GW1-2021-02673_Well Construction - GW1_20210901

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Qualifs-P 7 1 202,
WELL CONTRACTOR CERTIFICATION# 3073 A (,rO�e�0i0g Unit43cr9on
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 60 Ft.6.25 Sdr-21 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: Top Bottom20 Ft.benonite pumped
WELL CONSTRUCTION PERMIT#050221-13 : Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applicable)6553374529 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply ie Top Bottom Ft. in. in.
DATE DRILLED8-18-2021 Top Bottom Ft. in. in.
T Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: Franklin COUNTYMacon Top Bottom Ft.
Muskrat Vallev 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 lam'a 32.8450 ^DMS OR 3X.XXXXXXXXX DD 0 /60 clay
LONGITUDE 83 0^30 21.2540 ^DMS OR 7X.XXXXXXXXX DD 60 /255 ;granite
Latitudeflongitude source: M§PS Dropographic map /
(location of well must be shown on a USGS topo map andattached to l
this form if not using GPS) l
S.WELL OWNER /
Peter Williams /
Owner Name /
417 Muskrat Vallev. /
Street Address /
Franklin NC 28734 /
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:255
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO M
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 50 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use^+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
: PROV 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 Ck 8-23-2021
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED!WELL CONTRACTOR DATE
e. YIELD(gpm): 20 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.2109