389264_Well Construction - GW1_20101206

1. WELL CONTRACTOR:
GEO-THERMAL�WELL CONSTRUCTION RECORD
NON ONRESID.ENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 1 as S
Well Contractor (l$tdMduat) Name
Yatlki n Wel 1 Co nnanv ]•nr,.
Well Contractor Company Name
STREET ADDRESS 19fR Hampi-nnvi 11 e Rcpr9
Hamptonville NC 27020
city or Town State Zip Code
L336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION:
S ITE W ELL ID Mir applicable) /Z/( 3 Q
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT Of applicable) tAi U i (, s
WELL USE (Check Applicable Box) Monrtoring ❑ Municipal/Public 0
IndustnaUCommercial 0 Agricultural 0 Recov 0 Injection 0
Irrigation❑ Other list use)
i e Lcn
DATE DRILLED / /—/ () --/ 0
TIME COMPLETED 5 '
AM ❑ PM -Er
ELL
S. CITY L`1.4OLo �e--
COUNTditt'a,
3 86-7 -Pk,,.4- L -
(Street Name, Numbers, Community, Subdnnsion, Lot No, Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
ID Slope ❑Valley >flat ['Ridge❑ Otner
(check ap`pr`opnate box)
LATITUDE 3 S"" G j C
LONGITUDE ' 3 51S', 6 7fr
May h; in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: LIPS ❑Topoa aphis map
(location ofwefmust be shown on a USGS lopo map and
attached to thrs form rfnot using GPS)
4. FACILITY. is Use name of the business where the Well Is located.
FACILITY ID #(if applicable)
NAME OF FACILITY - �'✓c !` ,- L(t
3 Ssc� '7 iz,,•n f v e f L
2e211
State Zrp Code
GEO [ EA Q/t_v!J �Gu i ,e.�
MNG//ADDRESS
CZ Irycor(are State 2_6.2�(
zi
(76 f` l-C1W S'°Y W Zofl. 342- 61 ?g
Area code - Phone number
5. WELL DETAILS: 34
a. TOTAL DEPTH:
STREET ADDRESS
City or Tamil
CONTACT PERSON
n
/14 p Coda
b, DOES WELL REPLACE EXISTING WELL? YES ❑ NC:61
c. WATER LEVEL Befog/ Top of Casing FT.
(Use'+• if Above Top of Casing)
339264
d, TOP OF CASING IS .---------FT. Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance In accordance with ISA NCAC 2C .0118.
o. YIELD(gpm)- 30 METHOD OFTEST u/ri✓
f. DISINFECTION: Type HT'H Amount /74 i.,c yf
g. WATER ZONES (depth),
� p
From )' To p 1 . From To
From To From To
From To From To
6, CASING: Thickness/
Depth Diameter Weight Matenal
From To i Ft
From To"- Ft
From / To Ft
7. GROUT: Depth
/! Matenal Method
From 0 To3t,O° Ftrt!Nernla pO'"v�i
From To Ft 4'.S`i" - 1
From To Ft
8. SCREEN: Depth Diameter Slot Size Material
From To • FI in. In
From To Ft. fn. In,
From - To Ft to in
9. SAND/GRAVEL PACK:
. Depth - •
Size Material
From To Ft.
From / To Ft.
From" To Ft.
10. DRILLING LOG
From o
0 -
(0q (co`
11, REM RKS.:t
663)
Formation1Description
`
Os +
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ivpo
ra2016
inform-A+tor. r‘luCesstn
Q/ G 9 Unit
1 DO HEREBY CERTIFYTHATTHIS WELL WAS CONSTRUCTED Pr ACCORDANCE Writ
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THLS
REC9S»-M s BE N PROVIDED TO THE WE l 120w12ER.
ATUR F CERTIFIED WELL CONTRACTOR
dAy Gs V J 1 I:s
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mali Service Center- Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Date site visited: (o _f 3 'to by 0316 Permit required: ,1 )
DATE
Form GW-lb
Rev, 7/05
No
w cv hr- 0 f, p ,�

(c/1-fr`
BLS NAME:
)J d' Lf > r7 ivl L li
ADDRESS: G 20 c-e- ��� /�✓ /�- e >3, /2 C
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PHONE NUMBER: Cr -4jJ ��a 4 zo� / - o7-