386583_Well Construction - GW1_20100901

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GEO-THERMAL�WELL CONSTRUCTION RECORD
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
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WELL CONTRACTOR CERTIFICATION fi
3 6583
I. WELL CONTRACTOR.
—6(..AI ICJ C ��
Well Contractor (i fvidual) Name
Yadkin Well Comn.y Tnc,
Well Contractor Company Name
STREET ADDRESS 1 qOI} Hamptnnvi 1 1 e R�rl
Hamptonville NC 27020
City or Town Stale Zip Code
( 336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION: ��
SITE WELL ID+9(Itappllcabte) / r'-'rc./ ?
STATE WELL PERMITP(ii applicable)
DWQ or OTHER PERMIT #(if applicable) i&)Z62 Oo ` q Sl
WELL USE (Check Applicable Box) Monrtorm9 ❑ Municipal/Public D
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
irrigation❑ Other (list use) Ce..) i - . C.10.1?
75-00 MowGawtj - Fci v,� �-•
(Street Name, Numbers, Community, Subdwision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
I]Slope ❑Valley ❑Fiat ❑Ridge ❑ Oiner
(check appropriate box)
LATITUDE 3� / 0�, Q 73
LONGITUDE [-) , 06(
Latitude/longitude source: t3PS ❑Topod aphic map
{1oca&on of wefmusl be shown on a USGS lopo mop and
attached to this form rfnot using GPS)
4. FACILITY- is ine name of the business where the well Is located
FACILITY ID #(if applicable)
DATE DRILLED (y 'CO
TIME COMPLETED 4,:c11) AMC] PM.13
3. WELL LOC TION: � ]] //
CITY GN ✓ h (,v 1�1 z COUNTY,PC It/I 4�S
Maybe in degrees,
minutes, seconds or
In a d cimal format
ev NAME OF-FACILIFf `) C/en') .Sat k ev
STREET ADDRESS l
City or Tawn StateZip Codo
1.1 CONTACT PERSON RI VS f!J; I -the
e, MAIL;ING ADDRESS %G 2a (l' 0 e3-r e t(s CJlvy R
%%rrv�, E-4Q Ai c 2 `s a_ 16
City or Town State Zip Coda
( 70g )- 362- C/ $1X M7-G(//-oo0`
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2oo z
b, DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
c. WATER LEVEL Belay Top of Casing: FT,
(Use "+• if Above Top of Casing)
6. CASING:
Depth
From To Ft.
From To Ft.
From To Ft
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 (g pm). 30 METHOD OF TEST
f. DISINFECTION: Type HTH Amount
g. WATER6,4(
ZONES (depth)
From Ca 7 To to to • From To
From To From To
From To From To
Thfckness/
Diameter Weight Material
7. GROUT: Depth Warta! Method
From 0 To �D ' ev 4 c </G
Ft --(ILere RA/ r Q'rt(
From To Ft d-.Savct.t
From To Ft
3. SCREEN: Depth Diameter r SIOI Size Material
From To VI in. [n
From To Ft. fn. fn.
From To Ft. tn. in.
9. SANDJGRAVEL PACK:
Depth -
Frcm To Ft
From To Ft.
From To Ft.
10. DRILLING LOG
Fro�rl To
Size Material
Fium ation Description
a
,J 6 az..
d4L- cc Jfoir e
r—ThF'"r -i'�i
,r ,m9
btr�
Intorrneat A,';;n`'O
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED Pi ACCORDANCE WITH
isA NCAC 2C, WELL CONSTRUCTION STANOA.RDB, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWN
%/%id
ATURECERTIFIED W LL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUGTING THE WELL
Submit the original to the Division of Water Quality within
1617 Mall Service Center- Raleigh, NC 27699.1617 Phone No
Date site visited: 2- 9- /o by p 36
30 days. Attn: Information Mgt,,
. [phone] eXt 568.
Permit required: No
Form GW-lb
Rev. 7/05
D
ng Unit

BUILDERS NAME:
ADDRESS:
PHONE NUMBER: