WI0100044_Complete File - Historical_20220308

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��� � ! RECEI�i�aD
NC ' NR
North Carolina Department of Environment and Na ural ResK*69",' 2G�1
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Asheville Regional ft&fee an
Governor Director A offer Protection Secre ary
August 24, 2011 R
ECEIVE ID
Charles C. Campbell,President `4P Q �.��i l
Campbell Building Condominium Association, Inc.
151B NC Highway 9#185 Regional OfficeBlack Mountain,NC 28711 Aquifer P pta ipn
Ref: Issuance of Injection Well Permit W10100044
Issued to Campbell Building Condominium Association, Inc.
Black Mountain,Buncombe County,NC 28711
Dear Mr. Campbell:
In accordance with the application received on August 8, 2011, I am forwarding permit number WI0100044 for the
continued operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system located at
206 E. State St., Black Mountain, Buncombe County, NC 28711. This permit shall be effective from the date of
issuance until July 31, 2016, and shall be subject to the conditions and limitations stated therein.
Please be advised,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.
In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an
application to renew the permit 120 days prior to its expiration date. This permit is not transferable to any person
without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at(919)715-6166 or michael.rogersAncdenr.gov if you have any questions about your permit.
Best Regards,
Michael Rogers,P.G. (NC FL)
cc: Landon Davidson,Asheville Regional Office
WI0100044 Permit File
Buncombe County Environmental Health Dept.
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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
Campbell Building Condominium Association, Inc.
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 206 E. State St., Black Mountain,
Buncombe County,NC 28711, and will be constructed and operated in accordance with the application received
August 8, 2011, and in 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 July 31, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through VII hereof.
Permit issued this the 24fl' day of August 2011.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
WI0100044 UIC/5.QM-M.F.Renewal Page 1 of
Version 1/2010

PART I— OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as maybe appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, -or ordinances, which 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 other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
PART II—PERFORMANCE STANDARDS
I. 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.
WI0100044 U1C/5QM-M.F.Renewal Page 2 of 4
Version 1/2010

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 ofthis 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.
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.
WI0100044 . UIC/5QM-M.F.Renewal Page 3 of
Version 1/2010

PART VII—CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the 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
WI0100044 UIC/5QM-M.F.Renewal Page 4 of 4
Version 1/2010

Nilsson Construction Co. , Inc.
tla SrNto`a
w
w ` RESIDENTL9L WELL CONSTRUCTION RECORD O
North Carolina Department of Environment and Natural Resources-Division of Water Qualit
WELL CONTRACTOR CERTIFICATION# 2603
1.WELL CONTRACTOR: g. WATER ZONES(depth):
Larry Wells Top Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
AWD Services. Inc. : Top Bottom Top Bottom
Well Contractor Company Name
Thickness]
258 North Turkey Creek Rd. 7. CASING: Depth Diameter Weight Material
Street Address Top Bottom Ft.
Leicester NC 28748 Top Bottom Ft.
City or Town State Zip Code
Top Bottom Ft.
8( 281683-9223
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 40' Ft.Bentonite Pour
WELL CONSTRUCTION PERMIT# WI0100044 Top 40' Bottom 500' Ft.Pea Gravel Pour
OTHER ASSOCIATED PERMIT#(ir applicable) Top Bottom Ft.
SITE WELL ID*(if applicable) S. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom Ft.—in. _ in.
DATE DRILLED 2-20-07 Top Bottom Ft. in. _ in.
TIME COMPLETED AM❑ PM IV
Bottom Ft. in. in.
4.WELL LOCATION: 10.SANDIGRAVEL PACK:
Depth Size Material
CITY: Black Mountain COUNTY Buncombe
Top Bottom Ft.
CamDbell Office Building Condominium Top Bottom Ft.
(Street Name,Numbers,Community,Subdivieion,Lot No.,Parcel.Zip Code) Top Bottom Ft.
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
Q'Slope ❑Valley ❑Flat ❑Ridge OOther Elev. 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 35 "DMS OR DO /
LONGITUDE 83 "DMS OR DO /
LatitudeAongitude source: [t.PS Qropographic map
(location of well must be shown on a USGS topo map andahached to
this form if not using GPS) Lat . & Long. Unknown /
5.WELL OWNER /
Campbell Office Buildina Condominium /
Owner Name
/
206 East State Street / —
Street Address
Black Mountain NC 28711 i �- sst`3ft
City or Town State Zip Code
8( 28 )Area
---
Area code Phone number
6.WELLDETAILS: (4) Geothermal Bores 12. REMARKS:
Soil:
a. TOTAL DEPTH:500'
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: N/A FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDE TO THE WELL OWNER.
d. TOP OF CASING IS N/A FT.Above Land Surface' 1
'Top of casing terminated atfor below land surface may require 44 �/ 2-2-12
An
a variance in accordance with 15A NCAC 2C.0118. IGN TURE F CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): NIA METHOD OF TEST N/A Larry Wells
f. DISINFECTION:Type N/A Amount N/A PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-1a
1617 Mail Service Center,Raleigh,NC 27699-161, Phone:[phone] Rev.2109

HCDElNR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H.Sullins Dee Freeman
Governor Director Secretary
August 1, 2011
Charles Campbell :: y` c
151 B Highway 9 �'
Black Mountain,NC 28711
" C" C7iI
Subject: Notice of Expiration (NOE)
5QM Geothermal Injection Well I ' Office,
Permit No. WI0100044 }r'
Buncombe County
Dear Mr. Campbell:
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 located on your property at 206 East State Street, in Black
Mountain, NC, which was issued to you on January 10, 2007, and expires on December 31,
2011, is soon due for renewal. If you wish to keep this permit and operate the injection well
system,the permit must be renewed and issued in your name.
If Your Injection Well is Currently Inactive:
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 there has been a change of ownership of the property, an Injection Well Permit
Name/Ownership Change Form must also be submitted. The GW-30 and Name/Ownership
Change forms can be found at http:/inortal.nrdenr.org/web/wq/ans/gwvro/reportine-forms.
If Your Injection Well is Currently Active:
If the injection well system is still active and you wish to renew your permit, the renewal
application must be submitted within 120 calendar days of the expiration of your permit.
According to our records, you must submit your permit renewal by September 2,2011.
AQUIFER PROTECTION SECTION
1636 Mail Semce Center,Raleigh,North Carolina 27699-163E
Location.2728 Caoiral Boulevard,Raleigh.North Carolina 27604 One
Phone.[phone]\FAY,':919-715-0588:FAX [phone]E�Customer Service:1-877-623�6748 NorthCarolina
Inteme::www.navatemualflv.om p /
An Eaua'.00w1unm: Afi:rmam=ccno Emmor:.'

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
enclosed 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.
Please submit the appropriate forms 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
httn://h2o.enr.state.nc.us/ans/gpu/forms.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please contact me by phone at(919) 715-6196 or by email at eric.e.smith(a—ncdenr.eov.
Sincerely, p
Eric G. Smith, P.G.
Hydrogeologist
Enclosures
cc: Asheville Regional Office - APS w/o enclosures
APS Central Files - Permit No. WI0100044 w/o enclosures

\O��F vvn,r9QG
Michael F.Easley,Governor
Vj William G.Ross Jr.,Secretary
} North Carolina Department of Environment and Natural Resources
13 <
Alan W.Klimek,P.E.Director
Division of Water Quality
January 10, 2007 RECEIVE D
Mr. Charles C. Campbell JAN 19 2007
151B Hwy 9#185
Black Mountain,NC 28711
Asheville Regional OffiCQ/
Re: Issuance of Injection Well Permit Aquifer Protection
Permit No. WI0100044
Issued to Charles C. Campbell
Dear Mr. Campbell:
In accordance with your application dated November 10, 2006, 1 am forwarding Permit No.
WI0100044 for the operation of a vertical closed-loop geothermal mixed-fluid heat pump injection
well system to be located at 206 East State Street, Black Mountain, Buncombe County, North
Carolina. This permit shall be effective from the date of issuance until December 31, 2011, and shall
be subject to the conditions and limitations stated therein.
NOTE: This permit replaces the previous permit sent to you dated January 4,2007.
Pay special attention to the well construction standards in Parts II and V of your permit. You must
notify this office (Raleigh Central Office) and the Ashville Regional Office at least forty-eight (48)
hours prior to constructing the system, and forty-eight (48) hours prior to initiation of the operation
of the system.
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. 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 Mr. Qu Qi at(919) 715-6935 or me at(919) 715-6166.
Best Regards,
Michael Rogers
Hydrogeological Technician II
cc: Ted Minnick—Ashville Regional Office
Central Office File
Attachment(s)
tCarolina
ura!/g
Aquifer Protection Section 1636 Mail Service Center Raleigh,NC 27699-I636 Telephone: [phone]
Internet htt0Av v.ncwaterauality ore 2728 Capital Boulevard Raleigh,NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal Opportunity/Affirmative Action Employer—50%Recycled110%Post Consumer Paper Customer Service: [phone]

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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
CHARLES C. CAMPBELL
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5QM INJECTION WELL,
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 206 East State Street, Black Mountain, Buncombe County,North Carolina, and will be
constructed and operated in accordance with the application dated November 10, 2006, 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 December 31,
2011, and shall be subject to the specified conditions and limitations set forth in Parts I through
X hereof.
Permit issued this the 11 4.1, day of ,% 2007. t r
q
Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Page 1

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 not be located in an area generally subject to flooding. Areas that
are generally subject to flooding include those with concave slope, alluvial or colluvial
soils, gullies, depressions, and drainage ways.
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,DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1636
Mail Service Center,Raleigh,NC 27699-1636, 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 Aquifer Protection Section-Underground Injection Control (UIC), Central Office
staff, telephone number (919) 715- 6166 and the Ashville Regional Office Aquifer
Protection Section 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.
Page 2

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 Aquifer Protection Section-
Underground Injection Control (UIC), Central Office staff,telephone number (919) 715-
6166 and the Ashville Regional Office Aquifer Protection Section Staff, telephone number
[phone]. 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.
Page 3

a
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 Ashville Regional Office, telephone number(828)
296-4500, 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.
Page 4

PART VIH - PERMIT RENEWAL
The Permittee shall, at least 120 days 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.
Page 5

(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:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X-OPERATION AND USE SPECIAL CONDITIONS
None
Page 6

RE COPY , �v
AQUIFER PROTECTION SECTION i DEC 01 2006
APPLICATION REVIEW REQUEST FORM
Date: November 29. 2006
To: ® Landon Davidson, ARO-APS ❑ David May,WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Charlie Stehman,WiRO-APS
❑ Andrew Pitner,MRO-APS ❑ Sherri Knight,WSRO-APS
❑ Jay Zimmerman,RRO-APS
From: Michael Rogers, Groundwater Protection Unit
Telephone. [phone] Fax: [phone]
'E-Mail: Michael.Rogers(@,nemail.net
A. Permit Number: WI 0100044
B. Owner: Campbell Family Investments.LLC(Contact: Charles Campbell)
C. Facility/Operation:
® Proposed ❑ Existing ❑ Facility ❑ Operation
D. Application:
1. Permit Type: ❑ Animal ❑ SFR-Surface Irrigation❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ VE Lagoon ❑ GW Remediation(ND)
® UIC-(5QM) closed loop mixed fluid geothermal
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. 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 21 calendar days,please take the following actions:
® Return a Completed APSARR Form.
❑ 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 and 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. /J
RO-APS Reviewer: Date: %Z � , 7_0
FORM: APSARR 07/06 Page 1 of 1

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Date: / ►r za06 1IJ�E COPY County: .arn—
To: Aquifer Protection Section Central O t Permittee: r—
Central Office Reviewer: Project Name: _(rt 41 "-Ilwuf µ; tt(
Regional Login No: Application No.: W r01 00044
I. GENERAL INFORMATION
1. This application is(check an that apply): ®New ❑ 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 2q Other Injection Wells(including in situ remediation)
Was a site visit conducted in order to prepare this report? I&Yes or❑No.
a. Date of site visit: ?J06.
b. Person contacted and contact information: --J Sic✓rs t30,06vC CYa)U6-93o8
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 Infection 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): Z06 E•Swe Sl 1 vFer- Mn,12 7-1'7//
b. Driving Directions: US7067aJt*c mrilr9,;FA4- 690-NnC. UT7t7 E.1rnR's-
c. USGS Quadrangle Map name and number:
d. Latitude: 3'�t?p Longitude: ll c/9 4./ '
IL NEWAND MAJOR MODIFICATIONAPPLICATIONS(this section not needed for renewals or minor
modiTcations,skip to next section)
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification: a
2. Are the new treatment facilities adequate for the type of waste and disposal system?
FORM: Documentl I

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
❑ Yes ❑No tKN/A. If no,please explain:
3. Are,the new.siic 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 R
N/A..Ifno, please explain:
6. Are the proposed application rates for new sites(hydraulic or nutrient) acceptable?
❑Yes ❑No to N/A. If no, please explain:
7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain?
❑ Yes ZI No'❑ N/A., Ifyes, please attac)1 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 M 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 X 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 maior modification
systems)
Description Of Aa4e(S) And Facilities
1. Are there appropriately certified ORCs for the facilities? ❑Yes or El 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: Documentl 2

v" 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.) been 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:
FORM: Documenti 3

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT '
IV. INTECTION WELL PERMIT APPLICATIONS(Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells,and heat
pump injection wells.)
Description Of Well(S)And Facilities—New Renewal.And Modification
1. Type of injection system:
❑Heating/cooling water return flow (5A7)
E&Closed-loop heat pump system 5 M 5QW)
❑In situ remediation(51)
❑ Closed-loop groundwater remediation effluent injection(5LP Non-Discharge")
❑ Other(Specify:
2. Does system use same well for water source and injection? ❑ Yes ®No
3. Are there any potential pollution sources that may affect injection?❑ Yes - XNo
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? SO ft.
5. Quality of drainage at site: �Z 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.
Injection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation(e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
❑ Yes ❑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 ❑No. Imes explain:
3. 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: _fi1)14t,4eA1/AW
FORM: Documentl 4

J AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
Address: /Z�
iC�Jifk� i�G ',7,YJ
Certification number:-9 L-O3
5. Complete and attach Well Construction Data Sheet.
FORM: Documentl 5

AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT
V. EVALUATIONAND RECOIILVENDATIONS
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 issuance/renewal of this permit? ❑Yes [RNo. 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
N
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:
7
8. Signature of report preparer(s):
Signature of APS regional supervisor:
Date: /L /L M6
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: Documentl 6 -

jState of North Carolina
Department of Environment
and Natural Resources �'1 •f
Asheville Regional Office
Swan U. S. Highway 70 NCDENR
Swannanoa, NC 28778
Telephone: [phone] NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL-RESOUROEs
FAX Number: [phone]
F.c/A/X Transmittal
Date:
To: IA
q 9
From:
Number of Pages (including cover page):
A)-E 01

f f
AQUIFER PROTECTION SECTION 7IEC Q 12096
APPLICATION REVIEW REQUEST FORM
r ^}r.
Date: November 29, 2006
To: ® Landon Davidson, ARO-APS ❑ David May,WaRO-APS
❑ Art Barnhardt,FRO-APS ❑ Charlie Stehman,WiRO-APS'
❑ Andrew Pitner,MRO-APS ❑ Sherri Knight,WSRO-APS
❑ Jay Zimmerman,RRO-APS
From: Michael Rogers. Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
B Mail: Michael.Rogers(d),ncmail.net
A. Permit Number: WI 0100044
B. Owner: Campbell Family Investments.LLC (Contact: Charles Campbell)
C. Facility/Operation:
® Proposed ❑ Existing ❑ Facility ❑ Operation
D. Application:
1. Peranit Type: ❑ Animal ❑ SFR-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
2. 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 21 calendar days,please take the following actions:
® Return a Completed APSARR Form.
❑ 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 and 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: w`- --- Date: 12 d.l' 'Ze2
i
FORM: APSARR 07/06 Page 1 of 1

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type 5A7 and QM Wells
In Accordance with the provisions of NCAC Title 15A:02C.0200
Complete application and mail to address on the back page.
TO: DIRECTOR,NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 20 e(�
A. SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1) _ Type 5A7 wells inject water used to provide heating or cooling for structures.
(2) Type 5QM wells contain a subsurface system of continuous piping,that is
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes and/or corrosion
inhibitors.
(3) _ Type 5QW wells contain a subsurface system of continuous piping,that is
isolated from the 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 Geothermal-Water Only Injection Well System.
B. PERMIT APPLICANT
Name:
Address:
City: ,O /col I& State:,&t Zip CodeZew County:
Telephone: eze— or!!Jae
C. PROPERTY OWNER(if different from applicant)
Name: % LL
Address /S�/ s`t' S'
City: �N�s: Sate: MC-Zip Code: ounty: AN n e m�
Telephone: rj'— 777-3Z7y Z07//
D. STATUS OF APPLICANT
Private: Federal:_ Commercial: RECEIVED I DENR I DWO
State: _ Municipal: _ Native American Lands: AO�IFFR PRl1TFC NOV 17 00 200TION SECTION
6
Revised 7/06 GW/UIC-57 HP Page 1 of 4
Wl 0J Onp4

E. FACILITY(SITE)DATA
(Fill out ONLY if the Status of Owner is Federal, State,Municipal or Commercial).
Name of Business or Facility: O., i,e
Address: ZO(i 44 /
City:��e ,le rs boa, M--Wip Code: Zf-7/1 County: �9(ip y e aA"b 2
Telephone: 6^7r=Z// — 930r� Contact Person: J�/VLi-
F. HEAT PUMP CONTRACTOR DATA /
Name: ��» �PGi�� i✓P�� ion �r�e�o/ �J /e-3yes�G PM/L- �!
Address: 4o 4z2.&A@ /� �on/)PG m✓1/ >�/o�n ryP_ �� ki !J(ni UJ
City: Zip Code: County:
Telephone: Contact Person:
G. INJECTION PROCEDURE (Briefly describe how the injection well(s)will be used.)
12 LJ// 6� n✓PP 4 L ec G ®15'
�Di P /, �� XCtsA/q
ant Loa//i,y �4a�e✓R/ c.�v/ W�e�e ��i �.re� .c% R/o��s� �M Pnv7rv+as�sa�;
H. WELL USE / Will the injection well(s)also be used as the supply wcH(s)for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO
I. CONSTRUCTION DATA(check one)
EXISTING WELL being proposed for use as an injection well.Provide the data in
(1) through (7)below to the best of your knowledge. Attach a copy of Form GW-
1 (Well Construction Record)if available.
_ PROPOSED WELL to be constructed for use as an injection well. Provide the
data in (1) through (7) below as PROPOSED construction specifications. Submit
Form GW-1 after construction.
(1) Well Drilling Contractor's Name: d 6 y - - .
NC Contractor Certification number. 7i6 7
(2) Date to be constructed: Number of borings:
Approximate depth of each boring(feet): 3'00
(3) Well casing: Is the well(s)cased?
(a) YES X If yes,then provide the casing information below.
Type: Galvanized steel Black steel_Plastic Other(specify)
or-
Casing depth: Fro ito ft. (reference to land surface)
1-4 oL
Casing extends above ground inches
(b) NO
Revised 7/06 GW/MC-57 HP Page 2 of 4

(4) Grout(material surrounding well casing and/or piping):
(a) Grout type: Cement_ Bentonite-X Other(specify)
(b) Grouted surface and grout depth(referen land accJ:
around closed looppiping; from , d )
p p g; Q to feet).
_around well casing; from to_ e.
(feet)L
(5) Screens (for Type 5A7 wells)
(a) Depth: From to feet below ground surface.
(6) N.C. State Regulations (Title 15A NCAC 2C .0200) require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent(fluid being injected into the well)lines is required. Will there be a faucet on:
(a) the influent line? yes_no (b) the effluent line? yes_no
(7) SOURCE WELL CONSTRUCTION INFORMATION(if different from injection well).
Attach a copy of Form GW-1 (Well Construction Record). If Form GW-1 is not available,
provide the data in part K(1)of this application form to the best of your knowledge.
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS. IJ
J. PROPOSED OPERATING DATA(for Type 5A7 wells)
(1) Injection rate: Average (daily) gallons per minute(gpm).
(2) Injection Volume: Average(daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch(psi).
(4) Injection Temperature: Average(January) °F,Average (July)_° F.
K. INJECTION FLUID DATA
(1) Fluid source(for Type 5A7 wells) If underground,from what depth, formation and type of
rock/sediment unit will the fluid be drawn(e.g., granite,limestone, sand,etc.).
Depth: Formation: Rock/sediment unit:
Chemical Analysis of Source Fluid(for Type 5QM wells)
Provide a complete listing of all chemicals added to the circulating heat transfer fluid:
al
L. INJECTION-RELATED EQUIPMENT a
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
M. LOCATION OF WELL(S) Attach two maps.
Revised 7/06 GWARC-57 RP Page 3 of 4

(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.
N. PERMIT LIST: Attach a list of all permits or construction approvals 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
O. 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 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."
(rLc c C -
(Signature of Well Owner or Authorized Agent)
Ifauthorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner authorizing the above agent
P. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner 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 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 the Well
Construction Standards(Title 15A NCAC 2C .0200)
(Sure Of Property Owner If Dif1'e Applicant)
Please return two copies of the completed Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ RECEIVED I DENR I DWQ
1636 Mail Service Center AQUIEFR PRnTrUInN SECTION
Raleigh,NC 27699-1636 NOV 17 2006
Telephone [phone]
Revised 7/06 GW/JIC-57 HP Page 4 of 4

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