WI0400174_GEO THERMAL_20110308

~ ,,----._.;
GEO-THERMAL WELLGONSTRUCTION RECORD
', . ·NON RESIDENXIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality 391795
WELL CONTRACTOR CERTIFICATION# ) -ri )._
1. WELL CONTRACTOR:
w~ c~1.4:(1n~I) C lJ \ \ I''>
Yadkin We] 1 Cauooov Inc,
Well Con.tractor Company Name -
STREET ADDRESS l 908 Rarnptomzi J J e Road
Harn ptonville NC 27020
City or Town Slate Zip Code
~-468-4440
Area code-Phona number
2. WELL IN!=ORMATI0N: 3. a
5
_
SITE WELL ID #(If appllcable)...._A..........,'4,-..._L-'K.__-_~-~-----
STATE WELL PERMIT#(if.1pplicable) __ --;:--=-----r----=--
DWQ or OTHER ~ERMIT #{ir appiicabla) ~ D c./-0 IJl?'-f
~/ELL USE (Check Applicable Box) MonHoring O Municlpal/Public D
lndusllial/Commerclal □ Agricullural □ Recovery1o Injection □
Irrigation □ Olher)r{lisl use) C/pJ e ~ / 4/c'y:' t1 €s, ·t/viv,.
DATE DRILLED .. ~ -) Y-1 I ' 7
11Me coMPLETEo '.d "':40 AM ·o PM,@!•
~. WE.LL LOCATION:
Cl~: 8 kf _ _111;1 f:n :-·-co,UNTY._sfik:k'-¥-
2 6 o ~oJ.NJ\ l,J...)•~cl J ,
(Street Name, Numbers, Cornmunlty, SubdMsion, Lo.I No., Parcel, Zip Code)
TOPOGRAPHIC I lAND SETTING:
□Slope □Vallay □flat ORld_ge .□ ~lher___,, ____ _
(cneclc appropriate box)
LATITUDE _a_ ·c_ 2 I )S-7
LONGITUDE _R C 2'{ q' ~
May b::: In deg,rc:cs,
minutes, sec:onds or
In a dedmal rormat
Latitude/longitude source: )q'OPS □Top6graphic map
(k,cation of wel musl be shown on a USGS topo mop aod
attached to this form ii not using GPS)
4-. FACILITY-ls lh! r,.rn4 cf ti'~ 1;,i.lnu s wl\m t.'ir. wen Is lo.:al~.
FACILITY ID #{if applicabl9 ,_) ---.--------
NAME er I" CIUTY ·r,;:, ,,.,_ F !-<_V-1 _,, fl 9 STREET ADDRESS 2 ~ 0 Q d J L i... l~,l..,.2 d J
A /u.J /11,./-1, /ii(. ·Z.·10'1-f
City c,r To'Nll Stale Zip Coda
CONTACT PERSON 0v l'm l,, (.-Q L !ft"
MAILING ADDRESS:__ __________ _
City or Town Stale Zip Coda
tJ.i4 >-·3 9 9_··1 i 22 31(-f/6.S --2oc.~
Area code -Phone number
5, WELL DETAILS:
a. TOT AL DEPTH: S 6 Ci ...
b, DOES WELL REPLACE EXISTING WELL 7 YES O N~
C, WATER LEVEL Belon Top of Casing: ____ FT .
(Use •+• if Above Top o( Casing)
.
d, TOP OF. CASING IS ____ FT. Abo-..e Land Surface•
'Top or casing termlna!ed aVor below land surf ace may require
a variance In accordance with 15A NCAC 20 .0118.
o. YIELD (gpm}: d 'S"" -t METHOD OF TEST -----
f. DISINFECTION: Type HI1fI Amounl ____ _
g, WATER ZONES (depth): .-
;;) ~ From..B.l.._ To~ ..J,Jom __ To __
FromJ5V_ro2S:.£ :Jf:-rom __ To __ _
From __ To__ From __ To __ _
6. CASING: Thickness/
Depth Diameter Welght Material
From __ . To __ Ft.. __ _
From __ To __ Ft. __ _
From __ To_· __ Ft. __ _
7. GROUT: Deplh Matolial p/4 ..;Melbtd
·1 ··-_, ~ -, J. .... 91t( l:,\.! ~;;J.?~.;;,-,
From~ To~-Ft. /4Q.t~'1-~ n, 1,..,
Fron, __ To __ Ft.. _____ f '
From __ To __ Ft.. ____ _
8, SCREEN: O~pth Dlameler Slot Size Ma!Mal
From ___ To __ Fl. __ ln. In. __ _
From __ To __ Ft._._._ln, __ In, __ _
From __ To __ Ft., __ ln. __ in. __ _
9. SAND/GRAVEL. PACK:
, Deplh · · · · . Size Material
Frcm. ___ To __ Ft.. ________ _
Frcm To __ Ft. __________ _
From io __ Ft •. ___ ---.....,......--
10, DRILLING LOG
From T.R,
. 0 _..50
."3 D .. SoEJ
Formation Description s,1 · ,, ,::,~ me. Sc,4-1 7., S o~·ft),.,,e::: ~
MARO 8 20 1
I DO HERESY CER TlfY THATil-US WEtL Vl/'S CONS"mUC'TE:O el ACCOROA>~CE WITH
15A NCAC 2C, WELl COHSTRUC110N STANDARDS, mo nv.r A COf'V OF THIS
d-J<-( .. 1 L
DATE
P STRUCTING THE WELL
Submit the original to the Division of W~ter Quality with(n 30 days. Attn: lnfonnatton Mgt.,
1617 Mall Servlca Canter-Raleigh, NC 2769M617 Phone No.'(919) 733•7015 o.xt 568. FormGVMb
Rev. 7/05
Date site visited: 2.-_J .. // by rXJk? Permit required: ~X§s> No sc,;w c.~· --/2.· · J . c.,,,...,,~J
•
NCDENR
North Carolina Department of Environment and N
Division of Water Quality 7 4� S7d,. ;
Beverly Eaves Perdue Coleen H, Sullins
Governor Director
02/17/2011
Thomas Furlong
Susan Furlong -
260 Dodson Woods Ln,
Pilot Mountain, NC 27041
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No, 11110100? "-I
260 Dodson Woods Lin.
Pilot Mountain, NC 2704I
Dear Mr, and Mrs. Furlong:
On 02/16/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onI%
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 systern 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 submittea.
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 .0211(u)(2). Additionally, you should contact the Surry 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.RouersQncdenr.aov if you have any questions -
Sin ely, f
for Debr tts
5uperviso
cc; Winston-Salem Regional Office - APS
APS Central Piles - Permit No. WI0400174
Scary County Health Dept.
David J. Brown (Yadkin Well Co-, Inc_, 1908 Hamptonvilie Rd., Hamptonville, NC 27020)
Don'L Blevins (Blevins Brothers Heating & Air, 397 Blackwood Trail. Dobson, NC 27017)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh. North Cam$ na 27699-16K
Lorawn: 2728 Capral Boulevard, Raleigh, Writ, Gerohna 276:}4 One
Phono-: 919-733-322t i r'AX ? r 919.715-0588, rAX 2: 919.715-604S Customer Sarni a 1-977.523$70 ?��i- h Ca olin �l
Internet www.ncwatero 81u r,.oT' �:��7�r�r�ra�f�
An EgiW Qpmnwl9 At;.rmative Action Employe

Permit Number W10400174
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW )
Primary Reviewer
michael.rogers
Coastal 5W Rule
Permitted Flow
Facilit
Facility Name
Thomas Furlong SFR
Location Address
250 Dodson Woods Ln
Pilot Mtn NC 27041
Owner
Owner Name
Thomas Furlong
Dates/Events
Scheduled
Orig Issue App Received Craft Initiated Issuance
02I17111 02/18/11
Reo ulated Activities
Heat Pump Injection
Private residence, single famlly
Qutfall iA!,J I .L
Waterbody Name
Central Files: APS SwP
02/17/11
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
MajorlMinor Region
Minor Winston-Salem
County
Surry
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Thomas Furlong
Owner
250 Dodson Woods Ln
Pilot Mtn
Public Notice Issue
02/17/11
Stream Index Number Current Class
NC 27041
Effective Expiration
02/17/11
Subbasin

FA
CDE R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Thomas Furlong
Susan Furlong ,
· 260 Dodson Woods Ln.
Pilot Mountain, NC 27041
Coleen H. Sullins
Director
02/17/2011
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
Permit No. WI0400174
260 Dodson Woods Ln.
Pilot Mountain, NC 27041
Dear Mr. and Mrs. Furlong:
Dee Freeman
Secretary
On 02/16/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-only
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 we11 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 sub~itted.
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 Surry 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.Ro e:;:~r.gov if yon ve any questions.
~J:JYJ~-· ~~k_)
cc: Winston-Salem Regional Office -APS
APS Central File: -Permit No. WI0400l 74
Surry County Health Dept.
for Debr tts
Superviso
David J. Brown (Yadkin Well Co., Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020)
Don'L Blevins (Blevins Brothers Heating & Air, 397 Blackwood Trail, Dobson, NC 27017)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, Nonh Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwatergualitv.org
An Equal Opportunity\ Affirmative Action Employer
Nirth Carolina
:Vatitrall!I
Feb. 16. 2011 2:59FM
YADKIN WELL
- FA Nlk TRAMMON FORM
No.6932 ?, 1
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DATE: � � TIME: REF NO. _ LDG NO
`iy13
TO: ols-9111*
COMPANY RAW FAX NO, PLEASE
—
1 ❑IMMEDDEUVER
M1dEQll4TEtY
FROM: G---, (7-7E ) �410 -�
COMPANY --}}�- FAX NO. PLEASE
- RUSH
❑ REPLY
INDMflUAL
NUM DER OF PAGES PLEASE
INGWDING THIS SHEET zmc
_ REM 9Y
MESSAGE:
no -,h` -Gna. +t`
-r 1 --
'FOR ALL YOUR WATER' NEECS-
YADKIN WEL.1- CO., INC.
IWM "AMPTONVILLE ROAC
HA!•MPTONVILLE. NC 27024
DAVID J. BFROW . VICE PRIES,
TOLL FREE 000j Z4"355
❑FFtA£ I338-4440
u PAX [336fi1 468-4L54B
RCS [33W 468-4659
•nova NEWS nW[mCA • G= LPy6S 'IOU'
vEn
OWINAMFr.� S}G1�lAE S --�'
Aqulier • . .fi,
PLEASE INFC7M US %d1&TWI ELY F YOU DO NM ASCOVE Fr~C5 MU RN FULL

Feb. 16. 2011_ 2:59PNL-YADKIN WELL— -- -- - No. 6932—•P. 2
r W11q
NORTH CAROLINA
DEPART T OF P-NVIRONMENT AND NATURAL RESOURCES (NCi75TI]`ij
NOTMICATION OF INTENT TO CONSTRUCT A CLO<SYM-LUUP CEOTMRIMAL
WATJZR��Y iNJECIION WELL SYSTEM.,
TYPE 5—QM WELL 5
In Aceordauce with the previsions of NCAC Title 15A 02=00. &-wc
Muplete tlrls zotifieadou and poA to oddress on &e back page (please Zbxit as lum imformadon).
DATE: — W-40t i
A.
M31
Well Type Cantrmadon: Doft the proposed system circulate potable, water only (no additives) is
continuous piping that completely isdiate' the fluid from the m virvrtment (i-e-
cl4sed-loon)?
Y'es X_ Continue completing this l'arrn.
No Do Not mmplete this form Complete other MC application forms for installing
either a 5A7 well [anen-leop well Jaiesting potable water into the aquifer) or a SQM wail (closed-
luup well containiag aaditives such as lZ 21., ethanol, or other aedfreeze or crrmsion inhibitors).
PROPERTY OWNER(S)l"PLICAM(S)
Lest e-aa Property Owner ljste�d on iropuV deed ff owned by a busiucss or goverrment agency, state on a of
entity and a representative w/authority for signature}:
(1) Ma liag Ad dress: 2& 0- D11ZU",eW AJ.00 ,-) r 44nfZ, _
City: &e2z-'N 0 1-r smte :Zip Code:- 2A175i % County:
HotnelOf;tae Tale No.:.'VCo ,9 ^ IWS!7� coil q__ -
,Email Adder-%&---Website:
(2) Ptlysi=l Address ofValf Site (if different then above): -5�e-
city:
Stitt: zip Cade:
Hcrrseloffce Tale No.: Cell No_:
County:
AUTT30RIZED AGENT OF OWNER, Ir ANY (if the Permit Applicant does q own the subject property,
atmuh a lettar f orn tha property owner authoring Agent to ►nstail and QM -ate UIC well)
Company Name:
Contact Parson: _ .EMAIL Add z:
Address:
City' ;
Office Tale No.:
1Vebsite Aridness of Company, if
Stag: ZIP Cade: County:
itiZt.+r-+VGLl F UliNk Uve,j
.*jlfer F rcltlr:tbr, Suit
FEB It 201f

Feb. lb_ 201 1 2:59PV - - VADKIN WELL
S_ Q kj
C, WELL riltliUR INIGIRMATION
Comparsy-Vame:Yetiitin W li Co. c.
WeuDritler Coatxsctar's i aww rod r �tt� i"� lutattt?esrBrativn 1` itto&gIve
NC Conlractor CertifiicationNo.: 7572-A 3436- 354$-A
Coutw Pelson' David f. fl= ,T ?_t9�,� _ 'AIL Address: ahlefdrii er'a]�rsz.ea�
Address: 191a'$ Nar�sptdilvllieRd,
City: i3am torw2[le M . I Zip Coda 27020 cmmty. Yadkin
OfficeTelallo-; �.336-466-4440 CellNo.: 336-V4-3736
D. EIA.T >?TJ11 Y CONTR ALCTUR WORWA,TION (if diftfeiA Win driller)
Coatpany-Name:. &0-; /4 f AAA
Contact Person �G $L�u�+►!S I"sl►dAtl. Address- _ _
Addtass-. 3'11 7
City; I�OV541-I Zip Code: 2 Ta"? Coanty-
DfftcaTetr_No,: 936 73S 7l S-6 CcitNo.:
2. STATUS OF A.PPLICAM
Private: X Federal_ CotamercW;
State: Municipal: dative Amedcaa Lands.
F.
IVJECTIdN PRD CWUHE (bristly desralbe havvtbe injection wvr11(s) will be used)
O. WELL CON5'I' UCTION DATA .r, --;' o [ j
(1) Proposed date to be conshvcted:.2�� Number of hc4ngs:
Apprmcinwe depth of each baring (feet): -700 y�
(2) Type V� of tubing to 5e ej (copper, I}vr" etc). f � £ r• 1C `�
(3) Weil casing. Is the wells) caW? {check butler (a.) Yesu (b.) No below)
(a) Yes if yes, then grovids casing inforzoationbelow
Type; __-_galvarked steel blac siecai pi$stic other {specify}
Casing depth: Flom —to feet (,-vferencc to Ind surface}
Casing wands to abova ground] -;- ches
(b) Na x
(4) Groot Info (ma terraI suEm=d[A& well easing tA&cz piping); �'tk� C�
(a) Groatt �ypc: Next Cemeut Bentouite Other t$P )
(b) (3101;t piaement: FUJIgks¢g,X Pressure Qtt�e�
(c) Gmt depth of tubirsg (sdcrenceto land surface): from to {feet)
if)veli bas CAsisip, indRcate grant depth: from to Afeet}

Feb. 16. 2011 3:60FM "YADKIN WELL ^-- No. 6932 P. dr
11. 1N3ECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering tryout or proposed wodXcabou off rho injectiDa cquipment and exte;1w
pipirigltubing associated WM the waciion operation. The manufaettzr;r's brochure may provide supplcmeutaly
information.
I. LO CATION OF WFLL(S)
Attach two oopies of maps showing tie 60110wing infan='aon:
(1) ln�lzade a Site Map (can be drawn) showing: buildings, pro" lines, su&ce water bodies; pateutw
sources of groundwater caatamimtia and the orientation of and distances between the: proposed wr.U(a) and
any existing well(s) or waste disposal facilities such as septic tanks or drain folds located within 200 feat of
The geotherxnal heat pump well system. Label aII ;Patutes c1ce- ly and i cJudean soar.
(2) The site Map must show the subject property in Watiazz to the sturoUgftg arcs by Using at leant two fixed
reference points such as roads, streams, and/or highway intersections.
s. CBRTMCATION
Nate: This Permit App5cation must be signed by each person uppesring sac t&e
recorded legal property deed.
"I hereby certify, under peaelty of law, that I bane personAlLv mckwined sad am familiar with the information
subzTziUd in #his dac=cat and all attachments thereto and that, based on uzy itviry of those i:tdzviduals
4=ediatsly responsible for cbtg'n' g said inffozmadon, I believe that the inifor nation is true., accurate and complete.
I am aware dial there are slguificait penalties, including the possibi zy of Ernes and imprisonment, for aubnLttirjs
else information. 1 agree to construct' operate, maintain; repair, and if applicable, abandon the it ection well and
all related appur-:zpances in auccor&w= with the approved spccific atiozs and copditions ofthe PerviW'
8ignnaatuze of Property w/Appl me,
print or Type Full Name aura title
Sign3tam of pFo�7Crty C�`rnerlAppll
S 1 r-`" , t
print or Type Full Hama and title
5igoature of Autbmized Agezrt, if any
PrEW or Type pull Naze and title
Please return, two copies ofthe completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section -MC program
1636 Mail Service; Center
Raleigh, NC 2 7699-1636 RECEIVED / OENR I DM
Telephone [phone] At{tdler PmWdjon Segiwt
FEB 18 2011

F e b. 16, 2011 31 O PM
YADKIN WELL
No.032 P, 5
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