386589_Well Construction - GW1_20100901

IMF
GEO-THERMAL
� WELL CONSTRUCTION RECORD
NON , ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION 11
1. WELL CONTRACTOR:
ratio «
Well Contrac or (ndMdual) Name
Yardki n Well Cornpnv Mr -
Well Contractor Company Name
STREET ADDRESS 190A Hampfnnvi 1 1 e Roar -I
Hamptonville NC 27020
City or Town State Zip Code
( 336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable) 14.11.03 Oo j tt SL
WELL USE (Check Applicable Box) Monitoring D MunicipaUPubhc O
rndustnai/Commercial ❑ Agricultural ❑ Recovery Injection
injection O
irrigation❑ Other' (list use) ('�.t
DATE DRILLED 7 �' (O L;, y)
TIME COMPLETED Si." AM O PM
3. WELL LO/C TION. � Jr �// /
CITY. al, (0 i'Te- COUNTY /Pc-hfin4C(
7500 Mow tCVc.S.} Fcrv,.
(Street Name, Numbers, Community, Subdmsion, Lot No, Parcel, Zip Coda)
TOPOGRAPHIC / IAND SETTING,
OSlope OValley ❑Flat DRidge ❑ Other
(check appropriate box)
LATITUDE 3 -� 01,o70
LONGITUDE S.-.0 ! %. 0 C 1
May Too in degrees,
minutes, seconds or
Ina decimal format
Latitude/longitude source: »iPS OTopob aphis map
(roca(Dn of wag must be shown on a USGS ropo map and
attached to this form rfnot using GPSj
4. FACILITY- is the name DI tie business where the well is located,
FACILITY ID #(tf applicable)
r V NAME OF-FACIEt4Y � ,;7rn t')
STREET ADDRESS
City or Tom;
OUIJA
r StaleL Zip Codo
tye:h CONTACT PERSON G
kfs Cof .1; 11//ldt„
MAIL, //
ING ADDRESS 762-o tt 0 &-r e ((s Fay RI
t-- Q ,c/C, 2g2(6
City or Toren State Zip Code
( 70V J- 3612- J $X 14,70q_ GS1/-573054
Area code - Phone number
5 WELL DETAILS:
a. TOTAL DEPTH: Otli
b, DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Belo/YTop of Casing: FT,
(Use "+• If Above Top of Casing)
3 , r589
d, TOP OF CASING iS FT. Above Land Surface*
'Top of casing terminated ator below land surface may require
a variance In accordance wrath 15A NCAC 2C .011B.
o. YIELD (gpm): ( 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: Thickness/
Depth Diameter Weight Material
From To FL
From To Ft.
From To Ft
7. GROUT: Depth M tonal (
From Toa•Ct6 • t Ft (�c,r C.oe.‘'-
From To Ft
From To Ft
a. SCREEN. Depth Diameter Slot Size Material
Method
From To FI. in. In
From To Ft. fn. in, _
From To Ft. rn in
9. SANDIGRAVEL PACK:
. Depth Size Material
From
From
From
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From
v Y7
S 7 - 2-e4)'
Formajion Description
s F.rd (riapt• {e
Jtr 1 -
Ir11:10.71 -_.aSd
da Le r,
11, REMARKS:
- ' AQ 1e1-/-Re,��� f,e,
I DO HEREBY CERTTFYTHATTHIS WELL WAS CONSTRUCTED RI ACCORDANCE Wm{
T SA HCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
. ,/ (Ai *y 77 >to
1'�'ATUR:h.F CERTIFIED WELL CONTRAr7— CTOR DATE
� w n/k IA,
PRINTED NA iE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality wlthlt130 days. Attn: Information Mgt,,
1617 Mall Service Center- Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Date site visited: 2- 9- Jo by 1 —' Permit required: Ye No
r rr
Form GWlb
Rev. 7/05
1% 1.. Jar
2010
attl

BUILDERS NAME :
ADDRESS:
PHONE NUMBER: