GW1-2021-07513_Well Construction - GW1_20211116

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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 44 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#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply @f Top Bottom Ft. in. in.
DATE DRILLED-1 0/25/2021 : Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM Y
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size
CITY: $VIVA COUNTYJackson Top Bottom 'Ft. ',0�
NC 281 near Bear Lake Entrance Top Bottom IFt. NnV j��C>-
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box) ar DWR SLL i!ON
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other 11. DRILLING LOG -,FQRMATInfl/DI?f)r
Top Bottom Formation Description Nr7 l/Pr
LATITUDE 35 a^14 1 875.0000 "DMS OR 3X.XXXXXXXXX DD 0 /44 Clav
LONGITUDE 83 CU"4 329.0000 "DMS OR 7X.XXXXXXXXX DD 44 /880 Granite
Latitudellongitude source: FPS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) l
S.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
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:880 #2
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO p1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 0 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 1 FT.Above Land Surface-
*Top of casing terminated at/or below land surface may require iQ L I 11/09/2021
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE 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
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