GW1-2021-07106_Well Construction - GW1_20210915

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-r= Tipp RESIDENTIAL WELL CONSTRUCTION RECORD
" o North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2313
rl-WELL CONTRACTOR:
f. DISINFECTION:Type Hth Amount OZ
ymond C Brown III Contractor(Individual)Name 9• WATER ZONES(depth):
ymond Brown Well Company, Inc From 665 To 670 From TO
-
Well Contractor Company Name From TO From TO
STREET ADDRESS 1109 N Main From To From To 7. CASING:
Thickness/
Danbury NC 27016 Depth Diameter Weight Material
City or Town State Zip Code From ( TO 1 50 Ft B 4 crir 21
( nvr.
3 Ft.
36 )-593-8239 From From To To Ft.Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material
Method
SITE WELL ID#(if applicable) From 0 To 20 Ft. benonite _pour
WELL CONSTRUCTION PERMIT#3134 From To Ft.
OTHER ASSOCIATED PERMIT#(rfapplicable) From To Ft.
3.WELL USE(Check Applicable Box): Residential Water Supply 0 9• SCREEN: Depth Diameter Slot Size Material
PP Y From To Ft. in.
DATE DRILLED 5-25-18 From TO in,
Ft. in. in,
TIME COMPLETED):45 AM 0 PM Ox From To Ft.
in, in.
4.WELL LOCATION:
10.SAND/GRAVEL PACK:
CITY: Pinnacle COUNTY Stokes Depth Size Material
1059 Hauser Road From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING: From To Ft.
-
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box) 11.DRILLING LOG
LATITUDE May be in degrees,minutes,seconds or From TO Formation Description
— —
LONGITUDE— _ in a decimal format
Latitude/longitude source: 0 GPS 0 Topographic map 0 30 mil
(location of well must be shown on a USGS topo map and 30 45 sand rock
attached to this form if not using GPS)
5.WELL OWNER 45 685 blue aranite
OWNER'S NAME Randall Bowman t
STREET ADDRESS _ , .a=...�
City or Town State Zip Code 1ltl)+
c�1;1
Area code- Phone number 12. REMARKS•.
6.WELL DETAILS:
a. TOTAL DEPTH: 685
b. DOES WELL REPLACE EXISTING WELL? YES NO
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing: 90 FT 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use"+"if Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface` ` ��''a i�YV�C'`e''i C 01 i�,��• f ((( 5-25-18
*Top of casing terminated at/or below land surface may require SIGNATUa-E OF CERTIFIED WELL CONTRACTOR DATE a variance in accordance with 15A NCAC 2C.0118.
Raymond C Brown III
e. YIELD(gpm): 20 METHOD OF TEST_ 31ght PRINTED NAME OF PERSON',CONSTRUCTING THE WEL
l
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt.,1617 Mail Service Center—Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Form
Rey 3107
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