WI0400537_Application_20200114

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MECTION WELL9
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DATE; 20-9P, PERMIT NO. be completed by MR,)
W,!:: Dlbor?y
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCIE 0
�1) Aqueous (na per 13A NCAC 02C AM-1: x
(2), Direct Dtps Zjas pet 11A !E— Nuoibor dwells.,
D. STATUROF WELL OWNER (phoose one)
(1) Single Family, F68i7;0 *Wf this foratwo (1) business tap, prior to construction,
(1) Iusiog rfft'em trAAiio
(3) 30vo, Uuncipal-accuotyl federal ",$ubWt ibis fona.30 -days
prioeto cox"0ROlon,
C, WELL OWNER - For single residences, list the pavelty awrior(a). For all othom list name of *5
business, orgarazationj or government ageucy And person Mop* 8*atge a0thdrltY5
State: d j Zip code-.21-07comty; A A)al�VO4
Day Ttio CQU NO
EMAZ Address; la 1AAjhKh 3 hwit-, " or, Fax No.:
04 PHYSICAL LOCATION, OF WELL SITE,
1) Pawl Iddiltilicatim Number (PIN) of well sita-
(2) Physica A44=s(if diffoimtihanmOingadhess): 20'PdOkk Tell
city: Ly63ha Stattr.NC 7ApCode:
UIC/Closod-Loop Ged6candl Not 1&Wo&(R0vW.1d 9/5)2013) Page I

F. MAPS, PLANS, AND
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site -specific map showing the locations of the following:
See site plan E1
o Proposed injection well locations o Septic systems and associated spray irrigation
• Buildings sites, drain fields, or repair areas
o Property boundaries
o Surface water bodies o Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
See well construction diagram E-2
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at htto://i)oilal.ncdenr.org/web/wglaps/gwpro. All other additives require approval prior to use.
O. WELL DRILLER INFORMATION (if knpwn)
Well Drilling Contractor's Name: Makhhao> Brown 7ndv Mul 1 i c Mi l ton Cava
NC Well Drilling Contractor Certification No
Company Name; Yadkin Well ':Co. Inc. Contact Person: David Brown 2195—A
City: $amptonville State: NC zip coda702OCounty:Yadkin
DayTeleNo.: 316-468-4440 CellNo.: Z Z6-374—g716
EMAIL Address:-.DavidBrown(ayadkinwell . conFaxNo.:
H. NEAT PUMP CONTRACTOR INFORMATION
Company Name: 'Ac C- ] vvc}
Contact Perst ,Car.
Address: City: d. y�
o J9 L Zip Code: State: _County: Ih7RVam a
Office Tele No.: 6U -24S -U2)' Cell No.: Fax No.:
UIC/Closed-Loop Geothemal Notification (Revised 8/5/2013) Page 2

PROTECTION i'kavide a brief description of how (1) water supply welts; (2) surAce water bodies; and (3)
septic systems attd assoeiated spray ivigati'en sitos, drain Fields; ormpaic areas widtin 250 foot ofthe.proposed
infection wells willAe protected during Conanucbion oftlro wolfs»
X VAMANCC —Pursu oa to 15A NCACO2C.0211 tho 17ircctor dtheDivisimt of Water Resourommay grant
a variance frmn applicable well construction or operation standards provided that,
(t) use of tho well(s)Wili or the growtdwaker;,and
(2) that construction or operation in accordance with the,standards is not technically feasible or die
proposed eo!ishuction providos equal or hatter protection of the groundwater.
Any variance rggaoat should a¢campany sntnnittat of bib, notification to exped'Ita evaluation of the requcat.
The variance request form can be accessed online at ht ;/Iyotial nadem.or web/3vgtapslawprc/aormit
anolieadonx
X SIGNATURES -- The following section is to be completed as required below or by that persoa's autheuized
agent, 15A I, 4A 42 , .A21 t(e) requftes signatw•es as follows:
(a) for a corporation; by a responaible corporateofftcer,
(b) for a p tnarship or axle pr apri l'shipr by a gener alpartnei or the proprietor, respcotively;
(o.). fare mnnimpatity or a state, ,federal, or other poblio agency: by either a prtr'taipal executive
officer orranking publicly elected official,,,
(d) lar all others by the welt owner
(e) for say other person authorized toant on behalf of the applicant: doermtentation shall be
saflunitted with the notifrcation that =clearly, identifies the person, grants them signature
authority, and is signed and dated -by, the applicant;
`l bereby certlo, under- penalty of law, that, I have personally vviithied and any ,{ant1har V11A 1114
spitted in this doearment and all tattoohments therein and that, based an my Ingtdl�y of thaiee
immediately responsible for obialOng sold inftrr-mahan, f believe that the infer inatlon is true, u
cotrtte. Tamaivtti a that tltafe a+e sigla}leanl peturiflas, rttahing the passibility of dines ztnd`hrl
aliandon
Signature of Antharized,Agentbifaay
Print ar Type bull Name
U1CtClesW41,00p GeathelmaiNotifca lm(Revised 8/51,2013) Page 3

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