386575_Well Construction - GW1_20100901

NONRESIDENTLQL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality sp
WELL CONTRACTOR CERTIFICATION # 9-5-7 7
—1.WELL GC"NTRACTOR.
Well Contractor (Individual) Name
YADKIN `WELL COMPANY, INC.
Well Contractor Company Name
STREET ADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town State
( 336 ).468-4440
Zip Code
I
Area code- Phone number
2 WELL INFORMATION• A
SITE WELL ID #( applicable) A-A-ir:- 2
WELL CONSTRUCTION PERMIT#(d applicable) Jo C! 96.Ss,/
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitonng❑
Industrial/Commercial❑ AgriculturalD Recovery0
Irrigatioi OtherDj (list use)
Municipal/Public❑
Injection0
i
i
! DATE DRILLED - 3'T-/()
PMEls
A
Nec f<'IN" -f
TIME COMPLETED C'; Cie) AMC!
4 WELL LOCATION:
CITY (i/� 1 ✓Im 4-L COUNTY
ISOO PA&Or0Cv• o Pa VOA L
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
T POGRAPHIC / LAND SETTING.
Slope 0 Valley 0 Flat ❑ Ridge 0 Other
(check appropriate box)
LATITUDE 3 S 0 1, UQL
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE g 0 v 1"y Q 7
Latitude/longitude source. XGPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. FACILITY- is the name of the business where the well Is located
FACILITY ID #(if applicable)
NAME OF FACILITY ,Jyffle) .S4 .t5/_
STREET ADDRESS 7-rTh /4c. o v L IZ7v
City or Town State f ` Zip Code
CONTACT PERSON C 1 jj i ,1--1 i-. P •e ivet vy Oo>h; } i�
MAILING ADDRESS /
La
City or Town State
( 70 )4 )- .74; — 9'tir 7 -/
Zip Code
YESO N00
FT.
Area code - Phone number
6. WELL DETAILS. Q ,
a TOTAL DEPTH: / / s /
b. DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing /0
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance I�,�j.SA NCAC 2C .0118
e. YIELD (gpm) 95— 7 METHOD OF TEST AIR PUMP
f DISINFECTION: Type HTH Amount
g. WATER ZONES (depth) .4 j,-esst R siC
From 6f To 70 From To
From To From To
From To From To
7. CASING: Depth Diameter Thickness/Welght Matt1erial
From '-k"I To 4c5)— Ft 4 )5v t IV �-\J
From To Ft
From To Ft
8. GROUT: Depth t Material Method
From 0 To �1 Ft 33&' 4e t3^1pea
From To Ft 1
From To Ft
9. SCREEN: Depth Diameter Slot Size Material
From To Ft in In
From To Ft in in
From To Ft in. in
10. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
Fen r, 4. F�yrma�on Description
/
51) .. l0 I 4?,C/J t art . -fc
i• • ,1-' r-- r n P -- r
i=,i,l___v t_l!
SEP 1 — tofu
Information Processing Unit
uvv..1r1:)vu
SIZE OFF (G,.p)-c(
BIT SERIAL NO
12. REMARKS:
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
R BEEN P ViDEO TO THE WELL OWN
70? ro
S TURE OF ERTIFIED WELL CONTRACTOR DATE
OCC.t W r✓ o 1 .-s
PRINTED NA 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.
42
Fe
�O 7Uz� ti?C5Zt/!� vi 62 C Ja
q, ,, 1111 /i
Form GW-1 b
Rev.1 2/07