386582_Well Construction - GW1_20100901

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1. WELL CONTRACTOR:
GEO-THERMAL WELL CONSTRUCTION RECORD
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICATION it
U.J r' A l�F�
Well Contractor ndlvidual) Name
varlk� n WP] 1 Compnv inc.
Well Contractor Company Name
STREET ADDRESS 140R Hamptnnvi 11 t� Fe)arcl
Hamptonville NC 27020
City or TownState Zip Code
( 336 )_ 468-4440
Area code- Phone number 2. SrE#( tpTEINFORMATION:
L ID Iaplicable) 4,,K "l
q
2,
STATE WELL PERMITir(if applicable)
DWQ or OTHER PERMIT #(if applicable) bl)1IO Qot
WELL USE (Check Applicable Box) Monitoring ❑ Municipal/Public ❑
I
Induslnal/Commercial
0 Agricultural 0 Recovery ❑ Infectron ❑
Irrigation❑ Other (list use) (:s-e,,tki. Cto ff, /y
DATE DRILLED (—(.)- t 0
TIME COMPLETED 3) jo Am PlO
3.WELLLOC4TION: `` II
CITY GAAhto i�- COUNTY"PcAie,,
7 Too How c c✓c,t} Fel v,•. 4-1,-
(Street Name, tlumbers, Community, Subdrnseon, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope 0Valley ❑Flat El Ridge 0 Diner
(check appropnate box)
LATITUDE 3 ,070
LONGITUDE 3 L9,00
May be in degrees,
minutes, seconds or
Ina d:cimal format
Latitude/longitude source:*RGPS ❑Topod aphis map
(tocalron of wef must be shown on a USGS lopo map and
ai(ec/red /o (Pus form lino( using GPS)
4. FACILITY -Is the nano of the business where the well is located
FACILITY ID Of applicable)
ev NAME Of-FACIL•4Y .) u.nt ()
STREET ADDRESS
City or Turin T State Lto Zip Code
CONTACT PERSON oss Inlet^
/R
.e, MAIL,INGADDRESS 1 7eR,
20 F.0�'iIs vy
�l / ,2 ,VL. zS2t%
City or Town State
( 7QV )- rqz- G($X —GSi/
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Zip Coda
b, DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Bela, Top of Casing: FT,
(Use "+• if Above Top of Casing)
Submit the original to the Division of Water Quality within
1617 Mail Service Center —Raleigh, NC 27699.1617 Phone No
Date site visited: 2- 9- /o by�3f3
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): iO METHOD OF TEST
f. DISINFECTION: Type H II Amount
3
g. WATER ZONES (depth)
From To From To
From (/STo 117 From To
From To From To
6. CASING:
Depth
From To Ft.
From To Ft.
From To Ft
Thickness/
Diameter Weight Material
7. GROUT: Depth M tenet Method
From 0 To �c50 Ft -Milv10 Gook n'Te-
From To Ft `L3avJ
From To Ft
3, SCREEN: Depth Diameter StotSize Malerfal
From To FI in. In
From To Ft. fn. In,
From To Ft In in
9. SAND(GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
From To FI.
10. DRILLING LOG
From To
7U'
' c) - /av'
ae -
Formation Pescription
rue.-e Sa l crw. c
t�r
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—
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Prose
Informp.'n NQ113C
11, REMARKS:
- 200 ' /Lo tpl -f-liehpare
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED PI ACCORDANCE WITH
15A NCAC 2C, WELL COUSTRUCT)ON STANOARRROSS. AND THATA COPY OF THIS
O RECBEE PROVIDED
TTTOOTTHHEEE WELL V ER.
taTURE'��`CE IEDWEKLL/CONTRACTOR 7 /a
DATE
c) c 1,-/ /mil v lI :s
PRINTED NAM OF PERSON CONSTRUCTING THE WELL
30 days. Attn: Information Mgt.,
. [phone] ext 568.
Permit required: Ye No
rJ4e
Pam GWlb
Rev. 7/05
82
srn9 Unit

BUTT,nERS NAME:
ADDRESS:
PHONE NUMBER: