388075_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
City or Town
( 336 ) 593-8239
g WATER ZONES (depth)
Top 140 Bottom 142 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top Bottom 40 Ft 6 1/4 sdr 21 pvc
NC 27016 Top Bottom Ft
State Zip Code Top Bottom Ft
Area code Phone number 8 GROUT Depth Material Method
2 WELL INFORMATION Top 0 Bottom 20 Ft pour
WELL CONSTRUCTION PERMIT# JRW060810-01 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply 0
DATE DRILLED 07-18-10
TIME COMPLETED 3 30 AM ❑ PM Li
4 WELL LOCATION
CITY 463Cockerham Road COUNTY Surry
(Street Name, Numbers Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36
" DMS OR 3x XXXXXXxxx DD
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
LONGITUDE 75 " DMS OR 7x xxxxxxXXX DD 0 / 22
Latitude/longitude source ❑PS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Avery Wood
Owner Name
Street Address
NC
City or Town
(336 )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 625
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Cc
c WATER LEVEL Below Top of Casing 60 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above Land Surface* i•
*Top of casing terminated at/or below land surface may require / 07-18-2010
a variance in accordance with 15A NCAC 2C 0118 SIGNATURE 16 ERT I D WELL CONTRACTOR DATE
22 /30
30 /625
Formation Descnption
soil
sand rock
granite,...
/ ul I t➢ 7 2niro
/
12 REMARKS
InfurmatioP,
uVQ/Stir;
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
e YIELD (gpm) 3/4 METHOD OF TEST sight
f DISINFECTION Type HTH Amount 12 OZ
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion,to=lDnosion of Water QualitynforrriationTrocessing, Form GW-1a
1617 Mail Seniice Center, Raleigh;,NC 27699-1,61, Phone [phone] Rev 2/09