386592_Well Construction - GW1_20100901

DATE DRILLED 7- 1 p
TIME COMPLETED t - L r%
a. WELL LOC TION:
CITY ,I' a s (r) tTz-
7rOO ClowFct�,� �>^
(Street Name, Numbers, Community, Subdrvsion, Lot No, Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge 0 Other
(check appropriate box)
LATITUDE 3 L c)q,Q 70
LONGITUDE O if-9, OG
Latitude/longitude source: AeGPS ❑Topob aphio map
(/ocalron of weimusl be shown one USGS lopo map and
attached to this form it not using GPS)
4. FACILITY- is the narra al the business where the well is located,
FACILITY ID #(if applicable)
May bn in degas,
minutes, seconds or
Ina decimal format
ev NAME CF-FACILITY •3 a.nt) ,,SZin e.v
STREET ADDRESS
City or TONTI StateL Zip Code
1 CONTACT PERSON R J— T it)) Ithe .
e./ MAILING ADDRESS //76 20 It 0 Z-r e ((S Pcii,vy 121.
A./C, 2S2 tG
Zip Coda
- 1 '7O'/-GSA/-roc,$t
Phone
City or Town State
( 7(�Y Zq2 61 ?7?
Area code - number
1. WELL CONTRACTOR.
GEO-THERMAL WELL CONSTRUCTION RECORD
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of
Water Quality
WELL CONTRACTOR CERTIFICATION (1
Lc) 11v1.0\�
Well Contractor (1 dividual) Name
Yarlki n WA11 Company Tr c.
Well Contractor Company Name
STREET ADDRESS 1(10R HRmptnnvi 11 P ROar1
Hamptonville NC 27020
City or Town State Zip Code
( 336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable) 44 I< —
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)1A)-10
WELL USE (Check Applicable Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery'❑ Injection 0
Irrigation❑ Other (list use)
AWED P.0.14
%
COUNTY ifecA n �;q3--
5. WELL DETAILS:
a. TOTAL DEPTH:
2.oto'
6, DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Bela;Y Top of Casing. FT.
. (Use "+" if Above Top of Casing)
Submit the original to the Division of Water Quality within
1617 Mall Service Canter -Raleigh, NC 27699.1617 Phone No
Date site visited: 2- 9- Jo by p 36
3 a 9 2
d, TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance fn accordance with 15A NCAC 2C .011S.
o. YIELD (gpm), - METHOD OF TEST
f. DISINFECTION: Type HTH Amount
g. WATER ZOpIES (depth)
From 90 To /Uc) From To
From To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Matenal
From To FL
From .To Ft
From To Ft
7. GROUT: Depth Worm! Method
0t?i1.aG
From
To iCJCO FI-f-ke fir.,;, G.LJ F Pu rl01D %'
From To Ft. iit—$a.1d
From To Ft
a, SCREEN: Depth Diameter Slot Size Material
From To Ft in. in
From To Ft. fn. In.
From To Ft. In in
9. SAND/GRAVEL PACK:
, Depth
Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To e
57
S7• kuv
Formation 9escription
r�Gld(
kt fct G an
11, REMARKS: 1/
�7— if
.2.00 %lo(el I-/\e/Y
r� H
•\
SEP 1
Inbrmnivrt kjr
uvv'.
I DO HEREBY CERTIFY THATTH45 WELL WAS CONSTRUCTED Pi ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOR..• BEEN PROVIDED TO THE WELL 0WEN.
CJ J'/g T -oZ(G -CO
SITURE r CERTIFIED WELL CONTRACTOR DATE
ti),) ieno t (i s
PRINTED NAh1E OF PERSON CONSTRUCTING THE WELL
30 days. Attn: information Mgt,,
. [phone] ext 568.
Permit required: Ye No
Fate GVJ-1b
Rev. 7/05
- 2010
Unit
3Q0

BUILDERS NAME:
ADDRESS:
PHONE NUMBER: