GW1-2021-06838_Well Construction - GW1_20210419

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O RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of�Water QualityA
WELL CONTRACTOR CERTIFICATION# 3073
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1.WELL CONTRACTOR: g. WATER ZONES(depth)i
Rick Crane Top Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
Crane Bros. Well Drillino Top Bottom Top Bottom
Well Contractor Company Name
Thickness/
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address Top O Bottom 70 F,0.625 SDR-2 PVC
Franklin. NC 28734 Top Bottom Ft.
City or Town State Zip Code
8( 28 ) 524-4976 : Top Bottom I t.
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: TopO Bottom20 Ft.benonite pumped
WELL CONSTRUCTION PERMIT#0 11221-q Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applioable)6593002980 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED 2-24-2021 Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM Y ' Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: Franklin COUNTYMacon Top Bottom Ft.
Vista Road 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 []Other11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 35 [D*7 146.2000 DMS OR 3x.xxxxxxxxx DD 0 /70 iClay
LONGITUDE 83 0.22 55.0800 ^DMS OR 7X.XXXXXXXXX DD : 70 /280 iwanite
Latitude/longitude source: FOS Qfopographic 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
Gary Criner / �>
Owner Name
Vista Drive.
Street Address
Franklin NC 28734
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:280
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: 100 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`
"Top of casing terminated at/or below land surface may require `� I� c/ 4-1-2021
a variance in accordance with 15A NCAC 2C.0118. SIGN E OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 20 METHOD OF TESTAir rr /le
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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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