274 Baity Rd (3) «isrAre,;.. RECE11/ED
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Nater Quality N O V 0 8 2011
•.,,,��,xr• WELL CONTRACTOR CERTIFICATION# d',S` ?a--A
- -1.WELL CITRACTOR: d. TOP OF CASING IS FT.Above Land Surface'
-�1 'Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 26.0118.
Well Contract (Individual)Name
YADKIN WELL COMPANY, INC. e. YIELD(gpm): ) /�METHOD OF TESTAIR PUMP
Well Contractor Company Name f. DISINFECTION:Type HTH Amount /,G1,
STREETADDRESS 1908 HAMPTONVILLE ROAD g. WATER ZONES(depth):.
��
From t XL1 To /1b From To
HAMPTONVILLE NC 27020 From To From To
City or Town State Zip Code
3t 36 )-468-4440 From To From To
Area code- Phone number 7. CASING: Depth Diameter ThicknessWeight Material
2.WELL INFORMATION: From To-�� •17 Ft. a!1+ oS. -
SITE WELL ID#(if applicable) f,+(� � � / S
WELL CONSTRUCTION PERMIT#(if applicable)S'� 3- •$5��. rom To Ft.
OTHER ASSOCIATED PERMIT#(if applicable) KO� From To Ft.
3.WELL USE(Check Applicable Box)Monitoring[] Municipal/Publico 8. GROUT: Depth Material �� Method
Industrial/CommerciO Agricultural❑ Recovery❑ Injection❑ From 0 To 5- Ft. 6,17 e- Gj >gs Gc)L&e- Q
Irrigation❑ Other❑ (list use) From, Tom_Ft. e�in v'4 vr. ee
DATE DRILLED ��"' 'l t{ From To Ft.
TIME COMPLETED r3'0 AM❑ PIS- 9. SCREEN: Depth Diameter Slot Size Material
4.WELL LOCATION: ' From TO Fl. in. in.
CITY: �?b(kf r/%plc p�COUNTYFrom To Ft. in. in.
From To Ft. in. in.
(Street Name,Numbers,Commulhity,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC!LAND SETTING: 10.SAND/GRAVEL PACK:
"Slope❑ Valley ❑ Flat ❑ Ridge❑ Other Depth Size Material
(check appropriate box) From To Ft.
O May e in degrees, From To Ft.
LATITUDE v Ste. i_ minutes,seconds or
LONGITUDE OV_3 • Sf in a decimal format From To FL
—
I source: GPS ❑ Topographic map 11From ING LOG
From To ormation Description
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4
3 - 72'- —j`k�VXOP4
Z- 3ay �e •man-
5.FACILITY-is the name of the business where the well Is located.
FACILITY ID#(if applicable)
NAME OF FACILITY
STREET ADDRESS /
City or Town State Zip Code y�
C0NTACTPERSON t kr �I �( SIZE OFF -t
MAILING ADDRESS V t9a X BIT SERIAL NO:
( U� C-e, ��=���� � 12.REMARKS:
City or Town �S ate Zip Code
Area Phone numb
6.WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
r 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOe
c. WATER LEVEL Below Top of Casing: 5-0 FT. S UREJW CERTIFIED WELL CONTRACTOR DATE
(Use"+"if Above Top of Casing)' o�
PRINTED NAM OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form GW-1b
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.(919)733.7015 ext 668. Rev.12/07
DATE SITE VISITED: �I 7 w BY: &V PERMIT: YES NO
WHAT IS HEIGHT OF WELL CASING? MAYFRURE CASING IS 12"ABOVE GROUND LEVELM
BUILDERS NAME: � of ( yk G
ADDRESS: �� i6a k I Z
PHONE NUMBER:
3 0 .
W°"r G
he ;
.Oct.du 11 09:39a Information Services 33b tb;il6bu 13.1
r Davie County Environmental Health RECEIVED
P.O.Box 848/2.10 Hospital Street
Moctcsville,NC 27028 NOV 0 S 2011
(336)753-6780/Fax(336)753-1680
X%TLL PERMIT
Account #: 990003311 T'txP1N%EH#: 5823-30-5596-Well
Billed To: CKJ Building &Design,LLC •'�ul�division Info:.-
Reference Name: James Blakley Loca1ian1Addtess:-;274 Baity Road-27028
Proposed acuity: Building /Well Property-Size'. 7.578 Acres
-"TActrouri o�frthe�mployees of the Davie County EFi Sec"tion shall in'rio way be taken as a guarantee that this
well will produce water of any particular quantity or quality or for any amount of time. This permit is valid
for a period of 5 years from the date of issuance. 'This permit may be revoked if it is determined that there
has been a material change in any fact/circumstances upon which this permit was issued.
Permit Type: New 5fl Repair ❑ Abandonment ❑
Proposed well Location Diagram Certificate of Completion Diagram
a
nni
Comments: j)f a. (bCa ft?aj�t:L�L4 Driller
Certification#:
Grout Inspected:
Well Head Inspected:
GPS Coordinates:
EHS: Date: ` EHS: Date:
W.P.7-03