GW1-2022-01227_Well Construction - GW1_20220103

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
•6°'"""""`�� 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 : TopO Bottom 70 Ft.6.25 SDR 2 PVC
Franklin NC 28734 Top Bottom I .
City or Town State Zip Code
Top Bottom Ft.
828 524-4976
Area code Phone number 8. GROUT: Depth P Material Method
2.WELL INFORMATION: TOP Bottom20 Ft.benonite pumped
WELL CONSTRUCTION PERMIT#050621-P : Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applicable)6580910536 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED 1 1-24-2021 : Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: Franklin COUNTYNIacon Top Bottom Ft.
198 Welcome Lane Otto, NC 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 0*2 ' 55A070 "DMS OR 3X.XXXXXXXXX DD 0 170 iCiay
LONGITUDE 83 0°2 58.1150 "DMS OR 7X.XXXXXXXXX DD 70 /910 jgranite
Latitude/longitude source: BPS ❑ropographic map /
(location of well must be shown on a USGS topo map andattached to l
this form if not using GPS)
5.WELL OWNER
RD Home Sales. Inc. u�—
Owner Name
� �W
_....mm�
Street Address /
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:910
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 100 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
A VIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface'
'Top of casing terminated aUor below land surface may require ��C�sZC� 12-29-2021
a variance in accordance with 15A NCAC 2C.0118. SPNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):'f10 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