389263_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 ff '- STD_
1. WELL CONTRACTOR.
---S-0Gt t L J VV 10 \VS
_
Well Contractor Individual) Name
Yadkin Wel 1 Companv Inc
Well Contractor Company Name
STREET ADDRESS 1 q0A 'Rampfnnvi 11 e He 9
Hamptonville NC 27020
City or Town State
( 336 )_ 468-4440
Zip Code
- 3 U q
Area code- Phone number
2. WELL INFORMATION: %j
S ITE W ELL ID #(If applicable) A4 / t.
STATE WELL PERMIT#(rf applicable) i
DWQ or OTHER PERMIT d(if applicable) ZL ..t 473 00 ( 4 -
WELL USE (Check Applicable Bo c) Monrtoring 0 Municipal/Public 0
Industnal/Commercial ❑ Agricultural ❑ Recov I❑ tnfectron 0
Irmgation❑ Other list use) diaseei 4,Qv,,
DATE DRILLED /l ` G/J — f O
, qv.,
❑ P f»
�e �(.�t/�
TIME COMPLETED%�(2 :04) AM
a. WELL Cks4 O44 i -1-e COUNTYr:s'Y,.`CCh
//�� fl
3 ? r'a.N r'Y`Cri- Lh
(Street Name, Numbers, Community, Subdivisron, Lot No, Parcel, Zip Code)
TOPOGRAPHIC !LAND SETTING:
IJSIope ❑Valley Xfat DRldge 0 Olner
(check appropriate box)
LATITUDE 3 G i(, 3 `j L
,
Mayboindegreea,
minutes, seconds or
In a decimal format
G
LONGITUDE C a 61 tti. HO
Latitude/longitude source: tiPS ❑Topographic
(location ofwefmuslbe shown on a USGS lopo
attached to this form dno( usrng GPS)
4. FACILITY. Is the name el tta Wslness where the well Is located,
FACILITY ID #(if applicable)
map
mop and
NAME OF FACILITY 5 kVe 2c r. 4y
STREET ADDRESS 3 SSC.) % /z'in f-ve F L4-s
C-)\v1,"(k)J-ie /(% 2k211
City or Tar.'n p- Stalerr Zip Code
CONTACT PERSON r L-4)-e/�_oJJ 4-t�t1% /h.e
(`j�,@.0
MAULING ADDRESS T'(� ID 1l? OY J.p/(j Fekv., 2J
L s 0`'e P r�
/�
City orTown State
M( 76 S` 1- 0zr-..1aoY cti zv�[_
ZipCode
3q 2 - 61 eg
YES 0 NO
'
4'1FT.
Area code - Phone number
5. WELL DETAILS: �ry
a. TOTAL DEPTH: 3459� '
b, DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL BeIoNTop of Casing. it/
(Use'+' if Above Top of Casing) `
382C3
l
d, TOP OF CASING IS -- FT. Above Land Surface'
'Top of casing termInafed aVor below land surface may require
a variance fn accordance with 15A NCAC 2C 0118.
o. YIELD (gpm): 3d METHOD OF TEST a /ri
f. DISINFECTION: Type HTH Amount /fi.2..-G•wor
g. WATER ZONES (depth) J
From go' To er'd ` From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Matenal
From To Ft.
From /---"To Ft
Fr-1" To Ft
7. GROUT: Depth Matenal
From 0 To C FFt )(f - 3 GANA
From To Ft -4 Sc' w�
From To Ft
Method
8, SCREEN: Depth _— - Diameter Slot Size Material
From To FI, in In
From / To Ft. in, In.
From /' To Ft In in
9. SANDJGRAVEL PACK:
Depth j "� Size Material
From /To Ft.
From / To Ft.
Frojrt/ To Ft.
10. DRILLING LOG
From To Formation Description
v d r r
OS ��' Cs.ra.'1 -tP
'tl ��
s�ess
11. !REMARKS:
EM RKS: matton r 115 !
5) arm > 3 1 � L<, ��.4-
I DC HEREBY CERTIFY THATTHts WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCI)ON STANDARDS, AND THAT COPY OF THIS
_., BE N PROM EI 7�� ThJ� WELL
PA-1 giO
NA UR-'.F CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt,,
1617 Mail Service Center- Raleigh, NC 27699.1617 Phone No, [phone] ext 568.
Date site visited: (o--/ 3 -to by cold Permit required: { No
Form GW-1 b
Rev. 7/05

(71 cl-c
BLS NAME: //et) )) c -� > rTM t
ADDRESS: gco✓
PHONE NUMBER: (rr4L-V .E/i7 �U, f G