380887_Well Construction - GW1_20100202

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2080
1 WELL CONTRACTOR
Chris Kina
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
WELL CONSTRUCTION PERMIT# J F 121509-03
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [it
DATE DRILLED 01-08-2010
TIME COMPLETED AM ❑ PM [9(
4 WELL LOCATION
CITY COUNTY Surry
Roundoeak Church Road
(Street Name Numbers Community Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope [Walley ❑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
Lee Johnson
Owner Name
Street Address
City or Town State Zip Code
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 505
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ct(
c WATER LEVEL Below Top of Casing 60 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) 10 METHOD OF TEST siaht
f DISINFECTION Type hth Amount 8 OZ
g WATER ZONES (depth)
Top 320 Bottom 321 Top Bottom
Top 460 Bottom 461 Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 141 Ft 6 1/4 sdr 21 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal
Top 0 Bottom 22 Et cement
Top Bottom Ft
Top Bottom Ft
Method
pour
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
10 SANDIGRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /5
5 /130
130 /145
/
145 /165
165 /505
12 REMARKS
Size
Material
Formation Descnption
red clay
sand rock
blue granite
Sand rock
blue granite
ra rk/E'—
Li
022010
InlOrir,_t n ION
ig 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
G‘ 01-08-2010
SIGNATURE OF CERTIF ELL CONTRACTOR \-) DATE
Chris King
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to• Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Information Processing,
Form GW-la
Rev 2/09