382445_Well Construction - GW1_20100413

NON 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 Company Inc
Well Contractor Company Name
STREET ADDRESS 1109 N Main Street
Danbury NC 27016
City or Town State
( 336 593-8239
Zip Code
_)_
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Monitonng❑
Industnal/Commercial❑ Agricultural❑ Recovery❑
Irngation0 Other❑ (list use)
JRW 122909-01
Municipal/Public❑
Injection❑
DATE DRILLED 01-15-2010
PMD
Sorry
TIME COMPLETED 1 30 AM❑
4 WELL LOCATION
CITY Long Dusty Lane COUNTY
(Street Name, Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ 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 0 GPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5 FACILITY- is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY
STREET ADDRESS
City or Town State Zip Code
CONTACT PERSON Mike Johnson
MAILING ADDRESS
City or Town State
( )-
Zip Code
YES❑ NO8
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 365
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 10
(Use "+" if Above Top of Casing)
d TOP OF CASING IS FT Above Land Surface*
`lop of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 35 METHOD OF TEST sight
f DISINFECTION Type hth Amount 10 OZ
g WATER ZONES (depth)
From 330 To 331 From To
From To From To
From To From To
7 CASING Depth Diameter Thickness/Weight Matenal
From 0 To 56 Ft 6 1/4 sdr 21 pvc
From To Ft
From To Ft
8 GROUT Depth Material Method
From To Ft
From 3 To 40 Ft bentonite pump
From 0 To 3 Ft cement pump
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 Matenal
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
From To Formation Description
0 7 clay
7 50 sand rock
50 365 granite
II—‹ '[I— d „ u-- f ' f -
A H 1 3 2ftf
12 REMARKS Information Proc:ssing Untt
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A N C 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECO, r ,AS BEEN PROVIDED TO THE WELL OWNER
1-15-10
SIGNA URE OF C T FIED ggeCONTRACTOR 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-lb
Rev 12/07