382457_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
Chris J. Bullins
Well Contractor (Individual) Name
Raymond Brown Well Co
Well Contractor Company Name
P 0 Box 337
Street Address
Danbury NC 27016
City or Town State Zip Code
( 336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# DB022610-01
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 3-5-2010 J
TIME COMPLETED 3 30 AM El PM ly
4 WELL LOCATION
CITY COUNTY SUrrV
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑Valley ❑ Flat ❑ Ridge ❑Other
LATITUDE 36
LONGITUDE 75
" DMS OR 3x xxxxxxxxx DD
" DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ❑GPS 0-topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
John Henry Smith
Owner Name
157 Wayne Street
Street Address
Mount Airy NC
City or Town State Zip Code
(336 ) 352-4810
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 265
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO CAI
c WATER LEVEL Below Top of Casing 40 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) 5 METHOD OF TEST siaht
f DISINFECTION Type HTH Amount 8 OZ
try
g WATER ZONES (depth)
Top 215 Bottom 218 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 126 Ft 6 1/4 sdr 21 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 21 Ft C€w\P�r\ ¥ pour
Top Bottom Ft
Top Bottom Ft
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 / 12 red clay
12 /120
Svc coca
120 /265 Granite
/
/
12 REMARKS
=ssr
7O Unit
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
03-05-2010
SIGNATURE OF CEf2bIFIED WELL CONTRACTOR DATE
Chns 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