245 Tall Timber Dr (2) WELL CONSTRUCTION RECORD � >�! For InternalUse ONLY:
This form can be used forsingle ormultiplevvells
t1
1.Well Contractor Information: 2 .4
14.NATER ZONES
rn
O C•� l Y {l� �.1 !i i r rR0\I TO I DESCPIPTION /
Well ContractorN e N / I t:1 ft. ft 5-P4- 144c- tile- {4- O'i�'
,5"'7�+� •rT� CA m 0ft' ft.
NCNVeUContractor CertificatioaNumber 15.OUTER CASING(formells) Nlic O
FROMTO 1l1. Er
MATERUL
Yadkin Well Company, Inca ft ft. in.
CompanyName 16.EVER CASMG OR•TUBING fgcotherraal elosed400
rf J-I � ` rROMI TO DL�h[ETER THICKNIKSS MATERUL
2.Well Construction Permit Ph (x�`/ ft. ���Z�'in 5��-�-I �V
Lfst all applicable well corrstnrction pzrnt (i.e.Cann y,State,Parlance,etc.) ft. ft. in.
3.Wcll Use(cllechwell use): 17.SCREEN
NMI ter Supply Well. ]FroM1 TO DLAMIETER SLOTSIZE TMCIOYESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, in.
❑Geotherma)(Heating/Cooling Supply) k-esidential Nater Supply(single) fr. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
rP,OMr TO 11ATEML EMIPLACEMIENTNIETROD&AAIOULW
❑Lrigation
NonNater Supply WC11: it, 31 fr. bM1 Q u/e d
❑Monitoring ❑Recovery fr. 3)- ft.
Injection Well: ft. ft.
❑AquiferRecharge ❑Groundwater Remediation 19.SAND/GRAVELPACI{(ifa licalile)
[]Aquifer Storage and Recovery ❑Salinity Barrier ]FROM& TO &L4.=LAL EMIPLACEMIENTMIETROD
fc ft.
❑Aquifer Test ❑Stormrvater Drainage
fr. ir.
❑Experimental Technology ❑Subsidence Control
20.DRILLLVGLOG(attach ndditionolsheets ifnecessar•)
❑Geothermal(Closed Loop) ❑Tracer r•RoM1 TO DESCRIPTION calm,nerdness,sauh-ack type.Brain she,etc.
❑Geothermal(Heating/Coolin�g/Rehlnl) ❑Other(explain under 421 Remarks) C9 ft. !�� ft. c 4
4.Date Well '7s)Completed: 4l-l3 Well mfr'!- ®,6 y�-fr. 5pX-ft. �/f� ��ra f Qlv�y
ft. ft.
5n.Well Location: Phone numbe-r it. ft•
C° 44 ale -r f fr.
Facility/OwnerName L Facility IM(ifannlicable)
ft, ft
4(5'(G��^ rf5!�j f h bltf- f/1 Q/• ft. ft.
Physical Address,City,and Zip 21.REMARKS
County Parcel IdentificationNo.(PIN)
5b.Lafitude slid Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if-well field,one laVlong is sufficient) � �� •
3 5 Jil D SAN �d 3S-'? ®( ��
{yS' ature of fiedlVell Contractor Date
6.Is(are)the well .�,,s):�erininent or ❑Temporary By sig r1ng this form,I hereby certjj•that the rvell(s)eras(rere)cotstlixted fn accordance
iddi 13ANCAC 020.0100 or I5ANCAC 030.0200 Krell Consinrction Standards and that a
7.Is this a repair to an existing well: Dyes o1' jitrNo copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out laroirn Snell construction mformation and explain the nature of the
repo7rimderP21 remarkssection oron the backofthisforr.i. 23.Site diagram or ndditioval well details:
You may use the back of this page to provide additional Drell site details or well
li.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For muh ple h1 ecHon ornon-iraterittoply wells ONLYirith the saute construction,you can
submrlt oneform. SUBMITTAL INSTUCTIONS
9.Total well deptb below Iand surface: 5'0J (ft.) 242. For A_il Wells: Submit this form within 30 days of completion of well
Fnrmuhtp7eirellrlistolltl.pthsifdifrrent(ec0inple-3a200'and2@700') constructiontothefollowin.-:
10.Static water level below top of casing: ��• (ft.) Division of%lel•Ciunlily,InformntionProcessing Unit,
Ifuoterlevel is above cast»„rise"+" 1617 M ill Service CeD tet',Ralelgir,liC 27693-1617
11.Borehole diameter: �r(in,) Bit Off A J Da„` 24b.For Iniection r:elis- LI addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of~yell
12.Well cunsiructiunmethod; Rotary constructionto the following.
(i.e.auger,rotary,cable,d rect pwh,etc.) e
Division of Nater Quality,Underground Injection Control Program,
FOR.HATER SUPPLYWEL}ONLY: 1636 Mail Service Center,Enleigh,NC 27699-1636
131.Yield(gpm) PrIethod of test: fiu l y, 24c.Tarlhater Sunu]v R Yniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: cups completion of well construction to the county health department of the county
where constructed.
Form Gti11-1 North Carol na Depaitnlent ofEnvironment turd Natural
ReResources-Division ofWater Quality Revised Jan.2013
WPII 'Conatruoionl Perm It . :: =,-UrMftic�:-:use:oniv
Davie County Heahfh Department SCOP Fil®Number 187522 ,•
210 Hospital Street
P P:IiV.
mbr•_
e :F2-
P.O Rdif$48 :Nit _,..,,; p^. Q:•...�'.•�... . .,.dur•.�:,a•r.�•.;
qq!! r x�ii h_ 9�.i' ff:`ly.�^ipE PI'J!�`Vi1�'Q,l11i/ll'1.rr�tt•':.• .;..
r I:•1:��,,�tat��" .x�ri g���'I IIIi�� '. '°�/'. I i71�M�'a,''TT';:
Mockivlll
NO ,27028 P.
Phone:336 Fax:336-753-16.90
PERMIT VALID UNTIL: 3/18/2020
Property Owner: Charles Birdsong Applicpnt: Charles Birdsong
Addr®ss: 108 Spruce.S•troet �►ddress: Tall'timber Dr
CRY: ivIOCkSvlll® CRY: Mooksvllle
Statel,Lip: NC 27028 state0p: NC 27028
phone it: Phone#:
Property Location & site Information
Address/Road 0: SubdNislon: Phaso: Lot:
Off of Tall Timber drive Proposed use of WbIL•
Mocksville NC 27028
Directions If Other:
Site-Address:Off cif Tall.Timber Drive Directions;64 West,SherfQ10 Rd.td,.Q96- ia'Ra:t Tall,
'Timber'Dr
Well Contractor information
E,Ddllingtractor Driller Registration. . . . . . . . _. :. . _ . . . . . . . . . . . . . . . . . . . . .
Permit Conditions
*Permit Conditions
Well locapoq,,cor $ucUon andpprotw(on raustinep ap stag and.local r Iatlons�r� nu51,be,Irk ,.clad and•approv b �ulho�l ed,t Present ive•:Ql
the lAcdJ H''earth'C>bpaetiiiehtr7tte'p2rrriif••mnjr:be revolted etany.11�nc(orliic�'Cn comb`yGitlh`eidstlrig`r�ul�l�t''s.1`De slUrlg°bt�pptau�d watt.corisiruc(lon
area(s)by the Health Depwment Is to provide protection from the known possible sources of contamination,?tie-approved well areas)may not be changed
wlttlo ,written permission from al aulnoAzed repr Sent Ive,oi.Gng Local Health 4epanmerR;No volume,at quallsy al water.l.s gularanteed by lt�Health
Department,
$Issued By: 2140-Nations, Robert 'Date of Issue- 0 , 3 . 1 . 1 IF
. a 0 1
Authorized state Agent, on OHartd Drawing ()Import Drawing
Owner,^-Aiwa -...r .� Rifn Pigi11/L1rnwiq n -qft�ar.h�d�'
l d 989�b ° H11d3H 1d1N3W OUAN3 00 ND: [ S106 'Ll 'add EC36Q
•Dpuie County Health Oepartmpnt CDP File.Number. 187622
210 Hospital 5tP0O , F2.o04-Qao�7•o1
'
IPA Dox 148 County File iVumber.
` WIQt�k�VUie NC 27028 Bate: ,® . 1.1,a 1,a,u 1 5
Qinch
®raWing Type: Well Permit Scale' Mock
,
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