386618_Well Construction - GW1_20100827

GEO-THERMAL�yWELL CONSTRUCTION RECORD
NON WELL CONSTRUCTION RECORD 3
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION ti 72
1, WELL CONTRACTOR.
We Contractor r{Itdividual) Name
Yadkin WRT1 Cormaxv Inc
Well Contractor Company Name
STREET ADDRESS 1 qf)R Hampfrinvi 1 1 P Rcpr1
Hamptonville NC 27020
City or Town State Zip Code
( 336 )_ 468-4440
Areacode- Phone number
2. WELL INFORMATION: /3 Q
SITE WELL ID #(If applicable) ,trK— 1 V 3
STATE WELL PERMIT#(1i applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring ❑ Municipal/Public 0
tndustnat/Commercial 0 Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other 0 Viet use)
DATE DRILLED at-1- to
TIME COMPLETED 57;4ti AM O PM-
3. WELL LOC TION: /I // //
CITY CAU✓7a� COUNTY/41NZA(Phf/ 3
2209 kehry►cve '4ue,
(Street Name, Numbers, Community, Subdn;sion, Lot No . Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
„tglope ❑Valley ❑Flat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE 3•
LONGITUDE
May ho in degrees.
minutes, seconds or
In a decimal format
Latitude/longitude source' DGPS ❑Topographic map
(location of we:musl be shown on a USGS Iopo mop and
attached to Ihrs form dnof using GPS)
4. FACILITY- Is the name of Its business where the well Is located,
FACILITY ID #(if applicable)/ /
NAME or FACILITY rob(,,--1-
STREET ADDRESS 2 2.oCI ke n.KoyL �
(.4e-/.4_ J/L 2VzoS1
CI or Tc n State' Zip Code f
CONTACT �PERSON
h 6- e D U- E// j e f d .) U - k) J,w
IiiNG A a R � ., %�ca2a(�rJ l�31,4eKtk
City or Town State Zip Coda
c _) 3472-f1,4 ^A704 651/-Sbo f� Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH.
la, DOES WELL REPLACE EXISTING WELL? YES 0 NO ❑
c. WATER LEVEL Beto'rrTop of Casing FT,
(Use "+' if Above Top of 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): 3c'T METHOD OF TEST
f. DISINFECTION: Type I-1 TH Amount
g.
WATER ZONES (depth)
From / YC To / (od From To
From To From To
From To From To
6. CASING:
From
From
From
7. GROUT:
From D
From
From
8, SCREEN:
FromFr
From
9.
From
Thickness/
Depth `Diameter Weight Matenal
To , Ft
om To Ft
To Ft
Depth MaterialA� ha -Iced
1.
To a -SO Frfern.b m To Ft
To Ft
Method
Depth Diameter Slot Size I,latedal
To Fl in. In
To Ft. In. In,
To Ft. to in
SANDIGRAVEL PACK:
, Depth - • Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From _ T /�d Formation Description
4"
i‘i1-- r `rt, /Pine/S rf J. 4-1j
11, REMARKS:
RECEIVED
AUG 2 7 2010
DWQ/BOG
1 DO HEREBY CERTIFY THAT1HI5 WELL WAS CONSTRUCTED Pt ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT ACOPY OF THIS
RECEENP DED7�EWEL���
URE OF TIFIED WELL CONTRACTOR DATE
LR KW 3
PRINTED NAMNAMV OF PERSONICONSTRUCTING 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.
,ii
Date site visited: by ' Permit required: <0 No
Form GW-lb
Rev. 7105
r

l-1vi-c
'HERS NAME: geij cf io//,„v
ADDRESS: ?- 0 1-?? d 4
PHONE NUMBER: 20 9- c cz/ - SC) o sz
kol

NOWJH CAROLINA
DBPARTMFiNT Oki BI'WIRONMJ3NT AN) NA'I'UkAL Ri3SOURCJ S (NCD)iN1t)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED LOOP GEOTHERMAL
WA jury.(-QX it J Cr10N WELL SYSTEM:
TYPE S-QW _' cLL(S)
la Accordance with thcprolisloos ofNCAC Tito 15A; 02C.0200, please
complete this notification and Darin to address on the back page (please Print or A'pe lac tlon).
DATE: ' Q 7 ._, 20 / U
Wall Typo Confirmation: Darr the proposed system cirenlato potabla worn. nrly (no additives) in
continuous piping that completely .isolates the fluid from the environment (i.e.
(oscd-loop)?
Yes X__ Cort32uue completing this fern_
No Do Not complete this form. Complete other%JlC application forms for installing
olthcr a 5A7 wdl (opcu-loop won cct ng potable cT into the xcluifor) c,r n 5QM vwoll (ok od-
lonp'r oIJ containing additives such as R 22,. ethanol or othc,r antifretsze or carrosion inhibitors).
A. PROPERTY 0WN2rR(S)iAP'LIC1> T(S)
List each Properly Owner listed on properly deed (if °wil ( by a business cif government Agency, state name of
entity old u i c cesonterve wiauthorily for guutur.):
toe C.. HOC & WI 2 S Fe 7
(i)
(2)
hl�ailia€Address:
citr_e_pN 0\01-z At
y: ,('�'',4,., to 4\ e SSEdo:Ki( JFZinCoc1ef: Iry ?�.• /y County:(9rie C (C- _
'_ Oft3ce ale No.: f�•4 f! T� 9 +.' can .o.,;,�r t io 3. Z. Z. 3 .✓'7
ramoll A&tress:_ ,Websist:?:
Physic -a ActdxG5s ni' WciJ ;Witt (if di Croat than ttbovo); _. .
City. , Zip Code:
Home(Office Tele No.: CeilNo.:
County:
B. AU HORT2 D AGENT OF OWNER, r' ANY (if the Permit Applicant ORE
'� J 5 �rcpertY,
attach a letter from the j)1'i property owncr authorizing Agent to install and operate �41(1&el)7 2010
Company Name: ligeFi Fttat bWPracessinw-tfrttt
Contact Person: lZ6, IL Address: DWCWBOO
Address:
City: „ State: hip Code: County:
Oft oToleNu.: . �„ CeiaN4.:
Wobsito Address ofComixuny, if *my;

WELL DRILLER 1Nirali. 1LTIOi (
Compa yNa rua'Vadkin Welt Co, Inc.
Wolf Driller Contractor's Naixtc: 7odyMu1fl _ Matthe_wBrown
NC Contractor Cert fioatlonNO,; 2572-A 3036-A
ContactPersodl; David J. Brawn 219S-A EMAIL address: ciiiafdtliklc(amsn,cnm
Address:1908 Harnptouvllle Rd
City: 112motonyJl1R N.C. _ 7�ij Codo: 27020 County: Yadkin
Once TeleNo.: 336-463.4440 Ceil Ate,; 336 374-373d
), I7PATI'tYb'I£' CONT CZO1.11IIVORMA.7.701`i(if eiifiazent Hann d rilter)
compnnyMaine:— DS�i Q !tf'71'2-"frj Mee
Cocifact Pci;,son: Ci7e4 7 I / � - EMAIL Mdre.0 S'a 4,11h140
Address; zb2Z44.1e5._ ��/� J�
Code: __ , Coant : /' "r e-6-
Gift': a VI)
111-16
Onlca•rcle'lg .; :4/DLit:.. 9; ' b/c 'Ca11Nt1,f.7!% • lij/ ' .e7i ii
STATUS OP? cl.r1'X C. tNT
Private: V/ Federal: Commercial'
vigt:•t Municipal:. Zv'ativcAttack onLands.
T--
LN3LC'L'XON -ertOCED11T (brle0y describe how the tojection.wags) will be mil)
), WE'LL CONSTRUCTION DATA. IJ
(1)'Pror*sed date bo rc+otiatsnoted: G, -2- . .c 2X NUrni)er t}fborinex
Approximate rtmat© dep h of esoh boring (foot): 2 S-O % "
(2) Typo of tubing to bo -need (ooppor, PVC, etc r- l i) J Q (??. - 1
(3) Well easing. 3a ttw well() orraGd? (nlsouk eliber (ci.) Yos or (b,) No below)
(a) Yes ifyts, thcin Provide oaeing informWien below
Typo: __Artlyani2ed ateel bleak HNrof plactteti other (epee*)
Casing dopths Psorn: to foot (roforonoe to laud gurfaeo)
Casing a ttonclsto above ground. ivohoe
(b) Nei
(4) Grout Info. GcutThf&(zc tor:el 4urrnundIng well cH9ingand/orptpl»): T1er t/v � n cep'
(aa) Groat typo: Nowt Consent Bentonite .(( Other (epeoUy) _
(b)
(c)
Grout placement: Pumping. ' Proatue Other (� ` (�
Mont dcptlx of tc1 iog (roferont s to lend inn -face): floe to 3 (RiF E 1 \/ E D
]f w4I1.hn i c mlug, ladled* groAtdepth; Gom tom (fA° UG 2 7 2010
Information Processing Unit
DWQ/BOG

1<N'JECTIOJ-flELgT ) EQUIPMENT
Attach a diagram showing the engineering layout or proposed .modification of that injection equipment and exterior
piping/tubing associated with the injection operation. The matiullteturer's brochure may provide supplementary
information.
I. LOCtt'LXON OF WELL(S)
Athich two copies of maps showing the following information:
(1)
(2)
Include a Site Map (can be dnrwn) showing: buildings, properly flues, surface water bodies; potential
sources of groundwater coiv(nn nation and the orientation of and aistaucea between -the proposed well(s) and
any existing well(c) or waste dt potal facilities such es septic tanks ckr drain f e!ds located within 200 fact of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
The Site Map inust slimy the subject property in rc3ntion to the szcerotn ling arca by uaing at least t cw fixed
asiittene points such as roads. streams, and;/or high ay intersections.
J. CERTIFICATION
Note. This Pcrolit Application must be sdgned by oath poraon appeaalug on the
reCOY clLtd l%;zal Oroperty deed.
"1 1lereby certify, under penalty of law, that J. have personally ex&nlncd and mn 1ir111ar with cbo informmation
submitted in this document and ail et1 eh nenta thereto and that based on niy inquiry of those individuals
1mtnediatcly responsible for obtaining said information, I believe that fi o informattenis true, accurate uric complete.
t fiin aware Oct There are significant penalties, including the possibility of fines and hnprisonment, for submittir!g
fikt inform:41ot. I agrco 1>r consst.toot, operate, rsaznt ft3, repair, and if app3kzcbla, abondon the in utlon well and
all teiateJ appurtenances in accordance with tho lrov ft lee) atioTl+ indconl itions oftbe Permit"
Sisiisrureofproperry in�,a:�',1<ppliearf
1)0
s '
print or'I Type -Pull Name and title
1
aig,unitureof r'rpt t'hmer/Applitaut
Le 5 1 c 'e-- r.3 Cotr L InA. Q C.
Print or Typo 1.'1) ii 14ama and ti lta
rrint or Typo Full Mono and title•
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer ]Protection Section -TM 'Program
1636Mail Scavihe Center
Raleigh, It1'C 2/699-1636
TeYepLoue (919) 7i 5-6935
RECEIVED
AUG 2 7 2010
Information Processing Unit
DWQ/BOG