GW1-2021-01805_Well Construction - GW1_20210419

D
M^ RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3071-A
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 Top Bottom Top Bottom
Well Contractor Company Name
Thickness/
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address : Topo Bottom 133 Ft.).625 SDR-2 PVC
Franklin. NC 28734 Top Bottom Ft.
City or Town State Zip Code
8( 28 ) 524-4976 Top Bottom Ft.
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Topo Bottom20 Ft.benonite pumped
WELL CONSTRUCTION PERMIT#2020-1 9595-9-1 0244 Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if 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 DRILLED3-3-2021 Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM(� Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: SvIva COUNTYJackson Top Bottom Ft.
Cabe Road to Wild Bird Drive. 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
DRILLING LOG
Top Bottom Formation Description
LATITUDE 35 *1a 1455.0000 ^DMS OR 3X.XXXXXXXXX DD 0 /133 Clav
LONGITUDE 83 0'16 .466.0000 "DMS OR 7X.XXXXXXXXX DD 133 /605 !granite
LatitudeAongitude source: pGPS Oropographic map /
(location of well must be shown on a USGS topo map andattached to l
this form if not using GPS) l
5.WELL OWNER
Tyler Watchorn / �—
Owner Name
Wild Bird Drive.
Street Address
Svlva NC 28779 V1/ :.,, . �fl�
IG
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: 60 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PR VIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface-
*Top of casing terminated attor below land surface may require
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 10 METHOD OF TESTAIr - Crwy
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.2/09