382461_Well Construction - GW1_20100413

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2312
1 WELL CONTRACTOR
Chns J. Bullins
Well Contractor (Individual) Name
Raymond Brown Well Company Inc.
Well Contractor Company Name
1109 N Main Street
Street Address
g WATER ZONES (depth)
Top 290 Bottom 292 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 97 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 24 Ft cement pour
WELL CONSTRUCTION PERMIT# JRW22210-01 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(dapplicable) Top Bottom Ft
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [1ff
DATE DRILLED 02-23-2010
TIME COMPLETED 3 30 AM ❑ PM II
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
4 WELL LOCATION 10 SAND/GRAVEL PACK
Depth Size Material
CITY COUNTY Burry Top Bottom Ft
Classic Lane Top Bottom Ft
(Street Name Numbers Community, Subdivision, Lot No , Parcel, Zip Code) Top Bottom Ft
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36
LONGITUDE 75 °
" DMS OR 3x XXXXXXXXX DD
" DMS OR DD
Latitude/longitude source EGPS topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Leon Slate Farm
Owner Name
Street Address
City or Town State Zip Code
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Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 305
b DOES WELL REPLACE EXISTING WELL? YES f1 NO ❑
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*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 30 METHOD OF TEST siaht
f DISINFECTION Type hth Amount 10 OZ
11 DRILLING LOG
Top Bottom
Formation Descnption
0 / 11 red clay
11 / 90 sand rock
90 / 305 blue granite ,.
/
l ,qp1 - / Lf"�r--
l l,._ d 3�'�4
/ vr�la',- 0),
/ r ,
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
02-25-2010
SIGNATURE OF CERIED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to. Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-la
Rev 2/09