GW1-2022-03771_Well Construction - GW1_20220404

i 1
4'
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality.+ WELL CONTRACTOR CERTIFICATION#3073 A j
1.WELL CONTRACTOR: g. WATER ZONES(depth): 1
Rick Crane Top Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom I Top Bottom
Crane Bros. Well Drillina Top Bottom i' Top Bottom
Well Contractor Company Name
Thickness!
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address Topo Bottom 163 Ft.6 1/4 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 I, Material Method
2.WELL INFORMATION: Topo Bottom20 Ft.benonite pumped
WELL CONSTRUCTION PERMIT#0701 21-D ,• Top Bottom Ft.
OTHER ASSOCIATED PERMIT#('rf applicable) Top Bottom Ft.
SITE WELL ID#(if applicable)65873$9024 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Ie Top Bottom Ft. in. in.
DATE DRILLED03/22/2022 Top Bottom 11 in. in.
I�
TIME COMPLETED AM[I PM IIY Top Bottom Ft: in. in.
r;
i
4.WELL LOCATION: : 10.SAND/GRAVEL PACK: I1
CITY: Franklin COUNTYMacon Depth size Material
Top Bottom �Ft.
T & E Lane Top Bottom "Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
11.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
Top Bottom { Formation Description
LATITUDE 35 ]-14 455.0000 "DMS OR 3X.XXXXXXXXX DD : 0 /163 +i Clav
LONGITUDE 83 za '598.o000 "DMS OR 7X.XXXXXXXXX DD 163 /505 granite
Latitude/longitude source: 0211�PS aopographic map /
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) l
5.WELL OWNER I'
Diane Carillo
Owner Name
123 T& E Lane /
Street Address
Franklin NC 28734 / It . ray ..+..
City or Town State Zip Code
Area code Phone number �; I
12. REMARKS: I
6.WELL DETAILS:
a. TOTAL DEPTH:505
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
: PR 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 03/30/22
a variance in accordance with 15A NCAC 2C.0118. SIG ATURE OF CERTIFIED''IWELL CONTRACTOR DATE
e. YIELD(gpm): 30 METHOD OF TEST 8 r Rick Crane l
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of_Water Quality Informatwn Pracessing, ! Form GW-1a
f`-1617 all Service Center.Raleigh,NC 27699 161,Phone [phone] r * Rev.2/09