GW1-2021-06648_Well Construction - GW1_20211007

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t RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural.Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 3073 A
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 Drillina Top Bottom Top Bottom
Well Contractor Company Name Thickness)
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address : TOP Bottom 110 Ft.6.25 SDR-2 PVC
Franklin NC 28734 : Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft..
828 524-4976
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: TOP Bottom20 Ft.Benonite Pumped
WELL CONSTRUCTION PERMIT#01 0317-D : Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(If applicable) Top Bottom Ft.
SITE WELL ID#(if applicable)65988790 8 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply @{ Top Bottom Ft. in. in.
DATE DRILLED 09-29-2021 Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM Lg Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: Franklin COUNTYMacon Top Bottom Ft.
Mica Citv 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 a]"17 1102.0000 "DMS OR 3X.XXXXXXXXX DD 0 /110 clay
LONGITUDE 83 M"21 -737.0000 -DMS OR 7X.XXXXXXXXX DD 110 /780 granite
Latitudefiongitude source: FPS ❑Topographic map /
(location of well must be shown on a USGS topo map andattached to l
this form if not using GPS) LN
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5.WELL OWNER / j
Robert Brown/Michael Hiaasn MIA
/ r
Owner Name
Mica Citv Road / 4240 roe
Street Address
Franklin NC 28734
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:780
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO P
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 180 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVI ED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface'
'Top of casing terminated at/or below land surface may require ��,, l},,,,,`_p 10-4-2021
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 15 METHOD OF TESTAir Rick Crane If
C 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