WI0400163_GEO THERMAL_20110120

GEO-THERMAL WELL .CONSTRUCTION RECORD
NON RESJDENXIAL WELL CONSTRUCTION RECORD
North Carolina Oepart/nent of Environment and Natural Resources-Division of Water Quality
WELL CONT~CTOR CERTfFICATION ff 'j )'-f 8 ·-fl-
1. WELL CONTRACTOR,·/ _
j\/l I jv/1 /; Ct>v(.
Well Contractor (lndMdual} Name
Yadkin well Comp-mv Inc,.
Well Conlraclor Company Name -
STREET ADDRESS 19QB Hamptomd 11 e Road
Harn ptonville NC 27020
City or Town Stale Zip Code
t 336 )-468-4440
Area code-Phona number
2. WELL INFORMATION: A
s rre WELL ID #(If applicable) .r-rll /c 7 3 ~ ..L..
STATE WELL PERMIT#(ir applicable) __ ----;:------
DWQ or OTHER PERMIT #(i£ appiicabla), _________ _
\YELL USE (Check Applicable Box} Monitoring D MuniclpaUPublic □
fnduslriartComrnerclal □ Agricullural □ Reeovery1o lnjeclion □
Irrigation □ Olher)i((list use) 41 f>o .f4t .. ('"y1. t c r~ J~. ~-, _
DATE DRILLED , ).. .. JY -)-()//)
TIME COMPLETED_--=;2=--:_cJ_U __ AM'□
3, WELL LOCATION:
CITY: st) Qy·l-e,1. COUNTY.,A•l,le~.1 .. I .r
7 ~ ~;;,oft : ... '"" L ~ ---,-7
(Street Name, Numbers, Cornmunlty, SubdMsion, Lo.l No., Parcel, Zip Coda)
TOPOGRAPHIC/ LAND SETTING: .
□Slope DVallay OFlal ~ldge D Olher _____ _
{check appr"-riala box) .
LATITUDE _L -_b 2.'?, 'C( 7
LONGITUDE. X _J_ O{ I Y'..f 1'
May ho in degrees,
minutes, seconds or
In a d:drnal rormat
Latitude/longitude source: ~GPS oTop~graphic map
(location of wel must be shown on a USGS lopo map and
attached to this form if not using GPS)
4. FACIL(TY-ls lh-1t r,ar:-,6 gl It.a buslnus wl-.ua lh6 wen 11 Jc..:;la.:I,
FACILITY ID ~f applicabl•l
1
~ /,111."J 3(-l S 7 ~ I 7 7 /f
NAME OF FAeltm' /2 q r e I/ I cl e e -f s .
STREET ADDRESS e~ 6 ~l( loo z 8' Cctv'Q I '"-'1 fo q rt& . A/<--.2 t{ 7 r
;tiiy or Town _;, Stale _ . Zip C◊:Jo 'V/(
CONTACT PERSO ,__.__---'-'--'-'----.C....~--"a;=..c__._._. ...... _..._,4-" J
MAI
City or Town · State
c :J.3(. } ''J~)-)G. 2 ·2
Area code -Phone number
5. WELL DETAILS:
a, TOT AL OEPTH:._-'2'--: _.;;,LJ=--0=·· __
b, DOES WELL REPLACE EXISTING WELL 7 YES D NO }Y
C, WATER LEVEL Below Top or Castng: L FT,
(Use •+• if Above Top o( Casing)
d, TOP OF. CASING IS __..;.. ___ FT. Afx11e Land Surface•
'Top or casing terminated aVor below land surface may require
a variance In accordance with 15A NCAC 2C .0118. ·
o. YIELD (gpm}: h () METHOD OF TEST tf 'r
f, DrSINFECTION: Type HTH Amounl ~/.f' .. _''1f'Jf
g, WATER ZONES (depl~,
From 6 4 '"To 6'_ From~ To~
From~ To~ From __ To __
From.!1..l..:__ To__!l,:L_ From __ To __
6. CASING: Thickness/
Depth ~-Diameter Welght Malerial
From~·To_f __ FI.. __ _
From __ ..,;_. To __ FI .. __ _
From __ To_· __ Ft.. __ _
7. GROUT: Deplh Material Method
From-12.__ To~Ft. J k~r,11--i;~ f U "f'J -t'~
F1on1 __ To __ . _Fl.. ____ _
From_· __ To __ Ft.. ____ _
8, SCREEN: Depth Diameter Slot Size Material
From __ To __ Fl. __ in. In. __ _
:;:===· =~:=· === ~!:=· =·=~~: === :~: REC . .:: 1\1 E [)
9. SAND/GRAVELPACK: JAN O 2011
, Depth Size Malerlal B
Frcm To __ FI.. ________ _
,____ 'W'HER QLJAUI : -::i.::.1... i ,ON
FrClfTI To __ Ft. IAfeFm9.tion Pro .ssing Unit
From To __ Ft • .__ _______ _
10, DRILLING LOG
From To
1-: f,o
/11,,; -t J.S' us-?(It.I
Fomiation Description
· 00 HERESY CERTIFY THATlHIS WE\.L Wl'S CONSTRUCTED ,1 A ROAACE WITH
15.A"HCAC 2C, WELL COtlSTRUC1lON STANDARDS, ,'.NO THAT A COPY OF THIS
RECORD J-tAS BEEH PROV1DED TO. THE w~.w WHHER.ER.
