388069_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 Company Inc
Well Contractor Company Name
STREET ADDRESS 1109 N Main
Danbury NC 27016
City or Town State
( 336 )_ 593-8239
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT# LMB04910-02
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 8-27-2010
Water Supply 0
0 PM Ox
Surry
TIME COMPLETED 4.00 AM
4 WELL LOCATION
CITY Pilot Mountain COUNTY
156 Huntington Court
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source 0 GPS ii Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5 WELL OWNER
OWNER'S NAME Kim THanner
STREET ADDRESS
City or Town State
( )-
Zip Code
YES 0 NOX
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 245
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 30
(Use "+" if Above Top of Casing)
d TOP OF CASING IS _ 1 FT Above
Land Surface*
surface may require
2C 0118
TEST sight
*Top of casing terminated at/or below land
a variance in accordance with 15A NCAC
e YIELD (gpm) 40 METHOD OF
f
g
From
From
From
7 CASING
From
From
From
8 GROUT
From
From
From
9 SCREEN
From
From
From
10 SAND/GRAVEL
From
From
From
11 DRILLING
From
DISINFECTION Type Hth Amount 12 OZ
WATER ZONES (depth)
210 To 212 From To
To From To
To From To
Thickness/
Depth Diameter Weight Material
I To 116 Ft 61/4 sdr21 pvc
To Ft
To Ft
Depth Material Method
0 To 20 Ft cement pouring
To Ft
To Ft
Depth Diameter Slot Size Material
To Ft in in
To Ft in in
To Ft in in
PACK
Depth Size Material
To Ft
To Ft
To Ft
LOG
To Formation Description
0 10 soil
10 105 Sand and sand rock
105 245 granite
Il-1)11—( " tNC -li I
OCT 0 7 N0 iG
i..Gnrma inn f}i ni .SSina Unit
DWO/BOG
12. REMARKS:
I DO HEREBY
15A NCAC
RECORD
LA.kL
CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
HAS BEEN PROVIDED TO THE WELL OWNER
9/1/2010
SIGNATURE OF E IED WELL CtNTRACTOR 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 Maul Service Center — Raleigh, NC 27699-1617 Phone No [phone] ext 568
Form GW-la
Rev 3/07