389261_Well Construction - GW1_20101206

GEO-THERMAL�WELL CONSTRUCTION RECORD
NON WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION tt s% )--
1, WELL CONTRACTOR
3 eA, 1,,lV \S
Well Contractor Individual) Name
Yadici n Wel 1 Cnrnr nv Inc:.
Well Contractor Company Name
STREET ADDRESS 1 q()R Hampi-nnvi 1 1 P 130,r3
Hamptonville NC 27020
City or Town State
( 336 )_ 468-4440
Zip Code
Area cc -de- Phone number
2 WELLINFORfAATION:
SITE WELL ID ii(If applicable) 3?-5—
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT tt(if applicable)
WELL USE (Check Applicable Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 R overt' ❑ Injection 0
Irn3atlon❑ Other list use) 6r'Cs evp+_ 4 /
J
DATE DRILLED f / - 3 -- /0
0 P44$
et.)'(61kvvq
TIME COMPLETED 3- va AM
3. WELL LOCATIO? .
CITY (to .t.:.He-
/COUNTY/`
.S-g 2 ? -'rj Ib„ t L . ,
/
(Street Name, Numbers. Community, Subderision, Lot No , Parcel, Zlp Coda)
TOPOGRAPHIC / LAND SETTING
❑Slops [Valley ❑Flat ❑Ridge 0 Other
(check appropnate box)
LATITUDE 3 j n7,221,
May b:, in degrees,
minutes, seconds or
Ina d:cimal format
LONGITUDE k 0 S%7, / SZE
Latitude/longitude source AMPS ❑Topographic map
(bcabon of weUmust be shown on a USGS topo mop and
attached to (his form if no( using GPS)
-1 FACILITY-Isttoranoel1iagain.sst,hE,aL,a,.e:lIsla:.la,.
FACILITY ID #(if applicable) e-{'Q
ll �k(
1J4b"cnI FACO-1TY PcL Vf.-.- ck_to'- �a PpKx
STREET ADDRESS ,j 2-7 r ej- ,tGu7 h
( r� ` A (-• iS>2? 0
it
Tdr.rt State Zip Coda
1/4
CONTACT PERSON P0.`YrKdG- (iacJlL-
/)
MAILING ADDRESSOA-
City or Tarn State
( 76 fk)- 3C.)---f23 ?- /14 `70V-
Zip Code
-,r9-7//2
YES 0 NO '
FT,
A rea code - Phone number
5 WELL DETAILS: �,
a TOTAL DEPTH: / 1+ o
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Bela/ Top of Casing
(Use -+' if Above Top of Casing)
d, TOP OF CASING I5 FT Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance fn accordance with 154 NCAC 2C 0118
o. YIELD (gpm) j Sr METHOD OF TEST (.(r
f DISINFECTION: Type H1TH Amount f `�,t p
g. WATER ZONES (depth) ��//
From 72To 79 From To
From To From To
From To From To
6. CASING. Thickness/
Depth Diameter Weight Matenal
From To Ft
From To Ft
From To Ft
7. GROUT: Depth Matenal Method
From To 1 �Ft7�#f/hC ���pe/
From To Ft d S (;Ad !
From To Ft
8, SCREEN Depth Diameter Slot Size Material
From To Ft in. In
From To Ft In fn,
From To Ft In in
9 SANDJGRAVEL PACK.
Depth Size Material
Frcm To Ft
Frcm To Ft
From To F1
10. DRILLING LOG
From To Formation escription
O • 51g P
S f- /s-0
v‘N U
_ `(i1U
Zc L Ontt
cstng
11. REMARKS: ,niQlft (t) r1 Ig0G
/ SD 2 cx)es
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED PI ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
R _ BEE -RO`IIDEOTOTHE WELL OW 2'
id '1/% //.2-3 '0
DATE
ATURE 0'a ERTIFIED WELL CONTRACTOR
40(14 kJ Boll-5
PRINTED JE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt,,
1517 Mall Service Center- Raleigh, NC 27699.1617 Phone No. [phone] ext 56B.
Date site visited: �-f 9_l� by %), Permit required:, No
Form GW-lb
Rev. 7105

BUILDERS NAME:
ADDRESS:
PHONE NUMBER :