389259_Well Construction - GW1_20101206

GEO-THERMAL WELL CONSTRUCTION RECORD
NON WELL CONSTRUCTION RECORD
North Carolina Department of -Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N
38 59
1, WELL CONTRACTOR
J'-cLi fVL) U,
Well Contrac r (Individual) Name
Y�r3ki n Wel 1 Cctmran_v Tnc.
Well Contrzcict Company Name
STREET ADDRESS 1 9f1R Hamptnnvi 1 1 e
Hamptonville NC 27020
City or Town Slate Zip Code
L336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION: /
SITE WELL ID #(If applicabls) �/.�//ff /4"" 2 7—
STATE WELL PERMIT#(if applicable)_.__
DWQ or OTHER PERMIT #(f applicable) kit O:CD / _f (,
WELL USE (Check Applicable Box) Monitoring 0 Municlpat'Public 0
industrial/Commercial 0 Agriculturaa❑ l ❑ Recoveryinfection 0
Irrigation❑ OtherX(Iist use) ClOSeS h
DATE DRILLED 11 { -IO
TIME COMPLETED (6 ' AM ❑ PM (g7
3. WELL LOC)�JTIO�N, �{Il��pprr(��,���,, /
CITY l�hCt(r(,o�L COUNTY_L LCirPn
(Street Name, Numbers, Community, Subd aeon, Lot No, Parcel, Zip Coda)
TOPOGRAPHIC !'LAND SETTING'
❑SlopeXValley ['Flat ❑Ridge ❑ Olner
(check appropnate box)
LATITUDE 3 CTq ,123
LONGITUDE 3 0 y-7 / See
Latitude/longitude source' XIDS ❑Topographic map
(button of v,egtaus, be shown on a USGS fopo map and
attached to this form if not using GPS}
4 FACILITY- Is In: nano al IF9 business she,a the, ..efl Is locals,:
FACILITY ID #(if applicable)
May be in degrees.
minutes, seconds or
In a decimal format
NAME of MILITY Prt -vtat (Yuwk fdOrs L
STREET ADDRESS ,S SS2'% Pre J•4A L vt
-�ae.14-I. /V'L, 2-S(27o
City or Town Africk Slates / t, Zip Cc4o
CONTACT PERSON Afric t-J d4.t)i�
L
MAILING AIDIDRSS SS (7-'° 2- $27
0
City or To„ n Slate Zip Coda
( 70 )- 30- /237 tit 70y- S s-7_
Area code - Phone number / f 2
5 WELL DETAILS:
a TOTAL DEPTH.
ISM,
b, DOES WELL REPLACE EXISTING WELL? YES El WIC
c, WATER LEVEL Bela/Top of Casing FT.
(Use'+' if Above Top of Casing)
d, TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C 0118
o YIELD (gpm) ETHOD OF TEST cif //Y
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 Malenal
From To Ft
From To Ft
From To Ft
7. GROUT: Depth Matenal Method
From 0
To (,37) FtT1,-aAv4
Fran To Ft ,1-s ad
From To Ft
a, SCREEN Depth
Diameter Slot Size Material
From To FI tn. In
From To Ft In In
From To Ft In in
9. SAND!GRAVEL PACK:
Depth
Frorn To Ft.
Frorn To Ft
From To FI
10. DRILLING LOG
Fro To,
)Yi.
Size Material
Formation Description
56
Ire. I
Rtc
ma 11, REh1AR cron Processing vnS
a c tivv Lis
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED PI ACCORDANCE W rl-I
15A NCAC 2C, WELL CONSTRUCTION STANOARDS, AND T}L4T ACOPY OF THIS
RECORD HAS BEE PROVIDED TO THE WELL 1JWIER_ 10
TURE p CERTIFIED WELL CONTRACTOR DATE
sd1y1 6s-3-(11V((J
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt,,
1617 Mail Service Center— Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Date site visited: IS— 9-'0 by 0073 Permit required: Yes No
S'-"Q A�
Form GIN -lb
Rev. 7105

BUILDERS NAME:
ADDRESS:
i ylioNE SER : �O