GW1-2021-07510_Well Construction - GW1_20211116

~'+ 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 Drillina Top Bottom Top Bottom
Well Contractor Company Name
Thickness/
248 Crane Circle T. CASING: Depth Diameter Weight Material
Street Address : TopO Bottom 59 Ft.6.25 SDR-2 PVC
Franklin NC 28734 Top Bottom-Ft.-
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#201 8-1 1 997-9-91 55 Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(f applicable) Top Bottom Ft.
SITE WELL ID#(if applicable)7586-49-3802 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply @f Top Bottom Ft. in. in.
DATE DRILLED 10/15/2021 Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM(1�
4.WELL LOCATION: 10.SAND/GRAVELDepth
Sig el% j,1j:
CITY: Sylya COUNTYJackson Top Bottom Ft. �0 _,
NC 281 near Bear Lake Entrance Tap Bottom Ft. 6 2021
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
UVVK TOPOGRAPHIC/LAND SETTING: (check appropriate box) iA'FORMATION PR0r'-q
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other 11. DRILLING LOG SING()N
35 � to �sss.a000 Top Bottom Formation Description
LATITUDE ®°_ "DMS OR 3X.XXXXXXXXX DD 0 /59 Clav
LONGITUDE 83 °a 327.0000 ^DMS OR 7X.XXXXXXXXX DD 59 /805 Granite
Latitude/longitude source: EtPS (]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 /
Mary Ann Haskett /
/
Owner Name /
148 Nestina Quail Ln /
Street Address /
Mooresville NC 28117 /
City or Town State Zip Code /
Area code Phone number
6.WELL DETAILS* 12. REMARKS:
a. TOTAL DEPTH:805
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOPf
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing:( FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use°+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PR VIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface'
"Top of casing terminated at/or below land surface may require ! 11/09/2021
a variance in accordance with 15A NCAC 2C.0118. SI ATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 0 METHOD OF TESTAir Rick Crane
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] Rev.2/09