386585_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 if
1. WELL CONTRACTOR.
Well Contractor (Individual)Name I f GS
Yadkin WP1 1 Company Inc!.
Weil Contractor Company Name
STREET ADDRESS 190R Hampfnnv111 P ROR11
Hamptonville NC 27020
City or Town State Zip Cafe
( 336 )_ 468-4440
Area code- Phona number
2. WELL INFORMATION; i
SITE WELL ID #(If applicable) s/�/ e*: / 9.r
STATE WELL PERMIT#(dapplicable)
DWQ or OTHER PERMIT #(if applicable) iA1.i.0,3 Got
WELL USE (Check Applicable Box) Monitoring ❑ MuniclpatiPubitc q
indusInaUCemmerclal ❑ Agncuitural ❑ Recovery ❑ infection ❑
irrigation❑ ,
OtheX list use) jL-,�s, q ci" r�
DATE DRILLED 7-1C/0
TIME COMPLETED j 5' eD AM ❑ Pick
WELL LL, r 1— � 0 YTS- /
-�r Gh r,� COUNTY�P�IC� �'�u�S
.5-(Jo i w�vc G✓o�} Fctv,+ (. Y
(Street Name, Numbers, Community, Subd;wsion, Lot No . Parcel, Zip Cade)
TOPOGRAPHIC / LAND SETTING:
C7Slope ❑Valley ❑Flat ❑Ridge ❑ Olner
(check appro�pnaate box)
LATITUDE 3 J uO�C1 701
LONGITUDE S 7-9, «
Latitude/longitude source: , 'GPS ❑Topographic map
(/ocebon of weg must be shown on a USGS lope mop and
attached to this form if not using GPS)
4. FACILITY- is the name oI its business where the Well Is tocaled.
FACILITY ID #(if applicable)
May be in degrees,
minutes, seconds or
in a decimal format
v NAME CF-FACIldiY Z5 v.n PD
STREET ADDRESS
a, J e
r City or Town StateL Zip Code
s�r-� CONTACT PERSON Ross7 G.); 1-/mcN
(,((7 i✓ MAILING ADDRE S 4620 t o Z7 e l(s rzy 1z
ene4 f-FQ A! C, 2 S 2 l G
City or Tcmn State Zip Code
f 70Y) 3g2- 1 »? Nl7o;/_ G5i/-5-005L
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Q.oQ.
b, DOES WELL REPLACE EXISTING WELL? YES ❑ NO p
c. WATER LEVEL Bei r i Top of Casing: FT,
(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 fn accordance wth 15A NCAC 2C.0118.
e. YIELD (gpm): METHOD OF TEST
f. DISiNFECTION:Type HTH Amount
g. WATER ZONES (depth)
From To 713 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Matenai
From To Ft
From To Ft.
From To Ft
7. GRoUT: Depth M anal Method
PJ"
From 0 To 2e-14) Ft
From To Ft
From To Ft
a, SCREEN: Depth Diameter Slot Size Material
From To FI in. In
From To Ft. fn. in
From To Ft. to in,
9. SAND/GRAVEL PACK:
. Depth -- Size Malarial
From To Ft.
From To Ft.
From To Ft
10. DRILLING LOG
From To
5cS
, DC/4)'
Formatpnes/oiipdo D
go . 1 ra� #.1
r1 e-c1 /4 i. i1 sa. niann
n
SFP 11 — 2010
e i©5
mrormatron Process rng Unit
!NM/BOG
11, REMARKS:
.Zoo ' lal
1 DO HEREBY CERTIFY THATTHtS WELL WAS CONSTRUCTED IN ACCORDANCE Wm-1 15A NCAC 20. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD BEEN P OVIDEDTOTHE WELL OWN-
URE 0
_ RTIFIED WELL CONTRACTOR DATE
Pldh
PRINTED NAM 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.'(919) 733-761S ext 568.
Date site visited: 2- 9- /o byD `Tit Permit required:
fe
No
Fan GW.ib
Rev. 7/05

BUTT,nERS NAME:
ADDRESS;
PHONE NUMBER: