386590_Well Construction - GW1_20100901

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GEO-THERMAL WELL CONSTRUCTION RECORD
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #1
1. WELL CONTRACTOR:
.\ 6Atl kAS MJR�s
Well Contracr (Individual) Name
Yanki n Well C'cxnp nv Try:.
Well Contractor Company Name
STREET ADDRESS 19fR Hampi-nnvi 11 e Rr1ar3
Hamptonville NC 27020
City or Town State Zip Cocfe
L336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION: //%j
SITE WELL ID #(if applicable) /`�//%%/ 2 a-e-7a
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable) bV.2Q,3 00 j tf SL
WELL USE (Check Applicable Box) Monrtoring ❑ Municipal/Public q
fnduslnal/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ OtherX (list use) (s-r;,a JLt fr ,j CIQ rf
DATE DRILLED 7-) 3• (0 L, ?
TIME COMPLETED •d0
Or• AM'❑ PMg
3. WELL LOCAq/TION:
CITY G/' COUNTY f rcA 44 443
/soo Clow 4. c✓c S.} Foy,. 4.i-
(Street Name, Numbers, Community, SubdMsron, Lot No . Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE 3 d 7, O -16
LONGITUDE 8- 9• y,c) C
Latitude/longitude source: PS ❑Topographic map
(localron of waif must be shown on a USGS lopo mop and
attached to Mrs form ifno! using GPSj
4. FACILITY. Is the name of the business where the well Is located,
FACILITY ID #(if applicable)
May laz in degrets,
minutes, seconds or
In a dacimal format
ev NAME OF-FACII:4Y •.) rJ•nr'.) Sat )/(ev
STREET ADDRESS
r City or Tarm State Zip Coda
fZ:Y4 CONTACT PERSON k°fS
(l //
j7 e� MAI LNG ADDRESS 76 20 (l' 7 G' Its ra
C.I.rJv{� 1 Q .v C. 2 g Zi G
City or Tcrein Slate Zip Coda
( 7(9 ( ). 3q2- G (S M70q_ GS9-�o0
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 200x
b, DOES WELL REPLACE EXISTING WELL? YES Q NO 0
c. WATER LEVEL BelaA Top of Casing: FT.
(Use -+• if Above Top of Casing)
d, TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance fn accordance with 15A NCAC 2C .0118.
o. YIELD (g pm): 0 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 Metenaf
From To Ft.
From To Ft
From To
7. GROUT: Depth tonal Method
0 `
FromToe�C�) Ft Grp e
From To Ft. ,�t
From To Ft 54M `'t
3. SCREEN: Depth
Ft
Diameter Stol Size Material
From To Ft in. In
From To Ft tn. In.
From To Ft. In
in.
9. SAND/GRAVEL PACK:
. Depth
From
From
From
Size
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From lo
7
d c,c)
Material
Farmiion Description
/10 - (r r.cr.-e-t e
ir=
11, REMARKS:
200 ' /10 (€! 4fie/v olio
e'r-o11-2
01..1 -
�roCHt
DWQ/DO(
1 DO HEREBY CERTIFY THATTHt3 WELL WAS CONSTRUCTED IN ACCORDANCE WITH
iSA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RE BEEN OVDEDTOTHE WELL OVH93.
Gt./ 1 L=j 7_ a-3-/ o
SI URE .. CERTIFIED WELL CONTRACTOR DATE
`c cscA(/ (AJ �u\�•.3
PRIN ED NAM OF 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 27599.1617 Phone No. [phone] ext 563.
Date site visited: 2- 9- /o by p 3i3
Permit required:
No
Form GW-lb
Rev. 7105
010
sing Unit

BUILDERS NAME:
ADDRESS:
PHONE NUMBER: