388087_Well Construction - GW1_20101007

❑ Slope EValley ❑ Flat
LATITUDE 36
RESIDENTIAL 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 Co
Well Contractor Company Name
P 0 Box 337
Street Address
Danbury NC 27016
City or Town State Zip Code
( 336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# JRWO61710-03
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 08-10-10
TIME COMPLETED 5 30 AM ❑ PM 5{
4 WELL LOCATION
CITY COUNTY Surry
Old Rockford Road
(Street Name Numbers Community, Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Ridge ❑ Other
" DMS OR 3x XXXXXXXXX DD
g WATER ZONES (depth)
Top 130 Bottom 132 Top
Top 468 Bottom 470 Top
Top Bottom Top
7 CASING Depth
Top Bottom 94 Ft 6 1/4 sdr 21 pvc
} t.!
Bottom
Bottom
Bottom
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 23 Ft
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft in
Thickness/
Diameter Weight Material
Material
Method
pour
Diameter Slot Size Material
in in
in in
in
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Formation Description
LONGITUDE 75 " DMS OR 7x xxxxxxxxx DD 0 / 70 soil
Latitude/longitude source ❑GPS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Benchmark Mining And Farmina LLC
Owner Name
Street Address
NC
City or Town
3( 36 )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 505
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO CAI
c WATER LEVEL Below Top of Casing 45 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above Land Surface*.
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 6 METHOD OF TEST siaht
f DISINFECTION Type HTH Amount 16 OZ
70 /88
88 /505
/
/
12 REMARKS
sand rock
granite
� e ' 117: D
rp-'l
OvvQfS Sing Unit
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
08-10-2010
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chns J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
rSubmit within 30 days of completion to'Division of Water Quality - Information Processing;?
1617 MaiI�Service Center RaleighNC 27699-161, Phone (919)P807-6300
„ . ,„ ei was.?
Form GW-la
Rev 2/09