389262_Well Construction - GW1_20101206

GEO-THERMAL WELL CONSTRUCTION RECORD
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 11
1. WELL CONTRACTOR.
A S«9"L.. ,L3
Well Contractor (in dual) Name
Yadkin G,TPi 1 Co-nl»nv
Well Contractor Company Name
STREET ADDRESS 1_ 9(1R Ham= teny 1 i p Rt>, ri
Hamptonville NC 27020
City or Tom State Zip Code
( 336 468-4440
Area code- Phone number
2. WELL INFORMATION: a
SITE WELL ID#(Ifapplicable) /44k�-
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable) W (33 (,)CD 1(a 3
WELL USE (Check Applicable Box) Monrtofing ❑ Municipal/Public 0
IndustnalfCornmercial ❑ Agricultural 0 Retov5ry ❑ infection D
irrigation❑ Other list use) Cit• e cacl
944,
DATE DRILLED 1/—' //
TIME COMPLETED 4:-c) a AWE] PiNrer
3, WELL ELCA\IO%(ix 4� ���� //�
p,� /� COUNTYOr�(-`f'�'h I��f./�
3 S>j? /'^JM �YC� L -
(Street Name, Numbers, Community, Subdw s,on, Lot No„ Percel, Zip Code)
TOPOGRAPHIC f LAND SETTING:
❑Slope 0Valley)<Flat 0Ridge ❑ Olner
(check appropnate box)
LATITUDE 3 G Si?C
LONGITUDE �i 3
Latitude/longitude source* AirPS ©Topob aphic map
(txaton of wallmusf be shown on a USGS lopo mop and
attached to this form If not using GPS)
4 FACILITY -re the name clthe bJslnesswhere the aelltstocatad,
FACILITY ID #(if applicable)
NAME OF FACILITY 5 AVe /2 v d
STREET ADDRESS 3 ,hj 1 r rn the f /,.
Ci.vve /Lk. 2 K21I
City or Town Stale Zip Coda
CONTACT PERSON C'-�e / C f a e_beaii
MAI INGADDRR�ESS (,20 1O- pl/i gek
Itycort--crrrne_ 4' -2
Zip Coda
M( 7v y-65//-,,17i0Y Gt./ ci2-61 eg
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3
:H'LtG.
May bo in degrets,
minutes, seconds or
in a decimal format
b, DOES WELL REPLACE EXISTING WELL? YES 0 NO.
c. WATER LEVEL Bet*N Top of Casing• FT.
(Use "+":f Above Top of Casing)
f DISINFECTION: Type Hill Amount
g. WATER ZONES (depth)
From t -14 To i 3-S From To
From To From To
From To From To
6. CASING:
d, TOP OF CASING IS -"F Ab y.a Land Surface'
'Top of casing terminated at/or below land surface may require
a variance In accordance vnth 15A NCAC 2C 0118.
o. YIELD (gpm) 30 METHOD OF TEST k!'✓
(ffa 67-.r
Thickness/
Depth Diameter Weight Matenal
From To Ft
From To Ft.
From To Ft
7. GROUT:
From 0
Depth Material Method
To" O Ft-t"%efrl•.:, 6.c J� (� trove
From To Ft 1
From To Ft
3, SCREEN: Depth Diameter
From To FI. in
From To Ft. fn.
From To Ft. fn
9. SANDIGRAVEL PACK:
, Depth Size Material
f,latertal
From To FL
From To Ft
From To Ft
10. DRILLING LOG
From - To
.310o' /-- 4 &m '.;le
Scot Size
in
tn.
in
Formation Dascription
t
r jc:
' 6.1
'a0
lntaf mvIto al°RpG rig
1,
' C �REMARKS:
(--t� P i ' `y , p/ J
1 DO HERESY CERTIFY THAT' H{S WELL WAS CONSTRUCTED Pi ACCORDMCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND TR4TA COPY OF Hiss RECORD HAS BEEN PROVIDED TO THE yJEL�tiYNtrT.
/ `/'sir/A�J/J�y� -� /O
r?~4ATUR' .P CERTIFIED WELL CONTRACTOR DATE
PRINTED 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 27699.1617 Phone No. [phone] ext 568.
Date site visited: /'o-,3 -/0 by OM Permit required: ,Y6P No
Porrtt GVV-1b
Rev. 7/05
262
75- - I cKCi

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BARS NAME:
L,
ADDRESS: 16 2o
PHONE NUMBER:
/oe /--c41;,�, C
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