386591_Well Construction - GW1_20100901

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GEO—THERMAL]�WELL CONSTRUCTION RECORD
NON ON1RESIDENT.IAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION If
1. WELJ„DNAR,gCTOR.
1110
Well Contractor (lndhndual) Name
Yadkin Well Company inc.
Well Contractor Company Name
STREET ADDRESS 1'QR Hamptnnvi 11 P Road
Hamptonville NC 27020
City or Town State Zip Cafe
( 336 )_ 468-4440
Areacode- Phone number
2. WELL INFORMATION:
SITE WELL ID #(It applicable) i Q 01
STATE WELL PERMIT#(rf applicable)
DWQ or OTHER PERMIT #(if applicable) W.1.a3 001 (f Si
WELL USE (Check Applicable Box) Mondoring ❑ Municipal/Public 0
I
induslnal/Commercial 0 Agricultural 0 Recovery ❑ inJeclron ❑
Irrigation Other' (list use) .6-t..)t-kt kp,Ary ciusr
DATE DRILLED 7— . 3- f O L;, ye,
TIME COMPLETED (.0: 30 AM'❑ PM,gt%'"
3. WELL LOC TION: 1� -CITY G a 4. (v COUNTY/4CA / n h;IGS
7•soa itchy t Ci/oti- Pc,v" i-.
(Street Name, Numbers, Community, Subdveon, Lot No. Parcel, Zip Cade)
TOPOGRAPHIC / LAND SETTING.
❑Slope ❑Valley ❑Flat ❑Ridge 0 Other
(check appropnate box)
LATITUDE 3 J 0 q_ 0 70
LONGITUDE F; V q, vx I
Latttude/longitude source:rPS ❑Topob aphio map
(focalron of weg must be s own on a USGS lopo mop and
attached to this form if not using GPS)
4. FACILITY. Is the name DI tFe business where the well Is located
FACILITY ID #(if applicable)
May bc in degrees,
minutes, seconds or
In a dccimal format
0y NAME OF-FACibiiY gym(')
STREET ADDRESS
((' City or Tdwn Stale Zip Code
(-c'.i , CONTACT PERSON ROfs Q f /.ncp.
� I? e, MAILING ADDRESS 4fG 20 ji o zze lls �u.� a 1
I-4 �t/C 2gz (G
City or Town Slate Zip Code
( 70g •- 3g2- �f X k N170V-G5�l-�oC�
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2001
b, DOES WELL REPLACE EXISTING WELL? YES Q NO ❑
c. WATER LEVEL BelaN Top of Casing: FT.
(Use `+• if Above Top of Casing)
s7)._
3 h.591
d, TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated alfor below land surface may require
a variance in accordance with 15A NCAC 20.0118.
o. YIELD (gpm): ( METHOD OF TEST
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth)
From To From To
From To From To
From To From To
6. CASING:
Depth
From To
From
From
Thickness/
Diameter Weight Material
Ft.
To Ft
To Ft
7. GROUT: Depth vMl�rosttenetcc0 Method
From Todd6 Ft-� 4q'pio 6-'-' uM
From To Ft Save P
From To Ft
2, SCREEN: Depth Diameter Slot Size Material
From
From
From
To Ft in. In
To Ft, fn. in.
To Ft. in in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size Material
To Ft
To Ft.
To Ft.
10. DRILLING LOG
From To
h r6
Fo nnr'escription
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InforrTt�_.�.� ,r
11, REMARKS:
— .zoo ' Ito lei 11-he;��/PZ .
t DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED PI ACCORDANCE W nH iSA NCAC 2C, WELL CONSTRUCTION STANOARDs, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OW
SIG URE 0 ERTi D WELL CONTRACTOR DATE D
DATE
p4 f 1.3
PRINTED NAM OF PERSON CONSTRUCTING THE WELL
inessrng Unit
EOG
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27698.1617 Phone No,'[phone] ext 568.
Date site visited: 2- 9-f0 by f Ta3 Permit required: Ye No
fe
Forth GWib
Rev. 7/05

Burr,nERS NAME :
ADDRESS:
PHONE NUMBER: