386579_Well Construction - GW1_20100901

GEO-THERMAL WELL CONSTRUCTION RECORD
' ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION if (7-15- 7
1, WELL CONTRACTOR:
V Q W Of\AS q'
Well Contra or (Individual) Name
Yadkin WPl l company Tnc.
Well Contractor Company Name
STREET ADDRESS 14OR Hamptnnv3 1 1 P Rnarl
Hamptonville NC 27020
City or Town State Zip Code
( 336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION; n�/
SITE WELL ID #(If applicable) � V
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable) %11.'c,83 Go ` Si V
WELL USE (Check Applicable Box) Mondoring 0 MuniclpaUPublte D
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Infection 0
Ungat on❑ OtherV (list use)
DATE DRILLED f -7 - to
TIME COMPLETED CI-/0 AWE] K1rg-
3. WELL L004TION: 'I rr
CITY 6.,Aal.f o t f� COUNTY/4c-4/tn 4.45
7,SOO i'1ow.tc✓c,C.)- Lh
(Street Name. numbers, Community, Subdivision, Lot No, Parcel, Zip Code)
TOPOGRAPHIC! LAND SETTING:
❑Slope (Valley ❑Flat ❑Ridge ❑ Diner
(check appropnate box)
LATITUDE 3 0`f , � .7O
LONGITUDE 7 -7' OC(
Latitude/longitude source: DGPS ❑Topographic map
(boa bon of well must be shown on a USGS lopo map and
attached to this form if not using GPS)
4. FACILITY- is the nacre of 1te !wetness where the v. et) Is located,
FACILITY ID #(tf applicable)
Ot,�.�'v NAME CF•FACILL€Y Q m () ,SCan key
STREET ADDRESS
May ba in degrees,
minutes, seconds or
Ina d:cimal format
/ City or Town /� State Zip Code
(5,�r�CONTACT PERSON ofs T �M1cI,
(St j7e� tv1A141NGADDRE S //kt<J;
f6Z0 It02,7et(s
ZgZIG
City or Town State Zip Code
( 7oq )- 3612- 6f $X Ma0,!-G4'/-'00`�
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH' 2oo'
b, DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL BelaN Top of Casing: FT,
(Use '+' if Above Top of Casing)
Submit the original to the Division of Water Quality within
1617 Mall Service Center— Raleigh, NC 27699.1617 Phone No
Date site visited: 2- 9- )o by p 3�
3ryti
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 20.0118.
o. YIELD (gpm): .a6 30 METHOD OF TEST
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth
From irf To From To
From / STo 1?' / From To
From To From To
6. CASING:
Thickness!
Depth Diameter Weight
From To Ft.
From To Ft.
From To Ft
Material
7. GROUT: Depth M tenetef Method
From ' To 2-c—ID Ft-1-Gt«o G✓ai-
From To Ft.
From To Ft
t v-e-e
3, SCREEN: Depth Diameter Siol Size Material
From To FI in. In
From To Ft. In. In.
From To FL in in
9. SANDIGRAVEL PACK:
Depth
From
From
From
To Ft
To Ft.
Size Material
To Ft.
10. DRILLING LOG
From To
v� '
HR trY.A
-2 O
4(- :ev.
F�Qarm�� iio��
str 1 - n n 1f
Informl't on
•.,.nay
ILY���a�
11, REMARKS: I I
�7 — 200 ' ho (eJ -%"/\Q/ y of p e, .
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WEYNER.
SI''TUR 'F CERTIFIED ELL CONTRACTOR DATE
3 04-7 tiki i� (JL (‘`,S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
30 days. Attn: Information Mgt,,
.'[phone] ekt 568. _
Permit required: Ye
r 4e v
No
Form GW-lb
Rev. 7/05
Unit
EA-3 e4. 61,1{1^ 3M4 Zuoe

BUTT,DERS NAME:
ADDRESS:
PHONE NUMBER: