GW1-2021-07820_Well Construction - GW1_20211102

r_ ; RESIDENTIAL WELL CONSTRUCTION RECORD
r` North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 30 73 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. Inc. Top Bottom Top Bottom
Well Contractor Company Name Thickness/
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address : TopO Bottom 95 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: Topo Bottom20 Ft.benonite pumped
WELL CONSTRUCTION PERMIT#042121-D : Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if epplicable)6587408145 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply LEI Top Bottom Ft. in. in.
DATE DRILLED 10-5-2021 : Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM(1 Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: Franklin COUNTYMacon Top Bottom Ft.
Rose Creek Tall Timber Drive 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 14 1 305.0000 "DMS OR 3X.XXXXXXXXX DD 0 /95 clav
LONGITUDE 83 0°15 1267.0000 "DMS OR 7X.XXXXXX)=DD 95 /405 :.granite
Latitude/longitude source: FPS E3T'opographic map /
(location of well must be shown on a USGS topo map andattached to l
this form if not using GPS)
5.WELL OWNER 3
Ina Muncher / d
Owner Name
158 Tall Timber Drive / :«
Street Address
Franklin NC 28734 /
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:405
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 80 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
P 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 10-26-2021
a variance in accordance with 15A NCAC 2C.0118. SI NATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 20 METHOD OF TESTAIr Rick Crane
C DISINFECTION:TypeSterilene Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GWAa
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2/09