386237_Well Construction - GW1_20100812

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
PO Box337
Street Address
g WATER ZONES (depth)
Top 320 Bottom 322 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top t Bottom 69 Ft 6 1/4 sdr 21 pvc
Danbury NC 27016 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft
( 336 ) 593-8239
Area code Phone number 8 GROUT Depth Material Method
2 WELL INFORMATION Top 0 Bottom 20 Ft CJ:_oV\P.A pour
WELL CONSTRUCTION PERMIT# JRWO5O410-01 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft
SITE WELL ID #(ifapplicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 06-23-10
TIME COMPLETED AM ❑ PM a(
4 WELL LOCATION
CITY COUNTY SUrrV
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope ❑Valley ❑ Flat ❑ Ridge ❑Other
LATITUDE 36 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 75 " DMS OR 7x xxxxxxxxx DD
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
Nancy Devine
Owner Name
Street Address
NC
City or Town State Zip Code
336)
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 335
b DOES WELL REPLACE EXISTING WELL/ YES ❑ NO IR(
c WATER LEVEL Below Top of Casing 92 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) 25 METHOD OF TEST sight
f DISINFECTION Type HTH Amount 8 OZ
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
Formation Descnption
0 /30 soil
30 /63 sand rock
63 /335 granite
MI /fr—
/ '- U14£QIU
/ Infnrrnat,.._ ,.
vLrssstng Unit
/ hIA/I1ini...
/
12 REMARKS
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
y V 1 t .L..LX4) 06-23-10
SIGNATURE OF C TIFIED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
'
Submitywithin 30.days of completion to.°Division of Water Quality, ,; Informattori'Pr cesstng,;
617 Mail Service Center, Raleigh; NC 27699=161,'Phone [phone]
Form GW-la
Rev 2/09