GW1-2021-02480_Well Construction - GW1_20210901

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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: (� 9��� �
�.� 3 g. WATER ZONES(depth):14,
Rick Crane ; Top Bottom Top Bottom
Well Contractor(Individual)Name S tP n Top Bottom Top Bottom
Crane Bros. Well Drillina .e;rn UiliC : Top Bottom Top Bottom
Well Contractor Company Name l„(Ofl:'ak'"3''`�`JJ�
ql., ,On Thickness/
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address TopO Bottom 87 Ft.6.25 Sdr-21 pvc
Franklin NC 28734 Top Bottom Ft.
City or Town State Zip Code
t : 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#040221-D Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(f applicable) Top Bottom Ft.
SITE WELL ID#(if applicable)7506981269 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED7-15-2021 Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM Y Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: Franklin COUNTYMacon Top Bottom Ft.
Watauoa Road 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 Q"14 1 4.9020 "DMS OR 3X.XXXXXXXXX DD 0 /87 iclav
LONGITUDE 83 0"t9 26.1780 "DMS OR 7X.XXXXXXXXX DD 87 /755 igranite
Latitudellongitude source: FPS []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 /
Jeremiah Fausnauah /
Owner Name /
1557 Watauga Road. /
Street Address /
Franklin NC 28734 /
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:755
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: 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
PRO ED 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 c 8-23-2021
a variance in accordance with 15A NCAC 2C.0118. SIG A URE OF CERTIFIE ;WELL CONTRACTOR DATE
e. YIELD(gpm): 20 METHOD OF TEST/4ir 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 Proceessing, Form GW-1a
1617 Mail Service Center, Raleigh,NC 27699-161,Phone:[phone] Rev.2/09