388067_Well Construction - GW1_20101007

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2080
1 WELL CONTRACTOR
Chris King
Well Contractor (Individual) Name
Raymond Brown Well Comp Inc
Well Contractor Company Name
STREET ADDRESS 1109 North Main Street
Danbury NC 27016
City or Town State
( 336 )_ 593-8239
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT# SAS103009-01
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 9-13-2010
Water Supply 0
I PM I
Surry
TIME COMPLETED AM
4 WELL LOCATION
CITY Westfield COUNTY
681 Albion Church Road
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE
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 Charles M Bowman
STREET ADDRESS 681 Albion Church Road
Westfield NC 27053
City or Town State
( )-
Zip Code
YES 0 NO11;
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 205
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 20
(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) 15 METHOD OF
f DISINFECTION Type Hth Amount 8 OZ
g WATER ZONES (depth)
From To From To
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From () To 57 Ft 61/4 stir 91 pvc
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 20 Ft cement pour
From To Ft
From To Ft
9 SCREEN Depth Diameter Slot Size Material
From To Ft in in
From To Ft in in
From To Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
From To Formation Description
0-- 5 Red clay
5 50 sand rock
50 205 blue granite
12. REMARKS:
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORRHAS BEEN PROVIDED TO THE WELL OWNER
9-10-2010
SIGNATURE OF CERTI El IELL\GONTRACTOR DATE
Chris King
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