380870_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 (Individual) Name
Raymond Brown Well Company Inc
Well Contractor Company Name
1109 N Main Street
Street Address
Danbury
g WATER ZONES (depth)
Top 180 Bottom 181 Top
Top Bottom Top
Top Bottom Top
9 4 8 W, A
cy t, ut t
7 CASING Depth Diameter
Top 0 Bottom 40 Ft 6 1 /4
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
2 WELL INFORMATION Top 0 Bottom 20 Ft cement
WELL CONSTRUCTION PERMIT#JF100709-02 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [JJ
DATE DRILLED 12-10-09
TIME COMPLETED 12 30 AM p PM Ly
4 WELL LOCATION
CITY COUNTY SUrrV
447 Albion Church Road
(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 LAPS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Gordon Rogers
Owner Name
Street Address
City or Town State Zip Code
( )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 325
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO CAI
c WATER LEVEL Below Top of Casing 100 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
DISINFECTION Type hth Amount 5 oZ
Top Bottom Ft
9 SCREEN Depth
Top
Top
Top
Bottom Ft in
Bottom Ft in
Bottom
Bottom
Bottom
Thickness/
Weight
Material
sdr 21 pvc
Diameter Slot Size
in
in
Method
ppur
Material
Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top
Top
Top
Bottom Ft
Bottom Ft
Bottom Ft
11 DRILLING LOG
Top Bottom
/5
5 /35
35 /325
/
/
12 REMARKS
Formation Descnption
clay
sand rock
granite
Air n
— F m F „ iwor
FEB 2 2010
vrnTF-
Iiiform.tion Processing 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
12-10-09
SIGNATURE OF CER1IFIED 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