WI0300380_Permit (Issuance)_20230926

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Gary G and Susan D Clark
8426 Catawba Cove Drive
Belmont, NC 28012
NORTH CAROLINA
Environmental Quality
September 26, 2023
Re: Issuance of Injection Well Permit
Permit No. W10300380
Geothermal Heating/Cooling Water Return Well
Gaston County
Dear Gary and Susan:
In accordance with your permit renewal application received August 14, 2023, I am forwarding Permit No.
WI0300380 for the continued operation of geothermal heating/cooling water return well(s) located at the above
referenced address. Please note that this renewed permit shall become effective date of issuance until August
31, 2028, and shall be subject to the conditions and limitations stated therein.
Please Note:
During the site inspection by the Mooresville Regional Office (MRO) on September 14, 2023, the
effluent sampling port was not configured to allow for sampling. Per Section 11.4 of the permit,
and per 15A NCAC 02C .0224, the injection well system shall have a sampling tap present to collect
samples prior to being re -injected into the aquifer. Therefore, within 30 days of receipt of this
permit, please have system configured to have an identified and functional effluent tap, and
contact the MRO to return to collect samples (704-663-1699). These results will be forwarded to
you when they become available.
• Also, during the inspection, the MRO staff noted that the well construction is incomplete due to
the bentonite chip not being completed to the top of the grade. Contact a drilling contractor to
return to the site to perform completion activities.
• Once these activities have been completed, contact MRO to schedule a return visit to ensure that
the activities listed above are completed.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application
to renew the permit 120 days prior to its expiration date. As indicated in the permit, this permit is not transferable
to any person without prior notice to, and approval by, the Director of the Division of Water Resources. If you
have any questions regarding your permit or the Underground Injection Control Program, please call me at (919)
707-3662.
-y� North Carolina Department of Environmental Quality - Division of Water Resources
Q,,I Mailing address: 1636 MSC, Raleigh NC 27699-1636
er+s, rarri+a ' Physical address: 512 North Salisbury Street, Raleigh NC 27604
oaru.�m w E a�
919.707.9000

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Gary and Susan Clark
Gaston County
WI0300380
FOR THE CONTINUED OPERATION OF ONE (1) GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defined in Title 15A NCAC 02C .0224, which will be used for the injection of heat pump
effluent. This injection well is located at 8426 Catawba Cove Drive, Belmont, NC 28012, and will be operated
in accordance with the application received August 14, 2023, and conformity with the specifications and
supporting data, all of which are filed with the Department of Environmental Quality.
This permit is for continued operation of an injection well and shall be in compliance with Title 15A NCAC 02C
.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 issuance until August 31, 2028, and shall be
subject to the specified conditions and limitations stated therein.
Permit issued this the 26th day of September, 2023.
Karen Higgins, Chief
Water Planning Section
Division of Water Resources
Permit WI0300380
By Authority of the Environmental Management Commission.
Permit #WI0300380 Geothermal Heating/Cooling Water Return Well Page 1 of 5
ver. 09/21/2023

7. If not already provided, a copy of the Well Construction Record (Form GW-1) shall be submitted as
described in Part V.5 of this permit within 30 days after completion.
PART III — OPERATION AND USE CONDITIONS
1. The Permittee shall comply with the conditions of this permit and properly operate and maintain the
injection facility in compliance with the conditions of this permit and rules of 15A NCAC 02C .0200, even
if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C .0211(i)].
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface water
or groundwater resulting from the operation of this facility. In the event that the facility fails to perform
satisfactorily, including the creation of nuisance conditions or failure of the injection zone to adequately
assimilate the injected fluid, the Permittee shall take immediate corrective actions including those actions
that may be required, such as the repair, modification, or abandonment of the injection facility [15A NCAC
02C .02061.
PART IV — INSPECTIONS [15A NCAC 02C .02110)]
Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation of credentials, enter and inspect any property, premises, or place on or related to the
injection facility at any reasonable time for the purpose of determining compliance with this permit, may
inspect or copy any records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwater, surface water, or injection fluids.
2. DWR representatives shall have reasonable access for purposes of inspection, observation, and sampling
associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the injection
facility's activities.
PART V — MONITORING AND REPORTING REQUIREMENTS
Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on -site and available for inspection [15A NCAC
02C .0224(f)(2), (4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State and
compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
.0224(f)(1)].
3. The Permittee shall report any report any monitoring or other information that indicates noncompliance
with a specific permit condition, that a contaminant may cause the injected fluids to migrate outside the
approved injection zone or area. As specified in rule 15A NCAC 02C .0211(p), noncompliance notification
shall be as follows:
(A) Oral notification shall be given within 24 hours of the occurrence, or first knowledge of the
occurrence, to the Mooresville Regional Office, telephone number 704-663-1699.
Permit #WI0300380 Geothermal Heating/Cooling Water Return Well Page 3 of 5
ver. 09/21 /2023

(C) Each well shall be thoroughly disinfected, prior to sealing, in accordance with rule 15A NCAC
02C .0111(b)(1)(A), (B), and (Q.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe which extends to the bottom of the well and is raised as the well is filled.
(E) In those cases when a subsurface cavity has been created as a result of the injection operations,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water.
(F) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in 15A
NCAC 2C .0224(f)(4) within 30 days of completion of abandonment to the addresses specified
in Part V.5 above.
Permit #WI0300380 Geothermal Heating/Cooling Water Return Well Page 5 of 5
ver. 09/21/2023

