386594_Well Construction - GW1_20100901

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h�ti GEO-THERMAL WELL CONSTRUCTION RECORD
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION ff
1. WELL CONTRACTOR:
_30AL UJ As 1,k %S
Well Contractor\�Individual) Name
Yardkin Well Company The. Contractor Company Name
STREET ADDRESS. 19f1R Hamptnnvi 11 Q RCr7
Hamptonville NC 27020
City or Town State Zip Code
L336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION;
SITE WELL ID#(itapplicable) ,44k- SON
DATE DRILLED �•a s''10
TIME COMPLETED S.;-vv AM b FMi
3, WELL LOC TION.
CITY i/' L (J k �- COUNTYAC-A 4c( S
7soo / lvw. c✓G� } Fri fro,
(Street Name, Numbers, Community, Subdhsion, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
C0Slope DValiey ❑Flat ORidge 0 Olher
(check appropnate box)
LATITUDE 3 a 7,0 70
LONGITUDE gO 51.7. 061
Latitude/longitude source: �'GPS OTopographis map
(txahon of weff must be shown on a USGS fopo map end
attached to Mrs fort e not using GPS)
4. FACILITY- Is the nano of It9 business where the tell Is located,
FACILITY ID #(il applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable) WI- OS.? CO t
WELL USE (Check Applicable Box) Monitoring 0 Munlclpai/Publrc 0
industrial/Commercial❑ Agricultural Recovery0 Injection
Irrigation❑ Other (list use) f gpi.A �,,,;SS /N
L
May bo in degrets,
minutes, seconds or
In a decimal format
ev NAMEOF-FACILITY ' ernt)
STREET ADDRESS
sir, hey
rr City or Town State Zip Code
YCONTACT PERSON /Rots GJ; 7lhcN
e� MAILINGADDRE S 4G20 it OZ7et(S izy R
Lkaki,1 Q tic, 2g2 tG
City or Tct m State Zip Coda
( 70Y 1. 3612- (f X al-17o,l- G1/1-5-00‘
Area code - Phone number
5 WELL DETAILS:
a. TOTAL DEPTH: 2QQ,
6, DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Belor/ Top of Casing: FT,
(Use'+' if Above Top of Casing)
�s7a.
3`_' '594
d. TOP OF CASING 15 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance ‘nth 15A NCAC 2C .0118.
o. YIELD (gpm): 3 METHOD OF TEST
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth)
From 7(Or To /OG � From To
From To From To
From To From To
6, CASING: Thickness/
Depth Diameter Weight Material
From To Ft.
From To Ft.
From To Ft
7. GROUT: Depth Matenal
t rttu is at:
From 6 To r)�� Ft tite(o
From To Ft il-i%L {-,-54•S-.
From To Ft
Method
ek)11Vt4
3, SCREEN: Depth Diameter Sfol Size Material
From To FL in. In
From To Ft. fn. fn.
From To Ft. to in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To,,,
ys
- c7'7 r
c/Z- aU`O
Formation L9escription
CCD 'u — 90
11, REMARKS:
— 200 ' %Lo (i j -Ole/ 'Ape,
r,.r 0 =
100 HEREBY CERTIFY THATTHis WELL WAS CONSTRUCTED Pi ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ATUR
It) ` 74
F CERTIFIED WELL CONTRACTOR
PRINTED NAQ3 OF PERSON CONSTRUCTING THE WELL
,S `Li i1.1M`.
DATE
10
:g unit
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 56a.
Date site visited: 2- 9- )o by D `1.13 permit required: Ye No
Pam GVd-1b
Rev. 7/05

BUILDERS NAME:
ADDRESS:
PHONE NUMBER: