380888_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
Chns Kina
Well Contractor (Individual) Name
Raymond Brown Well Company Inc
Well Contractor Company Name
1109 N Main Street
Street Address
g WATER ZONES (depth)
Top 130 Bottom 131 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 120 Ft 6 1 /4 sdr 21 pvc
Danbury NC 27016 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft
336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
8 GROUT Depth Material Method
Top 0 Bottom 20 Ft cement pour
WELL CONSTRUCTION PERMIT# SAS120409-01 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(rf applicable) Top Bottom Ft
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply I (
DATE DRILLED 12-10-09
TIME COMPLETED 3 00 AM ❑ PM L�
4 WELL LOCATION
CITY COUNTY Surry
149 Howell 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
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft _ in in
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Formation Descnption
Latitude/longitude source ❑GPS propographtc map 0 /5 red clay
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) 5 /115 sand rock
5 WELL OWNER
Ed Linlev
Owner Name
Street Address
City or Town State Zip Code
�)
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 825
b DOES WELL REPLACE EXISTING WELL') YES LEI NO ❑
c WATER LEVEL Below Top of Casing 120 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) 1/2 METHOD OF TEST siaht
f DISINFECTION Type hth Amount 10 OZ
115 /825 blue granite
12 REMARKS
FEB 0 2 2010
WF-'i_. , , ,U, i i v c:PC` I Mini
InforrniVtion 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
Nu),
12-10-09
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chris King
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