386586_Well Construction - GW1_20100901

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Ci--)GEO-THERMAL WELL CONSTRUCTION RECORD
NONRESIDENT.IAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 11
1. WELL CONTRACTOR.
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Well Contractor (dividual) Name
Yadki n V,rp1 1 Cnrnpanv tnC-
Weli Contractor Company Name
STREET ADDRESS 7 9f R Hampi-nnvi 11 p Roars
Hamptonville NC 27020
City or Town State Zip Code
( 336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION; //��J /^^,� n
SITE WELL ID #(Iiappticable) MT/- K - 1."1
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(lf applicable) W:4..B.' Go 1 COI
WELL USE (Check Applicable Box) Monitoring ❑ Municipal/Public ❑
Induslnal/Commercial ❑ Agricultural ❑ Recovery ❑ Infection ❑
Irrigation❑ Other' (list use) G-iA tkt tiS,ta,1 Cleisr
DATE DRILLED -7-19-10
TIME COMPLETED 5.70a AM'❑ PMLA.-
3. WELL LOCpq//TION. �JJ -//
CITY cd„ b. l o 4�1 z. COUNTY/Pch fe,% kS
7,soo Fcffros�.,..
(Street Name, Numbers, Community, SubdM;sion, Lot No , Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge ❑ Olner
(check appropnate box)
LATITUDE 3 f l✓ 1,O 7o
LONGITUDE F--O 7,- Cr)
Latitude/longitude source: ( GPS ❑Topob aphis map
(location of well must be shown on a USGS logo map and
attached to lhrs form rfno! using GPSj
4. FACILITY- is Ili- name of tl'a business where the well Is located
FACILITY ID #(rf applicable)
May bs in degrees,
minutes, seconds or
In a decimal Co mat
ev NAMECF-FACIL•LFY 5ar•tt)
STREET ADDRESS
City or TOWn StaleL Zip Coda
CONTACT PERSON Rofr 4))17-01ctr
I
��l(7ri MAIL,INGADDRESS IA; f 0z-re((s v RA,Lkak Q A/C- 2 8 2 l
City or Town Slate
Zip Coca
( 70 ). 3672- G f �X 70,! Gw-500,
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Q.00
b, DOES WELL REPLACE EXISTING WELL? YES O NO ❑
c. WATER LEVEL Belorf 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 with 15A NCAC 20.0118.
o. YIELD (gpm): ILL METHOD of TEST
f. DISINFECTION: Type HI'H Amount
g. WATER ZONES (depth)
From To From 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 Malone! Method
From 0 To D-00 Ft -'tI' (f) tcc 6,•,y r p r_ am(
From To Ft 4•-SR-.J —
From To Ft
8, SCREEN: Depth Diameter Slot Size Material
From To FI in. In
From To Ft. fn. fn.
From To Ft. to in
9. SANDIGRAVEL PACK:
, Depth Size Material
From
To Ft
FromTo Ft.
From To Ft.
10. DRILLING LOG
From To Formation ❑ nptip n
M �f ' d S �'d-(r.A-.-t
• a-od
11, REMARKS:
;Zoo ' Ao /el , -% tQ/ pie
117)
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41
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT ACOPY OF THIS
RECORD .• :EENP-OVIDEDTOME WELL OI;
41.11! 7 f--fa
f►'lirURE s:� ERTIFIED WELL CONTRACTOR DATE
STCSotti
W
PRINTED NANA 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) 733-701S ext 568.
Date site visited: 2- 9- jv by p I -a Permit required: No
rictle
Form GW.1b
Rev. 7/05
1ir¢g Unit

BUILDERS NAME:
ADDRESS:
PHONE NUMBER: