388081_Well Construction - GW1_20101007

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# SASO4O610-01
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 08-02-10
TIME COMPLETED 5 00 AM ❑ PM IV
4 WELL LOCATION
CITY COUNTY Surry
349 Beehive Lane
(Street Name, Numbers, Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope :Walley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 36
"DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source [PPS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Joseoh Culler
Owner Name
Street Address
NC
City or Town
(336 )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 325
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO IX
c WATER LEVEL Below Top of Casing 54 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) 40 METHOD OF TEST siaht
f DISINFECTION Type HTH Amount 16 OZ
g WATER ZONES (depth)
Top 200 Bottom 202 Top Bottom
Top 390 Bottom 394 Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top Bottom 118 Ft 6 1/4 sdr 21 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 21 Ft
Top Bottom Ft
Top Bottom Ft
Material
9 SCREEN Depth Diameter
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft in
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /80
80 /108
108 /325
12 REMARKS
in
in
Size
Method
pour
Slot Size Material
in
in
in
Material
Formation Descnption
clay
sand rock
granite
Ol T 0 d
ZU1n
Inform.,.
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
SIGNATURE OF CEWItIFIED WELL CONTRACTOR
Chris J Bullins
08-02-2010
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
• •
• Submit withinh30days of completion°to Division of Water�Quality - Information Processing,
1617 Mail Service Center, Raleigh, NCo27699=161, Phone [phone]
�3 saz a Yv
Form GW-la
Rev 2/09