GW1-2022-03793_Well Construction - GW1_20220404

D I
Y RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
3073 A
WELL CONTRACTOR CERTIFICATION#
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 �Dlameter Weight Material
Street Address TOP Bottom 170 Ft:6 1/4 SDR-2 PVC
Franklin NC 28734 Top Bottom Ft:
City or Town State Zip Code Top Bottom I
828 524-4976
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: TopO Bottorr20 Ft.bencinite pumped
WELL CONSTRUCTION PERMIT#050321-D Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(it applicable)6546859371 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED02-16-22 Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM L� Top Bottom-Ft.-in. in.
i
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: Franklin COUNTYMacon Depth size Material
Top Bottom Ft.
i
Tumblewood Dr. Burninatown : 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 ED*13 s.osoo "DMS OR 3X.XXXXXXXXX DD 0 /170 Clay
LONGITUDE 83 Imo°31 206.0000 "DMS OR 7x.XXXXXXXxx DD : 170 /460 _granite
Latitude/longitude source: FPS Qropographic map /
(location of well must be shown on a USGS topo map andattached to l
this form if not using GPS) I
5.WELL OWNER /
Steve Hursev /
Owner Name
Tumblewood Dr. Burninatown /
Street Address /
Franklin NC 28734
City or Town State Zip Code / lllPn�4�i`"m
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:460
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO le
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 60 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 DED 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. SIGNATURE OF CERTIFIEDi WELL CONTRACTOR DATE
e. YIELD(gpm): 5 METHOD OF TEST/41r Rick Crane i
E DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
r:_Submit within 30 days of completion to Division of.Wafer'Quality inf6iinabon Processing, Form GWAa
1617 Mail Service Center,Raleigh;NC 27699 161,-.P hone:(919)'807.6300 --$ Rev.2/09