GW1-2021-07772_Well Construction - GW1_20211116

a.
RESIDENTIAL WELL CONSTRUCTION RECORD
' North Carolina Department of Environment and Natural Resources-Division of Water Quality
`aQ no,•
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 7. CASING: Depth Diameter Weight Material
Street Address : Top O Bottom 43 Ft.6.25 SDR-2 PVC
Franklin NC 28734 Tap 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#2018-11997-9-9155 Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(f 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 10/29/2021 Top Bottom Ft. in. in.
,.,/ Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM L� r�
4.WELL LOCATION: 10.SAND/GRAVELDept PACK.
CITY: SVlya COUNTYJackson Top Bottom iFt.
NC 281 near Bear Lake Entrance : Top Bottom Ft.— UV—� 1 071
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box) {� CV I IV
❑Slope []Valley ❑Flat ❑Ridge ❑Other 11. DRILLING LOG II.FORMATIONIPPOrFSSING MP
Top Bottom Formation Description
LATITUDE 35 Q"14 1 798.0000 "DMS OR 3X.XXXXXXXXX DD 0 /43 Clav
LONGITUDE 83 EU"4 '313.0000 "DMS OR 7X.XXXXXXXXX DD 43 /755 Granite
Latitude/longitude source: BPS ❑topographic map /
(location of well must be shown on a USGS topo map andattached to /
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
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:755 #3
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO Pf
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c- WATER LEVEL Below Top of Casing: 25 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 IDED 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): 3/4 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