387851_Well Construction - GW1_20101008

GEO-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. [phone] 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: