GW1-2021-07108_Well Construction - GW1_20211007

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RESIDENTIAL WELL CONSTRUCTION RECORD
- North Carolina Department of Environment and Natural Resources Division of Water 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 Drilling Top Bottom Top Bottom
Well Contractor Company Name Thickness/
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address Topo Bottom 48 Ft.6.25 SDR-2 PVC
Franklin NC 28734 : Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft.
828 524-4976 1
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: TOP Bottom20 Ft.Benonite Pumped
WELL CONSTRUCTION PERMIT#061021-D : Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applirable)6489377307 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED08-30-2021 Top Bottom Ft. in. in.
TIME COMPLETED AM[I PM
L� Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: Otto COUNTYMacon Top Bottom Ft.
Scratch Branch Road Top Bottom iFt.
(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°2 . 124.0000 ^DMS OR 3X.XXXXXXXXX DD 0 /48 day
LONGITUDE 83 0"23 1996.0000 ^DMS OR 7X.XXXXXXXXX DD 48 /455 granite
Latitude/longitude source: Ff,-PS ❑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 /
Charles Mclane
Owner Name / jet
Scratch Branch Road / :on f
Street Address
Otto NC 28763 /
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:455
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO pl
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 50 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 aUor below land surface may require ct � 10-4-2021
a variance in accordance with 15A NCAC 2C.0118. SIGNATURr=OF CERTIFIEDIWELL CONTRACTOR DATE
e. YIELD(gpm): 15 METHOD OF TEST/4ir Rick Crane
C DISINFECTION:Type Sterilene Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GWAa
1617 Mail Service Center,Raleigh,NC 27699.161,Phone:[phone] Rev.2109