qJi;ut;-t-C ---~ · 12--;;i;-10
SIGNATUR5 OF CERTIFIED WELL CONTRACTOR DATE
/\/1 ;· J 1-~ G Cc\ v..e
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
M ' l '1 -e ,. 41"A\ D ( • .
Submit the original to the Division of W~ter Qua1ity wlthln 30 days. Attn~ !nfonna.tlon M9t.,
1617 Mall Service Canter-Raleigh, NC 27699•1617 ·Phone No .. [phone] ext 568,
Date site visited: l t-19 ·/J by (;V' {l Permit required: ~
.5t!lt.v
~/1/ .J-. Lr;
No
FormGVMb
Rev. 7105
GEC -THERMAL WELLCONSTRUCTION RECORD
'%. NON
RESIDBMAL WELL CONSTWUCTION RECORD
- North Carollna Deparimcm or Environment and Natural Resourcers�- Dlvislon Dr Water Quality
+fi r WELL CONTRACTOR J CERTIF16TION 0 5- Lf
T. W£LL_C;TIT",
- �-- . vc
Well Contractor (IndlMdual) Name
Well Contractor Canpany Name
STREET ADDRESS j 4r1R T4;g sa0nSd 1-1_a Rryari
HaMPt04Vi11e TIC 27020
City or To m Slate Zip Cade
336 1- 468-4440
Area Code- Phonerwmber
Z. WELL INFORMATION
S IT W ELL 10 9(11 appl cable)
STATE WELL PER MIT#VI aVplicable i
DWO or OTHER PERWT #(it aprkabia)
VIELL USE (Cheek Applicable Box) MonRaring a kunlelpallPubfoc ❑
Indus lriaflCommerclal ❑ Agricultural a Recovery [p 1nfecl)on 1:3
Irr[gationO Other (0st use)M
DATE DRILL[ib f
TIME COMPLETED 9 . Q � Awo PM)(-
3. WELL LOCATION;
cin,: S RL►pej4ot COIJNT,f . . �',�
(Street Nam a. Numbers. CornrnuAlty, SubdMv lcn, Lot No., Faisal, Zip Code)
TOPOGRAPHIC 1 LAND STETTING'
❑Slopa ❑valtay ❑Fiat kkidga O Dlirer
(cheek appro data box{) LATITUDE
'
LATITUDE 3 - 8 , b May ba In degras,
r minute; Seconds or
LONGITUDE T I 0C,1r Ir:a decimal format
Latitudellongitude sourea: 60119 ❑Tapbgrephie map
(bcafion of wal must he shown on a USG hips map and
atfached fa this farm rfnot usrhg GPSy
4. FACILITY- lr N Hama of tta bt;STAlIf when %hA pen lr laealad,
FACILITY ID #(if appNca3ls)
NAME Or+lEttiT1' % r4 t'S .rX
e ell
87 REET ADDRESS N 6-Y Ld 0
-7 r 6Its 6"
x2 x-,A0 AJL
2 kc 7i_
ty or TuNn _ State
f
Zip C 94w h
CONTACT PEITscm VWAJ
y„ J
MAIL G ADPRESS— 7-Cl
G� t
� C!i.t�Q Grp .�'s rV6
_ Z.k!(Z'7
City or Town State
Zip Cede
i 9 �UJ-7- 76 2-
Area code- Phone number
S. WELL DETAILS:
a. 'TOTAL DEPTH: 20 d
b, DOES WELL REPLACE EXInNG WELL? YES ❑ NO
a. WATER LEVEL 9elok Top ar Casing: _Fr.
(usa'+ u Above Top of Casing)
MiW',ra
d. TOP OF CASINO lS --- FT. Above Land Surface
'Top of casing termini aVor bslokv land surface may require
s vertarsea fn aocordanoe with 15A NCAC 2C.111 i8,
a. YIELD(gprn}: � IAETHODOFTEST �/ r
f. DISiNrECTION: Type HiM Amount 6wA r
4. WATER ZCt�i:5 (depihY
Frain d Ta Fran 7a
Fr `� Ta From To
Fr d To�L Frcm Ta
6. CASING:
Thlcknessl
- a tlo�
Dlameler
Weight hiaterial
Front
Ft �—
Fran To
Ft.
From Tri
Ft.
7. GROLT I, Depth
Method
j�Matodal
From ToaV(). FL T* i «M
From Tc
Ft.
From Ts
Ft.
_
8, SCREEN, Depth
Dlameler
Slot Size 1400W
From 7o
Fl. in.
In.
FtaTL _ To
FAxrl To
Ft ._ Jn.
Ft. In,
In
l� r
9. sANDIGRAVEL PACK:
. Depth .....
. .. Slxa
MateddA N 2 0
a
Frtm To
FI.
From _ To
Ft.
_ WATER 011AUTY S'.0
FrorrL_Ta
Ft
lnfarm;�tlon Prooes
ng
io. DRILUIG LCG
From TO
Farmation Desarlption
d1
(J �
lt,, C^ r G� �c�►l 1 'C
ii. REMARKS:
C
I DO HEREBY CERTIW TMMIS WELL WAS CONSTRUCTEO VlACCORDANCE. WrrH
swr+cao sc, WELL carrsTxucncx sT:xorxna, wo TiNT A, COPY OF t+us
RECORD BEEN PROYaEpEL E WLawREA 2to
SIGNATURE OF C TIFIFD WELL CONTRACTOR DATE
M I ) F 4:;, ye-
t'RIHTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days, Attn: Information Mgt.,
1617 Mall Servlas Center— Raleigh, NO 27692.1617 Phone Ho: (9i9) 733 T615.ext 588.
Date site visited: I -I f by -Permit required,.' red•' �Mj No
Farm GW-Ib
Rev, 7rp5
D
f'iON
Unit
,S'4�,..

Permit Number W10400163
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facil:t
Facility Name
Russell & Joan Sheets SFR
Location Address
78 Carolina Ln
Raleigh NC 27675
Owne-
Central Files. APS SWP
12/02/10
Permit Tracking Slip
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville NC 27020
Major[Minor Region
Minor Winston-Salem
County
Alleghany
Facility Contact Affiliation
Owner Name Owner Type
individual
Russell J Sheets Owner Affiliation
Russell J. Sheets
PO Box 100
Sparta
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue
12/02/10 11/23/10 12/02/10
Re ,urated Activities
Heat Pump Injection
Outfall I '; I: !
Waterbody Name
Stream Index Number Current Class
NC 28675
Effactive Expiration
12/02/10
Subbasin

NOV.22. 2010 3: 44PM YADKiN WELL No, 6 6 7-.:--
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3:44PM YADKIN WELL
No. 6367 P....3
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Nov. 22, 2014 3,44PM YADKIN WELL No. 6H7 : p:, 4
11/1ar2030 THU is 06 FAI 330 372 1167 BLUE RIDGE 9LECTRIC CORD �QQ3l80&� a
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Attach two acpW vfwYs ahawf 9]b fOJM n$ lnfornWIM .
(i) %clrrdd a Site Map (can bs dmwp) allowlig balldlags, pprroopart' Ihm, sudia Crater bolt SO4l� I&J '
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rvfbre�e g4l0ts at�ah rstoeda� streams, andlbv lsXgh�vay inteliaciiar�, r •'•
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No. 636?
Nov. 22. 2010 3:45PM YADKIN WELL
t&PJf c�lI

Nov.22. 2010 3:44PM YADKIN WELL
No. 6367 P..
P,
O
FACUME TRMMLMON FORM
DATE: l Aa -nme REF NO.
TO: V z2 A • ;'
COMPANY NAME
T?,a
ATiE--
FROM: _ Y d t` c,
DEn
COMPANY NAME FA)f Np.
IHnrnnw� a� L � .
NUMBER OF PAGES � PLEASE QRIG}NAi0iC5
wri immin-mi5 5HEgr iiEPLl' 8Y SiGIUMPE
MESSAGE:
-
e:ram
41
"FOR ALL YOUR WATER NEEDS'
YADKIN WELL CO., INC.
19M HAMPYONVtLLE RGAO
HAMRTONVILLE. NC 27=
DAVIQ J. BROWN, VICE PRES. .
TOLL, FREE (AX*) 2444355
01 1rzCE (336) AGB-4440
FAX (�3361 af.6-4C59
REs 1 a86r+6ss� .
•GgpO racers 0kHtAJCA • G" LDVNJ YpU•
f
• r
PLEASE WGF1r! US *MEMffMf IF.WJ DO rW� ^