386581_Well Construction - GW1_20100901

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GEO�-THERMAL WELL CONSTRUCTION RECORD
1 1' ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION ft
1. WELL CONTRACTOR:
LI w01(
Well ContractorM
ncvidual) Name
Yadkin Wel 1 Company Inc.
Welt Contractor Company Name
STREET ADDRESS 140R Hampi-nnvl l 1 e Roar7
Hamptonvilie NC 27020
City or Town State Zip Code
( 336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION: SITE WELL IDII(Ifapplicable) 474-C -'9
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) WZ8,3 Gof' tit SL
WELL USE (Check Applicable Box) Monitoring 0 Municipal/Public 0
InduslnalCommercial 0 Agricultural ❑ Recovery ❑ Infection 0
Irrigation❑ Other (list use) CY-420 Pia, ii,.U,rA CIusn c
DATE DRILLED %.-C�! -/O La ye,
TIME COMPLETED ,) •QUO AM'❑ PN
Wr
3. WELLTYLOCiTION., 1 /
r.th J COUNTY/ J(fn443
1 •sva Mow, c✓oC-} Pcr I,. (-Ps
(Street Name, Numbers, Community, Subdotsion, Lot No, Parcel, Zip Cade)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE 3 F 0 , O "1 Q
LONGITUDE b y, 4 6
Latitude/longitude source: ACPS ❑Topod aphis map
Coca bon of weff must be shot», on a USGS lopo mop and
attached to fhrs form ,f no( using GPS)
4. FACILITY. is the nano of U'.e business where the well Is located,
FACILITY ID #(if applicable)
May bo in degrees.
minutes, seconds or
Ina d:cimal format
ev NAME OF-FACIL4FY \•3 c')
STREET ADDRESS
San 1'{ �y
�1 City or Term StaleZip Code
CONTACT PERSON R0fs 1 (xi; itncto,
ei MAILING ADDRESS 41(i 20 rl 0 ,ze ((S c ra.k
City or Town Slate Zip Code
( 709' )- 3g2- 6f $R itt7oi/_GSA/-rot) $
A rea code - Phone number
tit- 2g� t�
5. WELL DETAILS:
a. TOTAL DEPTH: �,o(�t�
b, DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Belocy 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 fn accordance with 15A NCAC 2C .0118.
o. YIELD (gpm)• Id METHOD OF TEST
3L, ar581
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth) , to 1 l'N.
From dp7 To 5:6 Froth To
From To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From To Ft
From To Ft
From To Ft
7. GROUT: Depth epdtan'al Method
From tf.:, To a ' F1"rkefr10 6-j4 U",Aitei
From To Ft d'Sa-et
From To Ft
8, SCREEN: Depth Diameter Slol Size Material
From To FI. in. In
From To Ft. fn. fn.
From To Ft. In in.
9, SAND(GRAVEL PACR:
Depth
From
From
From
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
(00
(CO (CUO
/Ov - 7c•
Size Malarial
Formation Desonption
,S o,
c��rtrg
tntORThn..
n+,nrC1dSC
11, REMARKS:
.:Zoo ' {to lei ei r �ehrif,
I DO HEREBY CERTFYTHATTHtS WELL WAS CONSTRUCTED Pi ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECOB N PROVIDED TO THE WEJLAWNER.
•
i ATU- +OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAM8 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: 2- `j- ]v by p T13 Pelt required: Ye No
lA For r ye
ats (li hrS
Fam GW-1b
Rev, 7/05
ED
310
,sing Unit
3

BUILDERS NAME:
ADDRESS:
PHONE NUMBER:
-71
9
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