Permit No. WI0300380
Date: 0911812023
County: Gaston
To: Blake Butcher
Central Office Reviewer: Blake Butcher
Permittee/Applicant: Gary G. and Susan D. Clark
Facility Name: Gary & Susan Clark SFR
L GENERAL INFORMATION
1. This application is (check all that apply): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification
a. Date of Inspection: 0911412023
b. Person contacted and contact information: Gary Clark eeclark59 ti mail.com / [phone]
c. Site visit conducted by: Edward Watson and Maria Schutte
d. Inspection Report Printed from BIMS attached: ❑ Yes ® No.
e. Physical Address of Site including zip code: 8426 Catawba Cove Drive, Belmont, NC 28012
L Driving Directions if rural site and/or no physical address: Travel on I-77 South to I-485 outer to exit 10B
to enter I-85 West toward Belmont, NC. Travel — 33 mile on I-85 exiting on exit 27 Belmont/Mt. Holly. Turn
left onto NC- 273. After —2 miles turn left onto S. Central Av. Take S. Central Av. for 4 miles, then turn Right
onto Lower Armstrong Rd/NC-273. Travel 2.36 miles and enter the roundabout and take the 2"a exit onto S.
New Hope Rd./NC-279 (Traveling briefly into S. Carolina). S. New Hope Rd. becomes Pole Branch
Rd/SC/279. You are only on this road for —0.1 miles. Turn Right onto Catawba Cove Dr. Travel for —1.5
miles. The property is on the right.
g. Latitude: 35' 09' 32.51 " Longitude: -81 ° 04' 02.85"
Source of Lat./Long & Accuracy (i.e., Google Earth, GPS, etc.): GCS WGS 1984 to nearest I second.
II. DESCRIPTION OF INJECTION WELL (S) AND FACILITY
1. Type of injection system:
® Geothermal Heating/Cooling Water Return
❑ In situ Groundwater Remediation
❑ Non -Discharge Groundwater Remediation
❑ Other (Specify:
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system only:
Were samples collected from Influent/Effluent sampling ports? ❑ Yes ® No.
Provide well construction information from well tag: The well construction is incomplete due to the
bentonite chip not being completed to the top ofgrade. The permittee was directed to contact the drilling
contractor to return to the site to perform completion activities.
b. Does the existing or proposed system use the same well for water source and injection? ® Yes ❑ No

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN MILLIS)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Sections A lm-- E, and M (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: t'Cv i Ste_ L t , 20 2-3 PERMIT NO. W10300380 (leave blank if New A lication)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as Geothermal Well prinking Water Supply Well
❑ Other Water Supply Use- Indicate use (i.e., irrigation, etc.)
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
❑ Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES gNO
If yes, indicate New Owner's contact information:
Name(s)
Mailing Address:
City:
State: Zip Code: County:
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non-Govemment: Individual Residence, Business/Organization
Goverment: State Municipal County Federal
C. WELL OWNER(S)/PERMIT APPLICANT — For single family residences, list all persons listed on the
property deed. For all others, list name of business/agency and name of person and title with delegated
authority to sign: p—*-e LTZ A,) f
Mailing Address:
City: �Ll; �d'(C -''� State: K C Zip Code:2.8'0 i 'L County: C*-tSTC"-J
Day Tele No.. Cell No.: — JI — )
Geothermal Water Return Well Permit Application Rev. 4-9-2019 Page 1

(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of I SA NCAC 02C .0107, except that:
(a) For screen and gravel -packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTING WELLS PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-I) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a)
M
(g)
K. OPERATING DATA
Depth of each boring below land surface
Well casing and screen type, thickness, and diameter
Casing depth below land surface
Casing height "stickup" above land surface
Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water -bearing zones with 1500
mg/L chloride or greater per 15 i NCAC 02C. 0107YI(8
Length of well screen or open borehole and depth below land surface
Length of sand or gravel packing around well screen and depth below land surface
(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.
L. SITE MAP —As specified in 15A NCAC 02C .0224(b)(4), attach a site -specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107 a 2 located within 250
feet of the proposed injection well(s).
Geothermal Water Return Well Permit Application Rev. 4-9-2019 Page 3

(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
NOTE. In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, eta can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
l 5_A_ NCAC 02C .0211(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by all theperson(s) listed on the ro en deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
11 hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit"
Signature of Property Owner/Applicant
Print or Type Full Name and Title
Signature of Property Owner/Applicant
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to the address below (also attach an electronic
version on CD or USB Flash Drive):
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Geothermal Water Return Well Permit Application Rev. 4-9-2019 Page 4

GEOTHERMAL HEATING/COOLING WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxes. Fill in depths below land surface (BLS) and
details of well construction on the blank lines provided. Use additional sheets as needed.
Open_Hole Well Desire Screened Well Design_
❑ Proposed ❑ Existing Existing ❑ Proposed
p [I Existing
❑ Injection; ❑ Supply;
El Dual Purpose El injection; ❑Supply;
❑ Dual Purpose
Record Depths Below
Land Surface (BLS)
on Lines Provided
Bottom of casing
(Ft. BLS) -
Total Depth
(FL BLS)
(FL)
Return or Supply Line
Casing
Grout
WELL DETAILS
Casing Material:
Casing Diameter (in.):
Grout Type: _
Grout Depth (BLS): _
Top of Bentonite Seal (if present):
Bottom of Bentonite Seal
Screen Material:
Screen Slot Size (in.):
Sand/Gravel Pack
Material Type: _
■ Bedrock
Hole
Record Depths Below
Land Surface (BLS) on
Lines Provided
1
Bentonite Seal Imm (Ft. BLS)
REM
(:f present)
(Ft. BLS)
Bottom of casing
Sand/Gravel Pack — (FL BLS)
Screen
(Total Depth
Ft. BLS)
NC Certified Well Driller Name: Certification No.: