Loading...
HomeMy WebLinkAbout387851_Well Construction - GW1_20101008GEO-THERMAL WELL CONSTRUCTION RECORD NON ONRESIDENTIA.ir WELL CONSTRUCTION RECORD North Carolina Department orEnvironment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION I/ 35'7)- 1. WELL CONTRACTOR. "ackti t/lf J 1 T Well Contractor (Individual} Name Yac9ki n Wel 1 Company TnC. Well Contractor Company Name STREET ADDRESS 1 clf1R Hamitt-nnvi 1 Le Rr (1 Hamptonville NC 27020 City or Town State Zip Code ( 336 )_ 468-4440 Area code- Phone number 2. WELL INFORMATION. t4 S tTE WELL ID #(II applicable) �- STATE WELL PERMIT#(il applicable) DWQ or OTHER PERMIT #(d applicable) y'/li'L 0 3 Cv /t3 WELL USE (Check Applicable Box) Monrtonng ❑ MuniclpaUPublic ❑ I Induslnat/Commercial 0 Agricultural ❑ Recovery ❑ InJeclron ❑ Irrigation❑ Other 0 (list use) DATE DRILLED 0 -?-3-/ U TIME COMPLETED 67.r(-52) AM'D Pf ==. s. WELL c' LOCATIp,tJk- 1[�� '1_ CI fr J Cl.a/ 9-10N 1 COUNTY /4k'4% r't (Street Name, Numbers, Community, Subdivision, Lot No . Parcel. Zip Cade) TOPOGRAPHIC / LAND SETTING ❑Slope ❑Valley ❑Flat ❑Ridge ❑ Other (check appropnate box) LATITUDE 3 \� (G� Yi-/ LONGITUDE O J 7 3'X May be in degrees, minutes, seconds or Ina decimal format Latitude/longitude source' GPS ❑Topographic map (bcabon of weUmusl be shown on a USGS fopo mop and attached to thcs form r(no( using CPS) 4 FACILITY• Is In! nano el t}e business v,he.e the ..etl Is Ia:ale: FACILITY ID #(if applicable) I2 n NAME GF-FAettITY To/n�J .41-1-on STREET ADDRESS ertPecot 2 2- 1j r e P c. w►n� CU/ 926 d2 City or Tovm State / Zcp podo CONTACT PERSON (Geote E/X ,v,. v-to)j. MA,IL}}NG APPDR SS 7620 f.102,e t /42S /eVvy /2A C�ur(,y 1/L 2t21C City or Tarim State Zip Coda ( -20 Y�)- Z92 _6 /S-2 it4 7o V--6x A rea code - Phone number 5 WELL DETAILS: a TOTAL DEPTH. a S(, -0 b, DOES WELL REPLACE EXISTING WELL? YES ❑ NO c. WATER LEVEL Helo7I Top of Casing. FT. (Use'+' if Above Top of Casing) d. TOP OF CASING IS FT. Above Land Surface' 'Top of casing terminated at/or below land surface may require a variance In accordance vnth 15A NCAC 2C 0118 o. YIELD (gpm) O METHOD OF TEST f. DISINFECTION' Type ITN'$ Amount g. WATER ZONES (depth) From To From To From To From To From To From To 6. CASING. Thickness/ Depth Diameter Weight From To Ft From To Ft From To Ft 7. GROUT: Deplh From t% From To Matenal Matanal Method Tog(( Ft 7 AL//rlO 6ra4A- 1)t1,•'zrod' Ft 4-3ci-ed From To Ft 8 SCREEN Depth Diameter Slot Size Material From To FI in In From To Ft fn. In From To Ft In in 9. SAND!GRAVEL PACK: . Depth Size Material From To Ft. Ft Ft From To From To 10. DRILLING LOG From To O- 11, REMAF}KiSt Formation Description �f?td C4 y S"evad'- sv�i d s irge,&" f's'7 t!d /I i 'SCe'o` t1 /ay y 0 RECEIVED -OCT - 8 2010 Inforrsat"^P P ocessinUnit i7ivv( 3(iG 21L7" Bore1 f-cry J I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED PI ACCORDANCE WM1 SSA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THLS RECORD HAS BEEN PROVIDED TO THE WELL 4.2e, Lei ll a��0 TURF CERTIFIED WELL CONTRACTOR DATE .1b;tcv/ 1-5 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. (919) 733-7615 ext 568. Date site visited: (u- 2-3- to by ban Permit required: No Form GW-lb Rev. 7/05 BUUZDIIIS NAt•E: ADDRESS: koJJ �• - ); h, PHONE NUMBER: