384280_Well Construction - GW1_20100602

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ? 5-7
2
1 WELL CONTRACTOR
k-"D lei u `\•s
Well Contract (Individual) Name
YADKIN WELL COMPANY INC
Well Contractor Company Name
1908 HAMPTONVILLE ROAD
Street Address
HAMPTONVILLE
City or Town
( 336 ) 468-4440
Area code Phone number
2 WELL INFORMATION WELL CONSTRUCTION PERMIT# -3-7t0-/ 6 5 a Le(D --&/
OTHER ASSOCIATED PERMIT#(if ap licable)
SITE WELL ID #(if applicable) (1/C—/ !'r/
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED
TIME COMPLETED c---°O AM ❑ PMA n-
4 WELL LOCATION
CITY 0 0 6 saw COUNTY ILA V (/ y
NC 27020
State Zip Code
(Street Name, Numbers Community, Subdivision Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
riklope ❑Valley ❑Flat ❑7Ridggee DOther
LATITUDE %� /< ('2 y" DMS OR DD
LONGITUDE (?)° '3 t56 "DMS OR DD
Latitude/longitude source 3PS LjTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER / (/ h 7 ) A C-
Owner Name
Street Address
CI0.4sz,h
City or Town State Zip Code
( 336.) 36:-?f2(
Area code Phone number
6 WELL DETAILS J ��
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELLS YES ❑ NO q-
c WATER LEVEL Below Top of Casing 7 D FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above Land Surface*
*Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) /y METHOD OF TEST a r've ra hy
f DISINFECTION Type HTH _ Amount CUPS
Top
Top
Top
9
Top 3a"l Bottom 30-- Top Bottom
Top Bottom Top Bottom
Top_ Bottom Top Bottom
WATER ZONES (depth) .7
7 CASING Depth
Top - ( Bottom q5— Ft Sim -a(
Top__ Bottom Ft
Top__ Bottom Ft
Thickness/
Diameter Weight Material
j)c/G
8 GROUT Depth Material q Mettiod Top O Bottom 2(0 Ft3Jaao n-t�.c' (rz. f.9,-),11t.(
Top_ Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Top Bottom
Top_ Bottom
Top_ Bottom
10 SAND/GRAVEL PACK
Depth
Bottom
Bottom
Bottom
11 DRILLING LOG
To.p, Bottorp
/ s�
_I 75 '
75`' / So.
ie.' / qD
a4/ o' _/ 5 •-o '
Diameter
Ft In
Ft in
Ft in
Ft
Ft
Ft
Slot Size
in
in
In
Material
Size Material
Formation Description
i-Yt .'ddy, hue
/'vt Co/ figs/ (
trio/ c50- 5o r ti
RECEIVED
JUN022010
iriforrnatiof; Ptu •- ;s '' -
D4JC;s";G'�'
1 REMARKS
•
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►:Ued_ 43 a4' C4-5 reaj -
cet_5�j - f Se-( z �i lace c{L'.
I DO HEREBY CERT,•FY T AT 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
TURE CERTIFIED WELL CONTRACTOR
.57'av-C o
DATE
-S sa tJ 1• J
PRINTED NAMEIOF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Date Site Visited C-/ k -(6 By: 1/8 Perirat: No
Form GW-1 a
Rev 2/09
What Is Height of Well Casing? Make Sure 12" Above Ground Level!!!!

BUILDERS NAME:
ADDRESS:
PHONE NUMBER:
C� 0