WI0400171_GEO THERMAL_20110308

GEO-THERMAL WELL .CONSTRUCTION RECORD
NON RESIDENT.JAL WELL CONSTRUCTION RECORD 39178~ North Carolina Depart~ent of Environment and Natural Resources-Divisio~ of Water Quality
WELLCONT~CTORCERTIFICATION# :;)S 72.,
Well Conlrac r (lndMdual) Name
Yaakin Well Com[EOV Inc,
Well Contractor Company Name ·
STREET ADDRESS 1908 Ramptomzi J 1 e Road
Hamptonville ~"'C 27020
City or To-NT\ Slate Zip Code
c 336 >· 468-4440
Area code-Phona number
2. WELL INFORMATION: . ,,( , ~
SITE WELLID#(lfapplleable) z:r4tc-. 5 2 (J
STATE WELL PERMIT#{if applic~ble,_ _ _..;i;,.--____ _
DWQ or OTHER PERMIT #(if appticabla)ty:l:' 0 'f: Oo 1 •1 1 ·
~JELL USE (Check Applicc1ble Box} Moottoring D MunlclpaVPublic D
fnduslrialtCommerclal □ Agricultural □ Re-eovery1 □ Injection O
Irrigation □ Other )({list use) c./ o5 ~J Lop 9A> .fl_~~r1i41
DATE DRILLED / -'j'/ • //
/ j
TIME COM.PLETED $ .. ··'3'0 AM'o PM.a,
~. WELL LOCATION·. ,.. I
CITY: it'i11.1 l~A-~J!b,-COUNTY._§J-.J.y..·./l
r~-'(!;,t2le >Gb~ .. t ,(2. ~ .
(Sire el Name, flumbera, Cornmunlly, Subdivision, Lo~ No., Parcel, Zip Code)
TOPOGRAPHIC/ LAND SETTING:
□Slope OVallay □Flat ~ldge D Oilier _____ _
(cheek app,opriate box)
LATITUDE _i -~ 03;i1J7
LONGITUDE ~ ~ Q..2.._0 en,
May ho in degrees.
minutes, ~onds or
lna<kdma.1 format ,.___ ____ __,
Latitude/longitude-source: Jl(pPS □Topographic map
(location of we'I musl be sho\•in on a USGS lcipo map and
attsched to this form if not using GPS)
4. FACILITY-ls Uu nama ol tr~ boslnHs whm l.'.a ;.en rs k,,:;I~.
FACILITY ID #{if applicabf9}. __ __,.....------,,----,-
NAME OF FACILITY c~l+Q '12' //,, It'. &(c,h<rh1d1.,n°"1c,
STREE1ADDRESS ___________ _
City or TO'tm Slate Zip COdo
CONTACTPERSOH Toi\,.. ~Ur:Jo .4G~.,...::--"
M/\ILING ADDRESS Pollx ,rec, ·7 1af clj!:rl.. -e tel
Gve <-"Shov~ ti~ ~ 7 "1-/6
Cit'/ o< Town . S1ate Zip Coda
d:3L r 2 7J-JfLf 7J
Area code. Phona number
5. WELL DETAILS: /McJ,,. a. TOTAL DEPTH: __ ~,___ ___ _
b, DOES WELL REPLACE EXISTING WELL? YES O NO:t
~. WATER LEVEL Belem Top of CasJng: ____ .FT.
(Use ·+• if Above Top of Casing)
d, TOP OF CASING IS ____ FT. A.oote land Surface•
•rop or casing terminated aVor below !arid surf <!Ce may require
a variance In accordance with 15A NCAC 2C .0118,
a, YIELD (gpm): _l-5" METHOD OF TEST___,._.:...• l-"---,,<.,,L--...r
f, DISINFECTION: Type HTH Amount-----"'-=----+-----'-"~
g, WATER ZONES (deplh}:
From_~_k_<ifo~ From __ To __
From __ To __ From __ To __ _
From __ To__ From __ To __ . _
6. CASJNG: Thickness/
Oep.lh Oi~meler Welght Material
From __ . To ___ FI.. __ _
From _ ___,To __ FL __ _
From __ To_· __ Ft. __ _
7, GROUT: Deplh Matorial Method
From_a__ To '/tXJ Fr:P, lo';}' _u-:,1 ~"Y)Gf
Fronl __ To __ Ft. 4.)( -,--
From __ To __ Ft., ____ _
8, SCREEN: Oeplh Diameter Slot Size Male-rial
From __ To __ Fl. __ in. In. __ _
From __ To __ Ft._._·_rn, .....____;. rn. __ _
From __ To __ Ft. ___ ln. __ In. __ _
9, SANDfGRAVEL PACK:
, Deplh Size Material
Frco,. ___ To __ Fl. ________ _
From To __ Ff.~--_____ _
From To __ Ft .. ___ -----,.--
10, DRILLIHG LOG
Fron, To •
0 .. t/0
Formation Description
~d:I .
~ \a t;l __ . t;;_, q~8u_, __ .,., __ ,. __ ,:.
11,mRK¾or 6_vn, wJfA (frn%~~''":;°.'.'
__ ·-c.4---l----e......:;.S~~.J___.;t:......._-U_·e.,,,_,{c......i.l _____ '~:;_,:;,;;Ji:,:·:.·:/"'·1,i
I DO HERESV CERTIFY 11-IA TlHIS WElL WAS COtlSTRUCTE:D Ill ACCOROAHCE WITH
1SA HCAC 2C, WELL CONSTRUC1lON STANDARDS, mo TI-V,T A Ct.lf"V OF THIS
~~-HA.<; BEEH PROVID!;O TO THEWELL O '1-l-
: · . /-31··11
NA E C IFIED WE(L CONTRACTOR DATE
PRTu4&~ oW'-eRs~~~T\~tr,NG THE WELL
Submit the original fo the Division of W~ter Quality wlth{n 30 days. Attn: fnfonnat_lon Mgt.,
1617 Mall Service Center-Raleigh, NC 2769!M617 Phone No •. [phone] ext 568. FormGYMb
Rw. 7105
Date site visited: _____ by _____ pennit required: Yes No
,"} , · + --r-1 b.,,,,Yh,.,I ~Cl"\J11c.J1"'Ac...,. 7?.rf v;,,,,~~, /,,A,•.Jf') rv;,)u I/\~, ~
rtu_j io. d<?a" CJtp
Permit Number
Program Category
Ground Water ·
Permit Type
WI0400171 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
mi cha el. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Caterpillar Inc
Location Address
3100 Temple School Rd
Winston Salem
Owner
Owner Name
Caterpillar Inc
Dates/Events
NC 27107
Central Files: APS_ SWP_
01/25/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classlficaticm
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville NC
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Wint Errol .
482 Wylie Dr
Normal IL
27020
61761
Orig-Issue
01/25/11
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
01/25/11
Expiration
01/21/11 01/25/1.1
Re g ulated Activities
Heat Pump Injection
Outfall NUI i
Waterbody Name Stream Index Number Current Class Subbasin
A,~
. NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Catepillar, Inc.
Erl'o1 Wint, Operc).tions Manager
482 Wylie Drive
Normal, IL 61761
Coleen H. Sullins
Director
1/25/201. 1
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Permit No. WI0400171
3100 Temple School Road, Winston-Salem, NC 27107
Dear Mr. Wint:
Dee Freeman
Secretary
On 1/21/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl y
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 ISA 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 .021 l(u)(2). Additionally, you should c.ontact the Forsyth 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.Rogers<@.ncdenr. 1rnv if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. W1040017 l
Forsyth County Health Dept.
Yadkin Well Co., lnc (David Brown)
AC Corporation (John Burds)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
lf~. t\ ~~--.
for Debra .~~~w~~
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-674G
Internet: www.ncwaterguality.org No1!S.kc 1· 01u1 aro 111a
}Vaturallll An Equal Opportunity I Affirmative Action Employe r
Ro gers, Michael.
From:
Sent:
To:'
David Brown [[e-mail]]
Friday, January 21, 2011 5:50 PM
Rogers, Michael
Subject: RE: Caterpillar 5QW
Michael,
The·. info in B, should be applicable to A. This is unusual, but I don't think we wili -find an actual-"owner" for Caterpiller.
The applicant has authorization to act,;
Thank you,
David J Brown
Yadkin Well Co. Inc.
From: michael .rogers @ncdenr.gov
To: [e-mail]
Date: Fri, 21 Jan -2011 14:50:14--0500
Subject: Caterpillar 5QW
DaVid-
We received a 5QW Notification Of Intent for what appears to be Caterpillar Inc. The property owners and mailing
_address was blank on. page -1. However, the authorized agent section B. is fill~d out as. Caterpillar Inc. Does the
information in section B. for ·authorized agent applicable to section A as property owner and mailing address? ,
Than~
Michael .Rogers, P.G. {NC & FL)
Environmental Specialist ..
NC Div'of Water Quality-Aquifer Protection Section {APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Lin·e [phone]; Fax [phone] {put to my attn on cover letter
http://portal.ncdenr.org/web/wq/ap~/gwpro/permit-applications#geothermApps
E-mail correspondence to and from this address r71ay be subject to the North Carp/ina Public Records Law and may be disclosed to third parties
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Jan.18. 2011 1:43PM YADKIN WELL
DATE: If g J011 T, REF No.
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No.631.1
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LOG NO.
COMPAN NAME W RO.
ATTENTION DEPT
FROM: _ <th-al- _ to .c (1.ZKYAT
COMPANY NAME _ FAX AD.
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INUPADUAL DEPT
NUML3ER 4F PAGES PLEASE ORGRAMITS ..
INCLUDING THIS SHEET REPLY 6Y SIGNATURE 'e9.
MESSAGE:
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-FOR ALL. YOUR ►M1IATCR NEE015"
YADKIN WELD, CO., INC.
19W HAWT'ONVrL LE ROAD
HAMPTONVIL.LE. NC 27020
DAVIO J. BROWN, VICE PRE5.
TOLL FRRi"r COW) 248'9$55
QFFiCE (3M) 468 44AD
FWAX 036? 468.40"
RE5 (3961
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-GOOD NEWS ALMEPPCA • Gp4 1,V S YOU-
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