GW1-2021-06834_Well Construction - GW1_20210419

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RESIDENTIAL WELL CONSTRUCTION RECORD
,. North Carolina Department of Environment and Natural Resources-Division ofjWater Quality
WELL CONTRACTOR CERTIFICATION# 3073 A
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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 Top Bottom Top Bottom
Well Contractor Company Name
Thicknessf
248 Crane Circle : 7. CASING: Depth Diameter Weight Material
Street Address : Top 0 Bottom 84 Ft.).625 SDR-2 PVC
Franklin. NC 28734 Top Bottom It.
City or Town State Zip Code
( 828 ) 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#021421-D : Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if appticable)7515083953 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Pf Top Bottom Ft. in. in.
DATE DRILLED 3-1 1-2021 Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: Franklin COUNTYMacon Top Bottom Ft.
Franklin Farm 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 Q^12 ' 31.9800 "DMS OR 3X.XXXXXXXXX DD 0 /84 !Clay
LONGITUDE 83 0°19 -4.9020 ^DMS OR 7X.XXXxxxxxx DD : 84 /855 igranite
Latltude/longitude source: IgtPS Uopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) l
5.WELL OWNER /
Dustin Holden
Owner Name /
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Franklin Farm Road.
Street Address / ?fn;1r55t'`T
Franklin NC 28734 `
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:855
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO Rf
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 250 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 (/�4ti..✓ 4-1-2021
a variance in accordance with 15A NCAC 2C.0118. SI NATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 10 METHOD OF TEST/41r CY A4 e-
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] i Rev.2/09
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