382292_Well Construction - GW1_20100408

RESJDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # + S 7
1a�T�,JR�\„kc�.
Well Conti etor (Individual) Namo
YADKIN WELL COMPANY INC
Well Contractor Company Namo
1908 HAMPTONVILLE ROAD
Street Address
HAMPTONVII LE
City or Town
( 336) 468-4440
Area code Phone number
2 WELL INFORMATION pp
WELL CONSTRUCTION PERMIT# " �U 2 1 O/ o —o f%
OTHER ASSOCIATED PERMIT;I(f applicable)
SITE WELL ID ypf applicable)
NC 27020
Slate Zip Code
- 03 o
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED 3 Ic'
TIME COMPLETED 5
4 WELLLOCATION
CITY hit 71t.7 f' Gf h p
CJ ii (e4.1/Yp
(Street tlamo, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
,tSiopo ❑Valley OFlat ❑Ridge DOther j`
LATITUDE "DMS OR ✓ , 36?DD
LONGITUDE " DMS OR A, 8 7d Z7DD
Latitude/longitude source 3PS I:Topographic map
(location of well must be shown on a USGS topo map andallached to
this form If not using GPS)
5 WELL OWNER
fct e
B: (( thotn
Owner Name
AM ❑ Phi.
COUNTY ,fCi t► fry
Street Address
City or Town Slate Zip Code
(cif2) frl/
Area code Phone number
6. WELL DETAILS:
a TOTAL DEPTH
3 4
b DOES WELL REPLACE EXISTING WELL? YES 0 NO,
c WATER LEVEL Below Top of Casing eQ • FT
(Use'+' if Above Top of Casing)
d TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C 0118
o YIELD (gpm) J 5 METHOD OF TEST
f DISINFECTION: Typo HTH Amount / CUP
WATER ZONES (9o).-
Top_l_ Bottom /(0 -to Bottom
Top Bottom -r Cf Bottom
Top Boltom Top Bottom
Thickness/
7 CASING Depth _ DDiameter Weight
^7
Top ./ ( Bottom ` ) Ft (0.Ps
Top Bottom Ft
Top Bottom Ft
Material
PVC-
8 GROUT Depth / Material -w:$ Method
Top 0 Bottom 20 FLektiel,' 3"-- ky tr'i 2c('
Top Bottom Ft r
Top Bottom FI
9. SCREEN. Depth Diameter Slot Size Material
Top Bottom Ft in In
Top Bottom Ft to in
Too Bottom Ft In in
10. SAND/GRAVEL PACK.
Depth Slzo Matorlat
Top
Top
Top
Bottom Ft
Bottom ft
Ft
Boltom
11. DRILLING LOG
Top Botto
—D
/
/
/
12 REMARKS
Formation Description
o.
CA.-% ntr
Z '
6.. 0 33
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
AT'4aRTIFIEDL� CTOR 3D,ATE�Oy'°
FD
PRINTED NAME IF PERSON CONSTRUCTING THE\WWLLU 8 1010
Submit within 30 days of.col4ipletionpdivision of Water Quality_- ;Information Processln'g,
1617 Mal( Service,Center, Ralelgli, NC'27699-161, Phone : (9.19j 807-6300
Date Site Visited 3 —(8�( 0 By: U'3 Peimdt Yes Na /Ile''r�.r
WHAT IS HEIGHT OF WELL CASING? MAKE SURE 12" ABOVE GROUND LEVEL!!I
lnformailorFormW;lag Unit
DVRV2109
2 if /4< S6
i jl (0 Ia 1 3 -0(-

BUILDERS NAME : t,/
ADDRESS:
PHONE NUMBER : C. Y 6 ?- 0 0 7