT APPLICANT
Name: Avery County Board of Education
Address: 775 Cranberry Street
City: Netaland State: _xC Zip Code: 286 County: -Am..y-.
�- o
Telephone: [phone]
o<
C. PROPERTY 01;'NER(if differr:t from applicant) —t+
ice.
Name: Mm
to z
Address: w �
City: Sate: _ Zip Code: County: rn
Telephone:
D. STATUS OF APPLICANT
Private: Federal:_ Commercial:
State; Dlunicral: X Native American Lands:
GW-57 HP (Ian,2000) Pa;c i c f
C/i. a E6E9 oN VVdlr: '. i _:; ( ' OE • unr

E. FACILITY (SITE)DATA
(Fill out ONLY if the Status of&xmer is Federal. State,Municipal or Commercial).
Name of Business or Facility: Newland Elementary Grhnol
Address: 750 Linville Street
City: Newland, NC Zip Code: 28657 County: Avery.
Telephone: [phone] Contact Person: Mrs. Meg Julian
F. HEAT PUMP CONTRACTOR DATA
Name: Norwell Comoanv, Inc.
Address: 136 East Elk Ave
City: Elizabethton Zip Code: TN County: Carter
Telephone: [phone] Contact Person: Sam Shanks
G. INJECTION PROCEDURE (Befly describe how the injection well(s) will be used.)
Well field to consist of 55 holes @ 316 ft. deep to be qG as
ground-coupled heat exchanger for a heat pump HVAC system.
H. WELL USE Will the injec'cn well(s) also be used as the supply well(s) for the following?
(1) The injection operatio=.2 YES % _ NO
(2) Personal consumption' YES_ NO x
I. CONSTRUCTION DATA (che`k one)
n/a EXISTING WELL being proposed for use as an injection well.=.Ovlde the d=ta in:
(1) througH(7)below to the best ofyour knowledge.Attach a cow_of Fornt GR--
1 ff ell Conn truction Record)if available.
n/a PROPOSED WELL to be constructed for use as an injection ve 1_ Provide the
data in. (1) through (7) below as PROPOSED construction S bmi:
Form GNy-1 after construction.
(1) Well Drilling Contractor's Name: Braswell Well Drilling
NC Contractor Certification number: 2133
(2) Date to be constructed: Aug-,
2088t. , Oc 5\rumber of borings: 55
Approximate depth of each boring (feet): 316
(3) Well casir.2: Is the well(s)cased? NO
(a) YES n/a If yes,then provide the casing information below.
Type: Galvanized steel Black steel_Plastic_Other(specify)
Casino depth: From ' to ft. (reference to land surface)
Casing extends above ground inches
(b) NO
GW-51 HP (Jan,2000) Pate 2 ref 4
C/2 • � 262q' ON H l5: H LH I ' OE ' un0

(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Ce,:,znr_ Bentonite Y Other(specify) Install 20 ft. of
bentonize grout from boctov
(b) Grouted surface a-d grout depth (reference to land surface): of ditch line and grout
aroundclose�—looppiping: from to (feet). between aquifers as
necessary.
_around well::sing; from to,(feet).
(5) Screens (for Type 5A i wells)
(a) Depth:From n/a to_feet below ground surface.
(6) N.C. State Regularoes r-tie 15A NCAC 2C .0200) require the pe rttittee to .=ac pro.l ions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent (fluid being inje-=red into the well) lines is required. Will there be a faucer on:
(a) the influent lime? yes nano__ (b) the effluent line? yes -/.- no
(7) SOURCE WHLL CONSTRUCTION ENTORNIATION (if different from injection well).
Attach a copy of Fo m GIV-1 (Well Construction Record). If Form GW-1 is =ot available,
provide the data in ca :K(1) of this application form.to the best of your
NOTE: THE NVELL DFJL�I NG=ONTRACTOR CAN SUPPLY THE DATA FOR El T HER EXISTI`Cr OR
PROPOSED'NSLLS It adt$NFORMATION IS UNAVAILABLE BY OTHER�t SANS.
J. PROPOSED OPERATING DAT1(for Type 5A7 wells)
(1) Injection rate: Average (daily)49gallons per minute ( -..)-
(2) Injection Volume: Average(daily) 2640 gallons per day(gpd). (Total volume in
(3) Injection Pressure: Average (daily) 40 pounds/square inch 2j5 stem)
(4) Injection Temperat-e Average (January) 45 ' F, Average (July) 35 ' F-
K. INJECTION FLUID DATA
(1) Fluid source (for Type SA7 wells) If underground, from what depth, formation and type of
rock/sediment unit will':,e fluid be drawn (e.g., granite, limestone, sand, etc.)-
Depth: n/a. Formation: Rock/scditrem unit
(2) Chemical Analysis of So,-Tce Fluid (for Type 5Q.'I wells)
Provide a complete ling of all chemicals added to the circulating heat transf-r fluid:
inhibited propylene glycol
L. INJECTION-RELATED EQU12MENT
Attach a diagram showing the er-gineering layout of the injection equipment and exteror pipmg'r-sbin_
associated with the injection cpermion. The manufacturer`s brochure may provide supplemMtary
information.
GW-57 HP (Jan,2000) Paee 3 9S4
C/5 •d RRHAN V1dWH L6061 'H ' unr

M. LOCATION OF WELL(S) Attach two maps.
(1) Include a site map (can be drawn) showing: buildings, property lines, surface x-ater 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 s_is:en:. Label all
features clearly and include a norh arrow.
(2) Include a topographic mad of the area extending one mile from the property botmLries and
indicate the facility's loca_on and the map name.
N. PERMIT LIST: Attach a list of ail permits or construction approvals that are related to he sit:.
Examples include:
(1) Hazardous Waste Management program permits under RCR\
(2) NC Division of.'.•'ate,-Qt_ity Non-Discharge permits
(3) Sewage Treatment and D:s-posal Permits
O. CERTIFICATION
"I hereby certify', under penalty of law, that I have personally examined and am rniiiar with the
information submitted in this document and all attachments thereto and that. based o- my inqui_-y of
those individuals immediately res onsible for obtaining said information.,I believe that the information
is true, accurate and complete. I n aware that there are significant penalties, including the possibility
of fines and imprisonment, for _emitting false information. I agree to construct. o_ ate; matratn.
repair, and if applicable, abandon the injection well and all related appurtenances in accordance with
the approved specifications and conditions of the Permit.-
A
(Signature of Weli Owner or Authorized.__ent)
Uauthor:_ed agent is acting on behalf of ti:a w?1
please supply a lzuer.signed by rite owner authori=s�=abocc es-_m
P. CONSENT OF PROPERTY Oi'•NER (Owner means any person Nvho holds the fee or other property
rights in the-well beins consn_cted. A well is real property and its consm-clier. on Lnd rests
ownership in the landowner in£:e absence of contrary agreement in writing.)
If the property is o%ned by someone other than the applicant. the property owne,-hereby conse^-s to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the injection well(s) conforms to {•re Well
Construction Standards(Title 15: NCAC 2C .0200)
(Signature Of Property Owner If Different From Applic:ant)-
Please return two c=ores of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
(jW-57 HP (Ian,2000) Pace 4 e
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0 /07/2000 14:53 4204226094 PBS:CHEh1ICALCO PAGE 01
'!o! GREEEEVILLE ar P.Y. 6 S. SaEutY a-uruV a sips D-a v. ,.
Olinsari
. .
OCSAIL NETWORK EIEERGENCY PHONE 1-800-OLIN 911 .
THIS MATERIAL SAFETY DATA SHEET (MSDS) HAS BEEN PREPARED IN COMPLIANCE WITH THE
FEDERAL OSHA HAZARD COMMUNICATION ST9CA0129 CFR 1910.1200.IRIS PRODUCT MAY BE
CONSIDERED TO BE A RAZARDOUS CHEMICAL MIR THAT STANDARD, (REFER TO THE OSHA
CUSSIPICATION IN SEC..I.)IBIS INFORMATION IS REQUIRED TO BE DISCLOSED FOR SAFETY
IN THE WORKPLACE.THE EXPOSURE TO THE COMMITY,IP ANT IS QUITE DIFFERENT.
1 . PRODUCT ID=RTIFICATION
REVISION NO 1
REVISION LUTE 6/03/98
PRODUCT CODE CPEO0642#
PILE NUMBER CPE00414.0010
PRODUCT NAXZ1 PROPTLM GLYCOL
SYNONTMS: PG; Methyl Ethylene Glycol; 1.2-dthydroaypropane
CHEMICAL FAMILY: Glycols
FORMULA: C.H2O,
USE DESCRIPTION: Solvent, carrier, intermediate
OSHA HAZARD CLASSIFICATION: Not considered hazardous per 29 CFR 1910.1200.
it. COMPMEEKT DATA
PRODUCI COMPOSITION
CAS or CHEMICAL 'NAME: 1,2-Propeaedi21
CAS NUMBER: 57-55-6
PERCENTAGE RANGE: 98-100%
HAZARDOUS PER '29 CFR 1910.1200; No
EXPOSURE STANDARDS: 50 ppm (8 hr. TWA) for total vapor and aerosol, 10
mS/cubic meter (8 hr. TWA) for aerosol alone - AIHA
PEEL Guideline
III . PRECADTIONS FOR Sari HAIEDLING AND STORAGI;
DO NOT TAKE INTERNALLY. AVOID CONTACT WITH SKIN,' EYES AND CLOTHING. UPON
CONTACT WITH SKIN OR EYES, WASH OFF WITH WATER.
STORAGE CONDITIONS: Store in a COOL. Cry, volt vsntilat®d place.
DO NOT STORE AT TZKrERATURES ABOVE: 49 Dvg.0 (120 Dej.F)
PRODUCT STABILITY AND COMPATIBILITY
SHELF LIFE LIMITATIONSi 6 months in drums or 12 months in bulk -
Point-lt•Fax Note 7671 Date Paaee�
To from
CO.I ev. Co.
Phone• Phone e
Fa:a Fe:k — -

*03/2000 14:53 4234226094 PBS:CHEMICALCO PAGE 02
?'rat F.31 i S. Safety, e-uruu r•nr w s
70: G.4E3EVICIF
INCOMPATIBLE MATERIALS FOR PACKAGING: Storage in unlined mild steel guy
cause discoloration and alter flavor -"
INCOMPATIBLE MATERIALS FOR STOL&GE OR TRANSPORT: Do not store or ship
with atcong oxidizers as a spill may result in a fire.
IV. PHYSICAL DATA
APPSARARCEE Clear, colorlees liquid
FREEZING POINT: -60 DeB.0 (-76 D S-F)
BOILING POINT: 187.E Deg.0 (349 Dag.F)
DECOMPOSITION TEMPERATURE: No Data
SPECIFIC GRAVITY1 1.04
BL'1_[ DENSITY: 8.66 lbs-/gal
PH @ 25 DEG.C: Not Applicable
VAPOR PRESSURE @ 25 DEG.C: < O.la Hg
SOLUBILITY IN WATER: Complete
VOLATILES, PERCENT BY VOLUME: No Iota
EVAPORATION HATE: No Data
VAPOR DENSITTc 2.62
MOLECULAR WEIGHT: 76.1
DOOR: Slight
COEFFICIENT OF OIL/WATER DISTRIBUTION- No Data
V. PgRSOKAL PROTKCTIVZ EQDIROINT REQUIRSKINTS
PERSONAL PROTECTION FOR ROUTINE SE OF PRODUCT:.
RESPIRATORY PROTECTION: Relpicatory protection net nor mally required.
However, if vapors, mists or aerosols are generated, wear ■ NIOSH
approved respirator it any sxgosure exceeds the recommended eapesure
guideline.
VENTILATION: It vapors, gists :r aerosols are generated, use local
exhaust ventilation to maintain levels to bslw the rs""manded
exposure, guideline. Otherwise, use general exhaust ventilation.
SKIN AND EYE PROTECTIVE EjuIPMEXT: Neoprene gloves and chemical
goggles.
EQUIPMENT 5?ECIYICATIONS (WHE.4 A.P?LICABLE) :
RESPIRATOR TYPE: Not norms:Iy required. However, wear a NIOSH approved
organic vapa:ldust mist respiratory if levels excead
the recommended exposure guideline.
PROTECTIVE CLOTHING TYPE (This includes: gloves., boots, apron,
protective suit): Neoprene
PAGE 2 OF 10 CFE00642#

06/03/2000 14:53 4234226094 PBS:CHEMICALCO PAGE 03
Tee Gt7E�EVIL[E ::Ot ?.B.`6 S. Safety 8-03-00 hffpa P. t o[ iu
.
Olin ' ', . in
VI . PIRL ARID Z=PLOS IOU HAZARD IVTORX&TIOY
FLAMMABILITY DATA:
FLAMMABLE: No
COMBUSTIBLE: No
PYROPEORIC: No
FLASH POINT: 107 Deg.0 (225 Deg.F) Test Mothodt Cleveland open cup
AUTOIGNITION TEMPERATURE: 371 Dv&.0 (700 Dea.F)
FLAMMABLE LIMITS AT NORMAL ATMOSPHERIC TEMPERATURE AND PRESSURE (PERCENT
VOLUME IN AIR)t LEL - 2.61 UEL 12.5I
VFPA RATINGS:
Health: 0
Flamability: '1
Reactivityt 0
HKIS RATINGS:
Health: 0
Flammability: 1
Reactivity: 0
EXTINGUISHING MEDIA: Alcohol leas, car-en dioxide', dry chamiaal, water
spray
FIRE ►IGNTING TECHNIQUES AND COMMENTS- Us* water to cool containers
exposed to fire. See Section XI for protective equipment for fire
fighting.
VII . RSAiViVITY INTOR ATION
CONDITIONS UNDER WHICH IHIS PRODUCT MAY BE UNSTABLE:
TEMPERATURES ABOVE: 218 Deg.0 (425 7e6.0
NECBANICAL SHOCK Olt IMPACT: No
ELECTRICAL (STATIC) DISCHARGE- NO -
HAZARDOUS POLYMERIZATION: Will not Occur
INCOMPATIBLE MATERIALS: Strong oxidizers
HAZARDOUS, DECOMPOSITION PRODUCTSt Carbon dioxide; carbon monoxide
SUSMAXY OF REALTIVITYt
OXID'LER: • No
PTROPHMICt No _
ORGANIC PEROXIDE: No
WATER REACTIVEt No
PAGE 3 OF 10 CPE00642#
4 31i
Wa

QB/03/2000 14:53 4234226094 PBS:CHEMICALCO PAGE -04
To: PEEIET11lE ':ra- ?.B. 5 S. Safety B•03-BO 1.!!pa D• ! ot,la
VIII, FIRST AID
EYES: Immediately flush with large amouwta of rater for at least 15
minutes, occasionally lifting the upper and lower eyelids. Calla
physician at ones. '
SRINt Iaoedistely flush with rater ,for 15 minutes. Mash the contaminated -
akin with soap and water. :f irritation develops, call a physician.
If clothing comes in contact with the product, the clothing should
be laundered before re—ass.
INGESTION: Immediately drink water to dilute. Consult a physician if
e yaptoms develop.
INHALATION: This product is not toxic by inhalation. Rmmove individual
to fresh air.
fE. TOIICOLOGT AND IIZALTR INFORUTION
ROUIES OF ABSORPTION-
Ingestion
YARNING STATEMENTS AND WARNING PROPERTIES
00 NOT TARE INTERNALLY. PROLOfZD CONTACT WITH THE EYES BAT CAUSE
IRRITATION. pROLONCED OR REFEA?ID SKIN CONTACT NAY CAUS9 IRRITATION.
HUMAN. THRESHOLD RESPONSE DATA
ODOR THRESHOLD: No data
IRRITATION THRESHOLD: No data
IMMEDIATELY DANGEROUS TO LIFE CR HEALTH: The IDLH concentration has net
been established for this product.
.SIGNS. SYMPTOMS, AND EFFECTS OF WOSURE
.INHALATION
ACUTE:
No significant adverse effects to health would be expected to occur
from inhalation withnOrmsl •ass of this product due to its low
volatility and vapor prsssurs.
CHRONIC:
There are no known or reported affects from' chronic exposure.
SKIN
ACUTE:
Contact with the akin is not expected to produce appreciable•
irritation. Skin contact way cause transient redness if not washed off
and left on the skin for an extended period of tins. This irritant
effect would net be expected to result in permanent damage.
PAGE 4 OF 10 CHOD6142/

06/03/2080 14: 53 4234226094 PES:CHEMICALCO PAGE 05
lo: GREEISVILLE -`:ra. ?3*.. i S. Safety 8-03-00 1H1ps p- D of le
Olin21111
CHRONIC:
There are no known or reported effects from chronic exposure except
for effects similar to those expecianced tram single exposure.
EYE
Propyleas glycol has not caused amy eye injury in humans or laboratory
animals. However, contact with t-ho eyes may cause transient eye
redness, atingiog, twitching and tearing if not washed out and left in
the eye for an extended period of time. No corneal involvement or
visual impairment would be expaetad.
INGESTION
ACUTE:
Ingestion may cause gastrointestinal discomfort with any or ■LL of the
following symptoms: nausea, vomiting, lethargy or diarrhea.
CHRONIC:
There are no known or reported effects from chronic exposure except
for effects similar to that$ experienced for single exposure.
MEDICAL CONDITIONS AGGRAVATED BY WCSGRE
There are no medical conditions k=-wn to be aggravated by exposure.
INTERACTIONS WITH OTHER CHEMICALS WHICH ENRA.YCE TOXICITY
There are no chemicals known to ons—ce the toxicity of the product.
ANIMAL TOXICOLOGY
ACUTE TOXICITY:
Inhalation LC SO: No data
Dorsal LD 50: > 2 g/kg. (rabbit)
Oral LD 50: > 5 g/kg. (rat)
Irritation: May cause mild skin wd eye irritation free prolonged
acute exposure.
ACUTE TARGET ORGAN TOXICITY:
No organs known to be damaged fry exposure to this product. May Cause
mild eye and skin irritation from prolonged acute exposure.
CHRON:C TARGET ORCaM TOXICITY:
There are no known or reported effects from repeated exposure. _
FADE 5 OF 10 CPE00642.F
c�r:

08/03/2000 14:53 4234226094 PSS:CHEMICALCO PAGE 06
Too GIEEDEVILEE f:a: P.S:6 S. Safety a-oruu IMP& a- a u: •°
REPRODUCTIVE AND DEVELOPMENTAL TOXICITY: -
There are no known or reported affect& en reproductive function or
fetal development from exposure to this product. -
i
Continuous breeding rsprod::eticn studies were conducted using mice' and
rats. The animals vacs fad propylene glycol in their food or water. No
adverse effects on reproductian ware found in either species•
Propylsno glycol has boon tested and was found to be non-teratogenic
in mice, and it demo not affect maternal or embryo-toxicity in sica,
rats, hamsters, or rabbits.
CARCINOGENICITY:
This product is not known or reported to be carcinogenic by any
t referents source including LAIC, OSHA, NTP or EPA.
Propylene glycol has been tested for carcinogenicity in rats and mice.
It vas found to be non-carciaogenic in both feeding study using rats
and in a akin application study using mice.
MGTAGENICITY•
This product is not know or reported to be mutagenic-
Propylena glycol has been tested in s battery of in vitro and in vivo
autagenicity and gocotoxicity aassys, The weight of evidence from
then assay■ suggests that ?"Pylons glycol is not mutsgsnic.
AQUATIC TOXICITY:
❑oldfish (Carassius auratus) , 24 hr. LC 50: > 5000 mg/1
(measured, static)
Rainbow trout (Selma gairdneri) , 24 hr. Acute lethality/mnrtatity
(non-LC50 testing) : > 50,000 mg/1 (nominal, static)
Brine shrimp, 24 hr. LCSO: > 10,000 216/1 (nominal, static)
Daphnia magna, AS hr, ECSO: > 10,000 119/1 (nominal, static)
_. ?L1k"pORT1fTI0M IWOR101TI01I
THIS MATERIAL IS HOT REGCLAT!D AS A LOT HAZARDOUS MATERIAL,
E 1. SPILL AMD LlU►1L11G= PROC=DURSS
FOR ALL TRANSPORTATION ACCIDENTS, CALL CHEMTREC AT 800-424-9300.
REPORTABLE QUANTITY: Not Applicsele
SPILL MITIGATION PROCEDURES: -
Evacuate all non-egmontial paraonnel. Hazardous concentrations in air
may be found in local spill area and. immediately downwind- Utilize
emer aney response personal protective equipment prior to the start of
PAGE 6 OF 10 CPEM42/

08/03/2000 14:53 4234226094 PSS:CHEMICALCO PAGE 07
To: GREDIEYI1lE ' i:a: P'8. fi S. Safety 8-83-80 Mips V. I of LU
Olin NMI .
any response.. R"ove'all sources of ignition. stop source of @pill as
soon as possible and notify apprcpriate personnel.
AIR RELEASE: Vapors may be suppressed by the use of water fog. Contain
all liquid for Croaraent and/or disposal as a (potential) -
he.wdous waste.
WATER RELEASE: This material is heavier than and soluble in water.
Notify all downstream water users of possible
contamination. Divert water flow around spill if possible
and safe to do so. If unable to divert, create on
overflow dam to contain material. Remove with a
vacuum system or pumping device for treatment and/or '
disposal. Continue to handle as described in land spill.
LAND SPILL: Create a dike or tranrh to contain materials. Spill
sateriale may be ■bscrSod using &and or vermiculite. Do
not place spill material@ back in their original container.
Containerize and Lapel all spill materials properly.
Decontaminate all clothing and the spill area using strong
detergent and flush with large amounts of water.
SPILL BESIDOES:
Dispose of per guidelines under Section III, WASTE DISPOSAL.
PERSONAL PROTECTION FOR MIGENCY SPIT: AND PIRE-PIGKTING SITUATIONS:
In ease of fire, use normal fire fighting equipment (including a NIOSN
approved self-contained breathing apparatus: SCBA) .
III . KLSTI DISP05kL
If this product become■ a waste, it D035 NOT most the criteria of a
hazardous caste as defined under 40 CFI 261, in that it does not exhibit
the characteristics of hazardous waste of Subpart C, nor is it listed u a
hazardous waste under Subpart D.
As a nonhazardous liquid rasto, it should be disposed of in accordance .
with local, state and federal reguletlons by incineration.
PAGE 7 OF 10 CP900642#
OL M1i

