GW1-2021-03173_Well Construction - GW1_20210625

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RESIDENTIAL WELL CONSTRUCTION RECORD j
- North Carolina Department of Environment and Natural Resources-Division of
Water Quality
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WELL CONTRACTOR CERTIFICATION# 3073 A I i
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1.WELL CONTRACTOR: g. WATER ZONES(depth):
Rick 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 24 Ft.6.25 SDR-2 PVC
Franklin. NC 28734 Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft.
828 524-4976
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top Bottom20 Ft.benonite pumped
WELL CONSTRUCTION PERMIT#0551221-D Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applicable)6488296639 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply @f Top Bottom Ft. in. in.
DATE DRILLED06-14- 2021 Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Deptht Size Material
CITY: Franklin COUNTYMacon Top Bottom Ft.
Carpenter Road Top Bottom Ft.
(Street Name,Numbers,Community,Subdivlslon,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 [5"o 157.3540 "DMS OR 3X.XXXXXXXXX DID 0 /24 CIaV
LONGITUDE 83 0"24 '9.a16o "DMS OR 7X.XXXXXXXXX DID : 24 /630 granite
Latitude/longitude source: Ff.PS oropographic map /
(location of wall must be shown on a USGS topo map andattached to l
this form if not using GPS) l
5.WELL OWNER
Kenneth Mattison
Owner Name / TJ `61ng Utzlt
Street Address /
Franklin NC 28734 /
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:630
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 AiCOPY OF THIS RECORD HAS BEEN
rIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' I
'Top of casing terminated at/or below land surface may require 6-29-2021
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED{ WELL CONTRACTOR DATE
e. YIELD(gpm): 20 METHOD OF TESTAir Rick Crane
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON,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.2t09
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