386619_Well Construction - GW1_20100827

GEO-THERMAL�yWELL CONSTRUCTION RECORD
1 ONI�ESIDENT,IAL WELL CONSTRUCTION RECORD �s
Y f f
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION N u' -47
1. WELL CONTRACTOR:
Well Contra or (Individual) Name
YYrlki n Well Company Inc.
Well Contractor Company Name
STREET ADDRESS 19f1R Hamptnnvi 1 lP Rccarl
Hamptonville NC 27020
City or Town State Zip Code
( 336 )_ 468-4440
Area code- Phona number
2. WELL INFORMATION:
SITE. WELL ID #(It applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery Injection Injection ❑
Irrigation❑ Other cJ (list use)
DATE DRILLED 6
TIME COMPLETED 3 UO
AM 14413-
3. WELL LOCiTION: 1'
CITY:Car a cocou r'f Vee , /o / liGs
22Qoj keh{h.cv-e. Ave,
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC ( LAND SETTING:
lope r)Valley ❑Flat ❑Ridge 0 Diner
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
In a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(foca(ron of waimusl be shown on a USGS lope map and
attached (o this form if not using GAS)
4. FACILITY- Is nhe name of the business where the well Is located,
FACILITY ID #(if applicable)y�.`/ /
NAME Or FACILITY ohPkT L» % Mprr.
STREET ADDRESS 2 ZQGf ke n.+"kr.`
City or Town Stale Zip Coda
CONTACT PERSON GetU-. eAk,.JJ-4- /,w.h4'
MAILING ADDRESS
a
City orToNn
State Zip Code
Area code - Phona number
5. WELL DETAILS:
a. TOTAL DEPTH:
b, DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Belo-rr Top of Casing: FT.
(Use •+• if Above Top of Casing)
6. CASING:
d. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated aVor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 5"4=' METHOD OF TEST
f. DISINFECTION: Type FITH Amount
g. WATER ZONgs (depth) ,
From t 7 To 151 From To
From To From To
From To From To
Thickness/
Depth Diameter Weight Material
From To FL
From To Ft
From To Ft
4
7. GROUT: Depth Material Method
ha4.c•tf
From �,'' To;%S° FFlYl.traiw C:a1.d ,trifek�
From To ii
From To Ft
8, SCREEN: Depth Diameter
From To Ft
From To Ft.
From To Ft
9. SAND!GRAVEL PACK:
Depth - Size
From To Ft.
From To Ft.
From To Ft
10. DRILLING LOG
From To r
4r . /3
in.
tn.
In
a5c>,
11. REMARKS:
Slot Size Material
In,
In.
Material
Formatwrt Description6-0
YY) ef)d'Pf' -1-v / j
RECEIVED
AUG 2 7 2010
Infor.,. {ter -Pr c s,, Dirt
DWQ/BOG
!DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED PI ACCORDANCE WITH TSA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THLS
RECORD HAS BEEN PROVIDED TO THE WE ER.
+: ATU: ° OF CERTIFIED WELL CONTRACTOR DATE
1/41
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Date site visited: by Ppl Permit required: <ED No
Fast GW-tb
Rev. 7/05

aimc
S NAME: f "1) d- it)//rncv
ADDRESS:
aa,- 6N 1u c
PHONE NUMBER: 20 C W - SD 0 S[
-cvor-4- £f'i , e..
)C01 r,aia.

Nc)lti CAROLNA
DEPARTMENT 01? ENVIRONMENT AND NATURAL RESOURCES (NCDi.Nlt)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED LOOP OEOTHF.IPMAL
WAtKU-O iJ Cr10N MIL SYSTEM:
TYPE S-OW, cLL(S)
In Accordance with thcpmvisloos ofNCAC Title 15A: 02C.02OO: please
complete this notification suti mul to address on tlic back' page (please Print ar; A'pe lufbtlon).
DATE: ! _R 20 /
Wail Confirmation! Does the proposed system ciraulato potable walhr only (no additives) in
continuous piping that completely iso)atcs the fluid from the cnvircmnient (i.e.
oscd-loop)?
Yes X_ Cont3rule completing this foam.
No Do Not complete this forth. Complete other TlIC application forms for installing
cltbcr a 5A7 wdl (opert-loop wvll in5cct*ngpottblc w into tbo aquifer) car n 5Q1Awall (olozoci-
lonp wall cont:ainiag additives such as R-22,, ethanol, or other antili'etsze or o01T091Ou inhibitors).
A. PROPERTY OWNIM(S)(APPLIC1i T(S)
List each Property Ow ter listed en property deed (if owned by Et business ar government Agency, Mate name of
entity old a fopregentarive wtauthority forte� naturo): {{ yy
(1) iviaiiieg:. ; .- r- C fAN.0City: (y 64,(b e statz-aiLzipCode: 43. County. t,'"ter (c
Mee Tele No.: _11 7 5 71' c-t05 9 G coi? Iss,;,x1� �' ;' Z 7. ' z_
3-4
1,;'ma 41 AdAi ee$:_ _ Websips:,
(2)
Physical Etdthuus of Well Site (if different than above):
City. StaCc Zip Code:
Hume/Office Tele No.: CellNo.:
County:
B. Al)'I']HORT7D AGENT OF OWNER, IF ANY (if tho Pennit Applicant &RE G tLVbbfedrt:?ropertY,
attach a letter from the property ovacr authorizing Agent To install and operate 111ig 'et )Z 2010
Company Name: tfiftntialtomProcessingttrrrt
Contact Person: LJ&L Address: DWQ/BOG
Address:
City:
State Zip Code:. County:
Office T1510No.! Cell N4
Wobstto Address of Company, if t{ayr

WELL DRILLER IPIFOY IVIATiON
CompanyNsmuc•VadlcinWolf Co, Imo.
Wall Dritier coniractor's Nave; IndyMulli4 _ Wihew131.owrm JAiltoCove
NC Contractor CcrdfioatlonNO,t 2572-A 3036-A _ 3 9�
ConiootPerson; David J. Brown, 219 -A
Address:1908 Rarnptogvipe Rd.
1 MA]L Address: ciii,afd[liicamsn,ccun
City: .11aniutonAll^ N.C. Z2Codo: 27020 County: Yadkin
Office TeleNo.: 336-463.4440 _ CeilNo,:336374-8736
A, MAT YLI'!YI£' CCTO1LIN.13O1 AZtOX(if diffnxant than dater)
t;ttn:gmly Mine: OS S Q M�.t.�/ f'7►' ' f
m
Contt:etFeiSain: ..t7D 4.-9
Addtess; L2_.k7271 feS._
City: t01, z1p Codoff
e: _ , County L°�4
Ofcc'rcleT<c .; p e S9, • b(& Cott T1D. 7 . k d¢/ • e �.14 i L
EMAIL Address'
` s.ra /—teiwr o-. e7
STATUS OF ci1'PX XLiiATT
p,:;yatee: (.' .Federal: Commercial'
StApi Moo tuipctS:_ , 7v,rtiv Arne -de an I, ands.
INIEC'L'fON E'TtOCEDURS (briefly ct,.sar1ba how the i ajectionwelt® 'Mil be ne i)
C, I ��� f— , f 24 (e.Ty r - e ers 9 e. e L l—
}, tv1iC NS IltiCTIMirDATA . 2
(1)171roirooedd foborcuwatr:Ioterh C-.1sTurn1,ernphorknas: �.
Appr<micuat© depth of ei oh bortns (foot): 2--ro % "
(2) Typo of tubsag to b -mod (ooppor, PVC, eta): /4 %)iO/ S D %z - I 1
(3) W oti coming. 3a flue we11(s) c*iaed? (uhuuk etiher (ci.) Yes or (b) No below)
CO Yes ltyco, thou pro'iclo oasinfi inforsokon below
Typo: _galyorti2ed ateel blhok gNrof plactto_ other (specify)
Cluing doptlu Ron to foot (roforonoo to 14ud gurftice)
Casing t nctoto above grout d. tnohes
(b) No A.
(4) (rout Info (r foriol 4urrnundIng hell ctt9.iugandfaplph}g): 7-4 err t��
(i0
(b)
(G)
tea evGed
(3 root typo: Naot Cot 13ento»lto .>(, Other (r psoify) _
Grout placement: P► n ping.,k,,,,, Primire Other (front depthof tnhing (rofcronco for lend outface): from Z ra to 3 lu rxr1 C E I V E D
Ifwc11hnxui=f1ug,indlaatagroAtdepth; 6om f toy' (Mot)aUG 2 ( 2010
Information Processing Unit
DWQ/BOG

TN'JECTZQ.? 2RIT Aitin EQUIPMENT
Match a diagram showing lho engineering layout or proposed .modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The ztfl E tuner's broclswe may provide supplementary
information.
LOCA'LXON OF Tr77ELL(S)
Aunch two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing: buildings, property Hues, surface water bodies; potential
sources of groundwater eontmninatton and the orientation of and aistaucas between the proposed well(s) and
ety existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 fact of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2)
The Silt; Map innst slmrty thc subject property 11t relation to the svi rot r ling arca by wing at least two fixed
to ilenev points such.as roads. steams, angor highway intersections.
J. CERTIFICATION
(I+ICATION
Nutt;: This 3'arnait Application i ntst be signed by ea eh person appear:1,g on the.
recorded Ie;gal property deed.
i;ereby certify, under pentlity of law, that J. have personally examined and um ihrnliJar with the adorn -Aaiun
submitted in this document and Ali afis; nenra ?hereto and that, based on my inquiry of those individuals
immediritGly r possible for obtaining said information, r bcliovc that the infor iratton is true, accurate and CUtill)tete.
1 nm aware that there are sigt ficani pc unities, including the possibility of tines and imprisonment, for submitting
:t),_e inffrm4':oxi. 3 a r: to cos;stxtiCt, operate, rsaznirdn, repair, and if avplieuble, abandon thu injection well aaact
u1l . oiate>1 asp t tenances in accordance Valle 1 r t lee) ai,J,*i nd con itions of the Permit"
SiaikanreofThoperry—«rw 'r�pplieanf
tO 100, 1-4 .- Loc. sA,., ,
Print Typo. full Name end title
„Jr)
Si0iwiure of P,r'.pr,t O'vu -r/AppJimut
Le 5 I Cal
Print or Typo 1w [1 Nano and title
a
Print or Typo Pull Name rand tit30
Please return two copies of the eompleted Application package to:
Notre Carolina DE:NIt.-DwQ
Aquifer Protection Section -MC Program
1636 Mali Service Center
Raleigh, C 21699-1636
ektpoue (919) 716-693S
RECEIVED
AUG 2 7 2010
Information Processing Unit
DWQ/BOG