139 Rumple Ln (2) WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
RECEIVED
1.Well Contractor Information:
l 14.WATER ZONES.
p�`O,�• 4t \ FROM TO DESCRIPTION
Well Contractor a
(CS-ft- 3, 'V ft 112.
o 5 7�-A- '37 ft 539 ' svel �-
NC Well Contractor Certification Number 15.OUTER CASING for mulsed wells OR LINER if a licable
FROM ITO DIMIETER THICKNESS NIATERIAL
Yadkin Well Company, Inc. it ft in.
Company Name 16.INNER CASING OR•TUBING eotbermal closed-loo
1 A / FROM TO DIAAIETER THICKNESS I MATERIAL
2.Well Construction Permit 4: 1 dr f / ft /19 ft. j2 s in. SEW,a) f jur�S
List all applicable well construction permits r.e. omny,State,parlance,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIA%IETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) OMesidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hrigation
Non-Water Supply Well: tt. 3 & �„�„e(�• LJl�.�
❑Monitoring ❑Recovery ft & �3e�•�t4��-I�
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft ft To MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sbeets if necessa
❑Geothermal(Closed Loop) []Tracer FROM To DESCRIPTION color,hardness soiVmcktype,grain size etc.
❑Geothermal(Heating/Cobling Return) ❑Other(explain under 421 Remarks) ft 10,
ft. 1 �^
4.Date Well(s)Completed:&� Well ID#/`f/'f L"J�CO
Sa.Well Location: Phone number a 3'.G ft 6 o ft
R� �l�`` des c� 336.101.' sg3a ft ft
Facility/Owner Name Facility ID#(if applicable)
�,Qp ft ft
lu
13q � molt 4.6 A0l9c P:l/r4G ft. ft
Physical Address,City,ala Zip
21.REbLARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(ifwell field,one lat/long is sufficient) •
W t3
afore ofCrtifiedWell Contractor Date
6.Is(are)the well(s): *ernianent or ❑Temporary By signtng this form,I hereby cera fy that the rvell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or t No copy oftiris record lyes been provided to the well owner.
If this is a repair,fill out known well construction iiformation and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 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: L construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLYwith the scone construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: k%2: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdt�erent(example-3@200'/land 2@100) construction to the following:4
10.Static water level below top of casing: ,0' (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,Ilse"++" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: i (in.) Bit Off &.090 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
24c.For Water Sunnly&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test:Q/v '"to h.,.� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: ��CU s completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
Date Site Visited: l0 --L3 BY: Ila
Builders Name: Owned Name: ,,O {fp/ 'fir
Address: Address:
Phone Number: Phone:
01
Cell Number:
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For otriCe use only
Well Construction Par6iit �
Davie County Health Department 'COP rile Number 122891
210 Hospital Street
�± PIN Number. E3-000-001104-01
P.O.lox 848
MoCksvltle NC 27028
Tax Lot tt: Tax Block =:
Phone: 336-753-6780 Pax:336-753-1680 .� Evaluated For: NEW
PERMIT VALID UNTIL: 9/1812018
Property Owne,r Randall Foster ' Applicant' Randall Foster
_ t
Address 3228 US Hwy 601 N Address- 3228 US Hwy 601 N
City. Mocksville City Mocksville
State'7..sp NC 27028 StatefZil): NC 27028
Phone-:. (336)492-5938 1 `., Phone,• (336)492-5938
Property Location,& Site Information
Address—Road"' Subdvi5ion: Phase: Lot:
Rumple Lane Troposed use of Well:
Mocksville NC 27028
birect;ions If Other:
Site Address: Rumple Lane Directions:601 North.Rumple Lane on right past Jolly
Rd.on left
_ Well Contractor Information
Drillina Contractor Driller Registration
t 1 t t t
Permit Conditions
"'Permit Conditions
Well location,lnst7±iatlen and prolectlon mint Ineet all state and local regulations and Mist Oe Inspected and approved by an vilhonzed representative of
tro Local l-tealM Department Inc pMmC may be nwoked at any time for failure to comply with existing reguhtlons The sl(Inq or tlx:well by the Health
Department Is to frovlon protection firm the Kr)s:tim possible sources of contamination The well site may MI bee hanged,eithout erritten permission from
an aumorized represen nme of tip Local HeaiAt DeRartment r,to volume or gUa►Icy of+A,_3:cr is Guaranteed by the Health Department
'Issued By 2744 -Daywalt, Andrew "Date of Issue 0 9 / 1 8 / 2 0 1 3
<JHand Drawing 0Import Drawing
Authorized St21eAgPnt�JWWQQ��_ - **Site Plan/Drawing attached.**
'Well'Construction Permit For Office Use Only
Davie County Health Department *CDP File Number 122891
210 Hospital Street
PIN Number: E3-000-00-104-01
r r P.O. Box 848
•
Mocksville NC 27028 Tax Lot#: Tax Block#:
"'"�""•
Phone:336-753-6780 Fax:336-753-1680 Evaluated For: NEW
PERMIT VALID UNTIL: 9/18/2018
Property Owner: Randall Foster Applicant: Randall Foster
Address: 3228 US Hwy 601 N Address: 3228 US Hwy 601 N
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)492-5938 ��Phone (336)492-5938
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Rumple Lane
*Proposed use of Well:
Mocksville NC 27028
Directions If Other:
Site Address: Rumple Lane Directions: 601 North, Rumple Lane on right past Jolly
Rd.on left
Well Contractor Information
Drilling Contractor Driller Registration
Permit Conditions
*Permit Conditions
Well location,installation,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 may be revoked at any time for failure to comply with existing regulations. The siting of the well by the Health
Department is to provide protection from the known possible sources of contamination. The well site may not be changed without written permission from
an authorized representative of the Local Health Department. No volume or quality of water is guaranteed by the Health Department.
*Issued By: 2244-Daywalt,Andrew *Date of Issue: 0 9 / 1 8 / .2 0 1 3
®Hand Drawing O Import Drawing
Authorized State Agent: **Site Plan/Drawing attached.**
Total Time:(HH:MM) 0 03 0 W-6-Well Construction Permit Issued-New Page 1 of 2
Hours Minutes
' WELL CONSTRUCTION PERMIT 122891
614 Davie County Health Department CDP File Number:
210 Hospital Street
P.O. Box 848
County File Number: E3-000-00-104-01
Mocksville NC 27028 Date: 09 / 18 / . 013
OInch
Drawing Type: Well Permit Scale: . O Block
O N/A J ft.
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Page 2 of 2
P1 P3
WELL CONSTRUCTION PERMIT
°046 Davie County Health Department
= 7 210 Hospital Street CDP File Number: 122891
�4 P.O. BOX 848 E3-000-00-104-01
County File Number:
�^ Mocksville NC 27028
Date: .0.9./ .1.8 /.2 0 1.3.
Drawing Type: Well Permit
Page 2 of 2 P1 P2
Well Certification of CompletionFor office Use Only
r Davie County Health Department
FICDPNumber 122891
210 Hospital Street
Number: E3-000-00-104-01
t_
� P.O.Box 848 Tax Lot#: Tax Block#:
Mocksville NC 27028 �,_EvauatedFor.
Phone:336-753-6780 Fax:336-753-1680
Property owner: Randall Foster Applicant: Randall Foster
Address: Rumple Lane Address: 3228 US Hwy 601 N
City: Mocksville City: Mocksville
StaterLip: NC 27028 State/Zip: NC 27028
Phone#: (336)492-5938 Phone#: (336)492-5938
irections Drilling Contractor
601 North, Rumple Lane on right past Jolly Rd. on ,
left Driller Registration
Date Drilled 1 1 / 0 4 / 2 0 1 3 Replacement Well [:]Yes No Total Depth Ft
Use of Well SINGLE FAMILY Static Water Ft
Yield gpm Water Zone 1) Ft 2) Ft 3) Ft 4) Ft
J
Chlorination Type: Amount:11,
Casing: Depth: Ft Thickness In. Diameter In Top of Casing In.
Material
rFrom-To-Ft.
out Depth Material Method Depth Material 7Metho
om`. .To� .Ft. From, To, .FL
"Liner Date:1 1 / 1 5 / 2 0 1 3 From- - .To_ .Ft Well Driller Signature
Grout Inspected by: EHS#2244-Daywatt.A rew 'Signature Date;1 1 / 1 5 / 2 0 1 3
Issued by. 'Date: 1 1 / 0 4 / 2 0 1 3
Location: Tee Oet) RYes []No Comments
Latitude
Longitude: Suction Line Yes �No
Temporary Yes �No
Enclosure E]Yes No Well I.D.Plate Yes []No
Enclosure Floor []Yes No pump I.D.Plate MYes E]No
Access Port ❑Yes [j No 2244-Daywalt.Andrew
Vent M Yes n N o EH S:
Bib Cock Yes []No Issue Date:
Back Flow Yes R No Water Sample F]Yes No
0
OHand Drawing 0Import Drawing
WELL CERTIFICATE OF COMPLETION
Davie County Health Department CDP File Number:, 122891
210 Hospital Street
County File Number: E3-000-00-104-01
P.O.Box 848
Mocksville NC 27028 Date:
Q Inch
Drawing Drawing Type: Well Certificate of Completion Scale: . ()Block
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• " ' Well Construction Perm it For Office Use OnIY
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*CDP Fite Number 122891Davie Count Health Department
210 Hospital Street
p PIN Number: E3-000-00-104-01
P.O. Box 848
Tax Lot Tax Block n:
Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 Evaluated For: NEW
PERMIT VALID UNTIL: 9118/2018
Property Owner: Randall Foster Applicant: Randall Foster
Address: 3228 US Hwy 601 N Address: 3228 US Hwy 601 N
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone r: (336)492-5938 Phone 4": (336)492-5938
Property Location & Site Information
Address/Road Subdivision: Phase: Lot:
Rumple Lane
'Proposed use of Well:
Mocksville NC 27028
Directions If Other:
Site Address: Rumple Lane Directions: 601 North, Rumple Lane on right past Jolly
Rd. on left
Well Contractor Information
Drilling Contractor Driller Registration
Permit Conditions
Permit Conditions
Well location,instwation,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 any time for failure to comply velth existing regulations. The siting of the Ezell by the Health
Department is to provide protection from the ktta:zn possible sources of contamination. The well site may not be changed vrillnout vaitten permission from
an authorized representative of the Local Health Department. No volume or quality of vaaeris guaranteed by the Health Department
=Issued By: 2244 -Daywalt,Andrew =Date of Issue: 0 9 / 1 8 / 2 0 1 3
Authorized State Agent: ** QHand Drawing Q Import Drawing **
Site Plan/Drawing attached.
WELL CONSTRUCTION PERMIT 122891
;F• Davie County Health Department CDP File Number:
210 Hospital Street
E3-000-00-104•01
Qt P.O. Box 848 County File Number:
CeA
Mocksville NC 27028
'��•-�;, .�� Date: o s l i a l 2 o i s
Q Inch
Drawing Type: Well Permit Scale: , QBlock
()N/A — ft.
40
OVS460 0Sd
v�Q _
Page 2 of 2
b PPLICATION FOR PRIVATE WDLL PERMIT
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax.(336)753-1680 !
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
,t
APPLICANT INFORMATION �`•=
Name ')RLL —(' Contact Person 4•,
Address Us Home Phone
City/State/71? C Business Phone 399 -A(,o-12-
Name on Permit if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A surveyylat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
Owner's Name �G r"N OA L s-reR Phone Number 3?j&- 3gOi 4(p"(
Owner's Address VAS \NCity/State/Zip KA0C%05Qt 1.L(ffj NC, -t
Property Address YYl 1 city MOGC1 E
Lot Size 04 dct eS Tax PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site: j}
0 l�'D
DEVELOPMENT INFOgYATION
Permit Type: New WellL Well Repair Well Abandonment Other(specify)
Facility Type: Residential Food Service Church Cmmercial Other
Are There Any Septic Systems Currently On The Site? YES NO V
Do You Intend To Install A New Septic System On This Site? YES L__: NO
TERMS AND CONDITIONS:
This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines
with dimensions,the specific location of the facility and any existing or future appurtenances,the location of any existing septic
system,sewer lines,water lines,any existing water supplies and any surface waters. The applicant is responsible for identifying
and marking the property lines and corners. The applicant is responsible for making the site accessible.
By signing this application,the applicant signifies that they understand the terms and conditions and that they give permission for
Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to
determine the best location for a well.
5-4 -
Signed Date �.
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
7/30/09 Account#
Invoice#