98/03/2000_14:5.3 4234226094 PSS:CHEMICALCO PAGE 06
To: GRE3EVI'LE .—._..- �:>•: P.S: b S. iifa:y 5-a3-ou r eepa P. a era a� .
CARE MUST BE TAKEN TO PREVENT ENVIRONMENTAL CONTAMINATION FROM THE USE
OF THIS MATERIAL. THE USER OF THIS MATERIAL HAS THE RESPONSIBILITY TO
DISPOSE OF UNUSED MATERIAL, RESIDLES AND CONTAINERS IN COMPLIANCE WITH;
ALL RELEVANT LOCAL. STATE AND FEDERAL LAWS AND REGULATIONS REGARDING - -
TREATMENT, STORAGE AND DISPOSAL ?CA HAZARDOUS AND NONHAZARDOUS WASTES.i
IIiI. ADDITIONAL [EGULATORT STATUS INi0RN11TIOM
TOXIC SUBSTANCES CONTROL ACT:
This substance is listed an the Toxic Substances Control Act
inventory.
SUPERFUND AMENDMENTS AND REk1:TSO1AnATION ACT TITLE III:
HAZARD CATEGORIES, PER 40 CFR 3:3.2:
HEALTH:
Nona
PHYSICAL:
None
EMERGENCY PLANNING AND COMMUNITY !IGRT TO KNOW, PER 40 CFR 355, AFP.Al
EXTREMELY HAZARDOUS SUBST,LYCE - 'HRESKOLD PLANNING QUANTITY:
None Established
SUPPLIER NOTIFICATION REQUIREKE57S, PER 40 CM 372.43:
None-Established
IIV. ADDITIONAL IN70RUATION
MSDS REVISION STATUS: Revisions mach to Exposure standards, Personal
Protective Equipment, Spill b Leak Procedures, and Reference Section
IV, NA,TOR REFSRINCES
1. Ishidate, M., at ■1., Primary Mutagenicity Screening of Food
Additives Currently Used in Japan, Food and Chemical Toxicology,
Vol. 22, No. 8, pp. 623-636, 1984.
2. Hayashi, M., at al., Micrracleu■ Test in Hies on 39 Food Additives
and Eight MiecallaMSOUS Chooicats. Food and Chemical Toxicology,
Vol. 26, Na. 6, pp. 487-5OC, 1988.
3. Bridia, A. L. , at al., The Acute Toxicity of Some Petrochemicals to
Goldfish, Water Research, Vol. 13, pp. 623-616, 1979.
4. Havorth, S., at al., Sa.,M=ella MutaRenicity Test Results for 250
Chemicals,. Envirommantal "tsgsn*si& Supplement No. 1, pp. 3-142,
1983.
S. Majeveki, H. $.,et al. , Accta Lethality and Sub-Lethal effects of
Acetone, Ethanoi, and Propy Lsns Glycol on the Cardiovascular and.
Respiratory Systems of Raiabov Trout (Sal■o gairdneri) , Water -
Research, Vol. 13, pp. 217-221. 1978.
PAGE B OF 10 CPEO0642g
r

0Lsl03/2000 14:53 4234226094 PES:CHEMICALCO PAGE 09
To, GI>EEf5vi10E Fiat. ?.5. 6 S. Safety a-el-U6 1,41pa 7 9 of lu
OlinMATERIAL :
6. Muhn, Renats, at al., Results of tbs Marmful Effects of Selected
water Pollutants (Anilines. Phenols, Aliphatic Compounds) to Daphnis
sagns. Water Research, VOL. I3. No. 4, pp. 495-499, 1989.
7. 4UIRE Database (squstie toxicity), Chemical Information Systems,.
Inc., Towson, MD.
B. Effects of Toxic Chsaical■ on the Reproductive Syatm. American .
flsdical Association, Chicago, IL, 1935.
9. Final Report on the Safety Assonment of propylene Glycol and
polypropylene Glycols. journal of the Asericsn College of
Toxicology. Vol. 13, No. 6, pp. 437-491, 1994.
10. Workplace Enviro®en Cal Exposure Level Guide (HEEL Guide), Propylens
Glycol, American Industrial Hygiene Association, Fairfax, VA, 1985.
11. 3M 1996 Respirator Selection Guide. 3N Occupational Health and
Enviroeaental Safety Division, SC. Paul, HM, 1996.
Additional references aft available upon request.
I
PAGE 9 OF 10 CPE00642j
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Wednesday 02 of Aug 2000, Faxination ->423 543 7109 Page 1 of 4
FAXI Date : 08/02/00
Total number of pages : 4
To : Sam Shanks/ C-W Concentrate From : tph3'
CompanN :
Department
Fax number : 14215437109
Subject:

` t
Wednesday 02 of Aug 2000, Faxination ->423 543 7109 Page 2 of S
MATERIAL SAFETY DATA SHEET: C-W CONCENTRATE Pagers
(000000-000000- -4429) DATE OF ISSUE SUPERSEDES
2/25/2000 IV06/1999
SECTION I - GENERAL INFORMATION -
Chemical Name . Synonyms Trade Name a Synonyms
N/A C-H CONCENTRATE
chemical Family: POrmula Mixture --> I
PHOSPHATE/S-_-GATE BLEND
---------------_-----------------------------------_---------------------------------------------------------_ _-__________-
manufacturer'& Name,
CCRTITIED L.NS, DIV. OP i1Cti CORP.
----------------------------------------------------_---______________
Address:
EC'X 152170
IRVING, TEXAS
----------------------------------------------------____________________:____________________________________-_ ______________
Prepared By: Product Pods Number M.-.eney Phone Numbe_
L 3OYNTCN 442P r72-438-1381
----------------------------------------------------------------------------------------------------------------------_______________
SECTION II - HAZARDOUS INGREDIENTS
THE HAZARDS PRESENTED 3=' 0W ARE THOSE OF THE INDIVIDUAL CO1'0V_4-TS
Chemical Name (Ingredients) Hazard TLV PEL STEL CAS 9
SODIUM TRLPOLYP HOSP FATE PNOC lu MG/Mi 1 I,, M]IMJ 1 NOT F_- '1718_79-4
SODVJM METASIL_lCAT3 PENTAHYDR4TE IRRITANT 2 M./Mi 1 2 M',/Mi 2 NOT ___ 5934-92-U
POLYO.v,YETHYLENE NONYLPHENYL STEER PROSFHAJE IRRITANT NOT SE.. 1 NOT EST. 2 NOT 3-__ 51911-70-1
SECTION III - PHYSICAL DATA
Boiling Point (F). 111A specific cravity
----------------------------------------------------—-----------------------------------------------------_-------__________________.
Vapor Pressure (121 HO): N/A Color: D:=-
Vapor Density (Aix-1): N/A Odor:
----------------------------------------------------_------------------------------------------------------------________________-
PH g 100% : 11 a In, Clarity: =FA='-=
____________________________________________________—__________________________________________________________-_ ______________-
A Volatile by Volume: 1 Evaperatian Rate CHU A/C-11: 11A
H2O Solubility: 0:1.0L TE viscosity: =_14 s
---------------------------------------------------------------------------------------------------------------- _______________-
SECTION IV - FIRE AND EXPLOSION HAZARD
Flash Point Flammable Limit. LEL
N/ W.. -'-
Extinguishing Media
X o--Fuuu X o--ALcollul Funn X <--___ E c__D.Y Cheaicel X <-=•latm Spa' X
----------------------------------------------------_---------------------------------------------------------___—_______________-
special Fire Fighting Procedures: -_
FLREFIGHTu SHOOLD WEAR A SELF-CGNTA:N-Z --- a- 3 __-i:L^US AND POLL PROT?CTIVE ,EAR. EXTINGU:SHLN; IC u:A , _e..__
CECSEN EASED ON THE NATURE OF TLIS SURE =D= +':=_.
----------_----------------------------------------_-----------------------------------------------------------___-__________________-
Unusual Fire and Explosion Hazards,
TIONC NNzC71.
--------------------------------__-----------------
____________________________________________________-_____________________-________
NFPA 704 Hazard Rating (O+Insignificant 1-Slight 2-Moderate 3.nigh 4-Extreme)
1 <--Heal tit t o--FL aiNnabtLlty O A--R-m[via c--5paciel
SECTION V - HEALTH HAZARD DATA
Threshold Limit Value:
NOT ESTAELIERED FOR MLXTORE. 5-3 SECTION :--
__-----------------_-------------------------------—___________________________________________________________________________.
E££ects at Overexposure:
-Acute (Short Term Exposure) OPUSES
5:(^1 CC:ITAC^: CAUSES SEVERE IRiL2ATIGN :ILSING X10 A EERNING SENSP.T:CN. EYE ':ITAOT: .., mEo c V_v
lRR:TATi b SEEN AS TEARING, REG:IESS, AN-1 A - - iEc:AL.AT:-N; CAUSES RESPIRATORY :RRISAF:ON'5E=: A-
.z•_.... aci.._:u.
MRE-
------21G AND SNEEZING. INGESTION: MAY CAUSE ----- _�1 ---- POSSIBLE NAjjSYA,------- VOMITING AND ------ REP..
-Chronic (Long Term ExpOSure)
NO HUMAN CRR;}IL] EFFECTS 7NOO1I. FGGJGAL 'ONZ-=,,t _PRAVATED BY 3XPOSURE ARE PRE-EXISTI'1:, RESPIRATORY AND =F:N
CONOITICNS SUCH AS ASTHMA, EMPHYSEMA, A`ID DERMA^:]IS_ TARSET OEGANS: NONE NNOWN. THERE IS NO PRIMARY RCUT_ -- -TAY
INTO THE ECDY. THE PRIMARY ROUTE OF E%T_SGRE :S SE=!: £G EYE CONTACT-
- --------------------------------------------------------------------------------------------------------------—-----------------
Primary Routes of ------ p
__________________ __ _________________________________________________________________________
Emergency and First Aid Procedures:

Wednesday 02 of Aug 2000, Faxination ->423 543 7109 Page . 3 of 5
MATERIAL SAFETY DATA .SHEET: C-W CONCENTRATE
SECTION V - HEALTH HAZARD' DATA (Continued)
Inhalation.
REMOVE PROM ONE AREA TO PRCSIt AIR. LCEI; FICDICAL A^=r=:1 iP RCLPIMTORY IMITATION DEVELOPS OR LP ➢NORTHING ➢C[CIG'.
DIFFICULT.
--------------------------------------_---____---_---------------------------------------------_--------
-Eye Contact:
IMMEDIATELY RINSE THE EYES WITH WATER. REMOVE A:1Y ?—= LENSES AND CONTINUE FLUSHING FOR AT LEAST 15 MINUTES. HE—
V.. NYN I.I I IS AVAMV TO NNF IINV NINNING (IV'VNV VN'VI J. „1.s4 OV 'INV NYVH ANII 1,111..4 WI.1'M WAI'NN. G: V I..NI I I A'I'V..MVIIICA1.
ATTENTION.
_______________________________________________ . -------____-
-Skin Contact:
MASH LFECTED IRE.".£ WITH LINRCE AMOUNTS CF ' Y'i IP_^--❑ R 15 MINUTES. REMOVE =NT..WrIV".T£D CLOTHING AND EROEE. -]
IZAIDDIATE MEDICAL ATTENTION. TIRED CLOTHING R'O — .—C ➢CFORE HOUSE. '
____ --------------------------_--------------------------
_f- -------_----
-Ingestion:
GIVE 3 TO 4 GLASSES OF 41ATER, BUT DO NOT :ND%_-'_ VOMi_ IF VOMITING OCCURS, GIVE FLUIDS AGAIN. SEEN MEDICAL AI—�__CN
IF DISC'CMFORT SCOURS.
_Notes to Physician:
THERE IS NO 57ECI eFFZC ANTIDOTE. TREAT THE PA7.__F7 STIG`LA3GLLY.
SECTION VI - TOXICITY INFORMATION
Product Contain. Chcmi..l. Listed o. Carcinogen br Pm=ial Cosoinegen Hy'
IM^_--> No NTP--> No '""-->No ACGCI!--> No . CTRCR-->No
SODIUM TRI?OLYPHOSPAATE
ORL-HAT LDSU: 3120 MG/KG 3.
SODIUM MSTASiLICATE PENTAHYDIv TE
ORL-RAT L050: 1153 14CI.,G 3.
:SRN-KMV1 J5n Mj;"4H SVVVNV 3.
POLYOXYETHYLENE NONYLPR-eNYL ETHER PH05P4ATE
NO TCI:ICITY DATA AVAILABLEE
WHEN TESTED PC., PHIMLIay EYE IRRITATICN, S:C=_M ;C`_:v-_LATE PRODUCED
CORROSIVE, NON-REMIESIBLE iNJURY. A 10% W:T_R ? -ODIUM
IU3TAGILLCATC PRODUCED COMICAL OPACITY GILD: 2 — —=UING,
IRITIS GRADS 1-E, CCIIJUNCTIVAL CNEMOZ:C GLC] - -aO=NCLD
GRADE J. A 5, WATER SOLUTION OF SODIUMME_AS=�_._JP_DUCED CORNEAL
CPA:Zrf GRADE 1, IRLTIS GRACE 1-1, CONJU..,.__:A_ __Fn=_ GRADE I-3
AND REDNESS GRACE 3. 4.
SECTION VII - REACTIVITY DATA
Stability: a o--Nr.r bLy o--In s:.pY
Ineompatlbility (Materials to Avoid): - -
ETRONC OXICL2INC ACENTE SUCH AS CHLORINE H_E._E I'__-] ACC..,E SUCH AS SODIUM THIOSULFATZ, 1-IDE PND
----------------------------------------------------—-------------------------------------------------------------_ ___.
Nererdom Deeompos itien Products:
OXIDES OF CARBON. PR'OSPHOROUS AND SODIUM; AMMZNC 3v.
HaZarCOUS POlyAeIiZatiOn:. A--MA y =CC'_ X A--Will Not occur
SECTION VIII - SPILL OR LEAK PROCEDURES
Steps to be Taken if Material is Released or Spilled:
TRANSFER SOLID INTO PROPERLY LABELED CCN^.AINER FCR F-SE OR DISPOSAL. IF NECESSARY WASH AREA WITH WATER AID PICH
WASH WATER FOR DISPOSAL. AVOID CREATING DUSTY COSZ=TC+=. WEAR APPROPRIATE PROTECTIVE CLOTHING.
Wastc Dicpoal Method(.);
DISPOZE OF IN ACCORDANCE WITH .ALL FEDERAL, G.:,E ?.SC KCAL REGULATIONS.
Neutralizing Agent:
NCIIE C1o:RI.
SECTION IX - SPECIAL PROTECTION, INFORMATION
Required ventilation:
LOCAL VENTELATICN I5 RECOMMENDED TO CONTROL EXPOSURE YE-M OPERATIONS THAT CAN GRNERAT2 DUSTY CONDITIONS.
____________
MI,piratory Protection, - ---------------------_----
L NICER/MAIM APPROVED RCOPLRATAOR FOR EXFCSUnO P VC = AOGIR TLV OR COCA PEL OR WHERE SUITING EXISTS.
Glove Protection:
NEOPRENE OR NITffiLE RUBBER GLOVES SHOULD BE WORN.
_______________________________________________________________
Eye Protection: ,
CHEMICAL GOGGLES SHOULD BE .WORN.
----------_-----------------------------------_----------------------------------------------------
Other Pretaction:
WEAR PROTECTIVE CLOTHING 1IIIEN HANDLING. ,

Wednesday 02 of Aug 2000, Fax?nation ->423 543 7109 Page 4 of 4
MATERIAL SAFETY DATA SHEET: C-W CONCENTRATE p'9"e '
SECTION IX - SPECI-AL PROTECTION INFORMATION (Continued)
SECTION X - ST-ORAGE AND HANDLING INFORMATION
Storage Temperature: EadGo:O--> X - --4HCatcd--> Rc_`r_3__arcd-->
Mlnlxl. T ceratu l-: 35'F Ma.imum Ter ce_..___^.
----------------------------------------------------_---------------------------------------------------_____
Precautions to be Taken in Handling and storing:
ALWAYS STORE MATERIAL IN -Is oRIGrv.l' (LIN7A:N-9. P _:`.-AINER TIGHTLY CLOSED WHEN NOT IN USE. SEEP AWAY ?RCM DANF
CONDITIONS AS :HIS PRODUCT WILL CASE.
-----------------------------------------------__-_--------------------------------------------------------_-
Othar Precautions:
KEEP CUT OF BEACH OF CHILIREN. READ THE ZS7:RE LAPEL —ZRE USING THE PRODUCT. FOLLOW THE LABEL DIRECTIONS.
SECTION XI - REGULATORY INFORMATION
Chemical Nam. CAS Number r t Limit
Man-
-----------------------------------------------—- --------------------------------------------------------__ _____________.
Tlws- LRgl-dim¢s list':) aLuve dLr subjaec - - P_ay I-yuil-nrcncs O1 3/3 Of Title III u1 rh- S_r IfmuJ
&landralms cold R-a.tll.l!rrtiOH A" of :. e.... _ -_ c 372.
-----------------------------------------------_---_--------------------------------------------------------—_ ____-__-_-___.
ul u,a 54 Call 1-RnD_9)]-ou1P rnr ynu aV? d Calllnrn la nn scams r.
This KEEP is not 1nt?nd9d tar USPIs -'- _... _ __ .=__D_ -a.
SEC_iON XII - REFERENCES
1. THRSSHv-`-D LIMIT VALUES FCR CHSKIICAL 5,____,.=_e __ R_.L.'IICAL EXPOSURE
INDICES, AC3:9. loop,
1. OSHA PEL.
J. RECIETRY OF TOXIC EFFECTS.IF OPEN-C:_ E. _._=C, - FCD ice, 19nn,
4. VE::DCR'o MED'e.
ALL CCMFCNLNT5 IN THIS FRCDUCT CAN DE ^_..] _. .__ ____:' T=A INVENTORY.
----------------------------------------------------________________-_
IRR:IRRITAlIT, V:C, TLA.MM:X:-Z, N/A:r COM3:__!C___ :R:COR¢OSLVE
CARULARCI`IOGEN Z, TO%:TO%"], N/A:f:OT
CCC:CLEVEL.0.`IL OPEN
CUP,
v,1A IA I Q J ' , __:TAG L' T A5VE
X. C)SION I.IMI'I',
NVPP:t9TI I. VINM 0V! I'I R AI'I(IN, : ,NA'. A(V V
THE RESEARCH CANCER, PPP:NATI-,NAt ' =R77-7: " .SH.A:C:CIJPATON
AL
SAFETY i HEALTH
t -_ � E OF GOVERNMENTAL
IAID05"RIAL ? IIENISTS, TLV:THR=SEOLDLIM= _- 3 5L3LE EXPOSURE
LEVEL, STEL,PHERT-TERM EXTCSURE LIMIT, MSDeNC__, H-_e=RATE, EEV.SEVERE,
iADT:MUPhPEt1I E, ALpNY%:ACPHYXIAHT, PUCC: F..R.I]_=:._C OTRDRNISE CLALOI-
FLED
-----------------------------------------------_---_--------------------------------------------------------__ --------------
THE INFORIMTION CONTAINED HEREIN I5 BASED ON DATA ==ERED ACCURATE IN LIGHT Ol CURRENT FORMULATION. HOWEVER. ]O
WARRANTY IS EXPRESSED OR IMPLIED REGARDING THE AC3RL_ OF THESE DATA OR THE RESULTS TO BE OBTAINED FROM THE U:
THEREOF.
CERTIFIED LABS, DIV. OF NCH CORP. as _ no r_ _ __=_ity for personal injury or property damage caused by the use.
storage, or disposal of the product in a Danner not ;emended on the product label. Users assume all risks ,
associated with such unrecommended use, storage, _r — r sal of the product.
----------------------------------------------------_-------------------------------------------------------------__--------------

Wednesday 02 of Aug 2000, Faxination ->423 543 7109 Page 1 of 6
FAXI Date : 08/02/00
Total number of pages : 4
To : Sam Shanks/ WT-1000 From : tphy
Company
Department
Fax number : 142 33437109
Subiecl:

Wednesday 02 of Aug 2000, Faxization ->423 543 7109 Page 2 of 6
MATERIAL SAFETY DAZ1 SHEET: WT-1000 11 Pay._ I
(000000-000000- -0376) DATE OF ISSUE SUPERSEDES' '
1/21/2000 a/12/1995
SECTION I - GENERAL INFORMATION
Chemical Rase A Synonyms Trade Ramel& Synonyms
N/A W-1000
________________________________________________ ---------------------------------------------_---_---_
Chemical Family: Formula Mixture --> T
ALXALLNE NITRITE SOLUTION
-----------------------------------------------____-------------------------------------------------------__
Manu fact...r'x Ram.,
CDRTLPICD LADS, DIV. Or YCII CORE:
-----------------------------------------------___ -----------------------------------------------------_ __-_____-_____
Address:
BOX 1`-2i7U
IRV:N'a, TEXAS
-----------------------------------------------_---_---------------------------------------------------_---____-----____-___.
Prepared By: Product Code Number Emc enoy Phone Numbe:
R STOLLEY/CHEMIST 0375 .71-432-1391
SECTION II - HAZARDOUS INGREDIENTS
THE HAZARDS PRESENTED 3=--DW ARE THOSE OF THE INDIVIDUAL COMPONENTS
Chemical Name (Ingredients) Hazard TLV PEL 5= CAS d
SODIUM NITRITE TOX/IRR NOT EST. 1 NOT EST. 1 - -- _ 15fi-OU-U
SODIUM METAPORATE GPTARYDR4TE IRRITANT NOT EST. 1 NOT EST. 2 - -a-. lUlS D=/e-/
AItLNCTRL(MIETKYLENEPHOBPHCNIC ACLDIPENTASGD::N IRRITANT NOT EST. 1 NET -ES7. 2 N^ S__ 2235_43-0
SECTION III - PHYSICAL DATA
Boiling Point (F), 212 Sp.ciEic Ora.ity (H2O-1), _.E_
_________________________________________ --_____________________________-___________________--_________-_—_____________.
Vapor Pressure CHN HO)I 10 color: .T._ _ ___•.A
-----------------------------------------------_---_---------------------------------------------------_-----_________-_______.
Vapor Density (Air-1): 0.6 Odor: _...C_•_
--------------------- --------------------------------------------------------___________----_.
PH @. 100% : 10.H Clarity' LFA--E
-------------------------------------------------- --------------------------------------------------------__—_________----_.
A..Volatile by Volume: 67 Evaporation Rate (BU A/C-I):. ...
----------------------------------------------------_--------------------------------------------------------__________________.
H2O Solubility: COMPLETE Viscosity: I N'N_V:=-s
SECTION IV - FIRE AND EXPLOSION HAZARD
Flash Point Flammable Limits LEL
NONFLTI4. / EETAFLAZ9 1./A N/A !:/L
-----------------------------------------------____--------------------------------------------------------—_______________-_.
Extinguishing Media
X c--POmn X <--.^.l eulml F^ dm \ c-__i X <--04 ':le!miedl X e-_We eat SUtay X
-----------------------------------------------_--- ----------------------------_--------------------------___--------_____.
Special Fire Fighting Procedures:
FIREFIGHTERS SHOULD WEAR A S'ELP-CCNTAI::ED - _- ' ATRIRATNiS AND FALL PROTECTIVE %.^EAR. EXTIN,UZSHL2i. to O-A FH__- :E
CHOaSEN BASED ON T92 NATURE OF THE SUAROO:1=D: :RS_
________________________________________ _—____________-__________________-_-_________________________________________
Vnum.l Fire .nd Explosion H....do,
UNPON DECOMPOSITION, SODIUM NITR_LT3 RCLEAZ=J CX'iL: 41Av SLIGHTLY IN- CREASE TRC RATE OP A FIRC. C-DIUM !;ZTS=
EX-LODE AT TEMPERATURES GREATER THAN 1000- 7
-----------------------------------------------_---_------------------------------------------------------------_______-______-__.
BEPA 704 Hazard Rating (O-InsigniLicant 1.3119hc 2-Hoderate 3-High Y=Extreme)
2 <--E'alih 1 <--FLATwTB511'ty i <--3eSCc'y'cr OX <--S-.Clal
SECTION V - HEALTH HAZARD DATA
Threshold Limit Value:
NCT ESTABLISHED FOR MIXTURE.
-----------------------------------------------_---—----------------------------------------------------___ -______________
Effects of Overexposure,
-Acute (Short Term Exposure)
SHIN CONTACT:. CAUSES IRRITATLCN SEEN PS C--= '- �55. WIDESPREAD CCNTACT 141TH DAMAGED SHIN CAN CAUSE 5E:5 SRSE
AND EROPTICNS DUE TO BORAT£5. EYE COtITACT: CA SS _=?TLCZ1 SEEN AS TEARLNG R1D REDNESS. INGESTION: CAUSES LRRLJA"Sti
WITH POSSIBLE NAUSEA, VCMITLNG RND DIP.RiH2A. =PaE MAY cAuSE CAUSING CYANCSIS:eLO'a P.:G ^_7
SEIN, HEADACHE, FLUSHED ?ACE, LLGH:-N.EPA'NESS, ADP3='^COORDIINATZC2N1. WEAKNESS, RAPID HEARTBEAT, LABORED
MP. "Al.j2V1 YIItiION, M"INNNII VINIIPI, NXIHIC811 MIGCO t:OMA ANTI u(ItiRIHI.Y IWA'IN. INXAIATION: fJ'INXN
RESPIR4TORY IRRITATION SEEM AS OO:YEZNG AND SNS=N.G_ =Y=ALATION OF LARGE AMOUNTS CAN CAUSE SYSTEMIC EFFECTS SIMLL.AR TD
TROST CAUSED BY INGESTION.
--------------------------------------_------------ --------------------------------------------------------—________________.
-Chronic (Long Term Exposure)
MIXTURE KITH SECONDARY AMINES MAY CAUSE TILE Cdi'.]:]S = NZTRCSAiINCS, WUICR ARB CARCINOGENIC CCMPO@NOS. TARGCT C—�?zSs
LIVER, KIDNEYS, SPLEEN, TESTES, CIRCULATORY SYS"=M —=ICNu^ AGGRAVATED BY EXPOSURE: PRE-EXISTING DISEASES OF THE
t

Wednesday 02 of Aug 2000, Faxination ->423 543 7109 Page 3 of 4
MATERIAL SAFETY DATA SHEET: WT-1000 Pages Z
SECTION V - HEALTH HAZARD DATA (Continued)
SSLN, RSSPIiATCRY AND CAROIOVAHCVLA.R SYSTEM.
______________________________<__-_________________________________________________________________________ -------_----
Primary Routes of Entry: X Lnh nlne'cn s o--_w:r ion X <--AbsoLatlOn
____________________________________________________----------------------------------------------------------- ---_________.
Emergency and First Aid Procedures:
-Inhalation:
4YMVV✓. ✓HCM '1'NY. AN,!A 'I'!1 •'4k.SH Al H. S."\ Mrll l!'p. a 1 I✓ NY'.\VI Yq'I'1!XY INNI'I'q'I'l l!rl IINVNI.1!V8 INN 11 NHM p'�MING M✓I;I:IVT
DIFFD70LT.
_______________________________ _____________________________________________________________________—________________.
-Eye Cantactl
RINSE THL EYED WLTII IIATCI. nEIUVZ ANY CONTACT "_.CCC ANC _INTINIUE :LULIIING WITH PLENTY OP P!ATCR FOR SCVCRAL MINVTZ..
DLCN ITDECAL AT=ITICN IP IRRLTATICN DEVCLJFC.
----------------------------------------------------------------------------------------------------------------_
-akin Contact:
NASH AFFECTBD AREAS WITH ?LENTY OF 5-CAP AND WATER FZA ESL-RAL MINUTES. SEEN M:DEIZAL ATTENTICN IF :RKTATION GEVELr=-S.
-----------------------------------------------_---_--------------------------------------------------------_
-ingestion!
GIVE 3 TO 4 CLASSES OF WATER, BUT DO NOT :NC-:_ V_H_ _F VCMITING OCCURS, GIVS FLUIDS AGAIN. GET UP@DIAT_ M___ --
ATTENTION. DO NOT r.IVE ANYTHING BY MOUTH TO AS :R CONVULSING PERSON.
----------------------------------------------------—------------------------------ ________
-Notes to Physician:
711- BZ]d3TI_11 ZF IIITR'TBS LMT'}THE B tt:• Z-NVERSLCR: C? HEMGGLCBUI INTO MSTAEMCGL:BIN I"F:ICH MAY :a.c`_
Z%.N ICSIS. '..E 3EVER5L0:1 _P METHEMnGLOBIN 3._R 2EH''B-11 CCC!RS 5?CEISANEGUSLY AFTER EXPCSJRE 15 ELrKNAT-0.
SECTION VI - TOXICITY INFORMATION
Product contains Chemicals listed as Carcinogen or E-__ial Carcinogen By:
AN!: > 11 HI'V--> tin (I.tiw 4__> `. P pf;!:I X__> Hn t,l'I'N YN-_>Nn
SODIOM NITRITE
v-PAT LD-O! BSMG/6S
-Y--RBT STANDARD LR.4IZEs^EST. 500 M1/24 H M_C :.
:L-RMN LGLO, -1 MC/ nC 3.
LUL-PAT LC50: 5511 IIG/rN 3.
SCDPIM N TABCRNTE O^_TA'1.1'D?ATE
CRL-RAT rD90: Z330 M-a/RG 4.
ANIMAL STUDIES IiIDICAT2 THAT BORATES REDUCE -- - _ — -__RIR PROOUCTION
CAUSING TESTICULAR ATRO?H:' P.ND WHEN GIvc':1 t'tn- ?4-MACS DURING DEST-
AT:10N, ^_ALL'c ES DEVELOPMENTAL CHANGES. THE.SS - ---A T9= :-NE ::HRONICALLY
a ____
q'1' F.z'VNnn✓. li(Lti YS Irl Nxi:•ri f1Y 'I'Nf1.tiN Ail r•I•:V'r. .• a _'_'-..a" ;!N AI. ✓.z VG.tiIINNti.
OR•-?_AT AND GOG a/Uu PPM: TESTICULAR ATR•OJ—H
C.RL-RAT AND COG 15U0 PPM: PTO TESTICULAR CHANG55 4
yL_HAT 120011 PGM LED TO FETAL MALFO]VT,:Z;n :: _. - TOXICITY 4.
i•RP01 STUDY '` ENPCEURE TO SCR:.TS DUST L.. AN _______.L.+. SETTING SHChED
C AUVCRSE A _ _ 4.
?l1:NOTBI(lizTU'.'LL11-u P[ICDF!i_;IIC 9CLG32CNT?L yell Y
w-SAT LO50: >17,801) MG/X.-. 4., 5XN-RB7 LGSU: 4.
-- --RBT ST?_NSP.RD CRAZES 7E5T: 3.7/110/24 H__RS: M---. -
5R1-RBT STANDARD DRSIZE :EST: 0.3/8.0/24 __ •-____ nIP!G 4.
GHT E'_- __ :N BONES '--TER SV6CnTP.NECJ•5 __. _. .ATS Tnh 7 DAYS
NI�Y .I✓Ill li:Nl! I.1 Vr.I, 1V1. , ANTI zlllrl✓v •Nr lf-r•"'�`
SECTION VII - REACTIVITY DATA
Stability: X <__SaabLz c__Unsraae
Incompatibility (Materials to Avoid),
C^.Atli OES, REDUCING AG GIITS,DUTM LCNC,AI044:P:11 C==7,:C_,F_TIIALI^_ ACIDS, ACIDS, At1IDBG, TUICCYAVATEG MID TiIGLU'L?A:S,
CCMBlSTI3Le
Mazardous Decomposition Products:
OXIDES OF ZAR3:::, NITRJJ_N AND ?HCS P"r"J:aOliS AS :4 -__ ___SFHU125
Razardons Polymerization: r__May Cc_'_. X e—Wlli Not Cceut
SECTION VIII - SPILL OR LEAK PROCEDURES
Steps to be Taken if Material lc Released or Spilled:
DIKE `IID -CNTAZV Ea^^ILL. 139ORB WITH AN INERT K.TER_^.L= RA.NSFER ALL nVERL`E, INTO A PRGPERLY LABELED CONTAINER ?=R
DIDFcDPAL. FREVLNT ?RCOUCT noM CCNTNIItIAT L!:G -:-: _1==M LNTERING CEWAGC MID DRAINAGB 5YETCMG AND DODIEL OP WAT_a-
____________—
Haste Disposal Method(s):
DIS?CSZ OF IN A_CRDAN=E WITH ALL SDE?AL• STN7- AN= _-=.L REGULATIONS.
Neutralizing Agent! -
NJA
SECTION IX - SPECIAL PROTECTION INFORMATION
Required Ventilation,
czNzR:Y tzNrEL9TEGM IS NGRIM..LLY AD-1UATE.

Wednesday 02 of Aug 2000, Faxination ->423 543 7109 Page 4 of 4
MATERIAL SAFETY DATA SHEET: WT-1000 P"qe23
SECTION IX - SPECIAL PROTECTION INFORMATION (Continued)
Respiratory Prot...I...
NONE RE]UIRED UNDER NORMAL CONDETC:NS C. _Si.
------------------__---------------------------_---_------------------------------------------------------
oi.yc Protection:
NEOPRENE OR EITAZLE AUBBER GLOVES IF RCPEATEO ZA : SKIN •.SbTACT Id LIKELY.
--------------------------------------___________-___________________-___________________________________---
�_
Eye FLOt.Gtlan:
SAFETY GLASSES W:TH SIDE SHIELDS IF THE MET-= :: S= P:=SENTS THE LI'n ELLHC00 OF EYE CONTACT.
____________________________________________________________________________________________
Other Protection:
GCOCRP:-CUT:' {JCR:: =7110E.
-----------------------------------------------_---—----------------------------------------------------------__—_______________-
SECTION X - STORAGE AND HANDLING INFORMATION
Storage Tempera Lure: Lndeoca--% X HeA4ed--: Relt:;^.rtGed--%
MIn IIIWl1 TYHLCI atu1 35 F. Manillma: T_._ _..i__.._ 1 F.
Precautions to be Taken in Handling and Storing:
EMPTY :•NTAINZZ CONTAIN PR=JU T RE'- - _ --= HAZARDS OF THE PRODUCT. KEEP FROM FREEZING. I_ ARC___.
..FREEZES ALLOW :. . ELCY.LY. WARM TC .RECM TOM? F8 � STIR. T:i CSOQGHLY BEFORE JSING.
_ _________________________________—_______________________ _________ _______ ____________-
Other Precautions:
GCCF CUT -1 1CA_1. _. _IQLORSN. HEAD _N]..+_ _-'_L USING V12 PRODUCT. FOLLC!v TILL' LABEL DIRCCTIC::C.
-------------------------------------_---------------------------------------------------------------—_________________-
SECTION XI - REGULATORY INFORMATION
Chemical Name CAS Humber Tl A Limit
SODIUM NITRITE ]fill-DD-O !It
-----------------------------------------------_---—_--------------------------------------------------------___—_______________.
'I'h Dd- Ingl-dl-, I1z1-0 ADnPR Aw ol,OjRnl r. -'Rg .gDIr.,,A Ot III OP 'I"11a I.I nr thR tin F!•"::-d
ARRIIdn�Rf_c And NRa,,hr,r17,TT.Ir.n Art D lie- '-I _ .112.
Please call 1-SUO-52I_Pe19 for addia_onAl- you are a California Cusmn.Rr.
This MSDS is not lnteadRd for users is -
SECTION XII - REFERENCES
1. THRESHOLD LLMLT VALUES FOR CHEM:CIC, S._.a.GS =, E:OLOGICAL
£X:Oe'URz LGu=_3E, .=CIH, 1499.
I. CONA EEL.
!. SAX'S GANvERC;S PRCFERTEES C.- ...L.a.a:-_ Y-.-ER_ E:GHTH ED iTIOPI,
RLCHARD J. =W!S, 5R.
4. VENDOR'S MSGS.
ALL CCHPONENT5 I.+ THIS PRODUCT CAN EE ._... _. _ _ __T TS.A :NVENTORY.
-----------------------------------------------_---____________________
AN:INN AMI', ✓I.i X%+I.A611A:YI.AMMAMI.k, !:(:m : ; M- -
CARC:CARCLNC.EN:C, TOX:TUXrC, N/A:Y= APT:'.A='E, N,E:i]T ESTABLISHED,
002-ILEV-LANO Op-1 CUP. Pi4CC:P'SlISriY_FFRT RI C ____ __ __ :TAGLIABUE
CLJSECCUP, LELLAWER EXPLOSION LIMIT, U-L:Wr-R - - :N LIMIT,
MFPA:NATIONAL FIRE PROTECTION - '- =—___NAL AGENCY FEE
_ :M THE REESARCH CN R, NTP .".TCCNA_^'1_>.___ __Y -- CEHAlCCCUPATLCNAL
SAFETY A GEALT11 ACIIINrSTRATLr N, PCI GTti::A]]I_.`I _ '— =' OF GOVERNMENTAL
INDUOT:LAL HYGIENISTS, TLV:THRESHOLG LIMIT VALE, ?' -E?ML3SI5LE EXPOSURE
LEVEL, STEL:SHCRT-TSRM EXPOSURE LIMIT, MLL:M:]C, wiC:TC`RATE, SEV+SEVSRE,
FIUT:FIL!TAGEN CC,ASZH"X:ASPHYXL APIT,2:i:]:?PET__:_?'ES N-_ E3:9ISE CLASSIFIED
-----------------------------------------------___-----------------------------------------------------------___—______________-
THE INFORMATION CONTAINED HEREIN IS BASED ON DATA CDL]]ERED ACCURATE IN LIGHT OF CURRENT FORFM.ATION. HOWEVER, NO
WARRANTY IS EXPRESSED OR IMPLIED REGARDING THE 1'—R3.-+ OF THESE DATA OR THE RESULTS TO BE OBTAINED FROM THE U!
THEREOF.
CERTIFIED LABS, DIV. OF NCH CORP. assumes Do respo._zic__'ity for persenel injury Or property damage caused by the uae,
storage, or disposal of the product in a manner on roccomended on the product label. Users assume all risks
associated with such unrecommended use, storage, er ._,scosal of the product.

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