382460_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
Danbury
City or Town
( 336) 593-8239
Area code Phone number 8 GROUT Depth Material
2 WELL INFORMATION Top 0 Bottom 30 Ft cement
WELL CONSTRUCTION PERMIT# JRW22210-0 1 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 Vc
DATE DRILLED 02-8-2010
TIME COMPLETED 5 30 AM ❑ PM ri
4 WELL LOCATION
CITY COUNTY Surry
Holly Cabin Trail
(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
LONGITUDE 75 " DMS OR DD
Latitude/longitude source ❑GPS 17Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 2 /6 granite
3 2 P. 1 4,,
g WATER ZONES (depth)
Top 340 Bottom 342 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 48 Ft 6 1/4 sdr 21 pvc
NC 27016 Top_ Bottom Ft
State Zip Code Top Bottom Ft
pour
Method
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 Description
0 /2 clay
5 WELL OWNER
Randy Hicks
Owner Name
6 /40 sand rock
/
40 / 365 Granite
d
/
Street Address /
City or Town State Zip Code /
c) /
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 365
b DOES WELL REPLACE EXISTING WELL? YES Li' NO ❑
c WATER LEVEL Below Top of Casing 88 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) 50 METHOD OF TEST siaht
DISINFECTION Type hth Amount IIOZ
12 REMARKS
a
2010
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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 OW I R
02-8-2010
SIGNATURE OF CERTIFI:Pi 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