181 Concord Ln (2) WELL CONSTRUCTION RECORD [orInternal Use ONLY:
This form can be used for single or multiple wells
I."Well Contractor Information:
3 jf�� 14.WATER ZONES
/ ' di'>y1+✓ r-✓I�I)G1/'� F'X-V
OM TO DESCRIPTION
Well Contrac`ttorllame ft. 7 q fts+�1.30A ft. �S- r ft
NC1VeUConh'actorCertification Nuinber 15.OUTER CASING for multi-cased ivells ORLTi`IER ifa licable
• PROM TO DI4r�ILTER THICIQ s M1IATERL4L
Yadkin Well Company, Ince rt ft. in.
Company Name 16.INNER CASING OR.TUBING(eotbermalciosed-loo )
FROM TO DL4b1ETER THICKNESS h1ATERLM
I hall]ConstructionPermitFt. ,J_3 ir. in. -Sd)!_2 J GSC.
Z(st all applicable lneT/eonsnvrcrlonpennits(i.E.County,Stale,Variance,etc.)
ft. ft. in.
3.Well Use(cbecicwell use): 17,SCREEN
NMI te r Supply Well; FROM TO DL4mrTER I SLOTSIZE I THICIW-SS MATERIAL
❑Agricultural ❑Municipal/Public rt ft in
❑Geothermal(Heating(Cooling Supply) .esidential Water Supply(single) —ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
FRO\r TO IIfATERL4L EMPLACEMENT M1lETHODSA75f0LU�NT
❑Irrigation V ft. 3 ft. h �5�. t l.P ...e!/• .'r�L.
Non 11'ater Supply Well:
❑Monitoring ❑Recovery a it Za
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVELPACK rifa ]stable
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM TO AtkTERL
rt• ft. 4L E(iIPL4CE1ENT METFI 'OD
❑Aquifer Test ❑Stormwater Drainage
t. ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets ifnecessa •)
❑Geothermal(Closed Loop) ❑Tracer MOM TO DESCRIPTION(color,hardness,soil/retic type,train size etc.
❑Geothermal(Heating Coolin Retium) f//❑Other(explain under 921 Remarks) ft V ft. o I
4.Date Well(s)Completed:�'���f 6 Well ID# 3 '/ ft Z�Z dt 144 �' 1
r
ft. ft
52.11'ellLocation: Phone Inumbeir ft fr.
Facility/Owner Name Facility IDS(if enpl icable)
p fr. ft
L) f � �t Co yrs l req f'f'L461C r,_ 6f G— ft ft.
Physical Address,City,and Zip
f�I 11.REnt4RI:s
N a.U('-q---•
County Parcel Identification No.(PIN)
5b.Ln titude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification J
(ifwell field,one ladlong is sufficient) �l
-35 N 70 W
-22
1 tl C
gnatureofCerdfiedWeonh•actor Date
6.Is(2rc)the well(s): f(dPermauent or ❑Temporary By signing oris forn+,I hereby cerli9 that the vell(s)leas 61-ere)conshvcted in accordance
///��I v th ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction$randards and that a
7.Is this a repair to an existing well: ❑Yes or AM coPl'ofthfsrecord has beenprovidedto the well olmer.
IfiRs fs a rapair,fill out known bell constniction ft formation and explain the nature ofthe
repair tinder 021 remmks section or on the back of thisfornr. 23.Site diagram or additional well details:
J You may use the back of this page to provide additional well site details o;well
3.Number of wells constructed: + construction details. You may also attach additional pales ifnecessary.
For multiple k ectlon ornon ieatersupply hells 0NZ3'vith the sriue construction,you can
submit onefornr. SUBIMITTAL DISTUCTIONS
9.Total Ivell depth below Innd surface: �% (ft.) 242. For All Wells: Submit this form within 30 days of completion of well
Pot-m:dr6plesrcllrlistalidap,hrond2�a"�.100') constructionto the following:
10.Static crater level belarn top of casing: U (ft.) Division of Nater Quality,Information Processing Unit,
I`n•aterlevel is above casing,use"+" 16171)NI Service Center,Raleigb,A1C 2 769 9-1 617
11.Borehole diameter:�/L (in.) B l L Of f e�t�,.� 24b.For Iuiection Wells- LI addition to sending the form to the address in 24a
above, also submit a copy of this form Nvithin 30 days of completion of well
12.Well construction method: Rotary cons`wction to the following:
(i.e.auger;rotary,cable,directpush,etc)
Division of 1Vater Quality,Underground Injection Control Program,
FOR WATER SUPPLYWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
' .d %Y 24c.For SVater Sunnly 1�:Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of fest: the address(es) above, also submit one copy of this form within 30 days of
Iib.Disinfection Type: HTH Amount: CU S completion of well construction to the county health department of the county
where constructed.
Builders Name: Owners Name:
Address: Address:
Phone Number: Phone:
Cell Number:
G