386576_Well Construction - GW1_20100901

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GEO-THERMAL WELL CONSTRUCTION RECORD
ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #1
1. WELL CONTRACTOR.
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Well Contractor(individual) Name
Yarlki n WA11 CcxnDanv ]-r1C
Well Contractor Company Name
STREET ADDRESS 19(1R Harnpfnnvi 11 e R r1
Hamptonville NC 27020
City or Tovm State Zip Cafe
L336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION; 44k-
STATE
SITE WELL ID Nit applicable) 44
WELL PERMIT(d applicable)
DWQ or OTHER PERMIT #(if applicable) 1A)1tjS Qvi yt }l
WELL USE (Check Applicable Box) Morrrtorrng ❑ MuniclpaUPublic 0
rndustnar/Cornnlercial 0 Agricultural 0 Reco"ery ❑ infection 0
Irrigation❑ OtherX (list use) C a
DATE DRILLED 6-30
TIME COMPLETED ffsi/D fiM ❑ Pgig
3, CITYWELOC\TION.
al-.
.Il (J %% /
COUNTY P �t�� �upS
7 so.a It .oc✓ce}
(Street Name, Numoers, Community, Subdiv s on, Lot No., Parcel, Zip Coda)
TOPOGRAPHIC / LAND SETTING;
0Slope LIValiey ❑Flat ❑Ridge ❑ Olner
(check appropnate box)
LATITUDE 3 l7 cZ 1,6
LONGITUDE e4J V 9,OG (
May b, in degrees,
minutes, r,econds or
Ina d drnal format
Latitude/longitude source• rPS oTopob aphis map
Coca bon of wet must be shown on a USGS lopo map and
allached to this fomi i!not using GPS)
4 FACILITY- Is the narns al Li a bbjsrness where the weft is located
FACILITY ID #-(if applicable)
Zv NAME OF-FACilsifY rJ,11 r')
rear'
STREET ADDRESS
} City or Town StaleL Zip Coda
CONTACT PERSON Rc.u.s
e MAIL,ING ADDRE S C/ 2° (t o z-r e ((s „ma r b
/.os4, (-- 2 Al g 2 t CG
State Zip Coda
( 70Y I 36/2 G -
Area code - Phone number
City or Torn
I X "7GYl - 00
5 WELL DETAILS:
a. TOTAL DEPTH: 2oct i
b, DOES WELL REPLACE EXISTING WELL? YES 0
e. WATER LEVEL 8elo7r Top of Casing'
(Use'+' if Above Top of Casing)
FT.
NO ❑
1C1D-1-
L '3 5 7 6
d, TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance fn accordance with 15A NCAC 2C .011S.
o. YIELD (gpm): / METHOD OF TEST
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth)
From 1i To qa ' From To
From To From To
From To From To
6. CASING:
From
From
Thickness/
Depth Diameter Weight Matenal
To Ft
To Ft.
From To Ft
7. GROUT: Depth Malarial Method
From 40 To fvi Ft 1tiiv.•ieJ
From `F}ulr� U �rt�
To Ft
From To Pt
2, SCREEN: Depth Diameter Slot Size Material
From
RPM
From
To FI in. In
To Ft. fn fn,
To Ft. In in
9. SAND/GRAVEL PACK:
Depth
Frcfn To
Size f,faaf'm
Ft
From To Ft.
From Fo Ft
10. DRILLING LOG
From To
0 l 3
Ste- G3
- z:
7u — •
Qz
5Z-
11. REMARKS:
LL O
SFP 1 — 2010
information Proves sing Unit
Formation DescriptionOlrfOE
, /
.-cc _4 oL
.!s old
£IJ -']-e
Sa.14,ae
kiu6,1,e---G1,1,/�z
200 ' lw (Pi , "0 Pry, e,
!DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED Pi ACCORDAnCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, MD THATA COPY OF THIS
flEC�: � - • BE PROVIDED 70TH��VHZ v
FCERTIFIED WELL CONTRACTOR ' DATE
U
CERTIFIED
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
TU
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: 2- 9-.70 bY_D 7713 Permit required: Ye No
✓
Form GVd•1b
Rev. 7/05
(I)e S(ktn �j► Lump

BUILDERS NAME:
ADDRESS:
PHONE NUMBER:
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