GW1-2022-04213_Well Construction - GW1_20220419

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ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#3073 A �.
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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 60 Ft.6.25 SDR-2 PVC
Franklin NC 28734 Top Bottom Ft.
City or Town State Zip Code
8( 28 524-4976 Top Bottom Ft.
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: TopO Bottom20 Ft.benonite pumped
WELL CONSTRUCTION PERMIT#030722-D Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(ff applicable) Top Bottom ft.
SITE WELL ID#(If applicable)6566823035 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED 3/25/2022 Top Bottom Ft* in. in.
TIME COMPLETED AM❑ PM Top Bottom Ft. in. in.
4.WELL LOCATION: : 10.SAND/GRAVEL PACK:
CITY: Franklin COUNTYMacon Depth size Material
Top Bottom Ft.
Olive Hill 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 33 °0 "DMS OR 3X.XXXXXXXXX DD : 0 /60 clay
LONGITUDE 83 0°_' "DMS OR 7X.XXXXXXXXX DD : 60 /330 granite
Latitude/longitude source: BPS ❑ropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) l
5.WELL OWNER / .
R 19.2@22
Junior Burch WiNvoke Pnn
Owner Name / O-binil
/ DWQ9W
2249 Olive Hill Road /
Street Address /
Franklin NC 28734 /
City or Town State Zip Code /
U /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:330
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO @f
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
: PROV ED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface'
'Top of casing terminated at/or below land surface may require 4-13-2022
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 20 METHOD OF TESTAir Rick Crane I
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30-days of completion to:-Division,of Water Quality- -Information Processing, 7 Form GW-1a
1617 Mail Service Center, Raleigh,NC 27699-161,Phone:[phone] Rev.2/09