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217 Vanzant Rd (3) WELL CONSTRUCTION RECORD ForIntemal Use ONLY: • This form can be used for single or multiple wells !t _- ,j'I 1.Well Contractor Information: rt 7-c, 14.WATER ZONES C I •1 �''"•�; �• t FROM TO DESCRIPTION Well Contractor Name ?ft 1-*'-ft �) 1 '� /�• n,ft. j"'?i ft NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a llcable FROM TO DLAMETER THICKNESS hIATERLAL Yadkin Well Company, Inc. & ft in. Company Name 16.INNER CASING OR.TUBING eotbermalelosed-loo ' //// FROM TO DLAMETER TIHcxNrss MATERLAL 2.Well Constr•uctionPermit 17: /'+b_boo —'_p© "t���� _ ft .� �, ft. �d}., in. -�-" " I i -+. i. List all applicable well constrrctionperinits(t.e.County,State,Parlance,etc.) ft ft. in. 3.Well Use(check well use): 17.SCREEN Water Supply Well: FRONI TO DIAMETER SLOT SIZE THICHIJESS MATERIAL ❑Agricultural ❑Municipal/Public ft, ft. in. ❑Geotherma (Heating/Cooling/Cooling Su 1 esidential Water Supply single ft ft. in. I� g d PP Y) � PPY(�(single) ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO NIATERLAL ENIPL,ACENIENT METHOD&AMOUNT ❑Irrigation ft ft. Non-Water Supply Well: ❑Monitoring ❑Recovery ft ) ft Injection Well: ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable) ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To NtnrERLAL ENIPLACENIENTMETHOD ft ft. ❑Aquifer Test ❑Stormwater Drainage • ft. ft ❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach ndditionnl sheets if necessar ❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness soil/rock type,grain size,etc. ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) d ft 4.Date Wells Completed:leted: :Well ID#_ / L- —�l f �` 1 ti ft. /i _•. ! C;, ,. 5a.Well Location: Phone number W�-•11 y3 l.�i' ft + �!7 ft. ft- ft ft. Facility/OwnerName Facility ID#(ifapplicable) p� ft. ft C X,1 H -7 ft ft. Physical Address,City,and Zip 21.REMARKS 1 County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: (ifwell field,one W/long is sufficient) Signature ofCertifiedWell Contractor + Date 6.Is(arc)the well(s): 1ernranent or ❑Temporary By signing this form,1 hereby cert that the ii,ell(s)was(were)constructed in accordance �' with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or NO copy offhis record has been provided to the well otivner. Ifihis is a repair,fill out known well construction Information afid explain the nature ofthe repair under#21 t eniorkr 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.veil site details or well S.Number of wells constructed: f construction details. You may also attach additional pages ifnecessary. For multiple injection or non-water sipply veils ONL with the same construction,you can: submit ane form l SUBMITTAL INSTUCTIONS ..l 9.Total well depth below land surface: ( r (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For nndtiple wells list all depths ifdifferent(example-3x@200'a nd 2r@J100) • construction to the following: 10.Static water level below top ofcasing: (ft.) Division of Water Quality,Information Processing Unit, Ifwaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: (in.) Bit Of f A", i'l" j 24b.Far Tniection 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 13a.Yield(gpm) ''t J Method of test: 2G G• 24c.For Water Suunly&Iniection 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 constnicted. /r Form GW-1 North Carolina Department of Friviromment and Natural Resources—Division of Water Quality Revised Jan.2013 Date Site Visited: BV': Address: �� ? f'_•c���v �•�� Zq Address: r Phone Number: Phone: ;�,�' w , Cell Number: t4 Gr /cc, va l f� s (3.2.075 -5710/Fax(336)753-1 WELL PERMIT Aocnunt M 989900079 Tax PIN/EH#: H2-000-00-044 Billed'To: Ronald Jones Subdivision Into: Reference Namo: Well Permit Location/Address: 217 Vanzant Road-27028 Proposed Facility Residence Well Proporty Size: . 13.54 Ac ATC Number: 0123 Actions of the employees ofthe Davic County El-I Section shall in no way be taken as a guarantee that this well will produce water of any particular quantity or quality or for any amount of Ome. This permit is valid for a period of S years from the date of issuance. 11is permit may be revoked ifit is determined that there has been a material change in any fact/circumstances upon which this permit was issued. Permit Type: New M Repair ❑ Abandonment ❑ Propo,icd WeU 1,4zation Diagmm Certificate of Completion Diagram 1 —�� M i L--���rC G•,f ' Q GrnnmenLq• Miler: Certification#: Grout Inserted: Well Head Inspected: GPS Coordinates: _ CHS: Date: '~ -/ 'ERS: Date: W.P.7.08