380863_Well Construction - GW1_20100202

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTOR
Chris Bullins
Well Contractor (Individual) Name
Raymonfd Brown Well Company
Well Contractor Company Name
STREET ADDRESS 1109 N Main
Danbury NC 27013
City or Town State
( 336 )_ 593-8239
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT# JF060909-07
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 12-04-2009
Water Supply fl
0 PM Ox
Surf)/
TIME COMPLETED 5,00 AM
4 WELL LOCATION
ciTY Dobson COUNTY
204 Starseed Trail
(Street Name, Numbers, Community Subdivision, Lot
TOPOGRAPHIC / LAND SETTING
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropnate box)
LATITUDE
No , Parcel, Zip Code)
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 WELL OWNER
OWNER'S NAME Silva Garcia----Tyde Diaz
STREET ADDRESS
City or Town State
( 336 )_ 374-2976
Zip Code
YES 0 NOR
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 66
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above
Land Surface*
surface may require
2C 0118
TEST sight
*Top of casing terminated at/or below land
a variance in accordance with 15A NCAC
e YIELD (gpm) 5 METHOD OF
f DISINFECTION Type Hth Amount 12 Oz
g WATER ZONES (depth)
From 310 To 312 From To
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From 0 To 76 Ft 61/4 stir 21 pvc
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 23 Ft cement pouring
From To Ft
From To Ft
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 8 Clay
8 70 sand rock
70 365 granite
Inc'r-,h'C! /r-li1
ll \L `c.,,,_ 0 If IL,I�l—,j
EL/3-0-2-
12 REMARKS WATEF QuAL i 1 0,,, , ui� Inform,:tion Processing Unit
1 DO HEREBY CER1IFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD �HAAS�B�EENN PROVIDED TO THE WELL OWNER
l--W uX) Q( a,, 12-4-2009
SIGNATURE OF CERTIFIEDj,WELL CONTRACTOR 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-la
Rev 3/07