386627_Well Construction - GW1_20100827

City or Town
( 336 ) 468-4440
Area code Phone number
2 WELL INFORMATION WELL CONSTRUCTION PERMIT# .S S 07, , z(() —O f
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(ifapplicable) /j¢ /` 3
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED 7-7-10
TIME COMPLETED 33o AM ❑ PMZ
4 WELL LOCATION
CITY
COUNTY SCt i/`(/
(Stre t ame, Num rs, Community ub !vision, Lot No , Parcel ip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
RESIDENTIAL l IAL WELL CONSTRUCTION RECORD
Nprth Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3o3 'J /T
1 WEA�L%%`` CONT CTO
!/477ut GrcCPI uc.
Well Contractor (Individual) Name
YADKIN WELL COMPANY INC
Well Contractor Company Name
1908 HAMPTONVILLE ROAD
Street Address
HAMPTONVILLE NC 27020 Top Bottom Ft
State Zip Code Top Bottom Ft
8 GROUT Depth Matenal Method
Top D Bottom 3 Ft lnn/k C'70/� �
Top 3 Bottom o25/ Ft /+Lp
n
g WATER ZONES (de th)
Topi:77ye� Bottom y3 Top Bottom
Top Bottom Top Bottom
' Top Bottom Top Bottom
Thickness)
7 CASING Depth Diameter WeightT,��M/aterial
Top_( Bottom 50 1 Ft 4 ./.)S SDR,P/ ' "--
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft In in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
fSlope ❑Valley ❑Flat DRidge DOther 11 DRILLING LOG
/'QQ Top Bottom Formation Description
LATITUDE " DMS OR ,‘ l3/72_ D O / 4,0
LONGITUDE " DMS OR fa. 3:2 CerAD v / S `r{oC
k.
Latitude/longitude source �PS Topographic map / / 1
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) /
5 WELL OWNER
Ph h i/ Mc
O er Name
Street Address
City or Town
( )
Area code Phone number
6 WELL DETAILS nn II __
a TOTAL DEPTH d lD)
State Zip Code
b DOES WELL REPLACE EXISTING WELL/ YES 0 NOX
c WATER LEVEL Below Top of Casing & 0 t FT
(Use "+" if Above Top of Casing)
)i
d TOP OF CASING IS / FT Above Land Surface`
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
12 REMAF1
RECEIVED
AUG 2 7 Znin
Information Process Un►t
a(4' I WQ/SOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e YIELD (gpm) 1r7o )4.-' METHOD OF TEST r1cV)ine'f-tk. OF -al 1 (C."-�(-CCnvde`
f DISINFECTION Type HTH _ Amount S PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to. Division of Water Quality - Information Processing;
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Date Site Visited 2 -- ‘--(O By: 0 Permit: Y_ees No
What Is Height of Well Casing? Make Sure 12" Above Ground Level!!!!
o L.e ,/ 5 £.tA,r
AwutLJL aAAA,/ 7-7 le
Forty GW-la
Rev 2/09

BUILDERS NAME: Lee 9,'/��f
ADDRESS: /� Z S,'/a
61-i'fry ail, C, 76 3U
PHONE NUMBER: 33 6 — 4' / — 0 Z O