388086_Well Construction - GW1_20101007

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2312
1 WELL CONTRACTOR
Chris J Bullins
Well Contractor (Individual) Name
Raymond Brown Well Company
Well Contractor Company Name
STREET ADDRESS 1109 N Main Street
Danbury NC 27016
City or Town State
(_)-
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT #(if applicable)
3 WELL USE (Check Applicable Box) Monitoring❑
Industrial/Commercial❑ Agricultural❑ Recovery❑
Irngation❑ Other❑ (list use)
JE081010-12
Municipal/Public❑
Injection❑
DATE DRILLED 08-12-10
PM❑�
Surry
TIME COMPLETED 5 00 AMC!
4 WELL LOCATION
CITY COUNTY
848 Quaker Church Road
(Street Name, Numbers, Community, Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropnate box)
LATITUDE
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source 0 GPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5 FACILITY- is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY
STREET ADDRESS
City or Town State Zip Code
CONTACT PERSON Chad Chilton
MAILING ADDRESS
City or Town State
( )-
Zip Code
YESO NO❑
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 765
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 30
(Use "+" if Above Top of Casing)
9
d TOP OF CASING IS 1 FT Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 33 METHOD OF TEST Timed
f DISINFECTION Type hth Amount 16 oz
g WATER ZONES (depth)
From 720 To 722 From To
From To From To
From To From To
7 CASING Depth Diameter ThicknessNVeight Material
From 0 To 61 Ft 6 1/4 sdr 21 pvc
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 23 Ft cement cuttini poured
From To Ft
From To Ft
9 SCREEN Depth Diameter Slot Size Matenal
From To Ft in in
From To Ft in in
From To Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
From To Formation Description
0 30 soil
30 54 sand rock
54 765 granite
Pit . 9@ Fr'r5
m .a K„ . _8 a t i V." iL.... II
12 REMARKS O C T 0 7 2010
information Processing Unit
L.,VJI /..LR
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
08-12-10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days Attn Information Mgt ,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No [phone] ext 568
Form GW-1b
Rev 12/07