387852_Well Construction - GW1_20101008

GEO-THERMAL WELL CONSTRUCTION RECORD
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of -Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION tl� ��-
1. WELL CONTRACTOR
Well Contract r (Indfwdual) Name
Yarlki n Well Company Inc.
Well Contractor Company Name
STREET ADDRESS 1 q(1R Himpi-nevi 1 le Rnec9
Hamptonville NC 27020
City or Town State Zip Code
( 336 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION: �� �; ` � 3-3�
SITE WELL ID #(If applicable) t
STATE WELL PERMIT#pf applicable)
DWQ or OTHER PERMIT #(d applicable) LUZ 0 3Cb /rg
WELL USE (Check Applicable Box) Monrtoring ❑ Municipal/Public 0
Induslnaf[Commercral 0 Agricultural ❑ Recovery ❑ Injectron 0
Irngabon❑ Other 0 (list use)
DATE DRILLED 49"&)"Li/
r Jo
TIME COMPLETED
5. WELL LOCATIPth
CITY We, C Cl/K4J-f0H /ti COUNTY fie(-FC/e/7/'
(J V V 4'h-ei AlGtdr.h. Jv-,
(Street Name, Numbers, Community, Subdrnston, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING'
❑Slop ❑Valley ❑Flat ❑Ridge 0 Other
(check appropnate box)
LATITUDE 3 S. [G��/j a/
LONGITUDE 8C% 5 .3x
AM ❑ Pt
May be in dcgrce ,
minutes, seconds or
In a d:cimal format
Latitude/longitude source rGPS ❑Topographic map
f ca(non of wag must be shown on a USGS lopo map and
attached to Mrs form if not using GPS)
4 FACILITY is Ire nano el U4 business whrre the laded
FACILITY ID #(if applicable) �1 /
NAME F TY J i7enei STREET ADDRESS iertpeoVo 2-/ e. P(c•
XVI/Ine., Ca/ 9l6 62
City or Tdrm / nState // Zip j o
CONTACT PERSONIreOW E//c, w. � wJ7 ?I'
�ATLC.NG A ,o_R�SS 42O f't.,DZse t 2 ��vvyr /aj
City or Twin State Zip Coda
( -7o' } 32 .6/ S-8 M 7o si—C W..So o t�
rea code - Phone number
5 WELL DETAILS: ((��
a TOTAL DEPTH . 7"3
b, DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL BelaNTop of Casing* FT.
(Use if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated allor below land surface may require
a variance In accordanceanwith 15A MAC 20.0118
V o. YIELD (g pm) METHOD OF TEST
f. DISINFECTION• Type HI'H Amount
g. WATER ZONES (depth)
From To From To
From To From To
From To From To
6 CASING. Thickness/
Depth Diameter Weight Matenal
From To Ft
From To Ft
From To Ft
C 852:
7. GROUT: Depth Matanal Method
From_ To o/-1--(40 Ft `t/%-e',MO 6Rid rpet/
From To Ft 4--3c 4A40
From To Ft
8, SCREEN Depth Diameter Slot Size Material
From To FI in.
From To Ft fn
From To Ft In
9. SANDIGRAVEL PACK:
Depth Size
From To Ft
From To Ft
From To FI,
10. DRILLING LOG
From To
aye
In
fn
in
Material
Fo_Lmation Despriptlon
C..l C
REUcIVED
OCT -8 2010
Information Processing Unit
uvvaB DG
11,REMA o 2Ski- &ref
I DO HEREBY CERTIFY WATTHtS WELL WAS CONSTRUCTED Pi ACCORDANCE Willi
ISA }MAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THLS
R EEN Pa°VIDEO TO THE WELL OWH.
low
Sj=.OURE 0 RTIFIED ELL CONTRACTOR DATE
t-J P/Li \ \. s
PRINTED NAM's OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality wlthfn 30 days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Date site visited: +u" 23- to by b Permit required: s No
�j'a w✓
Pam GW-lb
Rev. 7/05

BWIDERS NAME: /20S. j 7110
ADDRESS:
PHONE NUMBER