380883_Well Construction - GW1_20100202

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRAC FOR CERTIFICATION # 2312
1 WELL CONTRACTOR
Chris J Bullins
Well Contractor (Individual) Name
Raymond Brown Well Company Inc.
Well Contractor Company Name
1109 N Main Street
Street Address
Danbury NC 27016
City or Town State Zip Code
( 336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
9 ,ra c, ) Ay
g WATER ZONES (depth)
Top 180 Bottom 182 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 75 Ft 6 1/4 sdr 21 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal
Top 0 Bottom 24 Ft cement
WELL CONSTRUCTION PERMIT# SAS 1 12309-03 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply If(
DATE DRILLED 01-06-2010
TIME COMPLETED 12 30 AM 0 PM
4 WELL LOCATION
CITY COUNTY SUrrV
White Buffalo 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 ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Edward Radford
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 D NO CAI
c WATER LEVEL Below Top of Casing 66 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) 2 METHOD OF TEST sight
f DISINFECTION Type hth Amount 8 OZ
Top Bottom Ft
9 SCREEN Depth Diameter
Top Bottom Ft in
Top Bottom Ft in
top Bottom Ft in
Method
pour
Slot Size
In
In
In
Material
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
/
Formation Descnption
0 /6 red clay
/
6 /68 sand rock
/
68 / 205 blue granite
/
/
/
/
/
12 REMARKS
FER 0 2 2010
WATER QUALI i t a,_.., l lUN
Information 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
(JVun
- R4Z111-
SIGNATURE OF CERTIF D WELL CONTRACTOR
Chris J Bulllns
n 01-06-2010
DATE
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