386588_Well Construction - GW1_20100901

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1. WELL CONTRACTOR.
GEO-THERMAL WELL CONSTRUCTION RECORD
NON ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division7
of Water Quality
WELL CONTRACTOR CERTIFICATION ft
c-41b(.1 « r J l t3
Well Contractor (1 Ividual) Name
Yardki n Well Company inc.
Well Contractor Company Name
STREET ADDRESS 1 90R Hamptnnvi 11 P Rr)art
DATE DRILLED - "
TIME COMPLETED .3 411 AM ❑ Ptiktr
3. WELL LOC TION, CITY G/ ,a I- v F4 - r� COUNTY //ec-A n tS
T•.soo / Lc>w c C✓G! } Fcr 4. t-•
(Street Name, Numbers, Community, Subdnnsron, Lot No , Parcel, Zip Coda)
TOPOGRAPHIC f LAND SETTING,
❑Slope ❑Valley ❑Flat ❑Ridge 0 Olner
(check appropnate box)
LATITUDE 3 tc 07,0 70
LONGITUDE , © 0 cc I, JC f
Latitude/IongitUde source: XGPS ❑Topob aphic map
{/ccatron of weff must be shown on a USGS lopo map and
attached to this form if not using GPS)
4. FACILITY• is the name of U'e business where the wet: is located
FACILITY ID #(if applicable)
Hamptonville NC 27020
City or Town State Zip Code
( 336 )_ 468-4440
Area code- Phona number
2. WELL INFORMATION;
SITE WELL ID#(Irapplicable) (d(4"'qO
STATE WELL PERMIT#(dapplic' able) i
DWQ or OTHER PERMIT #(if applicable) Ppiicabla) VV;LB-1? Qot SL 4Z
WELL USE (Check Applicable Box) Monrtoring ❑ Municlpal/Public ❑
Industnaf/Commercial 0 Agricultural ❑ Recovery 0 Infection 0
Irrigation❑ Other'f (list use) G'9,1 0
May b in degrees.
minutes, seconds or
In a decimal format
ev NAME OF-FACilet+Y J vn't t')
STREET ADDRESS
ear^ kty
City or ToWrm StateL Zip Colo
CONTACT PERSON RT Sf•S et.); 1/-rtcf
e MAILING ADDRESS 4G 20 It 0 Zze t(S buy RI
City Of Temn Slate Zip Code
(7OY )- 3qz- G/ $X M7o4_G4'/-'001
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 200
b, DOES WELL REPLACE EXISTING WELL? YES Q NO 0
c. WATER LEVEL Serail Top of Casing: FT.
(Use "+- if Above Top of Casing)
3 _i 5 8 8
d, TOP OF CASING IS FT Above Land Surface*
'Top of casing terminated aVor below land surface may require
a variance In accordance with i 5A NCAC 20.0118,
o. YIELD (g pm): O METHOD OF TEST
f. DISINFECTION:Type HTH Amount
g. WATER ZONES (depth)
From To From To
From To From To
From To From To
6. CASING:
From
From
From
Thickness/
Depth Diameter Weight Matenal
To Ft
To Ft
To Ft
7. GROUT: Depth Mat al Method
e,I
From 0 Tof/t� uv F kerr.,o ct
UiC
From To Ft avzA
From To Ft
a. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in
From To Ft. Fn. Fn.
From To Ft. to in.
9. SAND/GRAVEL PACK:
Depth Size Malarial
From To Ft.
From To Ft.
From
To Ft.
10, DRILLING LOG
Froei To Fort fwn ascription
70 • id _ r''Iea/-f ,,le
I
Et' 1 -
Intormat.0,o r-
U 1!Y vL.:
11, REMARKS:
.2.o0 ' {to
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED PI ACCORDANCE WITH
iSA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT ACOPY OF THIS
RECORD . : EEN PROVIDED TO THE WELL OW61ER_
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SIG'•'.-E sF % RTIFIED WELL CONTRACTOR DATE
E�
lam' 1' )
PRINTED NAME orf PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,,
1617 Mall Service Center- Raleigh, NC 27699.1617 Phone No, [phone] ext 568.
Date site visited: 2- 9- ]o by ei sa
Permit required: No
Form GWlb
Rev. 7/05
2010
;.essing Urut
3G

BUILDERS NAME:
ADDRESS:
PHONE NUMBER: