386620_Well Construction - GW1_20100827

GEO-THERMAL WELL CONSTRUCTION RECORD
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION g5 71
1. WELL CONTRACTOR:
Well Contractor Individual) Name
Yarikin We..1.1 Comfy Tnc-
Well Contractor Company Name
STREET ADDRESS 1 Hampi-nnvi 11P RO,9r1
Hamptonville NC 27020
City or Town State Zip Code
( 336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Rif applicable) /4,4.e— /
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monrtoring ❑ Municipal/Public 0
rnduslnar/Commercial ❑ Agricultural ❑ Recovery Infection Infection ❑
irrigation❑ Other 0 (list use)
DATE DRILLED Cp d'C1 -
TIME COMPLETED S`eJ AM PM�
3. WELL LOC�TIONI �� 1/
CITY C U✓ o COUNTYl%d,iofr// outs
(Street Name, Numbers, Community, Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC f LAND SETTING:
5Iope ❑Valley ❑Fiat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: OOPS ❑Topog aphis map
(location of weLmust be shown on a USGS lopo map and
attached to this form if not using GPS)
4. FACILITY• Is the name of the business where the wets Is located.
FACILITY ID #(if applicable)
NAME OF FACH_ITY rob p / Jr_A MO r'-
STREETADDRESS 2 Zoc1 1-e ^Mire �
rlpt-ea_ 'VC 2 'ZD'
City or Town State, Zip Coda
CONTACT PERSON 6- e O f ./loj p`A„) U-1rJ/71rvr f•►
May be in degrees,
minutes, seconds or
In a decimal format
MAILING ADDRESS
City or Town
State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b, DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Below Top of Casing FT.
(Use'+' if Above Top of Casing)
cB ' u
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance fn accordance with 15A NCAC 2C.0118.
o. YIELD (gpm): S' METHOD OF TEST
f. DISINFECTION: Type BTH Amount
g. WATER ZONES (depth)
From 14 q To ( 541 From To
From 1 To (? From To
From To
6. CASING: Thickness/
Diameter Weight Material
From To
Depth
From To FL
From To Ft
From To Ft
7. GROUT; Depth National Method
From L) To 95-1
J ��\✓Irr.�c+�
From To Ft.
From To Ft
8. SCREEN: Depth Diameter Slot Size Material
From To FI in. In
From To Ft. In. in.
From To Ft. in. in
9. SANDfGRAVEL PACK:
Depth ..
From To
From
From
Ft,
To Ft.
To Ft.
Size Material
10. DRILLING LOG
Fro Ili To Formation Description
j(O -- DSc, eel ,, :4 a ,' rr
11, REMARKS:
A
Information Processing UIli
uwCWBOG
I DO HEREBY CERTIFY 7HATTEIS WELL WAS CONSTRUCTED Pr ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THLS
RECORD HAS BEEN PROVIDED 70 THE WELL 9W
6 e—( 0
ATUF CERTIFIED WELL CONTRACTOR DATE
PRINTED raktmE 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 p» Permit req
uired: CO No
Font GW-1b
Rev. 7/05
(2) "U' A.44 raw

NAME: (&1J f w,'/, ,
ADDRESS:
PHONE NUMBER: 7o S9- 6 Si/ - .Sv o 1
-eve- £( e.

MATE CA1ZOLINA
DEPARTMENT Oki ENVIRONMIT AN) NATURAL RI1SOURCJ S (NCDJdNit)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOJEv ,0OP GEOTHERMAL
WA 1.11-R-Q_X INJECTION wax, SYSTEM
TYPE S-0 _,_V JELL(S)
In Accordance with thcprov11oos oii"NCAC Tide 15A: 02CO2007 please
complete this notification sun n]nd to ocidress on the back page <please Print or; 2vpe I1 tOr rion).
DATE: (� ! , 201_61
Wall 2ypa Confirmation: Dons the proposed system ctraulato potable walrr (Ally (no additives) in
continuous piping that completely iso)atcs the fluid from the environment (i.e.
dosed -loop)?
$es X_ Continue cr inrleting this form.
No Do Not wmplote Allis form. Complete other T.JZC application forms for installing
o)tbcc a 5A7 wo11(opcu-loop wC1J in5cct*ngpotable cT into fha aquft r) or n 5QM(oJoscd-
loop 4tro?i contaisatug additives such as R 22). ethanol or othc,r ant&eac or corros{oit inhibitors).
A. PROPERTY OWNKR(S)iAPPLICANT(S)
List ouch Propw`rty Owner listed on props ry deed (l1 owned by a business ofr yoverninent Agency, sat Dame of
entity void a rapregent tiVe wlauthority fw s nA.ti r ): .. ,,M
/1 (1) hl�aiiingAds;rtss:. i C N1 �"�3 r � U e—
City: (Tto-Re Statc:K) ( Zip Cocle: ?. (14 County. if/44e C %. �?
0MDee ale. No.: _ ?J5 (L05 9 G COP �Itf.,,, �� 0 3- Z Z '3 Z-7-
13nus1l Ac14 es$: , _ YJebaiN:
(2)
Z'!iyssiczzl Addre . of Weld Site (if differont than nbove,):
City. 5Tate _ Zip Code: County:
HomeIOffice '1'eie No.: Cell No.:
B. A l ORT7 D AGENT OF OWNER, I' ANY gibe PermItApplicant d1 j feQroperty,
t
attach a letter from the property owncr authorizing Agennl to install and operate lTj1i J&e )7 2010
Company Name: t(iftsft#tdtr WProer3ss"sng-ttnA
Contact Person: 11 itAddresa: DWQ/BOG
Address:
City: �..��,. ,.. , State: Zip Code: County:
affico Trltc No.: Cei1No
Wobsito Add MS ofCompany, if any:

WELL DRILLER .111.CORIKA.T1rOlg
CompanyNeme•YadkiaWeil CA, Inc.
wolf DriUer Contractor's Nave; lady Millis _ Mat1RewBrown Xitto cp.vc
NC Contractor CertltioatlonNO,t 2572-A 3036-A 314Lk:
ConlcotPersbtl: David J. Brown 219S-A •„ _ , , TMA]L address: ciii,afdrilleamsn,ciun
Address:1908 Harnptauvllle Rd.
City: .11m31vtonyltt^ N.C'. 7 P Codo: 27020 County: Ysidkin
0ince Tele No.: 336-4613.4440 Coil No,: 336 374-8736
), ITAAT rIYMYI£'COM' CZOILJY01WAT[1DN(ifctifnrwitthxudriller)
copponyName: OS5 C W
ContwtPciisom (-)---e oTf—A.�10 EMAIL Address'
'dsas ; 16720 /ev zz qfe __ ,�;
Au..n•
City: diaS 0141Zip Codc: 02K Coanty:
LO�4.p
ofcc rag-1c,.: . e se • bet oallND.:._70/. • rij/ . .G if
i, STATUS 01 Li 11.1CA T
l mate: Federal: Commercial:
StoiN Mu:tleipal:_ NalvcAlma/kart Lands.
IN IECli!ON I'TWCEDUrt (brlo[ly fl..scr1ba bow the inject onwail(s) will be used)
C. lose f oi, , f e.,,,c, f y .r -I-e AI-. 5.e m # evikkALL
%Ta, f',ONb't'1WCTIONDI,TA. .2$a to
())'Proute ed 4late -'o bo rc'rait:ioted: ( 2 ' -b 2.) 7urnS,er of barinps:..
��
Approximate dapfh of eaoh yochng (foot):): .2.S--o 1
(2) Type of tubing to lye taod (popper, PVC, eta): /4 F)p/ ,C a r'..,11
(3) Well rsaohlg. is tlud well(s) owed? (oliouk eliher (ct.) Yes or (4) No below)
(e) Yes ii:yro, thin pro,/ ae casing inform:ifion below
Typo: _gnlyarti2ed ateel Wok stab} 1tlactto•, other (specify)
Cosine doktlis Rota to foot (roferonoe to laud surface)
Casing eactendato above b1rouasd ioohaa
(b) .No
(4) Or outlnfo(m&trie 4urmUndIng!yell casing andForplpl &errata G e_,►Ito .,Ge-
(c) 0rot type: Noat Coraasot 13crltonito .ZC , Oth$r(cpaoiiy)_
(b) Grout placonent: Prtmpik,,,, Proem Other 11\
(c) Cruet depth ofkcb3ng (Taf'eronv= to lima surface): from o to 3 l�"�1F C E 1 !/ E D
Ewell hos indloato grot►E depth; from f row— (fb'* U G 2 / 2010
Information Processing Unit
DWQ/BOG

INJEcTioN-fl LATD EQUIP -MINT
Attach a diagram showing the engineering layout or proposed modification of tho injection equipment and exterior
piping/tubing associated with the injection operation. The mactwlteturer's brochure may provide supplementary
information.
1. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1)
(')
Include a Site Map (can be drawn) shoving: buildings, property lines, surface water bodies; potential
sources of groundwater conitrninarior and the orientation of and (tistaucw betwwortibe proposed well(s) and
any existing well() or waste dieporal faclit€es such as septic tanks or drain fi ds located within 200 fact of
the geothermal heat pump well system. Label all features cIcarly and include a north. arrow.
The Situ lYlap must show the subjeot property in relation to tho sur•ccnnhiing areal by using it least two fixed
rei xeiie : points suchas roads. strains, amifor highway intersections.
J. CERTIFICATION
?Tutu; This t'erttlit Appitei ilon must be signet by oath poraoa alipearbig on the
recorded Ieaal Vrogct; t r deed.
.! i.ereby certify, tinder penalty of law, that J, have pe sonaily examined and riB ihmfllar with the information
sub anted in this docu.xiettt and All etecly ienfa thereto and 'that, based on my inquiry of those individuals
immediately respoDsib1G for obtaining said information, I believe that the i fonnattanis true, accurate and Ctut11)lete.
I am aware iitct there are significant Realities, including cite possibility of fines and it prisotnnen , for submitth g
ibkt infortn..I:Io.I agroo to r:onStxt'►Gt, operee, rsa?nt;*dn, repair, and if applif uble, abandon the in_jcutlon welt and
ail tolated appurtenance: to accordanco f. m'ationfziNtind con itions oftho Permit."
Sig Ounce ofpx'operry � ✓'r�pplieart
'k h? it LOC. It
Print vr'J ypa 3.'u!; Name end title
�q 7
Siguotire of ef.,p ,r trhvtar/Appplicant
Les LCP C. IA
Print or: 'TypoNome and title
'riot or Type lull Nztmn t,t J trtic
Please return two copies oldie completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-i1XC Program
1636 Mail S01vi3e Centex
Raleigh, 'NI C 2/699-1636
e/apisoue (919) 7i 6-693S
RECEIVED
AUG 2 7 2010
information Processing Unit
DWQ/BOG