WI0400162_GEO THERMAL_20110120

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GEO-THERMAL.WELL .CONSTRUCTION RECORD
~ Io '1 O<l Ho ,z.,.,
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NON RESIDENtiAL° \VELL CONSTRUCTION RECORD
North Carolina Depar1menl of Environment and Natural Resources• Division of Waler Quality 3 r os-.a 5
WELL CONTRACTOR CERTIFICATlON f# ~ S-7 )_
1. WELL CONTRACTOR:
-:5;.J~ { ,tJ C'.\-~ \ \ ~
ell Cont; tor (Individual} Name
Yadkin We] 1 Corooaov Inc -
W!:!11 Contraclor Company Name
STREET ADDRESS 19GB Hamptamzi-11 e Road
Hamotonville ~--c 27020
City or Town State Zip Code
, 336 )-468-4440
Arca code-Phana number
2. WELL INFORMATION: / _
SITE: WELL ID #(ffappllcable) rt!l/C-3 (C,
,, • : ... J
STATE WELL PERMIT#{if .ipplicable,_ _______ _
DWQ or OTHER PERMIT #(if applicable). _______ _
~/ELL USE (Check Applicable Box) Monitoring O ~,1uniclpaUPublic □
lnduslriartcommerclal □ Agricultural o R~over)o Injection □ j j. Irrigation □ Othar~(listuse) C {o;,()J /oo/2 d,(J,Q"ff.,el
DATE DRILLED /2-.-J..-/0 , J
TIME COMPLETED • ~ ,;~·~ AM'□ Pl\la?
3. WELL LOCATIO ,: / ·
. c1TY: lv •t\. ..... -Stice,""' couNrv. P,,~s y,/L
. ~.2.. 9 . /..J. .. /....c -;-L /)1,,,,-····· l
(SlreeLName, l~umbers. Cornmunlty, Subdivision, Lo.\ No., Parcel, Zip Code)
TOPOGRAPHIC/ LAND SE.TTING:
·~Iopa OVallay OFlal □Ridge D Other _____ _
(checl< appropriate box}
LATITUDE _L ·f_ 0 1/., q 7 0
LONGITUDE I I..)_ ? I « so l
May~ in dc&r~.
minutes. seconds or
In a dcdmal rormat
Latitude/longitude som'ce: t\1 OPS □Topographic map
(.'ocatkm of wer must be shown on a USGS topo map and
attached to this form if not using GPS)
FACILITY ID #{if applicabl9}--=------~----
NAME: OF FACILITY LV~; ~ s.'?·1·+)._ -Z,
STREET ADDRESS 2. z g Hr-(1 g (.)I; t J! ti'L t1
l (.)1n.1~ .. Sc1/e.;h !JG · 2)tJ )i
City or Town Stale Zip Cooo
CONTACT PERSON QqA1f &ow;I...
MAILIN 9 f,DDRESS
y" cl!ittHI ;lie.. ,V.G.
Cit'/ or Town · . Slate
2..'7of'J
Zip Cocl:1
< 33~ r ~{~--2o 0 S-~-JC{ 'i'--7 :!22
Ar1:a code -Phone number
5. WELL DETAILS:
~7 07' ·' a. TOTAL DEPTH:_-=_~<,__ ~U~--
b, DOES WELL REPLACE EXISTING WELL? YES □ NOM
C, WATER LEVEL Belay/ Top or Casing: ____ FT,
(Use ·+· if Above Top of Casing)
d. TOP OF CASING IS ____ FT. A'oote land Surface•
'Top or casil'\g terminated aUor below land sutfc'lea may require
a variance In accordance with 15A NCAC 2C .0118.
' o, YIELD (9pm): l) . METHOD OF TEST fl r
f, DISINFECTION: Type HT.fl Amounl _ / ~
g, WATER ZONES (de,rth):
From __ To __ From __ To __ _
From __ To__ From_· __ . To __ _
From ___ To __ From __ To __ _
6, CASlNG:
,..-~-Oeplh ..,,.,..., Diameter
Thickness/
Weight Material
From_· _·To __ Ft.. __ _
From __ To __ Ft. ____ _
From __ To_· __ Ft.. __ _
Method 7, GROUT: 0eplh Material +
From_D_ rqfOO_ FtJ h i('s~.~r:,J
Fro.-n __ To __ Fl.,__ ___ _
From __ To __ Ft. ____ _
a, SCREEN: Depth Diameter Slol Size Male-rial
From_· _To __ Fl. __ in. In. __ _
From __ To __ Ft._._._ln. In, __ _
Frorn __ To_._Ft. __ rn. __ in. __ _
9. SANDIGRAVEL PACK:
, Deplh Size Malerlal
Frooi. ___ To __ Ft. __________ _
From To __ Ft.,._ _______ _
From io __ Ft.. ______ _,,_ __
10. DRILLING LOG
Fr_om.,. •fq J° & _. J 0 6) I
11. REMARKS:
2. /Jo "":eJ
Fe nnaliov)jl scription s~ ... L .
BEeEI\IEI)
JAN 2 0 2011
lnform ~tt on :--mcessir.g ,;rm
,E OF PERSON CONSTRUCTING THE WELL
Submit the orlginal to the Division of W~ter Quality wlth{n 30 days. Attn: Information M9t,,
1617 Mall Service Center-Raleigh, NC 27699,1617 Phone No."(919) 733•7015 ext 568.
Date site visited: 1 .. ,3 -lo by D ~ Permit required: @ No
FormGVMb
Rev. 7/05
.J-/t-ti-1° S4_W,
GEC -THERMAL WELL CONSTRUCTION RECORD
Ak
NON. ESIDENT;lAL WELL CONSTRUCTION RECORD
Norlh Carolina DepariImonI of 9nvuonmen [ and Nalurat Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFI&TIGN II P3--7 )-
1, WELLCONTRACTOR-.
Li ryle
Well Conti for (IndNMdual} Name
Udell Contraclor Company Narne
STREET ADDRESS 1 GfIR Ti9M t-Qn Li j Te Eoarl
_k6MO--yriville N_ 27020
Ci[y Of Town Slate Zip Code
336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION: r
SETE WELL ld N(Ir upplic W6) 4_ _
STATE WELL PERM1T#(if a0pilcable)
❑ WQ or OTHER PERMIT 9(lf appticabla)
WELL. USE (Chach Applicahta Sox) MondorIng D Ivlunialpailf ublic E3
IndustriallConrnercfal Q Aaricullural ❑ Recrvery [ I Tn)ecIlon C3
trriCationQ Other (list usej C .aJ •F? oo 3 _ !�
DATE DRILLED I > ­3 ' i c
TIME CONiPLETED�AM C3 P[+W
3. WELL LOC ATIO is
CITY: LJ n !. - ix�tn+ rCOUNNTyY r--o-p
(Shee( Name, numbers. CornmlmHy, Subdhtston, LnlNo.. Petal. Zrp Casa)
TOPOGRAPHIC LAND SETTING'
*S Opa UValhy` ❑Fiat pfildgn Cl Other_
(ViecR appropriate bon)
LATITUDE 3 -� � r 7 (1 May b.1.dgram
minuses, seconds or
LONGITLIDE _T� 41 7 r__r _ MID In a d"Irnal format
Latitude/longitude svume: 40PS oTvpbgraphie map
(Fccation of via#musf b9 shown on a USGS ldpo map and
attached to this form i(nar using GPSJ
4. FAC[Ll TY. is srzs nana of Pa Luslrusswhxe thawen i; le arm.
FACILITY ID #(if opplicabIs)-
NAME OF FACILITY C►' a f f
d
STREET ADDRESS 22 b (
a i 44 LW
'U3',t i A,' t.r.
IQ
GilyorTaNn Sta a
tip Code
CONTACT PERSON 10 c
tviAtt[N " GGRf:5�5
�n
Ya J 1 r rV C.-
C7yr or Toro Slate
Zip Coda
3334G� )452 -2005- Il, 34 T- 7722
Ares code - Phone number
S. WELL. DETAILS:
r
a. TOTAL DEPTH:( l�}
b, DOES WELL, REPLACE EXISTING WELL? YES O NOX
o, WATFfR LEVEL Belau Top of Casing: FT,
arse'+' if Abova Top of Casing)
WTJ`J Oo 16 Z
d. TOP bF CASING tS FT. Above Lend Surface'
'Top of casing tetmInaled aVor belcr.v land surface may require
avarianca In accordaneewith I$ANCAC 2C.011S.
e. YIELD (gprnt: f,SETHODOr TEST It
f. DiSINFECTiON:TypeHl'H-_ Amnunt__
g. WATER ZONES (de), � J
From CTo From To
From To Frarrr To
From To From To
3z,.J.Seq�
S. CASING:
ThfcirlesO
caplh -
C]iameler Weight Material
From To
F't,
From TO
Ft.
prom Tp
Ff.
7. GROUT: ❑eplh
Material Mothed
From_a Lied Ft. er 4e;
From To_
FL.__ _ 3» f•,_
From To
Ft.
8. SCREZNt Depth
DIarneter Slpl Size Material
Fron Tn
Ft. in. In.
From To
F[. In. In,
FrQrt_ Ta
FL Tn. in.
9. SANDiGRAVEL PACK'
. Depth • -,
Sire Material
Fran To
FL
'=roar To
Ft.
From To
FI. _
10. DRILLING LOG
Frain -v
1=vtmn E]� criplian
— s w '
r-21 J-gq±4-:,i Vrzsr
Axil
11, REMAFtKM
17 r 1
f DOHE RE BY CERWY THAT TKZ WELL WAS CONSTRUCTED 4 r ACC9 RDAHCE W m4
ISA NCAC 2C. W ELL CQkSTRUMN STANDAR0S, AHO THATA COPY OF rKS
RECORONASti-ENPRC DEOTOTHEWE L rfM
e%GtiATUA T CERTIFIED WELL CONTRACTOR DATE
( uI
PR'NTfI3 NAt E OF PERSON CONSTRUCTING THE WELL
Submik the ❑rlginal to the DIvislon of Water QuaIIty within 30 days. Akin: Inform atlon I+rtgt., Form GW-lb
1617 Mail Servlce Center— Raleigh, NC 27699-1517 Phorte No,'[phone] ext 558.
k]y � � Rev.7ra5
Tate site visited: 8_/J -/.o Permit required: C�Ye W)
ib;v. . ..

Permit Number
Program Category
Ground Water
Permit Type
WI0400162 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael .rogers
Coastal SW Rule
Permitted Flow
Facilit ,
Facility Name
Craig and Ann Marie Smith SFR
Location Address
228 Heathcliff Pl
Winston Salem
Owner.
Owner Name
Craig
·Dates/Events
NC 27,104
Smith
Orig Issue
12/02/10
App Received Draft Initiated
11/19/10
Re ulated Activities
Heat Pump Injection
Outfall I\'.· k.L
Scheduled
Issuance
Central Files: APS_ SWP_
12/02/10
Permit Tracking Slip
Status
.Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville
Major/Minor
Minor
NC
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Craig Smith
228 Heathcliff Pl
Winston Salem
Public Notice Issue
12/02/10
NC
Effective
12/02/10
27020
27104
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
'A~Ai 8.!;~.ll
NcbENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Craig Smith
Ann Marie Smith
228 Heathcliff Place
Winston-Salem. NC 27104
Coleen H. Sullins
Director
12/2/2010
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400162
Craig & Ann Marie Smith SFR
Dear Mr. & Mrs. Smith:
Dee Freeman
Secretary
On 11/19/2010, the Aquifer Protection Section (APS) received-notification of your intent to construct a closed-loop water-onlv
geothermal injection well system for the operation of a ground-source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
· 3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .021l(u)(2). Additionally, you should contact the ForRyth County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Rog;ers(ciincdenr.rmv if you have any questions.
Sincerely,
/OrD~~~A~u
cc: Winton-Salem Regional Office -APS
APS Central Files -Pennit No. WI0400l.62
fi orsyth County Health Dept.
Yadkin Well Co., Inc. (David J. Brown)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. l~orth Carolina 27604-
Supervisor
Phone: [phone] \ FAX 1: 919 -715-0588: FAX 2: 919-715-6048 Customer Service: 1-877-623-6748
Internet: www.ncwaterqua1itv.org
An Equal Opportunity Affirmative Action Employer
NonehC 1· ort · ·aro 1na
JVaturally
Nov, 14, 2010
$:51AM YADKIN WELL No. 6355 Per 2-
NORTH CAROL INA :: J
DEPAR'lU9DIT OF ENVIROrPAINt AXD N•ATUMAL MOURCBS (NCD Mt3 ' n '
N'OTIFI<CATxON OF ]PVT TO CONSTRUCT A CLOSER-LdOF GEMIUM Ma
NAfrF&DIM xNTEcmx WELL S'YS'TM
TWi..rSfw WELUS)
In A=Wa= with the, pmidaw dXCAC Tir 15A: aZCMW, Fk=
OOP AletC this womfim and mW1 to address o3a.tltie Tack- page (plewe Wd of 1=thtb = i
DATE: - ZOLO
K
A.
VIA
Weff ryp Coofmnmab t: Does tba propesed system ekwWa potable wity (no 7016 8y Lii � iv _ '?
oandowas piping OW covVletely isolates the Raid ftm the an* t4:y:
clash lonl? r ;,
Yes X Cardhwe completing this form.
No Do Not complabe this fay. Complete other I31C aMikatioa fi0azw6
either a 5A7 wed sloop well Wa4 g potable water fto The aquifer) or a SQM Ii
loop well conothfmg AddthqM such as R 22, ethanol, or other anfiEreeze or catrCsion iobi ..
PROPERTY OWI=MAITLICAiYM
LAst ewh Propaty Oww listed an property doed (if ow=d by a. b=Ac s or govermwet agesq, Sod&
ea ty and a represeftdve wlanfficAty for M&UU re): if
(l) 1 wUngAddz=: —2 zrr I iPrw c��t ' ■'L ', r ~ ` `fi.'+ .
City: ; f+s - She. P"' Stow. Zip Cade: ? lay. ter.• ' t
HouwJOffift T-k Taw �S .- a�R�'3 Cell Na.:
(2) Physiml. Aoidim of Well Site (if &ffmnt th m above):
City: Staff: Zip Code:
HomelOfifce Tole No.: Cell-Nac -
AUTHORIZED AGENT OF OWNER, IF A" C¢ ffie PecmitApplicm t does not awn
attm$ a letter foam the p vpesty owner avtbmsng Agent to install and operafc MC well) r -
c4m)pBa Nam.
coNact Person: EMAII.�ddressr _#' � .s Y
Addms:
City: Stait: Zap Coda: corm ; �+. -
MoeTele Nw Call Nag- 7 ;
wehsite Address of Cempany, if any
r

Nov,19• 2010 8:57AM YADKIN WELL
No. 6355
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CordPwNsmo;Y'udkin Well CA
wen DdBd r Coftftmowea Name.- QMM
NC Cw&ador C 6M'M0.: 257z-A S -,A _ 3.798R'l . - -- -
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Address: 109 HamphinAc Rd.
City: SBt tnnvt Ee N.C, Tap Codes 27W* Cow Ytad
OfEm TekNo.: 336•46&4440 CdI No : 13&374-8736
i E
NUT 1'°U. W COMMACTOR MFORMATt[>Qtf (V Of"ent than drier)
� 1
CornpeatyNaiwz=Ptrrr��1lt'�� -
Addtrm.
"` = �L Li^
y .; ~,.•
J• .- Y
_ y
STAB OF APPLICANT
Pdvat, 5c,Fedrral: fu*amme iah
' .•
suit, �f munwpd: Native i1tAed= L' ub!
IIQEC•nQX pROC7DIME (hriegr dita% the ydaofic o walks) wX be =4
WSLL CONSTRUC1MXDATA
(I) Propmmed date to be camaht xft&. 1)0 Ll'- rc eNwtnb of um iag
Appwdmabe depth Of each b AVS {feet
F fah
V) Typc of tubing to bz Z= (cvpPor, I'VI;- da); = L S`j2 f;, - % t
(3) WoU cmft. B fte weiKs) oed? (ebmk elthcr (s-) Yes Vr"Ion >
(a) Yes ify*% gm provide casing W"Mwonbelow
Type: mad sled brook slag plwfic other (spc4.i'y)
Cwhig depth Frame to _____--__. feet (y0o ee to land. sumo)
C3dm w*wls to above gr&md. Incites:
(b) -No X
(4) ormtlnfo(m*rW =ouaft well cuftantliorpipiV: -k
(a) [iroat 6T= Neat Cement Omer tspcim
(b) Gwd pbce� Pimgpkx-- Prtimusa Offiff
(o) Giamt depth OfL (mfe mwc tta land wkce): from to
If well has rasing, itndlceto ova deptltc timm to (bet)

i
Nov.19. 2010 8;71AM YADKIN WELL No, 6.355
A#ach a diagram shawb26 dw "Pwadug Payout or proposed mWZcadan of the injed w a aqudpaaeatC .
associated whh the Wection operation. Do waAufixb oes hmcb= vay provide supplat� . f
r LOCATION OF .US)
Attach two oD s of mays slcmnug the Wowing iufcxmat ow
(1) behAs a site Map (can be dmw) dwwi ig� bvi�, Foperty hues, =&c* wnW bodW. a0t at
soarccs of gmwbdwaftr oareamtn &A and the orientation of and &stum between the posed w a)
vy wag wdl[s) or wwft &spasm fadd les such as saptio tanks or drain folds M=W w1wn.� l *0,: _
the geathcr teal. ia�,t Bump �veA system. TAW aft features dearly and mob* a now alyOy
(2) TM site Map must show the su*a popery in relation to the a g area.by mng at kast-tweud'
rtfuence points mch as rnad5, streams, aurOw highway intew"ons.
J. CERTnwAT10N
Natae: T16 Permit App&*tWts mast be signed by Mg person appeanc% an tJ*
recorded kWI pro" deed
°1 head twifY, under penatty of raw, that I Lave pessanafly wAmiwd and mn farm&-r.with ft p
suh d in his dwume t and all atmc m=u thereto and tlzt, based on my iDgouy of thm�
lxmm&tely respomible for "wh# said Ida muldoaf I believe W the iu%ion is tip, awwa*wa, .
I am wam AM there are 4gWBuu t pam9d0e. including 1he passx'bility of pros aad impdso=64 for ;
&kS in}wnzati zr. I a w to comsne% opsmle, maiutaun, tpeir, and if'appuffma, abandon the
all relate Vpwicames in a=wda om with the mourn sped ficadons ooaditi of the Parmi 4: r ,
". .,. -
5' party �wt�lAppliamf •
Print cc Type FuH Name and=@
.�� .
Sigwttme of Pr Applicant
&xA'222kl;:�
Print or Type PiM Ximm and title : r• � _�,
5igature ofAutorized Agent, if any
•C3�� y�r`-.3 i
Pdd or TAm FQ Name and tide
::
Please return two copra af•the Completed Aagimtoxt pdcage to:
North Carolina DENR DWQ
AquiferProtection Seeder -MC Program
1636 M2fi Service Cemter
Raleigh, NC 27699-16M
Tehrhone [phone] �' .

Nov, 19. 2010 8:58AM YADKIN WELL
c k4 IOfrw114
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MON

3'I
Nov. 19. 2010 8:57AM YADKIN WELL
No. 6.355 y' _:�` '.•
FAMMlLE TRU Mf ON FORM
DATE REF NO. LOG NO.
COMPANY NAME
FAX N0.
7rlATTEKnON
gm
FROM: i aAk.L LL)e-d
ra (J )
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690 f a �
•-i �i'-.
COMPANY NAME
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MHO'
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ir- r ;t.
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11 ii' OV' �
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INpMOUAL
DEPT.
NUMBEA OF PAGES
PLEASE ' QRIGiNATDFr5
INCLUDING THIS SHEET.
REALM BY SIdda"E
MESSAGE:
-FOR 'ALL YOUR WATER NEEDS'
YADKIN WELL CO., INC.
1908 mAMPTONVILLE ROAD
NAMPTONVILLE. NC r"20
DAVID J. BROWN. VICE FREE,
Talmo FREE (800) 24a!9055
OF'FICG (336) 4SB-"40
9-a CA 3 (3241 468O =^65s
RErJ t3+JBt 4BB•4658
•gpaa NC. ANfA1GA • GOO LOV99 V*IF
.•.:sue* ?.
PLEASE INFORM US IMMEMKrELY IF You Do }uw kamvF FR P'FFLl11} ;r