GW1-2022-01772_Well Construction - GW1_20220223

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lr � RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
A
WELL CONTRACTOR CERTIFICATION# 3073
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 Top O Bottom 64 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#0 10 121-D - Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(ff applicable)6571 81 6099 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply M Top Bottom Ft. in. in.
DATE DRILLED 01-31-2022 Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM e
4.WELL LOCATION: : 10.SAND/GRAVEL PACK:
CITY: Franklin COUNTYMacon Depth Size Material
Top Bottom Ft.
off Shoae Road Tap 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 °_' "DMS OR 3X.XXXXXXXXX DD : 0 /64 Clav
LONGITUDE 83 DMS OR 7X.XXXXXXXXX DD : 64 /505 granite
Latitude/longitude source: C33PS propographic 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 /
Paul Cook /
Owner Name /
etc
Street Address Mr7l,r.
Franklin NC 28734
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:505
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO Nf
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 40 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PRO ED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated attor below land surface may require l 2-15-2022
a variance in accordance with 15A NCAC 2C.0118. SO4ATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):20 METHOD OF TESTair Rick Crane I
If. 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
Rev.2/09
1617 Mail Service Center,Raleigh,NC 27699-161,Phone :[phone]