GW1-2021-00557_Well Construction - GW1_20210224

f
1
RESIDENTIAL WELL CONSTRUCTION RECORD
,- North Carolina Department of Environment and Natural Resources-Division of Water Quality 021
.� WELL CONTRACTOR CERTIFICATION# 3071 4 r r 2 2
1.WELL CONTRACTOR: g. WATER ZONES(depth)': ON"°i
Donnie Crane Top Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
Crane Bros. Well Drillina. Inc. Top Bottom Top Bottom
Well Contractor Company Name Thickness/
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address : TopO Bottom 73 Ft.6.25 SDR-2 PVC
Franklin. NC 2 Top Bottom Et.
City or Town State Zip Code Top Bottom Ft.
828 524-4976
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: TopO Bottom20 Ft.benonite pumped
WELL CONSTRUCTION PERMIT#0368 : Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(f applicable) Top Bottom Ft.
SITE WELL ID#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED 1-12-2021 : Top Bottom Ft. in. in.
TIME COMPLETED AM El PM
Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: BrvSOn City COUNTYSWain Top Bottom Ft.
Fontana Lake Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
[:]Slope ❑Valley ❑Flat ❑Ridge ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 35 ID`22 1 995.0000 "DMS OR 3X.XXXXXXXXX DD 0 /73 1Clay
LONGITUDE 83 I1°32 378.0000 „DMS OR 7X.XXXXXXXXX DD : 73 /605 iqranite
Latitude/longitude source: FPS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) l
5.WELL OWNER /
Rob Cicero /
Owner Name /
Fontana Lake Drive /
Street Address /
Bryson Citv NC /
City or Town State Zip Code
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:605
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO Pf
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 150 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' y
"Top of casing terminated attor below land surface may require 2-17-2021
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 10 METHOD OF TESTAir Donnie Crane
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON
t CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Information Processing, Form GW-1a
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2/09
i