389265_Well Construction - GW1_20101206

GEO-THERMAL WELL CONSTRUCTION RECORD
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of -Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION ti ;715-7
1. WELL CONTRACTOR.
Well Contracto (Individual) Name
Yaclki n WRIT Compnv rnc.
Well Contractor Company Name
STREET ADDRESS 1908 Harpi-nnNri 1 1 P Rclati
Hamptonville ATC
City or Town State
L 336 468-4440
Area code-. Phone number
2. WELL INFORMATION:
SITE WELL ID #(If appilcable)
STATE WELL PERMIT#(If applicable)
27020
Zip Code
DWQ or OTHER PERMIT #(if applicable) W . 0300 [6 3
WELL USE (Check Applicable Box) Monitoring 0 Mluniclpal/Publtc 0
rndustnal/Commercial ❑ Agricultural ❑ Recov%y❑ Injection 0
Irngation❑ Other r; (list use) u Lc>c
DATE DRILLED 8 -1)--f 0
TIME COMPLETED L"I '`‘12
AM ❑ PM.g'
w
3. LL
ECITY. LI.hQ Or o `
�e- COUNTY�"L
,� ee �Cch (2Ab;/.D
3 kc;_7 Prc.- L-S
(Street Name, Numbers, Community, Subdrvuion, Lot No. Parcel, Zip Code)
TOPOGRAPHIC i LAND SETTING:
DSlope ❑Valley Xlat ❑Ridge 0 Olfter
(check appropnate box)
LATITUDE 3 G 3- c
LONGITUDE ' 0 le8'.
May be in degrees,
minutes, scconds or
in a decimal format
Latitude/longitude source: ArOPS ❑Topographic map
{Coca bon of weffmusf be shown on a USGS lopo mop and
at eched fo (hrs form rfnof using GAS)
4. FACILITY -Is the name of the t,Jsrness when the well Is located,
FACILITY ID #(if applicable)
NAME OF FACILITY 5 &Vc /`fir, d y
STREET ADDRESS .3 SSC.)'7 %elm (-ve
2211
City or T09,71 Stale Zip Coda
CONTACT PERSON L'-CED j �4 ✓S,/le_o jJ
MA11INGADDRESS k 20 laOYap/b ge-17reJ
c N
City or'raNn State �� .2/
/�
Zip Coda
/14( (- Jao y w Zv�t_ 312 - 618'g
Area code - Phone number
5. WELL DETAILS:
a, TOTAL DEPTH: 3.
b, DOES WELL REPLACE EXISTING WELL? YES 0 Nt
c. WATER LEVEL Belau Top of Casing FT.
(Use'+' if Above Top of Casing)
392.35
d. TOP OF CASING IS / FT. Abo Land Surface*
'Top of casing terminated aVor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
o. YIELD (gpm): vZd METHOD OF TEST
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth)
From -7'5 To 7t' From To
From To From To
From To From To
6. CASING: Thickness!
Depth Diameter Weight Matenal
From To Ft.
Fr
om
To Ft
From TO Ft
7. GROUT: Depth
Matenal
From To3(e0 Ftrttvpf^'-aG.
From To Ft
From To Ft
Method
8, SCREEN: Depth /Diameter Siot Size Material
From To / Ft in, In
From -Tr- Ft. in fn.
From ..- To Ft. in in
9. SANDIGRAVEL PACK:
. Depth • • //
From To.V Ft.
From ,,To FL
From � To Fi.
Size Materiel
10, DRILLING LOG
From To Formalw Description
0 - `t0 So,�
3(no' /4o.d
RECEIVED
LJEL - 6 zO1u
Information Processing Unit
DWQ/BOCK
11, REM RKS: % %/ /
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED Pr ACCORDANCE W rnI
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF DRS
RECO1A,S BEEN PRCMDED TO THE WELL QWUER.
96fATURE 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 Mall Service Center- Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Date site visited: fo -i 3 -to by QA6 permit required: s No
5' G? w P l3 e,
Form GW-lb
Rev. 7105
i /, ''r, n . IAA

BLS NAME :
ADDRESS :G .Cs �� 'eG (� /�C'vdy /2(
? d c.
PHONE NUMBER : (rt. % 7C?y G --ro o
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