386250_Well Construction - GW1_20100812

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # , 1
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 #(i( applicable)
WELL CONSTRUCTION PERMIT# JF062810-01
OTHER ASSOCIATED PERMIT#(If applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 7-08-2010
Water Supply 0
0 PM 0
Surry
TIME COMPLETED 4.30 AM
4 WELL LOCATION
CITY Mount Airy COUNTY
280 Melton Road
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropnate box)
LATITUDE
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source o GPS o 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 Vanderbilt
EETTADDRESS no
City or To State
Zip Code
YES 0 NO
FT
Area co e - Phone number
6 WELL DETAILS
a TOTAL DEPTH 365
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 28
(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 vanance in accordance with 15A NCAC
e YIELD (gpm) 8 METHOD OF
3C7625 V
f DISINFECTION Type Hth Amount 12 oZ
g WATER ZONES (depth)
From 300 To 303 From To
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From () To 4g Ft R1/4 srtr21 pvc
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 28 Ft Cement pouring
From To Ft
From To Ft
9 SCREEN Depth Diameter Slot Size Matenal
From To Ft in in
From To Ft in in
From To Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
From To Formation Description
0 6 sod
6 43 sand rock
43 365 granite
r r7r'r:b0. /L I )
r ‘ Im..,' l- f V
AUG 1 2 ZQ?Q
I111UI IIIdt1Ul 1 1'- 1 Ui.Ca5Ii ly Vlilt
12. REMARKS DWQ/BOG
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
7/28/2010
SIGNATURE OOF CER IFIED WELL CONTRACTOR 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 Mail Service Center — Raleigh, NC 27699-1617 Phone No [phone] ext 568
Form GW-la
Rev 3/07