386593_Well Construction - GW1_20100901

1. WELL CONTRACTOR:
GEO-THERMAL WELL CONSTRUCTION RECORD
NON ONRESIDENTrAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICATION #f
Well Contract r (Individual) Name
Yatlki n WP1 1 Compnv Tnr.
Welt Contractor Company Name
STREET ADDRESS 1408 Hamptnnvi 11 P Rr�ar7
Hamptonville NC 27020
City or Town State Zip Code
( 336 468-4440
Area code- Phone number
2. WELL INFORMATION: r/
SETEWELL ID#(Ifapplicable) A4k f� '
3
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) WIO.3 Oo r9 u V
WELL USE (Check Applicable Box) Monrtonng ❑ MuniclpaJPublic 0
Induslnal/Commercial ❑ Agricultural ❑ Recovery ❑ Infection ❑
Irrigation❑ Other (list use) Ikty q �ruf'4
DATE DRILLED 7-, (p. ld
TIME COMPLETED S: GC
3. WELL LOCA`�TION. i//
CITY f� r,t t-(J -� e-
AM'❑ Pt�-
COUNTY/PJ Ifn 4C(
7,.yoo /'1v,v c c✓off} Fcr v,� r-.
(Street Name, Numbers, Community, Subdnosion, Lot No, Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
ID Slope ❑Valley ❑Fiat ❑Ridge 0 Other
(check appropnate box)
LATITUDE 3 Oq, O'7
LONGITUDE S( y-7, 00(
Latitude/longitude source: GPS ❑Topographic map
(4xabon ofwefmust be shown on a USGS lopo mop and
attached to this font if not using GPS)
4. FACILITY. is Sre name of the business where the weft Is located.
FACILITY ID #(if applicable)
ev NAME O-FACIU Y �S,2 ,nt')
STREET ADDRESS
May be in degrees,
minutes, seconds or
In a decimal format
.San Iz ty
rr City or Tarn
Y� CONTACT PERSON
MAIL,ING ADDRESS
City or Town
f 70q( )- 3 672
Preacode- Phone number
State t / Zip Coda
R s Q W:I.
�G 20
C-•
State
� oa-reIts �y R
282t6
Zip Coda
�l Nl 7oV- GSf/-rood
5. WELL DETAILS:
a. TOTAL DEPTH: 20a
b, DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
o. WATER LEVEL BeloN Top of Casing: FT.
(Use `+` if Above Top of Casing)
3 e 5 9 3
d, TOP OF CASING IS FT. Above Land Surface`
'Top of casing terminated aUor below land surface may require
a variance In accordance with 15A NCAC 2C .0113.
o. YIELD (gpm) 10 METHOD OF TEST
f. DISINFECTION: Type HTFI Amount
g. WATER ZONES (depth) ,
From '77 To 42`6 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Matenaf
From To Ft.
From To Ft.
From To Ft
7. GROUT: Depth atenai
From 0 To c Ft •k { F 11te
From To Ft. Cr �o , k .U-Sec.-A
From To Ft
a, SCREEN: Depth Dlameter Slot Size Material
Method
From To FI in. fn.
From To Ft. fn. In.
From To Ft. to in.
9. SANDIGRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
tGd S"z
Size Material
nrn 1
JLI u
11. REMARKS:
— .too ' ttQ l�J 4- e7Y ip e,
inf
;
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED Ri ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECOR BEEN PROVIDED TO THE WELL CAV ER.
GJ�
SI TURE ERTIFIED WELL CONTRACTOR DATE
j (' to P'L.)
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
2010
e rg Untt
�G
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,,
1617 Mall Service Center- Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Date site visited: 2- 9-Jn by Q 33 permit required: No
Forrq GW-lb
Rev. 7/05

BUILDERS NAME:
ADDRESS:
PHONE NUMBER: