380861_Well Construction - GW1_20100202

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. Buillns
Well Contractor (Indiviauai) Name
Raymond Brown Well Company Inc
Well Contractor Company Name
1109 N Main Street
Street Address
Danbury
3
.7 IJ li 3
g WATER ZONES (depth)
Top 185 Bottom 187 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 70 Ft 6 1/4 sdr 21 pvc
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 22 Ft cement pour
WELL CONSTRUCTION PERMIT# J F091409-03 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply l'
DATE DRILLED 12-28-09
TIME COMPLETED 4 30
AM ❑ PMII
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
fop 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 Surry Top Bottom Ft
Top Bottom Ft
❑Slope ❑Valley ❑ Flat ❑ Ridge ❑ Other 11 DRILLING LOG
(Street Name Numbers, Community, Subdivision Lot No , Parcel, Zip Code) Top Bottom Ft
TOPOGRAPHIC / LAND SETTING (check appropnate box)
Top Bottom Formation Descnption
LA FITUDE 36 ° " DMS OR 3x XXXXXXXXX DD /
LONGITUDE 75 " DMS OR DD
Latitude/longitude source LAPS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
SD Jessup Construction
Owner Name
Street Address
City or Town
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 205
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
c WATER LEVEL Below Top of Casing 30 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) 40 METHOD OF TEST siaht
f DISINFECTION Type hth Amount 8 OZ
0 / 10 red clay
10 / 64 sand rock
64 /205 blue granite
/
12 REMARKS
ll-.o'+61 i�
v`rn i L. , .a." �.. , _
Inform; tion Processing Unn
I DO HEREBY CERTIFY THAT THIS WEl L 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
12-28-09
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chris J Sullins
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