162 Nikkis Way (2) RECEIVED
. I � `_=IVED
MAR p 4 2016
VV ELL CONSTRUCTION RECORD , 1 4 2 16' Forintemal Use ONLY:
This form can be used forsingle ormultiple wells MEA LTH
1.`YellContracto Information:
C t'a.� HEALTH
14.NATER ZONES
ti TROM TO I DESCRIPTION
Well Contractor Name � a ft � ft.
?$Z.' 7-14 ft S ft a 6
NC Well Contractor CertifWionNumber 15.OUTER CASING(for mu]ti-easetliv s ORLENER ifa lieaUle
TRO" TO DL1ML'TER THICIQVESS h71,TERULL
Yadkin Well Company. Inc. it ft in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-looril
/ /
PrROAI ITO DMAILTER Tf1ICKNESS MATERLAL
2.Well Construction Permit r: /� 7 O/ ft. ft �t IZ5• in 5��2� v G
List all applicable reel/constnictlon peri�e.County, fate,Parlance;etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: MOnl TO MINIETER I SLOTSIZE I TMCIOYESS I MATERIAL
❑Agricultural ❑Municipal/Public fr. fr.
❑Geothermal(Heating/Cooling Supply) )ZesidentialWaterSupply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
TROhf TO MATERLtL EMPLACE01ENTh1ETHOD&AMOUNT
OL-rigation ft. ft. //' / l
Non-Water SupplylVcll: L L
til�rL
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑AquiferRecharge ❑Groundwater Remediation 19.SAND/GRAVELPACIC da liable)
❑AquiferStoragz and Recovery ❑ MOM Salinity Barrier ft• TO ft rEATERLAL I EMPL.4CEMENThIETHOD'
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional shectr if necessa, )
❑Geothermal(Closed Loop) ❑Tracer TRO\I TO DESCRTMON(color,b.idness mrthvck type,erain size etc.)
❑Geothermal(Heating/CoolingRehurl) 00ther(explain under#21 Remarks) ft ft
4.Date Well(s)Completed: Well 7 ID;YI`f �9
Z 3 d ft. �$— ft rr /aA i e "P
So.We—uLocation: Phone number 3, `�+ 5
7" 1 �IS— it. � ft.
L CL�q Se e_L1f�
1 G
Facility/OwnerNa/'Eme FacilityIDm tifaoplicablel fO/l
i /
IW.t G2 r t'cklk Cva� ft ft.
Physical Address,City,and Zip 21.RENL4RKS
1 le—
County , Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Cerlificafidn:
(ifivell field,one latgong is sufficient)
lv 6yirlc,� r r
Signature ofCettifiedWell Contractor Date
6.Is(at'C)the well(s): ermavent or ❑Temporary Ey sig irirg this form,I hereby cerr�6,that the rrell(s)was(sere)consncicted in accordance
with 15A NCAC O2C.0100 ar 15A NCAC OIC.0200 iP'eli Cacstrucdon$taadards and that a
7.Isthisis a r air f to an existing►velL' ❑Yes or o copy of this record has been provided to the well owner.
lfthis is a repair,fill out known irell consmiction bforninrion a d ecplaiii the nature of rhe
repair raider X21 remarks section or on the back of t6isfornr. 23.Site diagram or additional well details:
You may use the back:of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For inuhivle li jection ornon-iiatersupply wells ONL1'idth the sante consh•uctimyou can
submit oneform. SUBidITTAL INSTUCTIOUS
9.Total well deptb below land surface: a2 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulr�,)le irellr list all d+pihs rfd!rjerent(example-3U00'anjd 2L1`0') construction to the following:
10.Static water level below top of casing: 1 (ft.) Division ofWater Quality,Inforntatiou Processing Unit,
I n•oterlevel Is above casing itse"+" / /) 16171,1..0 Service Ceuta,Raleigh,NC 27699-1617
11.Bor•chole diameter: iP (iu.) Bi[ 0f 6'1.19 � 23b.For Iulettion Nell;: Lt addition to sending the form to the eddress in 24a
above,also submit a copy of this form within 30 days of completion of well
12.Well cuusirucliun melhud: Rotary construction to the following:
(i.e.auger,rotary,cable,du•ectpusli,etc.)
Division of Nater•Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
.11 13a.Yield(gpm) Method of test: A/y 24 c.For Water Sunnly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
�, completion of well construction to the county health department of the county
136.Disinfection type: HTH Amount: cups-
constructed.
Form GIV-1 r , North Carolina Department ofEnvironment and Natural Resources-Division of Water Quality Revised Jan.2013
l�atP titre [Tion-...a ..) r,___ 11A 11 iC .i- / . -
Builders Name• Owners Name:
Address:
Address:
Phone Number: Phone:
Cell Number:
Cl�� �is/
v
Vii IILL��S � Cr fi
S mG� C`
if
Well Construction Permit For Office Use Only
aid Davie County Health Department 7*CDPFileumber 123015
210 Hospital Streetmber D5-000.00-017 Site.1
P.O.Box 848
Mocksville NC 27028 Tax Lot#: Tax Block#::
Phone:336-753-6780 Fax:335-753-'1680 Evaluated For:WELL
PERMIT VALID UNTIL: 10/212020
Property Owner: Jonathan A.Sechrest Applicant: Jonathan A.Sechrest
Address: 207•Pepperstone Dr Address: 207 Pepperstone Dr
City: Mocksville CRY: Mocksville
State2ip: NC 27028 State0p: NC 27028
Phone#: Phone#:
Property Location Site Information
rddress/Rojad#: Subdivision: Phase: Lot:
of Nikkis Way *Proposed use of Weil:
cksvile NC 27028
If Other:
Latitude
Longitude Directions
Site Address:Off of Nikkis Way Directions:140 East, Exit Farmington Rd.turn left then
left on Hubert Rd. Right on Staya Way,then left on
'Nikkis,Property crosses go right.
l
Well Contractor Information
Drilling Contractor Driller Registration
1_r_ r r r r r , . . e r r r r. r r . . . r I if r r , r r—_1 I , , r I r r_ r tiff
Permit Conditions
*Permit Conditions
I
Well location,construction and protection must meet all state and local regulations and must be inspected and approved by an authorized representative of
the Local Health Department The permit maybe revoked at anytime for failure to comply with exisUng regulations.The siting of approved well construction
area(s)by the Health Department Is to provide protection from the known possible sources of contamination.The approved well area(s)may not be changed
without written permission from an authorized representative of the Local Health Department.No voiume of quality or water is guaranteed by the Health
Department
*Issued By. 2140-Nations,Robert *Date of Issue; 1 0 , / 0 61 , / 2 0 1 r 5
Authorized State A
(Hand Drawing 0Import Drawing
Owner/Applicant Signature: **Site Plan/Drawing attached.**
WSLL CONSTRUCTION P1=RMIT �23g1S
as Davie County Health Department CDP File Number:
Jot, 210 Hospital Street
P.O,Sax 848
' County Fite Number: $,Sano-oo ot7
Mocksviile NC 27028 date: 1 0 1 0 2 ! .1 0 1 5
OInch
Drawing Type: Well Permit Scale: QBlock
- 1,---I
...............
B
{ _
B
B
-