389260_Well Construction - GW1_20101206

GEO-THERMAL WELL CONSTRUCTION RECORD
NON ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of -Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION t/ �5�1
1. WELL CONTRACTOR
Well Contras r (IndMdual} Name
Yadkin '7e11 Company Tnc.
Well Contractor Company Name
STREET ADDRESS 19fR Hampi-nnvi 1 le Rand
Hamptonville NC 27020
City or Town State Zip Code
L336 )_ 468-4440
Area cede- Phone number
2 WELL INFORMATION,
SITE WELL ID #(It applicable)
Pc 5-
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) iu2 03 03/,r6
WELL USE (Check Applicable Box) Monrtonng 0 Municipal/Public 0
fndustnat/Commercial ❑ Agncutlur I 0 Recovery ❑ Injection O/�, t
Irrigation❑ Other Q(list use) C OSe3+��p r^'✓�^d
DATE DRILLED
TIME COMPLETED 4. AM
3. WELL L005TION �,j�_ /
CITY civ: to t COUNTY_�f I�� 1L_
(Street Name, Numbers, Community, Subdr sion, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING'
❑SlopeXValtey 0Flat IDRidge 0 Other
(check appropnate box)
LATITUDE 3 ,� G•7Q • /2- 3
LONGITUDE 3 0 Y-7_ In'
d
Latitude/longitude source XPS ❑Topog aphis map
Coca bor: ofweUmuslbe shown on a USGS lopo mop and
attached to fhrs form if not using GPS)
May be in degree,
minutes, seconds or
Ina dxcirnal format
3892E
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or beta land surface may require
a variance fn accordance with 154 NCAC 2C.0118
o YIELD (gpm) `, METHOD OF TEST
f. DtSINFECTION•Type RUT Amount
g. WATER ZONES (depth)
From 4- To q3 From
From To From
From To From
6. CASING.
Depth
From To Ft
From To Ft
From To Ft
7. GROUT: Depth
From -r7 To % 5 V Ft
From To Ft
From To Ft
To
To
To
c(A-1p.
Thickness/
Diameter Weight Matenal
Matanal Method
a, SCREEN. Depth Diameter Slot Size Material
From To FI in. In
From To Ft fn to
From To Ft In m
9. SAND!GRAVEL PACK:
. Depth Size Material
From To Ft
From To FL
From To FI
10. DRILLING LQG.
From To
Fa lion Description
.56b
7S� )51)1 rvte,( 610
L
4 FACILITY. Is lie nave el 0,3 bi stness tha..ell Ic..sle,0-4 trY40
FACILITY ID #(if applicable) ,I y '°- kW/
NAME @f^FALILITY PccJt UQ&i, t gad,* cCyr e /"rr G ie
STREET ADDRESS ,S S'27 ere j'•t-n L Ys
&kart )1"�i. 2�270
City or Town /� / Stale Zip Coda
CONTACT PERSON A. ✓(t{( 14au) k/
MAILING ADDRESS J-82. 7 Pvu-�A L
City or Torn Slate Zip Coda
( 70 i1 36r- l237 M. 7ocf- S s-9_
Area code - Phone number 7 I :2
5 WELL DETAILS:
/ r a TOTAL DEPTH. deSSIW. 5`s
b, DOES WELL REPLACE EXISTING WELL? YES 0 N0X
c. WATER LEVEL Beloit Top of Casing FT.
(Use'+' if Above Top of Casing)
ep11!
Una
1ntor rnattp QI BOGtn+�
1 DO HEREBY CERTIFY T}tATTHlS WELL WAS CONSTRUCTED Pr ACCORDANCE W rrH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORO. BEE PROVIDED TOTHE WELLOWHER_
T R
CERTIFIED WELL
(
WELLL CONTRACTOR DATE
UO �
PRINTED
ME OF PERSON CONSTRUCTING THE WELL
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: 3- 9 - / O by b Permit required: Yes No
scQ
Form GIN -lb
Rev. 7/05
4-

BUILDS Nam:
ADDRESS:
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