WI0400168_GEO THERMAL_20110120

GEO-THERMAL WELL .CONSTRUCTION RECORD
NON RESIDENTIAL WELL CONSTRUCTION·RECORD
. I
North Carolina Department orEnvironmenl and Natural Resources• Division of Waler Quality
WELL CONTRACTOR CERTIFICATION ff ___ ;)_t: __ -_7 ___ 2-. ____ _
Yadkin We] 1 Como=my Inc,
Well Contraclor Company Name ·
STREET ADDRESS l 908 Rarnptomri J J e Boad
Harnotonville ~"C 27020
City or Town Slate Zip Code ·
r 336 )-468-4440
Area code-Phana number
2. WELL INFORMATION:
SITE WELL ID #{It applicable) d:d/C;-3 '( K
STATE WElL PERMIT#(i! applicable} __ __.·"-------
DWQ or OTHER PERMIT #(if applicabla) __________ _
WELL US e (Check Applicable Box) Monitoring □ Munic1palJPublic O . I
rnduslnartcommerclal □ Agricullura1 □ Re¢overy □ lnJecllon D Irrigation□ Other~lisl use) C foJ (> ~ lu ~,;:, <jfl " -Mev'"V.t
DATE DRILLED j ::2-~ IL{-( 0
TIMECOMPLETED 5 :-,n:, AM'□ P~
3, WELL LOC(TION: , ·
c1rv: C e vi ,....,,.ol\.) couNTY Dau; & Joi,
(h / fl (c_o ff For~ f? !.
(Street Name, t~umbers, Community, Sul>dMsion, Lo,l Ne>., Parcel, Zip Code)
TOPOGRAPHIC I lAND SETTING: .
□Slope □Valley OFlal ~!S'Rldge O Olher _____ _
(check appropriate box)
LATITUDE ._a_-_r"' ,CZ. J °2C May~lndegre:es,
minutes_ seconds or
LONGITUDE _a:_ Q_ • { iJ 8 J...) In a d:clmat rormat
Latitude/longitude source: ~PS oTop~graphio map
(location of welmusl be shown on a USGS topo map and
attached tq (his form If no( using GPS)
4. FACILITY-II Uu nar:1a ol lt-s business wh.-ta l.'la wen Is Jcc;\id,
FACILITY ID #{if applicable} _________ _
NAME ol! FAc1urv Ofi.11rut Cvqilrv'
STREET ADDRESS ' / Y (,a j J For""' [2 L cJ~ l1J/n u/1 S Ai e,, 1 '] 0 l 2
City or TO'.vn Stale ·Zip COdo ·
CONTACT PERSON -Bf2,a.J. Fa l b / lo'i (ti\ /.J.-./-,+(
MAILI.NG ADORE .. SS \~/ Y 2 A/, C g-14 ~'J?',r btr
(,~ U L( h:,11 ~ ( rd{ e -;;;.__ ;() '-~ r_j__O (
City or Town Stale Zip Coda
c:J :J( >-q 2 y ~ 'II 6 I
Area code -Phone number
5. WELL OET AILS:
a. TOT AL DEPTH: ;}__ jt () 1
b, DOES WELL REPLACE EXISTING WELL? YES □ N9.Jr
c, WATER LEVEL BelC7H Top or Ga.sing: ____ FT.,
(Use ·+· if Above Top ot Casing)·
d, TOP OF CASING IS / FT. Aoote land Surface•
'Top or c;aslng terminated aVor below land surface may require
a variance In accordance with 1 SA NCAC 2C .0118 .
o. YIELD (gpm): 0 METHOD OF TEST 'i / V'
f. DISINFECTION: Type HTH Amounl 'JJ'( W/
g, WATER ZONES (depth):
From __ To __
From __ To __
From __ To __
From __ To_· __
From __ To __ _
From __ To __ _
6, CASING: Thickness/
_...Depth ,,,,,.,.,.--Dlnmeter Weight Material From_"_· To __ Ft.. __ _
From __ To __ Ft .. __ _
From __ To_· __ Ft.. __ _
7, GROUT: 0eplh Matolial Method
From_b__ To-™._Ft.1 -kerN G,A .IJc)o~~
From __ To __ Ft. . ..d-~ r 1
From_· __ To ___ Ft. ____ _
a. SCREEN: Depth Diameter Slol Size Ma\e-rlal
From __ To __ Fl. __ in. __ In. __ _
From_·_To_Ft.__..__:_Jn. -rn,,eAEI /ED From __ To __ Ft. __ ln. __ trf"'ic.L __ ,: ,, ·-
9· $A~D6~~VEL PACK: Size MatertaUA N 2 0 011
Frcm ______ To __ Ft. ________ _
From ______ To __ Ft. VVA-Y:ER QlJ,~UT"Y :;~l,1"10!'1 ~ lnform:.tion Proces mg Unit From,.___ __ To __ Ft. ____________ _
10, DRILLltlG LOG
From To
0 -f .l...
Fonnatio_n Description
I DO Hl:REBV CERTIFYll'IATlHIS WEll W>S CONSTRUCTED,, ACCORDAHCE wrrn
15.A NCAC 2C, WELL COllSTRUC'1lOH STANDARDS, AND ntt.T A COPY OF~
RECORD 1-1>.S BEEH PROVIDED TO THE WElL OWNER. ,
~.,,,¢._~~=:-g¥.-.£.__...1.Jt1:~~--f:-1-J'-f-lAJ TURE DATE
To "'1 .., ·hJ fYl u ( ( .. ~
PRINTED NAM E OF PERSON CONSTRUCTING THE WELL
Submit the orlginal to the Division of W~ter Qualitit wlthln 30 d!!!:Js. Attn: ~nfarmatlon Mgt,,
1617 Man Servlce Cent&r.-Raleigh, NC 27699·1617 Phone No,'[phone] ext 568.
Date site visited: I/-J O··•ff> by O Gt, Permit required: @ No
FOl'mGVMb
Rev. 7/05
.SQw,
Permit Number W104001 G8
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michaei.rogers
Coastal SW Rule
Permitted Flow
Facilit.
Facility Name
Dennis Craver SFR
Location Address
614 Scott Farm Rd
Clemmons
Owner
NC 27012
Central Files. AP5 SWP
01 /06/ 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
Davidson
Facility Contact Affiliation
Owner Name
Owner Type
Individual
Dennis Craver
Owner Affiliation
Dennis Craver
614 Scott Farm Rd
Ciemmons
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated issuance
Public Notice Issue
01 /06/ 11 12/01110
01/06/11
Regulated Activities
Heat Pump injection
Outfall f I
NC 27012
Effective Expiration
01 l0611 1
Waterbody Name Stream Index Number Current Class Subbasln

Beverly Eaves Perdue
Governor
Dennis Craver
614 Scott Fann Road
Clemmons, NC 2701..2
~7A ·
NCDEHR
North Carolina Department of Environm·ent and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
1/6/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400168
614 Scott Fatm Road , Clemmons, NC 27012
Dear Mr. Craver:
Dee Freeman
Secretary
On 12/1/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onh·
. geothermal injection well system for the operation of a ground-source heat. pump located at the address referenced above. An
individual pennit 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 injectipn well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .02B, 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 .0211(u)(2). Additionally, you should ·contact the Wake 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.Rogersrcimcdenr.cov if you have any questions.
cc: Wi.nston-Sak'111 Regional Office -APS
APS Central Files -Permit No. W10400168
Davidson County Health Dept.
Yadkin Well Co., Inc. (David J. Brown)
Logan Heating & Air Condi tioning (Scott Boyles)
AQUIFER PROTECTION SECTION
1636 Mail Se1Vice Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capitat Boulevard. Raleigh, North Carolina 27604
Sincerely,
for~A-~
Supervisor
Phone : [phone] \ FAX 1: 919-715-0588 ; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
hn EqLial Op portu nity Affi rm ative Actio n Em ploy er
One . N orthCarohna ,?\Jatutallu ,7
Dec. t 2010 8:59AM YADKIN WELL
No.6409 =p. -
- ealA J:
NORTH CAROLINA - X
DEPARTMENT OF $NV1RONMENT ANT) NAnMAL RESOURCES (NCDBM-.
NOTMCATION OF IlfUNT TO CONSTRUCT A CLOSED -LOOP a ' '� •, `' yr ' L'
TEONLY INUC7ION WELL SYSTEM-. W R
J.YPF, 5-VW, TTJJA. (
In Accordance iFitla the provisions of NCAC Title 15A: v2Co2vor please ' -
complete this notification aad mail to address on the liars page (please Print or vm inbd0t1*.-
Well Type C012fumdam Does The proposed system c rcalate potable water only.(uo addltnrq .' t •
ooat4=us piping that oompletely isolates the fluid from the enviror ffp
Glared-laon)7 r-'
Yes Continue completing this farm-
No *Do Not complete this form. Complete other 12C application forms -for 40t�,g
either a 3A7 well o e -loop wallet potable water into the agiiifwj Ora SQM hall
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosi0di i37 ifs �e' -
A. MO)?ERTY OWNER(S)iAPPLICA:NT(S)
List each Property owner listed an prop"deed (if awned by a business or government agan*;'s b sr y�Of,
entityend a repiesentaxive wlauthori f
ty for signature):.�^ram'
(1) Mailing Address:
City: r1je m e".9 el s , State: AI G7ip Code:_ . L -1 O C e _CoW; j" NL
Home/Office Tele No.: Call o.: r .'
Email Address: Webme:
(2) Physical Address of Well Site (if different then above): m� ',W + . '' •.��
City_ State: Zip Coda: Cotes. s.,..• .:� �'
HomeJDffice Tele No. Cell go.
B. AUTHORIZED AGENT Olt OWNER, XF ANY (if the Permit Applicant does ngj own tha suli9 1Pr$P�Y:.r _ -
attach a letter from the property owner authorb iug Agent to install and vpemte WC will) • : �' % i
Company Name:
Contact Pelson: Y-MAIL Address:
Address:
City: State: Zip Code: County- '•
Office Tele Na.. Cell
Website Address of Company, if any: ,

Dec,
C.
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F
G.
2010 9:06AM YADKIN WELL
No. b4a9
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P; �. , • .
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VV*JML DRILLER INFORMATION
company Name.:Yso4n.Wen ca Inc
Wail Driller Coutraetor's Name: Jodv Mullis Matthew -Brawn Milton Cave
•:� -
•
NC Contractor Cartif:cationNo.: 2572-A, _ 3016-A _ 3548-A
C.'outact PersonDavid 3.kbwyn 14.:A _ EM1�i[ Address: comer_
tnsn.C9ln
j
Address: 1909132mptanvills Rd.
City: Hsm to 1 a Zip Code: 27020 County. Yadkin
+
Office Take No.: ,_336-468-4440 CeB No.: 336-3744736
RLrAT PUMP CONTRACTOR MFORNIA7.10N (if different thFin driller)
•.
Company Naito:L �� � � r _Scar � $' k �yn ���7 a +Z ► � ci
`•�
ContactFersan: Sic 4-4- do _r EMAIL Addrm: %1'
_
Address: / P-z �((!.
r�
City: WLVj 7A-spt!r e � Zap Coda: �? i fib. Count}: 11;t-j Se
dfficeTexeNo.. 3,X—T��lCelINw 336--el%C— 58b'a
STATUS OF',A,PFMCANT
Private: Federal: Commercial:
�
• .•
`rr + -. •
�
State: Municipal r Native American lands:
7N37ECTION IRO CEDURZ (briefly describe how the ection w►*
� y isaj ells} �vii[ be used}
fj �[� �
ni
WELL CONSTRUCT.IONDATA
(1) Proposed Hate to be constructed: 20 I a Number of borings:
•
, f
rt
Approximate depth of each boring (feet):
(2) Type of tubing to be -used (coppw, PVC, ego): H00PA5' Pjf
(3) WeIl casing- is the vmlks) cased? {check either (a.) Yea or (b.) No below)
�' +• :.- " .
(a) Yes if yes, than provide casing information below
Type: ---galvani-tedsteel black steel plastic other (specify)
e
Casing depth: From to feat (reArenoe to land stsr#'ace)
Casing extends to above ground bches
(b) Ne
-
(4) Grout Info (material suwoutdjitg well casing and/or piping): I�
4.�
} -
' r
�j,�ft•r
_ ;�.,=:
(a) Grant type. Neat Cement Bentonitc0 the (Pew
(b) Grout placement; Purupin&� pressure Other
(o} Grout depth ❑f t'abing (3vfarence to land surface). rx= ZZO to
(£eat}
F � ' •-
1.f well leas casing, Wdlcate gout depth: from to

. . ' M . -
Dec. 1. 2010 9,4QAM YADKIN WELL No.6409 P.
15, INJECTION -RELATED EQUIPMENT
Attach a djq= showing the enginembg layout or proposed modification of the injection egnipaient.ad axtgrlor • �,,
pipiurtgltubirug associated with the Injection operation. The maaufactur;r's brochure may Provide StippIi , ' .
Z. LOCATION 010 WELL(s) h �
Attach twrr copies of maps showing the following infornnatiozL `" •�
(1) Include a Site Map (can be drawn) showing- buildings, property Unes, surfivi water 36 tktdntiai .'
sources of g mmdwatcr contamiilatxoA and the orientation of and distances beMori the pro=' -I
���)�•and-...
any existing well(s) or waste disposal fiLeWties such as septic tanks or drain %Isis located feet 6f '
the geothermal heat pump well system. Label all features clearly and luclude a north sum..
(2) The Site Map must Show the subject propeM itt relation to the surrounding. area by wing $t.l '� iced
reference points such as roads, streams, andlor highway intersections.
J. CER'I'MCATION
Nott: This Permit Appliaatiou must be signed by each person appearing on the
retoxtled legal property deed. _
"I hereby certify, under penalty of law, that I have personally examined and am -familiar with t a'infdimWo;
submitted in this -document and all attachments thereto and that, based on my. inquiry "of .t6sv 10ividuair,
immediately responsible for obtaining said Wb matic� I believe that the information is true, aoC4 wla gird tojr plet�--.
I am aware that there are significant penalties, including the possibility of fines and impr!sonmmat; .[ot.34mitft
false inform$tion- I agree to construct, operate, maintain, repair, and if applicable, abandon .the .iuj�3&n &D and
all related appurtenances in accvrdanae with approved specifications as renditions of the Feruitr"'
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Property OwuerlApplicaut "
Frint or Type Full Name and title. =
� r
Signature of Authorized Agent, if any
Print or Type loll Name and title "
Please return two copies of the completed ,A.pp2cation package to:
North Ca3roiia2 DENR DWQ ",; ��•- .
Aquifer Protection Section MC Program��-
1636 Mail Service Center _•"
Raleigh, NC 27699-1636 - • - + ' . �V
Telephone [phone]
_ .4-" r.
i 16

Dec, 1. 2010 9:00AM YADKIN WELL
No.6409 P. 5
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ADDRESS: _ J _I ]`_ ems_
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336— 60 [x cC IT2
()e-,,,M15 C rimer
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Dec, 1. 2010 8:59AM
YADKIN WELL
FAGS WU TRAMMON FORM
DATE: tI 1 i 110 TIME: REF NO.
TO.
FROM:
No.6409 P. 1
LOG NO..--!—..
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NO.
COMPYUiY NAM$
FAX NO.
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INDMOUAL
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NUMBER OF PAGES
PLEASE
ORUGIN,4ims
INGWDING THIS SHEET
REPLY BY
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MESSAGE:
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FOR ALL YOUR WATER PtEED$-
YADKIN Wl=LL CO., INC.
i SOU HAMPTOWILLE ROAD
NAMPTC14VILLE. NC P76AO
DAVI❑ J. BROWN. VICE PRES.
TOLL FREE (WO) 24X9MS
OFFICE (3M� 4584"0
FAX [phone]
R ES 133W &6&AG59
•6000 NEWS AuSAiCA - G06 LOVES VOV-
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PLEASE UZFOF41A US IMM MULOMY Ig VYJ DO N07 RI:pE71� L
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