GW1-2022-08220_Well Construction - GW1_20220419

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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: 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 Topo Bottom88 :Ft.6.25 SDR-2 PVC
Franklin NC 28734 Top Bottom iFt.
City or Town State Zip Code
( 828 ) 524-4976 Top Bottom Ft.
i
Area code Phone number 8. GROUT: Depth ¢ Material Method
2.WELL INFORMATION: Topo Bottom20 .!Ft.benonite pumped
WELL CONSTRUCTION PERMIT#111420-P Top Bottom +Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applicable)6478867296 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply L( Top Bottom Ft. in. in.
DATE DRILLED3/30/2022 Top Bottom !Ft. in. in.
Top Bottom iFt. in. in.
TIME COMPLETED AM❑ PM e
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: Otto COUNTY Macon Top Bottom Ft.
Mulberry Road Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parnel,Zip Code) TOp Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
[]Slope []Valley []Flat ❑Ridge OOther 11.DRILLING LOG
Top Bottom Formation Description
LATITUDE 35 a' 271•0000 "DMS OR 3X.XXXXXXXXX DD 0 /88 CIBy
LONGITUDE 83 E °24 1780.0000 "DMS OR 7X.XXXXXXXXX DD : 88 /430 granite
Latltudefiongitude source: M;PS propographic map /
(location of well must be shown on a USGS topo map andattached to / r_n
this form if not using GPS) / a L_
/ I
5.WELL OWNER /
Michael Giaho
Owner Name / DAlBOd
3016 Mulberry Road /
Street Address /
Otto NC 28763 /
City or Town State Zip Code /
U /
Area code Phone number
12. REMARKS:
8.WELL DETAILS:
a. TOTAL DEPTHA30
b. DOES WELL REPLACE EXISTING WELL? YES O NO 9' 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
: P IDED 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 4-13-2022
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
n tY
e. YIELD(gpm): oQ-� METHOD OF TEST Rick Crane
E 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.2/09