386584_Well Construction - GW1_20100901

GEO-THERMAL WELL CONSTRUCTION RECORD
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #1 6-7
1. WELL CONTRACTOR.
6e,tlJ r i LC�3
Well Contracto (individual) Name
Yadkin Well company Inc..
Well Contractor Company Name
STREET ADDRESS 190R Hamptnnvi 11 e ROari
Hamptonville NC 27020
Co
City or Town State Zip de
( 336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID {l(If applicable) i / 9�i
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)1A)-T-C)3 Go
WELL USE (Check Applicable Box) Monrtorrng ❑ Municipal/Public 0
fndustnal/Commercial ❑ Agricultural 0 Recovery ❑ infection 0
Irrigation❑ Other`» (list use) G-e...ativt tr,,u,,q
DATE DRILLED 7-1S-"I o
TIME COMPLETED 5[4!) AM ❑ PNl,{g
3. WELL LOCpA1lTION,
CITY G/,rat, c.)Yt�- COUNTYACAkit �t4-S
7500 flow FcfLe" (-t.
(Street Name, Numbers, Community, Subdvseon, Lot No. Parcel, Zip Cade)
TOPOGRAPHIC / LAND SETTING:
❑Slope. ❑Valley ❑Flat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE 3 O" 6 £ ' t
LONGITUDE r 0 4li 9- 06
Latitude/longitude source: CiPS ❑Topographic map
(loca(ron of well must be shown on a USGS lopo mop and
attached to this form if not using GPS)
4. FACILITY. Is th! name al the business where the well Is located
FACILITY ID //(if applicable) [[
�W-rev NAME Off-FACIL•I?'Y '-j J
001) an key
STREET ADDRESS
b May . in degracc,
minutes, seconds or
Ina decimal format
City or Tdrrn
(�8%F CONTACT PERSON
e. MAILING ADDRE
City or TarTulin
s
/�11 State
Zip Code
ILV,fS T W: fthef'
4162o liozze((s ivy R s
State Zip Coda
(70y 3g2 �l $g
Area code - Phone number
} - Hl 7O4_ G(//-5730
5. WELL DETAILS:
a. TOTAL DEPTH: Q.0cp/
b, DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL 8etocv Top of Casing: FT.
(Use "+• if Above Top of Casing)
d, TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated aVor belay land surface may require
a variance fn accordance With 15A NCAC 2C.0118.
o. YIELD (g pm): .D O METHOD OF TEST
f. DISINFECTION:Type HTH Amount
g. WATER ZONES (depth)
From 'U To c() / From To
From To From To
From To From To
6. CASING:
From
From
From
Thickness/
Depth Diameter Weight
To Ft.
To Ft.
To Ft
7. GROUT: Depth M tenal
uo '-ertkaA0[4
a Ft ern._ CxrvJ",
From 0 To '
From To Ft. et-Sa-"4
From To Ft
3, SCREEN: Depth Diameter Slot Size
From To Fl. in. In
From To Ft, fn. in,
From To Ft in in
9. SAND/GRAVEL PACK:
. Depth
From To Ft.
From To Ft.
From To Fl.
10. DRILLING LOG
From Tp
U (o D'
?o.
Matenel
Method
Material
Size Material
Formation Description
So•�
11. REMARKS: `/I
.2 0c, ' Az. 1El �`/te/ y er
t DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED Pi ACCORDANCE W rfl-I
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECO BEE F1PROVIDED TOTHE WELL QtiYNER.
KJ / `/
CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME 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] eut 568.
Date site visited: 2- 9- ]o by D 313
Permit required: Ye No
Form GW1b
Rev. 7/05
Unit
8 4

BUU fERS NAME:
ADDRESS:
PHONE NUMBER: