GW1-2021-06833_Well Construction - GW1_20210419

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D
r _; RESIDENTIAL WELL CONSTRUCTION RECORD
- North Carolina Department of Environment and Natural Resources-Division of1water Quality
WELL CONTRACTOR CERTIFICATION# 3073 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 95 t 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#091 O2O-D Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applicabte)6593887781 9. SCREEN: Depth ;Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED 1-15-2021 Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM i1f
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth I Size Material
CITY: Franklin COUNTYMacon Top Bottom Ft.
Lona 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 ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 35 0"9 - 6.3123 "DMS OR 3X.XXXXXXXXX DD 0 /95 Clay
LONGITUDE 83 [U°21 17.1678 "DMS OR 7X.XXXXXXXXX DID 95 /505 granite
Latitude/longitude source: RPS C]Topographic 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 /
Caleb Gibson
Owner Name
Lona Road.
Street Address /
Franklin NC 28734
City or Town State Zip Code
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:505
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO M'
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 ORTHIS 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 �,�y �Q« I 4-1-2021
a variance in accordance with 15A NCAC 2C.0118. SIG ATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 10 METHOD OF TESTAir
f. DISINFECTION:Type Amount PRI TED 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
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